The prevalence of poor sleep quality and associated risk factors among Chinese elderly adults in nursing homes: A cross-sectional study

Xidi Zhu; Zhao Hu; Yu Nie; Tingting Zhu; Atipatsa Chiwanda Kaminga; Yunhan Yu; Huilan Xu

doi:10.1371/journal.pone.0232834

Peer Review History

Original SubmissionNovember 17, 2019
30 Dec 2019 Decision Letter - Stephan Doering, Editor PONE-D-19-31759 The prevalence of poor sleep quality and associated risk factors among Chinese elderly adults in nursing homes: a cross-sectional study PLOS ONE Dear Dr Xu, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We would appreciate receiving your revised manuscript by Feb 13 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Stephan Doering, M.D. Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was suitably informed and (2) what type you obtained (for instance, written or verbal). If your study included minors under age 18, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. 3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. If you developed and/or translated a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. 4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 5. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ 6. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This study presents the original research that meets all applicable standard in ethics. Statistics, and other analyses are describe in sufficient detail. This article using standard English. Conclusions are presented and are supported by the data. Reviewer #2: I agree that sleep problems have become the most common complaints among elderly adults and I believe the study presented by the Authors from China are important. In addition to that the study sample is large and therefore the correlations shown beetwen the variables are strong. In my opinion it is a well written study. I only wonder why the Authors have chosen the eldrely with 60 age and above not from 65? and how did you judge the cognitive problesm as it is mentioned in the exculsion criteria? ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: REVIEWER DR EE.docx https://doi.org/10.1371/journal.pone.0232834.r001
Revision 1
14 Jan 2020 Author Response Response to [PONE-D-19-31759] Thank you very much for your valuable comments and critiques, which have improved the clarity of our manuscript to a greater extent. Accordingly, we have thoroughly revised our manuscript based on the editors’ and reviewers’ comments and suggestions. The changes are highlighted in red for added words, or strikethrough for deleted words. Additionally, minor language, grammatical and stylistic errors have been corrected. Our specific point-by-point responses to the comments and queries have been addressed and itemized as following: Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Answer: Thank you so much for your helpful comment. We have checked and ensured that our manuscript meets PLOS ONE’s style requirements. 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was suitably informed and (2) what type you obtained (for instance, written or verbal). If your study included minors under age 18, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. Answer: Thank you so much for your valuable comment. We have included the ethics statement in the Methods section as follows: This study was approved by the Ethics Committee of Xiangya School of Public Health of Central South University (No.XYGW-2018-49). Written informed consent was obtained from all participants of this study. 3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. If you developed and/or translated a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Answer: Thank you so much for your valuable comment. As suggested, we have included additional information regarding the survey or questionnaires used in the study. However, we did not develop nor translate a questionnaire as part of this study. Actually, all the questionnaires used in this study are Chinese versions, which have good reliability and validity as indicated in previous publish related studies. 4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Answer: Thank you so much for this important information. We have since checked on this link about information on unacceptable data access restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. Answer: Thank you so much for your valuable comments and suggestions. We provided our data availability statement as follows: Data for this study contain potentially identifying or sensitive patient information. Therefore, it would be available upon reasonable request from the Ethics Committee of Xiangya School of Public Health of Central South University (csugwxy@126.com). 5. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ Answer: Thank you so much for this important information. Accordingly, we have linked an ORCID ID for the corresponding author. 6. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript. Answer: Thank you so much for your valuable comment and suggestion. We have included our ethics statement in the Methods section as follows: This study was approved by the Ethics Committee of Xiangya School of Public Health of Central South University (No.XYGW-2018-49). Written informed consent was obtained from all participants of this study. Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Answer: Thank you so much for being satisfied with the technical level of our manuscript. 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Answer: Thank you so much for your satisfaction with the statistical analysis in our manuscript. 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Answer: Thank you so much for verifying that we provided the data availability statement as regards our manuscript. 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Answer: Thank you so much for your satisfaction with the way our manuscript has been presented. 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This study presents the original research that meets all applicable standard in ethics. Statistics, and other analyses are describe in sufficient detail. This article using standard English. Conclusions are presented and are supported by the data. Answer: Thank you so much for approving the importance and quality of our study. Reviewer #2: I agree that sleep problems have become the most common complaints among elderly adults and I believe the study presented by the Authors from China are important. In addition to that the study sample is large and therefore the correlations shown beetwen the variables are strong. In my opinion it is a well written study. I only wonder why the Authors have chosen the eldrely with 60 age and above not from 65? and how did you judge the cognitive problesm as it is mentioned in the exculsion criteria? Answer: Thank you so much for approving the importance and quality of our study. Also, thank you so much for your constructive questions regarding the sample selection and identification of cognitive problems in our manuscript. In China, the elderly age standard starting point is 60 years, which was provided by <Law of the People's Republic of China on Protection of the Rights and Interests of the Elderly> and National Bureau of Statistics of China. In addition, we have excluded participants who had a history of severe cognitive deficit based on the disease archives information provided by caregivers or health service providers in the respective nursing homes. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0232834.r002
13 Feb 2020 Decision Letter - Stephan Doering, Editor PONE-D-19-31759R1 The prevalence of poor sleep quality and associated risk factors among Chinese elderly adults in nursing homes: a cross-sectional study PLOS ONE Dear Dr. Xu, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We would appreciate receiving your revised manuscript by March 12, 2020. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Stephan Doering, M.D. Academic Editor PLOS ONE Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #3: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: No ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: this study is good enough but it may need some improvement data such as more specific characteristic demography, analysis data, and explanation more about quality of life among Chinese elderly adults. Reviewer #3: This is a cross-sectional study examining in 817 elderly residents in nursing homes the prevalence of poor sleep quality and its risk factors The study confirms a relatively high prevalence of poor sleep quality in nursing homes, previously reported. Anxiety symptoms had additive interactions with age, chronic disease and social support for poor sleep quality. On the whole, I have a quite positive opinion on this cross-sectional study. It has a quite large sample size and methods seem mostly accurate. Major concerns: 1. I understand but not completely agree on the reduction of scores of anxiety, depression and social support to categorical variables, using a cut off. I ask to integrate the current analyses using the actual scores. Not necessarily, this request means a deletion of categorical classifications, but continuous variables should also be consider din the analyses 2. Due to the number of comparisons performed, a significance level set al p<0.05 should be adequately corrected for multiple comparisons 3. Due to the potential effects of illumination levels in nursing homes on sleep-wake activity rhythms (e.g., Ancoli‐Israel et al. , 9: 373-379, 2000). I ask to collect (if possible) this information in the considered nursing homes and include this variable in their analyses ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: My Name is Elmeida Effendy, Psychiatrist (Consultant) Reviewer #3: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: REVIEW PONE-D EE.docx https://doi.org/10.1371/journal.pone.0232834.r003
Revision 2
16 Mar 2020 Author Response Response to [PONE-D-19-31759R1] Thank you very much for your valuable comments and critiques, which have improved the clarity of our manuscript to a greater extent. Accordingly, we have thoroughly revised our manuscript based on the editors’ and reviewers’ comments and suggestions. The changes are highlighted in red for added words, or strikethrough for deleted words. Additionally, minor language, grammatical and stylistic errors have been corrected. Our specific point-by-point responses to the comments and queries have been addressed and itemized as follows: Reviewer #1: this study is good enough but it may need some improvement data such as more specific characteristic demography, analysis data, and explanation more about quality of life among Chinese elderly adults. Answer: Thank you so much for your valuable comment. As suggested we have included and described more specific socio-demographic characteristics of the sample in relation to the study objectives. We did not dwell much on discussing quality of life of the elderly in the nursing homes because