Dear Dr. Treloar,

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Gamji Rabiu Abu-Ba'are, Ph.D, MA

Academic Editor

PLOS One

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Additional Editor Comments :

Dear Author, Thank you for submitting you important work for consideration with PLOS ONE. Overall reviewers had favorable comments and found your paper to have merits, however, there are some minor comments they recommend you address. Please respond to the review comments and return. Congratulations.

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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

Reviewer #3: Partly

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

Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

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??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Dear Authors,

I commend the your efforts to investigate the structural-level mechanisms for stigma reduction utilizing a qualitative methodology. Although the study did not include consumers as participants, the insights gleaned from other key stakeholders significantly contribute to the understanding of structural stigma reduction. The following comments are offered to facilitate the manuscript's improvisation:

General and Language-related comments

The coherence and flow of the paper require strengthening. Specifically, the connection between paragraphs, particularly within the introduction, should be made more explicit to ensure a smoother narrative progression.

Introduction Section

• It is imperative to define stigma in greater detail from a structural and governance perspective within the introduction. Furthermore, the authors must clearly articulate how stigma is operationalized for the current study.

• A typographical error appears to be present in line 81 on page 5 of the manuscript and requires correction.

Methods Section

• While acknowledging this study is part of a larger stigma reduction project, the authors are advised to explicitly specify the qualitative design or approach employed for this specific study within the Methods section.

• The use of adjectives such as 'high-level' insights (mentioned in line 167) should be avoided unless it is substantiated by relevant literature.

• It would be beneficial to state whether the authors utilized a-priori inclusion criteria for the selection of participants.

• I recommend providing a selection of broad questions from the semi-structured interview guide used during the data collection process.

• The pragmatic approach adopted for data analysis is considered well-justified.

Results and Discussion Section

• The Results section lacks a description pertaining to financing and societal pressures. The authors should reflect on these constructs in the discussion. If data related to these constructs did not emerge during the interviews, it is important to reflect on it.

• Considering the migration rate in Australia, integrating stigma reduction strategies at the structural level aimed at improving healthcare quality for Culturally and Linguistically Diverse (CALD) communities within the discussion section would substantially enhance the manuscript's value and relevance.

Reviewer #2: This qualitative study evaluates how stigma reduction can be embedded within existing healthcare quality and governance structures. Based on interviews with 20 key stakeholders in the Australian BBV/STI sector and guided by the CFIR “outer setting”, the manuscript identifies accreditation, quality standards, performance pressures, and workplace legislation as structural levers for sustainable stigma reduction. The paper argues that aligning stigma reduction with quality care mechanisms suggests a more effective alternative to individual-level interventions.

This manuscript provides a timely and persuasive framing of stigma as a quality-of-care issue and makes a strong case for focusing on structural rather than purely individual-level responses. The use of CFIR, particularly the emphasis on “outer setting” mechanisms, is appropriate and clearly supports the analysis. The study draws on rich qualitative data from highly experienced stakeholders, and the findings are clearly relevant to policy and practice, especially in relation to accreditation and governance processes within healthcare systems.

However, the absence of lived-experience perspectives limits the breadth of insight, and generalisation to other areas of healthcare should be made cautiously. In addition, some recommendations remain at a relatively high policy level, with less attention to how they might be translated into everyday practice or how risks of superficial, “tick-box” implementation could be addressed. The manuscript would also benefit from light editing to simplify some of the longer and denser sentences to improve readability.

Reviewer #3: This manuscript, exploring structural level mechanisms to address stigma, is about an important subject from an interesting perspective. This qualitative study has several strengths, but the manuscript also shows some weaknesses that I will try to point out below. I believe that a careful rewrite of some parts of the manuscript will improve its quality.

My comments:

1. The introduction, methods and discussion sessions contain a lot of, but important, text. For me, it was sometimes a little difficult to navigate the text. Consider adding subheadings to make it easier for the reader.

2. Please, review the language throughout the manuscript. During my reading, I found sentences that were incomplete (eg. Page 5, line 84 and page 11, lines 211-212), very long (e.g. page 14, lines 299-305) and xxx (e.g. xxx).

