PONE-D-20-04931

The External Realities of Individuals with Type 2 Diabetes – Understanding Disease Perspective and Self-Management via Grounded Theory Approach

PLOS ONE

Dear Dr. Swarna Nantha,

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 Nov 27 2020 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.

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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Janhavi Ajit Vaingankar

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

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2. Please include additional information regarding the interview guide or script used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a guide 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.

3. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

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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?

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

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

Reviewer #1: N/A

Reviewer #2: 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 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: No

Reviewer #2: Yes

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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

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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: Thank you for the opportunity to review this manuscript. The study is interesting and reports important findings about the experience of managing type 2 diabetes in adults in Malaysia.

The language throughout the paper is judgmental and needs to be revised using strengths-based, person-centered, and empowering messages. Negative, judgmental language is not only unhelpful to people with diabetes and health care providers, it negates much of what you found in your study. Please see my notes in the attached word document, where I have gone through the entire manuscript, made suggestions, and highlighted concerning examples. Please refer to the guidance published by the American Diabetes Association and Association of Diabetes Care and Education Specialists: Dickinson, et al. (2017). The use of language in diabetes care and education. Diabetes Care, 40, 1790-1799, which includes recommendations for changing specific words/phrases and rationale for doing so.

Only 7 of 18 references represent current literature and a few references are extremely dated.

Your discussion, implications, and conclusions do not sufficiently support the findings nor provide guidance to readers for how to change their practice. Again, your findings are important and I encourage you to consider submitting to another publication once these changes are made and inconsistencies remedied.

Reviewer #2: Dear authors,

thank you very much für the opportunity to read the manuscript „The external realities of Type 2 Diabetes Patients“.

I accepted the review because I was very interested in the title and the method, but unfortunately, more questions remained with me than I received answers. In the following lines, I explain what I mean by this.

I will skip the abstract and the introduction. My comments on this can be read in the overall evaluation.

Material and Methods

„A qualitative grounded theory approach“ ist double formulated. I don’t know a quantitative GT.

Purposive sampling is not the sampling approach for Grounded Theory. This is the theoretical sampling. This deviation should be well justified and should be mentioned in the limitations in my opinion.

Among the participants, it is not quite clear to me why doctors, diabetes pharmacists and pharmacists were questioned. When it comes to self-managment beliefs in T2D patients, the external perspective irritates me. If it needs it, please explain it better. I do not understand it and find it highly problematic. Were the different sources brought together? The title of the paper raises doubts about the usefulness of the expert information.

Why were the same patients questioned in focus groups in addition to the individual interviews? What were the topics? And so it leads straight over to my biggest question or my biggest concern: What did you actually ask in the interviews? You write they are in-depth interviews. That is where a narrative-generating impulse is set. Which one is that? I can't find it in the manuscript. Can you give us your central question. A little later I read "topic-guide". This does not fit to in-depth interviews. That would be semi-structured interviews. Following your advice, I looked at the study protocol and the topic guide. Afterwards I would very much question the term in-depth interview.

Furthermore, you write that you had a theoretical saturation after 10 interviews, but then you explored and enriched this with 14 more interviews. Is it perhaps because of the sampling that so many more interviews had to be conducted?

The description of the analysis does not go beyond the formation of categories. How does the theory emerge?

Results

I don‘ understand how do you observe „thought patterns“.

To Table 3: Experts argue splendidly whether a frequency count of categories is qualitative work. In a Grounded Theory work, I consider it obselete.

Table 3: Why is lifestyle one of the non-modifiable factors?

Chapter lifestyle: „In general, patient frequently miss taking their medikation when they are out of their homes. You cannot introduce such a statement with "in general". What do you base that on, 24 interviews? With this statement, you are overstressing your data.

The presentation of the results seems very descriptive, not very interpretative. So not so much based on Grounded Theory. I miss the merging of the areas; categories are not developed in further details. I cannot reconstruct how Food environment, lifestyle and sociodemographics became the background.

Discussion

I cannot understand the first sentence at all. Where does it come from, I did not read it out at all. I also can't find the content of the second sentence (or the background for it) in the description of the result at all.

The major themes are not comprehensible to me.

Implications: It is not easy for me to deduce possibilities for behavioural change from the categories presented in this paper or to find starting points for targeted interventions.

Overall

The present manuscript describes a small part of the results of the qualitative part of a mixed-methods study. The knowledge gained with the results presented here seems to me to be limited and I do not have the impression that it would help me in science or in practice. The result of the entire qualitative part could be interesting, but not this excerpt alone.

In addition, good mixed-method research is characterised by an integration of qualitative and quantitative parts on as many levels as possible (research question, data collection, analysis). Thus, separate presentation naturally remains below the actual possibilities.

The interview guide, with its strong focus on medication, does not seem to me to be so well aligned with the cognitive interest of the overall project. How the answers to these questions are to be used to develop a theoretical model that explains disease management in diabetics is questionable.

With these estimations, I come back to the introduction. Strictly speaking, it already seems to fit to manuscript. But I as a reader remain somewhat confused with my question: what is the overall question of the project, what is the question of the manuscript, how can the result presented in the manuscript contribute to the overall question.Mediators, categories etc. are mentioned in the paper from time to time, which become relevant in the overall project, but are not connected to the external realities for the time being. This is somewhat confusing.

I do not think that extracting this manuscript is a good idea or that it really needs to be presented more clearly. There are simply too many questions for me as a reader.

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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.]

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Attachments

Attachment

Submitted filename: PLOS ONE Swarna Nantha - External Reality (21.2.2020).docx

PONE-D-20-04931R1

The External Realities of People with Type 2 Diabetes – Understanding Disease Perspective and Self-Management Behaviour via Grounded Theory Approach

PLOS ONE

Dear Dr. Swarna Nantha,

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.

I urge the authors to address the comments from the second reviewer regarding the study design, data collection and results carefully in your revision.

Please submit your revised manuscript by Jan 22 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

We look forward to receiving your revised manuscript.

Kind regards,

Janhavi Ajit Vaingankar

Academic Editor

PLOS ONE

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. 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: Yes

Reviewer #2: No

**********

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

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. 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: No

Reviewer #2: No

**********

5. 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

**********

6. 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: Thank you for addressing reviewer feedback and changing the language in your manuscript. I hope you will continue to use person-centered, strengths-based, and empowering language going forward in speaking and writing.

Reviewer #2: Many thanks for the careful revision and the extensive explanations in the revision letter. A lot was explained to me, but unfortunately not everything convinced me.

I take a very critical view of the topic guide for the interviews with their strong focus on medication.

Regarding my problem with the inclusion of health care professionals, I was referred to a chapter in the manuscript. However, it remains open for me what external parties can contribute to the questions of the study and what questions were asked to the experts in their individual interviews. None of this clarified the revision for me. Somewhere in the "strenghs and limitations" I am reading that the statements of people with diabetes were submitted to the experts for verification. Why should this happen when it comes to the "realities" of people with diabetes.

In the results section I miss the framing. Incredibly many small individual dimensions are opened and quotes are added. But how they (can be) brought together in the larger dimension is hardly comprehensible for me.

I maintain that it seems unfavorable to me to publish this paper, which is separated from the overall results. In my opinion, this leaves too much open for the reader and the practical benefit seems doubtful to me.

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7. 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.

The External Realities of People with Type 2 Diabetes – Understanding Disease Perspective and Self-Management Behaviour via Grounded Theory Approach

PONE-D-20-04931R2

Dear Dr. Swarna Nantha,

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,

Janhavi Ajit Vaingankar

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. 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: Yes

**********

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

Reviewer #1: I Don't Know

**********

4. 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

**********

5. 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

**********

6. 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: Thank you for addressing the reviewer's feedback. I have nothing further to add at this time. Thank you.

**********

7. 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