Analysis of Stakeholder Requirements for the Development of Swallowing Health Management Services

Round 1

Reviewer 1 Report

REVIEW REPORT FOR THE STUDY “ANALYSIS OF STAKEHOLDER REQUIREMENTS FOR THE DEVELOPMENT OF SWALLOWING HEALTH MANAGEMENT SERVICES”

Journal: Applied Sciences

The paper " Analysis of Stakeholder Requirements for the Development of Swallowing Health Management Services", performs an analysis of the service requirements and their importance in developing comprehensive swallowing healthcare services from diverse stakeholders, including healthy seniors, individuals at risk, patients, guardians, and medical professionals, within the context of dysphagia.

Title and summary. The title and abstract express well the object of study, objectives, and results of the article.

Structure of the article. The contents are well organized and they adhere to the IMRaD structure. It includes a theoretical framework of the research problem but at this point, I suggest the authors incorporate some other bibliographic references that I miss in the text:

Shrestha A, Tamrakar D, Shrestha B, Karmacharya BM, Shrestha A, Pyakurel P, Spiegelman D. Stakeholder engagement in a hypertension and diabetes prevention research program: Description and lessons learned. PLoS One. 2022 Oct 20;17(10):e0276478. doi: 10.1371/journal.pone.0276478. PMID: 36264860; PMCID: PMC9584412.

Gaucher-Holm, A., Mulligan, C., L’Abbé, M.R. et al. Lobbying and nutrition policy in Canada: a quantitative descriptive study on stakeholder interactions with government officials in the context of Health Canada’s Healthy Eating Strategy. Global Health 18, 54 (2022). https://doi.org/10.1186/s12992-022-00842-4.

Focusing on the opportunity of the study, it must be said that it is useful work since it covers one of the major problems resulting from a health care system.

Materials and methods.

Regarding the material and methods section, the methodology is tailored to the object of study and the objectives and is explained in a transparent manner while it has been validly applied to guarantee the results. However, a paragraph containing an assessment of the construct and content validity as well as the reliability of the questionnaire used is missing.

Results.

The results are significant and they are presented in an adequate and understandable way not only through narration but also with self-explained figures that are also well elaborated in terms of presentation. The results justify and relate to the objectives and methods and the results are of sufficient interest.

Discussion.

The discussion appropriately compares the study results with other works, highlighting the main study findings. However, I would propose the inclusion of a couple of bibliographic references in the discussion section:

Linda D. Breeman, Mike Keesman, Douwe E. Atsma, Niels H. Chavannes, Veronica Janssen, Lisette van Gemert-Pijnen, Hareld Kemps, Wessel Kraaij, Fabienne Rauwers, Thomas Reijnders, Wilma Scholte op Reimer, Jobke Wentzel, Roderik A. Kraaijenhagen, Andrea W.M. Evers, A multi-stakeholder approach to eHealth development: Promoting sustained healthy living among cardiovascular patients, International Journal of Medical Informatics, Volume 147, 2021, https://doi.org/10.1016/j.ijmedinf.2020.104364..

Gyawali P, Tamrakar D, Shrestha A, Shrestha H, Karmacharya S, Bhattarai S, Bhandari N, Malik V, Mattei J, Spiegelman D, Shrestha A. Consumer acceptance and preference for brown rice-A mixed-method qualitative study from Nepal. Food Sci Nutr. 2022 Mar 4;10(6):1864-1874. doi: 10.1002/fsn3.2803. PMID: 35702294; PMCID: PMC9179153.

Tamrakar D, Shrestha A, Rai A, Karmacharya BM, Malik V, Mattei J, Spiegelman D. Drivers of healthy eating in a workplace in Nepal: a qualitative study. BMJ Open. 2020 Feb 25;10(2):e031404. doi: 10.1136/bmjopen-2019-031404. PMID: 32102804; PMCID: PMC7045197.

The 32% of the bibliography cited in the study belongs to the previous five years.

Overall, it is an interesting study and should be considered for publication in Applied Sciences, once the minor revisions proposed have been resolved.

Comments for author File: Comments.pdf

Author Response

We have carefully revised the manuscript by accommodating the suggestions and feedback of the reviewers. We have summarized our responses to the reviewers’ comments point-by-point. All the changes are highlighted in red Times font in the revised manuscript.

 Reviewer #1

The paper " Analysis of Stakeholder Requirements for the Development of Swallowing Health Management Services", performs an analysis of the service requirements and their importance in developing comprehensive swallowing healthcare services from diverse stakeholders, including healthy seniors, individuals at risk, patients, guardians, and medical professionals, within the context of dysphagia.

Title and summary. The title and abstract express well the object of study, objectives, and results of the article.

Structure of the article. The contents are well organized and they adhere to the IMRaD structure.

1. It includes a theoretical framework of the research problem but at this point, I suggest the authors incorporate some other bibliographic references that I miss in the text:

Shrestha A, Tamrakar D, Shrestha B, Karmacharya BM, Shrestha A, Pyakurel P, Spiegelman D. Stakeholder engagement in a hypertension and diabetes prevention research program: Description and lessons learned. PLoS One. 2022 Oct 20;17(10):e0276478. doi: 10.1371/journal.pone.0276478. PMID: 36264860; PMCID: PMC9584412.

Gaucher-Holm, A., Mulligan, C., L’Abbé, M.R. et al. Lobbying and nutrition policy in Canada: a quantitative descriptive study on stakeholder interactions with government officials in the context of Health Canada’s Healthy Eating Strategy. Global Health 18, 54 (2022). https://doi.org/10.1186/s12992-022-00842-4.

Focusing on the opportunity of the study, it must be said that it is useful work since it covers one of the major problems resulting from a health care system.

=> Of the references suggested by the reviewer, Shrestha et al. (2022) has been added to the introduction section.

2. [Materials and methods] Regarding the material and methods section, the methodology is tailored to the object of study and the objectives and is explained in a transparent manner while it has been validly applied to guarantee the results. However, a paragraph containing an assessment of the construct and content validity as well as the reliability of the questionnaire used is missing.

=> Two types of questionnaires (requirement survey questionnaire and importance evaluation questionnaire) were used in the study. The construct and content validities of the questionnaires were supported because the questions were prepared through discussions among four experts in rehabilitation medicine, language pathology, social welfare, and ergonomics, focusing on the general procedure of swallowing healthcare services experienced by healthy seniors, individuals at risk, and patients with dysphagia. However, the reliability of the importance evaluation questionnaire was not examined in the study, which has been addressed in the discussion section as a limitation of the study.

Results.

The results are significant and they are presented in an adequate and understandable way not only through narration but also with self-explained figures that are also well elaborated in terms of presentation. The results justify and relate to the objectives and methods and the results are of sufficient interest.

3. [Discussion] The discussion appropriately compares the study results with other works, highlighting the main study findings. However, I would propose the inclusion of a couple of bibliographic references in the discussion section:

Linda D. Breeman, Mike Keesman, Douwe E. Atsma, Niels H. Chavannes, Veronica Janssen, Lisette van Gemert-Pijnen, Hareld Kemps, Wessel Kraaij, Fabienne Rauwers, Thomas Reijnders, Wilma Scholte op Reimer, Jobke Wentzel, Roderik A. Kraaijenhagen, Andrea W.M. Evers, A multi-stakeholder approach to eHealth development: Promoting sustained healthy living among cardiovascular patients, International Journal of Medical Informatics, Volume 147, 2021, https://doi.org/10.1016/j.ijmedinf.2020.104364..

Gyawali P, Tamrakar D, Shrestha A, Shrestha H, Karmacharya S, Bhattarai S, Bhandari N, Malik V, Mattei J, Spiegelman D, Shrestha A. Consumer acceptance and preference for brown rice-A mixed-method qualitative study from Nepal. Food Sci Nutr. 2022 Mar 4;10(6):1864-1874. doi: 10.1002/fsn3.2803. PMID: 35702294; PMCID: PMC9179153.

Tamrakar D, Shrestha A, Rai A, Karmacharya BM, Malik V, Mattei J, Spiegelman D. Drivers of healthy eating in a workplace in Nepal: a qualitative study. BMJ Open. 2020 Feb 25;10(2):e031404. doi: 10.1136/bmjopen-2019-031404. PMID: 32102804; PMCID: PMC7045197.

The 32% of the bibliography cited in the study belongs to the previous five years.

=> Of references suggested by the reviewer, Tamraka et al. (2020) has been included in the discussion section.

Overall, it is an interesting study and should be considered for publication in Applied Sciences, once the minor revisions proposed have been resolved.

Reviewer 2 Report

Consider removing table 2 and explain better the choice for the contents to each group in the text

Figure 1 is unnecessary. You already explain the utilization of the likert scale in the text, and this figure does not improve our understanding.

The paragraph between line 132 and 143 is broken.

In the first round (to identify requirements for swallowing healthcare services), you used one-on-one interviews for patients and guardians, and a group interaction for therapists. How did you classify therapists’ agreement? By consensus? Or individually? This may create some significant bias when you try to analyse comparatively their answers (figure 2) and should be better explained to make it clear for readers.

Where did you find the healthy seniors? And the people at risk?

The guardians are somehow related to the patients?

Results:

It is missing a table providing the general characteristics of the sample. Male or female? Age? The underlying diagnosis, comorbidities, functionality, etc …

how many participants answered the questionnaires? This should be clear in the tables 3 to 5

In figures 2-4 “SE” is standard error? It should be the confidence interval.

Why did you opt not to present the inferential analysis in Figure 2?

I think figures 2-4 are column charts. Please consider changing it to a bar chart.

The presentation of the results could improve if you presented the results from each group in tables 3-5 and not the whole mean. As we see in the figure below, there are differences between the groups, leading to a confusing interpretation of the total sample mean. For healthy people, it seems to have low importance the question of the accessibility to the services “anytime/anywhere”, which is relevant for individuals at risk and even higher for providers. Although present in the figures, it would be better to show the mean and confidence interval in a table.

Discussion:

I agree with you when you say that “The findings of this study 275 underscore significant differences in the perceived importance of requirements for swallowing healthcare services among the stakeholder groups.” I think this is the most important conclusion of you article and it should be better discussed, not only to integrate different stakeholders in the decisions for healthcare organization, which is crucial, but also to discuss the differences and what they mean in the current organizational system. Why healthy seniors do not value accessibility for swallowing healthcare services? Why do providers, in general, value almost all the questions more than patients? Are the services designed to answer providers questions or to solve patients’ problems?

I don’t understand the tables in the supplementary material. Perhaps it would be clear to present a copy of the questionnaires.

In the objectives, you mention the “key service features were prioritized for the development”, but I cannot find it in the discussion.

Consider to include a last paragraph with your conclusions.

There are several minor aspects to imporve in english language.

Author Response

We have carefully revised the manuscript by accommodating the suggestions and feedback of the reviewers. We have summarized our responses to the reviewers’ comments point-by-point. All the changes are highlighted in red Times font in the revised manuscript.

1. Consider removing table 2 and explain better the choice for the contents to each group in the text

=> Table 2 is kept in the manuscript because it provides an overview of subjects being evaluated by stakeholder group in the importance assessment questionnaire. A brief description on the table has been added to the manuscript.

2. Figure 1 is unnecessary. You already explain the utilization of the Likert scale in the text, and this figure does not improve our understanding.

=> Figure 1 has been removed from the manuscript by following the recommendation of the reviewer.

3. The paragraph between line 132 and 143 is broken.

=> The paragraph has been corrected.

4. In the first round (to identify requirements for swallowing healthcare services), you used one-on-one interviews for patients and guardians, and a group interaction for therapists. How did you classify therapists’ agreement? By consensus? Or individually? This may create some significant bias when you try to analyze comparatively their answers (figure 2) and should be better explained to make it clear for readers.

=> As explained in the manuscript, two types of questionnaires (requirement survey questionnaire and importance evaluation questionnaire) were used in the study. In the first round, the requirement survey questionnaire was used to survey requirements in swallowing healthcare services. The requirements collected from the first round survey were reviewed and classified through discussions among four experts in rehabilitation medicine, language pathology, social welfare, and ergonomics. Then, in the second round, the importance of the swallowing healthcare requirements was evaluated by administering the importance evaluation questionnaire individually among participants of various stakeholder groups. The procedures of the two-round surveys in this study have been described in detail in the manuscript.

5. Where did you find the healthy seniors? And the people at risk? The guardians are somehow related to the patients?

=> The methods of participant recruitment have been described in detail in the Participants section.

Results.

6. It is missing a table providing the general characteristics of the sample. Male or female? Age? The underlying diagnosis, comorbidities, functionality, etc …

=> The participants were recruited for the selection criteria of the five stakeholder groups (healthy seniors, individuals at risk, patients, guardians, and medical professionals), as explained in the methods section, without considering gender and age. Lacking consideration of the participant recruitment in terms of age and gender has been addressed as a limitation of the present study in the discussion section.

7. How many participants answered the questionnaires? This should be clear in the tables 3 to 5

=> The number of participants has been added to the corresponding figures.

8. In figures 2-4 “SE” is standard error? It should be the confidence interval.

=> Yes, SE represents standard error, and SE intervals have been added to the corresponding figures.

9. Why did you opt not to present the inferential analysis in Figure 2?

=> The statistical significance information has been added to the corresponding figures.

10. I think figures 2-4 are column charts. Please consider changing it to a bar chart.

=> The column charts of the figures have been changed to bar charts by following the recommendation of the reviewer.

11. The presentation of the results could improve if you presented the results from each group in tables 3-5 and not the whole mean. As we see in the figure below, there are differences between the groups, leading to a confusing interpretation of the total sample mean. For healthy people, it seems to have low importance the question of the accessibility to the services “anytime/anywhere”, which is relevant for individuals at risk and even higher for providers. Although present in the figures, it would be better to show the mean and confidence interval in a table.

=> Standard errors of mean have been indicated in the corresponding figures and the tables summarizing the importance evaluation results of swallowing healthcare requirements have been added as Appendices D to F.

Discussion.

12. I agree with you when you say that “The findings of this study 275 underscore significant differences in the perceived importance of requirements for swallowing healthcare services among the stakeholder groups.” I think this is the most important conclusion of your article and it should be better discussed, not only to integrate different stakeholders in the decisions for healthcare organization, which is crucial, but also to discuss the differences and what they mean in the current organizational system. Why healthy seniors do not value accessibility for swallowing healthcare services? Why do providers, in general, value almost all the questions more than patients? Are the services designed to answer providers questions or to solve patients’ problems?

=> The interpretation of the importance evaluation results has been added to the discussion section.

13. I don’t understand the tables in the supplementary material. Perhaps it would be clear to present a copy of the questionnaires.

=> As explained in the manuscript, Appendices A to C present detailed requirements with prevention/screening, evaluation/diagnosis, and treatment/training among various stakeholder groups, respectively, and Appendices D to F present their importance evaluation results of the  requirements with prevention/screening, evaluation/diagnosis, and treatment/training, respectively.

14. In the objectives, you mention the “key service features were prioritized for the development”, but I cannot find it in the discussion. Consider to include a last paragraph with your conclusions.

=> Key service features were prioritized based on the importance evaluation results of the requirements, as addressed in the discussion section.

Reviewer 3 Report

introduction:

the introduction is well written and supported by literature. perhaps the research question could be stated a little more clearly at the end.

Method:

the method is sufficiently described and comprehensible.

Results

the results are interesting and also expected, especially the homogeneity of the results raises the question of whether the method may not be sufficiently suitable to differentiate the question sufficiently. The presentation of the results is thorough and easy to understand.

the discussion is informative and includes the literature. perhaps the limitations of this method/study could be addressed more.

source 24 looks incomplete

Author Response

We have carefully revised the manuscript by accommodating the suggestions and feedback of the reviewers. We have summarized our responses to the reviewers’ comments point-by-point. All the changes are highlighted in red Times font in the revised manuscript.

1. [Introduction] The introduction is well written and supported by literature. perhaps the research question could be stated a little more clearly at the end.

=> The research question of the present study has been added to the introduction section.

Method. the method is sufficiently described and comprehensible.

2. [Results] The results are interesting and also expected, especially the homogeneity of the results raises the question of whether the method may not be sufficiently suitable to differentiate the question sufficiently. The presentation of the results is thorough and easy to understand.

=> The statistical testing results have been added to the figures of the importance evaluation results of swallowing healthcare requirements.

3. [Discussion] The discussion is informative and includes the literature. perhaps the limitations of this method/study could be addressed more.

=> The limitations of this study have been added to the discussion section.

4. Source 24 looks incomplete.

=> Modified the reference.