3. The methods section needs more information about how the study was conducted. Consider using COREQ or other guideline for qualitative research to guide the presentation of the method.

a. The text about recruitment (page 8) needs more information, e.g. how many were invited, how many declined participation and for what reason?

b. The description about the data collection also needs to be elaborated. E.g. where and how were the interviews conducted (face-to-face/telephone/digital)? How long were the interviews? Please include the interview schedule, or at least the main questions.

c. The analysis is poorly described, which makes it difficult to understand the result. E.g. the different steps of the analysis are unclear and need to be described, it is also unclear what steps were inductive vs deductive.

d. I think I can understand the thought behind using a framework related to implementation science, but this needs to be clearly motivated in the manuscript.

4. As I wrote above, it was difficult to follow the result text when the analysis process was unclear. All constructs from the “outer setting” in CFIR are not represented in the result text. Does that mean that no data in the interview was related to those constructs? A table with an overview of the analysis process and/or an overview of the final analysis would be helpful for the reader.

5. The part on page 11, lines 229-235 – it is unclear if it is the participants view or if it is information about the setting (that then should be moved to the methods section).

6. A small detail - observe that on page 16, lines 354-355 you have written “to be implemented mid-2025”. Since it is now 2026, please update the text.

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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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Dear Dr. Treloar,

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 Aug 02 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.

• 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,

Helen Howard

Staff 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.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Partly

**********

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

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

**********

Reviewer #2: The revised version is improved, particularly in the introduction and methods, and the authors have responded constructively to reviewer comments. The use of CFIR “outer setting” constructs provides a clear organizing framework for the analysis, and the findings are presented in a way that is meaningful for policy and practice. The discussion is also appropriately reflective about the promise and limitations of structural approaches.

I remain broadly positive about the manuscript, and I think it is close to publishable form. My remaining comments are relatively minor:

Analytic clarity could still be strengthened slightly. While the authors have improved the methods section, the paper would benefit from one or two more sentences clarifying how structural stigma was identified in the data and how inductive insights were linked to the CFIR framework.

The absence of lived-experience perspectives remains an important limitation. This is acknowledged, which is appreciated, but I encourage the authors to state even more clearly that stakeholder perspectives on structural reform cannot substitute for the perspectives of people directly experiencing stigma in healthcare.

There is a small risk of overstatement in some parts of the discussion. The argument is persuasive, but the findings are based on a relatively focused Australian BBV/STI stakeholder sample. Some phrasing could be softened slightly to emphasize that the paper identifies promising structural pathways rather than demonstrating their effectiveness.

The discussion of implementation challenges could be sharpened. The manuscript notes the possibility that accreditation and governance processes may become “tick-box” exercises. This is an important point and deserves just a little more emphasis, given that it is central to the paper’s argument.

Overall, this is a strong and worthwhile manuscript. It offers a valuable conceptual and policy contribution and, in my view, would be suitable for publication after minor final refinements to clarity, caution in claims, and emphasis on the study’s limitations.

**********

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Reviewer #2: No

**********

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Dear Dr. Treloar,

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 Aug 26 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.

• 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,

Saima Aleem

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.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

**********

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

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

**********

Reviewer #2: This is a strong and policy-relevant qualitative manuscript. The study makes a valuable contribution by reframing stigma reduction as part of quality health care and by identifying structural mechanisms, particularly accreditation and governance processes, that may be mobilized to support stigma reduction. The use of CFIR outer-setting constructs provides a coherent analytic framework, and the findings are clearly linked to implications for health-system practice.

The revisions have adequately addressed most major concerns. The methods are now clearer, the authors have acknowledged the absence of lived-experience perspectives, and the discussion has appropriately softened causal or overly strong claims. I have only minor remaining suggestions. First, the manuscript should continue to emphasize that the findings identify promising structural pathways rather than demonstrating their effectiveness. Second, the limitation regarding the absence of direct patient/consumer perspectives should remain explicit. Third, the discussion of implementation challenges, especially the risk that accreditation becomes a “tick-box” exercise, could be sharpened slightly. Finally, claims about transferability beyond the Australian BBV/STI context should be phrased cautiously.

**********

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 #2: No

**********

[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

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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Stigma reduction as quality health care: A qualitative study of structural level mechanisms to address stigma

PONE-D-25-36923R3

Dear Dr.Carla,

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,

Surangi Jayakody, MBBS, MSc, MD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: