Dear Dr. Nik Mohd Nasir,

Please submit your revised manuscript by Dec 20 2024 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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Shairyzah Ahmad Hisham, PhD.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: No

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Manuscript Review for PONE-D-24-32929

Dear authors,

Congratulations on your research and on producing the manuscript. My comments serve to improve the clarity of reporting and ease comprehension for new readers.

Title:

The title is clear and reflects the objective and methods of your research.

Abstract:

The abstract was clear, structured and comprehensible.

Introduction:

Introduction was well-funneled and well-written in highlighting the background and why such research is needed. The main objective was clearly stated. No additional improvements necessary.

Methods:

1. Figure 1 contains a lot of abbreviation. Please include footnotes or relocate to the end of the Methods section as a section summary.

Section 2.2 Study tool

1. Please state the language used in ADU-Q.

Section 2.2.3

Assessment of domain validity

1. Please explain how assessment of domain validity was conducted; i.e. rating, open-ended feedback, etc.

2. Please state, in general, the years of working experience of the 3 domain validity assessors and whether they had extensive experience with asthma patients/management.

3. Please state whether any iterations to the ADU-Q after domain validity assessments were made after the first round.

Assessment of item validity

1. Please state, in general, the years of working experience of the item validity assessors and whether they had extensive experience with asthma patients/management.

2. Please clarify whether the study method of assessing content validity is a form a modified-Delphi or otherwise. If yes, please indicate in the manuscript.

3. Please clarify and cite the cutoff S-CVI/Ave value to indicate content validity.

4. Please indicate and cite the definition of “reaching consensus”.

5. In the flow chart, the second round of content validation was only conducted by 3 out of the 7 panels. Please restate this in the paragraph: who were the three and whether the reduction of the number of panels were permissible/good practice.

2.4 Face validation

1. Please omit the word asthma control and rewrite “(f) having the level of asthma control at Global initiative For Asthma (GINA) step 3 and below” to “(f) is Global initiative For Asthma (GINA) step 3 and below”. This is because “asthma control” refers to controlled, partially controlled and uncontrolled whereas the GINA steps refer to “asthma management”.

2.6.2. Factor extraction

1. Please elaborate and cite the decision to use the fixed number of factors method.

Results

1. Table 1: Final round content validity index (second stage) for item validation for ADU-Q Please clarify the number of experts who participated in the final round of the content validation; in figure 1 study flowchart reported 3 experts but table 1 presented results from all 7 expert.

2. Table 3 – Please substitute the word (GINA) “Stage” to “Step” in this table and throughout the manuscript.

Discussion

1. Page 25, first paragraph: “The mean average usability score for ADU-Q was 5.58 (SD ±1.19)”. Please clarify where readers could find this in the results section. Please elaborate on the total score permissible for the ADU-Q and what scores mean (higher, lower, categories, if any)

2. Page 25, first paragraph: “The mean average usability score for ADU-Q was 5.58 (SD ±1.19)”. Please clarify whether this reflects the usability of the ‘Buku Urus Kendiri Asma’ or something else.

3. Page 27, first paragraph: “In factor retention, several methods are used…”. Please consider moving this paragraph to a relevant subsection under Methods section.

Limitations

1. “There are four limitations to this study.” Please check and make clear whether you have listed these four limitations.

2. Please clarify on whether or not the small number of expert panels in the content validation stage is a potential limitation.

General comments:

Methods, Results and Discussions can be re-written more concisely. I recommend touching-up the manuscript for typos i.e. “dairy (page 3)”, grammatical errors and better sentence structure, for the readers’ benefits.

Congratulations again on this meaningful research and manuscript. Thank you.

Reviewer #2: Dear Authors,

Overall the research is relevant as currently there are hardly any studies being conducted to assess the usability of an asthma self-management tool. The following are the comments according to sub sections:

Abstract

The abstract should elaborate more on the background of the study. Perhaps including the current situation on the control of asthma among the Malaysian population which further emphasize the urge to conduct this research. The content of abstract was not equally divided according to subsection. Most of the content are elaborating on the methods part. Perhaps the results and discussion parts should be refine in the abstract for the readers to get a better overview of the research.

Introduction

In the first paragraph of the introduction, is it possible to add more details (RESONANCE study, no. of patients included with age range and other details such as comorbidities). The details need not be too long, it can be summarised within one or two sentences. In the paragraph, it was also mentioned ' In terms of healthcare burden, the cost to treat patients with uncontrolled asthma is higher than those with controlled asthma'. Is this sentence referring to the Malaysian population or other studies?. The following sentence on the costs of urgent care and maintenance care in Malaysia is also confusing as the costs were stated in USD. Perhaps the costs in both currencies can be stated.

Paragraph 3 and 4 are disconnected. The use of asthma self-management booklet was developed in 2016 and there had been an updated version in 2023 indicating some precipitating issues/problems leading to the update of the booklet. This could be related to the need for usability assessment. Elaboration on this will make a better flow.

Methods

I found that this part of the manuscript contains sufficient details of the conduct of the study. In figure 1, FMS was first mentioned. The author may want to spell out FMS in figure 1 and use abbreviations in the following paragraphs.

Results

Results were appropriately presented. However, i have preference in terms of presentation of table 4, table 5, table 6 e.g. putting the reference range underneath each table for ease of reference (factor loading>0.6 indicates items validity). I noticed there are a lot of results presented but not discussed in the discussion i.e. description/elaboration on the population distribution male vs female, reasoning on why there are more malay population etc. Another point for discussion would be conducting research in a semi-government university hospital would lead to different treatment approach hence affecting the GINA stages and treatment options as well as ACT score. the population's asthma duration can also be discussed further.

Discussion

Under discussion, there were several definitions given i.e questionnaire, good questionnaire. It could have been mentioned in the introduction instead to allow other important points to be included in the discussion e.g. elaboration on the results. Some parts of the discussion are redundant with the results for example "Test with Cronbach Alpha of >0.7 is considered reliable" and "overall ICC value was > 0.9 indicating good reproducibility and stability of the

score over time.

Strength and Limitation

In the results part it was stated that during the data collection, a copy of the Asthma Self-Management Booklet and an explanation regarding the usage of the book were given to the patient. Would there be any bias imposed to the data collection process.

Statistical Analysis

Psychometric properties - It was stated that all items in the questionnaire went through principal component analysis. Is this related to determining whether the factors are correlated before deciding to use promax rotations for analysis?. Is learnability strongly correlated with efficiency and satisfaction? etc.

That is the end of my comments. It is hoped that the issues can be addressed to enhance the readers' interest. Thank you.

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Reviewer #1: No

Reviewer #2: Yes: Aina Yazrin Ali Nasiruddin

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Attachments

Attachment

Submitted filename: PONE-D-24-32929 -reviewed.pdf

Dear Dr. Nik Mohd Nasir,

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.

==============================

ACADEMIC EDITOR:

==============================

Please submit your revised manuscript by Jan 05 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A 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 applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Mohd Ismail Ibrahim, MCom.Med

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: Yes

**********

Reviewer #1: Congratulations on producing a review of the manuscript. My comments serve to improve clarity and reader’s understanding.

Title:

Title clearly reflects the study scope and studied population, though slightly plain. If permitted, consider rephrasing the title. The use of a colon (:) in the title improves paper’s visibility in database searches.

Abstract:

Please rewrite the abstract guided by a structured format (Background -> Main Objective -> Methods -> Results -> Conclusion). An abstract should provide a concise overview of the study process whereas your abstract is a narrative and may appear too detailed. Recommend making more concise.

Introduction:

The background of study is sufficient to demonstrate to extent of problem, the role of asthma self-management and that a tool should be usable. However, please introduce the actual asthma diary itself as a foreshadowing to the aim of study. I suggest moving and rewriting the paragraph “The asthma diary used in this research was taken from The Asthma Self-Management Booklet…” from Methods (pg 6) to Introduction, in order to improve readers’ understanding of the study (which is to adapt and validate the M-MAUQ into the ADU-Q).

Methods:

If I understand correctly, the novelty of this research is the development of ADU-Q. However, the intention of the ADU-Q is first described only at the end of an extensive paragraph on M-MAUQ (pg 5). Please restructure the paragraph to begin with introducing the development of ADU-Q. In addition, please clarify whether all questions were adapted exclusively from the M-MAUQ. I suggest omitting the section “Study Tool” (pg 5) and moving contents to Phase I Adaptation and Content Validation (pg 6).

In Content Validation, “The experts were required to discuss and assess the relevance…” (pg. 7) , please clarify whether this is a form of Nominal Group Technique.

Based on the calculated I-CVI of the expert panel and their feedback, “the items that were deemed irrelevant or unclear were revised, modified or excluded as appropriate according to the expert panels’ suggestions” (pg. 8). Please clarify on how you decide whether which item gets omitted and which item gets iterated. Is there an objective measure (score/threshold level) as a guide or otherwise?

Reaching consensus is defined as “generally accepted opinion or decision among a group of people. In this case all experts agree….” (pg. 9). Please specify if there is an objective measurement of consensus e.g all items achieving a specific S-CVI or I-CVI value?

Please rephrase Figure 1 (pg. 15) concisely according to manuscript standard. Consider to alternately use concisely labeled pictograms to describe the study process instead.

Discussion

“The asthma diary has been part of various asthma guideline recommendation as a self-management tool for patients but a study by Tsang et al demonstrated that compliance to completing the asthma diary was low with only a quarter of participants still monitoring after six months. Thus, the lack of a suitable tool to assess the asthma diary usability has limited our ability to identify if this could be the potential reason for suboptimal compliance to improve on its usage….” (pg. 27) �This is a great study justification, and should be moved from Discussion to Introduction.

“However, to ensure that the participants remain homogenous, the inclusion criteria was set at GINA step 3 and excluded those with other underlying lung diseases” (pg. 28). Please correct to “GINA Step 3 and below”.

Please include that reliance of patient’s self-reporting is a limitation of this study however, as usability reflects user self-reflection, self-report is the most appropriate method for the study (pg 29)

Overall

Well done on producing valid and substantive research and manuscript. However, I strongly recommend a thorough language edit to polish this manuscript grammatically, improve sentence structure, flow and in alignment with scientific writing style. Thank you.

Reviewer #2: Dear Authors,

Thank you for addressing all previous comments. Here are some very minor additional comments.

Introduction part - In the first paragraph, it was stated that healthcare burden in Malaysia was approximately RM301 per patient. Can you clarify whether this is per month or per annum?

Methods- This part was clearly detailed out. Just one minor comment. Under sampling method, patient recruitment and data collection, can you elaborate on "clear verbal instruction" whether the instruction was given by a sole researcher/trained data collectors and whether the instruction is scripted or not.

Results- tables were self-explanatory. Table 3 under results (Gender), did not sum up to 100%. Male gender should be 21.9%. Table 5- Please correct the cronbach's alpha spelling.

Discussion- Please add year of publication for Tsang et al. (Para 1). I felt that the last paragraph under discussion was abruptly stopped. Conclude the discussion for a better flow.

That's all.

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: Yes: Aina Yazrin Ali Nasiruddin

**********

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Attachments

Attachment

Submitted filename: Reviewer Comments for PONE-D-24-32929R1.docx

Psychometric evaluation of the Asthma Diary Usability Questionnaire (ADU-Q): An adaptation and validation of a usability assessment tool among Adults with Asthma

PONE-D-24-32929R2

Dear Dr. Nik Mohd Nasir,

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.

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Kind regards,

Mohd Ismail Ibrahim, MCom.Med

Academic Editor

PLOS One

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