Sex Differences and Psychological Factors Associated with General Health Examinations Participation: Results from a Vietnamese Cross-Section Dataset

Round  1

Reviewer 1 Report

There are a number of grammatical errors throughout the manuscript. Please proofread the text closely. 

Page 1, para 1: “Dobell is the initiator of periodic health examination in 1861 as a 41 method of following up on the health status of tuberculosis patients [3].” oWho or what is “Dobell”? I found this sentence confusing.

62 “This mentality may be explained by the traditional gender roles that still prevail to this day in quite a 63 few societies:” 

o“In quite a few” is not very academic language; be more precise in your use of language.

85 “…examinations is a complicated decision, given that all sorts of psychological factors”. 

o“All sorts of” is another example of unsophisticated language.

“88 long‐term medical treatment. This study will (i) demonstrate the relationship between sex and

89 health statuses of relatives/friends to people’s hesitation to take health checkup because of illness

90 worries, and (ii) provide empirical evidence on the association of the time of the last health checkups

91 and the fear of potential health problems with the propensity of taking up GHEs.”

oI don’t understand what’s being studied here? The relationships among the variables to be examined are explained in a confusing manner. Be more precise in your use of language.•

“265 Not only due to time or money are people not ready for regular health checks [50], but

266 psychological factors, such as the fear of disease detection, also contribute to people’s perpetual

267 delay for regular health check.”

oThis is worded poorly. 

•

Although a study to determine whether men and women have different health care practices has merit, I struggled with the use of the English language throughout, to the point it distracted me from the content of the manuscript. Further, the discussion of the results felt incomplete. I expected to read more about the ramifications of the findings. As it were, I was left wondering about the usefulness of this research and whether it would make any difference to anyone. It might, but that’s the case I expect the authors to make. 

Author Response

Dear reviewer,

We would like to sincerely thank you for your insightful review. Following your suggestions, we have done major revisions. In the paper, we use yellow highlight for revisions on the old texts and green highlight for the added texts We will address each of the points you have made, along with our modification, below:

1.     Line 40-42:

Comments: Who or what is “Dobell”? I found this sentence confusing.

 We have added more information to the sentence to hopefully make the statement clearer.

“One of the first mentions of periodic health examination was by Dobell in 1861: he advocated for such examinations as a method of following up on the health status of tuberculosis patients [3].”

2.     Line 87-89: 

Comments: This mentality may be explained by the traditional gender roles that still prevail to this day in quite a few societies:” “In quite a few” is not very academic language; be more precise in your use of language.

We have revised the statement and rephrased the sentence.

“This mentality may be rooted in traditional gender roles: A man is the family’s breadwinner and usually accepts higher workplace risks while a woman has a higher priority for health matters of the family, which includes that of her own [29,35]; nevertheless, perception of health care might vary under the effect of marriage [36].”

3.     Line 106-108:

Comments: “…examinations is a complicated decision, given that all sorts of psychological factors”. “All sorts of” is another example of unsophisticated language.

We have modified our wording in this part.

“Studies confirm that spending money on preventive health practice such as general physical examinations is a complicated decision, in particular when psychological factors are taken into account.”

“This study will (i) demonstrate the relationship between, on one hand, biological sex and the health status of relatives/friends and, on the other, people’s reluctance to take health checkups due to worries over potential discovery of illness; and (ii) provide empirical evidence on the association between time gap since last health checkup and fear of potential discovery of health problems with the propensity of taking up GHEs.”

4.     Line 110-114:

Comments: I don’t understand what’s being studied here? The relationships among the variables to be examined are explained in a confusing manner. Be more precise in your use of language.

We have revised our language and rewrote the paragraph so as to express our idea in a more precise manner.

“This study will (i) demonstrate the relationship between, on one hand, biological sex and the health status of relatives/friends and, on the other, people’s reluctance to take health checkups due to worries over potential discovery of illness; and (ii) provide empirical evidence on the association between time gap since last health checkup and fear of potential discovery of health problems with the propensity of taking up GHEs.”

5.     Line 296-298:

Comments: “Not only due to time or money are people not ready for regular health checks [50], but psychological factors, such as the fear of disease detection, also contribute to people’s perpetual delay for regular health check.” This is worded poorly. 

We have revised the language of the passage.

“Reluctance towards regular health checks doesn’t only stem concerns over lack of resources, for example time or money [53]; psychological factors, such as the fear of discovering a potential negative health condition, also contribute to people’s perpetual delay for regular health checks.”

6.     Comments: “Further, the discussion of the results felt incomplete. I expected to read more about the ramifications of the findings. As it were, I was left wondering about the usefulness of this research and whether it would make any difference to anyone. It might, but that’s the case I expect the authors to make.”

 Thank you very much for your concrete suggestions. We have revised the language in our manuscript and further elaborate the discussion. Please check the discussion in the revised manuscript, we have tried to express the ideas better.

Once again we would like to thank you for your in-depth remarks and detailed suggestions. It is our honor to have the opportunity to work with you to improve our manuscript.

With our highest respects,

The authors

Author Response File: Author Response.docx

Reviewer 2 Report

Overall, this is an interesting study that seeks to explore the relationship or association betweenn the gender (i.e. sex) and psychological factors with periodic general health examination (GHE) behaviors. The main strengths of the paper is sample of valid observations and data analysis techniques using the basline category logit models.

However, the paper could be improved in the following areas:

Title: Please consider using the word ‘Gender’ as opposed to ‘Sex’.

Introduction – Please include some contextual issues around the general health of the population in Vietnam. Second some connections between 'sutainablility' and 'health' must be demonstrated to justify the relevance and publication within the 'Sustainability journal'

Material and methods: Please provide some justification for the appropriateness of the category logit model.  Secondly, the appropriate references of the equations as employed, particularily those on lines 148-150 should be provided as these are clearly based on the authors previous works as evidenced through the similarity checks.

Line 114 – Some explanations of while the women appeared to have accepted interviewes should be provided as these could lead to more insights. For insatnce, is it a cultural thing for women to be more concerend with such issues within the Vietnamese context?

Discussions – The skewness of the sample towards the female participants should equally be acknowledged within the limitations section. Most importantly, pleaes revisit the suage of the word “first” (see Line 306) when discussing the limitations as no further (i.e. second or third) limitations are subquently discussed.

Conclusions section – Line 319, pleaes specifiy the nature of the ‘statistical analysis’ underatken to avoid the vagueness.

Author Response

Dear reviewer,

We would like to sincerely thank you for your valuable remarks, following which we have revised our manuscript. Please find in this letter the summary of such changes. In the paper, we use yellow highlight for revisions on the old texts and green highlight for the added texts. We will address each of the points you have made as follows:

1.     Title.

Comments: Please consider using the word ‘Gender’ as opposed to ‘Sex’.

We explicitly chose the term ‘sex’ to highlight the physiological differences as a potential explanatory variable to diverging behaviors towards medical examinations. On the other hand, the term ‘gender’ has underlying social and political implications outside of the scope of our research. The context of our article being clinical, we wish to retain our word choice for the time being.

2.     Introduction. 

Comments: Please include some contextual issues around the general health of the population in Vietnam. Second some connections between 'sustainability' and 'health' must be demonstrated to justify the relevance and publication within the 'Sustainability journal'.

We have further elaborated on current public health in Vietnam and how it is linked to the issue of sustainability, especially in the context of the country in question (Line 49-66).

“Vietnam’s health care lacks sustainability on both institutional and personal levels, especially concerning periodic GHE. First, there is little regulation in this area. Most efforts at governmental level focus on health insurance, namely the expansion of insurance coverage, whose positive effect has been debated and refuted [11]. Otherwise, health-related programs mostly concern health communication – often at a rather rudimentary level such as education on basic hygiene – and improvement of infrastructure. This mostly applies to rural areas in order to compensate for the fact that the health system is still largely centralized, with many rural patients risking destitution to travel to larger cities to receive treatment [12]. This could result in overpopulation of central hospitals in large cities, especially during disease outbreaks, which clogs the flow of patients and lower treatment quality – characteristics of an unsustainable health system [13].

Secondly, Regarding periodic GHE, employers are required to organize minimum 1 GHE every 6 months for heavy manual workers and every year for other employees [14]. People are however skeptical about the quality of these enforced check-ups [15] and for a good reason: there are no regulations on the extent of a GHE, meaning that employers might want to cut down on costs by organizing inadequate GHE. This means that the only health checkups that should “count” are those taken by people on their own initiative. Yet most people only willingly perform health examinations when they suspect a health-related condition, which may lead to late discovery of illness and higher treatment costs later, exacerbating the risk of financial difficulty for individuals from rural areas.

3.     Material and methods.

Comments: Please provide some justification for the appropriateness of the category logit model.  Secondly, the appropriate references of the equations as employed, particularly those on lines 148-150 should be provided as these are clearly based on the authors previous works as evidenced through the similarity checks.

We have revised and added a short explanation accordingly.

4.     Line 141. Comments: Some explanations of while the women appeared to have accepted interviews should be provided as these could lead to more insights. For instance, is it a cultural thing for women to be more concerned with such issues within the Vietnamese context?

We have touched more upon the skewness of the sample and its potential implications (Line 137-141):

“It is worth noting that 64.08% respondents were female, which was significantly skewed compared to the man-to-woman ratio of 97,5:100 for the entire country and 96,7:100 for Hanoi (2017 preliminary statistics provided by the General Statistics Office of Vietnam – citation later). Women appear to have accepted interviews more often than men; this observation shall be further discussed later in this article.”

5.     Discussions.

Comments: The skewness of the sample towards the female participants should equally be acknowledged within the limitations section. Most importantly, please revisit the usage of the word “first” (see Line 306) when discussing the limitations as no further (i.e. second or third) limitations are subsequently discussed.

We have revised the language as well as added sample skewness towards females among limitations, following your suggestion.  Please see line 356-362 of the revised manuscript:

   “First, regarding the sample itself, the survey is limited to the vicinities of Hanoi, Vietnam, thus, the results presented here should be interpreted with care. The sample is also skewed in regards to biological sex, with over 64 percent participants being female. This has been discussed above; nevertheless, its slight effect on the representativeness should be taken into account when conducting any analysis of the dataset. Second, there are other psychological factors that are involved in health-related behaviors that the paper has not been able to examine.”

6.     Conclusions section: Line 379.

Comments: please specify the nature of the ‘statistical analysis’ undertaken to avoid the vagueness.

We have revised the statement with more precision (line 372-374):

“This paper has presented a statistical analysis using the baseline-category logit model to explore how the factors of sex differences and having family members/friends going through a long-term medical treatment are associated with the fear of discovering one’s own illness through GHEs.”

Once again, we would like to thank you for your precise advice, which is of tremendous help to the improvement of our manuscript. We are honored to have the opportunity to work with you on this paper.

With our highest respects,

Author Response File: Author Response.docx

Round  2

Reviewer 1 Report

•(81-83)”…in traditional views, men tend to (falsely) think of themselves as being stronger, tougher, and thus to be affected by injuries or illness [28,34]”. Instead, try:

•“…think of themselves as less susceptible to injuries or illness.”

•(110-111): remove “on one hand” and “on the other”. 

•(289–) “Reluctance towards regular health checks doesn’t only stem concerns over lack of resources, for example time or money [53]; psychological factors, such as the fear of discovering a potential negative health condition, also contribute to people’s perpetual delay for regular health checks. A preliminary observation on the descriptive statistics of the dataset alone has already revealed that within the framework of this research, men were less likely to accept interviews – which might or might not be related to the fact that the interview concerned health matters. We could only assume that in the context of Vietnam, men were less concerned with health; or that women were more reluctant to refuse an interview, regardless of subject matter. This is in itself is a phenomenon worth studying and could be symptomatic of other cultural factors – however, such an approach would be out of the scope of our article.”

oThis is confusedly written sentence. Are you saying that the participants showed reluctance towards getting regular health checks, and that variables such as time, money, and various psychological factors influenced their decision-making?

oThe second sentence is conjecture. These hypotheses are worth possibly exploring, but here they largely distract.

•(304): The results don’t indicate that people are not concerned with their health. That’s quite a leap to make. 

