-->PONE-D-24-34167-->-->Integrating Psychosocial Health into Disaster Risk Management: Insights from COVID-19 in Duran, Ecuador.-->-->PLOS ONE

Dear Dr. Borbor-Cordova,

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 Mar 29 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.. 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 . 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,

Ian Christopher N Rocha, MD, MBA, MHSS

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. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

The American Journal Experts (AJE) (https://www.aje.com/) is one such service that has extensive experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. Please note that having the manuscript copyedited by AJE or any other editing services does not guarantee selection for peer review or acceptance for publication.

Upon resubmission, please provide the following:

● The name of the colleague or the details of the professional service that edited your manuscript

● A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

● A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

3. Please note that funding information should not appear in any section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript.

4. Thank you for stating the following financial disclosure:

“Research reported in this publication was supported by the Pacific International Center for Disaster Risk Reduction at ESPOL (CIPRRD-03-2021), Secretary Risk Management of Ecuador, and the support on the field campaign by the Municipality of Duran.”

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.

5. 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.

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.

6. We note that Figure 1 in your submission contain map/satellite images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright.

We require you to either (a) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (b) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figure 1 to publish the content specifically under the CC BY 4.0 license.

We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text:

“I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.”

Please upload the completed Content Permission Form or other proof of granted permissions as an "Other" file with your submission.

In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].”

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

The following resources for replacing copyrighted map figures may be helpful:

USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/

The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/

Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html

NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/

Landsat: http://landsat.visibleearth.nasa.gov/

USGS EROS (Earth Resources Observatory and Science (EROS) Center) (public domain): http://eros.usgs.gov/#

Natural Earth (public domain): http://www.naturalearthdata.com/

Additional Editor Comments:

Please address the comments and suggestions of all reviewers. Thank you.

[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: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Partly

Reviewer #7: Partly

Reviewer #8: Yes

Reviewer #9: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #4: I Don't Know

Reviewer #5: Yes

Reviewer #6: No

Reviewer #7: Yes

Reviewer #8: Yes

Reviewer #9: 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.-->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

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: No

Reviewer #8: Yes

Reviewer #9: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: No

Reviewer #8: No

Reviewer #9: 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: 1. Subheading 3.1 - The statistical methods should be explained with procedures, interpretations, and equations/formulas.

2. Discuss these articles which focused on disaster vulnerability.

https://link.springer.com/article/10.1007/s10668-023-04149-1

https://link.springer.com/article/10.1007/s00477-022-02267-2

3. The subheading numbering should be properly arranged.

4. The results should be justified with the support of relevant published articles.

5. The influence of all variables (mentioned in the Tables) on disaster vulnerability should be explained in the Methods section.

6. Improve the quality of English to rectify the typo and grammatical errors.

7. Keywords - Include only 5 keywords which are relevant.

Reviewer #2: 1. Photos are not clear enough

2. Please give a brief description of the study area Duran such as population, economy, orientation, etc. to help the reader understand it

3. The introduction is too long and not very relevant. The methodological content is too simple and some necessary methodologies are not considered

4.221-223 grading criteria please add references

5. P-value should be italicized

6. How was the independent variable selected?

7. Is OR corrected and how are confounders considered?

8. How was sample size calculation considered?

Reviewer #3: Introduction

Please bring the following items

1- Definition of the research problem

2- The magnitude and importance of the study variable

3- Expressing the necessity of conducting the study

Finally, the practical purpose of the study should be stated

Methods

1.The method section should include the sample size formula.

2. Exclusion and inclusion criteria are fully stated.

3. The author did not mention any incomplete, incorrect or corrupted questionnaire.

4. The first paragraph of the discussion should be the overall result of the study.

5. Did the questionnaire undergo any changes in its questions post the validation and reliability test? Were any questions removed or added? Please provide clarification.

Conclusion

-What are the strengths and limitations of the study?

Conclusion

� What are your suggestion for future studies?

