PONE-D-24-52344-->-->Who gets sicker and why? Parents’ perceptions of COVID-19 disparities and how they would explain them to their children-->-->PLOS ONE?>

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Additional Editor Comments:

1. No information about the methods was provided in the abstract. Please provide information on the types of quantitative and qualitative data analysis used.
2. Please add information about the demographics of the participants to the abstract.
3. What are your findings of each analysis? Please provide clear and concise information in the abstract.
4. Please avoid any promotional statements in the manuscript. (e.g., "No research has looked at.."). It is not sufficient to indicate that a research topic has not been examined before in a way that the authors will examine it.
5. The current study section should briefly describe the research gap, aims, hypotheses/ research questions (RQs).
6. The rationales should be provided in the literature review, not in the current study section. Avoid any new information or new citations in this section.
7. What are your directional hypotheses?  Please explain them in the "current study" section.
8. Which analysis was used for each hypothesis/ RQs? Justification is needed for each analysis (e.g., mixed effect logistic regression). Please see reviewers comments.
9. The current version of the results section is poorly structured and difficult for readers to follow. Readers cannot manage that much information. I recommend providing a brief reminder to readers of which analysis was used for each aim and/or hypothesis.
10. What are your most important novel findings? Please explain in the first paragraph of the discussion.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Thank you for allowing me to review this paper. The problem is well developed (albeit lengthily--but given the complexity of the research question and its theoretical underpinnings and merits, this is acceptable). The analytical decisions are well explained. Every strand of the findings are thoroughly discussed.

I only have one recommendation, and that is to outline multisectoral interventions/policy implications that can be derived from the study.

Reviewer #2: Acknowledgement of disparities in health is important, and this topic has potential to make a contribution to the research in this area. However, as this paper has a strong focus relating to the covid-19 pandemic, the links to general discussion/acknowledgement of health disparities and the potential impact of this work is not clear.

It would be useful to strengthen the rationale for this work – what are the wider implications of this study and its results? The relationships between parental beliefs and discussion of health disparities with young children may differ based on the type of virus (as acknowledged in some of the parent responses, their conversations may have changed due to specific concerns/risks related specifically to covid-19) and this should be acknowledged/discussed in the paper.

The methods of this paper should be expanded. Much of this section includes results and instead should describe the questionnaire development, distribution, recruitment, etc, along with a description of the analysis plan. Could the authors expand on the process for modifying existing tools/questionnaires for this questionnaire – were they pilot tested or validated for use with this study population?

In the results, several models were included and described but this was difficult to follow. It would be useful to have some descriptive statistics (e.g. baseline characteristics of the study population, response rate (if known), distribution of the response options to questions, proportion of missing responses, etc). This might help justify/explain the choice for various regression models for the reader. For the qualitative coding, why were these results included in a regression model instead of processed as qualitative data?

The discussion provided a good general overview of results, but it would be useful to review the literature on parental beliefs regarding disparities and how that impacts discussions with children, and how the results from this study may compare. As mentioned above, I believe further reflection on the implications of this work is needed.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-24-52344R1-->-->Who gets sicker and why? Parents’ perceptions of COVID-19 disparities and how they would explain them to their children-->-->PLOS ONE?>

We have received reports from our reviewers on your manuscript, PONE-D-24-52344R1 “Who gets sicker and why? Parents’ perceptions of COVID-19 disparities and how they would explain them to their children”, submitted to PLOS ONE.

When preparing your revision, please carefully consider the reviewers’ comments, which are provided below.

Please submit your revised manuscript by Jul 02 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.

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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,

Emine Ozturk, Ph.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: (No Response)

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #3: Yes

Reviewer #4: Partly

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

Reviewer #3: Yes

Reviewer #4: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #3: This is a complex, multi-faceted study that took on the enormous yet worthy task of examining how parents think about health disparities across multiple social categories and how their beliefs and motivations influence what they might discuss with their children. It appears the authors have made substantial efforts to revise the manuscript after the initial reviews. Upon my reading, a strong rationale is provided, research questions for an exploratory study are clearly outlined, and the methods are well-described. Organizing results by research question was extremely helpful to maintain focus even while addressing findings across different categories.

