Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia.

INTRODUCTION: Providing patient-centered care is one of the key focus areas of the Ethiopian Health Service Transformation Plan. To this end, improving health literacy of the community is critical. However, there is limited evidence about the health literacy of Ethiopians, especially among those who visit health facilities.
OBJECTIVE: The aim of this study was to examine awareness of diagnosis, treatment plan and prognosis among patients at the time of their exit from public hospitals and health centers.
METHODS: A cross-sectional study was conducted among 627 patients in two public hospitals and selected health centers in Addis Ababa, using a systematic random sampling technique from inpatient and outpatient departments (OPD). A total of 579 study participants had complete data and were included in this analysis. A structured, pre-tested and interview-administered questionnaire was used to collect data. We used proportions to describe the findings and logistic regression analyses to assess factors associated with awareness of diagnosis, treatment plan and prognosis. RESULT: About three-fifths (61.9%) and 52.8% of the study participants knew correctly their diagnosis and treatment plan respectively. More than two-thirds, 68.4%, said that they knew about the prognosis of their illness. However, only 21 (3.6%) patient medical records had information on prognosis. Gynecologic patients had significantly lower awareness about their diagnosis and treatment plan as compared to those from a general outpatient department. Emergency patients had significantly lower awareness of their treatment plan (OR = 0.27; 95% CI: 0.11,0.68) and prognosis (OR = 0.21; 95% CI: 0.09,0.50) than new OPD patients. Patients who indicated they had a good experience at their clinical assessment had significantly lower awareness of their prognosis (OR = 0.25; 95% CI: 0.08, 0.81).
CONCLUSION: A significant proportion of patients didn't know their correct diagnosis, treatment plan and prognosis. This was more pronounced among gynecologic and emergency patients. More efforts are needed to strengthen patient-provider interaction.

Introduction

Patient care is shifting globally from a traditional approach towards a patient-centered approach that involves patients in their own care [1,2]. Patient-centered care is believed to optimize patients’ health literacy by ensuring their access to information about their diagnosis, treatment and prognosis. Improved health literacy will help patients understand, appraise and use health information to make decisions relevant to their health condition [3]. A patient-centered approach is directly related to effectiveness of patient care, increased patient satisfaction [4,5], better patient involvement in disease prevention, improved patient skills in self-management [6,7], patient engagement, and perceived quality of care [8,9].

Effectiveness of self-management of disease depends on close communication between healthcare providers and patients [10]. Patients’ health literacy and self-efficacy to manage their disease is also highly dependent on patient-provider communication and patient involvement in decision-making about their treatment plan [11,12], both of which are integral components of patient-centered care. Consequently, initiatives in patient-centered care and health literacy are contributing to the improvement of patients’ skills in self-management of their own diseases [2,5].

A systematic review on patient involvement reported that patients can actively monitor their own care if they get adequate information and are actively involved in the decision-making process [12]. Research has also showed that patient involvement in their own care and better patient-provider communication are strongly associated with medication adherence [13,14]. However, patient-provider communication is poor in many settings. As a result, only a limited proportion of patients receive adequate information about their health and healthcare. For instance, a meta-analysis studies, mostly from high-income countries, conducted among cancer patients reported that only 49% were aware of their prognosis [15].

Patients’ involvement in their medical care will promote mutual accountability and understanding between patients and health care providers. Primary care providers are ideally placed to engage patients in a discussion about their health conditions, treatment plan and lifestyle changes. Well-informed patients are more likely to feel confident to report both positive and negative experiences about their health and illness [16]. However, even if patients have a right to adequate information about their clinical assessment procedure, diagnosis and treatment plan and prognosis, evidence suggests that most patients do not know about their right [17].

Awareness about diagnosis, treatment plan and prognosis are key elements of patient-centered care. Evidence from another systematic review showed that about 75% of patients were not aware of their prognosis and 96% were not aware of their diagnosis [18]. Another study has shown that the majority (97.4%) of patients knew their physician’s name. The same study reported that men have better awareness about their health condition, treatment complication, medication administrated and plan of care than women [19]. Similarly, a study of awareness of prognosis in oncological patients at the end of life showed that the large majority of terminal cancer patients did not have adequate information about their diagnosis and prognosis [20]. On the other hand, research indicated that many patients with early-stage cancer want detailed prognostic information, presented in an open and honest manner [21].

With the ultimate aim of providing effective care for all patients in Ethiopia, the patient-centered approach has been integrated in the Health Sector Transformation Plan (HSTP) [22]. Published evidence from the Tigray region of Ethiopia showed that a considerable proportion of patients had poor experiences in their medical care [23]. A qualitative study in the Southern region of Ethiopia indicated that patients have positive perception of patient-centered care [24].

However, there is limited evidence on patients’ awareness about their health condition and management of their disease. Besides, the existing evidence is largely based on patients’ verbal reports. To our knowledge, there is no published study that objectively measures patients’ awareness of their diagnosis, prognosis and treatment plan. Therefore, the aim of the current study was to examine awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia.

