Title: A structural equation model linking health literacy, self-efficacy, and quality of life in
patients with polycystic ovary syndrome
Version: 1 Date: 02 Dec 2022
Reviewer's report:
Title: A structural equation model linking health literacy, self-efficacy, and quality of life in
patients with polycystic ovary syndrome.
Overview:
This manuscript is a cross-sectional survey study exploring health literacy, self-efficacy, and
quality of life in women with PCOS in Zunyi China, additionally, the authors attempt to elucidate
the associations of health literacy with self-efficacy and quality of life. Health literacy is an
important but under-studied area, and it is great that the authors are researching in this topic. They
concluded that health literacy is generally low among women with PCOS therefore highlighting
a need for clinicians and public health policy makers to work on strategies to improve overall
women’s health literacy. However, this manuscript is currently not suitable for publication and
my detailed comments are below.
Major issues:
• Throughout the paper, the authors need to be careful with the word “influencing” as it
indicates a causal relationship. Regression analysis and cross-sectional study generally indicates
an association only. For example:
o Results section in the abstract, the sentence “Multiple regression analysis revealed that the
main factors influencing of health literacy …”
o In the background, second paragraph “Moreover, low or inadequate HL is influenced by many
poor health indicators…”
• Some of the references used do not support the authors’ statement. For example:
o In the background section, first paragraph, reference 3. This is a narrative review discussing the
use of behavioural strategies in weight management of PCOS. It does not support the authors’
statement  on early diagnosis, treatment and weight loss in PCOS can reduce heart disease and
diabetes.
o In the background section, second paragraph, reference 13. The authors claimed that no studies
examined health literacy in women with PCOS but this study did.
• The methods section should be more detailed.
o Sociodemographic data: The authors mentioned data was collected via a questionnaire.
However there were details of weight and height being assessed. Please be clear.
o Health literacy scale: Please provide better reference for this scale. This scale is not easily
found in the literature and it is likely that other readers will not be familiar with it. Authors
should provide more information including if the scale has been validated. Also, the scoring of
the scale is unclear in the methods and should be better explained.
• The results section contains obvious mistakes. Some examples are below:
o First paragraph, line 5: “Most participants (n=300, 77.70%)…” The whole study population
is 300, therefore it can’t be 77.7%.
o First paragraph, line 7: “Less than years and 1-3 years…” The sentence is incomplete.
o Third paragraph, line 1: “As shown in table 3, marital status, education, duration of PCOS,
QOL, and SE were significantly higher HL scores…” This sentence needs rewording.
• It is hard to understand Table 2 what “total scores”, “mean scores” and “possessing rate”
indicate. The authors should explain better in the methods section how scores are interpreted.
• The discussion section, first paragraph line 1: “This study is the first to demonstrate the status
of HL in patients with PCOS…” This statement will be untrue given that reference 13 did that.
Perhaps the authors mean this is the first study for women with PCOS in China?
• The discussion section overall is quite vague without a clear message for the readers, and with
multiple repetition of the same information. Some suggestions for the discussion section include:
o Discuss the health literacy of other chronic diseases in China and how the results compare to
the current study findings
o Please discuss how this study finding’s compare to the results from reference 13
o Discuss more on the potential local causes of poor health literacy and provide constructive
suggestions to improve this.
Minor issues:
• It is really hard to give comments without including line and page numbering in the manuscript.
Please consider this for future submission.
• The are numerous grammatical and spelling error throughout the manuscript. The authors
should also consistently use a space after every comma or full stop. Use of a language editing
service may be helpful.
• All abbreviations should be expressed in full first before using the abbreviation. As per
journal’s authors’ instruction, please also provide a list of abbreviations with the manuscript.