Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

 

Overall Assessment

This manuscript is a well-written, theoretically grounded, and methodologically strong quantitative study. This cross-sectional study investigates the influence of user engagement with online health platforms (OHPs) on patient attitudes toward treatment-PAAT for Atrial Fibrillation. Grounded in the Health Belief Model and based on a comparative analysis of OHPs in the Netherlands and the United States, the study underscores the role of various factors in shaping health-seeking behavior. The findings are timely, relevant, and contribute meaningfully to the ongoing discourse on digital health. This manuscript is of high quality and acceptable in its current form, but could be further strengthened with minor revisions as outlined below.

Strengths

• The paper is clearly articulated, coherent, and grounded in a strong theoretical and conceptual framework.
• This cross-sectional study effectively combines theoretical grounding, methodological rigor, and clear presentation of results. The findings are contextualized through the Health Belief Model and additional conceptual frameworks, enhancing the study’s relevance to digital health research.

• This study offers a clear understanding of how online health platforms stimulate health-seeking behavior, particularly in the case of chronic diseases such as Atrial Fibrillation, where patients need urgent help. This study also underlines the importance of improving online health platforms to reduce the burden on health systems.

• The survey question is well developed, theoretically informed, and meets ethical requirements.
• This quantitative design is appropriate and well-executed, with findings that are well presented in a nuanced and accessible manner.

Limitation

• Referencing:

Most of the references are not recent and do not fall into the guideline of “within the last 5 years” from MDPI.

For instance, reference numbers 7, 29, 31, 45, 49, 51, 53, and 54 are older than 10 years and more, therefore cannot be used in a scientific article, even though they have relevance to the topic. It is suggested that finding similar and recent references will improve the quality of the paper.

Suggestions for Improvement

• This study is based on data collected from two different OHPs in the Netherlands and the USA; however, it is unclear whether they provide information in a similar manner on atrial fibrillation. Also, it is unclear whether those platforms have similar interfaces or not. If they don’t have identical interfaces, please clarify the differences between them and how these differences are adjusted during analysis. A short description of user interfaces in the introduction section and adjustment technique in the method section will provide a better understanding of the outcomes of this study.

 

 

Conclusion and Recommendation

This is a rigorous and well-presented manuscript that makes a valuable contribution to the literature on digital health and health-seeking behavior. With the addition of temporal details on user interfaces in the introduction section and an explanation of adjusting the differences in the method section, this paper will be further enhanced and better positioned to influence both scholarly debate and practical approaches to supporting digital health platforms.

Author Response

Please find our point-by-point response attached as PDF file.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Comments:
1. It is recommended to structure the abstract so that the materials, methods and results are clear
2. The materials and methods section contains a lot of theoretical information, it is recommended to transfer it to the introduction, and in materials and methods to focus on the description of a specific research design, the procedure for selecting and recruiting participants, the description of tools (questionnaire, measurement scales), etc.
3. The data on the study participants is not clear, their clinical and demographic data are not clear. The length of the disease, the form of AF, concomitant diseases and therapy, and access to medical care are not clear.
4. The participants were from different countries. What language was tested in? Have the questionnaire been adapted into native languages? Has the questionnaire been validated and cross-culturally adapted? There may be linguistic and cultural differences in the perception of the wording of the questions.
5. It is recommended to structure the discussion section around the key findings of the study. It is recommended to offer more specific practical recommendations.

Author Response

Please see the attachment for a point-by-point response to the comments.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript presents a relevant and contemporary study on a topic of growing interest: the influence of online health platforms on patient attitudes. The approach is based on a sound theoretical model (the Health Belief Model, HLM) and an appropriate methodological analysis (SEM—structural equation modeling).

 

The sample size (589 participants) is adequate, and the comparative approach between two countries (the Netherlands and the United States) provides an interesting intercultural dimension.

 

However, the manuscript is well structured overall but it needs many modifications that we will point out in the comments sections below:

 

Title: T long, complex, and overly descriptive. It would be preferable to shorten it by highlighting the central element of the study (e.g., the impact of health platforms or the role of psychological mediators), while avoiding an excessive accumulation of methodological concepts in the title.

Abstract :

The main numerical results (coefficients, significance, direct/indirect effects) are not mentioned, which limits the assessment of the robustness of the conclusions. It would be helpful to make the abstract more structured, more precise and more focused on key findings, in order to improve its readability and to more accurately reflect the scientific importance of the study. 

 

Introduction

- Please rewrite the last paragraph by indicating the question research and state clearly the objectives of this study (in one paragraph).

 

- Methods

Materials and methods

I suggest removing this sentence: “as previously noted,”

A study design subsection is required.

Inclusion and exclusion criteria should be defined.

Results

The results are summarized in very general terms (positive effect of engagement, no mediating effect of content type). Briefly indicate the strength of the relationships or their statistical significance (e.g., β, p-values, R²) to support the robustness of the conclusions.

 

Although mentioned, the HLM is neither contextualized nor adapted to the case of atrial fibrillation. Explain how threat perception and behavioral assessment fit into this model, and why these variables were chosen as mediators.

 

Discussion

Revise the Discussion section so that your first paragraph summarizes the objective of your case study.

- More references to previous studies supporting or contrasting the findings would strengthen the discussion.

The role of the country of residence is mentioned, but no concrete comparative results are presented. Indicate whether there were significant differences between the Netherlands and the United States in usage behaviors or attitudes toward treatments.

The conclusion highlights the managerial interest for platforms and healthcare stakeholders, but without specifying what concrete strategies can be derived from the results. The conclusion could be more impactful if it included concrete clinical recommendations based on the study's findings. It would also be relevant to add suggestions for future research.

Author Response

Please see the attachment for our point-by-point response.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors answered my questions and made corrections to the text of the article, which improved its quality.

Author Response

Thank you for providing your second round of comments. Please find our response attached.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

All issues have been well adressed by authors.

Author Response

Thank you for confirming that the issues have been addressed. We appreciate your helpful comments.