-->-->PONE-D-25-26733-->-->Academic Stress and Its Psychosocial and Behavioral Determinants in Medical Students: Findings from a Cross-Sectional Study-->-->PLOS One

Dear Dr. Karim,

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PLOS One

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“This study was undertaken as part of the academic curriculum for 4th-phase medical students during the Residential Field Site Training (RFST) program. It was conducted independently, without financial assistance from public, private, commercial, or non-profit organizations. Moreover, the authors did not receive any remuneration or honorarium for their involvement in the research.”

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“This study was undertaken as part of the academic curriculum for 4th-phase medical students during the Residential Field Site Training (RFST) program. It was conducted independently, without financial assistance from public, private, commercial, or non-profit organizations. Moreover, the authors did not receive any remuneration or honorarium for their involvement in the research.”

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Additional Editor Comments:

Line: 126: Remove the link and do proper Citation

Under the results chapter need to close the results finding with brackets

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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?

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: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: Yes

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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.--> 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

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

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Reviewer #1: No

Reviewer #2: Yes

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-->5. Review Comments to the Author

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Reviewer #1: The manuscript addresses a relevant topic and presents two major strengths: an adequate sample size and an interesting set of variables. Considering these aspects, I outline below the main suggestions aimed at achieving a version suitable for publication.

1. Introduction

1.1. Include data on Bangladesh with regard to the variables investigated in the study.

1.2. The timing of data collection coincides with the COVID-19 pandemic. This aspect needs to be considered in the introduction and, above all, in the discussion of the manuscript.

1.3. Some issues hinder the psychological interpretation of the data. For example, regarding the Stress Coping Style Inventory, it is important to briefly explain what each strategy means (i.e., coping styles: active emotional, passive emotional, active problem, and passive problem coping). The key question is: are all these strategies dysfunctional? Without prior clarification before the discussion section, readers may be led to inaccurate conclusions.

2. Methods

2.1. Please see suggestions 5.4.1, 5.4.2, and 5.5.

3. Results

3.1. In the logistic regression analysis, were all variables entered simultaneously?

3.2. Please clarify whether control variables were used in the analyses. If so, indicate when they were included and how they were handled. There is mention of control variables in the text, but this is not clearly specified.

3.3. Please see suggestions 5.4.1, 5.4.2, and 5.5.

4. Discussion

4.4. The discussion section of the manuscript is appropriate. However, based on the suggestions outlined below, modifications will be necessary.

4.5. Even prior to addressing the suggestions, it is important that the authors employ one or more theoretical frameworks (or previous empirical evidence) to explain the relationships among the variables.

5. Major Suggestions

5.1. Orthographic and technical revision of the manuscript: apply more technical and objective language.

5.1.1. Example 1: “Researchers created a forest plot to illustrate the primary predictors of academic stress using the results from a logistic regression model.” A more appropriate wording is: “The predictors of academic stress were illustrated using a forest plot based on the results of the logistic regression analysis.”

5.1.2. Example 2: “This mirrors findings from a recent Indian study that identified parental expectations and living arrangements as major contributors to stress among medical students (30)”. This excerpt could be written using structures such as: “These results are consistent with findings reported in a recent study…”; “Our observations align with those of a recent Indian study…”; “Similar findings have been documented in a recent study…”.

5.1.3. Example 3: in the excerpt “Insomnia was significantly associated with academic stress, echoing findings that poor sleep impairs cognitive function, emotional regulation, and stress resilience (32).”, the expression “echoing findings” is somewhat uncommon in technical writing for empirical articles.

5.2. The figures need to be improved in terms of quality.

5.3. The tables appear to have formatting issues in their lower sections.

5.4. The authors enumerate the strengths of the manuscript (e.g., large random sample, validated psychometric tools and advanced multivariate logistic regression). However, from a technical standpoint, the analytical aspect is imprecise. More specifically, given the number of variables (i.e., the factors of each measure), the analytical procedure adopted is overly simplistic. Therefore, two plausible suggestions are presented:

5.4.1. Use Structural Equation Modeling (SEM) to test an explanatory model. One suggestion is to test mediators and moderators to explain academic stress (dependent variable). In this framework, psychological aspects (anxiety and depression) would be the independent variables. Sociodemographic variables could function as control and/or moderating/mediating variables. Behavioral variables could likewise serve this role (i.e., as control and/or moderating/mediating variables). In this case, the role of sociodemographic and behavioral variables in the relationship between psychological aspects and academic stress would be tested. Consequently, theory and/or prior evidence must be used to justify the hypotheses and the function assigned to sociodemographic and behavioral variables.

