Psychometric properties of novel instrument for evaluating ambient air pollution health literacy in adults

I-Chen Chen; Chung-Yi Li; Chien-Yeh Lu; Yi-Chin Huang; Pei-Chen Lee; Ming-Yeng Lin; Yu-Chen Wang; Long-Sheng Chen; Chia-Lun Kuo; Wen-Hsuan Hou

doi:10.1371/journal.pone.0285001

Peer Review History

Original SubmissionJune 15, 2022
3 Feb 2023 Decision Letter - Mohammad Asghari Jafarabadi, Editor PONE-D-22-16885Psychometric properties of novel instrument for evaluating ambient air pollution health literacy in adultsPLOS ONE Dear Dr. Hou, 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 Mar 20 2023 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 ****** 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 ****** 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: The authors developed a questionnaire on health literacy of ambient air pollution and validated the tool in a sample of > 1000 Taiwanese adults. They find good psychometric properties of their tool, and lowest health literary scores in the dimension “appraising in disease prevention”. They conclude that the questionnaire represents a useful tool in guiding public health interventions. The underlying study aim is highly relevant, and the development and validation of the questionnaire seem to be valid. I have some concerns about the presentation of the data, though. • The sample size is large enough to support subgroup analysis, both for validation of the questionnaire as well as final health literacy scores. At least sex-stratified and subgroup analyses for the older, more vulnerable subgroup should be presented. • Could you expand a bit more on the potential redundancy of items. As far as I understood, the consensus that all items are necessary was based on the experts’ evaluation plus the value of the factor loadings (> 0.5) However, such a high Cronbach alpha (0.93) could point to potential redundancy. The structural evaluation showed that 12 dimensions fitted best, but not how many items were needed for each dimension. Please discuss further. • Within dimensions, how was the sequence of items determined? Judging from the English translation in Table 3, e.g. items 1 and 2, items 3 and 4, and items 7 and 8 seem to go from specific to general, whereas items 11 and 12, and items 13 and 14 seem to go from general to specific. • English language needs some polishing. “More than half of the participants were married female” – I’m not quite sure what this sentence is trying to say, or why it is a problem. This should be elaborated by pointing out the distribution of sex and marital status in the general population. Or L 323: “The AAPHL instrument can provide stakeholders with the profiles of capacities and the needs of the public.” What does that mean, exactly? • Was the information if participants resided in rural vs urban environment available? If not, please add to limitations. Other comments: One digit after comma should suffice for Table 1, in particular for proportions. L153: are these the same as in the first interview? L173: Institutional Review Board of which institution? L 315: please provide more context, e.g. elaborate how the difficulty in appraising looks like in the cited references L 317: “the results”: does this pertain to results from previous studies? Please elaborate. ****** 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 ******** [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.0285001.r001
Revision 1
23 Feb 2023 Author Response We thank the reviewer for his/her comments and feedback on our manuscript. We have revised the manuscript based on the comments and believe it has made the paper stronger. Reviewer #1: The authors developed a questionnaire on health literacy of ambient air pollution and validated the tool in a sample of > 1000 Taiwanese adults. They find good psychometric properties of their tool, and lowest health literary scores in the dimension “appraising in disease prevention”. They conclude that the questionnaire represents a useful tool in guiding public health interventions. Thank you for your comments. The underlying study aim is highly relevant, and the development and validation of the questionnaire seem to be valid. I have some concerns about the presentation of the data, though. • The sample size is large enough to support subgroup analysis, both for validation of the questionnaire as well as final health literacy scores. At least sex-stratified and subgroup analyses for the older, more vulnerable subgroup should be presented. Thank you for your comments. We have conducted sex-stratified and age subgroup analyses for validation of the questionnaire and health literacy scores. The results were described in the result section and presented as supporting information following the manuscript. “Sex-stratified and age subgroup analyses of model fits were presented in S1 and S2 Tables, respectively. Subgroups of male and female demonstrated similar trends in the three different models and the model fits of 12-factor model were acceptable. Subgroup of aged younger than 65 showed that model fits of 12-factor model was fair. On the other hand, subgroup of aged 65 or over did not demonstrate acceptable model fits in any models.” “Sex-stratified and age subgroup analyses of scores were presented in S3 and S4 Tables, respectively. Subgroups of male and female demonstrated similar performance across the 12 dimensions and the dimension with highest score was applying in disease prevention. Subgroup of aged 65 or over showed higher total score than subgroup of aged younger than 65. The dimension with highest score in the subgroup of aged 65 or over was applying in health promotion while the subgroup of aged younger than 65 had the highest score in applying in disease prevention.” • Could you expand a bit more on the potential redundancy of items. As far as I understood, the consensus that all items are necessary was based on the experts’ evaluation plus the value of the factor loadings (> 0.5) However, such a high Cronbach alpha (0.93) could point to potential redundancy. The structural evaluation showed that 12 dimensions fitted best, but not how many