The effect of framing on attitudes towards Alzheimer’s disease. A comparative study between younger and older adults

Fátima Cuadrado; Adoración Antolí; Bernardino Fernández-Calvo

doi:10.1371/journal.pone.0270959

Peer Review History

Original SubmissionMarch 28, 2022
6 Apr 2022 Decision Letter - Perla Werner, Editor PONE-D-22-09110What does Alzheimer’s disease mean for younger and older people? An approach to the effect of framingPLOS ONE Dear Dr. Cuadrado, 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. Please submit your revised manuscript by May 21 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're 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. 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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. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thanks for this opportunity to review an interesting paper. Please find my comments below. 1. The current title (What does Alzheimer’s disease mean for younger and older people?) is a bit misleading. I would suggest authors to modify. 2. On page 3, “it is understood that one can choose from among several alternatives to define different topics and that the application of a frame results in a specific interpretation of the problem, how it is defined and its causes”. Would it be possible to explain a bit more on the application of a frame may lead to a particular interpretation? 3. On page 8, “to measure the level of impact and basic emotions (happiness, sadness, anger, fear and disgust) experienced by the participants, they were asked six questions designed specifically for this purpose, answered using a five-point Likert scale”. Would it be possible to add the question asking impact? 4. Was data collected before the Covid-19 pandemic? If data was collected during pandemic, it would be appreciated that authors could consider/briefly discuss the Covid-related impacts on methodology. 5. On page 19, “it would be very interesting to carry out the same study with a sample that includes caregivers, people with AD and people from other cultures.” Older participants in the study are the young-old. It would also be interesting to conduct a study with sample of the oldest-old (aged 85 years and over). 6. As found in this study, there are age differences in attitudes towards AD, experiencing emotions and etc. Would it be possible to discuss the implications of age differences in relation to choosing frames and messages to reduce stigma? Would the findings support an age-targeting approach in advocacy and campaigns? Reviewer #2: Manuscript Number: PONE-D-22-09110 Manuscript Title: What does Alzheimer’s disease mean for younger and older people? An approach to the effect of framing Thank you for the opportunity to review the article titled “What does Alzheimer’s disease mean for younger and older people? An approach to the effect of framing”. The paper is very well written on an important topic. The article reports the results of a study that aimed to determine how AD framing influences attitudes towards AD and whether this influence differs between younger and older people. The study also seems well executed. I have some comments that might help strengthen the paper. I list conceptual and stylistic issues first then, under minor concerns, list a few that are more technical in nature. Within each section, my comments are listed in no particular order. Conceptual and stylistic issues: The introduction overall is strong. However, the characterization of Alzheimer’s would benefit from further development. For example, page 9 “and problematic behaviours of this dementia,” sounds more like behavioral variants of dementia rather than Alzheimer’s dementia. In addition, also on Page 9 “In this regard, general practitioners overestimate the presence of AD in people with mobility and hearing problems and memory complaints but frequently fail to identify AD in those who lived alone [12].” Perhaps softening and more closely specifying this sentence – “a prior study showed general practitioners can overestimate the presence … “ There are other confounders that are not being acknowledged such as availability of a clinical informant who is also a caregiver that might also explain these findings. Page 10, “Frames are used to present a topic in such a way that it can be understood by various audiences.” � Do the authors mean: “Frames are used to present a topic in such a way that it can be understood by an audience.” The concept of happiness warrants explicit discussion, given the context involves a debilitating, chronic neurodegenerative disease. Extant research shows that AD stigma differs by age group (Stites et al 2018). The current study is not ideally positioned to offer evidence of population age differences. However, the current study is well positioned to build upon prior work to answer the question: What are the implications of age differences on interventions that are aimed at reducing AD stigma? The study shows that the intervention had almost double the effect on the younger group as it did the older group (Table 2). Stites, S. D., Johnson, R., Harkins, K., Sankar, P., Xie, D., & Karlawish, J. (2018). Identifiable Characteristics and Potentially Malleable Beliefs Predict Stigmatizing Attributions Toward Persons With Alzheimer’s Disease Dementia: Results of a Survey of the U.S. General Public. Health Communication, 33(3), 264–273. https://doi.org/10.1080/10410236.2016.1255847 Page 14, please include rationale for appropriateness of the effect size of 0.25. It may also be appropriate to revisit this issue in the discussion as it relates to study limitations and interpretation of the meaningfulness of the results. Page 17, “responded to questions about the level of impact the campaign had on them” This aspect of the study is unclear. Can you give examples of these questions? Page 23 – “This information is key for identifying which characteristics of messages about AD can foster positive attitudes and thus reduce the stigma associated with the disease, therefore, like other authors [20, 29, 30], we believe it is necessary to avoid negative dominant frames and instead employ those that humanize people with AD. This should be the case regardless of the age of the population to which the message is addressed.” The conflation of ideas of “positive attitudes” and “humanizing people” may need to be more closely parsed as the notion of ‘positivity’ in the context of a serious neurodegenerative disease could be problematic and even damaging, and, simultaneously, humanizing individuals is not synonymous with ‘positivity’. I point out this issue here but the it applies at multiple points in the paper. Minor comments: Abstract “This findings suggest” � These? Quantification and statistical test supporting the conclusions would be useful. In addition, paper is framed around examining differences between older and younger respondents but abstract doesn’t report whether the frames examined in this study differed for the two age groups. In the methods, please add age ranges to help define the study groups of younger adults and older adults. Cell sizes in the tables would be useful. Page 24 – “had positive attitudes towards the disease” examples here would help. Page 17, younger and older groups were randomly divided into two sub-groups. � how was the randomization carried out? ****** 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.] 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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0270959.r001