Best regards

Reviewer #4: any restrictions on data sharing should be specified.

It is also suggested that the article elaborate more on the social and economic impacts of COVID-19 on mental health.

more detail could be provided on sample selection to address potential biases due to non-probabilistic sampling.

Please provide more information about handling missing or outlier data to increase accuracy.

The manuscript is generally clear and written in standard English. Minor typographical and grammatical errors exist (e.g., “stress and depression of volunteers aiming” could be clearer), and some sections (e.g., the Methods) could be streamlined for conciseness. A proofreading step before submission is recommended.

Additional Comments for Improvement:

Reorganize the Results section to highlight key findings concisely, avoiding redundancy with tables.

Expand the discussion on how the findings inform future disaster recovery policies, specifically within urban contexts similar to Duran.

Provide clearer links between psychosocial findings and broader systemic risks like climate change.

A broader description of forward-looking policies: The discussion could elaborate more on how the findings could be implemented in future disaster management and reconstruction plans, especially in cities with similar vulnerability structures.

Emphasis on practical solutions: The discussion could focus more on practical solutions and policy suggestions for reducing stress and depression in vulnerable populations.

Reviewer #5: Dear Authors

Thank you for your well performed study. The research is methodologically sound, and the integration of psychosocial health into disaster risk management is a commendable approach that can fill a significant gap in disaster preparedness literature. The findings related to gender, housing conditions, and chronic illnesses offer a critical perspective on psychosocial vulnerability in disaster contexts.

Reviewer #6: Introduction

• Line 68-181: While the introduction contains important evidence about COVID-19, psycho-social health, it also includes excessive descriptions that make it less focused. Some parts of the introduction appear unrelated to the research topic. For example, the integration of psychosocial health into disaster risk management is inadequately described and lacks sufficient context about Ecuador’s specific situation. I would suggest streamlining this section and ensure that all the introduction content directly supports the study’s objectives.

Methodology

• Line 183: The calculation of the sample size, the sampling distribution, and sampling representativeness of the study population are not clearly outlined in the methodology.

• Line 188-194: The study population under the methodology part describes about collection of blood samples and the use of non-probability sampling to select participants, however it does not adequately introduce the study area and population. I would suggest a clearer explanation of where the study was conducted and the characteristics of the study population.

• Line 196 – 213: The term “survey” is not clearly defined in the methodology. The description appears to mix different components of the methods part, including data collection, data collection tools, and other aspects. This makes it difficult for readers to determine which aspect of the methodology is being discussed.

• Line 234: The statistical categorization and analysis used for the modified Spanish version of the Perceived Stress Scale (PSS) and the Patient Health Questionnaire-9 (PHQ-9) need to be explicitly detailed and a clearer explanation of how these tools were analyzed would strengthen the methodological rigor of the study.

Results

• Line 257: The process by which the 340 participants were selected to complete the survey is not clearly described.

• Line 265: The terminology used to describe educational levels, such as “some level of high school education,” “some level of elementary school,” and “some level of undergraduate studies,” appears subjective and lacks precision.

• Line 269: Some variables presented in the table, such as education and marital status, sum precisely to 100%. The table should be checked for consistency to ensure accuracy.

• Line 342: The results section includes a discussion of self-reported stress, which is valuable. However, the methods section should explicitly describe under the methodology part how self-reported data were analyzed.

• Line 376: To improve the identification of risk factors and the prediction of stress levels, I would recommended to include adjusted odds ratio (AOR) results in addition to crude odds ratio (COR) results. This would provide a more comprehensive understanding of the associations between variables after adjusting for potential confounding variables.

Reviewer #7: The study addresses an important and timely issue by investigating the intersection of psychosocial health and disaster risk management in the context of the COVID-19 pandemic. The research is relevant to public health, urban vulnerability, and mental health resilience. However, several key areas require clarification and revision.

