Dear Dr. Islam,

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.

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Kshitij Karki, MPH, MA

Academic Editor

PLOS ONE

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The study was funded by the Directorate General of Health Services (DGHS) Bangladesh (invitation ref no: DGHS/LD/NCDC/Procurement plan/RPA (GOB) Service/2018-

19/ 2018/5217/SP-05) under the name of Saidur Rahman Mashreky as Principal  Investigator.

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Additional Editor Comments:

Please go through the suggestions from the reviewers and address. Thank you

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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: Partly

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

Reviewer #1: Yes

Reviewer #2: 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: Yes

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: This manuscript examines the stigma of attendants who bring mentally ill patients to a mental health facility in Bangladesh. Stigma was highest for hygiene issues (score: 5.4) and lowest for expertise (score: 6.4). There was more stigma for "relationships", "hygiene" and "visibility".

Overall it is well written. Some comments are listed below.

1. What are the mental illnesses of the patients in this study? Please also provide the characteristics of the subject patients.

2. Please provide details about the relationship between the attendant and the patient. (e.g., depth of relationship, duration of association, etc.)

Reviewer #2: The manuscript, “Personal and perceived stigma towards mental disorders among attendants of patients with mental illness in selected health facilities of Bangladesh,” addresses an important and underexplored aspect of mental health in low-resource settings. The topic is of considerable public health relevance, particularly in low- and middle-income countries like Bangladesh, where access to mental health care remains limited and stigma poses a major barrier to treatment. The mixed-methods design is appropriate, capturing both quantitative (n=176) and qualitative (n=20) perspectives. The use of the Day’s Mental Illness Stigma Scale, coupled with in-depth interviews, demonstrates an effort to understand nuanced perceptions across seven domains. Notably, the study highlights high levels of stigma in domains such as hygiene, relationships, and anxiety, while more positive attitudes were observed regarding treatability and trust in professional care—findings that could inform culturally sensitive interventions and awareness efforts.

Despite its strengths, the manuscript has several methodological and analytical limitations that should be addressed before it can be considered for publication. The use of convenience sampling, without adequate justification, introduces significant selection bias and limits the study’s generalizability. Additionally, the absence of stratification by key sociodemographic factors (e.g., urban/rural location, socioeconomic status, or diagnostic category) weakens the conceptualization of the study setting and undermines the representativeness of the findings. The rationale for the sample sizes in both components is not provided, and while the authors mention achieving thematic saturation in the qualitative data, no supporting documentation (e.g., saturation matrix or coding framework) is presented. Moreover, it is unclear whether the scale was validated for the local context. Providing details on translation, cultural adaptation, and psychometric validation—or citing appropriate sources—would strengthen the manuscript’s measurement validity.

The data analysis also requires enhancement. The manuscript presents only descriptive statistics, with no mention of inferential testing (e.g., p-values, confidence intervals) or specification of the statistical tests used to compare subgroups. The absence of multivariate analysis limits understanding of potential confounders, especially regarding the influence of age, sex, and education on stigma scores.

On the qualitative side, while the thematic findings are informative, the analysis lacks detail. The coding strategy, analytical framework, and measures to ensure reliability (such as double coding or inter-coder agreement) are not described. This limits confidence in the qualitative conclusions, which appear anecdotal rather than systematically derived. Furthermore, integration between qualitative and quantitative results is limited and should be improved to enrich interpretation.

Several sections of the manuscript would benefit from editing for clarity, conciseness, and grammar. The discussion section often reiterates results without deeper engagement or comparison with existing literature. Some citations are outdated or drawn from non-peer-reviewed sources; incorporating recent, peer-reviewed research would improve the scientific grounding. Ethical considerations also require greater detail—particularly regarding informed consent procedures, participant anonymity, and emotional safeguards during interviews. While the limitations are acknowledged, the discussion does not adequately address the implications of convenience sampling, diagnostic ambiguity, or cross-sectional design. These factors constrain the study’s capacity to make causal inferences and should be discussed more explicitly. Overall, the paper talks about an important topic and provides helpful initial findings, but it needs major revisions—especially in explaining the study design, improving analysis, and being clearer in reporting—to meet the publication standards of PLOS ONE. I believe that with these significant changes and clearer reporting, this study could substantially add to the research on mental health stigma in low-resource settings.

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Reviewer #1: No

Reviewer #2: No

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Dear Dr. Labida Islam,

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.

• 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. 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,

Kshitij Karki, MPH, MA

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. 

Additional Editor Comments (if provided):

Please revise as per the suggestions of the reviewer. Thank you

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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

Reviewer #1: Yes

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: (No Response)

Reviewer #2: Thank you for the revised submission. The authors have addressed some earlier concerns and made improvements to the manuscript. The introduction now presents a clearer rationale for investigating stigma in the Bangladeshi context, and the overall language has improved. These revisions show a good-faith effort to engage with reviewer feedback and are appreciated.

However, several key issues remain unresolved. Some of the claims made in the author response, such as the inclusion of multivariate analysis and the validation of the stigma scale, are not supported by the actual content of the manuscript.