Methods

Study design and context

An institution-based cross-sectional study was conducted to assess awareness of diagnosis, treatment plan, and prognosis among adult patients. St. Paul Hospitals Millennium Medical College (SPHMMC) and St. Peter Specialized Hospital and their catchment health centers were the study areas. The study was conducted between July 20th and August 30thof 2019. Patients who visited the outpatient department and inpatient departments of internal medicine, surgery, and gynecology and specialty clinics were listed. Patients who were critically ill and unable to respond and who visited the antenatal care and delivery unit and discharged from obstetrics admission, family planning clients, and patients at the HIV treatment clinic were not included in this study.

Sampling of study participants

Using proportion of effect (p) 55%, 95% level of significance, 5% margin of error 1.5 design effect and 10% non-response rate, we needed 627 study participants. The two public hospitals were selected purposively. A simple random sampling technique was used to select the catchment health centers of the two public hospitals and a systematic random sampling technique was used to recruit the study participants from the selected health institutions. The total sample was proportionally allocated to the health institutions based on their patient load. The sampling fraction was determined based on the daily patient flow of the health institution.

Inclusion/Exclusion criteria

All adult patients who would visit the outpatient and inpatient departments of Internal Medicine, Surgery, Gynaecology, Emergency and Specialty Clinics of the study facilities were eligible for inclusion. Patients who were critically ill and unable to respond were not eligible for this study. Besides, patients who visited ANC, Delivery, Family Planning, Anti-Retroviral treatment clinics were excluded.

Data collection procedures and instruments

After training of the data collectors, the data-collection process and questionnaire were pre-tested in similar contexts. Refinements to the data-collection process and questionnaire were made based on the lessons from the pre-test. Members of the research team interviewed study participants at the time of their exit or discharge from each facility. The data-collection process was supervised by two researchers. Prior to conducting interviews, the data collectors obtained informed consent from each study participant.

We used a structured and interview-administered questionnaire to collect data. The questionnaire had six domains: demographic characteristics, Patient Experience Questionnaire (PEQ) (25), Patient Perception of Patient-Centeredness (PPPC) scale (26), Perception on Quality of Health Service, General Patient Satisfaction Scale (27) and Items on Patients Awareness on their Diagnosis, Treatment and Prognosis (28).

The PEQ scale was used to explore patients’ experience of the care they received. Except for waiting time and perceived benefits, all items were based on 5-point response scale: “1 = not at all”, “2 = small extent”, “3 = moderate extent”, “4 = large extent”, and “5 = very large extent”. The PPPC was used to measure patient perceptions of patient-centered care during their visit to the health facilities. The instrument had 14 items scored on a 4-point Likert scale ranging from completely agree on the idea to not at all, and no subscales, with Cronbach’s reliability for the global score of 0.71(36). Then, experiences of patients, patient perception of patient-centeredness of care and general patient satisfaction were classified in to good and poor or satisfied and not satisfied using 75% of as a cut-off point [25-27].

Information related to the outcome variables, such as patients’ diagnosis, treatment plan, and prognosis, were collected from both the patient and the patient’s medical record by two different data collectors. Knowledge about prognosis of the disease was determined using awareness about the expected outcome of the treatment, which included cure, chronicity, and threat to life. Agreement between the two sources of information was examined [28]. Differences between the two data sources were verified through a thorough discussion with three experienced physicians. Patients were classified as having awareness when information from patients’ verbal report agreed with the information from their medical record.

Data analysis

Data were entered, cleaned and coded using Epi-data software. We used Stata 15.0 for statistical analysis. We summarized descriptive information in tables using proportions. We used logistic regression models to assess factors associated with awareness of diagnosis, treatment plan and prognosis. In the analysis of factors associated with awareness of diagnosis, treatment and prognosis, we controlled for the effects of potential confounders including type of facilities and departments within facilities. We used multiple logistic regression models to identify factors associated with each of awareness of diagnosis, treatment and prognosis. As the sample is proportionally distributed between hospitals and health centers, we don’t expect significant effect of clustering. We presented measures of adjusted odds ratios with 95% confidence interval and p values. P values less than 0.05 were considered to be statistically significant.

Ethical consideration

Ethical clearance to conduct this study was obtained from the Institutional Review Board of SPHMMC, St. Peter’s Specialized Hospital Ethical Review Committee Office (ERCO). Written informed consent was obtained from all study participants.

Results

Socio-demographic and clinical characteristics of the respondents

A total of 627 study participants were interviewed, making the response rate 98.1%. From these, 579 (92.3) had complete data and were included in this analysis. The mean age of the respondents was 40.3 (SD = 16.3) years. The majority were housewives (27.8%), orthodox Christians (78.9%), and had Amharic as their mother tongue (63.9%) (see Table 1).

Table 1

Socio-demographic and clinical characteristics of study participants (n = 579).

Variables	Categories	Values
Age (mean, SD)		40.3 (16.3)
Female (n, %)		339 (58.5%)
Urban residence (n, %)		494 (85.3)
Currently married (n, %)		350 (60.4)
Employment (n, %)	Government or NGO Employed	141 (24.4)
	Other occupation*	277 (47.8)
Education (n, %)	None	112 (19.3)
	Able to read and write	81 (14.0)
	Primary (1–8)	175 (30.2)
	Secondary & Preparatory (9–12)	163 (28.2)
	Tertiary or Higher	48 (8.3)
Religion (n, %)	Orthodox Christian	457 (78.9)
	Muslim	80 (13.8)
	Other religious followers**	42 (7.3)
Mother tongue is Amharic (n, %)		370 (63.9)
First encounter with the clinician		390(67.4)
Visited hospital		325(56.1)
Department	General OPD	281(48.5)
	Internal Medicine	75(13)
	Surgery	80(13.8)
	Gynecology	83(14.3)
	Other departments***	60(10.4)
Care type	Outpatient (new)	326(56.3)
	Inpatient	95(16.4)
	Emergency	41(7.1)
	Outpatient (Follow-up)	117(20.2)
Feeling	Very unwell	323(55.8)
	Moderately unwell	221(38.2)
	Slightly unwell / well	35(6)
Worry about illness	Very worried	302(52.2)
	Moderately worried	222(38.3)
	Slightly/not worried	55(9.5)

*Farmer, merchant, self-employed, retired

**Protestant, Catholic, Wakefeta

***Emergency& specialty clinics.

Among the study participants, 48.5% received the service at a general outpatient department. New outpatient visitors represented 56.3% and 67.4% had their first encounter with the clinician. A little more than half, 55.8%, felt very unwell and 52.2% were very much worried about their problem when they came to the health facility. Of all the study participants, 56.1% received service at hospital and 72.9% of them arrived at the health institution before 6:30 PM of local time (see Table 1).

Experience and perception of patients

Of the total study participants, 53.4% were not satisfied by the service they received and 41.3% had a poor experience during the contact for their clinical assessment. Also 39.2% had a poor perception of patient-centeredness and 21.8% had a poor perception of quality of service. A significant majority, 89.1%, mentioned that the physician didn’t introduce himself/herself to them during the clinical assessment and 92.6% did not know the name of the physician who treated them. Close to half, 44.6%, didn’t know the career position of the health provider. About a third, 34.7% indicated that the clinician did not talk to them in their mother tongue.

Awareness of diagnosis, treatment plan and prognosis

Among the study participants, 21.6% indicated that their clinician didn’t inform them about their diagnosis and 80.3% responded that they knew their diagnosis. However, 38.1% of them didn’t know their correct diagnosis at the time of their exit from the health facility.

More than four out of five patients, 82.2%, reported that they have received adequate information while 85.1% responded that they were informed about their treatment plan. About 92% of the study participants said they know about their treatment plan. Even if three quarters had no chance to discuss with the care provider after they bought the medication, 72.7% obtained the prescribed medication within the health facility. During verification of patients’ verbal report with the treatment plan written on the patient medical record, we found that 47.2% did not know their treatment plan correctly.

From the study participants, 58.5% reported that they were told about the prognosis of their illness by the clinician. More than two-thirds, 68.4%, said that they knew about the prognosis of their illness. However, only a fifth of patient medical records had information on prognosis status, of which 13 (62%) had similar information as described by the patients.

Among the study participants, more than half mentioned that their illness needed a follow-up. Of these, close to half were told about their follow-up date by their clinician and 46.8% knew their follow-up date. However, most of the patients’ medical records had no written information about the follow-up date. Of the 75 patient cards with written follow up date, nearly two-thirds had the same information as that of the patients’ verbal report. Details of these are illustrated in Table 2.

Table 2

Awareness of diagnosis, treatment plan and prognosis.

Background variables	Categories	Aware of diagnosisn (%)	P value	Aware of treatment plann (%)	P value	Aware of prognosisn (%)	P value
Gender	Male	120(60)	0.469	110(50.9)	0.469	152(63.3)	0.028
	Female	179(63.3)		163(54.2)		244(72)
Age	35 and below Years	144(61)	0.695	134(53.2)	0.869	209(74.9)	0.001
	Above 35 Years	155(62.8)		139(52.5)		187(62.3)
Marital status	Currently married	190(63.8)	0.287	175(57.4)	0.012	236(67.4)	0.537
	Currently not married	109(58.9)		98(46.2)		160(69.9)
Educational status	None	49(59.8)	0.983	40(42.1)	0.111	62(55.4)	0.004
	Able to read & write	47(63.5)		41(59.4)		55(67.9)
	Primary (1–8)	96(62.3)		86(53.1)		130(74.3)
	Secondary (9–12)	80(61.1)		77(53.1)		110(67.5)
	Tertiary or Higher	27(64.3)		29(63)		39(81.3)
Service providing department	General OPD	146(62.4)	0.061	156(58.4)	0.036	235(83.6)	<0.001
	Internal Medicine	41(66.1)		36(56.3)		29(38.7)
	Surgery	41(59.4)		31(44.9)		46(57.5)
	Gynecology	31(48.4)		29(43.9)		64(77.1)
	Emergency/specialty	40(74.1)		21(41.2)		22(36.7)
Patient getting care as	Outpatient (new)	157(61.1)	0.501	169(56.7)	<0.001	254(77.9)	<0.001
	Inpatient	48(57.1)		35(41.2)		54(56.8)
	Emergency	21(61.8)		8(23.5)		14(34.2)
	Outpatient (repeat)	73(67.6)		61(61)		74(63.3)
Encounter with the clinician	First Contact	180(57.9)	0.014	170(48.6)	0.005	274(70.3)	0.166
	More than one time	119(69.2)		103(61.7)		122(64.6)
Residence	Urban	266(63.2)	0.132	239(53.8)	0.250	350(70.9)	0.002
	Rural	33(53.2)		34(46.6)		46(54.1)
Experience at examination	Poor	131(60.4)	0.530	120(47.6)	0.021	169(60.4)	<0.001
	Good	168(63.2)		153(57.7)		227(75.9)
Patient-centeredness	Poor	107(59.4)	0.391	101(47.9)	0.062	132(55.2)	<0.001
	Good	192(63.4)		172(56.2)		264(77.7)
Quality of Service	Poor	53(60.9)	0.834	53(49.1)	0.383	69(54.8)	<0.001
	Good	246(62.1)		220(53.8)		327(72.2)
Patient Satisfaction	Unsatisfied	168(64.9)	0.150	157(56.5)	0.071	230(74.4)	0.001
	Satisfied	131(58.5)		116(48.5)		166(61.5)
Used mother tongue	No	110(66.3)	0.153	92(52)	0.786	125(62.2)	0.019
	Yes	189(59.6)		181(53.2)		271(71.7)
Health Facility type	Hospital	173(62.9)	0.601	139(51.5)	0.529	191(58.8)	<0.001
	Health Center	126(60.6)		134(54.3)		205(80.7)

