Socio-demographic determinants of infectious disease-related health literacy and knowledge in Armenia: Results from a nationwide survey

Zhanna Sargsyan; Zaruhi Grigoryan; Serine Sahakyan; Anya Agopian; Tsovinar Harutyunyan

doi:10.1371/journal.pone.0307300

Peer Review History

Original SubmissionDecember 14, 2023
8 Mar 2024 Decision Letter - Laura Brunelli, Editor PONE-D-23-40060Socio-demographic determinants of infectious disease-related health literacy and knowledge in ArmeniaPLOS ONE Dear Dr. Sargsyan, 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. ============================== ACADEMIC EDITOR: Please address the reviewers' feedback to improve your manuscript.============================== Please submit your revised manuscript by Apr 22 2024 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. 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PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. We will update your Data Availability statement on your behalf to reflect the information you provide. [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: 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 Reviewer #2: No ****** 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 Authors, This article deals with a very interesting topic. The relevance of this article is undeniable. Additionally, the article is well structured, the methods of analysis are relevant, and the tables are informative. However, before its publication, some changes need to be made. You will find my comments below. Sincerely yours ---------------------------------------------- 1. The introduction needs polishing. The authors should add statistics on infectious diseases in Armenia. 2. The authors mention that ‘The study team conducted a phone survey in the scope of existing larger study of COVID-19…’. What is the objectives of this phone survey ? 3. The authors said that ‘The infectious disease knowledge was measured using four questions.’ I suggest them to add the four questions. 4. ‘The infectious disease-specific health literacy was measured using nine questions’. Same comment as above. 5. In the discussion section do not use ‘It seems’. Use other words. ‘It seems’ is not a scientific word in these sentences. 6. I suggest to authors to refine the discussion. For example, to explain the effect of age, you need to take into account the differences in educational levels between younger and older people. You need to mobilize data and other studies on Armenia's socio-cultural context. 7. Finally, The authors need to add limitations regarding the type of survey (phone survey). In addition, I suggest that the authors add a section ‘Policy implication of findings’ Reviewer #2: Employing a comprehensive nationwide phone survey, the study endeavours to measure the extent of health literacy and knowledge concerning infectious diseases across Armenia, while also examining the impact of socio-economic factors on these variables. The article is generally well-written, and it includes a thorough review of the literature, presents a sound methodology, and discusses the findings in a comprehensive manner. Some minor revisions can be addressed to enhance the credibility and interpretability of the research findings; details are reported below. - I believe that an evidence-based definition of “working from home” and a consistent use of the related terminology for this exposure. - The study design should be understood from the title and the abstract; it should bel also mentioned in the methods section. - Even though the language adopted in the article is correct, I suggest refining the style to achieve better clarity and precision. Be careful in ensuring that the terminology used is the most accurate and specific to avoid ambiguity. - The methodology is well-structured, employing a nationwide phone survey to collect data. However, the study could benefit from a more detailed description of the survey questions and the rationale behind the selection of these specific questions. Clarification on how the questions were tailored to assess health literacy and knowledge specifically related to infectious diseases would strengthen the paper. - It's mentioned that the scale used to assess infectious disease-related health literacy was not previously validated, which could affect the reliability of the results. If possible, use a validate scale or, in future studies, consider validating the scale used in this paper. - While the paper acknowledges several limitations, including the potential bias introduced by phone surveys and the lack of validation for the health literacy scale, a more thorough exploration of these limitations and their implications for the study's findings would be beneficial. Additionally, discussing potential strategies for overcoming these limitations in future research could provide a more comprehensive picture. - A detailed participant flowchart or description of participant recruitment, inclusion, and exclusion criteria would enhance transparency in reporting. - The discussion effectively highlights the importance of the study findings in the context of Armenia and beyond. However, the paper would benefit from a broader consideration of the implications for public health policy and education strategies. Specifically, recommendations for how policymakers and educators can use these findings to improve health literacy and preparedness for future infectious disease outbreaks would be useful. - While the paper acknowledges several limitations, including the potential bias introduced by phone surveys and the lack of validation for the health literacy scale, a more thorough exploration of these limitations and their implications for the study's findings would be beneficial. Additionally, discussing potential strategies for overcoming these limitations in future research could provide a more comprehensive picture. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0307300.r001
Revision 1
7 Jun 2024 Author Response Dear Editorial Team, Thank you for the review and the constructive feedback on our manuscript entitled “Socio-demographic determinants of infectious disease-related health literacy and knowledge in Armenia”. On behalf of the authors’ team, I would like to upload the revised version of the manuscript which addresses the reviewer’s comment. Please find our response below. 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. Thank you, we followed the guidelines while preparing the revisions. 2. Thank you for stating the following financial disclosure: [Support to control covid-19 and other infectious disease outbreaks. Cooperative Agreement # 72011120CA00003. United States Agency for International Development (USAID)]. 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. Support to control COVID-19 and other infectious disease outbreaks. Cooperative Agreement # 72011120CA00003. United States Agency for International Development (USAID). “This study is made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents of this paper are the sole responsibility of the American University of Armenia Fund and do not necessarily reflect the views of USAID or the United States Government.” 3. We note that you have indicated that there are restrictions to data sharing for this study. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. The participants of this study did not agree to sharing their data publicly in a non-aggregated format; thus, in accordance with the study’s IRB approval and participant consent, the data is unable to be made available for public use. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. We will update your Data Availability statement on your behalf to reflect the information you provide. Reviewer #1: Dear Authors, This article deals with a very interesting topic. The relevance of this article is undeniable. Additionally, the article is well structured, the methods of analysis are relevant, and the tables are informative. However, before its publication, some changes need to be made. You will find my comments below. Sincerely yours ---------------------------------------------- Thank you! 1. The introduction needs polishing. The authors should add statistics on infectious diseases in Armenia. We polished the introduction section and added statistics on most common infectious diseases in Armenia. (lines 38-103) 2. The authors mention that ‘The study team conducted a phone survey in the scope of existing larger study of COVID-19…’. What is the objectives of this phone survey ? We added the primary objective of the larger study. “The primary objective of the study was to estimate the seroprevalence of antibodies against SARS-CoV-2 and assess the population’s knowledge, attitude, and practices regarding infectious diseases transmission, manifestation, and treatment in general among adults in Armenia.” (lines 107-110) 3. The authors said that ‘The infectious disease knowledge was measured using four questions.’ I suggest them to add the four questions. We added the four questions in the methods section. (lines 151-155) 4. ‘The infectious disease-specific health literacy was measured using nine questions’. Same comment as above. We added the nine questions. (lines 160-175) 5. In the discussion section do not use ‘It seems’. Use other words. ‘It seems’ is not a scientific word in these sentences. Thank you for the comment. We replaced the word “it seems” with “it is likely” (line 264) and removed word “seem” (line 256). 6. I suggest to authors to refine the discussion. For example, to explain the effect of age, you need to take into account the differences in educational levels between younger and older people. You need to mobilize data and other studies on Armenia's socio-cultural context. We added “This may be due to a lower education levels in older adults, although a majority (70.5%) of our sample had at least a university or vocational degree.” (lines 273-277) 7. Finally, The authors need to add limitations regarding the type of survey (phone survey). In addition, I suggest that the authors add a section ‘Policy implication of findings’ We would like to explain why the type of the survey being a phone survey might not be considered a limitation for this study. Out of 3,727 people who underwent blood sampling for the antibody testing 3,483 (93.5%) participated in the phone survey. The study participants gave written informed consent that after the blood sampling they will be contacted by the research team for a phone survey. However, it might be that those who agreed to give a blood sample for the bigger study might be more concerned and aware of their health and had a higher degree of health literacy and knowledge compared to those who refused to participate. To acknowledge this, we added in the limitations that “Also, those more concerned about their health and/or more aware of infectious diseases might agree to participate in the blood sampling for COVID-19 antibody testing introducing some degree of self-selection bias”. (lines 299-301) We also added a section on the Policy implications. (lines 311-328) Reviewer #2: Employing a comprehensive nationwide phone survey, the study endeavours to measure the extent of health literacy and knowledge concerning infectious diseases across Armenia, while also examining the impact of socio-economic factors on these variables. The article is generally well-written, and it includes a thorough review of the literature, presents a sound methodology, and discusses the findings in a comprehensive manner. Some minor revisions can be addressed to enhance the credibility and interpretability of the research findings; details are reported below. Thank you! 1. I believe that an evidence-based definition of “working from home” and a consistent use of the related terminology for this exposure. We would like to explain why we have used “stay at home from work/school” in some infectious disease-related literacy questions in our instrument. The questions were taken from the WHO survey tool designed to guide behavioural insights studies related to COVID-19 (https://iris.who.int/bitstream/handle/10665/333549/WHO-EURO-2020-696-40431-54222-eng.pdf?sequence=1&isAllowed=y). We did not change the wording as the similar wording was used by the government (Ministry of Health) to communicate the COVID-19 related preventive recommendations. We used the same terminology/wording, so the questions are understandable to our survey participants representing general population of Armenia. 2. The study design should be understood from the title and the abstract; it should bel also mentioned in the methods section. We added the study design in the title: “Socio-demographic determinants of infectious disease-related health literacy and knowledge in Armenia: Results from a nationwide survey”. (Lines 1-3) 3. Even though the language adopted in the article is correct, I suggest refining the style to achieve better clarity and precision. Be careful in ensuring that the terminology used is the most accurate and specific to avoid ambiguity. We edited throughout the manuscript to better refine the style and clarity. 4. The methodology is well-structured, employing a nationwide phone survey to collect data. However, the study could benefit from a more detailed description of the survey questions and the rationale behind the selection of these specific questions. Clarification on how the questions were tailored to assess health literacy and knowledge specifically related to infectious diseases would strengthen the paper. We added in the Data collection and study tool section explanation. “The infections disease-related health literacy questions were adapted to from the WHO survey tool designed to guide behavioural insights studies related to COVID-19 to cover general infectious disease-related health literacy.” (Lines 151-159) 5. It's mentioned that the scale used to assess infectious disease-related health literacy was not previously validated, which could affect the reliability of the results. If possible, use a validate scale or, in future studies, consider validating the scale used in this paper. Thank you for this note. Given that there was (is) no validated tool available in Armenian language, the infections disease-related health literacy questions were taken from the WHO survey tool designed to guide behavioral insights studies related to COVID-19. However, we adapted the scale to cover not only COVID-19 but infectious disease literacy in general and translated to Armenian. 6. While the paper acknowledges several limitations, including the potential bias introduced by phone surveys and the lack of validation for the health literacy scale, a more thorough exploration of these limitations and their implications for the study's findings would be beneficial. Additionally, discussing potential strategies for overcoming these limitations in future research could provide a more comprehensive picture. We added on the recommendations for future similar studies "Future studies may consider using validated scales and designing comprehensive questionnaires specifically focusing on the infectious disease-related health literacy and knowledge" (Lines 306-307) 7. A detailed participant flowchart or description of participant recruitment, inclusion, and exclusion criteria would enhance transparency in reporting. We added a reference to a study which explains the participant recruitment, inclusion, and exclusion criteria in more details (lines 125-126). 8. The discussion effectively highlights the importance of the study findings in the context of Armenia and beyond. However, the paper would benefit from a broader consideration of the implications for public health policy and education strategies. Specifically, recommendations for how policymakers and educators can use these findings to improve health literacy and preparedness for future infectious disease outbreaks would be useful. We added a section on the Policy implications. (lines 311-328) Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0307300.r002
1 Jul 2024 Decision Letter - Laura Brunelli, Editor Socio-demographic determinants of infectious disease-related health literacy and knowledge in Armenia PONE-D-23-40060R1 Dear Dr. Sargsyan, 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. 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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 Reviewer #2: 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 Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes 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 #1: Yes Reviewer #2: 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 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 #1: For p-values in tables, replace p=0.0000 with p<0.0001. The p-values are never zero, but rather close to 0. This is my only comment for the authors. Before the article is published, they must correct this. Reviewer #2: Dear Authors, I have carefully reviewed your responses to my comments and the revised version of your manuscript. I am pleased to inform you that your thorough revisions have adequately addressed all my concerns. The manuscript is now of a high standard and is suitable for publication. I commend you for your diligent work and thoughtful revisions. Best regards ****** 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 Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0307300.r003
Formally Accepted
10 Jul 2024 Acceptance Letter - Laura Brunelli, Editor PONE-D-23-40060R1 PLOS ONE Dear Dr. Sargsyan, 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. Laura Brunelli Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0307300.r004

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