Enhancing Quality of Life in Ostomized Patients Through Smart-Glasses-Supported Health Education: A Pre-Post Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Review for the manuscript titled Enhancing Quality of Life in Ostomized Patients Through Smart-Glasses-Supported Health Education: A Pre-post Study

This manuscript explores a timely and potentially relevant topic, namely the use of smart glasses to support health education for patients with ostomies. The overall concept is interesting and aligns well with current trends in digital and technology-enhanced nursing education. However, in its current form, the manuscript is difficult to follow and lacks methodological, structural, and conceptual coherence. I therefore recommend a major revision before it can be considered for publication.

I recommend removing the section titled "Highlights," as this format is not appropriate for the journal.

The abstract needs complete revision. Currently, it does not fully align with the manuscript's content and lacks methodological rigour. The description of the study design is inconsistent (pre–post, quasi-experimental, pilot study), and this confusion should be clarified. Therefore, I suggest that the authors clarify this and describe the methodology more cautiously, taking into account the small sample size, the absence of a control group, and the exploratory nature of the study.

The Introduction is too brief and insufficiently developed. In particular, the second paragraph (lines 81–83) on epidemiological trends does not directly support the research rationale and should be removed. I suggest that the authors strengthen the introduction by more clearly linking the clinical challenges of ostomy self-care, patients’ educational needs, and the rationale for choosing smart glasses as an educational intervention.

Several issues also need to be addressed in the Methods section. The text should consistently use past tense. More importantly, I recommend that the authors resolve the mismatch between the stated aims of the intervention (improving self-confidence, autonomy, and self-efficacy) and the outcome measure used, as the SF-36 does not assess these constructs. This could be achieved either by rephrasing the study aims or by providing a stronger justification for the chosen instruments. Additionally, the assessment of patient knowledge and the intervention itself would benefit from clearer documentation, possibly supported by visual materials, a schematic overview, or links to educational videos.

The Results section would benefit from simplification and clearer presentation. Currently, data are spread across multiple tables with unnecessary repetition, and the narrative does not adequately guide the reader through the main findings. I also suggest that the authors interpret the very large effect sizes more cautiously, considering the small, uncontrolled pilot design.

The discussion is generally clear and shows a reasonable effort to contextualise the findings within existing literature. The authors properly acknowledge key limitations of the study, such as the small sample size and the pre–post design without a control group. However, a more focused synthesis of the main messages would enhance this section and help ensure that the conclusions remain appropriately cautious and proportionate to the exploratory nature of the study.

Comments for author File: Comments.pdf

Author Response

We would like to thank you and the reviewers for the constructive feedback provided on our manuscript. We appreciate the opportunity to revise and improve our work. Below, we provide a detailed, point-by-point response to the reviewers’ comments and outline the revisions made to the manuscript. Changes in the revised manuscript are highlighted in bold for clarity.

Reviewer’s Comment:
This manuscript explores a timely and potentially relevant topic, namely the use of smart glasses to support health education for patients with ostomies. The overall concept is interesting and aligns well with current trends in digital and technology-enhanced nursing education. However, in its current form, the manuscript is difficult to follow and lacks methodological, structural, and conceptual coherence. I therefore recommend a major revision before it can be considered for publication.

Response:
We appreciate the reviewer’s positive feedback on the relevance of our topic and the innovative nature of our study. We acknowledge the need for improvements in the manuscript’s structure and methodological coherence. Accordingly, we have conducted a major revision to address the issues highlighted by the reviewer. Below, we provide detailed responses to each specific comment.

Reviewer’s Comment:
I recommend removing the section titled "Highlights," as this format is not appropriate for the journal.

Response:
The "Highlights" section has been removed from the manuscript, as suggested.

Reviewer’s Comment:
The abstract needs complete revision. Currently, it does not fully align with the manuscript's content and lacks methodological rigour. The description of the study design is inconsistent (pre–post, quasi-experimental, pilot study), and this confusion should be clarified. Therefore, I suggest that the authors clarify this and describe the methodology more cautiously, taking into account the small sample size, the absence of a control group, and the exploratory nature of the study.