Factors associated with awareness of diagnosis, treatment and prognosis

Patients who visited the Gynaecology department had significantly lower awareness about their diagnosis and treatment plan, while surgical patients had significantly lower awareness of their treatment plan and prognosis. Patients treated at the emergency department had significantly lower awareness of their treatment plan and prognosis. On the other hand, patients with good perception of patient-centeredness of care had significantly higher awareness of their prognosis. Details are shown in Table 3 below.

Table 3

Factors associated awareness of diagnosis, treatment plan and prognosis from multiple logistic regression models.

	Awareness of Diagnosis		Awareness of Treatment		Awareness of Prognosis
	OR* (95% CI)	P	OR* (95% CI)	P	OR* (95% CI)	P
Age (Ref: <36 years)
Age>35 years	0.80(0.51,1.27)	0.349	0.85(0.55,1.31)	0.466	0.81(0.5,1.32)	0.406
Gender (Ref: Male)
Female	1.40(0.91,2.15)	0.129	1.20(0.8,1.81)	0.374	1.17(0.73,1.86)	0.511
Marital status (Ref: Currently married)
Currently not married	0.80(0.52,1.22)	0.293	0.66(0.44,1)	0.049	1.01(0.64,1.59)	0.983
Educational status (Ref: None)
Able to read and write	1.03(0.50,2.10)	0.938	1.51(0.74,3.07)	0.257	1.57(0.73,3.37)	0.246
Primary (1–8)	1.13(0.61,2.12)	0.694	1.54(0.84,2.8)	0.160	1.77(0.93,3.36)	0.083
Secondary & Preparatory (9–12)	1.06(0.56,2.01)	0.853	1.69(0.91,3.12)	0.096	1.29(0.67,2.46)	0.445
Tertiary or Higher	1.24(0.54,2.86)	0.617	2.56(1.14,5.72)	0.022	2.71(1.02,7.21)	0.045
Department (Ref: General OPD)
Internal Medicine	0.74(0.32,1.68)	0.468	0.54(0.23,1.27)	0.159	0.11(0.05,0.27)	<0.001
Surgery	0.57(0.25,1.35)	0.202	0.34(0.14,0.84)	0.019	0.34(0.14,0.84)	0.020
Gynecology	0.29(0.12,0.73)	0.009	0.30(0.12,0.77)	0.013	0.92(0.34,2.52)	0.879
Other	1.32(0.54,3.25)	0.540	0.37(0.15,0.93)	0.034	0.20(0.08,0.49)	<0.001
Type of care (Ref: New outpatient)
In patient	1.33(0.68,2.59)	0.407	0.71(0.37,1.35)	0.293	0.61(0.31,1.18)	0.139
Emergency (Emergency Room)	0.82(0.34,1.98)	0.661	0.27(0.11,0.68)	0.006	0.21(0.09,0.50)	<0.001
Outpatient (Follow-up)	0.99(0.50,1.96)	0.975	1.09(0.55,2.16)	0.806	0.72(0.35,1.47)	0.361
Encounter (Ref: First)
Repeated	1.69(0.96,2.99)	0.071	1.82(1.05,3.16)	0.034	1.39(0.75,2.55)	0.293
Residence (Ref: Urban)
Rural	0.65(0.35,1.22)	0.183	0.91(0.5,1.68)	0.774	0.68(0.37,1.27)	0.226
Patient Experience (Ref: Poor)
Good	0.84(0.39,1.8)	0.658	1.63(0.8,3.34)	0.178	0.25(0.08,0.81)	0.020
Patient-centeredness of service (Ref: poor)
Good	1.38(0.63,3.06)	0.423	0.92(0.44,1.92)	0.829	10.21(3.11,33.55)	<0.001
Perceived quality of service (Ref: Poor)
Good	0.89(0.51,1.58)	0.701	0.85(0.51,1.43)	0.542	1.19(0.69,2.06)	0.525
General satisfaction (Ref: Not satisfied)
Satisfied	0.68(0.43,1.05)	0.082	0.75(0.49,1.14)	0.179	0.75(0.47,1.19)	0.222
Used mother tongue (Ref: No)
Yes	0.75(0.49,1.16)	0.194	1(0.66,1.51)	0.998	0.98(0.62,1.54)	0.934
Facility type (Ref: Hospital)
Health Center	0.59(0.3,1.17)	0.129	0.45(0.22,0.94)	0.033	0.78(0.36,1.69)	0.532

*ORs are adjusted for all the variables in the first column of this table.