our main focus was on sleep quality, a component of quality life, and its associated factors. Thus, we justified why it was important to study this phenomenon. However, we agree that an explanation about the quality of life among the Chinese elderly people would highlight some insights in understanding some issues that would affect the living conditions of this population. Therefore, we have added a paragraph in the section of introduction to describe some facts about the quality of life of this group of people. Nevertheless, this study did not examine the quality of life of this population in general, but just a component of it, namely sleep quality. We thank you so much for your observation, which we have taken as a consideration to investigate the quality of life of this population in our future research. Reviewer #3: This is a cross-sectional study examining in 817 elderly residents in nursing homes the prevalence of poor sleep quality and its risk factors The study confirms a relatively high prevalence of poor sleep quality in nursing homes, previously reported. Anxiety symptoms had additive interactions with age, chronic disease and social support for poor sleep quality. On the whole, I have a quite positive opinion on this cross-sectional study. It has a quite large sample size and methods seem mostly accurate. Major concerns: 1. I understand but not completely agree on the reduction of scores of anxiety, depression and social support to categorical variables, using a cut off. I ask to integrate the current analyses using the actual scores. Not necessarily, this request means a deletion of categorical classifications, but continuous variables should also be consider din the analyses Answer: Thank you so much for your valuable comment. It should be noted that the tools that we used to measure anxiety symptoms, depression symptoms and social support have high validity and reliability, and they are widely used to investigate anxiety, depression and social support among the Chinese elderly people. Besides, the cut-off points that we used on the total scores of these tools were adopted from other published studies on similar populations. However, according to the reviewer’s suggestion, we tried to consider anxiety, depression and social support as continuous variables, but the results did not deviate much from those when anxiety, depression and social support were considered as categorical variables (see the Table 1 below). Essentially, the results in the Table 1 below mean pretty much the same thing as the results in our original analysis . Table 1 Risk factors associated with poor sleep quality among the elderly in nursing homes Variable B SE Wald AOR(95% CI)† P-value Age (years) 60~ 1.00 70~ 0.58 0.25 5.15 1.78(1.08,2.92) 0.023 80~ 0.98 0.24 17.37 2.67(1.68,4.24) <0.001 Number of chronic diseases 0~ 1~ 0.72 0.20 13.31 2.05(1.39,3.01) <0.001 3~ 0.86 0.27 10.01 2.35(1.39,4.00) 0.002 Depression symptoms 0.07 0.02 17.29 1.08(1.04,1.11) <0.001 Anxiety symptoms 0.11 0.03 14.02 1.11(1.05,1.18) <0.001 Social support -0.03 0.02 5.32 0.97(0.95,0.99) 0.021 2. Due to the number of comparisons performed, a significance level set al p<0.05 should be adequately corrected for multiple comparisons Answer: Thank you so much for your valuable comment. A p<0.025 was set to indicate significant results for multiple comparisons in this study. 3. Due to the potential effects of illumination levels in nursing homes on sleep-wake activity rhythms (e.g., Ancoli‐Israel et al. , 9: 373-379, 2000). I ask to collect (if possible) this information in the considered nursing homes and include this variable in their analyses Answer: Thank you so much for your valuable comment. We have not collected this information in our investigation; therefore we will consider this information in our further study. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0232834.r004
23 Apr 2020 Decision Letter - Stephan Doering, Editor The prevalence of poor sleep quality and associated risk factors among Chinese elderly adults in nursing homes: a cross-sectional study PONE-D-19-31759R2 Dear Dr. Xu, We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements. Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication. Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. With kind regards, Stephan Doering, M.D. Academic Editor PLOS ONE Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #3: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: No ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: the author has improved the data, there has been better writing in this article. This article will be more interest if you choose update references. Reviewer #3: The authors adequately responded to the points that I raised. It seems now acceptable for publication ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #3: No https://doi.org/10.1371/journal.pone.0232834.r005
Formally Accepted
4 May 2020 Acceptance Letter - Stephan Doering, Editor PONE-D-19-31759R2 The prevalence of poor sleep quality and associated risk factors among Chinese elderly adults in nursing homes: a cross-sectional study Dear Dr. Xu: I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. For any other questions or concerns, please email plosone@plos.org. Thank you for submitting your work to PLOS ONE. With kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Stephan Doering Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0232834.r006

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