-->PONE-D-25-30680-->-->Breaking barriers:validation of a Spanish oral health knowledge tool to enhance patient-provider communication-->-->PLOS One

Dear Dr. Spivakovsky,

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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We look forward to receiving your revised manuscript.

Kind regards,

Hadi Ghasemi

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?

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

Reviewer #3: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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-->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: Yes

Reviewer #3: 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

Some comments and suggestions for further clarification are listed below.

1- Introduction:

a. Add related studies

b. Mention the knowledge gaps of the previous related studies and highlight the importance of your research

c. Write the hypothesis or null hypothesis

d. Clarify why open-ended oral questions are suitable for low-literacy populations

2- Results:

a. Tables are missing from the manuscript

3- Discussion:

a. Highlight the advantages of KROHL-S over other tools (oral administration, literacy independence).

b. Mention limitations (manual scoring, selection bias, generalizability)

4- Conclusion

a. Emphasize practical applications in clinical practice and patient education.

b. Highlight its contribution to addressing oral health disparities

5- Comprehensive English editing is needed

Good Luck with your submission

Reviewer #2: The article complies with PLOS One standards.

The study was well conducted, concise and objective. Also, it is relevant due to the high number of Spanish-speaking people living in the United States. Suggestions were made below in order to contribute to the publication.

Summary

The abstract is well structured and with all the information necessary to understand the study.

Introduction

On lines 84, 85 and 86: “Research consistently demonstrates a strong correlation between limited health literacy and poor oral health outcomes.” Cite the reference for this statement.

On lines 91 to 94: “Health literacy not only affects individual knowledge, attitudes and behaviors but also shapes skills related to disease prevention and self-management. In the clinical setting, health knowledge, a key component of health literacy, serves as an effective measure and it is widely used to assess public health interventions.” Cite the reference used for this statement.

At the end of the introduction, there is not a paragraph on the importance of validating this questionnaire for the Hispanic population. What contributions can this survey on oral health knowledge among Spanish-speaking adults bring to these people living in the United States?

Methodology

It is written objectively and with all the information necessary for the reproduction of the study.

Discussion

On lines 245 and 246: “In contrast to other oral health literacy measures, KROHL-S evaluates condition-specific and domain of knowledge specific aspects of the most common oral conditions.” Cite the reference that supported this statement.

On lines 272 to 274: “To address this issue, we are currently in the process of incorporation different technologies to capture the responses using voice-to-text applications, as well as training different AIs to automate the scoring.” Explain what these technologies are to capture the responses using voice-to-text applications, as well as training different AIs to automate the scoring, in addition to the types of studies that are being developed.

Reviewer #3: Dear Authors,

I have read your manuscript with interest and would like to offer the following comments.

General comment

I note that you have cited only 13 references. Although this journal does not set a minimum number of citations, I consider that the bibliography should be expanded, particularly in the Introduction and Discussion. Additional references to previous instruments, reporting guidelines, and relevant methodological sources would strengthen the rationale and lend greater weight to the claims made in the manuscript.

Introduction

The manuscript conflates two related but non-equivalent concepts, which may create confusion about what exactly the KROHL-S measures and what conclusions can reasonably be drawn. It would therefore be helpful to delineate the construct more clearly: oral health knowledge versus oral health literacy. While KROHL-S is presented as a knowledge tool, much of the framing draws on the oral health literacy literature. A clearer conceptual framework is recommended, including explicit justification for focusing on knowledge (rather than other literacy dimensions), as the current framing—grounded in health literacy and inequities—may lead readers to infer that the instrument measures oral health literacy more broadly.

I also perceive a gap regarding Spanish-language instruments. It would be useful to clarify which prior instruments exist in Spanish (if any), why they do not capture the intended construct or open-ended format, and what KROHL-S adds compared with available alternatives.

Methods

As data collection appears to have been conducted at a single centre, there is potential sampling bias. This should be explicitly acknowledged as a limitation in the Methods section as well.

No formal reliability reporting is provided to document how consensus between raters was established (e.g., ICC/kappa, double-scoring of a subsample). Given the open-ended nature of the responses and the scoring procedure, this information is important.

In addition, no a priori sample size calculation or formal sample size rationale is presented. As the study includes psychometric analyses (including CFA), it would be important to add an explicit “Sample size determination/rationale” section stating whether the final sample (n=177) resulted from convenience sampling and, if so, justifying its adequacy in relation to model complexity (number of factors/items and estimated parameters), the estimator used, and the handling of missing data.

