https://orcid.org/0009-0009-1817-3501
Peer Review History
| Original SubmissionOctober 30, 2025 |
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Dear Dr. Sumana, 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 Jan 08 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.
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Kind regards, Yasir Alvi 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 2. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. 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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. [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: No Reviewer #2: Partly ********** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: No Reviewer #2: Yes ********** 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 ********** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: No Reviewer #2: Yes ********** Reviewer #1: The manuscript presents a timely and important study on the factors affecting diagnostic and treatment delays in tuberculosis in Mysuru, South India. To further strengthen the manuscript and enhance the clarity and robustness of its conclusions, we recommend incorporating the following considerations and revisions. Methodology •The manuscript presents a contradiction by describing the study as "community-based" in the abstract and methods section, while simultaneously acknowledging it as "single-center, facility-based" in the limitations. Recruitment exclusively from a tertiary-care hospital inherently defines the study as facility-based, which impacts the generalizability of the results. This terminology should be clarified for consistency to accurately reflect the source of participants and the implications for external validity. •While "Diagnostic delay" and "Treatment delay" are adequately defined, the relationship between these and the "Patient delay" and "Health system delay" components, which sum to "Total delay," needs explicit clarification in the text. Relying solely on Figure 2 for this crucial relationship could lead to misinterpretation. The definitions should clearly state how "Diagnostic delay" and "Treatment delay" are situated within or relate to "Patient delay" and "Health system delay," respectively. Results and Statistical Analysis •The multivariable logistic regression models frequently yield extremely large Adjusted Odds Ratios (AORs) accompanied by exceptionally wide 95% Confidence Intervals (CIs). For instance, an AOR of 31.40 (95% CI: 3.46–284.74) for poor TB knowledge or 24.81 (95% CI: 10.34–59.50) for visiting more than three facilities indicates significant model instability, likely due to small cell sizes (quasi-complete separation). Presenting such point estimates without acknowledging this high imprecision is misleading. The discussion notably omits the interpretation of this instability. Future analyses may consider more robust statistical methods, such as Firth regression or Exact Logistic Regression to produce more stable and reliable estimates. •The practice of dichotomising continuous variables, such as knowledge and stigma scores, at their median is statistically suboptimal. This approach results in the loss of valuable data. Analysing these variables as continuous predictors (with appropriate checks or transformations) or utilising multiple ordered categories (e.g., quartiles) would provide a more complete and statistically sound understanding of their relationships with the outcomes. •The use of a p-value-based stepwise selection approach (p≤0.05 in bivariate analysis for inclusion in multivariable models) can lead to model instability, omitted-variable bias, and potentially spurious findings. A more robust and recommended approach involves selecting variables based on theoretical relevance or employing a less stringent univariate screening threshold (e.g., p≤0.20) to ensure the inclusion of important confounders in the multivariable models. Discussion •The discussion notes that factors like age, poverty, occupation, stigma, and smoking, initially associated with patient delay, lost significance after multivariable adjustment, suggesting indirect effects. To strengthen this observation, the discussion should elaborate on how these factors might operate indirectly or identify the most likely mediators in the study's specific context. For example, exploring whether they primarily influence informal education or TB-related knowledge could provide deeper contextual insights. •The discussion presents an intriguing paradox: while initially seeking care at private facilities is associated with significantly higher odds of delay (AOR: 17.28), being diagnosed at a private facility appears to be protective against delay in treatment initiation (AOR: 0.072). The discussion should provide a more explicit and detailed explanation of this distinction. It needs to clarify whether this implies that initial private consultations often involve misdiagnosis or a lack of TB services, thus causing delays. However, once a diagnosis is established within a private setting, the administrative process for treatment initiation is faster. Reviewer #2: Comment Clarification is required as the study was done at at the PKTB) Sanatorium, not in the community, hence study design is center based not the community based. 2. Abstract/Result author has mentioned system delay was linked to daily wage occupation (AOR: 6.15; 95% CI: 1.81–20.85 Comment: What were the attributes or factors considered under health system delay , as occupation and below poverty-line status, marital status etc cannot be considered as a risk factor for health system delay as it is more related to delays at patient level. 3. Abstract /conclusion, author has mentioned Nearly two-thirds of TB patients experienced diagnostic or treatment delay Comment: Need to explain whether 2/3rd of TB patients experienced diagnostic or treatment delay, as both are different things, factors responsible for delay and putting on treatment are different. 