What Shapes Perceived Patient Understanding in Dysphagia and Voice Care? A Survey of Barriers and Facilitators

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The topic of patient understanding in dysphagia and voice care is timely and important, particularly given the well-documented challenges with treatment adherence in these populations. The manuscript is clearly structured, and the integration of health literacy concepts provides a useful theoretical framework.

Several points, however, should be addressed to strengthen the scientific rigor and clarity of the paper:

1. Sample Size and Generalizability
   The small sample size (n = 29) and the predominance of voice patients seen primarily by one ENT clinician significantly limit generalizability. While this is acknowledged in the limitations section, the conclusions should be further tempered to reflect the exploratory nature of the findings. Please ensure that claims remain proportional to the scope of the data.

2. Statistical Analysis
   The results rely exclusively on descriptive statistics. Although this is acceptable for an exploratory study, the manuscript refers to “trends” in health literacy and understanding without statistical testing. If feasible, consider adding simple exploratory inferential analyses (e.g., chi-square tests or correlation analyses). If not, please clearly state that no statistical associations were formally tested and avoid interpretive language implying statistical relationships.

3. Handling of Missing Data
   Five participants had incomplete health literacy data. The manuscript would benefit from a clearer explanation of how missing data were handled and whether incomplete responses affected any analyses.

4. Measurement of Understanding
   Patient understanding was assessed using a single self-reported percentage item. This is an important limitation, as self-perceived understanding may not reflect objective comprehension. Please emphasize this more explicitly in the limitations section and consider briefly discussing how future studies might incorporate objective measures (e.g., recall tests or teach-back evaluation).

5. Discussion Focus
   Portions of the discussion reiterate descriptive findings. The manuscript would benefit from a slightly more concise synthesis that prioritizes the most clinically impactful findings and clearly distinguishes data-driven conclusions from broader theoretical reflections.

6. Minor Editorial Issues

   • The title could be streamlined for clarity (currently somewhat repetitive).

   • A few minor stylistic edits would improve readability, although the overall quality of English is good.

Overall, this is a meaningful exploratory study addressing an important clinical issue. With clarification of methodological limitations and careful moderation of conclusions, the manuscript would be strengthened and better positioned to inform future research in this area.

Author Response

Comment 1: The topic of patient understanding in dysphagia and voice care is timely and important, particularly given the well-documented challenges with treatment adherence in these populations. The manuscript is clearly structured, and the integration of health literacy concepts provides a useful theoretical framework. 

Several points, however, should be addressed to strengthen the scientific rigor and clarity of the paper: 

1. Sample Size and Generalizability 
   The small sample size (n = 29) and the predominance of voice patients seen primarily by one ENT clinician significantly limit generalizability. While this is acknowledged in the limitations section, the conclusions should be further tempered to reflect the exploratory nature of the findings. Please ensure that claims remain proportional to the scope of the data. 

Response: Thank you for pointing this out. We have added a sentence in the conclusion (page 17) to further emphasize the limited generalizability of the study findings.  

 

Comment 2: Statistical Analysis 
The results rely exclusively on descriptive statistics. Although this is acceptable for an exploratory study, the manuscript refers to “trends” in health literacy and understanding without statistical testing. If feasible, consider adding simple exploratory inferential analyses (e.g., chi-square tests or correlation analyses). If not, please clearly state that no statistical associations were formally tested and avoid interpretive language implying statistical relationships. 

Response: Agreed. We have added a sentence in the methods (page 7) stating that we have not made any formal statistical analyses throughout the paper.  

 

Comment 3: Handling of Missing Data 
Five participants had incomplete health literacy data. The manuscript would benefit from a clearer explanation of how missing data were handled and whether incomplete responses affected any analyses.  

Response: Thank you for this comment. We have added the following sentence to the results section (page 9) “Participants with incomplete literacy data (n=5) were excluded from analyses including health literacy classification. Other survey responses from these participants were retained and included in the analyses of facilitators and barriers. No imputation methods were used due to the exploratory nature of this study.”  