Overall, I recommend this article for publication with minor revisions. Below I make recommendations to clarify a few points and to expand on discussion of the findings.

Introduction: The authors provide sufficient (but not overwhelming) background information to ensure the reader has adequate context for the study design and analysis. There is an effort to equally attend to health disparities and parent socialization in relation to multiple social categories (age, race, social class) of relevance, despite disparate and often sparse bodies of literature.

1. One minor point of confusion was in the description of relevant constructs (p.8-10); it was stated that 5 constructs would be discussed, but only 4 subheadings are presented. It would help to include in the final sub-section a clarifying statement that essentialism and social constructionism are the fourth and fifth construct and explain why they are being discussed together (or to separate social constructionism into its own subheading).

Methods:

1. Under participants, given that all other demographics are listed as “self-reported,” the final statement that the sample was neither conservative nor liberal reads as an objective assessment; recommend clarifying that this is a statement of the average self-rating of participants. Conversely, it may be more concise to state early in this section that all demographic characteristics were self-reported.

2. Clarify for IMS whether there were 5 items for each of the 3 social categories (age, race, and social class) or only 5 items total. If only 5 total, creating 1 scale, why was this measure collapsed across groups whereas other measures had separate scales for each social category?

3. There remains debate about the appropriate kappa level to be deemed “reliable.” (p.19, line 387). Assessing that codes with kappa > .60 had acceptable interrater reliability would more appropriately be described as having moderate to strong/substantial agreement (e.g. McHugh, 2012; Hallgren, 2012).

Results:

1. Inconsistency in how measures are referred to and capitalized between RQs (e.g. “Disparity Judgment” p.22 and p. 26 vs “disparity judgment (forced-choice) task” p. 24). If these analyses use the same data, then would be best to clarify in RQ1 that the force-choice task data was used; if not, note it was the scale.

2. The indication of significance levels in Table 5 is extremely confusing given the text explains only specific comparisons met the corrected alpha level. Recommend providing all p-values in a separate column and using an indicator (perhaps bold font as in Table 4) to show only those that were significant at p> .017.

3. Similarly to previous comment, clarify on p. 25 line 494 that this analysis now uses the disparity judgment scale task. This allows readers to refer back to the Methods if desired to remind themselves how this measure was administered.

Discussion

1. The example provided on p.32, line 615 about protecting children from emotional harm regarding age and a grandparent seems inconsistent with the sentence and citations that follow which focus on parents’ unwillingness to discuss racial topics and that young children are aware of social inequalities. This example may fit better elsewhere.

2. The final sentence on p.33-34 does not need to be its own paragraph. Append it to the previous one or split this section into paragraphs in a logical place (perhaps line 650, “Parents’ explanation…”)

3. Some findings are summarized but not discussed. Why do the authors believe certain differences were found in light of previous literature? What are the implications of such findings?

- Why were behavioral explanations more likely when discussing social class disparities(p.34)? Knowledge about healthcare access is mentioned, but this seems to be a structural explanation. How could this relate to behavior?

- Similarly, why is the finding regarding political affiliation meaningful (p.34)? More discussion is needed regarding how this relates to past research, parent socialization practices, and/or implications for children’s development of awareness of health disparities.

-Further explanation for the social class difference related to essentialism is necessary (p.35). This seems consistent with prior research on social class beliefs in the US and that being poor is related to character rather than structural issues.

4. I appreciate the effort of the authors to address implications more thoroughly. However, it seems an acknowledgement should be made that some parents may be uninterested in learning about the existence of health disparities and that this study demonstrates that even providing established statistics did not change some parents’ minds about whether the disparity existed. The idea of an intervention focused on helping parents understand the value of “accurate explanatory frameworks” neglects the current political and social climate where what is viewed as “accurate” and factual seems up for debate. I wonder whether the authors have any suggestions for how to leverage parents’ understanding that some health disparities exist (e.g. for age) to create openness to recognizing others.

5. The paragraph on policy focuses more generally on adults and healthcare workers, but needs to find a way to circle back to parents and children. Given that parents may not be aware of (or accepting of) health disparities, an alternate way to approach this would be to consider what role other sources of socialization (educator, peers, health professionals, media) have on the development of children’s beliefs in addition to parents, particularly as children age.

Reviewer #4: The goal of this paper was to better understand whether and how parents discuss age-, status-, and race-related disparities in COVID-19 infections. The authors employed a cross-sectional design including 443 parents of a 5- to 12-year-old. Results of this exploratory study revealed age-related differences in parents’ inclinations to discuss race- and status-based disparities, and that, unsurprisingly, parents’ own attitudes and beliefs were associated with their proclivity to engage in these discussions with their children (though, the types of associated beliefs/attitudes that emerged as significant predictors were surprising). While I believe this work is important for understanding how children come to learn and understand health disparities, there remain some concerns that temper my enthusiasm. Below, I provide my specific comments and suggestions.

- Abstract: authors begin by discussing COVID health disparities and then jump to posing the question of whether parents discuss these disparities with their children. There seems to be a link missing. Perhaps open the abstract with the importance of promoting parent-child conversations about health disparities (such as covid). Authors also mention that they employed a “series of individual difference measures”. I think authors need to be a bit more specific so that the reader knows what types of measures were employed (without having to list them all).

- I was surprised to see that the paragraphs about the importance of parent-child conversations were placed so late into the introduction. I suggest moving them earlier and elaborating upon how these conversations shaped child outcomes (there’s research showing links between conversational content and youth outcomes during the pandemic).

- The connections between authors’ first aims and the aim regarding individual differences in attitudes weren’t well streamlined. The attitudes/beliefs authors explore aren’t integrated within a theoretical framework, which makes it difficult to understand why authors selected all of these (i.e., how are these attitudes and beliefs differentiated and how do they conceptually relate to one another? How does it meaningfully contribute to authors’ overarching narrative). I urge authors to think about which attitudes/beliefs are core to their investigation and perhaps remove or move analyses concerning others to the supplementary material.

- I was surprised that authors did not have any specific hypotheses, especially for aim 4 as there is some research on this topic already (at least in the domain of race-based conversations)

- Authors reported a sensitivity analysis in g*power but it sounds like they conducted an a priori power analysis to determine their sample size. Authors are also missing information about total predictors, tested predictors, power value, and alpha value.

- Do authors know the States from which this data was primarily collected? It’s great that authors collected data on political affiliation—it definitely matters for what parents talk about. I recommend including political leaning as a covariate in all multivariate analyses, as well as parent and/or child gender and age (if not already a predictor)

- Why didn’t authors explore race-related differences in their outcomes? 39% of the sample was bipoc—there may be some interesting differences in authors’ findings, especially the thematic analysis of content, strategies, and reasons parents provided.

- The parent explanation section is very interesting and could stand alone as a separate paper if authors were to further describe the findings qualitatively. Authors could unpack parents’ explanations further, especially regarding differences in themes by key demographics to determine who is saying what and how they are discussing the content. This would have important intervention implications.

- More information about the coding process is needed (i.e., how codes were developed and revised). Authors mention basing their coding scheme on Menendez et al, but it’s not clear whether the codebook was adapted for use with this data. Employing appropriate thematic analysis reporting procedures is recommended (Terry & Hayfield, 2021 could be helpful)

- I’m unclear about what the purpose of the confidence ratings was.

- RQ4: authors need to provide bivariate correlations between their attitudes/beliefs measures. The findings are quite perplexing. The results might be easier to digest if presented in a table rather than in text. The descriptives could be moved to the supplementary material. Was multicollinearity a factor if all variables were included in the same models?

- The political affiliation findings/discussion seem out of place.

- By the end of the paper, I am left wondering about the novelty of the findings. Authors present many results, but I think they could work toward crafting a more cohesive narrative to tie all the findings together. I think authors can leverage their findings in the implications section better.

- There are a few typos throughout.