items were needed for each dimension. Please discuss further. Thank you for your comments. We have added further discussion about the potential redundancy in the discussion section. “Bland and Altman suggest that critical values of Cronbach’s alpha may vary, which depends on different situations, and that value between 0.90 and 0.95 is desirable for clinical application [29]. However, Streiner suggest that values of Cronbach’s alpha greater than 0.90 may be too high and implies the potential redundancy among items [30].” • Within dimensions, how was the sequence of items determined? Judging from the English translation in Table 3, e.g. items 1 and 2, items 3 and 4, and items 7 and 8 seem to go from specific to general, whereas items 11 and 12, and items 13 and 14 seem to go from general to specific. Thank you for your comments. Even though the sequence of items was determined without specific concerns within a dimension, the dimensions and items were ordered from individual level to population level, which followed the concept of European Health Literacy Survey Questionnaire. • English language needs some polishing. “More than half of the participants were married female” – I’m not quite sure what this sentence is trying to say, or why it is a problem. This should be elaborated by pointing out the distribution of sex and marital status in the general population. Or L 323: “The AAPHL instrument can provide stakeholders with the profiles of capacities and the needs of the public.” What does that mean, exactly? Thank you for your comments. We have addressed the language concerns and elaborate more details in the discussion section. “According to data of the Department of Household Registration in 2021, 50.47%, 43.76%, and 38.59% of the population are female, married, and had college or higher educational level, respectively [37]. However, 55.59%, 65.00%, and 61.54% of the participants were female, married, and had college or higher educational level, respectively, which might be due to selective response.” “The AAPHL instrument can provide stakeholders with the profiles of capacities and the needs of the public, which provides information about what interventions might be needed to ameliorate health outcomes and new insight into how to improve AAPHL of the public.” • Was the information if participants resided in rural vs urban environment available? If not, please add to limitations. Thank you for your comments. We have addressed the unavailable information about participants’ residential environment as one of the study limitations in the discussion section. “Lastly, while EHL varies with cultural contexts and living environments, information regarding where participants resided in, either rural or urban environment, is unavailable.” Other comments: - One digit after comma should suffice for Table 1, in particular for proportions. Thank you for your comments. We have revised the values with one digit after comma in Table 1. - L153: are these the same as in the first interview? They were different interviewees in the two cognitive interviews. We have added more details in the materials and methods section. “Then, we invited 16 interviewees who were above 20 years of age and not involved in the first interview for the second face-to-face cognitive interviews.” - L173: Institutional Review Board of which institution? We have added more details in the materials and methods section. “The ethical approval of the final version of AAPHL instrument was obtained from Institutional Review Board of National Cheng Kung University Governance Framework for Human Research Ethics (#109-385).” - L 315: please provide more context, e.g., elaborate how the difficulty in appraising looks like in the cited references Thank you for your comments. We have added more descriptions about the difficulty in the cited references. “Our finding is consistent with the previous studies in Japan and Europe, which show appraising health information is the most difficult competency. Appraising information is considered as a complex health literacy competency. Although the valuable and reliable websites exist, these are not always accessible, understandable, or usable by the public with low health literacy. Then, it may become difficult for the public to judge information regarding health [18,31,32].” - L 317: “the results”: does this pertain to results from previous studies? Please elaborate. Thank you for your comments. We have provided more details about the results from previous studies. “Yet, our finding conflicts with the prior studies, which demonstrate the best competency is understanding health information. Information-processing of understanding is considered as a basic health literacy competency. Understanding health information is highly associated with educational level and socio-economic characteristics [18,31,32].” Attachments Attachment Submitted filename: Response to Reviewer.docx https://doi.org/10.1371/journal.pone.0285001.r002
13 Apr 2023 Decision Letter - Mohammad Asghari Jafarabadi, Editor Psychometric properties of novel instrument for evaluating ambient air pollution health literacy in adults PONE-D-22-16885R1 Dear Dr. Hou, 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, Mohammad Asghari Jafarabadi 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 ******** 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 ****** 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 ****** 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 authors‘ revised manuscript is appreciated. My points were sufficiently addressed, no further comments. ****** 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 ******** https://doi.org/10.1371/journal.pone.0285001.r003
Formally Accepted
9 Jun 2023 Acceptance Letter - Mohammad Asghari Jafarabadi, Editor PONE-D-22-16885R1 Psychometric properties of novel instrument for evaluating ambient air pollution health literacy in adults Dear Dr. Hou: 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 Mohammad Asghari Jafarabadi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0285001.r004

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