Discussion

In this facility-based cross-sectional study, we assessed patients’ awareness about their diagnosis, treatment plan and prognosis using data from exit interviews and patient medical records. The finding showed that the level of patients’ awareness about their diagnosis was considerably low. This was consistent with previous studies in Shanghai, China [28], United Kingdom [29] and Sri Lanka [30]. The lower level of awareness might relate to patients’ awareness of their right to ask for information about their health condition. In this regard, patients’ awareness about their rights to ask for and receive information about their own health condition and treatment plans need to be improved. Besides, clinicians also have a responsibility to ensure that patients are well informed about their medical care [31].

Our study found a relatively higher level of awareness of diagnosis than reported by some other countries [31-35]. These other studies recruited patients who had similar illnesses, but we sampled patients from various departments and health institutions. On the other hand, compared with studies conducted in South Africa [36] and United States [37], our study found a relatively low level of awareness of diagnosis. This might be due to the recruitment of patients with chronic illness for those studies. Patients with chronic illness usually have better chances to frequently contact their physicians and have more time to ask and acquire detailed information. This would help them to improve their awareness about their diagnosis, treatment plan and prognosis [36].

Even though it was higher than has been reported in other settings, we found a low level of patient awareness about their treatment plan and prognosis [17,20]. On the other hand, relatively higher levels of awareness about treatment plans were reported in South Africa [36] and China [38]. The difference might be related to the variations in medical treatment approach and better provider-patient interaction. The differences in the health systems’ capacity to deliver patient-centered services could also explain for these differences.

Low level of awareness of diagnosis among patients who received service at the gynecology department and among those who contacted the clinician for the first time might partly be due to their limited exposure to the healthcare system. This limited exposure may reduce the chances to seek and access more information about their illness. In China, adequate knowledge about chronic diseases was strongly associated with regular check-ups, especially for those who attended hospital settings [35].

Patients who received a service as an emergency patient had lower awareness of their treatment plan and prognosis compared to other outpatient cases. This is consistent with the study findings from Sudan that indicated emergency patents are necessarily not as well informed as others [39]. Consistent with the current study findings, patients who received care as an emergency patient and received service at general outpatient departments and gynecology departments had lower awareness of the prognosis of their illness. Visiting specialty clinics (like diabetes and hypertension clinics) and having repeated check-ups seem to be associated with a higher level of knowledge about current condition of the illness. Further, those who had a poor experience during the examination had a low level of awareness about the prognosis of their illness.

A significant proportion of patients didn’t know their correct diagnosis, treatment plan and prognosis. This was more pronounced among gynecologic and emergency patients. This shows that the health system in Addis Ababa needs to devise strategies to improve the quality of care provided in hospitals and health centers, particularly in terms of ensuring patients get all the necessary information about their diagnosis, treatment and prognosis. In this regard, improving patient-provider interaction needs to be one of the focus areas, especially for patients visiting gynecology, emergency and surgery departments. Further studies, with higher sample size and geographic coverage, are needed to explore the actual factors that contributed to the gaps in awareness of diagnosis, treatment plan and prognosis among patients in Addis Ababa.

There are some limitations associated with this study. The first limitation of this study is its cross-sectional nature. It was not possible to establish the direction of effect of some outcomes and explanatory variables. Secondly, this study focused on the main diagnosis. It didn’t fully explore information related to other comorbid conditions. Thirdly, information on how clinicians provide information to their patients was also not part of this study. Besides, the findings of this study may not reflect awareness of patients who visit private hospitals and clinics. Finally, there was limited information about prognosis in patient medical records and it was not possible to objectively verify patients’ verbal reports about their prognosis.

Conclusion

This study has shown that about two out of five patients didn’t know their diagnosis correctly. About half of the patients didn’t know their treatment plan correctly and one-third of them didn’t know their prognosis. Gynecologic and surgical patients had significantly lower awareness about their diagnosis and treatment plan. Emergency patients had significantly lower awareness of their treatment plan and prognosis. Patients who reported a good experience at their clinical assessment had significantly lower awareness of their prognosis. Health facilities need to improve patient-provider interaction and ensure that patients receive all important information, presented in a way they can understand.

6 May 2021

PONE-D-20-36374

Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia.

PLOS ONE

Dear Dr. Teklu,

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.

Your manuscript has undergone the peer-review process and the reviewers have provided their comments/suggestions. Kindly address these points/concerns before we make a decision.

Please submit your revised manuscript by Jun 20 2021 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 rebuttal 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:  http://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,

Kingston Rajiah

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 suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services.  If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following:

The name of the colleague or the details of the professional service that edited your manuscript

A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.

4. In the Methods, please discuss whether and how the questionnaire was validated for your context and/or pre-tested. If these did not occur, please provide the rationale for not doing so.

5. In your statistical analyses, please state whether you accounted for clustering by locality. For example, did you consider using multilevel models?

6. In statistical methods, please refer to any post-hoc corrections to correct for multiple comparisons during your statistical analyses. If these were not performed please justify the reasons. Please refer to our statistical reporting guidelines for assistance (https://journals.plos.org/plosone/s/submission-guidelines.#loc-statistical-reporting).

7. Thank you for stating the following in the Financial Disclosure section:

[This study was funded by MERQ PLC.].

We note that one or more of the authors have an affiliation to the commercial funders of this research study: MERQ consultancy PLC

1. Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

Please also include the following statement within your amended Funding Statement.

“The funder provided support in the form of salaries for authors [insert relevant initials], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.”

If your commercial affiliation did play a role in your study, please state and explain this role within your updated Funding Statement.

2. Please also provide an updated Competing Interests Statement declaring this commercial affiliation along with any other relevant declarations relating to employment, consultancy, patents, products in development, or marketed products, etc.

Within your Competing Interests Statement, please confirm that this commercial affiliation does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If this adherence statement is not accurate and  there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Please include both an updated Funding Statement and Competing Interests Statement in your cover letter. We will change the online submission form on your behalf.

Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests

8. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

9. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table.

10. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files.

[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: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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: No

**********

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

**********

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: 1. An overall comment is for the quality of writing: English language is sometimes not the most appropriate. I urge authors to check the text thoroughly before resubmission and to read other published papers from the journal to check the style of writing.

2. The author must add the inclusion and exclusion criteria in the study.

3. The research work Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia is well conducted among the patients, the sample size is to be increased, and further work may be carried out.

4. The authors also add the limitations of the study.

Reviewer #2: General comment: this study examines an important question about patients perception and understanding of care received. Inconsistencies in data and need of further clarity on methodology need to be examined.

Specifics:

Abstract: “Patients with good experience at their clinical assessment had significantly lower awareness of their prognosis"

Conclusion: “Patients with good experience at their clinical assessment had significantly higher awareness of their prognosis.”

--> both statements are in contradiction, also "(OR=0.25; 95% CI: 0.08, 0.81)” in the abstract does not correspond to the data in the table

Did the authors collect data on gender of health care providers? Was there a difference in patient knowledge of diagnosis, treatment plan or prognosis depending on provider gender? If provider gender was not examined would perhaps rephrase: “Patient care is shifting globally towards patient-centered approach [1, 2].”

“Questionnaire (PEQ) (25), Patient Perception of Patient-Centeredness (PPPC) scale (26), Perception on Quality of Health Service, General Patient Satisfaction Scale (27) and Items on Patients Awareness on their Diagnosis, treatment and Prognosis (28).”

was this translated or did the interviewer use the English version and each translate themselves? Were these instruments validated in the translated language? What language was used? Please provide a copy of the English and translated version as an appendix. Some validation of the instruments would be useful for this and future publications. This will also help readers to better understand how variables such as "patient centeredness" or "prognosis" or the variarious satisfaction/good care variables were defined.

Also authors could provide a reference indicating that documenting prognosis separate from the diagnosis and treatment plan is a requirement in medical notes. Is this now a requirement in Ethiopia, WHO, etc for example? Often prognosis is implicit in the diagnosis and treatment plan in medical notes.

“We used logistic regression models to assess factors associated with awareness of diagnosis, treatment plan and prognosis”

What variables were included in these models? Has were interactions assessed and managed? It is not clear in the results section which results were bivariate, which were from multivariate models and or variables were included in the models.

Gynecologic patients had significantly lower awareness about their diagnosis and treatment plan, compared to who? Why is this different from females in general?

How could patients understand prognosis if they don’t know the diagnosis or treatment plan?

Also in the introduction would indicate the location of the references like in the discussion.

% in the text of the result would be better in a table.

Data from the tables to keep tract

Awareness of Diagnosis Awareness of Treatment Awareness of Prognosis

Female

179(63.3) 163(54.2) 244(72)

1.40(0.91,2.15) 0.129 1.20(0.8,1.81) 0.374 1.17(0.73,1.86)0.511

Gynecology

31(48.4) 29(43.9) 64(77.1)

0.29(0.12,0.73) 0.009 0.30(0.12,0.77) 0.013 0.92(0.34,2.52) 0.879

General satisfaction (Ref: Not satisfied)

131(58.5) 116(48.5) 166(61.5)

0.68(0.43,1.05) 0.082 0.75(0.49,1.14) 0.179 0.75(0.47,1.19) 0.222

**********

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: 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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

24 Oct 2021

Date Jun 5, 2021

Kingston Rajiah

Academic Editor

PLOS ONE

Re: Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia.

Dear Dr. Kingston Rajiah,

Thank you for review of our manuscript. We found your comments and reviewers’ comments very helpful. We have revised the manuscript based on your comments. We have attached:

1. Response to Reviewers - A rebuttal letter that responds to each point raised by the academic editor and reviewer(s).

2. Revised Manuscript with Track Changes - A marked-up copy of your manuscript that highlights changes made to the original version.

3. Manuscript - An unmarked version of your revised paper without tracked changes.

We look forward to receiving hearing from you.

Kind regards,

Dr Alula M Teklu

On behalf of the authors

Responses to Editor’s comments

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

Response: We have edited the title page and file names based on the PLOS ONE’s style requirements.

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services. If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Response: The manuscript has now been copyedited for language usage by Christopher Crompton who is an experienced editor.

Upon resubmission, please provide the following:

• The name of the colleague or the details of the professional service that edited your manuscript

• A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

• A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

Response: We have included these files as per the PLOS ONE guidelines

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.

Response: English and Amharic version of the questionnaire and the consent forms that we developed as part of this study are attached as supplemental file.

4. In the Methods, please discuss whether and how the questionnaire was validated for your context and/or pre-tested. If these did not occur, please provide the rationale for not doing so.

Response: After training of the data collectors, the data collection process and questionnaire were pre-tested in similar contexts. Refinements to the data collection process and questionnaire were made based on the lessons from the pre-test. This information is included in the revised version

5. In your statistical analyses, please state whether you accounted for clustering by locality. For example, did you consider using multilevel models?

Response: In the analysis of factors associated with awareness of diagnosis, treatment and prognosis, we controlled for the effects of potential confounders including type of facilities and departments within facilities. As the sample is proportionally distributed between hospitals and health centers, we don’t expect significant effect of clustering.

6. In statistical methods, please refer to any post-hoc corrections to correct for multiple comparisons during your statistical analyses. If these were not performed please justify the reasons. Please refer to our statistical reporting guidelines for assistance (https://journals.plos.org/plosone/s/submission-guidelines.#loc-statistical-reporting).

Response: Most of our variables are categorical. Post-hoc multiple comparisons were not needed for these types of analysis. In the logistic regression models, we compared each category against the reference category.

7. Thank you for stating the following in the Financial Disclosure section:

[This study was funded by MERQ PLC.].

We note that one or more of the authors have an affiliation to the commercial funders of this research study: MERQ consultancy PLC

1. Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

Response: The authors’ contribution section is amended as suggested.

Please also include the following statement within your amended Funding Statement.

“The funder provided support in the form of salaries for authors [insert relevant initials], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.”

If your commercial affiliation did play a role in your study, please state and explain this role within your updated Funding Statement.

Response: The funding statement is amended as suggested.

2. Please also provide an updated Competing Interests Statement declaring this commercial affiliation along with any other relevant declarations relating to employment, consultancy, patents, products in development, or marketed products, etc.

Within your Competing Interests Statement, please confirm that this commercial affiliation does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If this adherence statement is not accurate and there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Response: The competing interests statement is amended.

Please include both an updated Funding Statement and Competing Interests Statement in your cover letter. We will change the online submission form on your behalf.

Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests

Response: Updated Funding Statement and Competing Interests Statement are included in the updated cover letter

8. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Response: Data contain potentially identifying patient information. Requests for access to data can be submitted to the corresponding author who can process data access.

9. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table.

Response: Included.

10. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files.

Response: All tables are within the main manuscript

Reviewers' comments:

Comments to the Author

Reviewer #1:

1. An overall comment is for the quality of writing: English language is sometimes not the most appropriate. I urge authors to check the text thoroughly before resubmission and to read other published papers from the journal to check the style of writing.

Response: The language has been carefully edited by Christopher Crompton.

2. The author must add the inclusion and exclusion criteria in the study.

Response: A sub-section on inclusion/exclusion criteria is included in the revised version.

3. The research work Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia is well conducted among the patients, the sample size is to be increased, and further work may be carried out.

Response: We agree with this suggestion and included it in our recommendations section

4. The authors also add the limitations of the study.

Response: Study limitations are described in the last paragraph of the discussion section

Reviewer #2:

General comment: this study examines an important question about patients perception and understanding of care received. Inconsistencies in data and need of further clarity on methodology need to be examined.

Response: We have revised the manuscript to improve clarity and ensure consistency.

Specifics:

Abstract: “Patients with good experience at their clinical assessment had significantly lower awareness of their prognosis"

Conclusion: “Patients with good experience at their clinical assessment had significantly higher awareness of their prognosis.”

--> both statements are in contradiction, also "(OR=0.25; 95% CI: 0.08, 0.81)” in the abstract does not correspond to the data in the table

Response: We have revised the text in the conclusion section and verified the data presented in the abstract against table 3.

Did the authors collect data on gender of health care providers? Was there a difference in patient knowledge of diagnosis, treatment plan or prognosis depending on provider gender? If provider gender was not examined would perhaps rephrase: “Patient care is shifting globally towards patient-centered approach [1, 2].”

Response: Data on gender of the provider was not collected. We have revised the text accordingly.

“Questionnaire (PEQ) (25), Patient Perception of Patient-Centeredness (PPPC) scale (26), Perception on Quality of Health Service, General Patient Satisfaction Scale (27) and Items on Patients Awareness on their Diagnosis, treatment and Prognosis (28).”

was this translated or did the interviewer use the English version and each translate themselves? Were these instruments validated in the translated language? What language was used? Please provide a copy of the English and translated version as an appendix. Some validation of the instruments would be useful for this and future publications. This will also help readers to better understand how variables such as "patient centeredness" or "prognosis" or the various satisfaction/good care variables were defined.

