Dear Dr. Abbaszadeh,

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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Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Authors,

Thank you for submitting your manuscript to our journal. We have now received feedback from four expert reviewers, who acknowledge that your work presents a novel idea and has the potential to be publishable. However, they have also raised several serious concerns regarding the conceptual framework, grammatical issues, and the presentation and discussion of your findings.

After careful consideration of the reviewers' comments, I have decided to offer you the opportunity to revise your manuscript. I strongly encourage you to address all concerns thoroughly, revising the text with great care. Please provide a detailed, point-by-point response to each of the reviewers' comments, along with the necessary modifications in the manuscript.

We look forward to receiving your revised version.

[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?

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

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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: Yes

Reviewer #3: Yes

Reviewer #4: No

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

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Reviewer #1: The study was conducted among good numbers of samples with reasonable rate of response rate (Though little low for face-to-face but okay for online survey). Reliable tools (3 item UCLA loneliness Scale, and SAS_SV for PSU were utilized which are with good internal consistency. Some suggestions are:

1. Avoid sub-headings in introduction section.

2. Line 55, need to revise (Grammatical and other issue (i.e., stagma) need to be verified and redo.

Line 135, No need to keep question here, just attach as annexure.

3. Line 193: Why total is kept in first row? I suggest to keep total in last row.

4. Line 210: There is no need to keep each tools' internal consistency score in description of results.

5. Chronbatch alpha may be calculated again if the tool was modified in local language.

Reviewer #2: 1. In abstract include number of participants not sample size 6504...6298

2. In abstract result part: prevalence of abdominal obesity, DM , hypertension and success rate of treatment … Not needed; it will not go with the objectives of the study. Which BMI category, age, and sex were associated with CVD?

3. Line 111: remove Participants aged 20 and older were recruited from design and geography… it was already in participant/population

4. Line 114/5: The study received approval from the Ethics Committee of Hormozgan University of Medical Sciences (IR.HUMS.REC.1401.080). … Include it in the ethical part.

5. Line 231 definition…>make it operational definition

6. Line 234/35: … Medical documents were scanned and reviewed by a cardiologist to confirm the definitive diagnosis. This is for IHD. How ischemic stroke or hemorrhagic stroke was diagnosed was not explained.

7. Line 260...: At what p-value was statistical significance for all the independent variables in the final model declared? because you described that Variables that exhibited a p-value of less than 0.05 in the univariate analysis were

included in the multivariable logistic regression model? How was the strength of association between independent and dependent variables assessed? Explain whether you use COR/AOR with a % confidence interval.

8. Line 358: prevalence of 7.8%....add confidence interval of prevalence

9. Lines 368-375 There is no need to discuss smoking and hookah use, as there is no finding in this study.

10. Discussion and recommendation are mixed

11. Discussion was not elaborated by comparing and contrasting findings with previous studies/literature

12. Conclusion and recommendation were mixed. Conclusion was not narrating the research finding… focus on your findings

13. No recommendation was given on isolated topic

Reviewer #3: Dear Editor,

I hope this message finds you well. I have completed my review of the manuscript entitled “Exploring Cardiovascular Disease Prevalence and Contributing Factors among Adults in Southern Iran, a Cross-Sectional Survey: Rationale, Design, and Primary Results” with manuscript Number: PONE-D-25-24170. Below, you will find my detailed comments and suggested revisions for your consideration.

Thank you for the opportunity to contribute to the peer review process.

Sincerely,

Comment 1:

Please revise the use of abbreviations throughout the manuscript. Ensure that each abbreviation is spelled out in full at its first occurrence, followed by the abbreviated form in parentheses.

Comment 2:

The manuscript contains several grammatical errors that affect readability and clarity. Additionally, ensure there is a space between the final word of a sentence and the subsequent reference citation. Please revise the entire manuscript carefully to correct grammatical inaccuracies, improve clarity, and ensure consistent formatting throughout.

Comment 3:

While the authors describe the use of cluster and stratified random sampling, the methodology lacks sufficient detail to assess its rigor. Please clarify:

• Cluster Selection: How were clusters defined (e.g., geographic units, institutions)? What criteria were used for their selection?

• Stratification: On what basis were strata established (e.g., socioeconomic status, disease prevalence)? How were sampling proportions determined?

• Urban/Rural Representation: Was the allocation proportional to population distribution? If not, justify the approach.

A flow diagram or visual summary of the sampling strategy would greatly enhance reproducibility and transparency.

Comment 4:

Although the use of WHO STEPS and GPAQ tools is noted, there is no mention of whether the questionnaire was pilot tested or validated in the local population. Please specify whether the adapted version underwent pretesting, and if so, how reliability and validity were assessed. This is crucial given cultural and linguistic differences that may affect data quality.

Comment 5:

While the use of SPSS and basic statistical tests is appropriate, the manuscript requires further clarification regarding the model-building strategy for the multivariable logistic regression. Specifically, please address the following:

• Variable Selection: How were confounding variables identified and selected for inclusion?

• Multicollinearity: Was multicollinearity assessed among predictors? If so, what measures were used (e.g., variance inflation factors, correlation matrices)?

• Inclusion/Exclusion Criteria: What statistical or theoretical criteria determined the final variables retained in the model (e.g., p-value thresholds, likelihood ratio tests)?

• Interaction Terms: Were potential interaction terms explored? If yes, how were they selected and evaluated?

Providing these details will enhance the reproducibility and methodological rigor of the analysis.

Comment 6:

Figures 1 and 2 are not properly indexed or cited within the main body of the manuscript. Currently, only the figure legends appear in the text, without any corresponding references or placements indicating where the figures should be consulted. Please ensure that both figures are explicitly referenced and appropriately positioned within the text to guide readers and enhance the clarity of the study’s methodology and results.

Comment 7:

The Discussion section does not adequately contextualize the study's findings in relation to previous research. A critical component of a well-structured discussion is the comparison and contrast of current results with those reported in existing literature. At present, this section lacks sufficient integration of relevant studies and does not effectively highlight consistencies or discrepancies with past findings. I recommend revising the Discussion to include a more comprehensive and analytical comparison with previous studies in your area, thereby strengthening the interpretation and significance of the results.

Reviewer #4: No. the authors mention data restrictions. A thorough language revision by a native English speaker is recommended to enhance readability.

This cross-sectional study by Farshdi et al investigates the prevalence, risk factors, and management of cardiovascular disease (CVD) in Hormozgan Province, Iran. The study includes data from over 6,500 males and females participants aged 20 and older using the WHO steps methodology with a high response rate (96.6%), increasing the validity and generalizability of findings to the local population. The authors highlight key sociodemographic, metabolic, behavioural, and psychological risk factors. While the study is valuable and timely, particularly in the context of growing noncommunicable disease burdens in the MENA region. However, some methodological and reporting issues need clarification to better understand the underlying the clinical relevance of these findings.

Major comments

The results of the analyses are interesting if somewhat predictable. Since it is not a longitudinal study, as a cross-sectional study, we can not interpret the association between risk factors and CVD. Authors need to clearly state this in the discussion and limitation section.

Table 5 shows the regression analysis of the variables such as depression, anxiety and son, but the definition and methods for the measurement of these variables are missing. Detailed methodology on how these variables were measured need to added with cut-offs or scoring system.

Univariate analysis show depression and anxiety are associated with CVD, however only severe anxiety remains significant in multivariate analysis. Again, authors need to explain how severity was categorized.

Table 5, smoking shows no association with CVD (OR = 1.038, p = 0.812), that contradicts with the literature or it could be likely self-reported bias and might not be fully reliable.

Minor Comments

Minor grammatical errors should be addressed to improve readability. All legends should explain all terms and abbreviations used.

**********

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Reviewer #1: Yes:  Dr. Kishor Adhikari

Reviewer #2: Yes:  DEBELA EJETA GEDEFA

Reviewer #3: No

Reviewer #4: No

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Attachments

Attachment

Submitted filename: Comment 1.docx

Attachment

Submitted filename: CVD in Iran PLOS ONE is due by Jun 18 2025.docx

Dear Dr. Abbaszadeh,

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 Oct 16 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.

• 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 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,

Amin Mansoori

Academic Editor

PLOS ONE

Journal Requirements:

1. 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. 

2. 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:

Dear Author,

Thank you for submitting your revised manuscript. Upon evaluation, I find that the paper has improved significantly. However, before we can proceed with acceptance, one of the reviewers has provided some constructive comments to further enhance the manuscript. I encourage you to address these suggestions carefully and submit an updated version for our final consideration. We appreciate your efforts and look forward to receiving your revised manuscript.

Best regards,

Amin Mansoori

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

**********

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

Reviewer #2: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: (No Response)

Reviewer #4: N/A

**********

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

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

**********

Reviewer #2: 1. Line 408-410: Our study provides important insights into the CVD landscape in Hormozgan Province, revealing a prevalence of 7.8% (CI=0.071-0.084), with IHD accounting for 6.7% (0.044-0.09) and stroke for 2.2% (0.018-0.025)

1.1.Confidence intervals (CI) should be reported in the same unit as the main value.

If you report prevalence as a percentage (e.g., 7.8%), then the CI should also be in percentage (CI: 7.1%–8.4%).

1.2. Discuss this finding(prevalence of CVD) by comparing and contrasting prevalence of CVD from other parts of the world. This helps the reader whether prevalence of CVD in the region is high or low compared to other parts of world.

2. Discussion line 445-451

Our logistic regression analysis …..increased age, increased BMI, hypercholesterolemia, diabetes mellitus, HTN, and severe anxiety….include female sex

Hypertension and severe anxiety was discussed but increased age, increased BMI, hypercholesterolemia, diabetes mellitus and sex should be also discussed by comparing and contrasting with previous studies(whether your finding is similar or different )

3. Line 463-465 and 471-472:Our study further emphasizes tailoring interventions, particularly to increase physical activity among women and urban populations….no finding in your study that suggest physical activity in women and urban population associated to CVD. Remove it

4. Line 469-70: even though prevalence of obesity is high, no finding in your study that suggest obesity associated factor to CVD: better to remove it.

5. Conclusion

Focus on your objectives

example like this. The prevalence of CVD was 7.8%(is it high/low comparing…). Factors significantly associated with CVD included older age, higher BMI, hypercholesterolemia, diabetes mellitus, hypertension, and severe anxiety. Interestingly, female sex appeared to be protective against CVD compared to male sex.

Reviewer #3: (No Response)

Reviewer #4: The authors have addressed all the comments and suggestions.

The manuscript has been significantly improved.

**********

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Reviewer #2: Yes:  DEBELA EJETA GEDEFA

Reviewer #3: No

Reviewer #4: Yes:  Rukhsana Gul

Associate Professor

Obesity Research Center

College of Medicine

King Saud University

Riyadh, KSA

**********

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Exploring Cardiovascular Disease Prevalence and Contributing Factors among Adults in Southern Iran, a Cross-Sectional Survey: Rationale, Design, and Primary Results

PONE-D-25-24170R2

Dear Dr. Abbaszadeh,

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,

Amin Mansoori

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: In abstract line 29 6289 individuals and line 35 says 6,298 participants....the number of participants should be same==>6298

**********

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.

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Reviewer #2: Yes:  Debela Ejeta Gedefa

**********