Results

Regarding interpretation of the total score: if the maximum score is 38, a mean of 8.34 suggests a possible floor effect. I would recommend providing the score distribution (e.g., histogram), the proportion of zero/low scores by domain, and item-level analyses (difficulty; floor/ceiling effects).

With respect to the CFA, the manuscript should avoid characterising model fit as “adequate” without qualification. Values of CFI=0.86 and TLI=0.83 are typically below commonly used thresholds, and RMSEA is statistically significant (p=0.044). These results should be reported in greater detail and interpreted consistently with the Discussion, avoiding overstatement where possible.

Please also report effect sizes and ideally 95% confidence intervals, and consider adjustment for relevant covariates (e.g., age, years in the USA, education/literacy, insurance status).

Discussion

The tone of the psychometric conclusions should be moderated, as the manuscript itself notes that “the fit of the overall scale structure was average”. The final summary and the Abstract should therefore avoid presenting the CFA results as “adequate” without nuance.

The manuscript mentions the possibility of voice-to-text and “training different AIs to automate scoring” as future work. It would be helpful to state explicitly:

that this was not evaluated in the present study;

what validation would be required (e.g., transcription error, dialect-related bias, comparison against human raters, privacy considerations); and

that any automation would necessitate a new study of validity and reliability.

Conclusions

Please avoid generalisations beyond the sample (single-centre, convenience sampling). In addition, the conclusions should be aligned with the CFA results (i.e., average/moderate fit).

Data repository

PLOS ONE requires a Data Availability Statement and that the underlying data be available without restriction. The manuscript indicates “available on request”, which is not acceptable under the journal’s policy.

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-->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.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

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-->PONE-D-25-30680R1-->-->Breaking barriers:validation of a Spanish oral health knowledge tool to enhance patient-provider communication-->-->PLOS One

Dear Dr. Spivakovsky,

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 May 30 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Yolanda Malele-Kolisa, BDS, MPH, MDent, PhD

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.

Additional Editor Comments (if provided):

justify and be explicit and specific with the confirmatory factor analysis . A more explicit explanation linking the final sample size to the complexity of the tested model would be necessary to support the robustness of the CFA results.

Second, there is still an inconsistency in the interpretation of model fit. While the Discussion adopts a more cautious tone, the Abstract continues to describe the CFA results as indicating “adequate fit.” Given the reported indices, this wording appears stronger than what the data support. The interpretation of model fit should be aligned throughout the manuscript to ensure internal consistency and appropriate methodological caution.

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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: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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-->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: (No Response)

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: No

**********

-->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 Response)

Reviewer #2: (No Response)

Reviewer #3: 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: (No Response)

Reviewer #2: Yes

Reviewer #3: 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: (No Response)

Reviewer #2: General comment

No formal reliability reporting is provided to document how consensus between raters

was established (e.g., ICC/kappa,double-scoring of a subsample). In this comment: "Internal consistency was good for the general scale and for the oral cancer and malocclusion subscales, and acceptable for dental caries and periodontal disease." It is necessary to include the values Internal consistency".

In addition, it is necessary that the research has not been published in any journal before and complies with the ethical principles of research with human beings.

Reviewer #3: Thank you for your careful revisions. The manuscript has improved substantially; however, two methodological issues remain insufficiently clarified.

First, although a “Sample Size Rationale” section has been added, the justification provided for the adequacy of the sample in relation to the confirmatory factor analysis remains too general. A more explicit explanation linking the final sample size to the complexity of the tested model would be necessary to support the robustness of the CFA results.

Second, there is still an inconsistency in the interpretation of model fit. While the Discussion adopts a more cautious tone, the Abstract continues to describe the CFA results as indicating “adequate fit.” Given the reported indices, this wording appears stronger than what the data support. The interpretation of model fit should be aligned throughout the manuscript to ensure internal consistency and appropriate methodological caution.

Addressing these points would further strengthen the transparency and coherence of the study.

**********

-->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: No

Reviewer #2: No

Reviewer #3: No

**********

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-->

Breaking barriers:validation of a Spanish oral health knowledge tool to enhance patient-provider communication

PONE-D-25-30680R2

Dear Dr. Spivakovsky,

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,

Prof Yolanda Malele-Kolisa, BDS, MPH, MDent, PhD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Line 348

Replace 'Citations' with References

Reviewers' comments: