PONE-D-22-31148Ref. KPB.B 1900/225/2565 11 December, 2022Validation of the depression, anxiety, and stress scales (DASS-21): among Thai nursing students in the online learning environment during the COVID-19 outbreak: A multi-center study.PLOS ONE

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Reviewers' comments:

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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

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

Reviewer #1: No

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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

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: No

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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: 1. Under study design & Population: It is not clear how they recruit the participants in their study since the sample was taken from a larger multi-center survey, and how they randomize them.

2.Do the survey was part of the larger study, or after the larger study completed they recruit the sample and send them the survey of DASS-21

2. "To interpret these results is comparable to the original version of DASS-41 that calculated from the total scores for each sub-scale multiplying by two". This statement is not clear. & why they have used the 21 items scale since the original was 41 items?

3. Reference number 24 is retracted.

4. Based on what you have enrolled this number of participant (3705)? and you have mentioned that you need 5 – 10 participants for each item.

5. The exclusion criteria are not clear in the manuscript.

6. Fatigue (VAS-F) is different construct than anxiety and depression. So how it was used to test the convergent validity of the DASS-18.

7. It is not clear how randomization of the participants was done?

8. It was mentioned that the parellel analysis revealed a single factor, then a 3 factor solution was created. how this was run?

9. What was the factor loading for the deleted items and in which factors they loading(the rule is to retain items if they had a factor loading of 0.4 or more).

10. Did the total variance changed after you remove the three factors?

11. The title of Table 2 need to be changed to "The title of the table should be Exploratory Factor Analysis of the DASS-18"

12. in page 11 under the tittle Confirmatory factor analysis, the term "subscales" is used instead of "Items".. there is a big difference between both.

13. What was Composite Reliability (CR) of the three factors as an evidence of reliability.

14. What was the Average Variance Extracted (AVE) for the scales ? (this is considered a measure of convergent validity)

15. What is the relation of gender to convergent validity? Gender is not a scale. how you consider is an evidence of convergent validity?

16. Table 3 has a lot of errors & empty cells. besides, this is a correlation table not a Convergent and discriminant validity for the subscale of the DASS-18.

17. How did you measure the variable "Online Learning". it was mentioned in table 3.

18. some non scientific terms are used such as "directly linked".. "values were discovered to exist"." comparable discoveries"

19. I am not sure why table 5 was reported. it is a correlation table. they have already run the factor analysis.

20. How the temporal stability of the tool was measure. " the term is mentioned in page 13 under "Discussion".

21. There are some typing and grammatical errors in the manuscript.

22. How did the authors know that female had more depression? We can’t know that by simple running correlation. You need to do a T-test

23. The authors have mentioned in the discussion that "no effect on both the DASS-depression and DASS-anxiety scales as we found no significant cultural problems with those two scales and there was no concern with the EFA findings as demonstrated by the statistical results". I think this couldn’t attributed to cultural factors only. This depends on the responses of the participants

24. The authors have mentioned that "The Thai version's convergent validity is supported by favorable correlations with VAS-F dimensions; correlations in this direction were anticipated which were expected to measure the same construct" Actually they are measuring different constructs, so they came up with this conclusion?

25. the authors have reported that there is an evidence of concurrent validity but it is not clear how it was measured (278 anxiety and depression are used in the same tool, so it can't be considered a concurrent validity.

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Reviewer #1: No

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PONE-D-22-31148R1Validation of the depression, anxiety, and stress scales (DASS-21) among Thai nursing students in the online learning environment during the COVID-19 outbreak: A multi-center study.PLOS ONE

Dear Dr. summart,

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 Jul 23 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.

Please include the following items when submitting your revised manuscript:

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• 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,

Omar M Khraisat, Associate Professor

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

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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 #2: All comments have been addressed

Reviewer #3: 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 #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: 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 #2: Yes

Reviewer #3: 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 #2: Yes

Reviewer #3: 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 #2: Thank you for the opportunity to review this manuscript. The article reports the validation of the Depression, Anxiety, and Stress Scales (DASS-21) among Thai nursing students in the online learning environment during the COVID-19 outbreak. The topic holds significant importance for the nursing profession, considering the global impact of the COVID-19 pandemic. I particularly appreciate the inclusion of universities from various regions of Thailand in their study. I commend the authors for undertaking this research.