The manuscript states that a non-probabilistic sampling strategy was used. However, it does not explain how this might have affected the generalizability of the results. The implications of this method for bias and generalizability were not found. The authors should justify why this method was chosen and discuss its limitations. The recruitment process lacks details about how participants were approached and selected, which is critical for assessing potential biases in the sample. Explain how the sample represents the broader population of Duran. Also, provide evidence/references that the Perceived Stress Scale (PSS) are validated/previously used for the Ecuadorian population?

The manuscript does not state whether potential confounders were adjusted for in the logistic regression models.

Given that multiple factors influence mental health (e.g., socioeconomic status, education, pre-existing conditions, vaccination status), were adjustments made? Provide goodness-of-fit tests and discuss whether multicollinearity was assessed. The study finds that women are more likely to experience depression. However, other factors (such as housing conditions, chronic illnesses, or socioeconomic status) could also contribute to depression.

Causal Language Should Be Avoided. Phrases such as “vaccination acted as a protective factor against depression” should be reworded to reflect association rather than causation. Provide a deeper comparison with global and regional studies, particularly in Latin America.

Reviewer #8: Framework, title, format:

1. The UNDRR has adopted the concept of "Disaster" to include pandemics and infectious diseases rather than focusing solely on natural disasters. The Sendai Framework for Disaster Risk Reduction, established in 2015, reflects discussions from the Convention on the Rights of Persons with Disabilities and emphasizes the growing collaboration between the health and welfare sectors and disaster sectors. The boundary between disasters and pandemics has virtually disappeared. However, why should we revisit the discussion in this manuscript about integrating psychosocial health with disaster risk management strategies?

2. Although this study is titled “Integrating Psychosocial Health into Disaster Risk Management,” it primarily focuses on examining the mental health effects of the COVID-19 pandemic. There is minimal mention of the connection between theories and practices of disaster risk reduction. Therefore, the title should be revised or the argument adjusted to better align with the title.

3. It does not consistently adhere to the specified styles and formatting. This includes the order of manuscript organization, abstract, numbering, and font size of sections and sub-sections, as well as citing references.

- Abstracts should be limited to 300 words and are usually unstructured.

- Cite references using square brackets instead of parentheses (for example, “[1]”).

- Include page numbers.

- These are just a few examples; the document needs significant revision.

Introduction:

4. Throughout history, humans have faced numerous pandemics, including HIV, the Hong Kong flu (H3N2 influenza A virus), SARS, and MERS since the late 20th century. Shouldn't we consider the effects of these past pandemics on psychosocial health in different regions during the discussion of this study?

5. It is crucial to emphasize the importance of the implementation in Ecuador, the universal nature of the results, their general and specific aspects, and the regional context surrounding these outcomes. As you know, people's health and behavior are closely connected to the target region's culture, customs, history, politics, socioeconomic background, and social institutions. Therefore, comparing one country to another or applying findings from one context to a different one may not be suitable. The discussion should differentiate between the regional and universal aspects of the results and then clarify the significance of what this study has uncovered. This also pertains to the novelty and originality of the study.

Methodology, Study area, Results:

6. Figure 1 must be adequately explained in the study area sub-section. This explanation should cover the location, population, urban environment, and social and family systems, among other things. Additionally, it should convey to the reader why this area is most suitable for this study. Regardless, the absence of text in the provided subsection is a significant issue. (Line 183-187)

7. Figures should be appropriately cited and described in the text. (Figure 1 and 3)

8. Multiple surveys are presented, creating the impression of a composite of several studies. Why are different surveys necessary, and what is their connection? For instance, a sub-section on blood sample collection before the "2.1 Survey" sub-section, without any reference to the relationship or necessity between the two, contributes to confusion. Sometimes, it may be necessary to divide the paper into several parts.

9. The section titles and setting sections require revisions to improve their suitability. For example, the sub-sections "2.1 Survey,” "2.2 Perceived Stress Scale," and “2.3 Patient Health Questionnaire-9 for Depression” should not maintain a parallel structure.

10. It is unclear which surveys and analysis methods are associated with which results.

Results:

11. What does this research reveal as the most significant new finding? Aren't all the at-risk individuals mentioned in the results those who have long been considered vulnerable in many studies? The abstract highlights that women experienced more significant psychosocial impacts; however, are these results different from those of the other countries mentioned in the introduction?

Discussion:

12. In the Discussion, it is essential to provide a scientifically valid interpretation based on the statistical trends and correlations found in the Results. This should include insights from previous studies in epidemiology, social sciences, and the humanities (these studies should be referenced in the introduction) and information about the study area.

13. It is essential to emphasize pre-disaster preparedness, as indicated by the term DRR (Disaster Risk Reduction) in the SFDRR. A categorized list of the study's findings and identified countermeasures, organized by disaster phase and target attribute, would enhance understanding.

14. How can perceptions of stress be lower among those experiencing high stress levels? At a minimum, what do the results of this study reveal about the challenges, blind spots, and bottlenecks in policies and efforts during the COVID-19 pandemic?

15. If the results indicate that married women are at a significantly higher risk than others, it is crucial to explore which policies and support measures could effectively address their needs based on the findings. What should the family, community, religion, and government have done?

16. Why are participants living in areas without paved roads experiencing higher stress levels (due to social and environmental factors)? Is it reasonable to classify residents of areas without paved roads as informal settlers? What is the reasoning behind this?

17. The reasons for elevated stress levels among those living in rental apartments require a more thorough explanation. What types of living environments, price ranges, and occupations do rental apartments in the target area typically accommodate, and how do these compare to other housing options?

18. A sub-section titled "Moving forward" should not be included as a subsection at the beginning of the Discussion. Instead, it should be placed at the end of the conclusion, depending on the content of the Discussion, if you wish to include it.

Reviewer #9: The manuscript presents a timely and relevant discussion on the integration of psychosocial health into disaster risk management, drawing insights from the COVID-19 experience. The study provides valuable perspectives on the intersection of mental health and disaster preparedness, which is crucial for strengthening resilience in future public health crises. The manuscript is well-structured, but certain areas require further clarification and enhancement. To enhance the manuscript, read and cite the following related articles in the discussion: https://doi.org/10.3390/ijerph18115719, https://doi.org/10.3389/fpsyt.2021.656664, https://doi.org/10.1017/dmp.2021.140, https://doi.org/10.1371/journal.pone.0280144, https://doi.org/10.1080/13623699.2021.1950519, and https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00354-7/abstract

**********

-->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 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 For information about this choice, including consent withdrawal, please see our Privacy Policy .-->.-->

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: Yes: Dr Reza HabibisaraviDr Reza Habibisaravi

Reviewer #6: Yes: Abdulnasir AbageroAbdulnasir Abagero

Reviewer #7: No

Reviewer #8: No

Reviewer #9: 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 . 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.. Please note that Supporting Information files do not need this step.

-->PONE-D-24-34167R1-->-->Integrating Psychosocial Health into Disaster Risk Management: Insights from COVID-19 in Duran, Ecuador.-->-->PLOS One

Dear Dr. Borbor-Cordova,

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 comment: In my opinion authors responded satisfactorily to most of reviewers' comments. However, some minor adjustments are still needed. Please address the new reviewers' comments below and resubmit.

Please submit your revised manuscript by Jan 22 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.. 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 . 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,

Massimo Palme

Academic Editor

PLOS One

Journal Requirements:

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.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

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 #4: All comments have been addressed

Reviewer #5: (No Response)

Reviewer #6: (No Response)

**********

-->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 #4: Yes

Reviewer #5: Partly

Reviewer #6: Partly

**********

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

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: 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.-->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 #4: Yes

Reviewer #5: Yes

Reviewer #6: 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 #4: Yes

Reviewer #5: Yes

Reviewer #6: 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 #4: (No Response)

Reviewer #5: Dear Author

Thank you for your submission. I read your manuscript and dropped some comments as following:

