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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: Partly

Reviewer #3: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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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: Yes

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #3: Yes

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Reviewer #1: Thank you very much for the opportunity to let me read this manuscript. I would like to address some issues for improving.

1In the abstract , you should provide full nme of COVID19

2. Please provide full named of OR

3. you need to give an example of the tailored program.

4. I just wonder, why you used P<.1 to put variables into the quation and <0.1 for the significant level, normally we used 25%.

Reviewer #2: Dear Authors,

Thank you for your contribution to this important article. Below, I have outlined some comments and suggestions for your consideration:

1. Title

Please consider revising the title to make it more concise.

2. Abstract

The abstract effectively sets the context and highlights key findings of the study, but a few improvements can enhance clarity including:

a) Consider making the abstract short and precise as it is written very long

b) Clarify the implications of sex as a moderator in the results

c) ensure consistent terminology and keep statements concise for better readability

3. Introduction

The introduction effectively outlines the impact of COVID-19. However, consider clarifying some points for better flow and coherence. For instance,

a) provide clearer transitions to enhance readability when mentioning studies

b) ensure that the rationale for the country-level comparison is clearly articulated, emphasizing its relevance to the study's objectives.

4. Methods

a) specify the criteria for compensation to ensure transparency when describing participant recruitment

b) The eligibility criteria could be simplified for better readability

c) clarify how the internal consistency of the infection worry variable was assessed

a) How are the statistical analysis methods clearly linked to the research questions?

5. Results

The results section effectively presents key findings across the three countries, highlighting significant differences in health behaviors related to psychological distress and infection worry. However, consider providing clearer summaries of the statistical findings for each country to enhance readability. For instance, clarify the impact of demographic factors, such as age and clinical diagnoses, on the results to contextualize the findings better. It may also be helpful to include a brief discussion on the significance of the observed sex differences in health behaviors to tie the results back to the study's main objectives.

6. Discussion

a) consider enhancing the clarity of the arguments by summarizing key findings more succinctly.

b) Additionally, while the limitations are well-articulated, it may strengthen the section to emphasize the implications of self-report bias and the need for future longitudinal studies.

7. Conclusion

The conclusions effectively summarize the study's findings and emphasize the significant impact of COVID-19 on mental well-being and health behaviors.

a) consider refining the wording for greater clarity, particularly in the call for country-specific interventions. It may be beneficial to explicitly state the implications of the findings for public health policy in each country.

b) Additionally, while the focus on reducing psychological distress is important, expanding on potential strategies for implementing these interventions could enhance the conclusion's practical relevance.

c) Lastly, reiterating the importance of understanding sex differences in health behaviors could further strengthen the argument for targeted approaches in future pandemics.

Reviewer #3: Title: Associations between psychological distress and infection worry with health behaviours among adults during COVID-19 in three countries: A sex-based analysis

MS ID: PONE-D-25-24290

General Comments:

The manuscript, as stated by authors, uses an exploration approach. In general, this exploration focused on associations between psychological distress (as related to COVID-19 pandemic) and a number of health-related behaviours, while considering the influence of participant sex as a moderator. Additionally, authors selected three nations (Columbia, Canada, and Ireland) for data retrieval. Results, using three separate logistic-regression statistical analyses for each nation, showed varied findings across main variables and sex as a moderator.

COMMENT and RECOMMENDATIONS:

I have many issues concerning the (a) write-up of the manuscript, and (b) the method / results employed by the authors. Given the database the authors are drawing on, I hope the comments and examples given below can further the inherent value of this science and author’s revision of the manuscript.

Line 51: Your first sentence - “Coronavirus disease or COVID-19 is an infectious disease…” is filled with a possible redundancy, ambiguity and inaccuracy. When using “Coronavirus disease” which one are you refereeing to? In terms of the recent pandemic the viral infection is referred to as SARS-CoV-2. The “COVID-19” moniker refers to the pandemic event; this is a difference between the event and the infection. Please write a direct sentence, avoid the use of the little word “or”; the sentence reads like a multiple-choice question; either coronavirus disease or COVID-19 is an infection disease. Please be direct, precise and accurate throughout the manuscript.

Line 66: The authors said, “From a psychological standpoint” anxiety symptom “or” depression are linked to impaired “or” poorer health. Again, please reconsider your literature review write up, and take care in the use of “or”. Using psychology as a “standpoint” appears too general; there are many psychological approaches and fields, - you should be more precise; direct the reader’s understanding to a specific approach or field of psychology concerning anxiety and health.

Line 84: Authors write “Sex is rooted in biological mechanisms, and in the context of COVID-19, appears to influence trends between psychological distress….” Given my read of the overall manuscript, the importance of this paragraph is critical to the logic, analysis, and conclusions of this research. Using biological mechanism as a pretext for understanding sex-differences in the context of COVID-19 is a misapplied concept. Yes, sex determination as being a biological mechanism (e.g., genetic and epigenetic processes) I have no doubts.

But the authors have not included a literature review where sex-differences are associated with socialization, gender development, stereotyping, culturalization that differentiate male/female preferences, expectations, and behaviors. Starting on Line 86, with a discussion about Canada, France, United Kingdom and Zimbabwe, are general descriptions reporting how different sexes have responded differently and have responded differently across differently countries. It is difficult to understand the logic of the authors how the biological mechanism alone (and not a social mechanism) becomes the explanation (i.e., sex as an important moderator – as claimed in the manuscript).

There is no review of sex differences rooted in a social/societal mechanism (e.g., see Social Psychology literature) in the introduction. Because the authors have conceptually focused on the sex-based factor in the write up and analyses, I strongly recommend the authors more thoroughly review and discuss sex-difference literature, especially concerning how sex-differences are understood socially and psychologically (i.e., sex-based preferences and expectations). As is, the authors have dedicated one paragraph to what is a central theoretical explanation to their results and their write up. Please make note of the sub-title of the manuscript, “…: A Sex-Based Analysis”.

Line 97: Authors begin a review of “country-level comparisons” and claim country-level comparisons “are effective method to identify consistent patterns in how sex may influence the associations between …” The authors go on to claim “This is because sex is based on biological factors that transcend geographical or cultural boarders”. Is there not a subtle contradiction implied here between these two contiguous sentences? Country-level comparisons are important to identify how sex influences, but then sex identified as a biological factor transcends the country-level factor? I do note the word difference and word substitution.

Never-the-less, there is little literature review regarding the importance of cultural / national influences on people’s habits and health practices. The authors again appear to neglect the psychological, sociological and cultural approaches to better understand “consistent” and inconsistent patterns among people. Again, I recommend authors to seek the literature, maybe starting in general with Harry Triandis’s psychological approach and what he called Cultural Syndromes. Yes, teasing out theoretically socially rooted sex-differences, and the connection with cultural differences is a challenge. But once again, this manuscript has focused on “country-level comparisons” and has dedicated very little literature review in the introduction on this topic.

Line 106: Authors describe the method in general as a secondary analysis of cross-sectional data. This data is a part of a greater data-base, specified as iCARE and led by MBMC. On Line 118, the authors briefly describe the data base as encompassing 42 countries. The authors then describe the different waves of recruitment. And then on Lines 128-129 the authors identify three nations to be analyzed for this manuscript: Canada, Columbia, and Ireland. I recommend that the authors explain the procedure for how these three nations were selected from the 42 counties listed in the iCARE database. No mention of this potential selection bias was mentioned – nor discussed in the limitation section of the Discussion. I refer the authors to the Clark et al. reference (see below) and take special note of the section 2.11 on p. 77. This section might be a good model for writing up a revision of this procedure.

Line 187: Section on Data Analysis describes the “exploration” of data by first seeking difference ( “t-test and chi-square tests” ) between selected countries (i.e., Canada, Columbia, and Ireland). The authors describe using logistic regression as means to isolate significant relations between variables for each country separately. Thus, I assume three different analyses, that is three different logistic regressions (Tables S2, S3, & S4). I realize the authors have identified the methodology as exploratory, but I question why the authors did not build and test an omnibus statistic or model to incorporate a country-level factor with the inclusion of the sex factor? I believe the paper’s logic and strength of contribution becomes compromised throughout by not clearly providing and structuring this overall analysis.

Line 285: A typo in the main heading – “Psychological distress had a consist role in …” – the word “consist” should read “consistent”.

One of the main goals of science is to identify and test variables for the purpose of (a) prediction and (b) treatment/intervention. The many nuanced findings in this manuscript (including similarities and differences) between country-level comparison makes for a difficult interpretation of the variables tested. See Line 337, the authors provide their take on the paper’s strengths. Basically, the strength of the paper is - you can “do” this research. Yes, you can “do” this research – but what did this paper actually tell us about the sex-based factor and the country-level factors? The authors statement - “sex-based trends can be assessed regardless of country-level factors” seems to be an overstatement without evidence provided by the author’s research. Actually, many of the statements given in the manuscript provide evidence concerning the importance of the country-level factor.

For instance, reading over the papers many diverse and singular findings, simply stated here: (a) you show how Canada and Ireland show consistent relations, while Columbia does not, or (b) Canada and Columbia show consistent relations, but not Ireland. Of course, adding sex-factor moderator increases the interpretative nuance. But as an applied health care expert, how do I “use” this information provided in this manuscript? I believe a revision of this manuscript is necessary to clarify the logic, statistical analysis, and the contribution of the findings; that is, how do these variables predict (or do not predict) and how do we then treat the negative effects of a future pandemic (is it at the sex-based factor, country/cultural factor, regime-based factor… etc).

Clark C, Davila A, Regis M, Kraus S. Predictors of COVID-19 voluntary compliance behaviors: An international investigation. Glob Transit. 2020;2:76-82. doi: 10.1016/j.glt.2020.06.003. Epub 2020 Jun 26. PMID: 32835202; PMCID: PMC7318969.

(See p 77, Section 2.11 – the Open Science Statement)

Also, these references might be helpful toward revising the logic and method of this manuscript.