Please see my comments below for strengthening the manuscript:

Introduction: The introduction section could be written with more clarity and focus on the research gap. Some statements are too generic and require context and clarification of terms. I have detailed them below:

• The reference to Lee et al (2019) was used to support the statement about low performance at work or school, disruptions in social life, and even suicide, but the reference is a study evaluating the Depression Anxiety Stress Scales, which is not directly relevant. It would be helpful to provide more specific and relevant references to support these claims.

• The statement about "more than a third of nursing students" and almost 'one half of these students' would be unclear without the total number of nursing students in the context of the study. Clarifying the total number of nursing students would provide better context.

• It would be beneficial to provide a clear definition of 'remote learning' or 'online learning,' whichever terms the authors choose, to establish the context. Additionally, the terms "high intentions," "extensive training and learning processes" need further clarification and explanation.

• The article mentions a research article explaining the high risk of infection exposure and fear of transmitting diseases among students, but it is not clear how this relates to the study's context of 'remote learning'. The connection between remote learning and these factors needs to be clearly established.

• The sentence in line 42-43 requires evidence to support the claim made. It would be beneficial to provide supporting references or data to strengthen this statement.

• There should be a brief explanation of DASS, its psychometric properties, and the difference between DASS-21 and the original DASS scale. Justifying the use of DASS-21 in this study would enhance the manuscript.

• It is important to define the young adult age group being referred to in the study. Clarifying the specific age range would eliminate ambiguity and improve the precision of the research.

• Considering the Thai context during the COVID-19 outbreak/pandemic, it would be valuable to include relevant information about the situation in Thailand, particularly during the data collection phase from April to June 2022. Providing contextual information would enhance the understanding of the study's findings.

Study instruments: I was unsure how the process of translating the original version into Thai was conducted, as the reference was to a DASS Brunei version. It would be helpful to provide information on who conducted the translation, whether there was any back-translation, and the measures taken to ensure there was no loss of meaning in the translation and to ensure consistency and validity. Additionally, information on the reliability and validity of the selected instruments, including the VAS-F scale, should be provided. Was there any pilot testing of the translated version?

Sample size calculation: Information on the sample could have been better. Who were these nursing students? What kind of remote learning did they engage in, how many hours, and what courses were included? How were they recruited? It would also be helpful to clarify whether students with existing CMDs (Common Mental Disorders) were excluded or not.

Line 130 - (group 1, n= 2,000, and group 2, n= 1,706). The total should be 3,706. Please verify this.

Statistical analysis: Can you include the statistical software used? I wasn't clear which items were removed and how the study ended up using DASS-18. It was only explained later on under the subheading "Confirmatory factor analysis." It would be helpful to signpost the reader by mentioning that this would be discussed later on.

The results and discussion sections are generally well-written. However, the statement in Line 274-276 should elaborate more on cultural factors and draw on relevant literature to support the discussion. Additionally, in relation to this statement, I wasn't sure what was meant by "no significant cultural problems." It would be beneficial to provide further clarification or explanation to ensure understanding.

Reviewer #3: (No Response)

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Reviewer #2: No

Reviewer #3: Yes: Emmanuel Z. Chona

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Validation of the depression, anxiety, and stress scales (DASS-21) among Thai nursing students in the online learning environment during the COVID-19 outbreak: A multi-center study.

PONE-D-22-31148R2

Dear Dr.,

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,

Omar M Khraisat, Associate Professor

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #2: 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 #2: No

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

Reviewer #2: 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 #2: 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 #2: 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 #2: I am pleased with the comprehensive revisions made in response to the comments. I would like to note that there is a discrepancy in line 144-5, where the total number is stated as 3,706 instead of 3,705 as mentioned elsewhere in the manuscript. Please double-check this inconsistency.

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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 #2: No

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