Introduction

The introduction has been substantially revised through the peer review process and now effectively establishes the research problem. It clearly articulates the gap between current DRM practices and psychosocial health integration, particularly in Global South contexts. However, I think there are some issues that need further attention, as follows:

- Some remaining redundancy (psychosocial health concept explained multiple times)

- Connection between climate hazards and COVID-19 could be more explicit

- Limited discussion of why Durán specifically is relevant beyond prior climate studies

- Some references dated (e.g., reference to 2010 census data for Durán population)

- Could include more recent DRM integration literature post-2020 ( also in discussion)

- Missing some recent systematic reviews on pandemic mental health ( also in discussion)

Methodology

Methodology is clear and reproducible, though the non-probabilistic sampling approach warrants careful consideration for interpreting results. There are some comments in this section to help for stronger methods as following:

- Please describe sample size calculation with justification

- Limited discussion of how multicollinearity among vulnerability variables was addressed

-There is no mention of data validation procedures

Results

Results are presented accurately and clearly with appropriate use of tables and figures. Data presentation is generally well-organized. There are just some comments to help you for better result presentation as following:

- Tables 3 & 4 are dense; some extreme OR values (>1000) indicate complete separation in logistic regression, limiting interpretability.

- Some confidence intervals extremely wide, suggesting sparse data in certain subgroups.

Discussion

The discussion is comprehensive, well-structured, and effectively interprets findings in context of existing literature. Recent revisions have significantly improved regional contextualization. There are more issues to consider:

- Limited discussion of potential reverse causality (does depression predict lower vaccination rates or vice versa?)

- Could discuss intersectionality more explicitly (overlapping gender, age, economic vulnerabilities)

- Implications for disaster preparedness could be more concrete

- Limited discussion of cultural adaptations needed for interventions in Durán context

Conclusions

Well written. Conclusion is evidence-based and consistent with research objectives, appropriately synthesizing findings and providing actionable recommendations.

References and Citations

References are properly formatted and citations are comprehensive, though formatting consistency has been improved.

Some older citations (2010 census data for Durán) could be updated with more recent statistics if available. There are more comments:

- Missing some recent COVID-19 mental health systematic reviews (2021-2024)

- Limited representation of Global South-specific disaster resilience literature

Reviewer #6: Line 154: The study was conducted in 2021; therefore, some of the findings and a portion of the referenced literature may now be considered outdated. Updating these elements could strengthen the manuscript.

Line 154: I continue to have reservations regarding the representativeness of the non-probabilistic convenience sampling approach used for the quantitative survey. Clarification or justification of this method would be helpful.

Line 164: The rationale for selecting community centers as recruitment sites appears somewhat subjective. Further explanation on how logistical feasibility, infrastructure adequacy, and safety considerations informed this decision would enhance clarity.

Line 168: It is unclear why 106 out of the 446 individuals who initially participated did not complete the study and were subsequently excluded. Providing additional detail on the reasons for non-completion would strengthen the methodology section.

Line 176: The explanation that sites were selected to capture urban neighborhood diversity and based on logistical feasibility may still appear subjective. Additional justification on how these criteria were applied would be beneficial.

Line 183: Please clarify the type of consent obtained and how it was documented electronically to ensure transparency and adherence to ethical standards.

**********

-->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 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 For information about this choice, including consent withdrawal, please see our Privacy Policy .-->.-->

Reviewer #4: No

Reviewer #5: Yes: Reza Habibisaravi, MD PhDReza Habibisaravi, MD PhD

Faculty Member

School of Allied Medical Sciences

Mazandaran University of Medical Sciences, Sari, Iran

Reviewer #6: 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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->

Integrating Psychosocial Health into Disaster Risk Management: Insights from COVID-19 in Duran, Ecuador.

PONE-D-24-34167R2

Dear Dr. Borbor-Cordova,

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. For questions related to billing, please contact  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support ..

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,

Massimo Palme

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: