Analysis of multi-level barriers to physical activity among nursing students using regularized regression

Muge Capan; Lily Bigelow; Yukti Kathuria; Amanda Paluch; Joohyun Chung

doi:10.1371/journal.pone.0304214

Peer Review History

Original SubmissionJanuary 25, 2024
1 Apr 2024 Decision Letter - Hao Wang, Editor PONE-D-24-02933Analysis of Multi-level Barriers to Physical Activity Among Nursing Students Using Regularized RegressionPLOS ONE Dear Dr. Capan, 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. It is a great pleasure to read your manuscript. Your discussion on healthcare providers’ well-being addresses a topic of utmost importance. However, as noted in the reviewers’ comments, some revisions are necessary before a final decision on publication can be made. Editor’s note: I recommend that the authors merge their introduction and literature review to focus more on their targeted questions: the identification of barriers and the association of these barriers with physical activity (PA). The manuscript contains redundancies that could be condensed for clarity. Additionally, minor changes could enhance the manuscript's quality. For instance, results discussed in the methods section, such as Cronbach’s alpha results, should be moved to the results section. Moreover, methodological details discussed in the discussion section, such as those found in Line 408-412, would be better suited for the methods section. Lastly, common statistical statements, such as 'p<0.05 considered statistically significant,' could be avoided. I suggest the authors delve into the clinical/practical significance of their approaches and explain why such approaches are valuable. Please submit your revised manuscript by May 16 2024 11:59PM. 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Kind regards, Hao Wang Academic Editor PLOS ONE Journal Requirements: 1. When submitting your revision, we need you to address these additional requirements. 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 https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating the following financial disclosure: University of Massachusetts Amherst -Elaine Marieb Center for Nursing and Engineering Innovation Faculty Pilot Grant supporting the study entitled "Exploratory Study to Identify Multi-level Factors of Physical Health and Well-being in Nursing Profession" (06/2023 – 06/2024, PI: M. Capan). Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 3. Thank you for stating the following in the Acknowledgments Section of your manuscript: The authors thank all participants for their participation and nursing faculty at the The Elaine Marieb College of Nursing for dedicating class time for the study data collection. The authors would like to acknowledge the Elaine Marieb Center for Nursing and Engineering Innovation at the University of Massachusetts Amherst for their financial support through the internal pilot grant entitled: ”Exploratory Study to Identify Multi-level Factors of Physical Health and Well-being in Nursing Profession” We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: University of Massachusetts Amherst -Elaine Marieb Center for Nursing and Engineering Innovation Faculty Pilot Grant supporting the study entitled "Exploratory Study to Identify Multi-level Factors of Physical Health and Well-being in Nursing Profession" (06/2023 – 06/2024, PI: M. Capan). Please include your amended statements within your cover letter; we will change the online submission form on your behalf. 4. In the online submission form, you indicated that Data cannot be shared publicly because of personal information to protect data privacy. De-identified data are available from the corresponding author at University of Massachusetts Mechanical and Industrial Engineering Department upon request. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either a. In a public repository, b. Within the manuscript itself, or c. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 5. 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. Additional Editor Comments: It is a great pleasure to read your manuscript. Your discussion on healthcare providers’ well-being addresses a topic of utmost importance. However, as noted in the reviewers’ comments, some revisions are necessary before a final decision on publication can be made. Editor’s note: I recommend that the authors merge their introduction and literature review to focus more on their targeted questions: the identification of barriers and the association of these barriers with physical activity (PA). The manuscript contains redundancies that could be condensed for clarity. Additionally, minor changes could enhance the manuscript's quality. For instance, results discussed in the methods section, such as Cronbach’s alpha results, should be moved to the results section. Moreover, methodological details discussed in the discussion section, such as those found in Line 408-412, would be better suited for the methods section. Lastly, common statistical statements, such as 'p<0.05 considered statistically significant,' could be avoided. I suggest the authors delve into the clinical/practical significance of their approaches and explain why such approaches are valuable. [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: I Don't Know ****** 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: Dear author, I found the topic of your manuscript to be interesting and well thought out. The background, Method, Results, and Discussion sections are good written. After reviewing it, I wanted to share two points on Method with you: You mentioned that one of the inclusion criteria for participants was consent to participate in study. This special criterion is an exclusion criterion. You reported about 14% data were missed. Although you Following imputation for retaining data, missing data might influence the result. As you applied electronic