On lines 103 to 106, the authors mention that the Day’s Mental Illness Stigma Scale was translated into Bengali and back-translated into English by bilingual researchers. While this is an important step, the manuscript provides no evidence of psychometric validation in the Bangladeshi context. There is no mention of reliability statistics, such as Cronbach’s alpha, no description of how the scale was culturally adapted, and no citation of any prior validation study. Since the scale forms the core of the study’s quantitative component, this omission limits the reliability of the findings.

Reference 17, which the authors cite in support of the scale, appears to point to a general Google Scholar search rather than a valid source. If the intention was to cite the Bangladesh National Mental Health Survey, that reference needs to be correctly formatted and clearly explained. Even if the survey used the Day’s scale, its use alone does not imply validation. If validation was conducted, the authors should cite the appropriate report and describe the findings. Otherwise, they should consider conducting a basic psychometric analysis themselves or referencing another study, such as the one listed as reference 26 or similar publications that have used the scale in Bangladesh. The current citation does not provide adequate justification for the scale’s validity.

In their response, the authors state that multivariate analysis was performed. However, the revised manuscript does not include any such analysis. The results section presents only descriptive statistics, including means, standard deviations, and frequencies. No regression models, p-values, confidence intervals, or adjusted comparisons are provided. This is a major gap, especially since the authors draw interpretive conclusions across demographic groups.

An ANOVA is included in the supplementary file (S1 Table), but this only compares mean scores across stigma domains within the scale. It does not examine how respondent characteristics, such as education or gender, influence stigma scores. This was the focus of the requested multivariate analysis and remains unaddressed. Without this level of analysis, it is not possible to understand the independent contributions of key variables or to control for confounding.

The methods section notes that SPSS was used, but the actual statistical procedures are not described. For example, Table 3 presents stigma scores by education level, but the manuscript does not report whether the differences are statistically significant. Statements which suggests that participants with higher education showed less stigma, are not supported by formal statistical testing.

The qualitative component also lacks sufficient methodological detail. While the manuscript states that thematic saturation was reached after 20 interviews, no explanation is provided for how this decision was made. There is no mention of how saturation was defined or assessed, and there is no coding framework, saturation matrix, or supporting evidence. This makes it difficult to evaluate the rigor of the analysis.

The authors also do not describe how codes were developed, how many researchers were involved in the coding process, or whether inter-coder reliability was assessed. There is no mention of using any established qualitative analysis framework. Without these details, it is hard to judge the trustworthiness of the qualitative findings. Additionally, the integration of qualitative and quantitative results is minimal. The findings are presented separately rather than used to build a coherent narrative that draws on both data types.

The sampling approach also remains a concern. The study uses convenience sampling from three health facilities. While this is acknowledged briefly, its implications are not discussed in sufficient depth. There is no reflection on how this may affect representativeness or introduce bias. The authors also do not stratify their analysis by meaningful variables, such as type of mental illness, rural versus urban setting, or the relationship between the attendant and the patient. These factors could provide important context for interpreting stigma but are not explored.

Lastly, some language in the manuscript still implies causation, which is inappropriate for a cross-sectional study. Since the data are observational, the conclusions should be limited to associations.

In summary, while the study addresses an important topic and the revisions show progress, significant methodological concerns remain. The absence of multivariate analysis, and the limited detail in both statistical and qualitative methods reduce the strength and clarity of the findings. I encourage the authors to address these issues more thoroughly in a future revision.

My recommendation is major revision.

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Reviewer #1: Yes:  Tetsuji Kitano

Reviewer #2: No

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<p>Personal and perceived stigma towards mental disorders among attendants of patients with mental illness in selected health facilities of Bangladesh

PONE-D-24-40944R2

Dear Dr. Labida Islam,

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,

Kshitij Karki, MPH, MA

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

**********

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

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

Reviewer #2: I would like to express my appreciation to the authors for their careful and thoughtful revisions. The revised manuscript shows clear improvements in both methodological transparency and analytical rigor.

Key concerns raised in the prior review, including the lack of psychometric validation for the stigma scale, absence of multivariate analysis, and insufficient detail in the qualitative methodology, have now all been addressed comprehensively. The authors have included appropriate reliability measures, regression modeling, and a well-articulated qualitative coding framework, including inter-coder agreement and use of thematic analysis. Importantly, they have also improved the integration between quantitative and qualitative findings, clarified the representativeness of their sampling strategy, and revised the discussion to reflect the observational nature of the data.

These changes significantly strengthen the credibility and contribution of the study. The paper now presents a compelling mixed-methods exploration of stigma toward mental illness in the Bangladeshi context, a topic of high relevance but limited coverage in the current literature. The author's revisions reflect sincere engagement with reviewer feedback and enhance the value of the work for both academic and public health audiences. I am satisfied with the quality of the revised submission and recommend the manuscript for publication in PLOS ONE.

I wish the authors the best of luck in their future scientific endeavors.

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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 #2: No

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