A register-based study of long-term health and social care costs among children with prenatal alcohol exposure

Mirjami Jolma; Mikko Koivu-Jolma; Taisto Sarkola; Mika Gissler; Niina-Maria Nissinen; Hanna Kahila; Anne Sarajuuri; Paulus Torkki; Ilona Autti-Rämö; Anne Koponen

doi:10.1371/journal.pone.0332113

Peer Review History

Original SubmissionOctober 8, 2025
3 Nov 2025 Decision Letter - Nafisa Jadavji, Editor -->PONE-D-25-42438-->-->A case-control register-based study of long-term health and social care costs among children with prenatal alcohol exposure-->-->PLOS ONE Dear Dr. Jolma, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ==============================-->-->Dear Authors,-->--> -->-->Both reviewers have provided comments that require your attention. I want to encourage you to please address is comment carefully in your resubmission. I look forward to reading your revised paper.-->-->============================== Please submit your revised manuscript by Dec 18 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript:--> A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. 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We look forward to receiving your revised manuscript. Kind regards, Nafisa M. Jadavji, PhD, MSc, BSc Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. 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Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions -->Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: No Reviewer #2: Yes ******** -->2. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #2: I Don't Know ****** -->3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: while the methodology of the study suggests a retrospective/non-concurrent design with the children being identified based on exposure andfollowed up for outcome the analysis is of a case control design. The measure of association we would look for would be relative risk rather than odds ratio. However the data is interesting and requires a resubmission after considering the suggestions Reviewer #2: This is a considered and well-written paper demonstrating a high level of expertise on a complex and nuanced subject. The methodology is sound, and the findings are interesting with potential for international impact. There are some minor changes I would recommend before publication: Terminology Clarification The term “Out-of-home care” may be problematic from an international perspective, as it could be misinterpreted to mean hospital admission. It appears the authors are referring to children under the care of the state or local authority, including foster care and possibly specialized mother-and-baby units? Clarifying this terminology early on is important to accessibility to a global audience. International Comparison to Sweden The inclusion of figures from Sweden in the introduction. It would strengthen the paper to briefly explain why Sweden is a relevant comparator and highlighting key similarities and differences between the two countries in terms of policy, demographics, or care systems for example. Table 1 – Combined Risk Factors It is good that Table 1 includes data on pre-pregnancy alcohol use and unplanned pregnancies. If possible, consider adding a combined metric showing cases where both factors were present. This could offer valuable insight into alcohol consumption prior to the recognition of pregnancy. This is an important factor in future prevention of PAE health promotion efforts. PAE and Control Group Considerations The paper appropriately acknowledges that the control group may include individuals with prenatal alcohol exposure (PAE), given the limitations of self-reporting. This along with the recognition that some individuals in the PAE group may have undiagnosed FASD is important. It would be good to see the limitations of recording PAE in general but also specific to this collection method in more detail in the discussion. Subgroup Analysis – FASD-like Characteristics The discussion refers to a subgroup within the PAE group that exhibits characteristics similar to FASD. It would be beneficial to describe this subgroup in greater detail and, if feasible, include this data in table form to support. Exposure Patterns and Outcomes I recommend expanding the discussion to explore whether differences in exposure patterns—such as episodic drinking during the first trimester—might influence outcomes like depression and anxiety. Some evidence suggests that timing and pattern of exposure may be as important as dose. Cost Comparisons In the discussion (and the introduction) including a comparison of the total costs associated with FASD and PAE to those of other prevalent conditions would provide useful context and underscore the broader public health implications. Reduced Injury Rates in FASD Group The finding of reduced injury rates in the FASD group is intriguing. Are there any known factors specific to Finland that might explain this? A comparison with data from other countries and further exploration in the discussion would be valuable. This could be an area for further research which could be highlighted in the paper too. ****** -->6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: Yes: KURYAN GEORGE Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. --> https://doi.org/10.1371/journal.pone.0332113.r001
Revision 1
6 Dec 2025 Author Response Editor: Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Our response: We thank you for the positive feedback. Below we give our response to the specific editorial comments and the comments from the reviewers. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Our response: Files have been named according to the instructions. 2. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. Please update your Data Availability statement in the submission form accordingly. Our response: Data availability clause has now been refined: “The data that support the findings of this study are available from the Hospital District of Helsinki and Uusimaa (HUS). However, restrictions apply to the availability of these sensitive data, which were used under license for the current study. Only those researchers who are named in the study permissions have access to the data, and no part of the data can be shared or placed in public repositories. Similar data can be applied from Findata Finnish Social and Health Data Permit Authority Findata https://findata.fi/en/. Link to the current legislation: https://findata.fi/en/services-and-instructions/legislation/.” 3. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Our response: Captions for Supporting Information have been added. 4. Please remove all personal information, ensure that the data shared are in accordance with participant consent, and re-upload a fully anonymized data set. Our response: Due to the strict research permit, no information that relates to individuals has been uploaded. 5. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Our response: There were no recommendations for previously published works. 6. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Our response: The reference list has been reviewed. Reviewer #1: while the methodology of the study suggests a retrospective/non-concurrent design with the children being identified based on exposure and followed up for outcome the analysis is of a case control design. The measure of association we would look for would be relative risk rather than odds ratio. However, the data is interesting and requires a resubmission after considering the suggestions. Our response: We thank the reviewer for the interest in our study. We have now replaced odds ratios with risk ratios in group comparisons. Reviewer #2: This is a considered and well-written paper demonstrating a high level of expertise on a complex and nuanced subject. The methodology is sound, and the findings are interesting with potential for international impact. There are some minor changes I would recommend before publication: Our response: We thank the reviewer for the interest in our study and for several useful suggestions to improve our manuscript. We give our point-by-point responses to the specific suggestion below. Terminology Clarification The term “Out-of-home care” may be problematic from an international perspective, as it could be misinterpreted to mean hospital admission. It appears the authors are referring to children under the care of the state or local authority, including foster care and possibly specialized mother-and-baby units? Clarifying this terminology early on is important to accessibility to a global audience. Our response: Out-of-home care has now been clarified (in abstract line 30) to include placements in foster or residential care. It has also been clarified similarly in Introduction (line 76) and in Discussion (line 357). International Comparison to Sweden The inclusion of figures from Sweden in the introduction. It would strengthen the paper to briefly explain why Sweden is a relevant comparator and highlighting key similarities and differences between the two countries in terms of policy, demographics, or care systems for example. Our response: This is an excellent suggestion, as the economic, societal, historic, demographic, cultural and geographical similarities between Sweden and Finland might not be self-evident to international readers. Brief explanation of similarities and comparability between Sweden and Finland has now been added to Introduction (lines 63-64). The information about Sweden having a comparable social and healthcare system to Finland has also been added to Discussion (line 398). Table 1 – Combined Risk Factors It is good that Table 1 includes data on pre-pregnancy alcohol use and unplanned pregnancies. If possible, consider adding a combined metric showing cases where both factors were present. This could offer valuable insight into alcohol consumption prior to the recognition of pregnancy. This is an important factor in future prevention of PAE health promotion efforts. Our response: The combination of unplanned pregnancy and daily or weekly alcohol use have now been added as additional rows in Table 1. PAE and Control Group Considerations The paper appropriately acknowledges that the control group may include individuals with prenatal alcohol exposure (PAE), given the limitations of self-reporting. This along with the recognition that some individuals in the PAE group may have undiagnosed FASD is important. It would be good to see the limitations of recording PAE in general but also specific to this collection method in more detail in the discussion. Our response: Unrecognition is a very important topic. More discussion about presence of probable undiagnosed FASD in PAE population has been added (lines 452-456). Also, description of problems in recognition and recording of PAE in antenatal care and limitations of register data has been added to limitations (lines 463-472). Subgroup Analysis – FASD-like Characteristics The discussion refers to a subgroup within the PAE group that exhibits characteristics similar to FASD. It would be beneficial to describe this subgroup in greater detail and, if feasible, include this data in table form to support. Our response: This subgroup of PAE exhibiting typical symptomatic diagnoses and cost patterns has now been addressed in the Results section as text (lines 327-331) and the new Figure 6. Its similarity to FASD diagnosed both in cost and diagnose patterns had been added to Discussion (lines 393-396) Exposure Patterns and Outcomes I recommend expanding the discussion to explore whether differences in exposure patterns—such as episodic drinking during the first trimester—might influence outcomes like depression and anxiety. Some evidence suggests that timing and pattern of exposure may be as important as dose. Our response: This is a very interesting and important topic warranting more research. The Discussion has been expanded to include this subject (lines 382-386). Cost Comparisons In the discussion (and the introduction) including a comparison of the total costs associated with FASD and PAE to those of other prevalent conditions would provide useful context and underscore the broader public health implications. Our response: This is another great suggestion for improvement. Comparison with costs of childhood asthma and epilepsy have been added (lines 66-68 and 401-404). Unfortunately, cost analyses for many chronic childhood conditions are still lacking. Reduced Injury Rates in FASD Group The finding of reduced injury rates in the FASD group is intriguing. Are there any known factors specific to Finland that might explain this? A comparison with data from other countries and further exploration in the discussion would be valuable. This could be an area for further research which could be highlighted in the paper too. Our response: This is indeed an intriguing and rather surprising finding that requires further research. Earlier studies have indicated that early diagnosis of FASD has protective effect on many adverse health outcomes, but we could not find other studies researching or showing protective effect on traumatic injuries. Discussion about some possible explanation this association in Finland is added (lines 361-372). Attachments Attachment Submitted filename: Response_to_reviewers.docx https://doi.org/10.1371/journal.pone.0332113.r002
