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\begin{document}

\title{Responses to reviewers}



\author[1]{wl1984 .}%
\author[1]{Mwidimi Ndosi}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 20, 2024}


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~REVIEWER 1 EVALUATION

~

1)~~~~~ The title is not corresponding with your work, Suggestion:
Translation, cross-cultural adaption and validation of the chinese
version of the educational needs assessment tool in knee osteoarthritis

~

\textbf{Response:}

The work included translation of the ENAT from English into Chinese
while taking account of the cultural context in which the language is
used. This was followed by statistical validation of the tool using
patient data. The term `cross-cultural validation' includes the
adaptation (which includes translation) and validation using the data,
the original title was correct. We have however changed this title to be
more specific, thus: \textbf{Cross-cultural validation of the
educational needs assessment tool into Chinese for use in severe knee
osteoarthritis}

~

2)~~~~~ The aim is not corresponding with your work, Suggestion: To
develop and validate the chinese Version of the ENAT for use in severe
knee osteoarthritis

~

\textbf{Response:}

This was not tool development project, the ENAT is already a
well-developed tool validated in over 10 countries. Our aim was to adapt
and validate the ENAT into Chinese, for use in severe knee
osteoarthritis. We have therefore not changed this statement.

~

3)~~~~~ Introduction: 2nd Paragraph: important references are missing,
e.g. OARSI or EULAR recommendations for the management of knee
osteoarthritis

\textbf{~}

\textbf{Response:}

Thank you for pointing this out. A reference to the EULAR
recommendations for the management of knee OA had been added in the
revised manuscripts.

~

4)~~~~~ Methods: I recommend to restructure this part: 1. Study design,
patients and ethical approval 2. Translation and cross-cultural adaption
3. Validation 4. Measures 5. Statistical Analysis

~

\textbf{Response:}

The term cross-cultural adaptation includes translation of the tool.
Validation includes testing for construct validity and concurrent
validity (using other measures) therefore including another sub-section
of `measures' would be repeating ourselves. We have therefore
restructured the methods into the following sub-sections. (i) Study
design, patients and ethical approval (ii) Cross-cultural adaption (iii)
Validation and (iv) Statistical Analysis

~

5)~~~~~ Results: 3.1. ``Patients'' is not needed, there is no focus on
patients. What is needed is information about PEPPI, SEE-C, SER and ENAT
(second part of Table 1), name it ``Descriptive data of the validation
setting'' 3.2 change title, e.g. into Development of the chinese version
of the ENAT (CENAT). Refer to Figure 1 in this section

~

\textbf{Response:}

We feel that including patient characteristics is important in this tool
validation study. Validation of the tool involves collecting data from
patients and we feel it is important to show the population from which
the measures have been drawn. What this study shows is that the ENAT is
valid for use in Chinese people with knee OA -- we do not have evidence
for use of the tool in Chinese patients with types of OA for example.

~

6)~~~~~ Discussion: 1st Paragraph: reference Beaton. delete second
sentence. 2nd Paragraph: delete first sentence (repetition). 3rd
paragraph: please rework, what exactly do you want to point out.

~

\textbf{Response:}

The section of the discussion has been amended to take account of the
reviewer's comments.

~

7)~~~~~ Conclusion: ok

~

8)~~~~~ References: Ref 9 is missing.

\textbf{~}

\textbf{Response:} {}

Ref 9 had been added.

~

9)~~~~~ Tables: Table 1: Change title into ``descriptive data of the
validation setting'' and delete Patient characteristics. Table 2: I
suggest to provide it as Appendix.

\textbf{~}

\textbf{Response:} {}

We thank the reviewer for this suggestion, but we believe this table
summarises the biographical and other characteristics of the patients
and there are no data on the settings therefore the title Patient
characteristics has been left as is.

~

10)~ Figures: Figure 1: see comment above Figure 2-4: I suggest to omit.
In General: the manuscript needs major improvement in english grammar,
punctuation an spelling

\textbf{~}

\textbf{Response:} {}

Figure 2,3 had been deleted, I advised Figure4 should be reserved,
because it is the result of CFA.{}

~

REVIEWER 2 EVALUATION

~

In order of importance:

~

1.~~~~~~~~ This tool would be very useful for all types of
osteoarthritis. Please add more detail on why the only knee
osteoarthritis was included in your study. Can you extrapolate findings
to all types of Osteoarthritis? If yes, describe. If not, why not?
Include in the discussion.~

~

In some European countries, the ENAT has been validated as a generic
tool for all major types of arthritis but in China, our study validate
this tool for use in knee osteoarthritis - the population of patients
from which we obtained the evidence of validity. We have added a
sentence in the study limitations that further evidence will be required
before the CENAT is used in other types of osteoarthritis in China.

~

2.~~~~~~~~ In the results section 3.4, you describe the correlations as
significant and conclude that criterion validity is established.
However, the r coefficients are moderate (i.e. r=0.398), not strong.
Please provide potential explanations for the moderate correlations. For
example, self-efficacy can take long to develop for some people. Include
in the discussion.~

~

We expected significant correlation between the CENAT and self-efficacy,
however we cannot claim that completing the CENAT in itself would lead
to higher levels of self-efficacy -- after all this was a cross
sectional study.

~

3.~~~~~~~~ In the results section 3.2, you introduce the ``Expert
Committee'' for the first time. It would be useful for the reader to
learn about the expert committee in the methodology section; describe
the role of the committee and where the committee fits in the process.~

~

Thank you for pointing this out. We have now described the role of the
``Expert Committee'' in the methods section (adaptation of the ENAT into
Chinese).

~

4.~~~~~~~~ Section 2.1.2 - describing the process of adaptation of the
ENAT into Chinese is not very clear to the reader. Figure 1 is much
easier to understand. Consider revising this section to improve
readability.

~

This part has been revised and figure 1 retained.

~

REVIEWER 3 EVALUATION

~

The topic chosen has significant relevance to the Chinese population not
only in China but in other parts of the world where Chinese patients can
be found.~

~

The paper was written in a way that is simple to read and comprehend.
Main facets of the study has been discussed with some justification for
the chosen methodology.

~

\begin{enumerate}
\tightlist
\item
  There should also be a brief discussion on the responsiveness of the
  original ENAT; its concurrent validity; its construct validity etc. Is
  the original ENAT designed to address the same issue as the authors
  were proposing?~
\end{enumerate}

\textbf{~}

\textbf{Response}{}

The information of the validity of the original ENAT and its
translations in other countries has been included in the introduction.
We have stated: `The ENAT has been validated for use in osteoarthritis
in Austria, the Netherlands, Norway, Portugal and the UK.'{}

~

\begin{enumerate}
\tightlist
\item
  In the absence of an independent trial steering committee to oversee
  the integrity of the research and to allow assessing the relevance of
  the study including determining the level of generalization possible
  from its results, it may be helpful to include more details, for
  example, the recruitment process, how potential patients were
  identified, how many clinicians/hospitals were involved with
  recruiting patients; were all patients hospital-based patients or
  recruited from community; how severe is their osteoarthritis; what is
  their BMI; did they have bilateral or unilateral knee osteoarthritis;
  etc.
\end{enumerate}

~

This study had overseen by three doctors. {Two of them are a experienced
orthropedics doctor, another one is a family
doctor.}\protect\hyperlink{_msocom_1}{{[}MN1{]}}~{}

~

\begin{enumerate}
\tightlist
\item
  I am also not quite sure what this means:``The participants'
  identifiable information was carefully protected throughout the
  survey'' (section 2.2, line 2-3). Can you please clarify how this was
  achieved?
\end{enumerate}

~

This section has been revised. We have stated: `Once returned, the data
from the questionnaires were anonymised and entered into a spreadsheet
for data cleaning and analysis'

~

\begin{enumerate}
\tightlist
\item
  It may also be useful to know if the clinicians who assessed the
  patients were also the one who recruited the patients and who
  administered the questionnaires. Was there an independent person who
  entered the data and analysed the data?~
\end{enumerate}

~

We have mentioned in the methods section that the senior author, WL who
was not involved in the data collection undertook the statistical
analysis.

~

\begin{enumerate}
\tightlist
\item
  Throughout the manuscript, there needs to be a consistency on the
  precision of the values given; e.g. Section 3.1, line 3 :``mean age
  63.61\selectlanguage{ngerman}±8.7'' - I would suggest 63.1 +/- 8.7 years; ``mean disease
  duration 11.48±6.6'' - 11.5 years will be a more meaningful value
  Section 3.3, line 4:\selectlanguage{greek}χ\selectlanguage{english}2 was 6458.531? Section 3.3, line 8: contribution
  rate was 67.860\% - I suggest keep to 1 decimal place
\end{enumerate}

~

Thank you for pointing this out. The reporting of statistics has been
reviewed throughout the revised manuscripts.

~

\begin{enumerate}
\tightlist
\item
  Spearman correlation coefficient was described including the relevance
  of the values that is " .20-.39, .40-.59, .60-.79 and .80 -1.0
  representing weak, moderate", and so on but the results did not relate
  to the strength of the correlation apart from saying they were
  significant.
\end{enumerate}

~

The correlations have now been specified in the revised manuscripts.
Thank you!

~

\begin{enumerate}
\tightlist
\item
  The correlation of CENAT with the data from PEPPI (r=0.398,
  p\textless{}0.001; SER r=0.397, p\textless{}0.001; SEE r=0.387;
  p\textless{}0.001) was weak based on the criterion given by authors.
  So what is the implication of this on the overall results and also the
  generalizability of the translated questionnaires?
\end{enumerate}

~

The CENAT identifies the educational needs of patients and once these
have been addressed, one expects their self-efficacy will increase. As
this was a cross-sectional study, a measure of needs may not necessarily
reflect self-efficacy, though one would expect higher correlation than
unrelated variables such as disease duration or age. This reason has
been added in the discussion section.

~

\begin{enumerate}
\tightlist
\item
  The limitations of the study can be further explored (e.g. potential
  bias etc) to allow readers to make sense of the results. Rephrasing
  this study as a preliminary study can be helpful.
\end{enumerate}

~

Thank you for this and we have added in the limitations that this was a
preliminary study and may have a risk of selection bias. {}

\protect\hypertarget{_msocom_1}{}{}

~\protect\hyperlink{_msoanchor_1}{{[}MN1{]}}This needs more
comprehensive response

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