Unraveling the complexity of nurses’ quality of life: A Fuzzy-Set Qualitative Comparative Analysis (fsQCA) approach to the interplay of psychological, occupational, and social factors

Xu Jun; Li Shasha; Mao Dandan

doi:10.1371/journal.pone.0348584

Peer Review History

Original SubmissionDecember 12, 2025
25 Feb 2026 Decision Letter - Omnia El Seifi, Editor PONE-D-25-65140Unraveling the Complexity of Nurses' Quality of Life: A QCA Approach to the Interplay of Psychological, Occupational, and Social FactorsPLOS One Dear Dr. Jun, 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. ============================== ACADEMIC EDITOR: ============================== Please submit your revised manuscript by Apr 11 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: A 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 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, Omnia S. El Seifi, M.D., Ph.D. 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 https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. 2. "We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: https://pubmed.ncbi.nlm.nih.gov/38825685/ https://www.mdpi.com/1424-8220/24/24/7921 In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed. 3. In the online submission form you indicate that your data is not available for proprietary reasons and have provided a contact point for accessing this data. Please note that your current contact point is a co-author on this manuscript. According to our Data Policy, the contact point must not be an author on the manuscript and must be an institutional contact, ideally not an individual. Please revise your data statement to a non-author institutional point of contact, such as a data access or ethics committee, and send this to us via return email. Please also include contact information for the third party organization, and please include the full citation of where the data can be found. 4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. 5. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. 6. Thank you for providing your underlying data as Supporting Information. We note that the data set contains text or data that is not in English. Please note that PLOS is an English-language publisher, so we require data sets to be provided in English as well. Please upload an English-language version of your data set. This will also allow us to determine if your data follows PLOS standards per our Data Availability policy here: https://journals.plos.org/plosone/s/data-availability. 7. 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? 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: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 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. Reviewer #1: Yes Reviewer #2: Yes ****** 4. 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 Reviewer #2: No ****** 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: language was clear, correct and unambiguous. except that they should consider writing in full the abbreviated word ‘QCA’ in the paper title. All other comments are written in the attached reviewer document Reviewer #2: Regarding the introduction, it is extensive and up-to-date literature review clear identification of research gaps and innovative methodological approach (QCA) was used. However, several ideas are reiterated multiple times (e.g., occupational stress, burnout, psychological distress, work-family conflict). You may condense overlapping concepts and avoid repeating definitions. Also, the introduction mentions Work-Family Conflict Theory but does not integrate a broader theoretical framework (e.g., Conservation of Resources Theory, Job Demands-Resources Model). A guiding theory to explain how stressors and resources influence QOL may be added. There are minor inconsistencies and typographical issues: as spacing errors (e.g., “life satisfaction(Sili et al., 2022)”), inconsistent author formatting (Antolí -Jover) and some references appear outdated (e.g., 2012, 2015) without justification for historical relevance. Kindly, ensure APA/Harvard consistency and remove typographical errors. As for the methods, using large sample size (n = 503) enhances statistical power and configurational diversity for fsQCA. Also, the clearly defined inclusion and exclusion criteria improve internal validity. However, the study lacks information on the country/region, hospital characteristics, and healthcare system context, which affects generalizability. Acknowledge selection bias in limitations. Also, there is no mention of response rate, refusal rate, or comparison between respondents and non-respondents. To improve interpretability, explain scoring and justify using SF-8 instead of profession-specific QOL tools. Kindly, justify using MBI-2 instead of full MBI or acknowledge reduced dimensionality because the 2-item version measures only emotional exhaustion and depersonalization, omitting personal accomplishment, which is a core burnout dimension. Most importantly, report ethics approval number and clarify data collection period. Moreover, the methods do not describe calibration procedures (anchor points for fuzzy sets), which is critical for fsQCA transparency, so describe calibration thresholds (full membership, crossover, non-membership). Minor grammatical and typographical errors (e.g., “Data analyze”) and inconsistent referencing style should be attended. As for the results, key statistics (means, SDs, p-values, correlations, β coefficients, R², consistency, and coverage) are clearly reported, enhancing transparency and reproducibility. The identification of multiple sufficient configurations for high and low QOL reflects methodological novelty. However, the table contains