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The authors have correctly addressed all the reviewers' suggestions.
The manuscript is improved. Reviewer 2 haa suggested some additional comments that may further improve the paper.
No other comments
No other comments
No other comments
The authors have addressed all my previous comments. I believe that the manuscript, in its current form, is ready for publication.
In the paragraph beginning with the primary objectives (line 127), this aims here should be concisely described, more similarly to how they were in the first iteration of this paper. The added text in this paragraph is useful, but misplaced and would be better in the stats section of the methods, while acknowledging that a feasibility is not able to assess statistical significance. Whichever aims are clearly and concisely described here, should be clearly defined in the results and largely used to inform the structure of results. I would recommend using subheadings in the results which correspond to the same wording as those in paragraph starting line 127. Regarding the aim about specific barriers. If this aim was prespecified on the trial registry, it should not be removed. Instead, the findings should be presented as much as possible, but with a careful consideration in the limitations section of the discussion on the small number of interviews etc and the implications this may have.
Line 322: this sentence in now not complete following the deletion of the second half. I suggest as below, as it seems to me you are using the whole sample to look at the proportions of people who completed etc: Analyses were conducted for both completers only and the total sample size (intention-to-treat with missing data etc etc).
The sample size justification appears to be lines 306-313 and is much improved. I can’t see it throughout the rest of manuscript, but it only needs to be justified here and nowhere else, to maintain concision.
Some insight into the 22 people who declined to participate would be useful to assess the context of the recruitment. 58% of people who are eligible are declining, this should be compared with other similar studies/ similar populations, and in the discussion, this should be discussed alongside the consideration of the feasibility as this would have implications on a bigger trial. Could anything be done to improve this?
I would suggest opening with a sentence, in the discussion which clearly states how many of the progression criteria were achieved. I agree with the more speculative summary which is currently the first sentence, but for maximum clarity and transparency, this would be strengthened by saying something along the lines “of our five progression criteria, X were achieved by all participants, as recruited and X by those who completed the trial only”. This is latter part of the paragraph, but I’d move to the start.
In the limitations, I’d add some nuance but citing few people doing the interviews.
In the conclusion, I’d add some insight into what this feasibility study will now enable. For example, reassessing feasibility following the proposed amendments you have identified? Do you think a full scale efficacy trial is warranted or needed? For example;
In its present form, there is little justification to continue to a definitive trial, although the exploratory analyses suggests that this intervention may be worth refining and retesting in a future feasibility trial. Such a trial would target people (define population). To reduce attrition, we would (add suggestions).
The authors have substantially improved the manuscript, and now it is much more transparent and clear. I have suggested throughout, more minor changes which will further improve clarity, I hope.
-Line 164: rephrase weight-associated disease to weight-associated conditions or comorbidities.
-Line 181-186 is misplaced in methods and could either be removed or moved to intro to justify why this intervention might be useful.
-Exit surveys paragraph
Please add in the data, or refer the reader to table 2. I also suggest that the sentence in lines 437- 438 could be deleted. Please revise ‘less emails’ to ‘fewer emails’. The last sentence in this paragraph is not clear. Please could it be revised for clarity?
-Line 455: I’d rephrase to “improved diet quality” as lifestyle is broad and could encompass things like sleep, exercise etc, which weren’t measured, or simply deleted this sentence as the data which immediately follows it is more useful.
Figure 1 is helpful and well conveys the experience of the participants. I am grateful to the authors for including. That being said, I wonder if it could be more helpfully visualised as a flow chart or gantt chart as such, with different components of each intervention in a different colour. Ie, eText sessions in green, diet record in grey, optional teleconference session in another colour, with baseline – 12 months as the time scale. The more frequent things (daily weighing etc) wouldn’t need to go on there, but perhaps as a footnote. I imagine the authors may need to present this on a landscape word document, if formatting allows.
Table 2 is helpful, and I am pleased the authors included this. For the first row, could authors please add the duration recruitment? For the second row, please could they add the actual % drop out (37.5%)? In row 3, there is only data for 4 components, but there are five in the bar chart. Once this is rectified, the bar chart could probably be deleted. For rows 4 and 5, I suggest splitting these cells to have the n=16 results in one column and n=10 in another
The authors should carefully address the reviewer 2' suggestions, especially. In particular, they should carefully detail and explain the feasibility criteria and the applied methodology in order to completely elucidated their study.
LIterature referecnes is sufficient and the background too. However, the authors missed to add the hypothesis of the study (specific comments in the uploaded file).
