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PONE-D-26-07737

Factors influencing perceived importance of hemodialysis adherence among end stage renal disease patients in tertiary care centers in Nepal

PLOS One

Dear Dr. Shrestha,

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PLOS One

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Partly

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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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Reviewer #1: This is a very practical and insightful study. Understanding what drives hemodialysis adherence in Nepal is incredibly important for improving patient care in tertiary centers.

I appreciate the straightforward methodology and the use of a validated tool like the ESRD-AQ. Your findings regarding the positive influence of family support (specifically, being accompanied by parents) are clear and offer valuable guidance for clinical practice.

I have no changes to request. Congratulations on completing a highly relevant and well-executed study.

Reviewer #2: This manuscript examines factors influencing patients’ perceptions regarding the importance of adherence to hemodialysis in two tertiary care centers in Nepal. The topic is relevant given the increasing burden of chronic kidney disease and the challenges of maintaining adherence to dialysis therapy in resource-limited settings.

However, the manuscript requires substantial revision to improve clarity, methodological transparency, and interpretation of results.

Major Comments

1. Conceptual clarity of the primary outcome

The central outcome variable is “perceived importance of adherence to dialysis.”

This raises several conceptual concerns:

• Perception does not necessarily translate into actual adherence behaviour

• The manuscript does not demonstrate why perceived importance alone is a meaningful outcome

• The ESRD-AQ instrument was originally designed to assess actual adherence behaviours, not only perceptions

The authors should:

• Clearly justify the conceptual framework

• Explain why perception is important independent of behaviour

• Discuss whether perception predicts attendance at dialysis sessions, medication adherence, or fluid restriction adherence

Without this clarification, the clinical significance of the study remains unclear.

2. Description and validation of the ESRD-AQ instrument

The manuscript lacks sufficient detail regarding the questionnaire.

The authors should clarify:

• Which domains of the ESRD-AQ were used

• Whether the questionnaire was translated into Nepali

• Whether cultural adaptation or validation was performed

• Whether reliability testing was conducted (e.g., Cronbach’s alpha)

Failure to address these issues raises concerns about the validity of the measurement.

3. Statistical analysis requires greater transparency

The statistical methods section is insufficiently detailed.

Please clarify:

• The specific regression model used to estimate adjusted prevalence ratios

• whether Poisson regression with robust variance or log-binomial regression was applied

• How variables were selected for inclusion in the multivariable model

• Whether multicollinearity was assessed

• Whether model fit was evaluated

These methodological details are necessary to ensure reproducibility and validity of the analysis.

4. Cross-sectional design and causal interpretation

Several statements in the Results and Discussion sections imply causal relationships.

Because this is a cross-sectional study, only associations can be inferred.

The authors should revise the text accordingly.

5. Strengthening the discussion

The discussion currently lacks sufficient engagement with existing literature.

The authors should compare their findings with studies from:

• India

• Pakistan

• Southeast Asia

• sub-Saharan Africa

where dialysis adherence barriers have been studied extensively.

Additionally, the discussion should address structural barriers, such as:

• travel distance to dialysis centres

• financial constraints

• dialysis availability

• healthcare workforce shortages

6. Language and editorial quality

The manuscript requires substantial language editing.

Numerous grammatical and typographical errors are present throughout the manuscript.

Professional English language editing is strongly recommended prior to resubmission.

See a Line-by-Line review below

Title

The title is acceptable but could be simplified.

Suggested alternative:

“Factors associated with perceived importance of haemodialysis adherence among patients with end-stage kidney disease (or chronic kidney failure) in Nepal.”

Abstract

Lines 18–22

The wording is unclear and contains multiple grammatical errors.

Example:

“Perception towards importance of adhering to hemodialysis affects treatment adherence.”

This statement requires citation and clarification.

Introduction

Lines 39–47

The introduction contains repetition and grammatical errors, including duplicated phrases.

Example:

“low-to middle-income patients’ needs renal replacement therapy…”

This sentence should be rewritten for clarity.

Line 48–49

“Renal transplantation relies highly on the intense availability…”

This statement is unclear and requires revision.

General comment

The introduction would benefit from:

• A clearer knowledge gap

• Explanation of why perception matters

Methods

Lines 68–70

“perception on of the importance of adherence”

This phrase appears multiple times and should be corrected to:

“perception of the importance of adherence.”

Study sites

The authors should explain why these two centres were selected and whether they are representative of dialysis services in Nepal.

Questionnaire

More detailed information is needed regarding the following aspects:

- Translation procedures

- Interviewer training

- Questionnaire administration

- Validation steps

Statistical Methods

The description of statistical analysis is insufficient. Please include the following information:

- Type of regression model used

- Criteria for variable inclusion

- Approach to handling missing data

Results

The results section is generally understandable but requires improvement in the following areas:

- Clearer presentation of tables

- Consistent reporting of confidence intervals

- A more organized narrative structure

Discussion

The discussion section should be significantly expanded. Important components that are currently missing include:

- A comparison with international studies on dialysis adherence

- Interpretation in the context of health system limitations in Nepal

- Acknowledgment of the study's limitations

Limitations

The following limitations should be explicitly stated:

1. Cross-sectional design

2. Bias from self-reported questionnaires

3. Limited generalizability beyond tertiary centers

4. Measurement of perception and practice, rather than actual adherence

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Reviewer #1: Yes:  Ganesh Praneeth Roy Avula

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Perceived importance of hemodialysis adherence .doc

Factors influencing perceived importance of haemodialysis adherence among end stage kidney failure patients in tertiary care centres in Nepal

PONE-D-26-07737R1

Dear Dr. Shrestha,

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.

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Kind regards,

Nik Hisamuddin Nik Ab. Rahman

Academic Editor

PLOS One

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