Revision 1
10 Jun 2022 Author Response Dear Academic Editor, Firstly, I would like to thank you for reviewing our work and giving us the opportunity to review our paper (Manuscript ID: PONE-D-22-09110). We have written a point by point cover letter indicating the changes we have made in the manuscript and the responses to each of journal requirements and the comments of the reviewers. Journal requirements: 1. We have ensured that our manuscript meets PLOS ONE’s style requirements (e.g. figures and tablets format). 2. With respect to Figure 2, all the images used were downloaded from the Pixabay website and were free of copyright under the Creative Commons CC0 license, so these images can be used and published freely. We have provided this information in Fig 2 legend. 3. We have ensured that our title page meets all requirements. 4. We have included citations 42 and 48, which have been included in the reference list. We have marked them in red so you can see it. Response to reviewer 1: 1. As suggested, we have modified the title of manuscript (before: What does Alzheimer’s disease mean for younger and older people? An approach to the effect of framing; now: The effect of framing on attitudes towards Alzheimer’s disease. A comparative study between younger and older people). 2. With regard to your comment about the frames interpretation, we have explained more on the application of a frame may lead a particular interpretation. (Page 4-5, lines 76-82). 3. As suggested, we have added the question asking impact and emotions experienced by the participants. (Page 10, lines 212-213). 4. The data was not collected during the pandemic, so we cannot discuss the Covid-related impacts on methodology, since there was no restriction or rule related to the pandemic that prevented the normal development of data collection. 5. We agree with you. Older participants in this study are the young-old, so we have added the oldest-old like an interesting sample that includes in future studies. (Page 23, line 478). 6. As suggested, we have discussed the implications of age differences in relation to choosing messages framed to reduce stigma. (Page 22-23, lines 459-466). Response to reviewer 2: Conceptual and stylistic issues: 1. Regarding your comment, we have been more thorough with the characterization of Alzheimer’s disease. For example, we have explained that Alzheimer’s behavioural and psychological disorders (neuropsychiatric symptoms) have been associated with stigma towards AD (Page 3, lines 31-34). 2. We have softened the sentence as you suggested (Page 3, lines 40-41). 3. Regarding your doubt about if we men “an audience” instead of “various audiences”, we have specified what we mean which “various audiences” (Page 4, lines 68-69). 4. We understand the incongruence that you indicate about happiness, but we need answer about all basic emotions (happiness, sadness, fear, anger, and disgust). In this context (chronic neurodegenerative disease), we know that people don’t answer with high levels of happiness, and we don’t intend it. On the other hand, some body-mind unity frame’s affirmations (e.g. she will lose some of her abilities, but she will still feel emotions) can provoke feeling of consolation or tenderness; in short, emotions congruent with happiness. In this way, we have explicated it. Moreover in “Results” section, we have indicated that both groups experienced low-medium levels of happiness (Page 18, lines 355-356). 5. We have included the information provided by you about Stites et al. (2018). (Page 5, lines 99-102). 6. We have specified more about the effect size of 0.25 and we have referenced it. (Page 9, lines 179-180 and lines 182-183). 7. As suggested, we have included an example of questions about level of impact the campaign had on participants. (Page 10, lines 212-213). 8. With regard your comment about “positivity” and “positive messages”, we have clarified what we mean and eliminated confusing concepts. (Throughout the “Discussion” section, e.g. page 20, lines 410-412). Minor comments: 1. With regard your comments about abstract: (1) we have corrected the abstract’s error (‘these’ rather ‘this’) (page 1, line 21), (2) we have added the statistical test (Page 1, line 13 and 15-16), and (3) we have reported more information about frames examined for the two age groups (Page 1. Lines 9-12). 2. Age ranges are added. We have underlined them in yellow so you can see them. (Page 8, lines 173 and 174). 3. Regarding your comment about cell sizes in the tables, we have included sample size. 4. With respect your comment about illustrate with examples, we have clarified why we knew that the participant had positive attitudes towards disease. (Page 21, lines 418). 5. With regard your question about how the groups were randomly divided, we have explained how the randomization was carried out (Page 11, lines 238-240). We hope that these changes have improved the manuscript and you will consider it for publication in PLOS ONE. Yours sincerely, Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0270959.r002
22 Jun 2022 Decision Letter - Perla Werner, Editor The effect of framing on attitudes towards Alzheimer’s disease. A comparative study between younger and older adults PONE-D-22-09110R1 Dear Dr. Cuadrado, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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 help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- 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. Kind regards, Perla Werner Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0270959.r003
Formally Accepted
27 Jun 2022 Acceptance Letter - Perla Werner, Editor PONE-D-22-09110R1 The effect of framing on attitudes towards Alzheimer’s disease. A comparative study between younger and older adults Dear Dr. Cuadrado: I'm 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 let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, 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. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Perla Werner Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0270959.r004

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