Response:
We have completely revised the abstract to ensure alignment with the manuscript’s content and to improve methodological clarity. The study design is now consistently described as a "quasi-experimental, pre–post pilot study." Additionally, we have emphasized the exploratory nature of the study, the small sample size, and the absence of a control group to ensure a cautious interpretation of the findings. The revised abstract now provides a concise yet comprehensive overview of the study’s aims, methods, results, and conclusions.

Reviewer’s Comment:
The Introduction is too brief and insufficiently developed. In particular, the second paragraph (lines 81–83) on epidemiological trends does not directly support the research rationale and should be removed. I suggest that the authors strengthen the introduction by more clearly linking the clinical challenges of ostomy self-care, patients’ educational needs, and the rationale for choosing smart glasses as an educational intervention.

Response:
We have significantly expanded the Introduction to provide a more detailed background on the clinical challenges of ostomy self-care and the educational needs of patients. The rationale for choosing smart glasses as an educational intervention has been clarified and supported with relevant literature. The second paragraph on epidemiological trends (lines 81–83) has been removed, as suggested, to enhance the focus and coherence of the introduction.

Reviewer’s Comment:
Several issues also need to be addressed in the Methods section. The text should consistently use past tense. More importantly, I recommend that the authors resolve the mismatch between the stated aims of the intervention (improving self-confidence, autonomy, and self-efficacy) and the outcome measure used, as the SF-36 does not assess these constructs. This could be achieved either by rephrasing the study aims or by providing a stronger justification for the chosen instruments. Additionally, the assessment of patient knowledge and the intervention itself would benefit from clearer documentation, possibly supported by visual materials, a schematic overview, or links to educational videos.

Response:

• The entire Methods section has been revised to ensure consistent use of the past tense.
• We have addressed the mismatch between the intervention’s stated aims and the outcome measure by rephrasing the study aims to focus on quality of life improvements, which aligns with the SF-36 domains. We have also included a justification for the use of the SF-36, explaining its relevance for assessing health-related quality of life in ostomized patients.
• To enhance clarity, we have added a detailed description of the intervention, including the three phases (knowledge assessment, personalized feedback, and hands-on workshop). Additionally, we have included references to the educational videos and provided a schematic overview of the intervention in the supplementary materials.

Reviewer’s Comment:
The Results section would benefit from simplification and clearer presentation. Currently, data are spread across multiple tables with unnecessary repetition, and the narrative does not adequately guide the reader through the main findings. I also suggest that the authors interpret the very large effect sizes more cautiously, considering the small, uncontrolled pilot design.

Response:
We have simplified the Results section by consolidating data from multiple tables into two main tables and one figure. This reduces redundancy and improves clarity. The narrative has been revised to guide the reader through the main findings more effectively. Additionally, we have included a cautious interpretation of the large effect sizes, explicitly acknowledging the limitations of the small sample size and the uncontrolled design.

Reviewer’s Comment:
The discussion is generally clear and shows a reasonable effort to contextualise the findings within existing literature. The authors properly acknowledge key limitations of the study, such as the small sample size and the pre–post design without a control group. However, a more focused synthesis of the main messages would enhance this section and help ensure that the conclusions remain appropriately cautious and proportionate to the exploratory nature of the study.

Response:
We have revised the Discussion to provide a more focused synthesis of the main messages. The section now emphasizes the key findings, such as improvements in emotional role, mental health, and physical function, and contextualizes these within the existing literature. We have also ensured that the conclusions are appropriately cautious and proportionate to the exploratory nature of the study. Additional details on the limitations of the study have been included to further balance the interpretation of the results.

We believe that the revisions have significantly improved the quality and clarity of the manuscript. We are grateful for the reviewer’s insightful comments, which have helped us to strengthen the methodological and conceptual coherence of our work. We hope that the revised manuscript now meets the high standards of the journal and look forward to your feedback.

Thank you for considering our resubmission.

Sincerely,

Reviewer 2 Report

Comments and Suggestions for Authors

The introduction of the manuscript would benefit from contextualization in terms of the concept and importance of digital health or virtual care. It would also benefit from a literature review on what is known about the use of virtual reality or augmented reality in health education, functional rehabilitation of patients after illness, or specifically in training patients in self-care.
Lines 86-87: This sentence would benefit from being supported by previous studies on ostomy care or self-care training in other areas.
Lines 90-91: What are you referring to in terms of technical rigour in ostomy care?
Line 92: Please give readers clues as to what you mean by complex environments.
Line 93: Is satisfaction and adherence referring to patients? Are you referring to adherence to treatment/self-care?
Material and Methods
Line 97: Is this a subheading for this section? Please format according to the journal's guidelines.
Lines 108-109: Are these subheadings? Sub-subheadings? Please refer to the journal's guidelines for further information.
Line 110: The phrase “Data were collected using a categorised data table” is not clear enough. How did the researchers collect the data? Through interviews with patients and family members? Based on the clinical process?
Lines 118-120: This sentence would benefit from being adequately supported by the authors of the assessment tool. Was this tool validated for the Spanish population? If so, please cite the respective authors. How was the questionnaire administered? Through interviews? If so, how many were conducted before and after the intervention?
Lines 121, 123, 135, and 138: Are these section subtitles?
Line 136: To increase the credibility of the study among readers, I suggest that you present the STROBE checklists as supplementary material for the article. I also suggest that you include the flowchart you used to describe the sample so that readers can see it in the form of a figure.
Line 137: How many patients were recruited? And how many participated? How was the sample size calculated? What effect size was this calculation based on? Were the patients who participated before the study the same as those who participated after the study? How did the researchers ensure that all patients had identical characteristics in terms of knowledge about stoma care?
Results
Lines 169-171: Please quantify these gains in comparison with the data before the intervention.
Discussion
Line 193: What kind of errors are you referring to?

 

Author Response

Reviewer’s Comment:
The introduction of the manuscript would benefit from contextualization in terms of the concept and importance of digital health or virtual care. It would also benefit from a literature review on what is known about the use of virtual reality or augmented reality in health education, functional rehabilitation of patients after illness, or specifically in training patients in self-care.

Response:
We have expanded the Introduction to include a more detailed discussion of the concept and importance of digital health and virtual care, particularly in the context of health education and patient self-care. Additionally, we have incorporated a brief literature review on the use of virtual and augmented reality in health education, functional rehabilitation, and self-care training. These additions provide a stronger foundation for the rationale of using smart glasses in our study. The revised text now includes references to key studies in these areas to support our claims.

Reviewer’s Comment:
Lines 86-87: This sentence would benefit from being supported by previous studies on ostomy care or self-care training in other areas.

Response:
We have added references to previous studies that specifically address the importance of self-care training in ostomy care and other areas. This strengthens the argument for the need for innovative educational interventions like the one presented in our study.

Reviewer’s Comment:
Lines 90-91: What are you referring to in terms of technical rigour in ostomy care?

Response:
We have clarified the meaning of "technical rigour" in the context of ostomy care. Specifically, we refer to the precision and accuracy required for tasks such as stoma cleaning, pouch application, and complication management.

Reviewer’s Comment:
Line 92: Please give readers clues as to what you mean by complex environments.

Response:
We have clarified what is meant by "complex environments" by providing examples relevant to the context of ostomy care and patient education.

Reviewer’s Comment:
Line 93: Is satisfaction and adherence referring to patients? Are you referring to adherence to treatment/self-care?

Response:
We have clarified that satisfaction and adherence refer to patient satisfaction with the educational intervention and adherence to self-care practices.

Materials and Methods:

Line 97: Is this a subheading for this section? Please format according to the journal's guidelines.

Response:
We thank the reviewer for pointing out the need to clarify the formatting of this section. The subheading "Study Design, Population, and Sample" has been formatted according to the journal's guidelines to ensure consistency and clarity throughout the manuscript.

Lines 108-109: Are these subheadings? Sub-subheadings? Please refer to the journal's guidelines for further information.

Response:
We appreciate the reviewer’s observation. The headings "Independent Variables" and "Dependent Variables" have been formatted as subheadings, as per the journal's guidelines, to improve the structure and readability of the manuscript.

Line 110: The phrase “Data were collected using a categorised data table” is not clear enough. How did the researchers collect the data? Through interviews with patients and family members? Based on the clinical process?

Response:
We agree that the original phrase was unclear. To address this, we have clarified that data were collected through structured interviews conducted by trained nursing staff during regular ostomy consultations. Additionally, clinical data were obtained from patient records to ensure accuracy and completeness.