 

Comment 4: Measurement of Understanding 
Patient understanding was assessed using a single self-reported percentage item. This is an important limitation, as self-perceived understanding may not reflect objective comprehension. Please emphasize this more explicitly in the limitations section and consider briefly discussing how future studies might incorporate objective measures (e.g., recall tests or teach-back evaluation). 

Response: We agree with this comment. Therefore, we have added a sentence to the limitations section (page 17) addressing the bias this subjective measure may cause, as well as added examples of objective measures of evaluating patient comprehension in the conclusion (page 18) 

 

Comment 5: Discussion Focus 
Portions of the discussion reiterate descriptive findings. The manuscript would benefit from a slightly more concise synthesis that prioritizes the most clinically impactful findings and clearly distinguishes data-driven conclusions from broader theoretical reflections. 

Response: Thank you for this comment. We have edited the discussion, aiming for conciseness and strengthening the distinction between data-driven observations and theoretical discussions. We have reduced repetition of descriptive findings and streamlined sections that focussed on broader theoretical concepts.  

 

Comment 6: Minor Editorial Issues 

• The title could be streamlined for clarity (currently somewhat repetitive). 

• A few minor stylistic edits would improve readability, although the overall quality of English is good. 

Response: Thank you for your comment. We have changed the title to “What Shapes Patient Understanding in Dysphagia and Voice Care? A Survey of Barriers and Facilitators” to improve clarity. We have also made some minor edits throughout the paper with the goal of improving readability. 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for allowing me to review your paper. 

The manuscript addresses a worthwhile topic, but substantial revision is needed to improve clarity, conceptual consistency, and methodological transparency. Across the paper, key terms such as adherence, compliance, understanding, appointment information, and shared decision making are used inconsistently, and in several places the language appears to conflict with patient autonomy and ethical framing; this should be revised throughout. The introduction also needs stronger focus, clearer antecedents, and more citations, particularly to support dysphagia rather than relying primarily on voice-related quality-of-life literature. In the methods, results, and tables, the authors need to define exactly what was measured (confused whether the authors were reporting patient understanding, understanding when appointments were scheduled or a perception of understanding), clarify participant characteristics (nationality vs ethnicity) and inclusion criteria, explain how analyses and percentage groupings were calculated (analysis section), and resolve inconsistencies between narrative and tabulated data. Several interpretations are not fully supported by the presented figures, and the discussion, clinical implications, limitations, and conclusion should be revised so that the recommendations are internally consistent, especially regarding whether the authors are advocating a tailored or universal approach in regard to patient decision making. Overall, the study has potential, but the manuscript would benefit from tighter terminology, more precise reporting, and closer alignment between the data, analysis, and conclusions.

 

Line 39: Misguided statement-patients should make own decisions based on federal law and ethics

Adherence is a “paternalistic term” consider changing the term

 

Some citations are superscripted others are in brackets

Line 49: beginning to mention multiple concepts-voice and dysphagia, citations only support QOL voice disorders

Line 51: “ANY” the word should be removed

All references are QOL voice articles, where are the references to support dysphagia?

Line 54: citations: may be think about finding a different citation rather than from a book

Line 55: this article is about adolescents-find a citation about adults or across age groups

Line 55: begins in line 55-56-needs citation how restoring well being

Line 56: are patient’s required to adhere to a clinicians recommendation

-adherence concept shoulde be reframed throughout manuscript

Line 62: What does “it” refer to?

Line 63: What does “these” refer to? Voice, age groups? People? Disorders? What population specifically? Compliance should be reworded; people are “not” required to comply

Line 63: “this” what gap? Be specific

“this” is used tow times and makes it difficult to understand what authors are trying to convey

In general: change or discard unclear antecedents. The unclear antecedents should be avoided throughout the manuscript

Line 66: use person 1^st language throughout manuscript: People with….

Line 100: what are the characteristics of the individuals? Patients? Other clinicians?

Line 89: What understanding is being measured? Is it the appointment time? Information being discussed? Educational information? Diagnosis?

Table 1: participant demographics should go under descriptive statistics. Where did the mean and SD and percentages come from? The analysis section is lacking in communicating what the reader should be looking for in the results and how the analysis was calculated or conducted.

Inclusion criteria: indicates have to understand and write in English but the table reads differently-clarify

In results: you use  76%: are the results primary English speakers or only English speakers? Needs clarification

Table indicates 79% in table but 80% in narrative-be clear in reporting

Table 1: Race and Ethnic groups: I don’t think Canadians or Brazilians, Iraqui’s are races or ethnicities-they are nationalities

Are you suggesting Canadians and Asians are mutually exclusive? Perhaps rename the heading.

Line 116: Just a thought, it would be interesting to compare educational levels to health literacy classification

Line 123-125: I don’t think I understand what “appointment information” actually means

You need to help the reader understand what you are measuring

I think if you have a more detailed method and analysis section it would improve the understanding of the information presented

For example: help the reader understand the calculations of 25% intervals; how was information clustered into percentages?

It is not clear where the “appointment info”  was collected in the method

How were 25% intervals calculated needs to be explained in the analysis section

Line 125-127: Where is the comparison? The comparison was not discussed in the analysis section

Not sure if it is the journal or the authors but formatting needs some help

“appointment information” is this educational? What do the authors mean? It’s awkward and not defined well. What is the operant definition?

Line 139: Barriers to what?

 

3.3 content analysis

Not clear where this ties back to analysis section

Is this the analysis of the themes? Use language that ties the concepts together

Line 150: Is this appointment understanding? The authors need to be consistent in their language and terminology throughout the entire manuscript to facilitate clarity (understanding) for the reader.

Line 155: appointment is used as a different modifier

-using appointment (noun) as an adjective is confusing-consider a different way to convey

Line 180: according to the data presented in figure 1: the data does not support your contention

The people in the excellent group didn’t have better health literacy than sufficient group; fix graph or fix sentence but they are not congruent

Figure 4: SES needs to be defined in the manuscript

-mediators box-needs examples like you have in the “moderators” box

What is 1^st half and 2cd half referring to? Needs clarification and an explanation

Line 193: “adherence” needs further explanation

-patients may be making a choice; the clinician is not in charge of the patient’s decision making-ethically or legally

Line 197: What does “this” refer to? Is

-Is it a tailored approach or universal design? They are mutually exclusive.

Line 198: Are clinical appointments the same as appointment information?

Line 203: Shared decision making (1^st time mentioned in the entire manuscript)-previously in the manuscript you used language like “adherence” and “compliance”-patient centered decision making is diametrically opposed…which one is it?

Line 203: statement needs to be softened…include a word like “may”

Line 211: Is it patient understanding or appointment understand?

I’m not sure I understand what was actually measured? This is an issue.

Line 225: On the concept of “grasping”…the authors may consider citing the foundational work- 1936  work in cognitive assimilation and accommodation-this was the original work of Piaget! Needs rework

Line 230: what disease process or illness doesn’t require lifestyle or home modifications? What makes voice and dysphagia distinct? How are voice and dysphagia different from a limb amputee? Or someone with a diagnosis of ALS?

Line 233: As I read the manuscript, it seems the authors measured patient perception rather than patient understanding-Is this correct? Making statements about improving understanding need to be softened

Line 254: needs citation

Clinical Implications

Be clear-which do you suggest? A tailored approach to practice or a universal approach? Your clinical implications are not congruent-previously the authors suggested a tailored approach

Line 270: 5 participants incomplete data should be in the results section

Line 271: needs further explanation what sub-group analysis?

Line 273: Is the sentence “these biases” or “this bias”

Line 276: the authors may need to add that you did not measure understanding

-the authors do not know the complexity of information shared with the participant which could be a confounding variable/issue.

-impact of diagnosis e.g. cancer dx vs. MTD would impact level of understanding and complexity provided to participant. The diagnosis may also impact the ability of the participant to listen to what is being said-complexity of the issue could be a big consideration in how the participant responded

Line 281: perception of self-reported understanding might be a better way to convey your findings

Conclusion:

Again, your contentions are not-congruent…are you promoting universal approaches or tailored approaches?

-other things to consider: the confidence of the speaker or even what the speaker is wearing could make a difference in perception of understanding

Line 287: another limitation would be to actually measure understanding  

Author Response

Comment 1: Line 39: Misguided statement-patients should make own decisions based on federal law and ethics 

Response: Thank you for this important comment. We have revised the wording in the Introduction to remove language that may imply a paternalistic interpretation (e.g., “adherence”) where possible and instead emphasize patient understanding and engagement with recommended care. These revisions better align the manuscript with principles of patient autonomy and patient-centered care. 

 

Comment 2: Adherence is a “paternalistic term” consider changing the term 

Response: Thank you for highlighting this. We agree that “adherence” may carry paternalistic connotations and does not fully align with contemporary patient-centered care models. We have revised the manuscript to use alternative terms such as “engagement with recommendations” and “participation in care” where appropriate. When referencing prior literature that uses the term “adherence,” we have retained the original terminology for accuracy but have contextualized it within a more patient-centered framework. These revisions better align the manuscript with principles of shared decision-making and respect for patient autonomy. 

 

Comment 3: Some citations are superscripted others are in brackets 

Response: Thank you for pointing this out. We have corrected these mistakes throughout the manuscript.  

 

Comment 4: Line 49: beginning to mention multiple concepts-voice and dysphagia, citations only support QOL voice disorders 

Response: Thank you for this comment. We have revised the first sentence to include reference [14], a systematic review exploring dysphagia and quality of life, ensuring that the impact of dysphagia on quality of life is appropriately supported alongside voice-related literature. (page 4) 

 

Comment 5: Line 51: “ANY” the word should be removed 

Response: This word has been removed.  

 

Comment 6: All references are QOL voice articles, where are the references to support dysphagia? 

Response: Thank you for this comment. We have revised the first sentence to include reference [14], a systematic review exploring dysphagia and quality of life, ensuring that the impact of dysphagia on quality of life is appropriately supported alongside voice-related literature. (page 4) 

 

Comment 7: Line 54: citations: may be think about finding a different citation rather than from a book 

Response: Thank you for this comment. Due to differences in line numbering, we believe this may refer to reference [1]. We have retained this citation as it is the source of the survey instrument used in this study (HLS19). As such, it is essential to include for methodological transparency and reproducibility. 

 

Comment 8: Line 55: this article is about adolescents-find a citation about adults or across age groups 

Response: Thank you for this comment. We agree that this reference did not align with our target population and have replaced it with a more relevant study examining identity and stigma in phonotrauma [16] (page 4). This revision better reflects adult populations and strengthens the applicability of the cited literature. 

 

Comment 9: Line 55: begins in line 55-56-needs citation how restoring well being 

Response: Thank you for this comment. We have revised this sentence to avoid overgeneralization, and ensure that claims remain appropriately supported by the cited literature by using “may help” instead of “are essential” (page 4) 

 

Comment 10: Line 56: are patient’s required to adhere to a clinicians recommendation 

-adherence concept should be reframed throughout manuscript 

Response: Thank you for your comment. “Adherence” has been reframed to “engagement with treatment recommendations” throughout the manuscript to encourage a more patient centred framework.  

 

Comment 11: Line 62: What does “it” refer to? 

Response: Thank you for this comment. Due to revisions made during the editing process, the specific instance may have changed; however, we have reviewed the manuscript to ensure that all pronouns (e.g., “it”) have clear antecedents and revised any ambiguous phrasing to improve clarity. 

 

Comment 12: Line 63: What does “these” refer to? Voice, age groups? People? Disorders? What population specifically? Compliance should be reworded; people are “not” required to comply 

Response: Thank you for these corrections. The sentence has been reworded for clarity, and to avoid certain terms that may be ambiguous or problematic. “Despite the importance of identifying factors that influence patient understanding and engagement with treatment recommendations, research in dysphagia and voice disorder populations remains limited.” 

 

Comment 13: Line 63: “this” what gap? Be specific 

“this” is used tow times and makes it difficult to understand what authors are trying to convey 

In general: change or discard unclear antecedents. The unclear antecedents should be avoided throughout the manuscript 

Response: Agreed. These terms have been removed and specified throughout the manuscript.  

 

Comment 14: Line 66: use person 1st language throughout manuscript: People with…. 

Response: Thank you. This has been adjusted.  

 

Comment 15: Line 100: what are the characteristics of the individuals? Patients? Other clinicians? 

Response: Thank you for this comment. We have revised the wording to clarify that this refers to patient participants in the study. 

 

Comment 16: Line 89: What understanding is being measured? Is it the appointment time? Information being discussed? Educational information? Diagnosis? 

Response: We agree that this needed to be explicitly stated. We have added the sentence “In this study, patient understanding refers to participants’ overall perceived comprehension of communicated information during the clinical appointment, including diagnosis, findings, and recommended treatment strategies” in the methods (page 6).  

 

Comment 17: Table 1: participant demographics should go under descriptive statistics. Where did the mean and SD and percentages come from? The analysis section is lacking in communicating what the reader should be looking for in the results and how the analysis was calculated or conducted. 

Response: Agreed, therefore we have added a couple of sentences in the methods section (page 6) clarifying what analysis was used and the calculation process.  

 

Comment 18: Inclusion criteria: indicates have to understand and write in English but the table reads differently-clarify 

Response: Thank you for this comment. The table indicates native language, not languages spoken. Participants that could not understand, read and write in English were not included in the study, to which their native language had no influence. We have edited this section to “First language” for clarity.  

 

Comment 19: In results: you use 76%: are the results primary English speakers or only English speakers? Needs clarification 

Response: Thank you for this comment. They are primary. This has been corrected for “first language” as stated above.  

 

Comment 20: Table indicates 79% in table but 80% in narrative-be clear in reporting 

Response: Thank you, this has been corrected.  

 

Comment 21: Table 1: Race and Ethnic groups: I don’t think Canadians or Brazilians, Iraqui’s are races or ethnicities-they are nationalities 

Are you suggesting Canadians and Asians are mutually exclusive? Perhaps rename the heading. 

Response: Thank you for this comment. No, that is not what we are suggesting nor what was intended. During our data collection, the survey question asked, “What is your race or ethnic group (e.g. Asian, Latin American, Métis, White, Black, Middle Eastern)”, however some participants answered with their nationality instead. After discussing with the study team, we decided to include the answers as they were originally submitted, instead of making assumptions of their ethnicity or excluding the participant from analysis. A sentence clarifying this process has been added to the table (page 8). 

 

Comment 22: Line 116: Just a thought, it would be interesting to compare educational levels to health literacy classification 

Response: Thank you for this suggestion. While examining the relationship between educational level and health literacy classification would be informative, this analysis was beyond the scope of the current study and not part of the original analytic plan. We agree this represents an important direction for future research. 

 

Comment 23: Line 123-125: I don’t think I understand what “appointment information” actually means 

You need to help the reader understand what you are measuring 

I think if you have a more detailed method and analysis section it would improve the understanding of the information presented 

For example: help the reader understand the calculations of 25% intervals; how was information clustered into percentages? 

It is not clear where the “appointment info” was collected in the method 

How were 25% intervals calculated needs to be explained in the analysis section 

Response: Thank you for this comment. We have added the following to the methods (page 6) to improve clarity of analysis process “Patient understanding was assessed using a self-reported percentage item, with responses recorded in predefined 25% intervals and summarized using frequencies”. We also rephrased “appointment information” to “information communicated during the appointment,” (page 10) and along with the added definition of what is patient understanding in the methods.  

 

Comment 24: Line 125-127: Where is the comparison? The comparison was not discussed in the analysis section 

Not sure if it is the journal or the authors but formatting needs some help 

Response: Thank you for pointing this out. We agree it needed some rewording. We changed the sentence to “When examining health literacy categories alongside self-reported understanding, a trend was observed in which participants with higher health literacy tended to report greater understanding” (page 10) to remove the implication of statistical testing.  

 

Comment 25: “appointment information” is this educational? What do the authors mean? It’s awkward and not defined well. What is the operant definition? 

Response: Thank you for this comment. We have revised the terminology throughout the manuscript to improve clarity, replacing “appointment information” with “information communicated during the clinical appointment.” Additionally, we clarified how patient understanding of this information was measured. We believe these revisions address the ambiguity previously noted. 

 

Comment 26: Line 139: Barriers to what? 

Response: Thank you for this comment. It has now been clarified that it is a barrier to patient understanding.  

 

Comment 27: 3.3 content analysis 

Not clear where this ties back to analysis section 

Is this the analysis of the themes? Use language that ties the concepts together 

Response: Thank you for your comment. This heading has been changed to “Thematic Analysis of Open-Ended Questions” to facilitate clarity (page 12).  

 

Comment 28: Line 150: Is this appointment understanding? The authors need to be consistent in their language and terminology throughout the entire manuscript to facilitate clarity (understanding) for the reader. 

Response: Agreed. Term has been changed to “information communicated during the clinical appointment” (page 12).  

 

Comment 29: Line 155: appointment is used as a different modifier 

-using appointment (noun) as an adjective is confusing-consider a different way to convey 

Response: Thank you for this comment. The line numbers are different in our version and yours, however I am assuming you are referring to the “Limited Appointment Time” heading. This has been changed to “limited time during the clinical appointment” (page 12).  

 

Comment 30: Line 180: according to the data presented in figure 1: the data does not support your contention 

The people in the excellent group didn’t have better health literacy than sufficient group; fix graph or fix sentence but they are not congruent 

Response: Thank you for pointing this out. To resolve this, we have indicated that the relationship was not linear.  

 

Comment 31: Figure 4: SES needs to be defined in the manuscript 

-mediators box-needs examples like you have in the “moderators” box 

What is 1st half and 2cd half referring to? Needs clarification and an explanation 

Response: Thank you. SES has been defined (page 13), mediator examples have been added to figure 4, and the first and second half have been identified in the previous explanation of them (what shapes health literacy and what health literacy does) (page 13).   

 

Comment 32: Line 193: “adherence” needs further explanation 

-patients may be making a choice; the clinician is not in charge of the patient’s decision making-ethically or legally 

Response: Thank you for this comment. We have revised the manuscript to replace the term “adherence” with more patient-centered language (“engagement with recommendations” and “participation in care”) to better reflect patient autonomy and shared decision-making.  

 

Comment 33: Line 197: What does “this” refer to? Is 

-Is it a tailored approach or universal design? They are mutually exclusive. 

Response: Thank you for this comment. We have revised this sentence to remove the ambiguity from the word “this”, as well as explain that both tailored communication and universal design are being described. In this section we are giving examples of strategies clinicians could take up.  

 

Comment 34: Line 198: Are clinical appointments the same as appointment information? 

Response: Thank you for this comment. In this sentence, we are saying that during clinical appointments (consultations), health literacy could be assessed by the clinician or staff to them tailor communication strategies.  

 

Comment 35: Line 203: Shared decision making (1st time mentioned in the entire manuscript)-previously in the manuscript you used language like “adherence” and “compliance”-patient centered decision making is diametrically opposed…which one is it? 

Response: Thank you for this comment. We agree that language should be consistent. We have replaced the term “adherence” throughout the manuscript to more neutral language such as “engagement”. We would like to clarify that our intent is not to present shared decision-making and engagement as opposing concepts. Rather, patient understanding encompasses both processes: it supports informed and collaborative decision-making, while also enabling patients to make autonomous choices about how they engage with clinical recommendations.  

 

Comment 36: Line 203: statement needs to be softened…include a word like “may” 

Response: Agreed, “may” has been added (page 15).  

 

Comment 37: Line 211: Is it patient understanding or appointment understand? 

I’m not sure I understand what was actually measured? This is an issue. 

Response: Thank you for this comment. We have revised the manuscript to ensure consistent terminology of “patient understanding of information communicated during the clinical appointment.” We have also added an operational definition in the Methods to clarify what is measured (page 6).  

 

Comment 38: Line 225: On the concept of “grasping”…the authors may consider citing the foundational work- 1936  work in cognitive assimilation and accommodation-this was the original work of Piaget! Needs rework 

Response: Thank you for the suggestion, this citation has been added for a more comprehensive understanding (page 15).  

 

Comment 39: Line 230: what disease process or illness doesn’t require lifestyle or home modifications? What makes voice and dysphagia distinct? How are voice and dysphagia different from a limb amputee? Or someone with a diagnosis of ALS? 

Response: Thank you for this thoughtful comment. We agree that many health conditions require lifestyle and home-based modifications. Our intent was not to suggest that dysphagia and voice disorders are unique in this regard, but rather that these conditions often rely heavily on patient understanding and day-to-day implementation of recommendations (e.g., diet modifications, swallowing strategies, voice use behaviors) for safe and effective management. We have revised the text to clarify this distinction and to avoid overgeneralization (page 15) 

 

Comment 40: Line 233: As I read the manuscript, it seems the authors measured patient perception rather than patient understanding-Is this correct? Making statements about improving understanding need to be softened 

Response: Thank you for this important clarification. We agree that our study captures self-reported (perceived) understanding rather than objective measures of comprehension. We have revised the manuscript to reflect this distinction, including softening statements that implied objective understanding. We now consistently refer to “perceived understanding” where appropriate and have added this as a limitation. We have also clarified in the Discussion that future research should incorporate objective measures (e.g., recall or teach-back) to more directly assess understanding. 

 

Comment 41: Line 254: needs citation 

Response: We agree, therefore we cited a 2018 study discussing the influence of time pressures on care (page 15) 

 

Comment 42: Clinical Implications 

Be clear-which do you suggest? A tailored approach to practice or a universal approach? Your clinical implications are not congruent-previously the authors suggested a tailored approach 

Response: Thank you for this comment. We have clarified that we suggest combining these approaches and treating them as complimentary rather than as mutually exclusive (page 16).  

 

Comment 43: Line 270: 5 participants incomplete data should be in the results section 

Response: Thank you, this has been moved to the results section (page 10).  

 

Comment 44: Line 271: needs further explanation what sub-group analysis? 

Response: This sentence has been removed but has been further explained in the results. Participants with incomplete health literacy data were included when looking at trends of facilitators and barriers but excluded from the health literacy relationship analyses (page 10).  

 

Comment 45: Line 273: Is the sentence “these biases” or “this bias” 

Response: Thank you for this comment. Due to the discrepancies in line numbers, we are not certain which line you are referring to; however we have tried to improve language clarity throughout this paragraph.  

 

Comment 46: Line 276: the authors may need to add that you did not measure understanding 

-the authors do not know the complexity of information shared with the participant which could be a confounding variable/issue. 

-impact of diagnosis e.g. cancer dx vs. MTD would impact level of understanding and complexity provided to participant. The diagnosis may also impact the ability of the participant to listen to what is being said-complexity of the issue could be a big consideration in how the participant responded 

Response: Agreed that this should be added. “Patient understanding was assessed using a self-reported percentage item, which may not accurately reflect comprehension and may be subject to bias. Furthermore, the complexity, amount, or emotional impact of the information communicated during the appointment was not standardized nor measured, which may have influenced participants’ perceived understanding” has been added to the limitations section. 

 

Comment 47: Line 281: perception of self-reported understanding might be a better way to convey your findings 

Response: Thank you for this suggestion. We have reframed the manuscript to use “perceived understanding” to more accurately reflect the self-reported nature of the outcome. This change has been applied consistently throughout the manuscript to improve clarity and precision. 

 

Comment 48: Conclusion: 

Again, your contentions are not-congruent…are you promoting universal approaches or tailored approaches? 

Response: Thank you for this comment. We have revised the Conclusion to clarify that universal and tailored approaches are complementary rather than mutually exclusive. 

 

Comment 49: -other things to consider: the confidence of the speaker or even what the speaker is wearing could make a difference in perception of understanding 

Response: Thank you for this thoughtful suggestion. Good point! We added that “the clinician’s communication style” was not standardized nor measured to the limitations section (page 17).  

 

Comment 50: Line 287: another limitation would be to actually measure understanding   

Response: Thank you for your comment. “Patient understanding was assessed using a self-reported percentage item, which may not accurately reflect comprehension and may be subject to bias” has been added to the limitations section to emphasize this limitation.  

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the revised manuscript. The authors have made clear and meaningful improvements, particularly in language, structure, and clarification of the methodology. The manuscript is now much easier to follow and overall significantly strengthened.

A few minor points remain to be addressed:

1. Formatting
   • Please provide a clean version of the manuscript without tracked changes or formatting marks.
2. Title
   • The title could be simplified to improve clarity and readability.
3. Sample Size
   • The small sample size (n = 29) is acknowledged; a slightly stronger emphasis on its impact on generalizability would be helpful.
4. Interpretation of Findings
   • As no statistical associations were tested, it would be preferable to frame observed trends more cautiously.
5. Self-Reported Measures
   • A brief additional note on the limitations of self-reported understanding (e.g., potential overestimation) would strengthen the discussion.

Overall, the manuscript is improved and close to being ready for publication.

Author Response

 

1. Formatting 

• Please provide a clean version of the manuscript without tracked changes or formatting marks. 

 

RESPONSE: Thank you for your suggestion. We have now attached a clean manuscript.  

 

1. Title 

• The title could be simplified to improve clarity and readability. 

 

RESPONSE: Thank you for this suggestion. We aimed to ensure the title clearly reflects the key elements of the study, including perceived patient understanding, the clinical context, and the focus on barriers and facilitators. We considered simplifying it further, but felt this would reduce important specificity. As such, we have retained the current title. 

 

1. Sample Size 

• The small sample size (n = 29) is acknowledged; a slightly stronger emphasis on its impact on generalizability would be helpful. 

 

RESPONSE: Thank you for your suggestion. We agree that this needs to be strongly emphasized as it is a big limitation. We have added even more emphasis on this in the limitations section (page 18).  

 

1. Interpretation of Findings 

• As no statistical associations were tested, it would be preferable to frame observed trends more cautiously. 

RESPONSE: Thank you for emphasizing this point; we agree. Throughout the manuscript, we have revised the language to avoid terms implying causation or statistical association (e.g., “association,” “influenced”), replacing them with more descriptive, non-causal phrasing. We have also further emphasized this consideration in the limitations section (page 19). 

1. Self-Reported Measures 

• A brief additional note on the limitations of self-reported understanding (e.g., potential overestimation) would strengthen the discussion. 

RESPONSE: Thank you for this suggestion. The sentence “additionally, self-reported measures may be subject to overestimation, as participants may perceive their understanding to be higher than their actual comprehension” has been added to the limitations section (page 19).   

Reviewer 2 Report

Comments and Suggestions for Authors

The journal provided a PDF with all editorial markup for the second-level review. Unfortunately, it was virtually impossible to make meaningful suggestions or edits to the document. While reading the document, several grammatical and spelling errors were observed. Please check before your final submission. Otherwise, the manuscript in its current form is acceptable. 

Author Response

The journal provided a PDF with all editorial markup for the second-level review. Unfortunately, it was virtually impossible to make meaningful suggestions or edits to the document. While reading the document, several grammatical and spelling errors were observed. Please check before your final submission. Otherwise, the manuscript in its current form is acceptable.  

 

RESPONSE: Thank you for your time, and your suggestion. We have done a final read through of the paper to check for any grammatical errors.