Comment on: Validity and reliability of the Chinese version of digital health readiness questionnaire among hypertension patients in rural areas of China

Abstract

It is the comment on the published article of “Validity and reliability of the Chinese version of digital health readiness questionnaire among hypertension patients in rural areas of China.” The discourse primarily referred the innovative aspects of the d research, while also addressing certain limitations in the study. Furthermore, the paper delineates key areas for future investigation.

Dear Editor,

We have thoroughly reviewed the article by Xu L et al. regarding “Validity and reliability of the Chinese version of Digital Health Readiness Questionnaire among hypertension patients in rural areas of China.” ¹ While this study makes a valuable contribution to validating the Chinese version of the Digital Health Readiness Questionnaire (DHRQ), we wish to discuss several noteworthy issues:

The study included only participants who completed the questionnaire, potentially introducing significant selection bias. Excluded participants were older; less educated, and had lower incomes. It is suggested that the study results predominantly reflect outcomes from a relatively younger, more educated rural population, potentially confounding the study's conclusion that higher education and income levels correlate with higher DHRQ scores. In this study, the authors have thoroughly discussed the reasons for it. However, it is important to note that the segment of participants with incomplete questionnaires may represent a significant proportion of the rural hypertension population. Given the unique characteristics of these individuals, they may face distinct challenges in the management and prevention of hypertension. As such, the absence of data from these incomplete questionnaires could have introduced limitations to the reliability of the study's findings. Consequently, the results may not fully reflect the overall condition of rural hypertension patients, potentially compromising the study's ability to accurately represent the broader population. To enhance the validity and reliability of the research, it is recommended that the authors consider expanding the sample size or implementing techniques in subsequent studies. These methods could help to better represent the rural hypertension population and ensure that the findings are more representative of the entire population under investigation.

The researchers eliminated two items (use of laptops/notebooks and wearable devices) based on statistical results. While this improved model fit may have compromised the questionnaire's content validity, sacrificing comprehensiveness. Firstly, “digital use” originally encompassed usage patterns across various digital devices. Computers/laptops and wearable devices represent distinct categories of digital technology. Removing these items might result in the questionnaire overlooking significant aspects of technology use and learning patterns. Moreover, although these items may have low usage rates in the current sample of rural Chinese populations, they could represent crucial aspects of digital health readiness. As time progresses and technology becomes more widespread, these items become increasingly relevant to digital health. The previous study mentions that the education level may be closely related to hypertension incidence in rural areas,^2,3 In this study, it is mentioned that individuals with higher education levels may score higher on the DHRQ (Digital Health-Related Questionnaire), which may be related to their familiarity with digital technology and higher health literacy, suggesting that the education level and laptops or wearable devices could act as confounding factors. The authors need to provide a more detailed explanation of how this affects the questionnaire's content validity and discuss potential alternatives within the context of this study.

The study also found that the modified questionnaire demonstrated a better fit, indicating that even among populations with limited digital health literacy, there may indeed be individuals with high acceptance and willingness to learn new technologies. These individuals could potentially influence digital health research outcomes, as they may be more likely to participate in digital health interventions and could facilitate the adoption and acceptance of digital health tools. Consequently, this could enhance literacy in these areas. We anticipate that the authors will discuss this subgroup further in future research.