5.4.2. Use Network Analysis. This technique is a powerful tool for understanding, visualizing, and quantifying patterns of interdependence. Importantly, all variables would be considered within a single analytical procedure (i.e., truly multivariate). This approach would allow for the evaluation of Betweenness (measures the extent to which a variable acts as a bridge between other variables in the network), Closeness (measures how close a variable is to all other variables in the network), Strength (measures the strength or number of connections a variable has with others), and Expected Influence (measures the overall impact of a variable on the network, considering both the direction - positive or negative - and the strength of the connections). Consequently, network analysis would enable the visualization of complex relationships and the prioritization of key variables for intervention, offering a richer understanding of academic stress than traditional analyses.

5.5. The authors state that “This study highlights the complex interplay of factors…”. For this claim to be truly plausible, it is necessary to conduct appropriate analytical procedures (see points 5.4.1 and 5.4.2).

5.6. There is no section on practical implications in the manuscript. A standardized section is needed to concretely explore possible intervention pathways, rather than offering vague and generic mentions.

Reviewer #2: Dear Authors,

First and foremost, I would like to commend you on this robust, timely, and well-conducted study. Investigating academic stress among medical students is of paramount importance, as these individuals will become future professionals entrusted with human lives. The mental, emotional, and physical well-being of medical students inevitably influences the quality of care they will provide to the broader population. In this sense, your work addresses a highly relevant public health and educational concern.

Below, I offer some suggestions to further strengthen the manuscript:

Introduction:

While the gap in the literature is clearly articulated, I encourage you to expand the justification for the study by more explicitly highlighting its social and methodological contributions. Beyond addressing an academic gap, what are the broader societal implications of your findings? How might they inform institutional policies, mental health interventions, or educational reforms? Additionally, clarifying the methodological contributions of the study (such as the integration of multiple predictors within a single analytical framework) would further reinforce the originality and added value of the research. Strengthening these aspects would enhance the overall rationale and impact of the manuscript.

Methods:

The study benefits from a large and well-distributed sample, which significantly strengthens the robustness of the analyses and the generalizability of the findings. This is an important methodological strength and should be clearly emphasized as such in the manuscript.

Results:

The results are presented in a clear, coherent, and methodologically appropriate manner. No additional comments or revisions are necessary.

Discussion:

No additional comments. I consider this section to be very well written, coherent, and appropriately supported by the literature.

Conclusion and Recommendations:

I recommend strengthening this section by emphasizing the broader scientific, educational, and social significance of the study. Rather than reiterating previously presented results at the outset (which makes the section somewhat repetitive) it would be more impactful to focus on the implications of the findings for medical education, mental health policy, and institutional practices.

If the authors consider it essential to retain a concise summary of the main findings, I suggest relocating this synthesis to the end of the Discussion section, where it would serve as a natural transition into the conclusion. This adjustment would improve the manuscript’s structure, reduce redundancy, and enhance the overall coherence and flow of the paper.

It would be valuable to include explicit recommendations for future research based on the limitations identified in the present study. Doing so would not only strengthen the scientific contribution of the manuscript but also provide meaningful guidance for future researchers in this field. Clearly outlining potential directions (such as longitudinal designs, inclusion of additional psychosocial variables, or cross-cultural comparisons) would enhance the article’s impact and relevance for advancing the literature on academic stress.

General recommendations: It is strongly recommended that the manuscript undergo a careful and comprehensive proofreading process to address spelling, grammatical, and stylistic issues. Additionally, the authors should thoroughly review the journal’s submission guidelines to ensure full adherence to all editorial and formatting requirements.

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Reviewer #1: No

Reviewer #2: No

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<p>Academic Stress and Its Psychosocial and Behavioral Determinants in Medical Students: Findings from a Cross-Sectional Study

PONE-D-25-26733R1

Dear Dr. Karim,

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.

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Kind regards,

Tailson Evangelista Mariano, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: