Dear Dr. Robinson,

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: 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: No

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: Yes

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Reviewer #1: This manuscript addresses an important and underexplored area: treatment perspectives on urinary incontinence (UI) among frail older adults and caregivers. The focus on acceptability and perceived feasibility of interventions is a clear strength and aligns with contemporary patient-centered and implementation-oriented research priorities.

Strengths include the inclusion of both older adults and caregivers, capturing the dyadic nature of care and highlighting caregiver burden as a key factor in treatment decision-making. The qualitative design is well described, is appropriate for the study questions and yields clinically actionable insights, particularly the preference for non-invasive interventions and the role of treatment nihilism. Overall, the findings have practical relevance for improving patient-centered and caregiver-informed continence care.

There are some areas on which I suggest revision:

Background section:

1.Tighten up the background section. There is considerable epidemiological evidence, and it takes quite a bit of text to arrive at the study aims.

2. Is there a conceptual framework (e.g. a health behavior theory, or something of the like) that could be introduced to this section? Such an addition would more prominently set up *why* treatment perceptions matter, and not just that they are understudied.

Methods:

1. Please clarify the rationale for the chosen sample size - was thematic saturation was achieved? Alternatively, what was the rationale for analytic sufficiency given the small, purposively selected sample?

2. Please provide additional description of interviewer training and standardization, particularly given the use of multiple interviewers with varying levels of experience and mixed interview modalities (in-person and telephone). Were any steps taken to ensure consistency?

3. The description of the analytic approach is particularly thin in comparison to the rest of the methods. Please describe in more depth, including how coding decisions were made, how discrepancies were resolved, and the role of the senior qualitative researcher.

Results:

1. These data are so important for the field, but could benefit from deepened analysis that moves beyond description to more interpretive insights that *explain* phenomenon of interest. I would personally like to see a comparison of perspective between older adults and caregivers.

2. Theme boundaries could be refined to reduce conceptual overlap and improve clarity - find places to reduce repetition.

3. I would like to see stronger intentionality with data excerpts - to not only demonstrate that a theme is present, but also to show how it varies across participants and contexts, including areas of tension or nuance. This revision would strengthen both the credibility and interpretive depth of the findings.

Discussion:

1. This section would benefit from a stronger shift from description to explanation and integration. While the authors appropriately link findings to existing literature and clinical guidelines, the section remains largely confirmatory. What are the mechanisms underlying key findings - for example, *why* does treatment nihilism persist? How does caregiver burden shape intervention feasibility and decision-making?

2. The implications section could also be strengthened by offering more specific, actionable guidance for intervention design and implementation, particularly around caregiver-inclusive models and feasibility in real-world settings.

Reviewer #2: Overall, the manuscript addresses an important and underexplored topic and makes a valuable contribution to the field. It has clear potential for publication, and I hope the following comments will be helpful in improving the manuscript.

Comments

Methods

1. The study includes ten participants (five older adults and five caregivers), which is acceptable in qualitative research; however, the manuscript does not sufficiently justify how this sample size was determined.

• How was the final sample size decided?

• Was data saturation considered?

• What indicators were used to determine that sufficient depth and breadth of data had been achieved?

2. Participants were recruited via a gatekeeper within an ICPOP service, which may introduce selection bias.

• How might this recruitment approach have influenced the characteristics of the sample?

• Could participants be more engaged with healthcare services than the broader population of frail older adults?

• How might this affect the transferability of the findings?

3. Data collection occurred in two phases, with variation in interviewer configuration (single vs paired interviewers) and mode (face-to-face vs telephone).

• How were these differences managed to ensure consistency across interviews?

• What steps were taken to minimise variability introduced by different interviewers or formats?

• Could these differences have influenced the depth or nature of the data collected?

Data analysis 1. While reflexive thematic analysis is described, the manuscript would benefit from greater transparency regarding the analytic process.

• How were coding decisions made collaboratively across researchers?

• Were there disagreements during coding or theme development, and how were these resolved?

• How did the research team actively reflect on and manage their own assumptions during analysis?

Discussion and Conclusion

1. Some conclusions, particularly regarding the “urgent need” for improved healthcare provider assessment and treatment, appear stronger than what the qualitative data alone can support.

• Are these claims directly grounded in the data presented?

• Could the conclusions be more cautiously framed to reflect the exploratory nature of the study?

2. The manuscript states that this is the first qualitative study focusing specifically on urinary incontinence treatment perspectives in a frail older adult population.

• Can this claim be fully substantiated?

• Would it be more appropriate to frame this as “to our knowledge” or “one of the first”?

• Could the authors clarify what specific aspect of the study is novel (e.g. focus on frailty, treatment perspectives, or inclusion of caregivers)?

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Reviewer #1: No

Reviewer #2: No

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Re: Perspectives of Frail Older Adults and Family Caregivers on Urinary Incontinence Interventions: A Qualitative Study

PONE-D-26-14259R1

Dear Dr. Robinson,

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,

Alison Parker

Academic Editor

PLOS One

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