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Knowledge and Practice of Hemodialysis Catheter Care and Associated Factors Among Patients on Maintenance Hemodialysis: An Analytical Cross-sectional Study

PLOS One

Dear Dr. Ambikile,

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Additional Editor Comments:

Dear Authors,

Thank you for submitting your manuscript to PLOS ONE.

Both reviewers recognized the clinical relevance of the topic and the potential importance of continuous patient education in hemodialysis catheter care. However, important methodological concerns were raised that need to be addressed before the manuscript can be considered further.

In particular, the conceptual overlap between “knowledge” and “practice,” the limitations of the cross-sectional design, insufficient validation details of the questionnaire, and the reliance on self-reported practice measures require more cautious interpretation and clearer methodological justification.

Please revise the manuscript accordingly and provide a detailed point-by-point response to all reviewer comments.

I look forward to receiving your revised manuscript.

Sincerely,

Yoshtiaka Ishibashi

Academic Editor

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: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

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Reviewer #1: For effective care of hemodialysis catheters, the authors investigated the gap between

patient knowledge and practice, using a structured questionnaire. Regarding practice, knowledge was the only independent predictor. The strengths of this paper are twofold. First, it evaluated the importance of continuous education based on the facts that shorter duration on hemodialysis was independently associated with better knowledge. Second, it clearly identified areas of weakness in both knowledge and practice. There are no problems with the methodology or discussion. This paper deserves to be accepted.

Reviewer #2: This manuscript addresses an important clinical issue regarding knowledge and practice of hemodialysis catheter care among patients receiving maintenance hemodialysis. Catheter-related complications remain a major challenge, particularly in resource-limited settings, and patient education is undoubtedly an important component of prevention strategies.

However, the study has several important methodological and conceptual limitations that substantially weaken the validity and interpretability of the findings. In particular, the insufficient distinction between “knowledge” and “practice,” the limitations inherent to the cross-sectional design, concerns regarding questionnaire validity, and the reliance on self-reported practice measures significantly limit confidence in the central conclusions. In addition, the relatively small single-center sample further restricts the robustness and generalizability of the results.

While the topic is clinically relevant, the current manuscript does not provide sufficiently rigorous evidence to support its main conclusions in its present form.

1. Conceptual overlap between “knowledge” and “practice”

The most important limitation of this study is the insufficient separation between the constructs of “knowledge” and “practice.” Several practice items appear to directly reflect knowledge-based behaviors, such as recognizing infection signs, reporting symptoms, and following healthcare instructions. This conceptual overlap likely inflated the observed association between knowledge and practice (AOR 47.39). Without formal assessment of construct independence (e.g., factor analysis or validation analysis), the conclusion that knowledge independently predicts practice is not adequately supported.

2. Cross-sectional design cannot support directional interpretation

The manuscript repeatedly implies that improving knowledge would improve catheter care practice. However, because this is a cross-sectional study, causal or directional relationships cannot be inferred. Reverse causation is also plausible, whereby patients with better practices may acquire greater knowledge through increased engagement with healthcare providers. The interpretation throughout the Discussion and Conclusion should therefore be substantially tempered.

3. Questionnaire validity is insufficiently demonstrated

Although Cronbach’s alpha is reported, internal consistency alone is insufficient to establish questionnaire validity. The manuscript lacks adequate information regarding construct validity, item development, translation validation, and potential redundancy between items. Furthermore, the questionnaire itself is not provided as supplementary material, limiting reproducibility and external evaluation of the measurement tool.

4. Self-reported practice may substantially overestimate adherence

Practice was assessed entirely through self-reported responses collected during dialysis sessions in the presence of healthcare personnel. This creates a substantial risk of social desirability bias and may lead to overestimation of appropriate catheter care behaviors. The absence of objective observational measures further limits confidence in the reported practice outcomes.

5. Small single-center sample limits reliability and generalizability

This study included only 97 participants from a single center. Such a sample size may be insufficient for stable multivariable logistic regression analysis with multiple predictors. The limited sample and single-center design also substantially reduce the external validity and generalizability of the findings to broader hemodialysis populations.

Although the study addresses a clinically meaningful topic, the current manuscript has substantial methodological and conceptual weaknesses that limit confidence in the findings and their interpretation. In particular, the overlap between the “knowledge” and “practice” constructs and the limitations of the measurement methodology require major reconsideration.

A substantially revised manuscript with clearer construct validation, more cautious interpretation, and stronger methodological justification would be necessary before the study could be considered for publication.

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Reviewer #1: No

Reviewer #2: No

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Knowledge and Practice of Hemodialysis Catheter Care and Associated Factors Among Patients on Maintenance Hemodialysis: An Analytical Cross-sectional Study

PONE-D-26-19552R1

Dear Dr. Ambikile,

Both reviewers now find the manuscript substantially improved, and the major methodological concerns raised during the previous review round have been adequately addressed. Reviewer 2 raises only a minor remaining concern regarding the use of causal language when describing the relationship between knowledge and practice. I agree with this comment. Given the cross-sectional design of the study, the conclusions should consistently describe this relationship as an association rather than implying causality. This is a minor wording issue that can be readily addressed without further external review. Subject to these minor textual revisions, I consider the manuscript suitable for publication.

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Kind regards,

Yoshitaka Ishibashi

Academic Editor

PLOS One