-->PONE-D-25-05636-->-->What affects a patient’s satisfaction with healthcare? An empirical study from Patient Exit Interviews in Khyber Pakhtunkhwa, Pakistan-->-->PLOS ONE

Dear Dr. Petitfour,-->-->

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[Open Access funding enabled and organized by Projekt DEAL. We gratefully acknowledge financial support as part of a scientific collaboration with the KfW Development Bank (“Scientific implementation research on outpatient-department (OPD) services in the social health protection initiative, Khyber Pakhtunkhwa (KP) province and the Gilgit Baltistan (GB) area”).].

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[Open Access funding enabled and organized by Projekt DEAL. We gratefully acknowledge financial support as part of a scientific collaboration with the KfW Development Bank (“Scientific implementation research on outpatient-department (OPD) services in the social health protection initiative, Khyber Pakhtunkhwa (KP) province and the Gilgit Baltistan (GB) area”).]

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[Open Access funding enabled and organized by Projekt DEAL. We gratefully acknowledge financial support as part of a scientific collaboration with the KfW Development Bank (“Scientific implementation research on outpatient-department (OPD) services in the social health protection initiative, Khyber Pakhtunkhwa (KP) province and the Gilgit Baltistan (GB) area”).]

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Reviewers' comments:

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

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Reviewer #1: Yes

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Dear Authors,

Congratulations on the successful submission of your manuscript titled . I commend you for your hard work and dedication in bringing this research to fruition.

With minor edits and clarifications, this paper is ready for publication. The research is original, well-designed, and has strong potential policy relevance for healthcare delivery in LMIC contexts.

A general comment is to use smaller sentences; some sentences, especially in introduction and discussion sections are very long, these can be split into smaller sentences for better readability. Please see additional comments/suggestions in the attached document and address them for resubmission.

Best of luck and warm regards,

Reviewer #2: It is a good study that attempted to study determinants of patient satisfaction in the Khyber Pakhtunkhwa province of Pakistan. However, it suffer some major limitations and ambiguities. The detailed feedback is presented below

Title:

"What affects a patient’s satisfaction with healthcare?"

• The title is currently too broad. Consider specifying the determinants being assessed — for example, whether they are related to health system factors, patient characteristics, or both. The current phrasing is vague and lacks focus.

Abstract:

• Clearly state the objective of the study at the outset.

• Specify the tool or instrument used to assess satisfaction (e.g., “A 13-item scale was used to measure patient satisfaction…”).

• To improve clarity, organize the results by factor type — for instance, patient characteristics versus systemic or facility-level factors. Currently, these are mixed together.

• The sentence “being insured by an inpatient-focused insurance was significantly associated with satisfaction” requires clarification. Since the survey targeted patients exiting outpatient services, it's unclear how inpatient insurance coverage applies here.

Data Availability:

• The statements are contradictory: first, it says “No – some restrictions will apply”, then it claims data will be publicly available. Please clarify the actual data availability status and correct inconsistencies.

Introduction:

• Include studies conducted in Khyber Pakhtunkhwa (KP) province to enhance contextual relevance. Consider citing other papers:

o https://journalofkcd.com/kcd/article/view/25

o https://jpma.org.pk/index.php/public_html/article/view/9990

• The rationale for the study is currently weak. Clearly highlight specific gaps in the existing literature and explain how this study addresses them. The current explanation is generic and does not clearly demonstrate the study’s unique contribution.

• The phrase “…identifying determinants of patients’ satisfaction…” should be more specific. Explicitly mention whether these determinants include demographic, financial, structural, or service-related factors.

Methods:

• Clearly state the study design and the rationale for the selection of districts. Was the sampling random, purposive, or part of a larger study?

• Define the eligibility criteria for participants — such as age, type of medical condition, or type of healthcare service utilized.

• Explain how the sample size was determined. If this is a secondary analysis, indicate whether the existing sample was sufficient for your study objectives.

• Describe the interview setting, duration, and who conducted the interviews.

• Line 119–120: Clarify whether these variables were additional to the 21 satisfaction items or overlapping.

• Line 124–125: The phrase “capacity to explain…” is unclear and should be reworded for precision. Similarly, ‘rate of the quality of care’?

• Line 126–127: “It further included eight binary satisfaction variables…” needs clarification. If these overlap with the previously mentioned variables, reorganize and integrate this information earlier for coherence.

Construction of composite index

• Line 144: Explain why four general satisfaction variables were excluded.

• Line 145: Explain the reason for removal of variables with clear statistical criteria (e.g., low factor loadings or communalities). Mention the cut-off values used.

• Line 148: Clarify the rationale for using normalized eigenvalues as satisfaction scores instead of first principal component. The eigenvalues tell us the variance component of PCA.

• Overall, the section on satisfaction item lack conceptual clarity. Whether the tool was validated or whether the 17 satisfaction items comprehensively captures all the dimensions of the satisfaction construct. A conceptual framework or mapping of domains would enhance clarity.

Statistical Analysis:

• Patients were sampled equally across facilities, despite variations in patient volume. Explain why weighting was not used to adjust for this imbalance.

Table 2:

• The stated rationale “Higher satisfaction in private facilities” needs clarification. It does not align clearly with the indicator ‘asset quintile’.