formatting and labeling errors (e.g., unclear “Job position Yes/No”, missing N for working years less than 5 years. Also, the use of χ² (X²) for continuous QOL comparisons is unclear; ANOVA F-values would be more appropriate. The statement “social support was negatively correlated with QOL (r = 0.615)” is contradictory. A positive r indicates a positive correlation. This is a major reporting error that undermines credibility. Kindlyn review this interpretation. The statement “social support was negatively correlated with QOL (r = 0.615)” is contradictory. Regression assumptions better be reported (normality, multicollinearity diagnostics, VIF, tolerance). The results use causal language (“sufficient conditions,” “determine QOL”) despite cross-sectional data. This should be framed as configurational associations, not causal inference. Kindly, rephrase these sentences. The discussion exhibits a strong interpretation of configurational findings, literature integration, and practical relevance. However, Overstated causal language should be reviewed. The discussion assumes interventions based on cross-sectional findings without acknowledging contextual constraints can be generalized (e.g., hospital type, cultural factors, healthcare system differences). This limits external validity. The discussion does not acknowledge major limitations (convenience sampling, self-report bias, CMV, cross-sectional design, cultural context). This is a critical omission for high-impact publications. Regarding the limitations, Transparent acknowledgment of sampling and self-report limitations; clear summary of configurational findings and strong practical relevance. The limitations are brief and not comprehensive. Critical issues are omitted, including, cross-sectional design limiting causal inference cultural/contextual specificity affecting external validity and fsQCA calibration and threshold subjectivity. The conclusion summarizes empirical findings but does not link them to theoretical frameworks. Future research suggestions are generic. More advanced directions (e.g., longitudinal QCA, mixed-method designs, intervention studies, cross-cultural comparisons) would strengthen scholarly contribution. ****** 6. PLOS authors have the option to publish the peer review history of their article (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: No Reviewer #2: Yes: Dr. Lareen Magdi El-Sayed Abo-Seif ******** [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. Attachments Attachment Submitted filename: plos one REVIEW_DORIS HAGAN.docx https://doi.org/10.1371/journal.pone.0348584.r001
Revision 1
12 Mar 2026 Author Response Dear Editor and Reviewers, We sincerely thank the editor and both reviewers for their constructive and insightful comments. We have carefully addressed each point and made corresponding revisions to the manuscript. All changes are highlighted in the tracked-changes version. Below we provide a point-by-point response. Response to Journal Requirements (Editor) Comment 1: Manuscript format should comply with PLOS ONE style templates. Response: We thank the editor for this reminder. The manuscript has been reformatted in accordance with PLOS ONE's style guidelines Comment 2: Minor text overlap with two previously published works was identified. Response: We thank the editor for identifying these overlaps. We have carefully reviewed the flagged passages, added appropriate citations to both works, and rewritten the overlapping sentences in our own words throughout the manuscript. The revised sections are highlighted in the tracked-changes version. Comment 3: The data contact point must not be an author on the manuscript. Response: We apologize for this oversight. The data availability statement has been revised. Data cannot be shared publicly because of participant privacy protections and institutional data governance regulations. Data are available from the Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University Institutional Data Access / Ethics Committee (contact via nbhospital@126.com) for researchers who meet the criteria for access to confidential data. Comment 4: ORCID iD for the corresponding author must be validated. Response: The corresponding author has logged into Editorial Manager and validated their ORCID iD. The ORCID is now linked and verified in the submission system. Comment 5: Ethics statement should only appear in the Methods section. Response: The ethics statement has been moved exclusively to the Methods section. Comment 6: The uploaded dataset contains non-English content. Response: We have prepared and uploaded an English-language version of the dataset. Variable names, labels, and value codes have all been translated and are consistent with the manuscript's terminology. Response to Reviewer #1 Comment 1: The authors should consider writing the abbreviated word 'QCA' in full in the paper title. Response: We thank for this suggestion. The title has been revised to include the full term. Comment 2:Generalizability is limited due to convenience sampling and focus on two tertiary hospitals. Response: We fully acknowledge this limitation. The Limitations section has been expanded to explicitly address this concern. Comment 3:Self-reported data may introduce response bias (social desirability, recall bias). Response: We agree that self-report methodology is a meaningful limitation. We have explicitly acknowledged response bias. Comment 4:The study does not account for contextual factors such as organizational culture, healthcare policies, or regional differences. Response: Thank you so much for this valuable suggestion. We have added acknowledgment of this limitation in the Limitations section and have incorporated a brief discussion in the Discussion section. Comment 5:Data availability relies on request to corresponding author, limiting transparency. Response: We thank the reviewer for raising this point. In accordance with both this recommendation and the journal's data policy requirement, we have updated the data availability statement. At last,We greatly appreciate your careful review and valuable guidance, which has significantly improved the clarity and rigor of our manuscript. Response to Reviewer #2 Comment 1: Several ideas are reiterated multiple times (e.g., occupational stress, burnout, psychological distress, work-family conflict). Overlapping concepts should be condensed. Response: Thank you so much for this valuable suggestion. The introduction has been substantially revised to eliminate repetition. Each construct (occupational stress, psychological distress, burnout, work-family conflict, social support) is now introduced once with a concise definition and its relationship to QOL, followed by a synthesizing paragraph. Please see the revised Introduction. Comment 2: The introduction mentions Work-Family Conflict Theory but does not integrate a broader theoretical framework (e.g., Conservation of Resources Theory, Job Demands-Resources Model). Response: We thank the reviewer for this valuable suggestion. We have added a theoretical framework paragraph to the introduction, integrating the Conservation of Resources (COR) Theory (Hobfoll, 1989) and the Job Demands-Resources (JD-R) Model (Bakker & Demerouti, 2007). These frameworks help explain how stressors deplete personal and professional resources, while social support serves as a key resource that buffers against adverse QOL outcomes. The added paragraph is marked in the revised manuscript. Comment 3: Minor inconsistencies and typographical issues: spacing errors, inconsistent author formatting, and some references appear outdated without justification. Response: We have carefully proofread the entire manuscript. All spacing errors (e.g., "life satisfaction(Sili et al., 2022)" → "life satisfaction (Sili et al., 2022)") have been corrected. Author name formatting has been standardized (e.g., "Antolí-Jover" corrected throughout). References from 2012 and 2015 that were cited for foundational or historical definitions have been retained with brief contextual justification added in-text. All citations have been verified for APA consistency. Comment 4: The study lacks information on the country/region, hospital characteristics, and healthcare system context. Response: We appreciate this comment. We have added the following information to the Participants section: this study was conducted in Zhejiang, China. Both hospitals are tertiary-level general hospitals located in urban areas, serving a large and diverse patient population. This context is important for understanding the occupational demands faced by the nurses in our sample. Comment 5: There is no mention of response rate, refusal rate, or comparison between respondents and non-respondents. Response: We have added the following information to the Data Collection section: A total of 537 questionnaires were distributed, of which 520 were returned. After excluding 17 responses due to completion time under 3 minutes or patterned response styles, 503 valid responses were retained, yielding a valid response rate of 96.73%. Comment 6: SF-8 selection should be justified instead of profession-specific QOL tools. Response: We have added a justification sentence in the Measurements section: "The SF-8 was selected over profession-specific QOL instruments because it enables comparison with general population norms and across healthcare professions. Its brevity reduces respondent burden in busy clinical settings, and its validated Chinese version (Lang et al., 2018) ensures measurement reliability in our sample." Comment 7: Justify using MBI-2 instead of full MBI or acknowledge reduced dimensionality. Response: We acknowledge this limitation. We have added a justification in the Measurements section: "The MBI-2 was selected for its efficiency in rapid screening in large-scale surveys among healthcare workers (Li-Sauerwine et al., 2020). We acknowledge that, as a 2-item measure, it captures only emotional exhaustion and depersonalization and omits personal accomplishment, which is a core burnout dimension in the full MBI. This limitation is acknowledged in the Limitations section, and future studies are encouraged to employ the full MBI for a more comprehensive burnout assessment." Comment 8: The methods do not describe calibration procedures (anchor points for fuzzy sets), which is critical for fsQCA transparency. Response: Thank you so much for this valuable suggestion. We have added a detailed calibration paragraph to the Data Analysis section. Calibration was performed using the direct method in fsQCA 3.0. For each condition, three anchor points were defined: full membership (0.95), the crossover point (0.50), and full non-membership (0.05). The specific thresholds were determined based on theoretical meaning and the empirical distribution of each variable. Comment 9: Grammatical errors (e.g., "Data analyze") and inconsistent referencing style. Response: We are so sorry for that. "Data analyze" has been corrected to "Data Analysis". A full proofreading has been conducted and all grammatical and referencing inconsistencies have been corrected. Comment 10: Ethics approval number should be reported; data collection period should be clarified. Response: The ethics approval number ([Ethics Approval No.KYSL-2024-001-059]) has been added to the Ethics Statement in the Methods section. The data collection period has also been specified in the Data Collection subsection. Comment 11: Table contains formatting and labeling errors (unclear "Job position Yes/No", missing N for working years ≤5 years). Response: We are so sorry for that.. "Job position Yes/No" has been relabeled as "Management Position (Yes/No)" to improve clarity. The missing sample size for the "≤5 years" working experience group (N=113) has been restored. All table formatting has been reviewed and corrected. Comment 12: The use of χ² for continuous QOL comparisons is unclear; ANOVA F-values would be more appropriate. Response: We thank the reviewer for this observation. We confirm that one-way ANOVA was used for all group comparisons of QOL scores across demographic subgroups (as stated in the Data Analysis section). The column header in Table 1 has been corrected from "X²" to "F" to accurately reflect the statistical test used. We apologize for this labeling inconsistency. Comment 13: "Social support was negatively correlated with QOL (r = 0.615)" is contradictory — a positive r value indicates a positive correlation. Response: We sincerely apologize for this critical reporting error. This was a typographical error in the text. The Pearson correlation between social support and QOL is r = 0.615 (p < 0.01), which correctly indicates a positive correlation — higher social support is associated with higher QOL. The sentence has been corrected to read: "social support was positively correlated with QOL (r = 0.615, p < 0.01)." We have carefully re-examined all other correlation statements to ensure consistency with the reported r values. Comment 14: Regression assumptions should be reported (normality, multicollinearity diagnostics, VIF, tolerance). Response: We have added a paragraph reporting regression assumption checks: "Prior to hierarchical regression, assumptions were verified. Normality of residuals was confirmed via inspection of P-P plots and the Shapiro-Wilk test (p > 0.05). Multicollinearity was assessed using Variance Inflation Factor (VIF) and tolerance values. All VIF values were below 5 and tolerance values exceeded 0.2, indicating no significant multicollinearity among predictors." Comment 15: The results use causal language despite cross-sectional data. Response: We have carefully revised all instances of causal language throughout the Results section. Phrases such as "sufficient conditions for determining QOL" and "determine QOL" have been replaced with configurational/associational language, e.g., "configurations associated with high/low QOL" and "configurations sufficient for the outcome of high QOL." Comment 16: Overstated causal language in the Discussion. Response: All causal language in the Discussion has been revised. For example, "addressing these factors will reduce burnout" has been changed to "addressing these factors may be associated with reduced burnout." We have consistently framed our findings as configurational associations derived from cross-sectional data throughout the Discussion. Comment 17: Discussion does not acknowledge major limitations. Response: Thank you so much for the reminder. The Limitations section has been substantially expanded. Please see revised manuscript. At last,We greatly appreciate your careful review and valuable guidance, which has significantly improved the clarity and rigor of our manuscript. Attachments Attachment Submitted filename: response letter.doc https://doi.org/10.1371/journal.pone.0348584.r002
20 Apr 2026 Decision Letter - Ahmed El-Sayed, Editor Unraveling the Complexity of Nurses' Quality of Life: A Fuzzy-Set Qualitative Comparative Analysis (fsQCA) Approach to the Interplay of Psychological, Occupational, and Social Factors PONE-D-25-65140R1 Dear Authors 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, Ahmed Abdelwahab Ibrahim El-Sayed, Academic Editor PLOS One Additional Editor Comments (optional): Dear Authors, Thank you for submitting your study. I am pleased to inform you that your manuscript is accepted for publication in PLOS ONE in its current form. Congratulations on this achievement. Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. 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? 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: 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. Reviewer #1: Yes Reviewer #2: Yes ****** 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 Reviewer #2: 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: I have reviewed the paper and seen that all comments raised by reviewers have been duly addressed. authors have also explained why they can not make some part of the data available to reviewers. According to their submissions, The data availability statement has been revised. Data cannot be shared publicly because of participant privacy protections and institutional data governance regulations. Data are available from the Ningbo Municipal Hospital of Traditional Chinese Medicine (TCM), Affiliated Hospital of Zhejiang Chinese Medical University Institutional Data Access / Ethics Committee (contact via nbhospital@126.com) for researchers who meet the criteria for access to confidential data. I therefore recommend it for publication since it meets the guidelines of the journal. Reviewer #2: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (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: DORIS HAGAN Reviewer #2: Yes: Dr. Lareen Magdi El-Sayed Abo-Seif ******** https://doi.org/10.1371/journal.pone.0348584.r003
Formally Accepted
Acceptance Letter - Ahmed El-Sayed, Editor PONE-D-25-65140R1 PLOS One Dear Dr. Dandan, 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. Ahmed Abdelwahab Ibrahim El-Sayed Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0348584.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .