Dear Dr. Estifanos,

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: The authors did a great job assembling a large, population-based dataset and applying a rigorous approach to a public health gap in lung cancer symptom awareness in Ethiopia.

Here are my remarks:

Abstract

1) Lines 32-33: For the aim, consider rewriting to a single clear objective sentence (such as "to identify latent classes of symptom awareness and their predictors”).

2) Line 50: Conclusion states “one-fourth (25 %)”; “one-fourth” already implies 25 %. Delete duplication.

Introduction

3) Line 65: Add citation for WHO guideline.

4) Lines 78–111: These three background paragraphs are dense and contain several ideas that are later repeated. Please condense them into 3–4 focused sentences that (i) summarise the burden of lung-cancer symptoms in Ethiopia, (ii) note the need of local awareness data, and (iii) introduce latent-class analysis as a novel approach. Merge this concise version with the end of the third paragraph (line 77).

Methods

5) Line 139: Include a citation for the formula.

6) Line 194-196: Collapsing current & former smokers into “ever” obscures an important gradient; mention rationale.

7) Line 253: Add a statement on how missing data was handled.

Results

8) Lines 317–318: Add a phrase on non-responders (n = 47).

Discussion

9) Line 546-548: Add citation to support speculation related to difference in findings for males vs. females.

10) Discussion is very lengthy, condense repetitive comparisons with prior studies.

Conclusion:

11) Delete details on subgroups for each category (such as "(secondary, diploma and vocational, and degree and above)") and condense findings to two sentences before policy implications.

General comments:

12) Ensure consistent decimal places for p-values throughout manuscript (preferably 2 decimal places except <0.001).

Reviewer #2: To identify latent classes within the population based on their levels of lung cancer symptoms awareness and predictors of class membership, in this manuscript, the authors conducted a face-to-face interview among 2388 adults in Addis Ababa, Ethiopia, for Lung Cancer Awareness Measurement. They found that only one fourth (25%) of the study participants had good awareness based on lung cancer awareness (LCA), and that respiratory lung cancer symptoms are more known than non-respiratory. The authors suggest that there is a need for class-specific educational intervention to raise awareness and focus on the less-known symptoms to reduce the likelihood of lung cancer being detected too late. These findings are interesting and significant. The manuscript is well written and the research data is presented in a logical way. Before publication of this manuscript in PLoS One, the following issues should be addressed:

Specific issues:

1. Authors should analyze and compare the differences of the lung cancer symptoms awareness between males and females in more detail with statistics and provide explanations.

2. Authors should also compare the differences of lung cancer symptoms awareness between smokers and non-smokers in more detail with statistics.

Reviewer #3: This research provides new insights into the knowledge of lung cancer symptoms in Ethiopia.

It aimed to identify population subgroups according to their level of lung cancer symptom knowledge as well as to obtain predictors of class membership using LCA among adults in Addis Ababa, the capital of Ethiopia.

The great utility of their results lies in the fact that such inferences can provide baseline evidence for the design of future intervention strategies.

However, the presentation of the manuscript and the development of the sections should be reviewed and improved before publication.

Main issues reviewed:

1) Abstract: In this section, lines 42 to 49 include only one sentence! Please shorten the sentences and write them correctly.

2) Introduction: It seems to be a good section for this topic, emphasizing various aspects of lung cancer, the risk factors associated with its incidence, some gaps in the literature about approaches to measurements of prior knowledge of early-stage disease,....etc. However, the authors should try to reduce its length in, for example, 4 important paragraphs.

In the abstract, lines 42 to 49 include only one sentence! Please shorten the sentences and write correctly.

It is too long, unnecessarily repetitive.

3) Methods: i) Air pollution, particularly particulate matter (PM2.5), is recognized as one significant risk factor for lung cancer in Ethiopia, contributing to increased hospitalizations and premature deaths. Both outdoor and indoor air pollution exacerbate this risk. In the research by Demeke Endalie et al (PLOS Digit Health. 2023 doi: 10.1371/journal.pdig.0000308,

"Analysis of lung cancer risk factors from medical records in Ethiopia using machine learning") were identified two important factors for lung cancer: air pollution and obesity, with significance weights of 0.21 and 0.14, respectively.

Considering the aforementioned is that my concern about the level of inference (and generality) of this work to the entire country is the level of generality is incorrect and exaggerated. Also, according to official data from 2023, the Ethiopian rural population accounts for about 78% of the total population. This means that the majority of Ethiopians live in rural areas, with agricultural production. Several papers have reported higher lung cancer incidence (and mortality) rates in rural areas compared to urban areas. Furthermore, specific research suggests that this disparity is related to factors such as higher prevalence of smoking, obesity, poor living conditions, limited access to health care and diagnostic centers, among others.

So:

-What can the authors say about the inferences made in this manuscript for the whole country?

-How might those factors or conditions (cited above) confound the context of residents' prior knowledge about lung cancer? This would basically affect the levels of lung cancer symptoms awareness.

The authors should consider this aspect and justify the generality of the work.

ii) line 133. The authors should rewrite this sentence describing the sample correctly.

iii) line 141: Proportion is a number P, 0=<p<=1! correct=" " please=" " this.=" ">iv) line 140-141: "Since the proportion of lung cancer awareness in our context was unknown, a conservative assumption of P = 50% was made". Please explain this choice better. In other countries, there are some papers with very different proportions that can serve as a reference. In my opinion, being quite conservative leads to smaller sample sizes. Please justify.

3) Results:

i) Figures 1 - 2 require better definition.

ii) The authors should emphasize the essence of the results presented in the tables and not describe them by reproducing them. Please rewrite some paragraphs since there is no need for so much explanation!

5) Discussion: i) It is too extensive, addressing too many aspects (and others) of the work. In doing so, it suffers from too many generalizations. Also, it reproduces numerical results already presented in the previous section (what for? they have already been read...).

The authors should focus on the main results and analyze why they contribute to creating new knowledge, i.e., identify distinct classes of population based on their level of knowledge of lung cancer symptoms and predictors of class membership. Rewrite please.

ii) line 631.633: "However, the study has its limitations. Given the cross-sectional design of the survey,

it is difficult to establish causality.

It is not difficult, it does not exist as such! Causality studies have a different methodological design.

iii) line 632-633: "In addition, the outcome of interest was measured through using spontaneous response questions, which may lead to overestimates by offering the possibility of guessing"

Just those limitations? the authors should comment on issues related to the type(s) of questionnaire used, the nature of the response (self-reported), etc, etc.

6) Conclusion: It is a succinct restatement of the results. There should be a synthesis of the results, and this should be presented in its entirety and in the context of the study. Rewrite.</p<=1!>

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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<p>Lung cancer symptoms awareness among Ethiopian adults, Ethiopia: Latent class analysis

PONE-D-25-05177R1

Dear Dr. Estifanos,

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.

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Kind regards,

Xingyu Xiong, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: Authors addressed my comments properly with results and discussion in revised manuscript. I highly appreciate authors' good response.

Reviewer #3: The authors have submitted a thorough revision of the manuscript, including corrections to the discussion (two important items) and conclusion. These two aspects were central to the original recommendation.

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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 #2: No

Reviewer #3: Yes:  Maria del Pilar Diaz

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