Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Summary

This qualitative CBPR study examines how housing-insecure youth in San Diego obtained COVID-19 health information through arts-based engagement sessions. The subject is socially important, and the three main themes, which were relational trust, conditional institutional trust, and structural mismatch with public health guidance, are strongly supported by participant data. However, several issues must be addressed before publication.

 

Major Issues

1. Reliance on an unpublished companion paper for core methodological justification

The arts-based engagement methodology, which is central to this study's design, is only briefly outlined here. The authors refer to Reference 21, a companion paper that is currently "in preparation; to be submitted" and not accessible to readers or reviewers. As a result, the main methodological justification cannot be independently assessed. To address this, the authors should either include enough methodological details in this manuscript for evaluation or provide the companion paper as a supplementary file.

 

2. Cultural and ancestral knowledge finding is absent from the Discussion

Participants in the Spanish-language session reported relying on herbal remedies and practices they referred to as "witchcraft" during the pandemic (Section 3.2.3, lines 264–269). This finding stands out as particularly significant, with direct implications for how community-based health communication is framed for Latinx YEH. However, it is not discussed analytically in the Discussion, and this gap should be addressed.

 

 

 

3. Intersectionality invoked without analytical substantiation

The Discussion highlights the diversity of participants in terms of sexual orientation, gender identity, and race/ethnicity, using "intersecting systems of oppression" as a framework (lines 397–401). However, the findings do not differentiate between these groups; the themes are shown as consistent across the entire sample. Although subgroup analysis might not have been possible given the sample size, this limitation should be clearly acknowledged rather than presented as an analytical insight.

 

4. Social media recommendation contradicts the findings

Section 4.1 suggests that health guidance be "delivered by trusted messengers via social network and online (e.g., social media) modalities" (lines 409–410). However, this contradicts the findings, as participants consistently viewed social media as a less trusted source that warrants active scepticism. The evidence supports interpersonal, relational delivery but does not endorse social media as a recommended channel. This recommendation needs to be revised.

 

Minor Issues

5. Duplicate subsection numbering in Results

Two subsections are numbered 3.2.3 : "Culture and Ancestral Knowledge" and "Social Media." The "Social Media" subsection should be renumbered as 3.2.4.

 

6. Duplicate section numbering at 3.3

Both the 'Make it make sense' section (conditional government trust) and the infodemic section are labeled as 3.3. One of these sections needs to be renumbered.

 

7. Table 1 session duration format

Session duration is shown in hh:mm:ss format in Table 1 but expressed in minutes in the text. These should be standardized.

 

8. Age eligibility discrepancy

The eligibility criteria specify a minimum age of 12 (line 119), but the youngest participant was 13 (Table 2). This inconsistency remains unexplained and needs clarification.

 

9. Parental consent waiver not explained

The manuscript mentions that parental consent was waived for participants under 18 (line 152) but does not specify the reasons for this waiver. Given the population's vulnerability, a brief explanation is needed beyond just providing the IRB protocol number.

 

10. "Infodemic" not defined

The term "infodemic" appears in a section heading but is neither defined nor referenced, despite substantial literature on the concept. A brief definition and relevant citation should be included.

 

11. Incomplete references

References 6 (APHA, 2017) and 18 (2025 PITC-Regional and Cities Breakdown) lack complete bibliographic details for retrieval. Please add URLs, DOIs, or full publication information as needed.

 

12. Disease examples in Highlights

The second point highlights hantavirus and Ebola as examples of emerging post-pandemic threats. However, hantavirus is not as globally significant as Ebola and is not currently classified as a PHEIC by WHO. The authors should select more appropriate examples, like MPOX, or simply describe the threat categories without naming specific diseases.

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article has a contribution in addressing an important and emerging topic in explaining how youth experiencing homelessness and housing instability (YEH) accessed, evaluated, and acted upon COVID-19-related health information. It contributes valuable evidence concerning trust, health literacy, information overload, and structural barriers among a highly marginalized population. However, I would like to highlight some aspects that need improvements and amendments, in particular:

1. The study reports 21 participants across six sessions, but additional context would improve interpretability. The authors should provide the mean and range of participant ages, clarify whether participants attended only one session or whether any attended multiple sessions, and discuss how the predominance of participants connected to a youth-serving organization may have influenced findings related to trust in service providers.
2. The study references qualitative sampling guidance but does not explicitly discuss saturation or information power. how the research team determined that sufficient thematic depth had been achieved should be explained.
3. The participants described widespread use of social media while simultaneously expressing skepticism toward it. This tension is theoretically interesting and deserves more analytical attention.
4. The authors need to discuss differences between information exposure and information trust and consider linking findings to contemporary literature on digital health literacy and misinformation.
5. The discussion should be expanded on how structural barriers influence the ability, not merely willingness, to comply with public health recommendations.
6. The findings also should be connected more explicitly to structural vulnerability and health equity frameworks.
7. Section 3.3 is titled "Make it make sense": Conditional Trust in Government and the Role of Politics. The subsequent section is also labeled 3.3 (Navigating an Infodemic). The latter should likely be 3.4.
8. The quotation: "They fired everybody [...] so I ended up getting kicked out of that rental assistance program." I was back homeless for a couple weeks."
9. The manuscript alternates between:

• "housing insecure youth,"
• "housing-instable youth,"
• "youth experiencing homelessness and housing instability (YEH)."

I recommend using YEH consistently after the initial definition.

10. Reference 21 is listed as: Felner, J.K.; Escobedo, R.; Carson, J.; Lopez, A.R.; Reynolds, H.E.; Chien, L.; Jellá, S.; Calzo, J.P. “Arts-Based Engagement Ses-545 sions”: Reflections and recommendations on blending expressive arts and focus group methodology to facilitate discussions 546 about health among youth experiencing homelessness. School of Public Health, San Diego State University, San Diego, CA, 547 USA. 2026, manuscript in preparation; to be submitted).

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for inviting me to review this paper. I found it very interesting as well as clear and easy to follow. The pandemic affected all of us in various ways, none more so than members of marginalized group including people experiencing homelessness. That you chose to investigate the experiences of a group of youth and their uptake and use of COVID related information during this time provides what I believe you set out to do, a small window into the function of a number of Public Health literacy efforts. Further, that your sample included youth with a range of ethnicities and gender identities provides further insights to factors at play with youth who were homeless or unstably housed at some point during 2020-23.

As to how you might improve this work, that is a good question. As you note, your sample size is small and limited geographically. However, that does not affect validity of the current piece as generalizability is not the point of such work. The only thing I might put even greater emphasis on is the need for Public Health and health literacy efforts to diversify their approached to this group and not depend on provision of information alone. Information is great, but evidence strongly suggests that it only held for so long and real change, understanding and incorporating the information into one's life in a useful way, takes much more. Hence the need for relational based learning among other things, that allows the youth or individual to incorporate learnings in a way that fits in their life. Thus, I believe that not just understanding of the structural constraints is needed, but how to manage them as well! The youth/information consumers are well positioned to tell us just what that might be.

Much good luck to you in your future research!

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf