Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. No clear power calculation effect size, alpha, power, expected prevalence???
2. Sampling method unclear, risk of selection bias. Convenience sampling likely limits external validity.
3. Cross-sectional design but causal language used. Associations interpreted as effects must correct.
4. If Likert scales were used: unclear whether treated as continuous vs ordinal???
5. Regression model specification incomplete a) No clear model-building strategy b) No justification of included covariates c) Risk of overfitting not addressed
6. Confounding not adequately controlled. Key variables (age, education, SES, comorbidities) either missing or not justified.
7. Multicollinearity not assessed. No reporting of VIF/tolerance.???

8. Missing data handling not reported.  No mention of % missing, Method complete case? imputation?

9. Assumptions of statistical tests not checked, Normality, Linearity (for regression), Homoscedasticity.

10. Should include ORs, β coefficients, confidence intervals.
11. Inconsistent reporting format (mean ± SD vs median)
12. P-values not reported precisely p<0.05 instead of exact.
13. Tables lack clarity units, reference categories.
14. Confidence intervals formatting inconsistent

Best of Luck

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript addresses a relevant, current, and strategic topic.

The work is well-structured, methodologically clear, and presents coherent results. However, there are issues that should be addressed before considering publication:

- The PHM-Q instrument was developed for this study and assesses the "endorsement of concepts related to PHM," but the items that compose it reflect general principles of health promotion, integrated care, and social determinants, and not distinctive aspects of PHM as an operational model. Therefore, it is my understanding that there is a risk that high levels of agreement reflect the social desirability of the participants or agreement with normative values, and not a true informed acceptance of PHM. Thus, the authors should reinforce the discussion about the construct validity of the PHM-Q, clarifying more critically that the instrument measures attitudes favorable to general principles of person-centered care, and not PHM as a technical-organizational approach.

- Some interpretations go beyond what the data allow to conclude, given that the cross-sectional design prevents any causal/directional inference. The conclusion suggests implications for the implementation of PHM in primary care, but the data mainly reflect attitudes, not effective behavior or operational understanding. Thus, adopting more cautious language in the Discussion and Conclusions, emphasizing that the results inform conceptual receptiveness, not readiness for PHM implementation.

The study is conducted in a single context, which limits the representativeness of the general Saudi population. The high proportion of participants with secondary or higher education may bias the results. I suggest reinforcing this point in the limitations section and avoiding implicit extrapolations to other contexts, especially rural or lower literacy contexts.

The text should be revised for greater terminological consistency; it would be helpful to clarify what types of programs were available in the studied context, as low participation may reflect limited supply and not just low adherence.

Minor linguistic adjustments are needed to reduce redundancies in the Discussion, and some tables could be summarized or referenced more succinctly in the main text.

Author Response

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Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

• The major concern regarding the construct validity of the self-developed PHM-Q instrument remains unresolved. The questionnaire still lacks proper psychometric validation such as exploratory or confirmatory factor analysis, and Cronbach’s alpha alone is insufficient to establish validity.
• The PHM-Q items mainly assess general positive healthcare beliefs and socially desirable attitudes rather than a clearly defined Population Health Management construct. Therefore, the study conclusions regarding PHM awareness and endorsement remain conceptually weak.
• Although the authors acknowledged several limitations in the discussion, most concerns were addressed descriptively rather than methodologically. The revision appears largely textual without sufficient analytical improvement.
• The study relies only on descriptive and bivariate analyses after removal of regression models. Without multivariable analysis, the reported associations remain un-resolve able to confounding and cannot be interpreted.
• The cross-sectional design, self-reported measures, and possible social desirability bias further weaken the strength of the conclusions.
• Despite revisions, the manuscript still overinterprets associations and discusses implications beyond what can be supported by the available data and study design.

Author Response

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Author Response File: Author Response.pdf