Development and Validation of the Healthcare-Seeking Intention Questionnaire in Patients with Diabetic High-Risk Foot [Letter]

Dear editor

We read with great interest the article by Wang et al on the development and validation of a questionnaire assessing healthcare-seeking intentions in patients with diabetic high-risk foot (HRF).¹ Moreover, the nurse also has deficit knowledge regarding the prevention of diabetic foot ulcers (DFU)² While we commend the effort in addressing this critical issue, a few methodological clarifications are warranted to enhance the reproducibility and rigor of the study.

First, the term “diabetic high-risk foot” requires clarification. According to the International Working Group on the Diabetic Foot (IWGDF), a high-risk foot is defined by the presence of loss of protective sensation (LOPS) or peripheral artery disease (PAD), with additional risk factors such as a history of diabetic foot ulcer (DFU), amputation, or end-stage renal disease.³ In their study, Wang et al selected participants based on the presence of peripheral neuropathy, overlooking other key risk factors outlined in the IWGDF guidelines. This discrepancy may limit the generalizability of the findings, as the sample may not fully represent the broader HRF population.

Second, there are inconsistencies in the reporting of the study’s Phase I. Although the authors describe Phase I as involving four stages, only three are explicitly detailed. The semi-structured interviews are ambiguously presented, particularly with respect to their relationship to the item generation process. The methods section does not clearly explain how the initial pool of items was generated, leaving readers unclear about the origins of the questionnaire’s content. While the discussion section attributes the items to a combination of literature review, group discussions, and semi-structured interviews, the distinction between these processes is not well articulated. Moreover, the absence of a detailed literature review in the methods section weakens the transparency of the item development process.

Additionally, the application of the Delphi method, though commendable, lacks clarity regarding the origin of the items being rated by experts. Were they drawn from the initial item pool, the semi-structured interviews, or both? The Delphi results themselves are insufficiently detailed, with no clear indication of which items achieved consensus or required revision. This lack of transparency extends to the pre-survey phase, which is described as a critical step in refining the questionnaire, yet the process and outcomes of this phase are not reported. Addressing these concerns would strengthen the methodological rigor of the study and ensure the questionnaire.