4. MATERIALS AND METHODS , author has mentioned, Study designed mentioned is retrospective and the study population comprised newly diagnosed TB patients aged ≥18 years who gave written informed consent and were available for interviews during the study period. Comment: Why author has mentioned retrospective study if new cases were enrolled.. selection criteria needs clarification in terms of inclusion/ exclusion criteria and sampling technique used, as the Centre is offering IPD/OPD based services From where the cases were enrolled. 5. MATERIALS AND METHODS /Sample size and selection, author has mentioned prevalence of approximately 40.5%,a margin of error of 5% Comment: This formula fits more for community based study not the Centre based one, current study is Centre based. This margin error was relative precision or absolute precision, needs clarification. 6. Results, author has given description for Sociodemographic characteristics of the study participants. Comment: Table 1 can be removed to avoid duplication Clinical characteristics/ 7. In the result , Factors associated with patient/diagnostic/treatment/health system delay has been reflected. Comment : 1)Needs to figure out of total 331 interviewed cases, what were presenting symptoms and the risk factors for delays ( patients/health system) in context for microbiologically confirmed cases of pulmonary and extra pulmonary Tb cases, and factors should analyzed separately, for all types of delays patient/diagnostic/treatment /health system delays for pulmonary and extra pulmonary Tb cases 8. Comment: Table 1 to 5 can be omitted to avoid duplication as summarized through text only, table number 8 where Factors associated with health system delay among tuberculosis patient has been depicted. 9. Table/s can be placed at the end after the references . 10. Discussion is i is lengthy, needs to make concise and crispy 11. Strengths and limitations of the study : It includes a large, diverse sample that strengthens the reliability and generalizability of findings within the regional context. Comment : This is single center based Study with sample size of 331 so results can be generalized so lacks external validity. ********** 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: Prof. (Dr) Arun Kokane Reviewer #2: Yes: Dr. Rashmi Sharma ********** [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.
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| Revision 1 |
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Dear Dr. Sumana, 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 16 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.
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, Yasir Alvi 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. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 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??> Reviewer #1: Yes Reviewer #2: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ********** 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 ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ********** Reviewer #1: The manuscript presents a timely and important study on the factors affecting diagnostic and treatment delays in tuberculosis in Mysuru, South India. I recommend the publication of this manuscript. Reviewer #2: Following are the revised comments for Factors Affecting Diagnostic and Treatment Delays in Tuberculosis: A Cross-Sectional Study in Mysuru, South India 1. Title reflects health system delays however patient related delay is missing. for health system delays which mainly includes diagnosis and treatment delays or slowing down timely diagnosis and treatment after a patient seeks care. Which is within healthcare infrastructure, inadequate resources, provider practices, and patient flow, including limited diagnostic tools (like X-ray, smear tests), poor referral systems between public/private sectors, insufficient clinician awareness of diseases (like TB), geographical barriers, long wait times, author has mentioned some of them correctly that Health system delay was linked to first seeking care at private facilities (AOR: 17.28; 95% CI: 5.86–50.94), and visiting more than three healthcare facilities before diagnosis, ) however as per earlier comment that Health system delay was linked to daily wage occupation (AOR: 6.15; 95% CI: 1.81–20.85), below-poverty-line economic status (AOR: 13.89; 95% CI: 3.38–57.17) is still leading to confusion to consider it as patient related delay rather than Health system delay. 2. In results about Sociodemographic characteristics of the study participants have been already mentioned as per earlier comments to avoid repetition table 1 can be removed. 3. Regarding Clinical characteristics in result section as per earlier remark author has mentioned only symptoms related to pulmonary TB, however there were 14 Extra pulmonary TB cases it would be interesting to know what was the presenting or clinical finding. ********** 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: Prof. (Dr) Arun Kokane, AIIMS Bhopal 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.
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| Revision 2 |
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Patient and health system related factors affecting diagnostic and treatment delays in tuberculosis: A cross-sectional study in Mysuru, South India PONE-D-25-57862R2 Dear Dr. Sumana, 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, Yasir Alvi Academic Editor PLOS One 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: This revised mansucript can be accepted for publications, it would be better if table one which describes sociodemographic information which is already reflected in subsequent tables and text can be ommitted to avoid duplication of information ********** 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: Yes: Rashmi Sharma **********
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| Formally Accepted |
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PONE-D-25-57862R2 PLOS One Dear Dr. Sumana, 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. Yasir Alvi Academic Editor PLOS One |
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