Response: The English version of the tool was translated to Amharic by expert translators. The translated version was reviewed by experts and was the pre-tested before use. We have provided a copy of both the English and Amharic versions of the questionnaire.

Also authors could provide a reference indicating that documenting prognosis separate from the diagnosis and treatment plan is a requirement in medical notes. Is this now a requirement in Ethiopia, WHO, etc for example? Often prognosis is implicit in the diagnosis and treatment plan in medical notes.

Response: Yes, information about prognosis is also implicit in Ethiopia. We asked the patient if he or she knows whether his/her diagnosis is curable or not. For most of the information, we asked the treating physician about prognosis. Overall, prognostic information was largely inferred from the diagnosis.

“We used logistic regression models to assess factors associated with awareness of diagnosis, treatment plan and prognosis”

What variables were included in these models? Has were interactions assessed and managed? It is not clear in the results section which results were bivariate, which were from multivariate models and or variables were included in the models.

Response: All the variables in table 3 were included in each logistic regression model (awareness of diagnosis, treatment and prognosis). We presented only adjusted ORs. We presented descriptive stats (bivariate) in table 2. In the revised version, we have indicated the variables and included in the models and that the ORs are adjusted.

Gynecologic patients had significantly lower awareness about their diagnosis and treatment plan, compared to who? Why is this different from females in general?

Response: This is compared to the reference category (patients in general outpatient department). We have controlled in the effect of gender in the model. But the reason behind this needs further study.

How could patients understand prognosis if they don’t know the diagnosis or treatment plan?

Response: The question we asked about prognosis is generic (whether the condition is treatable or not) and doesn’t need specific knowledge of diagnosis or details of treatment plan.

Also in the introduction would indicate the location of the references like in the discussion.

Response: We used the same reference style in both the introduction and discussion section.

% in the text of the result would be better in a table.

Response: We have reduced some of the %s indicated in the text.

Data from the tables to keep tract

Awareness of Diagnosis Awareness of Treatment Awareness of Prognosis

Female

179(63.3) 163(54.2) 244(72)

1.40(0.91,2.15) 0.129 1.20(0.8,1.81) 0.374 1.17(0.73,1.86)0.511

Gynecology

31(48.4) 29(43.9) 64(77.1)

0.29(0.12,0.73) 0.009 0.30(0.12,0.77) 0.013 0.92(0.34,2.52) 0.879

General satisfaction (Ref: Not satisfied)

131(58.5) 116(48.5) 166(61.5)

0.68(0.43,1.05) 0.082 0.75(0.49,1.14) 0.179 0.75(0.47,1.19) 0.222

Response: These data from Table 2 and 3 go together. However, to keep the tables simpler, we put them in two tables.

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: 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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

13 Dec 2021

6 Jun 2022

Responses to reviewers’ comments

1-Decription of prognosis assessment in the African setting is important. More information how this was done would be helpful. For example, in the method section specifically described what questions were used and how was prognosis knowledge defined. Specifically, was it based on threat to life in short or long term, or possibility of disease chronicity? How were diagnosis in Ethiopian same or different to conditions in the reference's articles: cancer, schizophrenia in Western medicine setting? Explicit description of who with what diagnosis met prognosis understanding criteria would help.

Response:

Prognosis in this study was determined based on threat to life in short or long term and need for continued treatment (chronicity). Patients were asked if their doctors have told them about possibility for cure (if they were told whether the treatment will cure them or if they needed to take it for life), as well as life expectancy life expectancy (threat to life). What the patients reported was compared with the patient record. Any patient with any condition who has been told that he will be cured after the treatment, any patient who has a knowledge of the chronicity of the disease and any patient who knows the estimated number of months/years s/he is left with, is categorized as “know their prognosis” when verified by the document and the panel of physicians. A revision is included in the manuscript.

2-The multiple regression analysis could use further clarity and description in the method section and table 3 (the title does not state that this is a multiple regression. Also, it is not clear what are separate models, what are controlling variables, also interactions assessment is not addressed, the issue of multiple analysis alpha level adjustment mentioned by the editor also needs attention).

Response: We have refined the data analysis section based on your comments. The title of table 3 now indicates that the outputs are from multiple logistic regression. By separate models, we mean we ran three models- one for awareness of diagnosis as an outcome, a second for awareness of treatment, and a third for awareness of prognosis as outcome. As the multiple logistic regression analysis was exploratory, the OR for an independent variable were controlled for all other independent variables in the model. We have checked interactions among key variables in model 3. But we didn’t get any significant interaction. We appreciate the comment on alpha level adjustment. However, we think this would increase type II error.

Submitted filename: Responses to reviewers_2.docx

Click here for additional data file.

10 Jun 2022

Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia.

PONE-D-20-36374R2

Dear Dr. Teklu,

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 for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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,

Kingston Rajiah

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

14 Jun 2022

PONE-D-20-36374R2

Awareness of diagnosis, treatment plan and prognosis among patients attending public hospitals and health centers in Addis Ababa, Ethiopia.

Dear Dr. Teklu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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.

If we can help with anything else, please email us at plosone@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

Associate Professor Kingston Rajiah

Academic Editor

PLOS ONE