Overall, I appreciate the focus of the research. Discovering differences between the sexes in their willingness to initiate health screenings is important to understand. With that said, the manuscript needs a thorough editing. There are many many instances throughout where the English grammatical structure and flow needs improvement. I recommend that the authors find someone who is highly proficient as an English editor for this work. Further, there are instances within the Discussion where the authors stretch their findings to include implications that the results do not conclusively suggest. I suggest that they pull back on conjecturing. 

Author Response

Dear reviewer,

We would like to sincerely thank you for your insightful review. Following your suggestions, we have done major revisions. In the paper, we use yellow highlight for revisions on the old texts and green highlight for the added texts. We will address each of the points you have made, along with our modification, below:

1.      (81-83)”…in traditional views, men tend to (falsely) think of themselves as being stronger, tougher, and thus to be affected by injuries or illness [28,34]”. Instead, try “…think of themselves as less susceptible to injuries or illness.”

Thank you for your suggestions. We have changed the sentence accordingly.

2.      (110-111): remove “on one hand” and “on the other”. 

Thank you for your comments. We have removed the words accordingly.

3.      (289–) “Reluctance towards regular health checks doesn’t only stem concerns over lack of resources, for example time or money [53]; psychological factors, such as the fear of discovering a potential negative health condition, also contribute to people’s perpetual delay for regular health checks. A preliminary observation on the descriptive statistics of the dataset alone has already revealed that within the framework of this research, men were less likely to accept interviews – which might or might not be related to the fact that the interview concerned health matters. We could only assume that in the context of Vietnam, men were less concerned with health; or that women were more reluctant to refuse an interview, regardless of subject matter. This is in itself is a phenomenon worth studying and could be symptomatic of other cultural factors – however, such an approach would be out of the scope of our article.”

This is confusedly written sentence. Are you saying that the participants showed reluctance towards getting regular health checks, and that variables such as time, money, and various psychological factors influenced their decision-making?

Thank you for your comments. We have changed the first sentence as follows:

“Reluctance towards regular health checks doesn’t only stem from concerns over lack of resources, for example time or money [53]; psychological factors, such as the fear of discovering a potential negative health condition, as this study has shown, could also influence people’s decision-making regarding the services.”

4.      The second sentence is conjecture. These hypotheses are worth possibly exploring, but here they largely distract.

Thank you for your comments. We agree that the rest of the paragraph adds to the confusion and have removed this part.

5.      (304): The results don’t indicate that people are not concerned with their health. That’s quite a leap to make. 

Thank you for your comments. We have rewritten the sentence and pulled back on making conjectures in the discussion.

6.      Overall, I appreciate the focus of the research. Discovering differences between the sexes in their willingness to initiate health screenings is important to understand. With that said, the manuscript needs a thorough editing. There are many many instances throughout where the English grammatical structure and flow needs improvement. I recommend that the authors find someone who is highly proficient as an English editor for this work. Further, there are instances within the Discussion where the authors stretch their findings to include implications that the results do not conclusively suggest. I suggest that they pull back on conjecturing. 

Thank you for your feedbacks. We have substantially edited the grammars and wordings of the manuscript, we have also removed redundant words to make the manuscript more concise.

Once again, we would like to thank you for your in-depth remarks and detailed suggestions. It is our honor to have the opportunity to work with you to improve our manuscript.

With our highest respects,

The authors

Author Response File: Author Response.docx

Reviewer 2 Report

The quality of the revised manuscript has significantly improved, and the reviewer is grateful to the author for the professional manner in which the comments have been addressed.

Author Response

Dear reviewer,

We would like to sincerely thank you for your insightful review. Following your suggestions, we have done major revisions. In the paper, we use yellow highlight for revisions on the old texts and green highlight for the added texts. We will address each of the points you have made, along with our modification, below:

The quality of the revised manuscript has significantly improved, and the reviewer is grateful to the author for the professional manner in which the comments have been addressed.

Thank you very much for your comments. We have substantially edited grammars and wordings of the manuscript. In the discussion, we have removed any redundant parts as well as the unsubstantiated conjectures. We hope that the revised manuscript is more concise, focused and easier to follow.

Thank you once again for spending time helping us to improve our work. It is our honor to have the opportunity to work with you.

With our highest respects,

The authors

Author Response File: Author Response.docx