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Reviewer #3: No

Reviewer #4: No

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<p>Who gets sicker and why? Parents’ perceptions of COVID-19 disparities and how they would explain them to their children

PONE-D-24-52344R2

Dear Dr. Menendez,

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.

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Kind regards,

Janet E Rosenbaum, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #3: Yes

Reviewer #4: (No Response)

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

Reviewer #3: Yes

Reviewer #4: (No Response)

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4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #3: Yes

Reviewer #4: (No Response)

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

Reviewer #3: Yes

Reviewer #4: (No Response)

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Reviewer #3: (No Response)

Reviewer #4: I thank the authors for reviewing their work and considering some of my comments. I provide additional feedback below. My remaining concerns are mostly regarding flow, theoretical integration, and density of findings. Overall, I believe this paper provides a meaningful contribution to the field.

Overarching comment:

- Authors argue for maintaining their pre-registered ideas throughout the response letter. The purpose of pre-registration is to maintain scientific transparency and having a preregistration does mean that authors cannot further improve and adapt the narrative of their paper (so long as critical deviations are reported). Here are a few papers that delineate helpful uses of preregistrations that do not contradict the natural development of authors’ ideas and are in line with best scientific practices:

https://myscp.onlinelibrary.wiley.com/doi/10.1002/jcpy.1209

https://journals-sagepub-com.proxy.lib.sfu.ca/doi/full/10.1177/25152459231213802

https://online.ucpress.edu/collabra/article/10/1/117094/200749/When-and-How-to-Deviate-From-a-Preregistration

Prior comments:

- Abstract: Authors are still lacking flow from one point to another. E.g., the second sentence addresses gaps in the literature and the following statement states how research questions will be addressed. I recommend changing the second sentence to be explicitly about authors’ research questions or adjusting the language. Examining associations between parents’ attitudes and beliefs about social categories and their relation to conversations is a core focus, but this is not posed as a research question. Please clearly outline specifically what the aims/questions are within the abstract to increase clarity (how authors state their aims at the end of the introduction section on page 5 is great).

- “We first want to clarify that we did not employ a full thematic analysis, but thank the reviewer for guiding us on how to appropriately report our qualitative analyses. We employed a codebook approach with a combination of inductive and deductive codes. We have added information in the Method section about the process of creating the coding scheme, and provide details on which codes came from prior codebooks established in the literature and which were created specifically for this paper.”

o Thank you for clarifying. There are different coding approaches that fall under the umbrella of thematic analysis that nevertheless require appropriate reporting. The authors’ revisions better describe their process and the coding scheme.

- “Given that these measures were pre-registered, we do not feel comfortable excluding them from the manuscript. However, we note that we took an exploratory approach, given little prior work addressing these questions. We also added our rationale for selecting these measures, namely, they have been found to relate to how people think about social categories and/or parenting behaviors associated with conversations about social categories.”

o Authors still lack meaningful integration. Why these five measures? Do they each tell us something unique and meaningful about certain aspects of individual differences and how they relate to parent-child communication? Some more coherence beyond indicating that the measures were included in the preregistration (see overarching comment above) and related to how people think about social categories is needed.

- “We created a new table to display our Q4 results in a more digestible format. We added the descriptives and bivariate correlations to the Supporting Material. Additionally, multicollinearity was not an issue for any of the models, with all variance inflation factors below 5.05.”

o A typically recommended VIF cutoff is 5.

Additional comments:

- Authors would benefit from adjusting their subheadings to be more specific (e.g., “Parental input regarding race, social class, and age” --> “Parent-child communication about race, social class, and age”; Attitudes and beliefs about social categories --> The Role of Parental attitudes and beliefs about social categories on communication

- It would be helpful if authors could separate the procedure from the measure descriptions for clarity and flow. Perhaps a flow chart of the procedure would benefit the clarity of the paper.

- Research on intergroup helping by Jellie Sierksma shows that children tend to help outgroup members more when they perceive them as less competent. This could resonate well with your findings re: race disparities and discussions.

- Tables require APA formatting

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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 #3: No

Reviewer #4: No

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