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The reviewer is happy that you have addressed all initial concerns.
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The suggested modifications have all been made to my satisfaction
Thank you for your submission. Both reviewers have identified major revisions which must be addressed before we can consider your paper for publication. Further work is required on the background / introduction and on the rationale for the methodology employed (sample strategy, recruitment, construction of open ended question).
The introduction is very short and does not adequately justify the need for doing this research. I think this could be solved by adding more content in and by expanding on some of the content that is already there. For example, why should the role of pharmacists in Indonesia be expanded? There is reference to a government policy but no detail provided. What do pharmacists do at the moment and what does the literature suggest pharmacists COULD do in service of people with Type 2 diabetes to help manage the health crisis. The authors could draw on research from developed countries that may have already expanded their services.
I have some concerns about the methods.
Lines 97-104: The authors state that they need a sample of 200 for the 'analysis of factors' - does this mean they intended to carry out some kind of factor analysis? If so, they have not done this but they also would have no justification for doing this in light of the aims of the research. It might be that this just needs to be reworded to reflect the sample size requirements for regression, which is what the authors carried out. It would be helpful to clarify what is meant here.
Line 114: the authors state that inclusion criteria include patients with a 'diagnosis of Type 2 diabetes for which they were receiving oral antidiabetic medications' - is this the only form of treatment for Type 2 diabetes. I noted in Table 5 and Table 6 that partiicpants referred to pharmacists providing advice on insulin usage - but I thought insulin was only for Type 1 diabetics (this may reflect ignorance on my part). Or was it that the participants were thinking more broadly than their own condition?
Line 126-128: My biggest concern with the paper lies in the wording of the open ended question (In your opinion, what are the five most important services that should be provided at pharmacies to assist you with your diabetes?). The use of the word 'should' may prime participants' prior expectations of what pharmacists ALREADY do, rather than enable them to think about what pharmacists COULD do... I'm not sure how much of an issue this is but I thought the point of the paper was to consider how to evolve community based pharmacists in their role, not to validate what they already do in their role. I was also not sure why the authors limited the participants to the 'five most important services'. The authors could do with considering the wording with regards to the data they got back.
Line 138-140 - just a point of clarification - was the reliability assessed on the 10 pilot participants?
Line 158-160: it would be very helpful to have more detail on what actually happened during content analysis. What did the authors actually do? Did they follow a widely accepted process for this - if so, a reference would be helpful.
Line 166-168: authors state that "some of the activities were grouped together if they related to the same theme for which a mean rating was calculated, and converted into a binary variable as above." This sentence did not make sense to me. Specifically which activities were grouped together, to form which variables? Also, I don't understand the mean rating and conversion into a binary variable. It will be helpful for the authors to expand on this.
Line 173: "To calculate the mean, a 'no' response was classified as '0', and a 'yes' response was classified as '1'; the mean was treated as a continuous variable. Not sure I understand this.
I'm largely okay with the results section, although I do have a few specific comments.
Line 212; I don't know what HbA1c is or refers to - could the authors specify please?
Line 220-229: I recognise that this is a summary of what's in Table 5 but when I reviewed the table there are some interesting sub-results that may be worth highlighting.
Line 237-238: The authors state that "No new services were raised from this open-ended question". I think this is because the question was worded in such a way as to prime participants to access their existing expectations of what a pharmacist already does. As such, it doesn't surprise me that you didn't get anything new. I'm wondering about the value of the research for this reason. The open ended question was important in the context of the aims of the research and I worry it was written in such a way as to only access what participants already understand of the pharmacists role.
Line 327-337: I'm wondering if the authors should discuss the wording of the question as a potential limitation?
The general reporting of the study is quite good. However a major limitation is not including the survey response rate. I would imagine that this may have a large impact on the results - i.e. depending on which patients respond.
There are flaws in the design. Firstly the sample is not randomly selected and no details are given on exactly how the pharmacies were selected - or on how patients were recruited.
The authors have not tried hard enough to address the limitations of the study - i.e. they have ignored mentioning the original method of selection of pharmacies for the previous survey in which they were used, response rates amongst patients, and discussion of possible response bias.
The authors describe results of a diabetes survey conducted amongst patients that visited 10 separate pharmacies across Indonesia. The survey’s general aim was to elicit patients views on the roles of pharmacists and to also determine what demographic and patient characteristics influence these views. The paper is generally well written and reasonably detailed. However there is a serious flaw in the study design for inferences to be made about patients views of pharmacist’s roles in general.
Detailed comments
1. The sampling strategy is referred to as a stratified sample (but stratified on what?) when in fact it is a convenience sample based on pre-identified pharmacies that were used in a previous survey. As such there may be a serious bias in the findings for these Pharmacies compared to others in the community with respondents having different views from pharmacies/patients that were not recruited. What was the previous sampling strategy used for these pharmacies?
2. Please provide details on how patients were approached and recruited.
3. Approximately 20 patients were recruited for each pharmacy but no data is provided on the response rate. If it is low, then there is a serious concern for bias given that patients that respond to surveys would be far more likely to provide positive views than those not responding. This is a serious limitation of the study that should be discussed.
4. Although the sample may be representative in terms of control, treatment and complications this does not ensure they are representative in terms of their views – as compared to non-responders.
5. What was the justification for dichotomising the Likert scale of 1 to 6 at 4/5?
6. The composite variables used in the analysis for patient views assumes equal weightings i.e. importance for each of the questions. This may be unrealistic. A better approach would have been to use factor analysis to create a composite score.
7. Figures should be provided for the number of patients in each of the various categories in Table 7.
8. For the tables that present patient characteristics it would be useful to see the corresponding figures for compliance from a national survey in order to show the representativeness of the population.
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