-->PONE-D-24-58875-->-->The prevalence of the mistreatment of older women and associated risk factors in an area of Eastern Andalusia, Spain: A cross-sectional, community-based study-->-->PLOS ONE

Dear Dr. Ricoy-Cano,

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.-->

The manuscript describes a technically sound piece of scientific research with data that supports the conclusions.

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Academic Editor

PLOS ONE

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This work was supported by the EXCMO. Ayuntamiento de Úbeda under Grant number 2022168. Project title: Detection and analysis of situations of violence in older women in Úbeda and its surrounding areas. The author(s) also reported receiving the following financial support for authorship of this article: One author (Adrián Jesús Ricoy-Cano) was funded by the European Union through the “NextGenerationEU” program, as part of the “Grants for the Requalification of the System” program. Spanish University for 2021-2023 under the “MARGARITA SALAS” modality.

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Additional Editor Comments:

The authors should make it clear in the introduction why it's crucial to document the problem of violence and abuse against older adults.

It is necessary for the authors to clarify: Even if the terms: violence," "mistreatment," and "abuse" are related in a very close way, it is necessary to deepen them conceptually and specify in the manuscript to which they refer. Consider that they are not synonymous

For the title, there is no need to cut it to 20 words.

Unify in the manuscript, where possible, the term: older adults.

Emphasize how the study contributes to broadening knowledge of the phenomenon of abuse to older adults.

Clarifying in methods: the context of older adult women being studied. And, where appropriate, separate; women in their homes by type of family and women in specialized institutions for elderly care.

Clarify the type of sampling performed. There are two opposing views: snowball and non-probabilistic sample. What was actually done?

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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: Yes

Reviewer #2: Yes

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

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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-->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: The prevalence of the mistreatment of older women and associated risk factors in an

area of Eastern Andalusia, Spain: A cross-sectional, community-based study

All my comments are categorized as major, minor and recommendation. You may or may not consider addressing the comments that are only meant for recommendation. I hope my comments will help increase the quality of your work.

Title

<minor> Per PLoS guidelines, you should include a Short Title as Running Head.

<recommendation> Although your full title is under suggested 250 characters, I suggest keeping it under 20 words.

Abstract

Kindly note that my comments on the abstract may not be repeated in the main text, but they are intended to apply wherever relevant throughout the manuscript.

<major> The use of ageist language such as “elderly,” “aged,” “seniors” to describe older adults is highly discouraged in scientific literature. Please use other aging friendly language such as “older adults,” “older persons” throughout the manuscript. However, since “elder abuse” is a legal term, this term is accepted for its global legal implication. On the other hand, “elder” is considered somewhat accepted; however, I still discourage using this term.

<minor> While it is often stated that research on the mistreatment of older women in Spain is scarce, such claims can sometimes be overly general. Since your study is only about prevalence and associated factors, please reconfirm this assertion of research gap under this topic. And also, kindly discuss the strength, if you have not, under the “Strengths and Limitations” your study provides to fill up this research gap on older women in Spain.

<recommendation> The words like “violence,” “mistreatment,” and “abuse” may be closely related, but they are not the same concepts. Please use one of the terms that your study is primarily about and be consistent throughout the manuscript. You may describe all three terms briefly in the introduction and state which of these terms your study is specifically about. This will enhance clarity on what your study is specifically about.

<recommendation> You specified that your study is among non-institutionalized women. However, I find your conclusions for the abstract more relevant to abuse among institutionalized women, and thus you may require making it more relevant or distinct to address issues of abuse in community settings, including specific recommendations to address the issues of abuse in household settings.

Introduction

Your introduction is well-written covering major aspects of providing a background, highlighting the existing research and potential research gap. However, I have a few additional suggestions:

<major> I realized that your study is primarily about abuse in domestic settings. Please make sure you do not mix up the concepts of violence against older women with abuse against older women although these two concepts intersect; and please make sure that your writings and cited literature are primarily about abuse among older women, not about violence against women. Violence against women is another broad topic of research studied widely in Spain.

<major> International readers might not know what type of society exist in Spain. For example, is it an individualistic or collectivist society in Spain? Are families in Spain multigenerational or nuclear? Is the older care provided by family members or other informal caregivers or by assisted living professionals? These background information help readers to understand the settings related to older care in Spain.

<major> Although you discussed very briefly that there are strong regulations to protect abuse against older women, you might consider adding a separate short paragraph for global and local readers to learn what specific legal frameworks are tailored to protect older women against abuse in Spain. And, based on existing literature, I suggest you provide some justification behind higher prevalence of elder abuse among women in Spain, despite robust laws and policies against elder abuse.

<recommendation> Please add a conceptual framework to enhance clarity.

<recommendation> If you can, it is better to integrate a relevant gerontological theory to strengthen your study. Please discuss one suitable relevant gerontological theory in the introduction section and elaborate your findings in support of the existing theoretical framework.