questionnaire, you could have coped with data missed randomly. It seems that missing data were nonrandom. That means students avoided to response to some questions. Please describe this limitation in the “Discussion”. Discussion: Please update the references used in your manuscript. Reviewer #2: Thank you for the opportunity to review this interesting study “Analysis of Multi-level Barriers to Physical Activity Among Nursing Students Using Regularized Regression”. This is a cross-sectional study that used survey data to quantify self-reported barriers to physical activity and used multiple factors to predict physical activity barrier scores (PABS). This study attempts to use the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to identify factors that may contribute to a participant’s overall physical activity barrier score. Participants were Nursing students currently enrolled in a nursing degree program at the study institution. The total number of participants was 163. The participants completed a 174-question survey that combined elements from multiple surveys to model the multiple domains of the NIMHD framework when assessing physical activity barrier score. The authors then performed statistical analysis to develop four different linear regression models to predict PABS. This is an interesting study that is well-written with some issues that affect its quality. Abstract - Overall well-written but exceeds the 300 word limit Introduction/Relevant Literature - Minor grammatical changes: “Improving nurses’ PA relies on better understanding the factors acting as barriers to engage in PA specifically in nursing population”. “However, there is a lack of research that studies PA, and particularly barriers to PA disproportionately experience by certain populations…” Materials and Methods - Table 1: elements of the table are listed above and below the table. Please only list the elements of the table underneath and include PhenX Social Determinants of Health (SDOH) toolkit Results - 296-305: This section compares several means and reports associated confidence intervals. Consider including associated p-values for these data. - - Why does fig 2. Only includes data for level of education. Why was level of education chosen for this example? - 366-376: Variable x8 in this model is “attained a master’s or other graduate degree” and is reported as significantly influential in this model with a coefficient of 5.64. This model has only 7 participants in the “masters or other graduate degree” category compared to 92 and 64 for high school diploma/GED and bachelors degree respectively. Please address this limitation. - 371-372: Variable x6 is family income and is has the coefficient − 5.00 · 10−6 o It might be useful to give an example of how this part of the formula works. Does it mean a decrease in PABS of 5 for every 1 million dollars in family income? Discussion - Paragraph lines 398-405 is redundant and can be removed. ****** 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. 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Revision 1
5 May 2024 Author Response Please see submission file "Response to Reviewers". The content is copy pasted below as well for your reference. PONE-D-24-02933 Analysis of Multi-level Barriers to Physical Activity Among Nursing Students Using Regularized Regression Editor’s note I recommend that the authors merge their introduction and literature review to focus more on their targeted questions: the identification of barriers and the association of these barriers with physical activity (PA). The manuscript contains redundancies that could be condensed for clarity. Thank you for your valuable feedback. In the revised manuscript we merged introduction and literature review sections to improve the content and flow of the manuscript and reduced repetitive information. Additionally, minor changes could enhance the manuscript's quality. For instance, results discussed in the methods section, such as Cronbach’s alpha results, should be moved to the results section. We moved the Cronbach’s alpha results to the results section, as recommended. Moreover, methodological details discussed in the discussion section, such as those found in Line 408-412, would be better suited for the methods section. We absolutely agree. We moved the discussion of methodological details to methods section. Lastly, common statistical statements, such as 'p<0.05 considered statistically significant,' could be avoided. We made sure that common statistical statements were removed. I suggest the authors delve into the clinical/practical significance of their approaches and explain why such approaches are valuable. Thank you for this insight. We believe that the revised manuscript provides a clear discussion of the clinical and practical implications and significance, and how studies like our can lay the foundation for important future research directions. Review Comments to the Author Reviewer #1: I found the topic of your manuscript to be interesting and well thought out. The background, Method, Results, and Discussion sections are good written. Thank you for your feedback, we greatly appreciate it. After reviewing it, I wanted to share two points on Method with you: You mentioned that one of the inclusion criteria for participants was consent to participate in study. This special criterion is an exclusion criterion. We revised the language in Study Population section to clarify “consent to participate” as an exclusion criterion. You reported about 14% data were missed. Although you Following imputation for retaining data, missing data might influence the result. As you applied electronic questionnaire, you could have coped with data missed randomly. It seems that missing data were nonrandom. That means students avoided to response to some questions. Please describe this limitation in the “Discussion”. Thank you for bringing up this