My comments related to the methods and results section are specifically detailed in the uploaded file. Major revision is required for this section.
The study is interesting for PeerJ readers. In particular, the strength of this study is the long intervention of on-line weight programs which is understudied in the literature. However, discussion and conclusion should be improved (see the attached file).
The authors aimed to assess to feasibility and acceptability of an online weight loss program in rural, underserved communities. Within the introduction, there is decent explanation on why different rural communities may need online resources which justifies the need for this trial and the interventions.
Throughout the manuscript, there is repetition and the manuscript could be tidied up. For example, lines 130-139, the inclusion criteria included not pregnant/ lactating, and so does the exclusion.
In the methods, lines 152- 211, this would be clearer to be depicted visually, or in a table, on how the 3 interventions interplayed with one another. It is difficult, currently, to understand what happened to participants, once they take part in all 3 interventions.
There is overlap on methods and results. For example, lines 285-287 are not appropriate for methods. I suggest this can be deleted.
There is a lack of information on how all of the aims were achieved/ attempted to be achieved.
a) Adapt the EMPOWER weight loss for rural populations; there is no explanation of how this was done. I would expect this to be adapted in line with patient feedback. It appears to have been suitably done, but there is little detail.
b) Assess the feasibility and acceptability; feasibility criteria is described, but assessment of acceptability could be more clearly and concisely described.
c) Uncover specific barriers that may hinder the successful expansion. Only 2 interviews were conducted, which is not sufficient. The likert scale will not provide this insight, and only addresses the second aim.
The sample size is poorly justified and I would expect more detail on how they assume 16 people will be adequate to enable them to assess feasibility based on the feasibility criteria.
Lines 241-254. It is unclear where or how these measurements were taken, or who by. More detail is needed.
Data on the preregistered feasibility criteria should be more clearly presented, potentially in a figure of table. On clinicaltrials.gov, there are 5 primary outcome measures, which could be more clearly described in a table, with corresponding data.
It is unclear the role of dietary assessment. It appears to be used as a coaching tool but they are also presented as results. The authors indicate they were collected to indicate feasibility of collecting this data, but this is not specified earlier in the manuscript that feasibility of outcome criteria collection is being assessed. Presumably, the same can be said for all other outcomes? In which case, the authors should make this clearer. For example, anthropometric measures were presumably collected as indicators of early efficacy? If this is true, it should be clearly stated.
It is not appropriate to report the feasibility criteria based on the completers only (n=10), lines 324-326. The denominator here should be 16, not 10, as clearly 100% of people did not complete the surveys- this is misleading. The feasibility criteria (lines 214-216) do not state that completion will be measure of only people who complete the study. If the authors intended to use the completers only, this should have been prespecified, which it is not. The authors justify this on lines 285-287, but I do not agree with this justification. Weight loss does not differ between the completers and non-completers but the study is not powered to detect a difference in weight loss, so this cannot be used to justify presenting key feasibility criteria, which is unrelated to weight loss (such as completion of surveys) for completers only. As such, what if there had been a significant difference in weight loss between completers only and all participants? Further, I have checked the raw data and there are 6 participants with no data presented, so how do the authors know the weight loss data does not differ?
Some outcomes have been analysed at time points different to those prespecified? For example, change in weight at 2 years is prespecified, but here weight change is presented at 6 months. In the discussion it is mentioned that at 12 months, >50% had maintained >5% weight loss, but this data is not presented. Other data is analysed at 12 months, such as dietary. The supplementary figure provided do not appear to describe weight, or other outcomes, clearly at 12 months, but the axis are not clearly labelled so it is hard to tell.
The raw data indicates mean weight change is available at 12 months. The authors should clearly specify this, and I have serious concerns about this omission from the manuscript and deviation from prespecified analyses. The weight losses indicated in the raw data look promising and inline with other studies for weight change at 12 months, and this would be usefully placed in the discussion.
The criteria, as presented by the authors, only tell us that there is some good retention of people once recruited to the trial (which is useful to know), and of those that are retained, they can attend eText sessions and complete surveys. Ideally, a feasibility trial should inform the authors, and reader, if it is worth progressing to full trial and as such should incorporate progression criteria based on recruitment/ follow up, fidelity of intervention delivery and availability of data, while providing data which may be indicative of effectiveness. The authors could be much clearer in presenting data related to the prespecified primary outcome data- which would provide more insight (this includes recruitment etc)
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