Lines 118-120: This sentence would benefit from being adequately supported by the authors of the assessment tool. Was this tool validated for the Spanish population? If so, please cite the respective authors. How was the questionnaire administered? Through interviews? If so, how many were conducted before and after the intervention?

Response:
Thank you for highlighting this point. We have now included information confirming that the Spanish version of the SF-36, which has been validated for the Spanish population, was used in the study. The respective authors have been cited to support this information. Additionally, we have clarified that the questionnaire was administered through face-to-face interviews conducted by trained nursing staff, both before and after the intervention.

Lines 121, 123, 135, and 138: Are these section subtitles?

Response:
We appreciate the reviewer’s attention to detail. The headings in these lines have been reviewed and formatted as subheadings or sub-subheadings, as appropriate, to align with the journal's formatting requirements.

Line 136: To increase the credibility of the study among readers, I suggest that you present the STROBE checklists as supplementary material for the article. I also suggest that you include the flowchart you used to describe the sample so that readers can see it in the form of a figure.

Response:
We thank the reviewer for this valuable suggestion. The STROBE checklist and the flowchart used to describe the sample have been included as supplementary material (Supplementary Material 2). We believe this addition enhances the transparency and credibility of our study.

Line 137: How many patients were recruited? And how many participated? How was the sample size calculated? What effect size was this calculation based on? Were the patients who participated before the study the same as those who participated after the study? How did the researchers ensure that all patients had identical characteristics in terms of knowledge about stoma care?

Response:
We appreciate the reviewer’s detailed questions regarding the sample. The following clarifications have been added to the manuscript:

• A total of 20 patients were initially recruited for the study, and 14 participants met the inclusion criteria and completed both pre- and post-intervention assessments.
• The sample size was not calculated a priori due to the pilot nature of the study. However, the effect size was retrospectively calculated to evaluate the magnitude of the intervention’s impact.
• The same patients participated in both the pre- and post-intervention assessments.
• To ensure consistency in baseline knowledge about stoma care, all participants were recruited from the same hospital, where they received standardized care and education prior to the study. Baseline knowledge was also evaluated through a structured questionnaire during the first phase of the intervention to identify individual needs and ensure tailored feedback.

Results
Lines 169-171: Please quantify these gains in comparison with the data before the intervention.

Response: Thank you for your valuable comment. We have revised the results section to include a detailed quantification of the improvements observed in the SF-36 domains. Specifically, we have added the percentage changes for each domain to provide a clearer comparison with baseline data. For example, the emotional role improved by 18.87 points, representing a 24.0% increase, while mental health showed an 8.24-point improvement, equivalent to a 10.4% increase. Similarly, physical function improved by 7.48 points, a 10.4% increase, and vitality improved by 1.86 points, reflecting a 2.7% increase. These changes have been incorporated into the revised manuscript to enhance clarity and address your feedback.

Discussion
Line 193: What kind of errors are you referring to?

Response: We appreciate your suggestion to clarify the type of errors mentioned in the discussion. The errors referred to are primarily related to the misinterpretation or improper application of ostomy care techniques by patients. These include, but are not limited to, incorrect stoma cleaning, improper placement or application of the ostomy pouch, and failure to identify potential complications such as skin irritation, leakage, or infection. Such errors are often attributed to insufficient education, lack of confidence, or anxiety related to self-care tasks. In the revised manuscript, we have clarified this point and emphasized how the use of smart-glasses aimed to mitigate these challenges by providing immersive, first-person instructional videos that facilitated better understanding and execution of self-care techniques.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for your detailed, point-by-point responses to my comments.

I would like to commend you for the substantial effort invested in addressing all suggestions during the review process. The manuscript Enhancing Quality of Life in Ostomized Patients Through Smart-Glasses-Supported Health Education: A Pre-post Study has been improved across all sections, particularly the Abstract, Introduction, Methods, Results, and Discussion.

In my opinion, the revised version fully addresses the earlier concerns and is suitable for publication in Healthcare.

Thank you for your careful and professional approach to the revision process. I wish you every success with the publication of your work.

Kind regards,

Reviewer

Comments for author File: Comments.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,
I was very pleased that my comments were useful in improving the manuscript.
Good luck with your research!