Materials and methods

Study design, sites and participants

<major> You need to clarify the sampling approach used in your study. Was the design based on probability sampling, or did it follow a purposive or non-probability approach? The first paragraph suggests characteristics of snowball sampling, but this is not explicitly stated. On the contrary, the second paragraph suggests a random sampling. If you have used random sampling, please detail out the process. Also, please provide a rationale behind your sample size. Clear identification of the sampling method is essential for understanding the representativeness and limitations of your findings.

<minor> You have hinted a little. However, I am curious to learn whether the study was undertaken within their household or outside of the household. If it was taken in the household, what measures were taken to avoid the interruption from other family members given the sensitivity of the topic? It will be helpful to add whether or not proxies were allowed. Also, how was the data collected? Did you use paper surveys or tablet questionnaire? If paper surveys were used, how did you digitize the data. If tablet version was used, please elaborate a little on how you designed the software and performed data management.

Measures

Geriatric Mistreatment Scale

<recommendation> Please specify how you checked the internal consistency of the Geriatric Mistreatment Scale in your study. I am asking this question because if you have used Cronbach alpha, although widely used it is not considered a robust measure to assess internal consistency. If you want to, you may consider using alternative measures such as split half or McDonald’s Omega instead of using Cronbach alpha to test reliability.

Socio-demographic information

<major> The information on socio-demographic information lacks clarity. Were the variables recoded during the data analysis? Or were the variables collected in the way those were explained. If it is the former case, please make sure to detail out how the variables were recoded. Your explanation of the categories is not sufficient. For example, how did you determine whether the place was urban or rural. What standard was used? Likewise, what did “enough” vs “not enough” income level mean? These are some examples. Please add clarity to all other variables.

Statistical analyses

<minor> How was the data imported into SPSS environment? If paper-based survey was used, what were the measures taken to minimize the data-entry bias during the digitization process?

<minor> Please clarify the type of logistic regression you used to assess abuse. Is it adjusted multivariable logistic regression?

<major> Did you check for multicollinearity issues? If not, please do. Also, consider performing advanced diagnostics to check for influential observations, and conduct the treatment if necessary. Please report the value under AUROC, preferably concordance statistics for logistic regression, and then cite relevant methodological paper.

<major> Regression often washes out the variables with missing data. So, please clarify if you used any imputation process to address missing data? Or, please clarify what your final analytic sample was.

Ethical considerations

Please add a statement describing that participant had the right to refuse to response to any question, terminate the interview at any time without penalty, and were also given the option to withdraw after the interview.

Results

Maltreatment and socio-demographic/lifestyle variables

<major> Although you have several types of elder abuse enlisted, you have not defined what each of these types are under the methods section. Please, provide an operational definition to each of these subtypes, and how you measured each type and overall abuse.

<major> Please check your results for Table 2 and make sure that all of the bivariate relationships were assessed using Chi-square test, as some cell counts show potential implication of alternative method like Fisher Exact Test.

Risk factors for abuse of older women

<major> Please clarify what type of logistic regression did you use? Also, indicate your cut-off point for p-values and level of confidence intervals.

While you have mentioned using the backward elimination method, it would be helpful to briefly explain this technique for readers who may not be familiar with it. Specifically, you could describe how variables are removed based on statistical significance and how this impacts model interpretation. This description should be integrated under the methods section.

Could you also clarify whether you used a stepwise regression for backward elimination? If stepwise regression was applied, I recommend revisiting the model selection process. These techniques, although commonly used, have known limitations. They can sometimes exclude variables that may not be statistically significant but have important theoretical or practical implications. This description should be integrated under the methods section.

Consider discussing the rationale behind your modeling choices, especially in the context of your research question. Including variables with substantive relevance—even if they're not statistically significant—can enhance the interpretability and applicability of your findings. Also, kindly note that p-values are not definitive indicators of variable importance and I suggest not to solely rely on p-values. Those closer to the cut-off point of 0.05 might still provide some evidence regarding the association. Therefore, you may consider describing the variables that are not statistically significant but approach significance.

<minor> You may remove the column indicating β values in Table 3, since OR=e^β in logistic regression can be easily derived.

<major> Please consider revising the interpretation for the log-odds for the first one or two results in each paragraph. This helps the reader to interpret and understand the results correctly. For example, include at least one or two interpretations in the general way logistic regressions are interpreted, including the variables you controlled . For example, after adjusting for marital status and general health, participants aged 60–69 had more than twice the odds of experiencing overall abuse compared to those aged 80 or older (OR = 2.36; 95% CI: 1.11–4.99). Similarly, those aged 70–79 had 187% higher the odds (OR = 2.87; 95% CI: 1.40–5.87) of facing overall abuse than those 80+ years after holding other variables in the model constant. Also, please report CI instead of p-values along with OR in your logistic regression interpretations. Confidence intervals are preferred more than the p-values. Please also restructure your table 3 to show what the reference category for each variable was.

Discussion

<minor> In the first paragraph, instead of reporting what sociodemographic variables were investigated, kindly report what variables were found to establish significant association with abuse.

<major> Neglect and psychological abuse are two most prevalent types of abuse. It was interesting to see such a low prevalence in your study. Kindly provide a strong justification behind such low prevalence. Also, please balance your discussion discussing both higher and lower ends of prevalence of neglect in literature. This applies to all other sections wherever applicable.

<major> To balance your discussion section, also discuss some of the variables that were close to significance, yet not significant and provide the justification in light of existing literature.

<recommendation> If you integrate a theory in the introduction section, kindly discuss your findings supporting or refuting the theory.

<recommendation> Please reduce the length of implications. You may not require three separate subheadings.</recommendation></recommendation></major></major></minor></major></minor></major></major></major></major></major></minor></minor></major></recommendation></minor></major></recommendation></recommendation></major></major></major></recommendation></recommendation></minor></major></recommendation></minor>

Reviewer #2: I would like to express my sincere gratitude to the editor for the opportunity to review the study titled "The prevalence of the mistreatment of older women and associated risk factors in an area of Eastern Andalusia, Spain: A cross-sectional, community-based study." I appreciate the effort into this research and look forward to providing constructive feedback to enhance its quality and impact. I have outlined several comments and suggestions below that aim to strengthen the overall quality and clarity of the manuscript:

1. Some parts are overly verbose. Aim for more concise sentences to maintain reader engagement.

2. The literature review could be strengthened by including more recent studies or contrasting findings to highlight gaps in existing research.

3. The sample size (209 participants) may limit the generalizability of the findings. Write about sample size.

4. More detail on the Geriatric Maltreatment Scale's validation process would enhance credibility. How was it adapted for this study?

5. Some claims lack sufficient backing from the data presented. Ensure that all assertions are supported by the results in discussion.

6. The implications for practice and policy could be more explicitly stated. What specific actions should be taken based on the findings?

7. The discussion of limitations could be expanded. Consider discussing the potential impact of cultural factors on the findings.

8. It could reiterate the importance of addressing the identified issues in a more impactful manner.

9. Suggest future research directions more explicitly to guide subsequent studies.

10. The manuscript is generally well-written, but proofreading for grammatical errors and clarity is recommended.

**********

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Reviewer #1: Yes: Aman Shrestha

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PONE-D-24-58875_review.pdf

-->PONE-D-24-58875R1-->-->Prevalence and risk factors of abuse against older adult women: a cross-sectional community study in Eastern Andalusia, Spain-->-->

PLOS One

Dear Dr. Ricoy-Cano,

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 Apr 23 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.

Please include the following items when submitting your revised manuscript:-->

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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,

Vandana Dabla, Ph.D.

Academic Editor

PLOS One

Journal Requirements:

1. 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.

2. 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.

Additional Editor Comments:

We acknowledge author efforts to address the reviwers comments, however, some methodological and interpretative issues require clarification, particularly regarding sampling, measurement reliability and interpretation of the high prevalence estimate.

1. The study used non-probability purposive sampling through institutional networks (women’s associations and social services). This approach may introduce selection bias, potentially affecting prevalence estimates. Thus, author must clarify the recruitment process in “more detail” and explicitly acknowledge the limitations for generalizability in the discussion section.

2. The reported prevalence of 49.3% abuse within 12 months is considerably higher than most international estimates. The study classifies a participant as abused if she answered “yes” to at least one of the 22 items in the Geriatric Mistreatment Scale, and this  approach inflates prevalence estimates. Thus, it becomes extremely vital to provide a stronger explanation in the discussion, noting that the estimate may reflect a) the screening nature of the instrument, b) classification of abuse based on any positive item out of 22 , c) and non-probability community sampling.

3. Internal consistency for the Geriatric Mistreatment Scale in this sample was moderate (ω ≈ 0.69). Author must report reliability estimates for each abuse subtype or provide additional justification for using the combined “any abuse” variable in the analysis.

4. The manuscript used backward stepwise logistic regression, which may lead to unstable models or exclusion of theoretically important variables. Thus, author must briefly justify the modeling strategy and discuss its limitations in the limitations section.

5. Ensure consistent use of the term “abuse against older adult women” throughout the manuscript.

6. Several socio-demographic variables (such as age, education, and income) were recoded into broad categories, which may reduce variability & statistical precision. The manuscript should briefly justify these recoding decisions and explain how the chosen categories align with previous research or contextual considerations.

7. Author may do minor language editing to remove repetitions.

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: 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 #1: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: I appreciate how the authors worked to improve the manuscript and address/integrate my comments/suggestions. Thank you for your sincere effort. I do notice that the internal reliability of the Geriatric Mistreatment Scale is not that great; but it is what it is based on the dataset you analyzed. If possible, please acknowledge this limitation in your manuscript and if you are able to justify briefly why you think your McDonald's omega value was only acceptable. Other than that, your revised version now has robust methods, clear presentation of results, and succint overview and discussion.

**********

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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 #1: Yes: Aman Shrestha

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Prevalence and risk factors of abuse against older adult women: a cross-sectional community study in Eastern Andalusia, Spain

PONE-D-24-58875R2

Dear Dr. Ricoy-Cano,

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,

Vandana Dabla, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: