Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I thank the authors and the journal editor for the opportunity to review this important manuscript. I have a few comments.

Typically, in the introduction, there should be a substantive discussion of the research gap. The authors briefly addressed this writing "To our knowledge, there is limited qualitative information on how patients perceive and value online content related to scars and whether the content meets their needs. " (lines 57, 58) To enhance transparency, the author may need to dig into the literature to ensure the statement is backed up with references. For example, what does this study offer that others such as Boroumand et al. (2022), Mathews et al. (2023) or Young-Afat et al. (2024) do not? (References below, if interested)

The methods section lacks several key elements necessary for transparency. It is unclear whether participants were recruited purposively or by convenience, how sample size was determined, or whether data saturation was considered. The procedures for conducting the focus groups have limited detail regarding group composition, consistency of the interview guide across sessions, or how prior treatment relationships between moderators and participants were managed. The authors did not describe how coding disagreements were resolved, how consistency was ensured when only one researcher analyzed the third focus group, or whether a codebook or audit trail was maintained. There is also no discussion of reflexivity or strategies used to ensure trustworthiness (e.g., credibility, dependability, confirmability), which is important given the moderators’ clinical roles and institutional affiliation with the study site. For the sake of transparency and reproducibility, all of these items MUST be addressed. These are required of qualitative manuscripts.

The results are missing descriptions of negative cases, divergent viewpoints, or tensions between participants’ perspectives, which limits insight into the complexity of patient needs. I also could not determine the distinction between participant feedback on MyScarSpecialist as a specific case example or from broader preferences about online scar-related information. This makes it difficult to determine which findings are context-specific.

In the discussion, methodological limitations and how they shaped the findings should be addressed (e.g., heterogeneous focus groups, uneven analytic procedures). 

I look forward to reviewing a revised draft.

1. Boroumand, M. A., Sedghi, S., Adibi, P., Panahi, S., & Rahimi, A. (2022). Patients' perspectives on the quality of online patient education materials: A qualitative study. Journal of education and health promotion, 11, 402. https://doi.org/10.4103/jehp.jehp_1127_21

2. Mathews, A., Costa, B., Mikkola, A., & Harcourt, D. (2023). 'Scars: How Our Wounds Make Us Who We Are': Improving appearance-based stigma, conceptualisation of beauty and body esteem through a documentary. Scars, Burns & Healing, 9, 20595131231205398. https://doi.org/10.1177/20595131231205398

3. Young, V. L., & Hutchison, J. (2009). Insights into patient and clinician concerns about scar appearance: semiquantitative structured surveys. Plastic and reconstructive surgery, 124(1), 256–265. https://doi.org/10.1097/PRS.0b013e3181a80747

 

Author Response

I thank the authors and the journal editor for the opportunity to review this important manuscript. I have a few comments.

Author response: Dear reviewer, thank you for taking the time to review our manuscript and for your thoughtful and constructive comments. We greatly appreciate your insights, which have helped us to improve the clarity of the paper.

Comment 1: Typically, in the introduction, there should be a substantive discussion of the research gap. The authors briefly addressed this writing "To our knowledge, there is limited qualitative information on how patients perceive and value online content related to scars and whether the content meets their needs. " (lines 57, 58) To enhance transparency, the author may need to dig into the literature to ensure the statement is backed up with references. For example, what does this study offer that others such as Boroumand et al. (2022), Mathews et al. (2023) or Young-Afat et al. (2024) do not? (References below, if interested)

Authors’ response:  We have adjusted the introduction, added some literature and have more explicitly indicated the research gap. 

Comment 2: The methods section lacks several key elements necessary for transparency. It is unclear whether participants were recruited purposively or by convenience, how sample size was determined, or whether data saturation was considered.

Authors’ response: We have elaborated on the patient recruitment and data saturation. We used convenience sampling and have explained that we conducted a third focus group to assess data saturation.

Comment 3: The procedures for conducting the focus groups have limited detail regarding group composition, consistency of the interview guide across sessions, or how prior treatment relationships between moderators and participants were managed.

Authors’ response: We have added more information. Regarding the relationship, we have added the number of participants with a prior treatment relationship and in the limitations section, we pointed out that we believe this relationship did not interfere with the answers provided by those participants.

Comment 4: The authors did not describe how coding disagreements were resolved, how consistency was ensured when only one researcher analyzed the third focus group, or whether a codebook or audit trail was maintained.

Authors’ response: the codes and subthemes were discussed with all the authors in several meetings following the two focus groups and we had another meeting after the third focus group to reach agreement. The third focus group was analyzed by one coder because there was not much discussion regarding the themes. It is common practice in qualitative research that the first subset of interviews is coded by two researchers separately whereas the subsequent interviews are coded by one researcher. We followed that approach.

Maintaining an audit trail was deemed to have no additional value, given the descriptive nature of the study and the use of the same approach across the three focus groups.

Comment 5: There is also no discussion of reflexivity or strategies used to ensure trustworthiness (e.g., credibility, dependability, confirmability), which is important given the moderators’ clinical roles and institutional affiliation with the study site. For the sake of transparency and reproducibility, all of these items MUST be addressed. These are required of qualitative manuscripts.

Authors’ response: thank you for pointing this out. We have added a paragraph (refer to 2.4 Rigor) describing strategies to pursue credibility. Regarding your comment regarding the affiliations, we included this as a study limitation.

Comment 6: The results are missing descriptions of negative cases, divergent viewpoints, or tensions between participants’ perspectives, which limits insight into the complexity of patient needs. I also could not determine the distinction between participant feedback on MyScarSpecialist as a specific case example or from broader preferences about online scar-related information. This makes it difficult to determine which findings are context-specific.

Authors’ response: we used a qualitative research design which has a slightly different approach compared with e.g. a phenomenological approach. Descriptive designs typically describe the experiences rather than the in-depth understanding of underlying phenomena. Accordingly, we report the broad range of perspectives expressed by participants, although not all participants may have similar needs. For example, not all participants mentioned the impact of psychological care as a need. Nevertheless, we have made some adjustments. The results are now presented in a manner that enables readers to discern whether a view reflects a more widely shared perception or a more isolated statement. (refer to text in red color)

Comment 7: In the discussion, methodological limitations and how they shaped the findings should be addressed (e.g., heterogeneous focus groups, uneven analytic procedures). 

Authors’ response: In the discussion, we mention that preferably the focus groups should be homogeneous. As explained earlier, the analytic procedure by one coder is common practice after the first two focus groups were analyzed by two researchers and no additional themes arose.

 

I look forward to reviewing a revised draft.

Authors’ response: Thank you again for your time and effort to review our manuscript.

 

Reviewer 2 Report

Comments and Suggestions for Authors

• Pathological scarring is common yet underrepresented in patient-centered digital health research. The co-creation approach with patients and carers is innovative and adds credibility to the website design process. Results provide actionable insights for improving scar-information websites and broader patient education tools. 

• Study needs improvemetns: Needs sharper framing of the problem–solution–novelty arc.

  • Consider adding prevalence data and citing recent studies on online health literacy and scar misinformation.

  • Participant demographics could be presented more clearly 
  • expand on how prior relationships between moderators and participants may have influenced responses.

  • Strengthen integration with existing literature on readability of online health materials and peer support in burn care.

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Comments on the Quality of English Language

Simplify complex sentences; avoid stacking multiple clauses.  Use consistent terminology (e.g., “scar-information website” vs. “educational platform”). Ensure keywords align with indexing standards (e.g., “scar management,” “digital health,” “patient education”).

Author Response

Comments and Suggestions for Authors

Author response: Dear reviewer, thank you for taking the time to review our manuscript and for your thoughtful and constructive comments. We greatly appreciate your insights, which have helped us to improve the clarity of the paper.

Comment 1: Pathological scarring is common yet underrepresented in patient-centered digital health research. The co-creation approach with patients and carers is innovative and adds credibility to the website design process. Results provide actionable insights for improving scar-information websites and broader patient education tools. 

Authors’ response: Thank you for your comments.

Comment 2: Study needs improvements: Needs sharper framing of the problem–solution–novelty arc.

Consider adding prevalence data and citing recent studies on online health literacy and scar misinformation.

Authors’ response: The introduction has been revised with the aim of presenting the problem in a clearer and sharper manner.  

Comment 3: Participant demographics could be presented more clearly 

Authors’ response: we have reported some in the text

Comment 4: Expand on how prior relationships between moderators and participants may have influenced responses.

Authors’ response: We have addressed this issue in the discussion.

Comment 5: Strengthen integration with existing literature on readability of online health materials and peer support in burn care.

Authors’ response: we have added more existing literature in the discussion in line 416-420.

Comment 6: Comments on the Quality of English Language

Simplify complex sentences; avoid stacking multiple clauses.  Use consistent terminology (e.g., “scar-information website” vs. “educational platform”). Ensure keywords align with indexing standards (e.g., “scar management,” “digital health,” “patient education”).

Authors’ response: Thank you for the suggestions. We have replaced some complex sentences and checked the keywords.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I thank the authors for addressing my concerns. I have no further comments or questions.

Author Response

Thank you very much for your time to review our manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

Satisfactory revision done by the authors. Manuscript can be accepted for publication 

Comments on the Quality of English Language

Simplify complex sentences; avoid stacking multiple clauses.  Use consistent terminology (e.g., “scar-information website” vs. “educational platform”). Ensure keywords align with indexing standards (e.g., “scar management,” “digital health,” “patient education”).

Author Response

Dear reviewer, thank you for your valuable suggestions.

Comments 1:

Simplify complex sentences; avoid stacking multiple clauses.  

Response 1:

As suggested we made some changes mainly in the introduction and discussion section for smoother reading. We believe these changes improved flow and clarity by simplifying syntax, breaking up long sentences, and reducing stacked clauses in order to enhance readability.

Comments 2:

Use consistent terminology (e.g., “scar-information website” vs. “educational platform”).

Response 2:

Terminology was adapted for more consistency.

Comments 3:

Ensure keywords align with indexing standards (e.g., “scar management,” “digital health,” “patient education”).

Response 3:

We adjusted the keywords. Scar management and digital health were removed, but we choose to retain patient education, as it is important to be found as such.