12 Jan 2026 Decision Letter - Nafisa Jadavji, Editor -->PONE-D-25-42438R1-->-->A case-control register-based study of long-term health and social care costs among children with prenatal alcohol exposure-->-->PLOS One Dear Dr. Jolma, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Feb 26 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript:--> A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. -->If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Nafisa M. Jadavji, PhD, MSc, BSc Academic Editor PLOS One Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments (if provided): Reviewer 1 has asked that all references to case control studies be removed, since the study is a non-concurrent cohort study. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions -->Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.--> Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** -->2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes Reviewer #2: Yes ****** -->3. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #2: I Don't Know ****** -->4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: PLEASE REMOVE ALL REFERENCES TO CASE CONTROL STUDIES AS THIS IS A NON-CONCURRENT COHORT STUDY. OTHERWISE tHIS MANUSCRIPT IS FINE Reviewer #2: Overall this is an very interesting piece of research with impactful findings. I can see my comments have been addressed satisfactorily and I am happy to recommend publishing this paper with a few minor amendments. Please consider rephrasing the line 42 of abstract. "..support and rehabilitation for birthmothers with alcohol consumption during and after pregnancy" (and line 475 of conclusion) to be less blaming and less directed at birth mothers, also the term rehabilitation used in this line heavily suggests all prenatal alcohol exposure results from dependent drinking which would be incorrect. It may be helpful to phrase this as "prevention of alcohol exposed pregnancies and increased support need" for example. Line 119 where it reads "mental and behavioural", I think should be "mental health and behavioural". Kind regards ****** -->7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. --> https://doi.org/10.1371/journal.pone.0332113.r003
Revision 2
13 Jan 2026 Author Response Response to Editor and Reviewer Editor: Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. 1) Reviewer 1 has asked that all references to case control studies be removed, since the study is a non-concurrent cohort study. Our response: We thank the editor for the encouragement. Following the reviewers suggestion, we have removed all instances where we refer our study as “case-control”. Additionally, below we give our response to the comments from the reviewers. Reviewer #1: 1) PLEASE REMOVE ALL REFERENCES TO CASE CONTROL STUDIES AS THIS IS A NON-CONCURRENT COHORT STUDY. OTHERWISE tHIS MANUSCRIPT IS FINE Our response: We thank the reviewer for the continuing interest in our manuscript and for the time spent reviewing it. We have removed all instances of “case-control” from the title and the text, as requested. Reviewer #2: 1) Overall this is an very interesting piece of research with impactful findings. I can see my comments have been addressed satisfactorily and I am happy to recommend publishing this paper with a few minor amendments. Our response: We thank the reviewer for the positive response and for the time spent reviewing the manuscript. 2) Please consider rephrasing the line 42 of abstract. "..support and rehabilitation for birthmothers with alcohol consumption during and after pregnancy" (and line 475 of conclusion) to be less blaming and less directed at birth mothers, also the term rehabilitation used in this line heavily suggests all prenatal alcohol exposure results from dependent drinking which would be incorrect. It may be helpful to phrase this as "prevention of alcohol exposed pregnancies and increased support need" for example. Our response: We have rephrased the passages in abstract and conclusions following the suggestion. 3) Line 119 where it reads "mental and behavioural", I think should be "mental health and behavioural". Our response: The phrase “mental and behavioural disorders” refers to the name of a class of diagnoses in ICD-10 classification. Attachments Attachment Submitted filename: Response_to_reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0332113.r004
28 Jan 2026 Decision Letter - Nafisa Jadavji, Editor A register-based study of long-term health and social care costs among children with prenatal alcohol exposure PONE-D-25-42438R2 Dear Dr. Jolma, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Nafisa M. Jadavji, PhD, MSc, BSc Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions -->Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.--> Reviewer #1: All comments have been addressed ******** -->2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes ****** -->3. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes ****** -->4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes ****** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes ****** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: this study deals with an important issue and needs to be highlighted. However the faalcies of using record based information must be highlighted ****** -->7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: No ******** https://doi.org/10.1371/journal.pone.0332113.r005
Formally Accepted
Acceptance Letter - Nafisa Jadavji, Editor PONE-D-25-42438R2 PLOS One Dear Dr. Jolma, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Nafisa M. Jadavji Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0332113.r006

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