PONE-D-21-26584Over-indebtedness and health in Switzerland: a cross-sectional study comparing over-indebted individuals and the general populationPLOS ONE

Dear Dr. Hämmig,

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.

 Your paper has been reviewed by two expert referees, who (although highlighting the value and merit of the work) request for some major changes, amendments and clarifications from you. After a careful review of the manuscript, I agree with them on the fact that the paper must be improved, especially in regards to methodological flaws that still can be fixed in order to better support and provide validity to your conclusions, even in a post-study phase.Also, please note the need to strengthen the discussion of the paper. Personally, I would suggest you to check the linearity and raise the discussion and conclusions in the light of the core study aim.

Please submit your revised manuscript by Mar 06 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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Academic Editor

PLOS ONE

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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: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

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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: No

Reviewer #2: No

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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: No

Reviewer #2: Yes

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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: Summary

The paper reports on the association between over-indebtedness and health, based on cross-sectional studies conducted in Switzerland, a) survey among over-indebted clients of debt advisory centers in the Canton of Zurich (over-indebtedness study, n=219) and b) nationally representative Swiss Health Survey (n=1997). The combined dataset included n=2216 adults aged 18 and over. Clients of debt advisory centers (a) were considered over-indebted, whereas respondents of the Swiss Health Survey (b) were considered not over-indebted. The paper described a higher prevalence of poor self-rated health, musculoskeletal disorders, depression and sleep disorders among over-indebted individuals compared to the Swiss general population. Multiple logistic regression analyses showed a significant association between over-indebtedness of these self-reported physical and mental health outcomes, adjusted for sex, age, education, nationality, marital status, employment status.

From a public health perspective, the research question is highly relevant and so far, little to no data is available on the health status of over-indebted individuals, specifically in Switzerland. From my point of view, however, there are several major issues that require revision. In the following, I focus on these major issues and may provide more comments on further minor issues at a later stage.

(1) Methods. The authors combined cross-sectional data among over-indebted clients of debt advisory centers collected in 2019, with the Swiss Health Survey conducted in 2017.

a. Please clarify the recruitment process and response rate in both surveys. Did both surveys include only respondents from the Canton of Zurich? If not, to what extent are the four official debt advisory centers in the Canton of Zurich and clients presenting to these centers representative for centers and clients across Switzerland? Please clarify the study population early in the methods section. What eligibility criteria was applied in the Swiss Health Survey? What were sources and methods of selection of participants in the Swiss Health Survey? How was the subsample of adult respondents of the Swiss Health Survey selected? In Table 1 the authors mention that the Swiss Health Survey data was weighted. How was the weighting process carried out?

b. In the methods section, the authors state that descriptive statistics, bivariate and multivariate association analyses were performed (266-274). From my point of view, the authors should revise this section to clarify what measures they used to achieve which purpose. The authors state “multiple adjusted odds ratios (aOR) as measures of the relative risk” (273) which, in my view, is not a correct description of the statistical measure. What significance level was applied? How were missing data addressed? The different numbers of cases per model (Table 3, Table 4) indicate that individual cases were excluded from the multiple logistic regression analyses. Did the authors conduct any sensitivity analyses?

c. In order to clarify the methodological approach, I suggest to present key elements of the study design early in the paper, and to provide detailed information later. From my perspective, the authors could focus more on describing key characteristics of the methodological approach (study design, setting, participants, variables, study size, variables, statistical methods) and reduce additional details (e.g. 207-214) to avoid redundancy (“As already mentioned before…” 215) and, above all, make it easier for readers to understand which methods were used. The authors, for instance, list measures of over-indebtedness (178ff.) in the methods section and describe in detail why primary data was collected (172-194). Instead, the authors could briefly summarize these aspects and elaborate on relevant aspects in the discussion section, e.g. with regards to potential limitations of the study design or measures used in the study.

(2) Results. In the results section, the authors report descriptive statistics and key findings of multiple regression analysis.

a. I suggest to revise the description of the characteristics of the sample included in the analyses. Please report numbers of individuals at each stage of the study, e.g. numbers potentially eligible, examined for eligibility, confirmed eligible and included in each survey, and numbers included in the combined dataset and numbers analysed.

b. Please also specify sociodemographic data (mean, standard deviation) for the subsamples (278-286). What were the proportions of individuals considered over-indebted and not over-indebted? Explicitly state the share of over-indebted individuals included in the combined dataset (278-280).

c. I recommend to revise the description of findings, specifically with regards to the link between income (income, categorized into no/ low / medium / high income) and health outcomes. The authors mention in the table footer (Table 4) that Odds ratios were “adjusted for sex, age, education, nationality, marital status, employment status” (342). (Why) did the authors not adjust for income? Moreover, the authors describe that “Low or no personal income was associated with a significantly increased probability of and risk for poor SRH, independent of educational attainent or of over-indebtedness or no over-indebtedness” (323-325). They also state “However, there was no a linear and/or significant effect of the amount of income on the other health outcomes examined.” (325-326). In my view, multiple logistic regression analysis is not suitable to examine a linear relationship (or probability) as stated by the authors.

d. From my point of view, male sex was not significantly associated with poor self-rated health but marked bold in Table 3 (aOR 0.89; CI 0.69-1.14).

