Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India.

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Self-care in diabetes includes appropriate diet, regular exercise, blood glucose monitoring, medication adherence and foot care. The purpose of the study was to assess the obstacles faced by diabetes patients for self-care practices and to determine the factors associated with these obstacles. Methods A facility-based cross-sectional study was conducted among 107 type 2 DM patients aged >18 years using the Diabetes Obstacles Questionnaire-30. Patients scoring a mean score >3 were considered to have an obstacle. We included age, gender, socioeconomic status (SES), duration of DM and blood glucose levels as factors for regression analysis and a p-value <0.05 was considered to be statistically significant. Results A large majority (64.5%, n = 69) of our participants were aged above 55 years and belonged to lower socioeconomic status (65.4%, n = 70). Family history of DM was present in 41% (n=44) of the participants. The median duration of DM among the participants was 10 (4 – 7) years. In our study, the participants faced obstacles for two items in the domains: Support from friends & family (mean score: 3.73) and knowledge of the disease (mean score: 3.58). A multinominal regression analysis revealed SES was a predictive factor for participants who could not understand information from literature with a p-value of 0.002 (OR: 3.65, CI: 1.60-8.338). Conclusion The two major obstacles to diabetes self-management practices were in the domains of support from friends and family, and knowledge of the disease. Socioeconomic status was identified as a predictive factor associated with the participants who could not understand information from the literature. 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F1000Research 2025, 12 :839 ( https://doi.org/10.12688/f1000research.138146.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] Rekha T https://orcid.org/0000-0003-2278-1445 1 , Murali Mohan R https://orcid.org/0000-0002-6272-5694 1 , Nithin Kumar https://orcid.org/0000-0003-4665-9401 1 , [...] Kausthubh Hegde 1 , Bhaskaran Unnikrishnan https://orcid.org/0000-0003-0892-8551 1 , Prasanna Mithra https://orcid.org/0000-0002-7153-411X 1 , Ramesh Holla https://orcid.org/0000-0002-2296-3719 1 , Balanarayana Suma 1 , Aadithya M Rao 1 , Patil Nikitha 1 , Aysha Roushida Sahama M 1 Rekha T https://orcid.org/0000-0003-2278-1445 1 , Murali Mohan R https://orcid.org/0000-0002-6272-5694 1 , [...] Nithin Kumar https://orcid.org/0000-0003-4665-9401 1 , Kausthubh Hegde 1 , Bhaskaran Unnikrishnan https://orcid.org/0000-0003-0892-8551 1 , Prasanna Mithra https://orcid.org/0000-0002-7153-411X 1 , Ramesh Holla https://orcid.org/0000-0002-2296-3719 1 , Balanarayana Suma 1 , Aadithya M Rao 1 , Patil Nikitha 1 , Aysha Roushida Sahama M 1 PUBLISHED 18 Mar 2025 Author details Author details 1 Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India Rekha T Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Murali Mohan R Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Nithin Kumar Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Kausthubh Hegde Roles: Investigation, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Bhaskaran Unnikrishnan Roles: Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Prasanna Mithra Roles: Formal Analysis, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Ramesh Holla Roles: Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Balanarayana Suma Roles: Investigation, Writing – Original Draft Preparation Aadithya M Rao Roles: Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Patil Nikitha Roles: Investigation Aysha Roushida Sahama M Roles: Investigation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Manipal Academy of Higher Education gateway. This article is included in the Health Services gateway. Abstract Background The management of diabetes mellitus (DM) extends beyond clinical care, with self-care being equally important to achieve optimal treatment outcomes and prevent complications. Self-care in diabetes includes appropriate diet, regular exercise, blood glucose monitoring, medication adherence and foot care. The purpose of the study was to assess the obstacles faced by diabetes patients for self-care practices and to determine the factors associated with these obstacles. Methods A facility-based cross-sectional study was conducted among 107 type 2 DM patients aged >18 years using the Diabetes Obstacles Questionnaire-30. Patients scoring a mean score >3 were considered to have an obstacle. We included age, gender, socioeconomic status (SES), duration of DM and blood glucose levels as factors for regression analysis and a p-value <0.05 was considered to be statistically significant. Results A large majority (64.5%, n = 69) of our participants were aged above 55 years and belonged to lower socioeconomic status (65.4%, n = 70). Family history of DM was present in 41% (n=44) of the participants. The median duration of DM among the participants was 10 (4 – 7) years. In our study, the participants faced obstacles for two items in the domains: Support from friends & family (mean score: 3.73) and knowledge of the disease (mean score: 3.58). A multinominal regression analysis revealed SES was a predictive factor for participants who could not understand information from literature with a p-value of 0.002 (OR: 3.65, CI: 1.60-8.338). Conclusion The two major obstacles to diabetes self-management practices were in the domains of support from friends and family, and knowledge of the disease. Socioeconomic status was identified as a predictive factor associated with the participants who could not understand information from the literature. READ ALL READ LESS Keywords Type 2 Diabetes mellitus, Cross-sectional study, Blood glucose self-monitoring, Socioeconomic status, Diabetes Obstacles Questionnaire-30 Corresponding Author(s) Nithin Kumar ( [email protected] ) Close Corresponding author: Nithin Kumar Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 T R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: T R, R MM, Kumar N et al. Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.12688/f1000research.138146.3 ) First published: 17 Jul 2023, 12 :839 ( https://doi.org/10.12688/f1000research.138146.1 ) Latest published: 18 Mar 2025, 12 :839 ( https://doi.org/10.12688/f1000research.138146.3 ) Revised Amendments from Version 2 We have thoroughly revised the manuscript in response to the reviewer’s valuable feedback, ensuring greater clarity, depth, and rigor. In the discussion section, we have incorporated citations specific to the Indian context, particularly focusing on socio-cultural factors influencing diabetes self-care barriers, and have added missing citations to strengthen our arguments. The study limitations have been explicitly detailed, including the constraints of a small sample size, facility-based sampling, and the absence of longitudinal data, which restricts generalizability and long-term assessment of self-care practices. Additional methodological details have been provided to improve transparency and replicability. We have included a section on the pretesting of the translated questionnaire, describing a pilot study conducted among 30 participants to refine language and ensure content validity. The handling of missing data has been clarified, noting that listwise deletion was used for incomplete responses. Ethical considerations have been elaborated, highlighting the measures taken to maintain participant privacy, anonymity, and informed consent. The statistical analysis section has been expanded to discuss potential confounders and the limitations of small sample size affecting statistical power. We have also included an analysis of non-significant factors to provide a more comprehensive interpretation of the findings. Furthermore, we have broadened the discussion to include additional barriers to self-care that may arise in different populations, such as older adults, gender-based differences, and rural communities. Finally, to ensure transparency and reproducibility, the dataset has been uploaded to a public repository, with the access link included in the manuscript. We have thoroughly revised the manuscript in response to the reviewer’s valuable feedback, ensuring greater clarity, depth, and rigor. In the discussion section, we have incorporated citations specific to the Indian context, particularly focusing on socio-cultural factors influencing diabetes self-care barriers, and have added missing citations to strengthen our arguments. The study limitations have been explicitly detailed, including the constraints of a small sample size, facility-based sampling, and the absence of longitudinal data, which restricts generalizability and long-term assessment of self-care practices. Additional methodological details have been provided to improve transparency and replicability. We have included a section on the pretesting of the translated questionnaire, describing a pilot study conducted among 30 participants to refine language and ensure content validity. The handling of missing data has been clarified, noting that listwise deletion was used for incomplete responses. Ethical considerations have been elaborated, highlighting the measures taken to maintain participant privacy, anonymity, and informed consent. The statistical analysis section has been expanded to discuss potential confounders and the limitations of small sample size affecting statistical power. We have also included an analysis of non-significant factors to provide a more comprehensive interpretation of the findings. Furthermore, we have broadened the discussion to include additional barriers to self-care that may arise in different populations, such as older adults, gender-based differences, and rural communities. Finally, to ensure transparency and reproducibility, the dataset has been uploaded to a public repository, with the access link included in the manuscript. See the authors' detailed response to the review by Ganesh Kumar Saya See the authors' detailed response to the review by Saurabh Kumar Gupta READ REVIEWER RESPONSES Introduction Diabetes mellitus (DM) is a complex, chronic metabolic illness characterized by continuously elevated blood glucose levels which if not controlled leads to complications related to the eyes, nerves, kidneys, and cardiovascular system, ultimately resulting in death. 1 The World Health Organisation (WHO) has estimated that diabetes and kidney disease was responsible for over 1.6 million deaths in 2022, with 47% of the deaths occurring before 70 years of age. 2 The rise in prevalence of diabetes is predominantly reported in low- and middle-income countries, where deaths due to DM has increased by 13% over the past 20 years. 1 , 3 , 4 India accounts for around 17% of the total diabetes population and is often referred to as the ‘Diabetes capital of the world’. 5 India ranks among the top three countries with the highest population of people living with diabetes, along with China, and the USA. 6 The National Noncommunicable Disease Monitoring Survey (NNMS) carried out among adults aged between 18-69 years reported a 9.3% and 24.5% prevalence of DM and impaired fasting blood glucose (IFG) respectively. 7 A multi-centric study conducted in 2017 reported that 47% of DM cases remain undiagnosed in India, emphasizing the fact that awareness regarding the disease remains poor in the population. 8 These undiagnosed cases of DM will end up with complications and burden the health system at various levels of care. Diabetes also leads to significant financial implications, with the global economic burden estimated around US $1.31 trillion. 9 Effective control and management of diabetes can prevent or delay the progression of the complications and can reduce the morbidity, mortality and the costs associated with this condition. 10 Treatment of diabetes is multifactorial, with availability of multiple interventions which work synergistically to control hyperglycemia. Weight loss and intensive lifestyle and behavioural modifications are the initial modalities of treatment, along with pharmacologic methods which includes use of drugs of various categories, like metformin, sulfonylureas, glinides, DPP-4 Inhibitors, and SGLT-2 inhibitors. 11 In addition to the various modalities of treatment available, self-management or self-care plays a pivotal role in the management of DM and prevention of its complications. The WHO defines self-care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider”. 12 Self-care in diabetes include regular monitoring of blood glucose levels, regular physical activity, healthy eating, foot care, and compliance to medication. 13 Relationship with medical professionals, support from friends and family, knowledge of the disease, and uncertainty about consultation are some of the other factors that can also influence diabetes self-care. 10 Self-monitoring of blood glucose levels provides a quick and easy way for the patient to identify periods of hyperglycemia. Based on the blood glucose levels, the healthcare provider can adjust or modify the treatment, while the patient can keep track of his blood glucose level. 14 , 15 Diet control is one of the most significant factor that can be used to determine the level of self-care achieved. 13 Weight loss is the cornerstone of the dietary recommendations by the American Diabetes Association, which recommends a lowered caloric intake to successfully induce weight loss and reduce obesity. 16 Physical activity and exercise also improves the overall physical and psychological health of the patient, and acts as an adjunct to the weight loss regimen. 17 Foot care includes a variety of interventions such as foot temperature measurement, use of therapeutic footwear, patient education, inspection and assessment by professionals. 18 Proper foot care practices can lead to reduced development of complications like ulcers and amputations. 19 However, a shortage of trained podiatrist staff in India, and lack of foot care knowledge among the patients has resulted in a rise in the incidence of diabetes-related foot complications. 20 Adherence to the treatment is also critical component of self-care as missed doses of the prescribed drugs can lead to elevated glucose levels and development of the complications. 21 Improved self-care behaviour adherence has been linked to increased patient involvement in treatment decisions and satisfaction with provider communication. 22 Patient’s knowledge about the disease, his attitude, and perception towards lifestyle modifications and various other aspects of diabetes self-care including treatment adherence and advice is considered to be important drivers for the prevention and control of diabetes. 13 Clinicians may further influence the patient’s knowledge and attitude towards self-care by using effective communication techniques, at the same time being supported by a well-integrated healthcare system. 23 It is important to consider perspectives of both the patient and the health care provider when exploring the barriers for diabetes self-care practices. Several factors influence a patient’s ability to follow diabetes self-care practices on a day-to-day basis. Studies have reported obstacles arising from poor communication between the medical practitioner and the patient, and also due to the unavailability of diagnostic facilities and short supply of drugs. 24 Another important factor that results in poor management of DM is the inadequate knowledge about the disease or its management, either due to ignorance or scarcity of trustworthy sources that provide information regarding the disease. 23 In developing counties, financial difficulties majorly affect self-care and monitoring. Poor moral support from the family members or the lack of desire to impact a change on patients’ lifestyle also affects their self-care. 22 , 23 To prevent the spread of COVID-19, countries resorted to frequent lockdown. This in turn, resulted in decreased access to outpatient care for regular check-ups. Isolation and stress also resulted in mental health issues, and this in turn also acted as barrier to self-management of DM. 25 The long-term management of diabetes requires a huge self-motivation on the part of the patient, and sustained support from loved ones. The overwhelming demand for DM self-care can negatively impact daily life, causing “Diabetes-related Distress” which can reduces self-care motivation, leading to decreased physical and psychological well-being, potentially increasing the chances of complications and mortality. This psychological component and its impact on DM self-care is often neglected in rural India, where the resources for healthcare are limited. 26 Effective self-management has extended psychological benefits, with decreased anxiety and depression reported among adherent patients. 27 Self-management thus plays a crucial part in the control of diabetes. It is crucial to identify the barriers or obstacles that may impede self-care practices among the people living with diabetes. Understanding and identifying these barriers at the early stage of treatment is very important to achieve optimal blood glucose control and prevent complications in the future. This facility based cross-sectional study was carried out to identify the obstacles to self-care practice, and the factors associated with the obstacles among the type 2 DM patients admitted to a tertiary care centre in Mangalore. Methods Study area Mangalore is a major port city in the district of Dakshina Kannada and is one among the largest city in the southern State of Karnataka, with a population of over 6 lakhs. 28 With an average literacy rate of 93.7% 28 which is higher than the national figure of 85%, the city is considered to be one among the educational hub in South India. It also serves as a major economic and health care centre with a health care index of 62. 29 Dakshina Kannada is one among the high burden districts for diabetes with a prevalence of 14.8% and 15.4% among men and women respectively. 28 This facility based cross-sectional study was carried out in the hospitals affiliated to Kasturba Medical College, Mangalore. Participants In this cross-sectional study, 107 patients with type 2 DM attending the medicine out-patient department in the hospitals affiliated to Kasturba Medical College, Mangalore were assessed regarding the obstacles for practicing diabetes self-care. All the participants were aged 18 years and above and were diagnosed with DM for at least a year. The study was conducted in the months of November and December 2019. The sample size of 110 was calculated based on the assumption that 50% of the DM patients face obstacles when practicing self-care, with an absolute precision of 10%, 95% confidence interval and adding a 10% non-response error. Gender of the participants was documented based on self-report. Gender difference in seeking care was not taken into consideration for the design of the study and reporting of the results, since it was a facility-based study and patients were already seeking health care, we assumed that the barriers faced by the patients of either gender would be similar. The majority of the study participants were recruited from District Wenlock Hospital, the primary tertiary care hospital serving not only the district of Dakshina Kannada, but also the neighboring districts of Shimoga and Chikmagalur. Data collection The participants were briefed about the purpose and objectives of the study. Written informed consent was obtained from the willing participants, following which the participants were taken to a separate room to ensure privacy, and face-to-face interviews were conducted by one of the authors (interviewer) who was familiarized with the contents of the semi-structured questionnaire, to avoid any bias in interview. The interviews were conducted in the language the respondents were comfortable with, and the responses were recorded in a printed questionnaire by the interviewer at the time of interview. The duration of the interview was for 15-20 minutes on average. The data was collected using a semi-structured questionnaire prepared after extensive review of literature. The questionnaire consisted of the following sections: Section A : Socio-demographic information of the study participants Section B : Details regarding the diabetes and self-care practices followed by the participants Section C : Diabetes Obstacles Questionnaire-30 (DOQ-30) 10 Section D: Clinical examination and lab investigations Diabetes Obstacle Questionnaire-30 The Diabetes Obstacle Questionnaire-30 is a validated instrument developed by Pilv L, et al. 10 and consists of 30 items which gives a measure of Diabetes Related Quality of Life in nine subscales. The nine subscales include Relationship with medical professionals, Support from friends and family, Knowledge of the disease, Lifestyle changes, Exercise, Self-monitoring, Uncertainty about a consultation, Medication and Insulin-use among others. Each sub-scale comprises of 2 to 4 items which were assessed using a five-point Likert-scale (i.e., 5-Strongly Agree, 4-Agree, 3-Neutral, 2-Disagree and 1-Strongly Disagree). The DOQ-30 has a good internal reliability and construct validity. 10 The questionnaire was translated to Kannada, a local language, and was pretested and content validated for the language. The socioeconomic status of the participants was assessed using Modified Kuppuswamy’s Scale. 30 Pilot testing A pilot study was carried out to validate the language and content of the translated questionnaire. It was done among 30 participants, selected using convenience sampling technique. The participants of the pilot were excluded from the main study. Based on the findings of the pilot study, language modification to modify ambiguous and confusing terms was done for all the 4 sections of the questionnaire, while content validation was done for sections A, B and D. No changes to content were made to Section C since it was a standard questionnaire. Interviews of the participants were conducted by the same interviewer to reduce inter-observer bias and ensure consistency in data collection. Ethical considerations The study protocol was approved by the Institutional Ethics Committee (IEC) of Kasturba Medical College, Mangalore (IEC number: IECKMCMLR/022/2018). Permission was obtained from the Medical Superintendent of KMC Hospital, Attavar, Mangalore, and District Medical Officer of Government Wenlock Hospital, Mangalore for conducting the study among the patients. To maintain the privacy of the patient, the interview was conducted in a separate room attached to the outpatient department. Written informed consent stating the purpose and objectives of the study, and data confidentiality was obtained from all the participants of the study. Personal identifier (names) was not included in the questionnaire to maintain the participant anonymity. Data management and analysis The collected data was entered in and analyzed using IBM SPSS (Statistical Package for Social Sciences) Statistics version 25.0 for Windows (Armonk, NY: IBM Corp). The missing data were not considered for the analysis by listwise deletion of the participant record. The record of 3 participants were deleted due to incomplete information. The results were expressed using mean (standard error of mean), median (inter-quartile range) and proportions. For the purpose of analysis and ease of interpretation, strongly disagree/disagree and strongly agree/agree were stratified into disagree and agree, respectively. The items in the domains of DOQ-30 were considered an obstacle if the mean response score was 3 or more. For the items which were identified to be an obstacle, multinomial logistic regression (MLR) analysis was applied taking neutral as reference modality to find out the factors responsible for the obstacle. Stepwise MLR was carried out to adjust for the potential confounding effects of age, socioeconomic status (SES), duration of DM, and RBS level on the dependent factor (social support and understanding of diabetes related literature) to identify the most important predictor variable. Educational status of the patient was not included as an independent variable since it was one of the component of the scale used to measure the SES. Adjusted. Odds ratio (OR) and corresponding 95% confidence interval were reported and p < 0.05 was considered as statistically significant association. Results A total of 107 type 2 DM patients were included in the study. Majority (64.5%, n = 69) of the participants were aged above 55 years, with the mean age of 60.3 (±10.9) years. A higher proportion (72%, n = 77) of the participants were males and belonged to lower socio-economic status (65.4%, n = 70). Family history of DM was present in 41% (n=44) of the participants. The median duration of DM among the participant was 10 (4–7) years. About 58% (n = 62) of the participants had at least one comorbidity, with hypertension being the most common (82.2%, n = 51). The general information of the study participants is given in Table 1 . The full dataset can be found under Underlying data. 46 Table 1. Study participants information (N = 107). Variables n (%) Age group (in years) ≤45 11(10.3) 46–55 27(25.2) >55 69(64.5) Gender Male 77(72.0) Female 30(28.0) Religion Hindu 84(78.5) Christian 14(13.1) Muslim 09(08.4) Socioeconomic status * Upper 02(01.9) Upper middle 11(10.3) Lower middle 24(22.4) Upper lower 66(61.7) Lower 04(03.7) Family history of diabetes Present 44(41.1) Absent 63(58.9) Comorbidity Present ** 62(57.9) Absent 45(42.1) Smoking status Never 77(72.0) Past 22(20.6) Current 08(07.5) Alcohol status Never 72(67.3) Past 26(24.3) Current 09(08.4) * Modified Kuppuswamy scale, 2017. ** Hypertension – 51 (47.6%). The obstacles for diabetes self-care as assessed using DOQ-30 is depicted in Table 2 . The mean response score for most of the items under various domains was less than 3. Table 2. Obstacles for self-care among the study participants - findings of Diabetes Obstacles Questionnaire-30 (N = 107). Subscales Mean (SE of mean) Agree n (%) Relationship with medical professionals I am not assisted in setting realistic targets to change my lifestyle 2.35(0.13) 32(29.9) I have not been told what to expect from my treatment 2.41(0.13) 30(28.0) The good and bad aspects of each choice have not been discussed with me 2.66(0.13) 31(29.0) Treatment alternatives are not explained to me 2.67(0.14) 38(35.5) Support from friends and family I feel I get little support from my family 1.92(0.12) 20(18.7) I feel I get little support from my friends 2.11(0.13) 25(23.4) I feel very alone with my diabetes 2.04(0.11) 15(14.0) I would manage my diabetes much better if I had encouragement socially 3.73(0.12) 79(73.8) Knowledge of the disease I do not know as much as I need to know about the consequences of having diabetes 2.73(0.12) 37(34.6) I do not know enough about the treatment of diabetes 2.71(0.12) 35(32.7) I do not know as much as I need to know to manage my diabetes 2.82(0.12) 38(35.5) I have difficulty understanding information from literature 3.04(0.12) 45(42.1) Lifestyle changes My diabetes has placed a strain on my personal relationships 2.88(0.13) 40(37.4) Changes in my diet have put a strain on my family 2.60(0.13) 31(29.0) I feel resentful that I am obliged to change my eating habits 2.82(0.12) 34(31.8) My diabetic diet spoils my social life 2.83(0.13) 35(32.7) Exercising I have not found an exercise I enjoy 2.93(0.11) 30(28.0) I lack the motivation to exercise 2.90(0.11) 33(30.8) I am unable to fit exercise into my lifestyle 2.85(0.10) 28(26.2) I am unable to afford the cost of exercising on a regular basis 2.67(0.10) 19(17.8) Self-monitoring Self-monitoring makes me feel frustrated 2.73(0.07) 6(5.6) I find it too uncomfortable to self-monitor 2.75(0.07) 9(8.4) I find it extremely hard to test when I am busy 2.70(0.06) 3(2.8) Self-monitoring makes me fearful of a high reading 2.74(0.06) 6(5.6) Uncertainty about a consultation The way that I was told I had diabetes made me feel afraid 2.87(0.14) 49(45.8) I feel a sense of helplessness when I am consulting with the nurses 2.04(0.09) 7(06.5) Medication I do not feel I am being prescribed a medication dose that is right for me 1.93(0.12) 21(19.6) I do not feel I am being prescribed a medication that is right for me 1.94(0.12) 22(20.6) Insulin use Using insulin makes life too complicated 2.73(0.07) 10(09.3) Using insulin means my diabetes is getting worse 2.69(0.07) 07(06.5) However, in one item each from the domains of Support from Friends and Family, and Knowledge of the disease, the participants scored more than the average cut-off of 3, suggesting an obstacle. The mean response score for item, ‘I would manage my diabetes much better if I had encouragement socially’ (item one) under the domain, Support from Friends and Family, was 3.73 (0.12 SEM) with 79 (73.8%) participants agreeing that social support is important for diabetes control. The mean of response to the item, ‘I have difficulty understanding information from literature’ (item two) under the domain, Knowledge of the Disease was 3.58 (0.09 SEM) with 66 (61.7%) participants agreeing that they were unable to understand the information related to diabetes from the literature. Multinomial logistic regression (MLR) was applied on the two items identified to be obstacles for self-care to find out the significant factors associated with them. About 74% (n = 79) of participants stated that item one was an obstacle for self-care practice, while 7.47% (n = 8) of them were neutral about their response to this statement. MLR analysis with neutral as the reference category revealed no predictive factors for this obstacle. Item two was an obstacle for 61.68% (n = 66) of the participants, while 23.3% (n = 25) were neutral about their response. MLR analysis revealed socioeconomic status is a strong predictor of this obstacle with p value of 0.002 (odds ratio: 3.65 and confidence interval: 1.60-8.33). The other factors were statistically insignificant. This data is presented in Table 3 . Table 3. Factors associated with obstacles for self-care practices among diabetes patients (N = 107). Factors Agree Disagree Adjusted odds ratio (CI) P value Adjusted odds ratio (CI) P value Item 1: I would manage my diabetes much better if I had encouragement socially Age 0.96 (0.89-1.03) 0.329 0.99 (0.912-1.07) 0.835 Socioeconomic status 1.71 (0.71-4.09) 0.226 2.22 (0.764-6.48) 0.143 Diabetes duration 1.04 (0.95-1.15) 0.348 1.00 (0.899-1.12) 0.916 Random blood glucose 0.99 (0.98-1.01) 0.881 1.00 (0.989-1.024) 0.496 Item 2: I have difficulty understanding information from literature Age 1.00 (0.95-1.05) 0.807 1.01 (0.92-1.09) 0.812 Socioeconomic status 3.65 (1.60-8.33) 0.002 0.23 (0.08-0.64) 0.005 Diabetes duration 1.01 (0.94-1.07) 0.761 1.01 (0.92-1.10) 0.825 Random blood glucose 1.00 (0.99-1.01) 0.783 1.00 (0.99-1.02) 0.470 Discussion In this facility based cross-sectional study, 107 type 2 diabetes patients were assessed about the obstacles for self-care practices using the Diabetes Obstacles Questionnaire-30 (DOQ-30). 10 Among the 30 items across 9 domains of self-care, only 2 items were considered as obstacles by the participants in our study. The lack of social encouragement for better management of disease and difficulty in understanding the literature about the disease were agreed upon by the participants to be a barrier for practicing self-care. Lack of social support as a barrier for diabetes self-management was reported by a multi-national study, where effective social support system with constant motivation and encouragement from friends and family members were identified as enablers for self-management. 31 The importance of social support in diabetes has been documented in multiple studies from India and abroad, which have reported that a strong social support leads to a better degree of self-management and overall positive outcomes in diabetes patients. 32 , 33 A systematic review and meta-analysis conducted by Youngshin et al. 34 found social support to be significantly associated with self–management, with the strongest effect on regular glucose monitoring. On the contrary, lack of support and isolation, for example a patient living alone, is associated with poor self-management, including a reluctance to use insulin, medicines, and irregular testing of blood glucose levels. They are also more likely to not follow any diet plan to avoid the stigma and embarrassment associated with diabetes. 35 A study conducted in Punjab, India, identified the lack of family support as a significant factor contributing to non-compliance with diabetes self-care practices. Participants cited non-preparation of appropriate diabetic meals, and delayed medication reminders as contributing factors to their non-compliance. 36 The lack of support from family and friends can directly lead to poorer psychological wellbeing, improper or less than adequate self-management, and ultimately lead to suboptimal glycaemic control and poor outcomes for the patient. 37 Difficulty in understanding diabetes related literature was also identified as an obstacle in our study. The role of education in diabetes self-care is well documented with various studies reporting a correlation between lower educational status of the patient and poor self-management practices. Low educational status leads to reduced health literacy, which can adversely affect individuals’ ability to manage chronic conditions like diabetes. 38 Poor level of knowledge among patients with chronic diseases, especially diabetes is well documented, with low level of health literacy being reported between 15 to 40% of the population. 39 Various studies from USA and Japan have documented that low health literacy was associated with poor diabetes knowledge, which can in turn affect the practice of diabetes self-care. 40 – 42 Poor diabetes related knowledge was also identified to be an important obstacle for diabetes self-care practice in a study from India by Gupta et al. 36 Participants in the study believed they lacked knowledge of foot care, blood sugar control, and methods to reduce diabetes care stress. They cited the lack of knowledge and awareness about appropriate physical activities as the cause of inadequate physical activity. 36 A study by Aziz, et al. , 19 reported a correlation between education of the patient and foot care practices, along with a decreased rate of amputations associated with diabetes. A similar study conducted by Chai et al. 43 showed a significantly increased psychological health and decreased glucose levels after six months following self-management education. An integrative review by Olesen et al. 44 found a patient centred approach to diabetes self-management education to have a noticeable impact in improving the self-management, leading to better haemoglobin A1c levels, as well as the quality of life of the patients. Several studies have reported an adequate control of blood glucose levels and improvement in morbidity and mortality if the patients follow self-management behaviors such as blood glucose monitoring, nutrition, exercise, medication, and foot care. 19 , 43 – 48 Diabetes education is thus very important and should be an integral part of every diabetes control program. Social support and education have been identified to work synergistically to bring about improvement in clinical outcomes in a diabetes patient. 12 The other objective of our study was to identify the factors that may be predictive of the obstacles for the self-care management among diabetes patients. We considered two statements from DOQ-30: ‘I would manage my diabetes much better if I had encouragement socially’ and ‘I have difficulty understanding information from literature’, which were reported to be the obstacles faced by the study participants and we tried to predict the factors for these obstacles. MLR analysis revealed socioeconomic status (OR – 3.65, CI – 1.60-8.33 and p – 0.002) to be significantly associated with participants not being able to understand the diabetes related literature. No factors were found to be significantly associated with lack of social support for diabetes management among the participants. Socio-economic status is a multidimensional factor, which is a combination of education, income, and occupational status. It is linked with Social Determinants of Health (SDOH) which includes accessibility to quality health care, good nutrition, transportation, housing, and social engagement, all of which can affect disease management. Low SES indicates a lower level of education. In our study, SES was found to be a predictive factor for patients not being able to understand information regarding diabetes from literature. All levels of SES have been consistently reported to be a strong predictor for disease onset and progression for many chronic diseases, including diabetes. 49 Financial constraints, including the inability to purchase necessary medications not readily available in the public health system, and the cost of testing in private laboratories due to the absence of blood sugar testing facilities, particularly in rural areas, have been identified as significant obstacles in a qualitative study conducted in Punjab, India. 36 Poor SES has been reported to be a major predictor of poor medication adherence among surveys in Indian diabetic populations. 38 , 50 Patients belonging to lower SES are more likely to develop diabetes, poor self-care management, experience complication, than those belonging to higher SES . 51 , 52 Although age was not identified as a significant factor in our study, it can significantly influence diabetes self-care practices. Diabetes self-care is a complex process which involves dietary modifications, regular exercising, regular blood glucose monitoring and compliance to treatment, all of which work synergistically to achieve an optimum blood glucose level. Older diabetes patients have a unique set of problems which make practicing diabetes self-care challenging. Decreased physical and cognitive abilities, presence of comorbidities, and complications, polypharmacy, absence of support system, change in dietary habits, and depression associated with chronic diseases hamper the diabetes self-care behaviour in geriatric patients. 48 , 53 , 54 In contrast, younger adults, due to their demanding and active lifestyles, may encounter challenges in maintaining a rigid diet and exercise regimen. Peer pressure can also lead to the adoption of unhealthy eating habits. 55 In a country like India, several social and cultural factors significantly influence diabetes self-care practices. Young unmarried women with diabetes often face diabetes-related stigma, which may affect their marriage prospects. This may prompt them to hide their condition and not follow any self-care practice. 50 , 53 Women with diabetes may also compromise their dietary needs for familial preferences. Factors such as unsafe neighborhoods and a lack of recreational facilities, can also prevent compliance with exercise regimens. 50 Walking or exercising in public may not be culturally acceptable for some women, and work commitments leave little time for physical activity. 50 , 56 Many prefer traditional healers or local remedies for diabetes management due to high costs. Rural areas lack diabetes specialists, leading to improper or delayed treatment. 36 People with diabetes may hide their condition due to fear of judgment or weakness. In rural areas, some believe diabetes is a result of past sins or fate, leading to reluctance or delay in seeking proper care. 57 Lack of dietary disinhibition, a traditional carbohydrate-rich Indian diet, and frequent social gatherings, especially in rural areas, pose significant challenges to diabetes self-care in India. 58 , 59 Addressing these cultural and social factors is crucial for effective diabetes care, especially in a diverse country like India. The obstacles of diabetes self-care faced by the participants in our study were mainly due to their poor education and lower economic status. Based on the results of the DOQ-30, the majority of the patients did not have any problem following a diet or an exercise pattern as they felt that these lifestyle modifications were necessary to lead a longer and better life. The healthy relationship between the participants and healthcare providers likely ensured better information exchange to manage their diabetes in an efficient manner. Limitations The results of this facility-based investigation cannot be generalized to the broader population due to the smaller sample size. Also, the smaller sample size may have affected the statistical power, potentially limiting the robustness of some of the associations. The domain of self-monitoring was difficult to assess since the majority of the participants in our study belonged to low SES and did not have provision for self-monitoring of blood glucose. Also, the domain of Insulin use was also difficult to assess since the majority of our study participants were not prescribed insulin. Conclusions and recommendations In our study, the two major obstacles for self-management practices that were identified were in the domains of Support from Friends and Family, and Knowledge of the Disease. Socioeconomic status was identified to be a predictive factor associated with the participants who are not able to understand information from the literature. Self-management is an integral component of the treatment plan of diabetes and can lead to more positive outcomes. Targeting these barriers as identified in our study could improve self-management. Having a strong social support network could be advised and encouraged. An increased focus on patient education and awareness both in primary care as well as awareness programs could lead to decreased rate of complications, and an increased quality of life for patients moving forward. A culturally sensitive and community-based approach is paramount for enhancing diabetes care in India. By comprehending and addressing social and cultural determinants, healthcare professionals can devise more effective, enduring, and patient-centered diabetes management strategies. Data availability Underlying data OSF: “Obstacles for Self-Management Practices Among Diabetes Patients - A Facility-based Study from Coastal South India.” https://doi.org/10.17605/OSF.IO/9EN45 . 60 This project contains the following underlying data: - Final.xlsx [raw data] Extended data This project contains the following extended data: - Key.xlsx [This Microsoft Excel Spreadsheet has the key to interpret the data in the file named Final.xlsx] Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). Acknowledgements We are thankful to all of our study participants for their cooperation in our research study. We thank the Department of Community Medicine, Kasturba Medical College, Mangalore, and the Manipal Academy of Higher Education (MAHE), Manipal for their support for this research and its publication. 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Kumar N: Obstacles for Self-Management Practices Among Diabetes Patients - A Facility-based Study from Coastal South India.2023. Publisher Full Text Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 17 Jul 2023 ADD YOUR COMMENT Comment Author details Author details 1 Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India Rekha T Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Murali Mohan R Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Nithin Kumar Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Kausthubh Hegde Roles: Investigation, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Bhaskaran Unnikrishnan Roles: Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Prasanna Mithra Roles: Formal Analysis, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Ramesh Holla Roles: Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Balanarayana Suma Roles: Investigation, Writing – Original Draft Preparation Aadithya M Rao Roles: Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Patil Nikitha Roles: Investigation Aysha Roushida Sahama M Roles: Investigation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (3) version 3 Revised Published: 18 Mar 2025, 12:839 https://doi.org/10.12688/f1000research.138146.3 version 2 Revised Published: 02 Dec 2024, 12:839 https://doi.org/10.12688/f1000research.138146.2 version 1 Published: 17 Jul 2023, 12:839 https://doi.org/10.12688/f1000research.138146.1 Copyright © 2025 T R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article T R, R MM, Kumar N et al. Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.12688/f1000research.138146.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 3 VERSION 3 PUBLISHED 18 Mar 2025 Revised Views 0 Cite How to cite this report: Gupta SK. Reviewer Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.177922.r371536 ) The direct URL for this report is: https://f1000research.com/articles/12-839/v3#referee-response-371536 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 19 Mar 2025 Saurabh Kumar Gupta , PGIMER, PGIMER, Chandigarh, India Approved VIEWS 0 https://doi.org/10.5256/f1000research.177922.r371536 Revised version of the manuscript ... Continue reading READ ALL Revised version of the manuscript looks good. Congratulations to the authors. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Implememntation research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Gupta SK. Reviewer Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.177922.r371536 ) The direct URL for this report is: https://f1000research.com/articles/12-839/v3#referee-response-371536 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 2 VERSION 2 PUBLISHED 02 Dec 2024 Revised Views 0 Cite How to cite this report: Gupta SK. Reviewer Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.175392.r345564 ) The direct URL for this report is: https://f1000research.com/articles/12-839/v2#referee-response-345564 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Jan 2025 Saurabh Kumar Gupta , PGIMER, PGIMER, Chandigarh, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.175392.r345564 1. Is the work clearly and accurately presented and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on diabetes self-care barriers. However, some cited references ... Continue reading READ ALL 1. Is the work clearly and accurately presented and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on diabetes self-care barriers. However, some cited references are general rather than specific to India, and the focus on global contexts may overshadow region-specific challenges. Some points lack citations, reducing the depth of the argument. 2. Is the study design appropriate and is the work technically sound? Answer: Partly A cross-sectional design is appropriate for identifying self-care barriers at a specific time point. However: The small sample size and facility-based sampling limit generalizability. Lack of longitudinal data restricts understanding of long-term self-care practices. While technically sound, the study's design could be strengthened by addressing these limitations. 3. Are sufficient details of methods and analysis provided to allow replication by others? Answer: Partly The study provides an outline of the methods, including participant recruitment, use of the DOQ-30 tool, and statistical analysis. However, there are gaps: Missing details on the pretesting of the translated questionnaire. No description of how missing data were handled in the analysis (e.g., imputation or exclusion criteria). Limited information on the ethical considerations during participant interviews. 4. If applicable, is the statistical analysis and its interpretation appropriate? Answer: Partly The statistical methods (e.g., multinomial logistic regression) are appropriate for identifying predictive factors. However: Results for some associations lack robustness due to the small sample size. There is no discussion of potential confounders or adjustments for multiple testing. Interpretation of findings is logical but could benefit from deeper analysis of non-significant trends. 5. Are all the source data underlying the results available to ensure full reproducibility? Answer: No The study mentions the availability of source data but does not provide access or detailed descriptions of the dataset. Full reproducibility requires transparent sharing of anonymized data, which is missing here. 6. Are the conclusions drawn adequately supported by the results? Answer: Partly Conclusions about the role of social support and socioeconomic status as barriers are supported by the data. However: Generalizability is limited due to sample size and study design. The study does not adequately address other barriers that could emerge in different populations or settings. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Implememntation research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Gupta SK. Reviewer Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.175392.r345564 ) The direct URL for this report is: https://f1000research.com/articles/12-839/v2#referee-response-345564 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 06 Feb 2025 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India 06 Feb 2025 Author Response 1 . Is the work clearly and accurately presented, and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on ... Continue reading 1 . Is the work clearly and accurately presented, and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on diabetes self-care barriers. However, some cited references are general rather than specific to India, and the focus on global contexts may overshadow region-specific challenges. Some points lack citations, reducing the depth of the argument. Response: Thank you, sir, for your suggestion. We have updated the discussion with cited references which focus on the Indian context explaining the socio-cultural factors responsible for obstacles for self-care practices. Also, citations have been provided for uncited statements improving the discussion. The reference list has also been updated. 2. Is the study design appropriate and is the work technically sound? Answer: Partly A cross-sectional design is appropriate for identifying self-care barriers at a specific time point. However: The small sample size and facility-based sampling limit generalizability. Lack of longitudinal data restricts understanding of long-term self-care practices. While technically sound, the study's design could be strengthened by addressing these limitations. Response : Thank you for your insightful feedback. We acknowledge the limitations of a cross-sectional design, particularly in terms of generalizability due to the small sample size and facility-based sampling. We have mentioned the same as the limitation of our study. Since the study was carried out in a tertiary hospital which caters to the patients from not only the study area, but the neighboring districts, the follow up of all the participants of the study would not have been possible. However, we recognize that the absence of longitudinal data restricts the ability to assess long-term self-care practices is also one of limitations of the study. 3. Are sufficient details of methods and analysis provided to allow replication by others? Answer: Partly The study provides an outline of the methods, including participant recruitment, use of the DOQ-30 tool, and statistical analysis. However, there are gaps: Missing details on the pretesting of the translated questionnaire. No description of how missing data were handled in the analysis (e.g., imputation or exclusion criteria). Limited information on the ethical considerations during participant interviews. Response: Respected Sir, we respect your constructive feedback. Missing data: The missing data were not considered for the analysis since they were removed by listwise deletion of the participant record. We have included the statement in the data analysis section. Pretesting of the questionnaire: A pilot study was carried out to validate the language and content of the translated questionnaire. It was done among 30 participants, selected using convenience sampling technique. The participants of the pilot were excluded from the main study. Based on the findings of the pilot study, language modification to remove ambiguous and confusing terms was done for all the 4 sections of the questionnaire, while content validation was done for sections A, B and D. No changes to content were made to Section C since it was a standard questionnaire. Interviews of the participants were conducted by the same interviewer to reduce inter-observer bias and ensure consistency in data collection.We have included a section on pretesting of the questionnaire in the manuscript. Ethical considerations during interviews: To maintain the privacy of the patient, the interview was conducted in a separate room attached to the outpatient department. Written informed consent stating the purpose and objectives of the study, and data confidentiality was obtained from all the participants of the study. Personal identifier (names) was not included in the questionnaire to maintain the participant anonymity. 4. If applicable, is the statistical analysis and its interpretation appropriate? Answer: Partly The statistical methods (e.g., multinomial logistic regression) are appropriate for identifying predictive factors. However: Results for some associations lack robustness due to the small sample size. There is no discussion of potential confounders or adjustments for multiple testing. Interpretation of findings is logical but could benefit from deeper analysis of non-significant trends. Response: Thank you, Sir. We acknowledge that the small sample size may have affected the statistical power, potentially limiting the robustness of some of the associations. This is an inherent limitation of the study, and we have included a statement in the discussion section highlighting this point. We have also included discussion on the non-significant factors in the discussion of the manuscript. 5. Are all the source data underlying the results available to ensure full reproducibility? Answer: No The study mentions the availability of source data but does not provide access or detailed descriptions of the dataset. Full reproducibility requires transparent sharing of anonymized data, which is missing here. Response: Thank you, Sir. The source data set has been uploaded in the repository and the link for the same has been provided in the manuscript as per the requirement of the journal. The data set can be accessed at https://doi.org/10.17605/OSF.IO/9EN45 6. Are the conclusions drawn adequately supported by the results? Answer: Partly Conclusions about the role of social support and socioeconomic status as barriers are supported by the data. However: Generalizability is limited due to sample size and study design. The study does not adequately address other barriers that could emerge in different populations or settings. Response : We acknowledge the limitations in generalizability due to the sample size and study design. As per your suggestion we have included the discussion on the possible barriers for self-care in different population like old age and gender and in rural areas and updated the references. Is the work clearly and accurately presented, and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly 1 . Is the work clearly and accurately presented, and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on diabetes self-care barriers. However, some cited references are general rather than specific to India, and the focus on global contexts may overshadow region-specific challenges. Some points lack citations, reducing the depth of the argument. Response: Thank you, sir, for your suggestion. We have updated the discussion with cited references which focus on the Indian context explaining the socio-cultural factors responsible for obstacles for self-care practices. Also, citations have been provided for uncited statements improving the discussion. The reference list has also been updated. 2. Is the study design appropriate and is the work technically sound? Answer: Partly A cross-sectional design is appropriate for identifying self-care barriers at a specific time point. However: The small sample size and facility-based sampling limit generalizability. Lack of longitudinal data restricts understanding of long-term self-care practices. While technically sound, the study's design could be strengthened by addressing these limitations. Response : Thank you for your insightful feedback. We acknowledge the limitations of a cross-sectional design, particularly in terms of generalizability due to the small sample size and facility-based sampling. We have mentioned the same as the limitation of our study. Since the study was carried out in a tertiary hospital which caters to the patients from not only the study area, but the neighboring districts, the follow up of all the participants of the study would not have been possible. However, we recognize that the absence of longitudinal data restricts the ability to assess long-term self-care practices is also one of limitations of the study. 3. Are sufficient details of methods and analysis provided to allow replication by others? Answer: Partly The study provides an outline of the methods, including participant recruitment, use of the DOQ-30 tool, and statistical analysis. However, there are gaps: Missing details on the pretesting of the translated questionnaire. No description of how missing data were handled in the analysis (e.g., imputation or exclusion criteria). Limited information on the ethical considerations during participant interviews. Response: Respected Sir, we respect your constructive feedback. Missing data: The missing data were not considered for the analysis since they were removed by listwise deletion of the participant record. We have included the statement in the data analysis section. Pretesting of the questionnaire: A pilot study was carried out to validate the language and content of the translated questionnaire. It was done among 30 participants, selected using convenience sampling technique. The participants of the pilot were excluded from the main study. Based on the findings of the pilot study, language modification to remove ambiguous and confusing terms was done for all the 4 sections of the questionnaire, while content validation was done for sections A, B and D. No changes to content were made to Section C since it was a standard questionnaire. Interviews of the participants were conducted by the same interviewer to reduce inter-observer bias and ensure consistency in data collection.We have included a section on pretesting of the questionnaire in the manuscript. Ethical considerations during interviews: To maintain the privacy of the patient, the interview was conducted in a separate room attached to the outpatient department. Written informed consent stating the purpose and objectives of the study, and data confidentiality was obtained from all the participants of the study. Personal identifier (names) was not included in the questionnaire to maintain the participant anonymity. 4. If applicable, is the statistical analysis and its interpretation appropriate? Answer: Partly The statistical methods (e.g., multinomial logistic regression) are appropriate for identifying predictive factors. However: Results for some associations lack robustness due to the small sample size. There is no discussion of potential confounders or adjustments for multiple testing. Interpretation of findings is logical but could benefit from deeper analysis of non-significant trends. Response: Thank you, Sir. We acknowledge that the small sample size may have affected the statistical power, potentially limiting the robustness of some of the associations. This is an inherent limitation of the study, and we have included a statement in the discussion section highlighting this point. We have also included discussion on the non-significant factors in the discussion of the manuscript. 5. Are all the source data underlying the results available to ensure full reproducibility? Answer: No The study mentions the availability of source data but does not provide access or detailed descriptions of the dataset. Full reproducibility requires transparent sharing of anonymized data, which is missing here. Response: Thank you, Sir. The source data set has been uploaded in the repository and the link for the same has been provided in the manuscript as per the requirement of the journal. The data set can be accessed at https://doi.org/10.17605/OSF.IO/9EN45 6. Are the conclusions drawn adequately supported by the results? Answer: Partly Conclusions about the role of social support and socioeconomic status as barriers are supported by the data. However: Generalizability is limited due to sample size and study design. The study does not adequately address other barriers that could emerge in different populations or settings. Response : We acknowledge the limitations in generalizability due to the sample size and study design. As per your suggestion we have included the discussion on the possible barriers for self-care in different population like old age and gender and in rural areas and updated the references. Is the work clearly and accurately presented, and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 06 Feb 2025 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India 06 Feb 2025 Author Response 1 . Is the work clearly and accurately presented, and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on ... Continue reading 1 . Is the work clearly and accurately presented, and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on diabetes self-care barriers. However, some cited references are general rather than specific to India, and the focus on global contexts may overshadow region-specific challenges. Some points lack citations, reducing the depth of the argument. Response: Thank you, sir, for your suggestion. We have updated the discussion with cited references which focus on the Indian context explaining the socio-cultural factors responsible for obstacles for self-care practices. Also, citations have been provided for uncited statements improving the discussion. The reference list has also been updated. 2. Is the study design appropriate and is the work technically sound? Answer: Partly A cross-sectional design is appropriate for identifying self-care barriers at a specific time point. However: The small sample size and facility-based sampling limit generalizability. Lack of longitudinal data restricts understanding of long-term self-care practices. While technically sound, the study's design could be strengthened by addressing these limitations. Response : Thank you for your insightful feedback. We acknowledge the limitations of a cross-sectional design, particularly in terms of generalizability due to the small sample size and facility-based sampling. We have mentioned the same as the limitation of our study. Since the study was carried out in a tertiary hospital which caters to the patients from not only the study area, but the neighboring districts, the follow up of all the participants of the study would not have been possible. However, we recognize that the absence of longitudinal data restricts the ability to assess long-term self-care practices is also one of limitations of the study. 3. Are sufficient details of methods and analysis provided to allow replication by others? Answer: Partly The study provides an outline of the methods, including participant recruitment, use of the DOQ-30 tool, and statistical analysis. However, there are gaps: Missing details on the pretesting of the translated questionnaire. No description of how missing data were handled in the analysis (e.g., imputation or exclusion criteria). Limited information on the ethical considerations during participant interviews. Response: Respected Sir, we respect your constructive feedback. Missing data: The missing data were not considered for the analysis since they were removed by listwise deletion of the participant record. We have included the statement in the data analysis section. Pretesting of the questionnaire: A pilot study was carried out to validate the language and content of the translated questionnaire. It was done among 30 participants, selected using convenience sampling technique. The participants of the pilot were excluded from the main study. Based on the findings of the pilot study, language modification to remove ambiguous and confusing terms was done for all the 4 sections of the questionnaire, while content validation was done for sections A, B and D. No changes to content were made to Section C since it was a standard questionnaire. Interviews of the participants were conducted by the same interviewer to reduce inter-observer bias and ensure consistency in data collection.We have included a section on pretesting of the questionnaire in the manuscript. Ethical considerations during interviews: To maintain the privacy of the patient, the interview was conducted in a separate room attached to the outpatient department. Written informed consent stating the purpose and objectives of the study, and data confidentiality was obtained from all the participants of the study. Personal identifier (names) was not included in the questionnaire to maintain the participant anonymity. 4. If applicable, is the statistical analysis and its interpretation appropriate? Answer: Partly The statistical methods (e.g., multinomial logistic regression) are appropriate for identifying predictive factors. However: Results for some associations lack robustness due to the small sample size. There is no discussion of potential confounders or adjustments for multiple testing. Interpretation of findings is logical but could benefit from deeper analysis of non-significant trends. Response: Thank you, Sir. We acknowledge that the small sample size may have affected the statistical power, potentially limiting the robustness of some of the associations. This is an inherent limitation of the study, and we have included a statement in the discussion section highlighting this point. We have also included discussion on the non-significant factors in the discussion of the manuscript. 5. Are all the source data underlying the results available to ensure full reproducibility? Answer: No The study mentions the availability of source data but does not provide access or detailed descriptions of the dataset. Full reproducibility requires transparent sharing of anonymized data, which is missing here. Response: Thank you, Sir. The source data set has been uploaded in the repository and the link for the same has been provided in the manuscript as per the requirement of the journal. The data set can be accessed at https://doi.org/10.17605/OSF.IO/9EN45 6. Are the conclusions drawn adequately supported by the results? Answer: Partly Conclusions about the role of social support and socioeconomic status as barriers are supported by the data. However: Generalizability is limited due to sample size and study design. The study does not adequately address other barriers that could emerge in different populations or settings. Response : We acknowledge the limitations in generalizability due to the sample size and study design. As per your suggestion we have included the discussion on the possible barriers for self-care in different population like old age and gender and in rural areas and updated the references. Is the work clearly and accurately presented, and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly 1 . Is the work clearly and accurately presented, and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on diabetes self-care barriers. However, some cited references are general rather than specific to India, and the focus on global contexts may overshadow region-specific challenges. Some points lack citations, reducing the depth of the argument. Response: Thank you, sir, for your suggestion. We have updated the discussion with cited references which focus on the Indian context explaining the socio-cultural factors responsible for obstacles for self-care practices. Also, citations have been provided for uncited statements improving the discussion. The reference list has also been updated. 2. Is the study design appropriate and is the work technically sound? Answer: Partly A cross-sectional design is appropriate for identifying self-care barriers at a specific time point. However: The small sample size and facility-based sampling limit generalizability. Lack of longitudinal data restricts understanding of long-term self-care practices. While technically sound, the study's design could be strengthened by addressing these limitations. Response : Thank you for your insightful feedback. We acknowledge the limitations of a cross-sectional design, particularly in terms of generalizability due to the small sample size and facility-based sampling. We have mentioned the same as the limitation of our study. Since the study was carried out in a tertiary hospital which caters to the patients from not only the study area, but the neighboring districts, the follow up of all the participants of the study would not have been possible. However, we recognize that the absence of longitudinal data restricts the ability to assess long-term self-care practices is also one of limitations of the study. 3. Are sufficient details of methods and analysis provided to allow replication by others? Answer: Partly The study provides an outline of the methods, including participant recruitment, use of the DOQ-30 tool, and statistical analysis. However, there are gaps: Missing details on the pretesting of the translated questionnaire. No description of how missing data were handled in the analysis (e.g., imputation or exclusion criteria). Limited information on the ethical considerations during participant interviews. Response: Respected Sir, we respect your constructive feedback. Missing data: The missing data were not considered for the analysis since they were removed by listwise deletion of the participant record. We have included the statement in the data analysis section. Pretesting of the questionnaire: A pilot study was carried out to validate the language and content of the translated questionnaire. It was done among 30 participants, selected using convenience sampling technique. The participants of the pilot were excluded from the main study. Based on the findings of the pilot study, language modification to remove ambiguous and confusing terms was done for all the 4 sections of the questionnaire, while content validation was done for sections A, B and D. No changes to content were made to Section C since it was a standard questionnaire. Interviews of the participants were conducted by the same interviewer to reduce inter-observer bias and ensure consistency in data collection.We have included a section on pretesting of the questionnaire in the manuscript. Ethical considerations during interviews: To maintain the privacy of the patient, the interview was conducted in a separate room attached to the outpatient department. Written informed consent stating the purpose and objectives of the study, and data confidentiality was obtained from all the participants of the study. Personal identifier (names) was not included in the questionnaire to maintain the participant anonymity. 4. If applicable, is the statistical analysis and its interpretation appropriate? Answer: Partly The statistical methods (e.g., multinomial logistic regression) are appropriate for identifying predictive factors. However: Results for some associations lack robustness due to the small sample size. There is no discussion of potential confounders or adjustments for multiple testing. Interpretation of findings is logical but could benefit from deeper analysis of non-significant trends. Response: Thank you, Sir. We acknowledge that the small sample size may have affected the statistical power, potentially limiting the robustness of some of the associations. This is an inherent limitation of the study, and we have included a statement in the discussion section highlighting this point. We have also included discussion on the non-significant factors in the discussion of the manuscript. 5. Are all the source data underlying the results available to ensure full reproducibility? Answer: No The study mentions the availability of source data but does not provide access or detailed descriptions of the dataset. Full reproducibility requires transparent sharing of anonymized data, which is missing here. Response: Thank you, Sir. The source data set has been uploaded in the repository and the link for the same has been provided in the manuscript as per the requirement of the journal. The data set can be accessed at https://doi.org/10.17605/OSF.IO/9EN45 6. Are the conclusions drawn adequately supported by the results? Answer: Partly Conclusions about the role of social support and socioeconomic status as barriers are supported by the data. However: Generalizability is limited due to sample size and study design. The study does not adequately address other barriers that could emerge in different populations or settings. Response : We acknowledge the limitations in generalizability due to the sample size and study design. As per your suggestion we have included the discussion on the possible barriers for self-care in different population like old age and gender and in rural areas and updated the references. Is the work clearly and accurately presented, and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 17 Jul 2023 Views 0 Cite How to cite this report: Saya GK. Reviewer Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.151323.r273975 ) The direct URL for this report is: https://f1000research.com/articles/12-839/v1#referee-response-273975 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Sep 2024 Ganesh Kumar Saya , Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, Tamil Nadu, India Approved VIEWS 0 https://doi.org/10.5256/f1000research.151323.r273975 This is an important public health issue due to the high problem burden of diabetes. However the following points may be clarified: Since this study is done in a tertiary care hospital, the original residential status ... Continue reading READ ALL This is an important public health issue due to the high problem burden of diabetes. However the following points may be clarified: Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section. Whether there are similar studies by using the same questionnaire? If so, it may be applied for minimal sample size calculation. Whether details of accepted standard self care practices may be elaborated in methods section as mentioned in section B of data collection? If self management practice also convey the same meaning, same words may be used. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Maternal and Child health, disability I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Saya GK. Reviewer Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.151323.r273975 ) The direct URL for this report is: https://f1000research.com/articles/12-839/v1#referee-response-273975 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 02 Dec 2024 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India 02 Dec 2024 Author Response Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section . Response: Thank you, ... Continue reading Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section . Response: Thank you, sir, for the suggestion. The details have been incorporated in the manuscript. Whether there are similar studies by using the same questionnaire? If so, it may be applied for minimal sample size calculation. Response: During our review of literature, we couldn’t find any Indian studies where self-care practices was assessed using the Diabetes Obstacles Questionnaire-30 (DOQ-30). Few of the studies had used Summary of Diabetes Self-care Activities (SDSCA) scale. Hence we went by the assumption for sample size calculation. Whether details of accepted standard self-care practices may be elaborated in methods section as mentioned in section B of data collection? If self-management practice also conveys the same meaning, same words may be used Response: The participants were asked about diabetes self-care practices under the domains of diet, exercise, blood glucose monitoring, medication compliance, and foot care. They were also asked if they had any self-reported obstacles to following these practices during the preceding week of the study. Diabetes self-management and Diabetes self-care practices are the same. Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section . Response: Thank you, sir, for the suggestion. The details have been incorporated in the manuscript. Whether there are similar studies by using the same questionnaire? If so, it may be applied for minimal sample size calculation. Response: During our review of literature, we couldn’t find any Indian studies where self-care practices was assessed using the Diabetes Obstacles Questionnaire-30 (DOQ-30). Few of the studies had used Summary of Diabetes Self-care Activities (SDSCA) scale. Hence we went by the assumption for sample size calculation. Whether details of accepted standard self-care practices may be elaborated in methods section as mentioned in section B of data collection? If self-management practice also conveys the same meaning, same words may be used Response: The participants were asked about diabetes self-care practices under the domains of diet, exercise, blood glucose monitoring, medication compliance, and foot care. They were also asked if they had any self-reported obstacles to following these practices during the preceding week of the study. Diabetes self-management and Diabetes self-care practices are the same. Competing Interests: nil Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 02 Dec 2024 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India 02 Dec 2024 Author Response Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section . Response: Thank you, ... Continue reading Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section . Response: Thank you, sir, for the suggestion. The details have been incorporated in the manuscript. Whether there are similar studies by using the same questionnaire? If so, it may be applied for minimal sample size calculation. Response: During our review of literature, we couldn’t find any Indian studies where self-care practices was assessed using the Diabetes Obstacles Questionnaire-30 (DOQ-30). Few of the studies had used Summary of Diabetes Self-care Activities (SDSCA) scale. Hence we went by the assumption for sample size calculation. Whether details of accepted standard self-care practices may be elaborated in methods section as mentioned in section B of data collection? If self-management practice also conveys the same meaning, same words may be used Response: The participants were asked about diabetes self-care practices under the domains of diet, exercise, blood glucose monitoring, medication compliance, and foot care. They were also asked if they had any self-reported obstacles to following these practices during the preceding week of the study. Diabetes self-management and Diabetes self-care practices are the same. Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section . Response: Thank you, sir, for the suggestion. The details have been incorporated in the manuscript. Whether there are similar studies by using the same questionnaire? If so, it may be applied for minimal sample size calculation. Response: During our review of literature, we couldn’t find any Indian studies where self-care practices was assessed using the Diabetes Obstacles Questionnaire-30 (DOQ-30). Few of the studies had used Summary of Diabetes Self-care Activities (SDSCA) scale. Hence we went by the assumption for sample size calculation. Whether details of accepted standard self-care practices may be elaborated in methods section as mentioned in section B of data collection? If self-management practice also conveys the same meaning, same words may be used Response: The participants were asked about diabetes self-care practices under the domains of diet, exercise, blood glucose monitoring, medication compliance, and foot care. They were also asked if they had any self-reported obstacles to following these practices during the preceding week of the study. Diabetes self-management and Diabetes self-care practices are the same. Competing Interests: nil Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 17 Jul 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 3 (revision) 18 Mar 25 read Version 2 (revision) 02 Dec 24 read Version 1 17 Jul 23 read Ganesh Kumar Saya , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India Saurabh Kumar Gupta , PGIMER, Chandigarh, India Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Gupta S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 19 Mar 2025 | for Version 3 Saurabh Kumar Gupta , PGIMER, PGIMER, Chandigarh, India 0 Views copyright © 2025 Gupta S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Revised version of the manuscript looks good. Congratulations to the authors. Competing Interests No competing interests were disclosed. Reviewer Expertise Implememntation research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Gupta SK. Peer Review Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.177922.r371536) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-839/v3#referee-response-371536 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Gupta S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Jan 2025 | for Version 2 Saurabh Kumar Gupta , PGIMER, PGIMER, Chandigarh, India 0 Views copyright © 2025 Gupta S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 1. Is the work clearly and accurately presented and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on diabetes self-care barriers. However, some cited references are general rather than specific to India, and the focus on global contexts may overshadow region-specific challenges. Some points lack citations, reducing the depth of the argument. 2. Is the study design appropriate and is the work technically sound? Answer: Partly A cross-sectional design is appropriate for identifying self-care barriers at a specific time point. However: The small sample size and facility-based sampling limit generalizability. Lack of longitudinal data restricts understanding of long-term self-care practices. While technically sound, the study's design could be strengthened by addressing these limitations. 3. Are sufficient details of methods and analysis provided to allow replication by others? Answer: Partly The study provides an outline of the methods, including participant recruitment, use of the DOQ-30 tool, and statistical analysis. However, there are gaps: Missing details on the pretesting of the translated questionnaire. No description of how missing data were handled in the analysis (e.g., imputation or exclusion criteria). Limited information on the ethical considerations during participant interviews. 4. If applicable, is the statistical analysis and its interpretation appropriate? Answer: Partly The statistical methods (e.g., multinomial logistic regression) are appropriate for identifying predictive factors. However: Results for some associations lack robustness due to the small sample size. There is no discussion of potential confounders or adjustments for multiple testing. Interpretation of findings is logical but could benefit from deeper analysis of non-significant trends. 5. Are all the source data underlying the results available to ensure full reproducibility? Answer: No The study mentions the availability of source data but does not provide access or detailed descriptions of the dataset. Full reproducibility requires transparent sharing of anonymized data, which is missing here. 6. Are the conclusions drawn adequately supported by the results? Answer: Partly Conclusions about the role of social support and socioeconomic status as barriers are supported by the data. However: Generalizability is limited due to sample size and study design. The study does not adequately address other barriers that could emerge in different populations or settings. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Implememntation research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 06 Feb 2025 Nithin Kumar, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India 1 . Is the work clearly and accurately presented, and does it cite the current literature? Answer: Partly The study provides a detailed narrative and references current literature on diabetes self-care barriers. However, some cited references are general rather than specific to India, and the focus on global contexts may overshadow region-specific challenges. Some points lack citations, reducing the depth of the argument. Response: Thank you, sir, for your suggestion. We have updated the discussion with cited references which focus on the Indian context explaining the socio-cultural factors responsible for obstacles for self-care practices. Also, citations have been provided for uncited statements improving the discussion. The reference list has also been updated. 2. Is the study design appropriate and is the work technically sound? Answer: Partly A cross-sectional design is appropriate for identifying self-care barriers at a specific time point. However: The small sample size and facility-based sampling limit generalizability. Lack of longitudinal data restricts understanding of long-term self-care practices. While technically sound, the study's design could be strengthened by addressing these limitations. Response : Thank you for your insightful feedback. We acknowledge the limitations of a cross-sectional design, particularly in terms of generalizability due to the small sample size and facility-based sampling. We have mentioned the same as the limitation of our study. Since the study was carried out in a tertiary hospital which caters to the patients from not only the study area, but the neighboring districts, the follow up of all the participants of the study would not have been possible. However, we recognize that the absence of longitudinal data restricts the ability to assess long-term self-care practices is also one of limitations of the study. 3. Are sufficient details of methods and analysis provided to allow replication by others? Answer: Partly The study provides an outline of the methods, including participant recruitment, use of the DOQ-30 tool, and statistical analysis. However, there are gaps: Missing details on the pretesting of the translated questionnaire. No description of how missing data were handled in the analysis (e.g., imputation or exclusion criteria). Limited information on the ethical considerations during participant interviews. Response: Respected Sir, we respect your constructive feedback. Missing data: The missing data were not considered for the analysis since they were removed by listwise deletion of the participant record. We have included the statement in the data analysis section. Pretesting of the questionnaire: A pilot study was carried out to validate the language and content of the translated questionnaire. It was done among 30 participants, selected using convenience sampling technique. The participants of the pilot were excluded from the main study. Based on the findings of the pilot study, language modification to remove ambiguous and confusing terms was done for all the 4 sections of the questionnaire, while content validation was done for sections A, B and D. No changes to content were made to Section C since it was a standard questionnaire. Interviews of the participants were conducted by the same interviewer to reduce inter-observer bias and ensure consistency in data collection.We have included a section on pretesting of the questionnaire in the manuscript. Ethical considerations during interviews: To maintain the privacy of the patient, the interview was conducted in a separate room attached to the outpatient department. Written informed consent stating the purpose and objectives of the study, and data confidentiality was obtained from all the participants of the study. Personal identifier (names) was not included in the questionnaire to maintain the participant anonymity. 4. If applicable, is the statistical analysis and its interpretation appropriate? Answer: Partly The statistical methods (e.g., multinomial logistic regression) are appropriate for identifying predictive factors. However: Results for some associations lack robustness due to the small sample size. There is no discussion of potential confounders or adjustments for multiple testing. Interpretation of findings is logical but could benefit from deeper analysis of non-significant trends. Response: Thank you, Sir. We acknowledge that the small sample size may have affected the statistical power, potentially limiting the robustness of some of the associations. This is an inherent limitation of the study, and we have included a statement in the discussion section highlighting this point. We have also included discussion on the non-significant factors in the discussion of the manuscript. 5. Are all the source data underlying the results available to ensure full reproducibility? Answer: No The study mentions the availability of source data but does not provide access or detailed descriptions of the dataset. Full reproducibility requires transparent sharing of anonymized data, which is missing here. Response: Thank you, Sir. The source data set has been uploaded in the repository and the link for the same has been provided in the manuscript as per the requirement of the journal. The data set can be accessed at https://doi.org/10.17605/OSF.IO/9EN45 6. Are the conclusions drawn adequately supported by the results? Answer: Partly Conclusions about the role of social support and socioeconomic status as barriers are supported by the data. However: Generalizability is limited due to sample size and study design. The study does not adequately address other barriers that could emerge in different populations or settings. Response : We acknowledge the limitations in generalizability due to the sample size and study design. As per your suggestion we have included the discussion on the possible barriers for self-care in different population like old age and gender and in rural areas and updated the references. Is the work clearly and accurately presented, and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Gupta SK. Peer Review Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.175392.r345564) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-839/v2#referee-response-345564 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Saya G. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Sep 2024 | for Version 1 Ganesh Kumar Saya , Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, Tamil Nadu, India 0 Views copyright © 2024 Saya G. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is an important public health issue due to the high problem burden of diabetes. However the following points may be clarified: Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section. Whether there are similar studies by using the same questionnaire? If so, it may be applied for minimal sample size calculation. Whether details of accepted standard self care practices may be elaborated in methods section as mentioned in section B of data collection? If self management practice also convey the same meaning, same words may be used. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Maternal and Child health, disability I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 02 Dec 2024 Nithin Kumar, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India Since this study is done in a tertiary care hospital, the original residential status of the participant details may be mentioned in methods section . Response: Thank you, sir, for the suggestion. The details have been incorporated in the manuscript. Whether there are similar studies by using the same questionnaire? If so, it may be applied for minimal sample size calculation. Response: During our review of literature, we couldn’t find any Indian studies where self-care practices was assessed using the Diabetes Obstacles Questionnaire-30 (DOQ-30). Few of the studies had used Summary of Diabetes Self-care Activities (SDSCA) scale. Hence we went by the assumption for sample size calculation. Whether details of accepted standard self-care practices may be elaborated in methods section as mentioned in section B of data collection? If self-management practice also conveys the same meaning, same words may be used Response: The participants were asked about diabetes self-care practices under the domains of diet, exercise, blood glucose monitoring, medication compliance, and foot care. They were also asked if they had any self-reported obstacles to following these practices during the preceding week of the study. Diabetes self-management and Diabetes self-care practices are the same. View more View less Competing Interests nil reply Respond Report a concern Saya GK. Peer Review Report For: Obstacles for self-management practices among diabetes patients: A facility-based study from Coastal South India. [version 3; peer review: 2 approved] . F1000Research 2025, 12 :839 ( https://doi.org/10.5256/f1000research.151323.r273975) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-839/v1#referee-response-273975 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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