important issue regarding missingness in the data. We agree that survey-based data, as utilized in this study, may exhibit missingness that can be nonrandom as participants (in this case nursing students) may have intentionally refused answering some questions. We added this limitation in the discussion section for clarification and as potential future analysis area. Discussion: Please update the references used in your manuscript. We reviewed and updated the refences. Reviewer #2: Thank you for the opportunity to review this interesting study “Analysis of Multi-level Barriers to Physical Activity Among Nursing Students Using Regularized Regression”. This is a cross-sectional study that used survey data to quantify self-reported barriers to physical activity and used multiple factors to predict physical activity barrier scores (PABS). This study attempts to use the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to identify factors that may contribute to a participant’s overall physical activity barrier score. Participants were Nursing students currently enrolled in a nursing degree program at the study institution. The total number of participants was 163. The participants completed a 174-question survey that combined elements from multiple surveys to model the multiple domains of the NIMHD framework when assessing physical activity barrier score. The authors then performed statistical analysis to develop four different linear regression models to predict PABS. This is an interesting study that is well-written with some issues that affect its quality. Thank you for your feedback, we greatly appreciate it. Abstract - Overall well-written but exceeds the 300 word limit The abstract in the revised manuscript is under the 300 word limit. Introduction/Relevant Literature - Minor grammatical changes: “Improving nurses’ PA relies on better understanding the factors acting as barriers to engage in PA specifically in nursing population”. “However, there is a lack of research that studies PA, and particularly barriers to PA disproportionately experience by certain populations…” We appreciate the reviewer pointing out the minor grammatical changes needed. We revised the manuscript to ensure the grammatical errors are eliminated. Materials and Methods - Table 1: elements of the table are listed above and below the table. Please only list the elements of the table underneath and include PhenX Social Determinants of Health (SDOH) toolkit Results We listed the elements under the table as recommended. - 296-305: This section compares several means and reports associated confidence intervals. Consider including associated p-values for these data. We have added the p-values as recommended. - Why does fig 2. Only includes data for level of education. Why was level of education chosen for this example? This Figure aimed to provide one example of descriptive data visualization applied while exploring the data. We agree that it may cause confusion to share the boxplot og one particular variable used in the models discussed later in the manuscript. We removed this Figure and revised the section. - 366-376: Variable x8 in this model is “attained a master’s or other graduate degree” and is reported as significantly influential in this model with a coefficient of 5.64. This model has only 7 participants in the “masters or other graduate degree” category compared to 92 and 64 for high school diploma/GED and bachelors degree respectively. Please address this limitation. We absolutely agree with reviwer’s point. We combined categories. Level of education now had two categories: High school diploma/GED 92 (56.4%) and Bachelors, Masters or other graduate degree 71 (43.6%) as shown in revised Table 2. All four models were re-run, all results updated accordingly. In revised modeling results, Model 3 contains variable x6 (“total family income in the last year”), variable x7 (“attained a bachelor's degree or higher”), and a new variable x8 (“male biological sex”). Variable x6 has a coefficient of 5.75 · 10−6, variable x7 has a coefficient of 1.94, and variable x8 has a coefficient of 2.46. These results show that education is still an influential predictor, but that male biological sex is also influential for this population. After combining the categories for education, there were slight improvements in the predictive performance Model 3. The changes resulting from this have been reflected in Table 2, Table 4, Figure 3, and in Model 3. - 371-372: Variable x6 is family income and is has the coefficient − 5.00 · 10−6 o It might be useful to give an example of how this part of the formula works. Does it mean a decrease in PABS of 5 for every 1 million dollars in family income? We have provided an updated explanation for this variable in the revised manuscript. Every $10000 increase in family income is associated with a PABS decrease by 0.0575. Discussion - Paragraph lines 398-405 is redundant and can be removed. Thank you, we removed these redundant elements. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0304214.r002
9 May 2024 Decision Letter - Hao Wang, Editor Analysis of Multi-level Barriers to Physical Activity Among Nursing Students Using Regularized Regression PONE-D-24-02933R1 Dear Dr. Capan, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Hao Wang Academic Editor PLOS ONE Additional Editor Comments (optional): Authors responded appropriately to all the comments. The revised manuscript is now considered suitable for publication. Reviewers' comments: https://doi.org/10.1371/journal.pone.0304214.r003
Formally Accepted
14 May 2024 Acceptance Letter - Hao Wang, Editor PONE-D-24-02933R1 PLOS ONE Dear Dr. Capan, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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 Dr. Hao Wang Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0304214.r004

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