How Are You Feeling? Interpretation of Emotions through Facial Expressions of People Wearing Different Personal Protective Equipment: An Observational Study

Round 1

Reviewer 1 Report

Confidential Comments to Authors:

The goal of the manuscript submitted by of Díaz-Agea et al. was to analyze the identification of four basic emotions (happiness; sadness; fear/surprise, and disgust/anger) through 3 types of personal protective equipment (FFP2 respirator, protective overall, and powered air-purifying respirator – PAPR), by using photographs. To accomplish that, they conducted a cross-sectional descriptive study evaluating photographs by volunteers.

Thirty-two high resolution photographs were taken of 2 actors without PPE and with different PPEs which partially covered their face. The 32 photographs were inserted into a Google Forms form (Google Forms®), that was handed out through social networks and through email groups throughout Spain. The population of study were individuals older 147 than 13 without cognitive limitations

Major revisions

1.     In the abstract in the methods section is not clear the population involved in the study and how the authors performed the study.

2.     In the conclusion section of the abstract the authors stated: “Given that the expression of sadness could be one of the first signs of negative emotional states or burnout, early detection of sadness is important because it would facilitate supporting strategies among co-workers…” but this is not what results show and is not the aim of the study.

3.     The population involved is very large (individuals older >13 without cognitive limitations) and include very different ages and characteristic. Moreover, the results are difficult to apply to a population like that of health care workers with different characteristics, a particular training, more likely skilled to interpret facial emotions.

4.     The main hypothesis of the study was that the PPE, that hides part of the face, impedes the correct interpretation of the emotions of the individuals wearing them but the conclusion stated: “The results from this study provide evidence that the PPE worn by health …” but the population tested was not composed by health care workers.

5.     Could the author specify in the results section the results related to the age groups younger than 18.

Minor revision

Could the authors correct “ During the pandemic due to coronavirus (COVID-19)…” the coronavirus is SARS Cov2.

Moderate English changes required

Author Response

Dear reviewer, thank you very much for your comments and suggestions. Please see the attached file with the responses to the reviewers (Rebuttal letter) and the file with the manuscript edited and modified according to your suggestions.   

Author Response File: Author Response.docx

Reviewer 2 Report

The submitted manuscript entitled “How are you feeling? Interpretation of emotions through facial  expressions of people wearing different personal protective equipment. An observational study” describes a study on emotional expressions recognition. In the context of both the pandemic and nurse/physician contact, the study is justified and could bring important verification of supposed worsening of emotion recognition according to wearing personal protective equipment. The study brought such data. However, I have some questions and suggestions to the methodology and statistics.

#1. How the sample size was determined? The Authors have to also add to the manuscript power analysis.

#2. I am also wondering why the Authors did not use ANOVA with repeated measurements design. It would be better in precision of the estimation. Even if the Authors have some justification not to use ANOVA-rm, I would like to see the exact statistical test they have used in the particular analysis clearly indicated in the tables and in the manuscript (t-test, chi square etc.). Additionally, the effect size estimated should also be included in the text.

#3. Table 1 is lacking result on sadness and happy recognition. Moreover, if the Authors conclude that the participants recognized better happiness than sadness, these conclusion should be supported by a statistical test showing that this difference was statistically significant.

#4. The analyses including age/gender/level of education should be introduced in the introduction and justified by the theory In the present form this justification is lacking.

#5. All post-hoc tests should be described in details. Which tests were used? Were the test corrected for multiple comparisons?

#6. The Authors focus on the impairments in recognition of sadness in the light of risk of job burnout. Which are other consequences of this impairment for nurse/physician contact with the patients? This issue should also be discussed.

#7. The discussion is lacking the limitations of the study.

Author Response

Dear reviewer, thank you very much for your comments and suggestions. Please see the attached file with the responses to the reviewers (Rebuttal letter) and the file with the manuscript edited and modified according to your suggestions.   

Author Response File: Author Response.docx

Reviewer 3 Report

This article is interesting because it explores health professionals' perception of the work situation of miscommunication caused by COVID-19, where few research studies focus on the importance of non-verbal communication. This work shows evidence of its influence on the work environment.

As suggestions after reviewing this article:


Introduction:
It would be convenient to review the order of the information presented, which is sufficient and appropriate to the article.

Method:
I recommend mentioning which descriptive observational study protocol has been followed, such as STROBE, and providing a checklist.

Results:
Good analysis of results.

Discussion and conclusions:
I suggest changing reference 28 to another one related to the work environment and non-verbal communication.
The relationship between the data provided and the healthcare work environment should be specifically developed.
Limitations of the study should be reflected.

Author Response

Dear reviewer, thank you very much for your comments and suggestions. Please see the attached file with the responses to the reviewers (Rebuttal letter) and the file with the manuscript edited and modified according to your suggestions.   

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

i am satisfied of the edits made by the authors

Author Response

Thank you very much

Reviewer 2 Report

The Authors corrected their manuscript whic resulted in its improvement. However, I have further suggestions:

#1. l. 197- 201: The statistics are missing. It is difficult to interpret the p = .047 due to a lack of information regarding the test which obtain such a value of probability.

#2. In table 2 and 3 the exact values of t test should be provided followed by p values and effect sizes (e.g. Cohen’s d).

#3. l. 225-250: Again, the statistic tests’ values are absent (F-values). When the Authors reports differences obtained in post-hoc analysis, they should report F value first (p value and eta square) and afterwards, the post-hoc tests p-values.

#4. I failed to find information about ANOVA design and analysis of interactions: emotion x condition (no facemask vs. various types of face mask).

#5. The minimal age of participants described by the Authors as inclusion criterion should be explain. The participants were expected to be younger than 18 years old. Did the Authors obtain the parental consent to the children participation?

#6. I think that in the abstract the number of the participants should be 690, not 609.

Author Response

Dear reviewer, thank you very much for your suggestions. They will serve to improve the manuscript. We hope that the changes we have made are appropriate. Please, see the attached file.

Author Response File: Author Response.docx