(3) Background. Please clarify the objectives of the study. What are the key objectives of the study? Was the study conducted to compare sociodemographic characteristics of those over-indebted to the general population in the Canton of Zurich (166) and/or to study the prevalence of health problems and association between over-indebtedness and health (146-153)?

Overall, I recommend that authors have the manuscript proofread by native speakers to avoid misunderstandings. The designation of statistical methods should be critically examined in some places.

Checklists for reporting research results (such as STROBE) should be used by the authors to reduce the manuscript to key relevant reporting points, avoid redundancies and ensure that the procedure carried out is described transparently and comprehensibly.

Reviewer #2: Although this study is on interesting research topic, there is a main methodological concern and limitation which need to be addressed in this present study. This is related to definition of over-indebtedness construct which is dichotomous and lacking of indicators for over-indebtedness. It is important to explain why measuring over-indebtedness indicators were not given priority in designing this present study.

Besides that, in the introduction section—the author(s) may highlight why research addressing over-indebtedness is important in Switzerland and why over-indebtedness might be increase in Switzerland?

In line no 313--please revise and specify the statement “...main predictor turned out to be the strongest risk or explanatory factor by far…” Please specify IF the author(s) refer to “the poor health outcomes” or something else.

In line no 357-358--please revise and specify the regression analyses authors referring to—do the authors refer to multiple logistic regression?

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Reviewer #1: No

Reviewer #2: No

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PONE-D-21-26584R1Over-indebtedness and health in Switzerland: a cross-sectional study comparing over-indebted individuals and the general populationPLOS ONE

Dear Dr. Hämmig,

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.

Your paper has been reassessed by two of our previous referees. Although our reviewers highlight the value of most of the improvements and rationales offered by you, more work seems to be needed. Specifically, many sections of the paper (especially those containing technical issues, results or their interpretation) remain unclear, requiring further major revisions from you, alongside a further round of reviews, in order to validate the adequacy of these amendments. Please submit your revised manuscript by Jul 30 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Sergio A. Useche, Ph.D.

Academic Editor

PLOS ONE

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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 #3: (No Response)

Reviewer #4: All comments have been addressed

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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 #3: Yes

Reviewer #4: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: Yes

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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 #3: (No Response)

Reviewer #4: Yes

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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 #3: Yes

Reviewer #4: Yes

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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 #3: Important public health paper on over-indebtedness and health in Switzerland.

Paper is lengthy, particularly Introduction and Discussion. Try to short and avoid repetition.

Add paragraph on how the covariates were measured (e.g. income) or point to Table 3 and 4 (and add a footnote there for additional description).

The Analyses (line 269), first paragraph is stratified by sex for study population and second paragraph for over-indebted. That is unclear, and not only because in the Results the stratification took place for the over-indebted group only. More importantly, why this stratification and why (ultimately) only for the indebted group? Was there an interaction between sex and over-indebtedness?

Line 366: you indeed show that the covariates cannot (fully) explain the impact of over-indebtedness. The key thing is to add “fully”, as you have not shown mediation analyses indicating the extent to which the impact of over-indebtedness is explained by the covariates (but not fully, I agree).

Discussion, line 418-420. Why is the need for a longitudinal study related to the over-indebted people being hard to reach? Does it not fit better with the reversed causation problem (line 400)? 2nd: Talking about case – control study is confusing, as you seem to imply that the over-indebted are cases and the other are controls. In epidemiological research cases are the one with the disease and controls are the ones without disease. This is confusing (line 420-432). 3rd: paragraph 433-447 switches from a limitation (no variation within over-indebtness), which might or might not be problematic (as there might be differences in “the level of indebtedness”) to a report on a design that you did not use (having only over-indebted group) which is of course good, but one can always imagine more worse designs than your own. The whole paragraph is lengthy and too much words combining pros and cons in confusing way.

Minor

Reference for social disparities in Switzerland (line 154).

Methods: tip of the iceberg sentence (line 209): think of having such reflections in the Discussion.

Methods: reason for over indebtedness (line 211 and further): is that not more Results?

Type line 250.

Think of having a sentence in Measures saying you have two physical and two mental health outcomes. Otherwise, Table 3 and 4 initially are a bit unclear.

Line 31: better in Measures section on SRH?

Line 315-316: “very poor health status”? You do not know, you only know that they report poor health more often. Formulate otherwise.

Line 323: “by far”: uncommon in academic writings.

Line 381: aOR=8.5?

Reviewer #4: Dear Author,

The manuscript significantly improved after this revision.

However, introduction and limitation sections unnecessarily long that need to be concise before final decision.

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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 #3: Yes: Hans Bosma

Reviewer #4: No

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[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.

Over-indebtedness and health in Switzerland: a cross-sectional study comparing over-indebted individuals and the general population

PONE-D-21-26584R2

Dear Dr. Hämmig,

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,

Sergio A. Useche, Ph.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 #3: (No Response)

Reviewer #4: All comments have been addressed

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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 #3: Yes

Reviewer #4: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: 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 #3: Yes

Reviewer #4: Yes

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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 #3: Yes

Reviewer #4: Yes

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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 #3: Well done! Only few minor suggestions:

* Line 320: 'most strongest". Delete "most".

* Line 273-276: too long sentence with resulting unclear message.

Reviewer #4: This manuscript addressed most of the comments that were raised during the review process. I recommend its publication.

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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 #3: Yes: Hans Bosma

Reviewer #4: No

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