PONE-D-24-38967Perceptions of COVID-19 risk among individual with preexisting health conditionsPLOS ONE

Dear Dr. Loomans-Kropp,

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.

==============================Dear authors,Many thanks for submitting your manuscript to PLOS ONE. The manuscript has now been reviewed by two expert reviewers.As you will from their comments below, while they both appraciated your work, they also raised a number of concerns that need to be addressed before the manuscript can be considered for publication. I look forward to receiving a revised version of the manuscript. Best wishesNicola Diviani==============================

Please submit your revised manuscript by Jan 22 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Nicola Diviani

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. 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: This work was supported by The Ohio State University Comprehensive Cancer Center (OSUCCC) internal funding, a supplement to OSUCCC core support grant (P30 CA016058) and the OSUCCC RISSR (P30 CA016058). The Ohio State University Center for Clinical and Translational Sciences grant supports (National Center for Advancing Translational Sciences, Grant UL1TR001070) publications related to this project.  

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 Competing Interests section: Electra Paskett would like to acknowledge grants to the institution from Merck Foundation, Pfizer, Genentech, Guardant Health and Astra Zeneca and is a Member of Advisory Board for GSK and Merck. All other authors have no competing interests to declare.

Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: ""This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests).  If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. 

Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

4. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For 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. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. 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.

Please update your Data Availability statement in the submission form accordingly.

5. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

[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: Partly

**********

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: No

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: Review

PLOS ONE

Perceptions of COVID-19 risk among individual with preexisting health conditions

This manuscript investigates the relationship between preexisting health conditions (PECs) and perceptions of COVID-19-related risk in the early stages of the global pandemic, as well as how these perceptions changed over time. By analysing data from baseline and follow-up surveys, the authors explore differences in risk perceptions among individuals with and without PECs. The paper considers an important issue and addresses its research questions sensibly. It employs a good sample size and contributes meaningfully to the field of risk perceptions research. However, it needs to address the following points before publication is considered. In particular, greater clarity in defining the category of risk perception the manuscript is addressing, and greater justification of the analytical strategy would add to the manuscript. I hope the following suggestions can contribute to an enhanced manuscript.

Abstract

Some more clarity earlier on in the abstract would help “perceptions of the risk of COVID-19” are not clarified until the results in the abstract, where you state “catching COVID-19”. The literature around risk perception during COVID is extensive, therefore it is important to specify the ‘perception of what’ you are addressing. Precision of what you are measuring in the method would add clarity, as would information about the size and nature of your sample.

“The main effects models showed overall significantly increased self-concern of getting COVID-19 for individuals with any PEC (PR, 1.15; 95%CI, 1.03- 1.29), compared to none, and reduced self-concern at follow-up, compared to baseline (PR, 0.68; 95%CI, 0.65-0.71).”

This is a confusing sentence. I think the confusion comes from the use of ‘increased’ which would suggest change over time, but then you highlight there is overall reduction from baseline to follow-up, which suggests you are initially referring to a difference between groups. I suggest “self-concern of getting COVID-19 is higher in individuals with any PEC, compared to those with none” to avoid potential confusion.

Introduction

Is it right that “the presence of pre-existing conditions may exacerbate infection” or is it that it may exacerbate the extent of the potential detrimental effects of the infection? This is a point that needs greater clarity throughout, I would suggest stressing that the concern around people with PECs is that they are more likely to experience severe symptoms from COVID-19 than those without PECs. Also, in the introduction you are sometimes referring to risk of infection, risk of severe symptoms, and risk of fatality, so avoid using “perception of COVID-19 risk” alone, to increase clarity.

You state “Over half (51.8%) of adults” … is this globally, or in a specific country?

You mention that “perception of risk may impact acceptance of preventive interventions” an important follow-up might be to mention that though perceived risk of contracting COVID-19 may increase adherence to preventative hygiene behaviours (mask wearing etc), it may lead to a reduction in health effort and poorer health behaviours due to a decreased sense of control. See the body of literature around this topic for suggested citations:

COVID-19: the relationship between perceptions of risk and behaviours during lockdown

https://doi.org/10.1007/s10389-021-01543-9

The Relationship Between Perceived Uncontrollable Mortality Risk and Health Effort: Replication, Secondary Analysis, and Mini Meta-analysis

https://doi.org/10.1093/abm/kaad072

The Uncontrollable Mortality Risk Hypothesis: Theoretical foundations and implications for public health

https://doi.org/10.1093/emph/eoae009

Method

You state that you “examine the association between 85 preexisting health conditions and perceived risk of COVID-19”. I think the use of ‘association’ is unclear/misleading, in the context of statistical associations, as you are mostly looking at differences between those with and without PECs, not strictly the association between variables.

“Differences in baseline characteristics were assessed using Kruskal-Wallis and chi-square tests for continuous and categorical variables, respectively” This is fine, but perhaps inform the reader why Kruskal-Wallis – were ANOVA assumptions not met?

“Respondents’ ‘high concern’ for catching COVID-19 at baseline and during follow-up was modelled as a binary outcome in logistic regression models.” I think the reader would be interested to learn your rationale for not treating perceived risk of catching COVID simply as a continuous variable, what is gained by treating it as a binary variable, what is lost, and why the threshold of 75 (well at least I’d be interested to know)?

Results

“(83.7%) of the participants had a history of any PEC” - This is high. Not necessarily a problem, but different to the statistics you cite in your introduction. Presumably as a result of your sampling? A sentence to acknowledge/discuss the impact that this may have on your findings or their generalisability would be useful.

For the evaluation of the individual PECs. It is not very informative to only provide the p values, without the effect size, please include this for greater statistical transparency.

Table 1 - The inclusion of p values is confusing without having to jump up and down to see what test you are referring to, and with no test statistic. I suggest simply reporting the descriptive sample characteristics, then moving on to inferential models.

Discussion

To what extent might seasonal effects have impacted the overall decline in concern between baseline and follow-up? As people are more susceptible to respiratory infections in the winter months, the baseline data collection (June 19, 2020 to November 30, 2020), leading into winter may, have resulted in a higher level of risk perception, compared to the follow-up in march to July.

More likely, and more important to discuss, what impact do you think the vaccine rollout had on risk perceptions during this time. I don’t know about the availability of the vaccine in Ohio at the time of data collection, but I imagine that people with PECs were likely to have been prioritised over people without PECs. Perhaps people with PECs were more likely to have received a vaccine than those without, potentially levelling out the risk between groups. This potentially altered the actual risk of contracting COVID-19 between those with/without PECs.

These are not criticisms of the study, but points that warrant some acknowledgement/discussion.

A final point regarding your discussion of the wider topic of risk perception… when discussing the overall decline in perceived risk of contracting COVID-19, it would be sensible to highlight literature pointing out this as a normal feature in risk perception – that novel risks are perceived as more threatening when they first appear, but often decline as prevalence increases and the population becomes more familiar with that risk.

This leads nicely to discussions around the primary bias in risk perception, which would be pertinent here:

Judged frequency of lethal events

https://doi.org/10.1037/0278-7393.4.6.551

Perceptions of control over different causes of death and the accuracy of risk estimations

https://link.springer.com/article/10.1007/s10389-023-01910-8

PLOS ONE Criteria:

1. The study presents the results of original research. YES

2. Results reported have not been published elsewhere. AS FAR AS I AM AWARE

3. Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail. YES – WITH SOME COMMENTS TO BE ADDRESSED

4. Conclusions are presented in an appropriate fashion and are supported by the data. YES – WITH SOME COMMENTS TO BE ADDRESSED

5. The article is presented in an intelligible fashion and is written in standard English. YES

6. The research meets all applicable standards for the ethics of experimentation and research integrity. AS FAR AS I AM AWARE

7. The article adheres to appropriate reporting guidelines and community standards for data availability. AS FAR AS I AM AWARE

Reviewer #2: Thank you for the opportunity to review this paper, which investigates risk perception during the COVID-19 pandemic with a specific focus on preexisting health conditions (PEC). I believe this is a timely and relevant topic, as understanding individual and social phenomena during the pandemic is crucial for future pandemic preparedness. The study's large sample size and longitudinal design are commendable strengths, allowing for a robust exploration of the research question. However, there are several issues, both major and minor, that need to be addressed to improve the clarity, rigor, and overall contribution of the paper.

Abstract

• The conclusion in the abstract emphasizes the role of experience and increased knowledge in shaping risk perception. While this interpretation is interesting, it appears to go beyond what is directly supported by the study's findings. I recommend revising this to more closely align with the results.

Introduction

• Theoretical Framework: The introduction would benefit from referencing established theoretical frameworks related to risk perception. Specifically:

o When discussing the self-perceived risk of contracting COVID-19, it would be appropriate to use the term "susceptibility".

o Similarly, the self-perceived risk of fatality should be referred to as "severity".

o These terms align with common frameworks such as the Health Belief Model and provide a more precise context for the discussion.

• Existing Literature: While the study aims to contribute to the understanding of risk perception during pandemics, the introduction could better situate this research within the existing body of evidence. Incorporating references to previous studies on pandemic-related risk perception would help highlight the study's unique contributions.

Results

• Results should be presented objectively, without interpretation or commentary. For example, in line 75, the use of the word "interestingly" introduces a subjective tone that is best reserved for the discussion section. I recommend revising such language to maintain a neutral reporting style.

Discussion

• Sample Characteristics: The paper acknowledges the large sample size as a strength, but it is notable that many respondents reported a history of PEC. While self-reporting is identified as a potential limitation, this point requires further discussion. For instance:

o Could the high prevalence of PEC in the sample introduce bias or affect generalizability?

o What are the potential implications for interpreting the findings?

• Additional Limitations: While the limitations section touches on underreporting, there are likely other limitations that merit discussion, such as possible sampling biases or challenges inherent in longitudinal designs (e.g., attrition).

• Knowledge and Risk Perception: The interpretation linking changes in risk perception to increased knowledge requires further justification.

o Why is this claim made, and how is it supported by the data?

o To strengthen this interpretation, it would be helpful to introduce the construct of "knowledge about pandemics" in the introduction and discuss its potential impact on risk perception.

Conclusion

• I would suggest separating and titling the conclusion section. Ensure that the conclusions remain closely tied to the study’s findings and avoid overgeneralizing. It is important to clearly articulate what is supported by the data and what remains speculative.

**********

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: Yes:  Dr Richard Brown

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.

Perceptions of COVID-19 risk among individuals with preexisting health conditions

PONE-D-24-38967R1

Dear Dr. Loomans,

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,

Nicola Diviani

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 #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: (No Response)

Reviewer #2: No

**********

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: The authors have done a wonderful job at attending to all comments with a comprehensive and sensible approach. This provides a valuable contribution to the literature.

Reviewer #2: The authors addressed all comments of my previous review and the ones of the other reviewers. The manuscript has improved, especially the introduction and discussion sections.

**********

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: Yes:  Richard Brown

Reviewer #2: No

**********