Hensel L, Witte M, Caria AS, Fetzer T, Fiorin S, Götz FM, Gomez M, Haushofer J, Ivchenko A, Kraft-Todd G, Reutskaja E, Roth C, Yoeli E, Jachimowicz JM. Global Behaviors, Perceptions, and the Emergence of Social Norms at the Onset of the COVID-19 Pandemic. J Econ Behav Organ. 2022 Jan;193:473-496. doi: 10.1016/j.jebo.2021.11.015. Epub 2021 Nov 19. PMID: 34955573; PMCID: PMC8684329.

He, Z., Jiang, Y., Chakraborti, R., & Berry, T. D. (2022). The Impact of National Culture on Covid-19 Pandemic Outcomes. Internatinal Journal of Social Economics., 49(3), 313-335 https://doi.org/10.1108/IJSE-07-2021-0424

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Reviewer #1: Yes:  Nitikorn Phoosuwan

Reviewer #2: No

Reviewer #3: No

**********

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Dear Dr. Cohen,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jan 07 2026 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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We look forward to receiving your revised manuscript.

Kind regards,

Prof. Anat Gesser-Edelsburg, Ph.D.

Academic Editor

PLOS ONE

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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

Reviewer #1: Thank you for your revision. You have addressed my concern. I am really satisfied with revision. It is a good manuscript for publication.

Reviewer #3: Title: How sex impacted associations between psychological distress and worry on adults’

health behaviours during SARS-CoV-2

MS ID: PONE-D-25-24290R1

General Comments:

After reading over the three reviewers’ comments on the original manuscript, I am impressed with authors efforts, edits, and the changes made to the original manuscript. The revised manuscript is a much better write-up.

My only reservation involves the how the three nations were selected (i.e., Canada, Columbia and Ireland). I wonder if the authors could clarify how these three nations were selected out of the 42 nations that completed (or nearly completed) the electronic surveys.

I note the Gunther Eysenbach citation, and understand the use of CHERRIES. I note that the three nations had good completeness scores (98%, 95.5% and 78.7%). With that being noted, how again were Canada, Columbia and Ireland selected from the original 42 nations? For instance, were these nations selected because they represented the “top three” completeness scores, thus more statistically stable than the other 39 other nations?

Maybe you could include the mean and ranges of the completeness score of all 42 nations (as you would in a basic Method section under a Participant section description of a human participant sample).

For example, (“… the average completeness score of the 42 nations was 50%, ranging from 23% to 98%.”). Again, if I am missing something here, I apologize; but I do not read in your revision, how Canada, Columbia and Ireland were specifically selected out of the 42 nations that had some chance or opportunity to be included in your analysis.

Again, were the three nations selected because they were the top three? Or was another consideration used for inclusion. Please note the difference between stating “Eligibility for this analysis” (line 156) and “Inclusion for this analysis”.

The manuscript notes eligibility as defined as completeness (connection to Eysenbach), but the paper does not mention the overall baseline or a comparison score to the other less eligible nations (the other 39 countries). Of course, this the asks the question, how was inclusion (selection) of a nation/country defined? How was this inclusion unbiased, and unbiased given the completeness scores of the other 39 nations?

Thank you for your revision.

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Reviewer #1: Yes:  Nitikorn Phoosuwan

Reviewer #3: No

**********

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How sex impacted associations between psychological distress and worry on adults’ health behaviours during SARS-CoV-2.

PONE-D-25-24290R2

Dear Dr. Cohen,

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,

Prof. Anat Gesser-Edelsburg, 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

**********

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

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

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

The PLOS Data policy

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

Reviewer #3: Title: How sex impacted associations between psychological distress and worry on adults’

health behaviours during SARS-CoV-2

MS ID: PONE-D-25-24290R2

General Comments:

The authors have responded to my comments. My confusion specifically focused on how the three nations were selected (Ireland, Canada, and Columbia out of 42 possible nations). The authors have made clear the selection process. I believe, in part, the confusion rested on the language used. See line 134-136 of Revision 1, “… data analysis as these three countries had ‘COMPLETE nationally representative data collected…” (emphasis added). Earlier authors used the word ‘complete’ to refer to completion rates. Thus, attempting to understand the selection of these three nations without further explanation was a burden. Authors rewrites and edits are a welcome addition to the manuscript.

Authors have added further clarity to the Limitations and Strengths section. This section of edits is also welcomed. However, see lines 407 to 409. The sentence beginning with “In would be incredibly insightful ….). Besides the typo (“In” should read “It”, right?). I think this sentence is unnecessary, is an obvious point, and is an unsubstantiated claim. I would request this sentence be deleted.

Another typo, see line 416, and the word “tool”. I believe you mean to use the word “took” – as in “and given the conservative approach we took…”.

I would check again for typos within the manuscripts, specifically correctly spelled words, but incorrectly used words, like the use of “tool” for “took”.

Thank you for an interesting manuscript and research. I appreciate your efforts during this review process.

**********

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #3: No

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