Comment on “Level of Health Literacy Predict the SelfCare Activities in Middle Age with Type 2 Diabetes Mellitus”

Dear Editor,

The original article “Level of Health Literacy Predict the Self-Care Activities in Middle Age with Type 2 Diabetes Mellitus” published in the Indian Journal of Endocrinology and Metabolism, is a meaningful contribution.[1] The article’s objective was to examine the level of health literacy as a predictor of self-care activities among type 2 diabetes mellitus.[1] As emphasized, self-care in diabetes mellitus is an integral pillar of the management of the chronic condition and accounts for improvement in the quality of life and delays the onset of development of disease-related complications.[1]

I thoroughly read the article and have some observations and suggestions to improve the overall quality. To start with, it was reported that the study population was 554 diabetes patients, but I was surprised to note that the authors took only 101 (18.2%) of these, without any scientific justification for the same.[1] Whenever we decide on sample size, it should always be based on some statistical formula, and the sample size must represent the entire study population, which is difficult to believe as less than one-fifth of the study population was selected.[2] The authors have used purposive sampling, which is a non-probability sampling method and is generally not considered a good approach to augment the internal validity of the study.[1,3] This becomes a valid comment because the total study population was large, and the authors could have gone ahead with some type of probability sampling, where each member of the population has an equal chance of getting selected.[3]

I was happy to note that two of the tools that were used were validated and checked for reliability.[1] However, I am not sure whether the Summary of Diabetes SelfCare Activities questionnaire was validated in the local settings[1] In continuation, even for the first semi-open questionnaire (the better term would be semi-structured questionnaire), multiple parameters have not been mentioned – who designed it? How? Was it validated? Pilot testing of the tool? etc.[4,5] In-fact, the concept of pilot-testing of all three questionnaires has not been mentioned, which is an integral aspect of any study. It was mentioned that the study participants should be able to speak and write the local language (Bahasa), but then nothing has been reported about language validation of the first and the third questionnaire.[1,4] Ideal approach for language validation would have been in two stages: English to Bahasa (first stage: By an expert), followed up by the translation of the Bahasa version to English (second stage: By a second expert), and then matching the two English versions for consistency and uniformity.[4,5]

The discussion section has been written quite well and happy to note that the authors have identified their study limitations.[1] To summarize, the current study adds useful information about health literacy is an important predictor of better self-care; nevertheless, the findings of the study would be more valid if the authors had adopted a systematic approach for sample size selection and validation of the study tools.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.