-->PONE-D-26-08610-->-->Qualitative Study on Social Isolation Experience of Elderly Patients with Type 2 Diabetes Mellitus-->-->PLOS One

Dear Dr. Hu,

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.-->-->

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The topic is relevant and timely, particularly in the context of population ageing and chronic disease management, and the manuscript draws on qualitative data that has the potential to provide meaningful insights into patient experiences. However, following careful evaluation of the manuscript and the reviewers’ reports, several substantive concerns have been identified that currently limit its scientific robustness and suitability for publication.

The primary concern relates to the insufficient rigor and transparency of the qualitative methodology. The manuscript does not clearly specify or justify the qualitative approach adopted, and key elements such as participant recruitment, sampling rationale, and the process by which data saturation was achieved are inadequately described. In addition, the analytical procedures lack sufficient detail, particularly regarding coding processes, theme development, and whether multiple researchers were involved in analysis and validation. The manuscript also does not address essential criteria for qualitative rigor—such as credibility, dependability, confirmability, and transferability—nor does it include a reflexivity statement. These omissions need to be addressed comprehensively to meet expected standards.

Regarding the results, while the thematic organization is generally clear and supported by participant quotations, the analysis remains largely descriptive. Greater analytical depth is required to move beyond reporting experiences toward interpreting their meaning within a conceptual or theoretical framework. There is also some overlap between themes and redundancy in the presentation, which reduces clarity and coherence. Refinement of the thematic structure and more selective use of quotations would strengthen this section.

The discussion section requires substantial revision to enhance its scholarly contribution. At present, it largely reiterates the findings and places disproportionate emphasis on prescriptive recommendations that are not always sufficiently grounded in the data. A more critical and interpretive discussion is needed, including stronger engagement with the international literature and clearer articulation of the study’s contribution. In addition, the manuscript does not adequately address its limitations, particularly those related to sample size, single-site design, and contextual specificity, which are essential for assessing transferability.

In summary, while the manuscript addresses an important topic and is based on potentially valuable qualitative data, it requires significant improvement in methodological rigor, analytical depth, and clarity of reporting.

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We look forward to receiving your revised manuscript.

Kind regards,

André Luis C Ramalho, 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?

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Reviewer #1: Partly

Reviewer #2: No

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

Reviewer #1: N/A

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 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: Yes

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

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Reviewer #1: No

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:  The manuscript addresses an important topic but shows consistent weaknesses across all sections. The introduction lacks clarity, logical flow, and a clearly articulated research gap with several language and structural issues. The methodology provides a basic qualitative framework but lacks rigor with insufficient detail on sampling, data saturation, analytical procedures, and trustworthiness criteria. The results are well-organized and supported by rich participant quotes, yet remain largely descriptive with overlap between themes and limited analytical depth. The discussion aligns broadly with the findings but mainly restates results, overemphasizes recommendations and lacks critical engagement with literature and study limitations. Overall, the study requires substantial revision to improve coherence, methodological transparency and analytical rigor. I have provided few points below to improve the article for future correspondence. But this time I am unable to accept its publication due to the standard of the esteem journal.

Introduction:

The introduction addresses a relevant and important topic (T2DM, ageing, and social isolation). However, it has major issues in clarity, structure, language and logical flow. It currently reads as fragmented and partially incomplete and requires substantial revision before being suitable for publication. It needs deep background check.

• Lack of clarity and coherence: The introduction contains grammatical errors, incomplete sentences and unclear phrasing, making it difficult to follow.

• Poor structure and organization: Ideas are presented in a disjointed manner, with no logical progression from background to research gap and study aim.

• Weak research gap and justification: The need for the study- especially the qualitative approach is not clearly or convincingly explained.

• Inadequate use of literature: Citations are poorly integrated and some claims are oversimplified or lack proper contextual explanation.

• Conceptual and scientific issues: Definitions (e.g., social isolation) are somewhat inaccurate or oversimplified and causal relationships are presented too simplistically.

• Language and readability problems: The text requires substantial editing for grammar, conciseness and academic tone.

Methodology:

Methodology demonstrates a basic qualitative framework; however, it lacks sufficient rigor, transparency and detail. Key aspects such as sampling justification, data saturation, analytic procedures and trustworthiness criteria are inadequately addressed. In tables no mention of units i.e. Age (years/months/days???), Duration of illness (years/months/days???). These are very basic. Substantial revision is required to meet qualitative research reporting standards.

• Unclear study design: The qualitative approach is not well specified or justified and the choice of design is inadequately explained.

• Sampling limitations: Purposive sampling is mentioned but recruitment procedures, sampling rationale, and evidence of data saturation are insufficiently described; single-site sampling limits generalizability.

• Insufficient detail in data collection: Interview procedures lack depth with no discussion of researcher reflexivity, interviewer role or adequacy of interview duration.

• Weak rigor and quality assurance: Key criteria for qualitative rigor (credibility, dependability, confirmability, transferability) are not addressed.

• Inadequate data analysis description: The coding and thematic analysis process lacks transparency, with no detail on coding framework, inter-coder agreement, or theme development.

• Ethical and reporting gaps: Ethics approval is not reported and the methodology does not adhere to established qualitative reporting standards.

Results:

Results part partially align with the study objective of exploring social isolation among elderly patients with type 2 diabetes, as they present relevant experiences related to psychological distress, relational dynamics and environmental barriers. However, this alignment is not consistently strong or explicit. The central concept of social isolation is not systematically integrated across all themes and some findings (e.g., environmental or healthcare system issues) appear indirectly related rather than clearly tied to the core objective. Additionally, the lack of deeper analytical interpretation and weak link to the guiding theoretical framework limit the extent to which the findings fully address and advance the stated research aim. There is overlap between themes, limited integration with the theoretical framework and issues with redundancy and verbosity. Greater clarity, conceptual refinement, and analytical interpretation are required to strengthen the findings.

• Thematic structure issues: Although themes and subthemes are clearly presented, there is overlap between categories and insufficient justification for the thematic framework.

• Limited analytical depth: The findings are largely descriptive with minimal interpretation or higher-level conceptual analysis.

• Quotation overuse: Participant quotes are rich but often too lengthy and repetitive, reducing clarity and impact. Please learn how quotes are presented in academic journal. Very poor presentation.

• Weak integration with theory and objectives: The results are not consistently linked to the stated theoretical framework (social ecological theory) or clearly anchored to the core concept of social isolation.

• Redundancy and lack of rigor: Repetition of similar ideas, absence of thematic prevalence indicators and limited transparency in how findings were derived weaken the rigor.

Discussion:

Discussion demonstrates a clear effort to organise findings within a socio-ecological framework and maintains thematic consistency with the results. However, it falls short in delivering critical, in-depth interpretation and scholarly engagement. The section reads more as a set of practical recommendations than a rigorous academic discussion, with insufficient attention to limitations, contextualization and theoretical advancement. Substantial revision is needed to strengthen analytical depth, balance, and scientific contribution.

• Limited analytical depth: Discussion largely restates the results using theoretical language, with insufficient deeper interpretation or exploration of underlying mechanisms.

• Weak engagement with literature: Existing studies are cited mainly for support, with little critical comparison or positioning of findings within broader research.

• Overemphasis on recommendations: A substantial portion focuses on intervention strategies which are often overly prescriptive and not fully grounded in the data.

• Lack of methodological reflection: There is no discussion of study limitations, context or transferability, leading to potential overgeneralization of findings.

• Imbalance and structure issues: The section is uneven, with minimal interpretive discussion and extensive policy-like recommendations, reducing academic rigor.

• Underutilization of qualitative insights: The richness of the data is not fully translated into higher-level conceptual or theoretical contributions.

Reviewer #2:  1. The study presents limited results of insufficient qualitative research with only 14 participants in the entire study.

2. The participants characteristics are inadequately presented. There is need to present the mean age / standard deviation or median age and interquartile range.

3. The result column indicating duration of illness is unclear. What illness was considered?

4. A single session of in-dept interview is inadequate to reach remarkable conclusions.

5. Conclusions made are not valid because results are insufficiently presented from inadequate data.

6. The research methods and design have not referenced to justify the use of 14 participants for only a single session. This compromises the integrity of the whole study.

7. The study requires major revisions and may only be accepted when additional information on the methods, the number of sessions of the in-dept interview is more than once.

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Reviewer #1: Yes:  Dr. Ipsita Basu.

Researcher

INRCA - IRCCS l Italy

(National Institute of Health and Science on Ageing)

Reviewer #2: Yes:  Babatunde Abdulmajeed Akodu

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Attachments

Attachment

Submitted filename: Social isolation in elder DM Plos One.pdf

Attachment

Submitted filename: Qualitative Study on Social Isolation Diabetes comments.docx

Experiences of social isolation among older adults with type 2 diabetes mellitus: a qualitative study

PONE-D-26-08610R1

Dear Dr. Li,

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,

André Luis C Ramalho, PhD

Academic Editor

PLOS One

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 #2: All comments have been addressed

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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 #2: Yes

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

Reviewer #2: Yes

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-->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 #2: Yes

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-->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 #2: Yes

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-->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 #2: Authors have satisfactory responded to the queries raised in the initial submission.

They have improved the table title and participants characteristics. Authors have provided more details in the materials and methods section with more clarity. The discussion is now well compared and contrasted with past studies with reasons for similarities and differences.

This is to affirm that the manuscript titled “Experiences of social isolation among older adults with type 2 diabetes mellitus: a qualitative study” which has been resubmitted to PLOS One for re-review has been re-examined by me. I hereby confirm that the authors have responded satisfactorily to both reviewers comments. I recommend that manuscript be accepted for publication.

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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.

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Reviewer #2: Yes:  Babatunde Abdulmajeed Akodu

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Attachments

Attachment

Submitted filename: Reviwers comment for PLOS One 2026.docx