• For the Sehat Plus Card variable:

o a) Re-confirm whether all residents of KP were eligible at the time of data collection or if it was limited to low-income groups. Per my understanding, SCP services for everyone in the KP who has a KP national identity card.

o b) Since the Sehat Card covers only inpatient services, please explain the relevance of this indicator when the focus is on outpatient care.

Line 184:

• The dimension of ‘experience with healthcare seeking’ doesn’t seem to be studied comprehensively. It merely has only 3 indicators.

Line 192–194:

• Strengthen the justification for cut-off used for out-of-pocket expenditure (OOPE).

• Provide more detail on the modeling approach: “We tested our model for both the logarithmic of OOPE and its square”.

Results:

• In Table 3, clarify what the values in parentheses represent — are these standard errors, or something else?

Discussion:

• Not accounting for the type of service received by patient is also a limitation.

Overall feedback:

While some of the findings are interesting, the study suffer major limitations: a) the rationale is weak as it does not specifically highlight the gaps in existing literature on the topic and how this particularly study addresses these gaps and add unique value to the existing body of knowledge; b) the study revolves around patient satisfaction; however, the assessment of satisfaction lack conceptual underpinnings. Furthermore, the validity and reliability of the tool and the way construct is developed is unclear. Factor analysis would have been a better technique to develop the overall satisfaction construct; c) certain dimensions of determinants are not comprehensively captures such as environmental and experience of health seeking only has 2 and 3 variables, respectively.

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Reviewer #1: Yes: SYED FARHAN ALI TIRMIZI

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PATIENT SATISFACTION_ plosone_ReviewerComments.docx

-->PONE-D-25-05636R1-->-->Examining individual, health service, and experience of care determinants of patients’ satisfaction - a cross-sectional facility-based study in KP, Pakistan-->-->PLOS One

Dear Dr. Petitfour,

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.-->--> -->-->A minor revision is required before the journal can consider the manuscript for publication.

Please submit your revised manuscript by Feb 13 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.

Please include the following items when submitting your revised manuscript:-->

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• 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,

Dr Syed Khurram Azmat, PhD, MPH, MD

Academic Editor

PLOS One

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Reviewers' comments:

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Reviewer #1: All comments have been addressed

**********

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Partly

**********

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

Reviewer #1: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: No

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: General Assessment

The manuscript tackles a very relevant, important topic. The data is unique, coming from several districts, and encompasses public, as well as private, facilities. The methodological toolkit is, overall, appropriate, and the manuscript is well-explained. However, there appear several aspects, mainly related to sampling and sample size, that need clarification, concerning the overall goal of the study, with regard to intrinsic coherence. These points do not make the manuscript incorrect, per se, but need correction.

MAJOR COMMENTS

1. Absence of Sample Size Justification: The manuscript does not provide a sample size calculation or justification, either at the facility or patient level.

Suggested action: Explicitly state whether the sample size was determined by feasibility/programmatic constraints, or a formal power calculation was conducted. If no formal calculation was done, authors should justify why the achieved sample (n=666) is sufficient for multivariable modeling, and acknowledge this as a limitation.

2. Unclear Primary Sampling Unit (Facility vs. Patient): The manuscript does not clearly define the sampling unit, and the description alternates between facilities as the unit of selection, and patients as the unit of analysis. This ambiguity affects interpretation of representativeness, variance estimation, and external validity.

Suggested action: Clearly state the primary sampling unit (PSU), the secondary sampling unit, and how this informed the analytical approach.

3. Sampling Strategy: The described approach resembles a two-stage cluster sampling design, but this is never explicitly stated, nor analytically accounted for beyond clustering SEs.

Suggested action: Authors should explicitly describe the design as facility-based cluster sampling, acknowledge that patient selection was non-random, and discuss implications for generalizability.

4. Inconsistency ‘8 Interviews per Provider’ vs ‘per Facility’: There is inconsistency in the Methods section. In some places, the target is described as 8 interviews per provider; elsewhere, it is described as 8 interviews per facility. This is confusing, particularly given that facilities may include multiple providers.

Suggested action: Standardize terminology throughout the manuscript. Clarify whether the target was per facility-day, or per individual provider within facilities.

5. Shift in Study Objective (Satisfaction Determinants vs. Health Insurance)

The stated objective focuses on “…individual characteristics; health facility infrastructure; and patients’ experience with health service delivery.” However, health insurance (Sehat Plus Card) appears prominently in the analysis and discussion. The framing increasingly suggests insurance as a key exposure, despite outpatient services not being covered. This creates conceptual drift between stated objectives, analytical emphasis, and interpretation of findings.

Suggested action: Either explicitly include insurance/social protection as a determinant in the stated objectives, or reframe insurance as an exploratory or secondary exposure.

MINOR COMMENTS

Discussion

• Interpret the insurance finding more cautiously, emphasizing that causality cannot be inferred.

Language & Style

• Minor grammatical edits needed (e.g., tense consistency, phrasing such as “abidance” vs. “adherence”).

• Some sentences are overly long and would benefit from simplification.

**********

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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: SYED FARHAN ALI TIRMIZI

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Attachments

Attachment

Submitted filename: PATIENT SATISFACTION_ reviewer comments.docx

Examining individual, health service, and experience of care determinants of patients’ satisfaction - a cross-sectional facility-based study in KP, Pakistan

PONE-D-25-05636R2

Dear Dr. Petitfour,

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,

Syed Khurram Azmat, PhD, MPH, MD

Academic Editor

PLOS One

Additional Editor Comments (optional):

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