PONE-D-25-65007-->-->Comfort or Conservation? Investigating Patient Choices Between Plastic and Metal Speculums-->-->PLOS One?>

Dear Dr. Kalaskey,

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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Alessandro Favilli, PhD, MD

Academic Editor

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: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

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 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.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

Reviewer #2: Yes

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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: The study demonstrates several strengths, including clear research objectives, an appropriate cross sectional design, and an adequate sample size of 203 participants for descriptive analysis. The authors are commended for their transparent disclosure of AI tool usage in data analysis and for including an informative environmental impact comparison table. The acknowledgment of study limitations further strengthens the manuscript’s credibility. However, a few areas warrant clarification or improvement. The data collection period stated in the abstract (November 2024–June 2025) differs from that reported in the Methods section (September 15, 2024–June 16, 2025), and this discrepancy should be addressed. Additionally, providing more demographic details such as race/ethnicity and parity, if collected, would help better characterize the sample. The borderline significant chi-square result for the age preference association would benefit from reporting the actual p-value. Finally, the Data Availability Statement should specify the nature of the restrictions and provide contact information for data requests. No concerns regarding dual publication, research ethics, or competing interests were identified, and the study received appropriate IRB approval with implied consent procedures.

Reviewer #2: The study addresses a clinically relevant and timely question with implications for both patient experience and healthcare sustainability. The research is well-motivated, the methods are appropriate for the research questions, and the discussion thoughtfully contextualizes the findings within broader clinical and environmental considerations.The manuscript addresses an understudied topic that has practical implications for gynecologic practice. The integration of patient comfort preferences with environmental sustainability considerations is novel and timely given increasing attention to healthcare's environmental footprint. The authors provide appropriate ethical oversight documentation and transparent reporting of AI use in data analysis. The discussion section is particularly well-developed, offering practical clinical recommendations including alternative positioning techniques, innovative speculum designs, and self-sampling alternatives for HPV screening. The comparison with the Dutch study adds valuable cross-cultural perspective to the findings.

Minor Issues Requiring Revision

1. Methodological Clarifications

Sample size and power (Lines 161-163), the authors acknowledge the study was underpowered to detect significant associations between age group and speculum preference. A prospective power calculation should be reported, or the authors should clarify whether this was a convenience sample. Additionally, reporting the target sample size and how it was determined would strengthen the methods section.

Recruitment period discrepancy, the abstract states data collection occurred "between November 2024 and June 2025," while the methods section (Lines 102-104) indicates "September 15th, 2024 through June 16th, 2025." The authors should reconcile this inconsistency.

Survey instrument validation, the authors do not describe whether the survey instrument was piloted or validated. Information about how questions were developed, whether they were adapted from existing instruments, and any pilot testing would strengthen confidence in the measurements.

Response rate, the manuscript does not report how many patients were approached versus how many completed the survey. The response rate is important for assessing potential selection bias and should be included.

2. Statistical Analysis

Chi-square results (Line 128-129), the text states "A chi-square test revealed a borderline significant association between age group and speculum preference" but does not report the chi-square statistic, degrees of freedom, or p-value. These statistics should be provided in the text or a supplementary table.

Multiple comparisons, the study appears to conduct multiple statistical tests without correction for multiple comparisons. The authors should address whether any adjustment was made or justify the exploratory nature of the analyses.

Missing data handling, the manuscript does not describe how missing data were handled. Given that the total sample is 203 but some response categories do not sum to this total (e.g., sanitation perceptions in Lines 134-136 sum to 199), clarification is needed.

3. Presentation Issues

Table 1: The percentages in Table 1 sum to 99.9%, which appears to be a rounding artifact but should be verified. Additionally, consider presenting confidence intervals for the percentages to convey uncertainty.

Table 2: This environmental comparison table is informative but the sources should be more specifically cited. The current citation format (references 10, 11, 13, 15) does not clearly indicate which data points come from which sources. Some values appear to be estimates or ranges, and this uncertainty should be acknowledged.

Figure 2 legend: The legend uses "Metallic" while the text consistently uses "metal." Terminology should be consistent throughout.

4. Writing and Terminology

Line 33-34: The phrase "Patient discomfort remains a primary barrier from maintaining consistent patient care" is grammatically awkward. Consider revising to "Patient discomfort remains a primary barrier to maintaining consistent patient care."

Speculum/specula: The manuscript uses "speculums" throughout. While both "speculums" and "specula" are acceptable plural forms, the authors should verify PLOS ONE style preferences for consistency.

5. Discussion and Interpretation

Generalizability (Lines 164-167), the authors appropriately note limited demographic diversity, but additional demographic information would help readers assess generalizability. The manuscript mentions participants identified as "cisgender women" but does not report the full demographic breakdown (race/ethnicity, socioeconomic status, rural/urban residence). Given that West Virginia has unique demographic characteristics, this context would be valuable.

Environmental concern interpretation (Lines 203-208), the interpretation that younger respondents' comfort outweighs environmental concerns is reasonable but somewhat speculative. The survey design does not appear to have directly assessed this trade-off. The authors should temper this conclusion or clarify if direct trade-off questions were asked.

6. Data Availability

The data availability statement indicates "The data is and will continue to be stored in Qualtrics. It can be made available upon request." PLOS ONE generally requires data to be publicly available. The authors should either deposit de-identified data in a public repository or provide detailed justification for restricted access, including specific contact information for data requests.

Minor Issues

Line 47 contains an awkward superscript placement: "experience.1,2,3" should likely have a space before the citation or use consistent formatting.

Reference 8 cites "Verified Market Reports" which is a commercial market research source. The authors should consider whether a peer-reviewed source is available for this market data, or acknowledge the limitations of commercial market reports.

The SRQR checklist is mentioned (Lines 116-117) as being included in Supplement A, but I could not verify its inclusion in the submitted materials. The authors should ensure this supplement is included with the final submission.

In Summary, this manuscript addresses a practical clinical question with relevance to both patient experience and healthcare sustainability. The study is well-conceived and the discussion provides thoughtful clinical context. The identified issues are minor and addressable through revision. With attention to the methodological clarifications, statistical reporting, and presentation issues noted above, this manuscript will make a valuable contribution to the gynecologic literature. I recommend acceptance after minor revisions.

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what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Faisal AlkulaibFaisal AlkulaibFaisal AlkulaibFaisal Alkulaib

Reviewer #2: Yes: Ahmed Abdullah AlshehriAhmed Abdullah AlshehriAhmed Abdullah AlshehriAhmed Abdullah Alshehri

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Comfort or Conservation? Investigating Patient Choices Between Plastic and Metal Speculums

PONE-D-25-65007R1

Dear Dr. Kalaskey,

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,

Alessandro Favilli, PhD, MD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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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 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.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: 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: (No Response)

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Reviewer #1: The following minor points could be considered to further enhance the discussion:

1- The discussion of limitations could be slightly expanded to include the potential for social desirability bias, particularly concerning environmental awareness. Participants may have over-reported their concern for the environment as it is a socially desirable attitude, which might not reflect their true influence on their preferences in a clinical setting.

2- For future research, they might consider suggesting a study design that could more directly explore this, such as a discrete choice experiment. This would be a valuable next step to build upon their current exploratory findings.

Reviewer #2: (No Response)

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what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). 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 For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy..-->

Reviewer #1: Yes: Faisal AlkulaibFaisal AlkulaibFaisal AlkulaibFaisal Alkulaib

Reviewer #2: No

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