Review Reports - Examining Differences in Health-Related Technology Use between Millennial and Older Generations of Caregivers

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for the opportunity to review your manuscript titled "Examining Differences in Health-Related Technology Use Between Millennial and Older Generations of Caregivers." Your research addresses an important and timely topic, and the insights provided could significantly contribute to the understanding and improvement of caregiver interventions. However, I have identified few areas where the manuscript could be strengthened to enhance clarity, accuracy, and comprehensiveness. Below are my detailed comments and suggestions for revisions:

1. Inconsistent Use of Statistical Terms:

Ensure that statistical methods are consistently applied and justified for each type of data. Clarify the rationale behind choosing chi-square tests and Kruskal-Wallis non-parametric tests for different analyses.

2. Refinement of Caregiver Definition:

The broad definition of caregivers used in the study may include individuals with low or non-existent day-to-day engagement. Consider using a more specific definition and provide detailed assessments of caregiving responsibilities, including frequency, intensity, and duration.

3. Engagement Metrics for Health/Wellness Apps:

Table 4 indicates differences in health/wellness app usage but lacks details on engagement levels and types of apps used. Adding these metrics would better elucidate how different generations utilize these tools.

4. Practical Implications of Findings:

While you note statistically significant differences, the manuscript lacks discussions on the practical implications of these differences. Supplement statistical significance with practical significance to provide a more rounded interpretation of the data.

5. Addressing Missing Data:

The manuscript does not discuss the potential biases introduced by missing data. Perform and report sensitivity analyses to assess the impact of missing data on the study's conclusions.

6. Expansion of Intervention Design Discussion:

Provide more detailed recommendations for designing digital interventions tailored to Millennials, considering usability, accessibility, and engagement strategies. This will make your findings more actionable for intervention development.

Thank you for your attention to these matters. I look forward to reviewing the revised manuscript.

Best regards

Comments on the Quality of English Language

The manuscript is generally well-written and clear. The authors have successfully communicated their findings and analysis in an understandable manner.

Grammar and Syntax:

There are occasional grammatical errors and awkward phrasings throughout the manuscript. It would benefit from a thorough proofreading to correct these issues. For instance, some sentences are overly complex and could be simplified for better clarity.

Consistency:

Ensure consistent use of terminology throughout the manuscript. For example, the terms "caregiver" and "informal caregiver" should be used consistently to avoid confusion.

Technical Language:

The manuscript effectively uses technical language appropriate for the field. However, some complex terms and concepts could be better explained or simplified to ensure they are accessible to a broader audience.

Punctuation:

Punctuation errors, such as missing commas and periods, are present in some sections. Careful attention to punctuation will enhance readability.

Clarity and Conciseness:

Some sections of the manuscript could be more concise. Reducing redundancy and focusing on the main points will improve the overall flow and clarity of the manuscript.

Sentence Structure:

Varying sentence structure can improve the readability of the manuscript. Avoid overly long sentences that can confuse readers.

Spelling:

A few spelling errors were noted. Running a spell-check and proofreading the document will help in identifying and correcting these errors.

Examples of Issues:

In the introduction, the sentence "Due to the physical, emotional, and time demands of caregiving, these informal caregivers are at risk for adverse mental health, physical health, interpersonal, and occupational outcomes." could be revised for better flow and clarity.
In the methods section, the phrase "Participants were excluded if their age was missing, due to this paper’s focus on generational status." could be rephrased for clarity.

Author Response

Please see attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

General comments

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The paper “Examining differences in health-related technology use between Millennial and older generations of caregivers“ aims to evaluate “the extent to which Millennial informal caregivers of adults with chronic conditions differ from other generations of caregivers in health-related technology access and use (see lines 69-71).In terms of methodology, the authors have used data from the Health Information National Trends Survey (HINTS) Version 6, conducted from March 7 to November 22, 2022, in the US. As a statistical approach, the authors applied descriptive statistics analyses and determined group differences by using Chi-square and Kruskal-Wallis tests between the subgroup of Millenials and older age groups. Additionally, post-hoc sensitivity regression analyses were conducted.

The manuscript is easy to understand and well-written in style. Obviously, the manuscript was produced by a team of native English speakers. With regard to contents, however, in my opinion, the present manuscript suffers from a few flaws concerning the theoretical background, a lack of a research gap and specific research questions, the selection of the central constructs, and the core contribution. Due to, not very severe, shortcomings in content, the manuscript is not of sufficient quality to justify publication in its present form. The paper has a largely descriptive character, with a total absence of a clear theoretical framework at the moment. Additionally, it lacks a well-structured, sophisticated literature review, as well as a conclusive deduction of specific research questions.

To sum up, in relation to the present manuscript, there are some major and minor weaknesses that have to be resolved before it can be considered for publication in Nursing Reports.

I would like to elaborate on the weaknesses of the present manuscript in detail. Although there are nine issues I have raised, none of them are obstacles to publication, and most of the issues raised are minor. In general, in my view, all of the issues raised can be tackled with manageable afford in a quick review round.

Specific comments

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Major comments

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Please regard the following points as constructive criticism.

1. The problem of the present study is that the author should put more emphasis on underlining their core contribution. What is new compared to what is already known from existing literature? Although the specific age range of Millenials (25-41 years) as compared to older generations might not have been investigated so far, there should be a lot of literature available confirming differences between generations with regard to digital health-related technology use. So, does it constitute the core contribution of the present study? Is it the usage of HINTS 6, considering that data collection is well-founded and nationwide? However, the group of Millenials only consists of n=73 respondents, which is a small subsample size compared to, e.g., the Baby Boomers (n=277) or Gen X (n=149). The authors should try to underline their core contribution and elaborate on existing literature dealing with age gaps regarding health-related technology use.

2. The Introduction does not lead to specific research questions in a stringent form. Thus, the authors should strengthen the logical flow of the introduction by giving not only an overview of the care responsibilities differences between age groups, which is interesting too and well written in its present form. In my view, the authors should also add a short overview of the developments in the respective literature, considering the state-of-the-art existing studies dealing with health-related technology use across different age categories. At present, the introduction does not lead to research questions in a logical and stringent form. In my opinion, some clearly defined, literature-based research questions would lead to a more systematic results section and a better-structured discussion section. At present, the whole manuscript seems to be more or less based on a mere data-driven approach. The authors should elaborate on what has been known so far in the research area of interest to underline their core contribution with the results they found.

3. In the Measures section, the authors differ between predictors and dependent variables, but later on in the Statistical Analyses section, they mention that they have calculated Chi-square tests and Kruskal-Wallis tests. Only one sentence mentions a regressional approach without explaining the details. The authors are cordially invited to explain and include the results of the regression analyses as well in their Results section to better align the Measures section with the Results section.

Minor comments

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4. In chapter 2.1 HINTS 6 is explained briefly. I would add some sentences to explain that the data collected are available upon request and that the authors did not collect the data by themselves. If the authors contributed to data collection in some respect, this should be added too.

5. In lines 88-89, it is stated that the analysis reports data from n=545 respondents “who self-identified as the primary, unpaid caregiver for an adult with a chronic health condition.” The item measuring caregiving responsibility was the following: “Are you currently caring 90 for or making health care decisions for someone with a medical, behavioral, disability, or some other condition?” In the original survey of HINTS, 6 people had the possibility to mark “all that apply”. So, the category “multiple conditions” was not delivered in HINTS 6. The authors should include a footnote explaining that this option was not delivered but calculated by summing up all people who ticked more than one condition.

6. As caregiving characteristics are crucial for the focus of the present manuscript, I would add a separate subheading, “Caregiving characteristics” (2.2.2.), and not merge them with “demographic and sociodemographic characteristics” (2.2.1.). Instead of writing “primary predictor: generation,” I would only write “Age categorization into generations” (2.2.3.) and refer to Figure 1 once again.

7. In my view, the dependent variables are chosen more or less arbitrarily, and the authors should justify their selection, either theoretically or in terms of argumentation, as to why specific variables were selected from HINTS 6 and not others. There is, e.g., a special section on “Looking for health Information” (questions A1 – A5) and a section on “Using the Internet to Find Information (questions B1-B15), which could also be interesting for the present study but weren’t chosen. The authors should justify their selection.

8. Social media usually encompasses all the platforms and apps that allow people, creators, and businesses to communicate with one another, create online communities, exchange ideas, and share content. In HINTS, social media are exemplified by the following statement: “including Facebook, Twitter, TikTok, Youtube or Instagram”. WhatsApp, however, is not mentioned. As far as I know, is WhatsApp the social media app that is most frequently used by several generations. Excluding WhatsApp from the list and its rationale, should be at least explained by the authors or mentioned in the Limitations (as they used an existing survey with no influence on the items’ wording).

9. In Table 1, the answer options for telehealth use should be explained. I have looked it up in the HINTS 6 survey and saw that the answer options were binary (1=yes, 2=no). Maybe it would be wise to add the original question ID of the HINTS to each variable of interest, like “telehealth use reason” (D5), in a separate column of Table 1.

To sum up, the theoretical background should cohere with the results and clear research questions should run like a golden thread through the whole manuscript.

Good luck with your research!

Author Response

Please see attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Editor and Reviewer,

Thank you for the opportunity to review the article "Examining differences in health-related technology use between Millennial and older generations of caregivers," which aims to explore digital health-related technology use across caregiver generations.

The article could be interesting but requires significant revisions to be clear to the author, for which I suggest the following changes:

Title:

Why does the title only reflect Millennials when results from numerous generations are presented?

Abstract:

Statements that may be controversial are made at the beginning of the article that are not directly related to the study's topic "Millennial caregivers are a growing, at-risk cohort for mental health distress. Digitally delivered mental health and caregiving interventions hold promise for supporting them." It would be important to include more objective items in the abstract (clear study objective, methodology, participants, main results). The abstract is very confusing.

Introduction:

The introduction addresses themes that are not the exact focus of the study. For example, "Additionally, Millennial caregivers may be at even further increased risk of poor mental and physical health outcomes because in general, Millennials have higher rates of psychological distress and chronic health problems relative to older generations. [11,12]" It needs to be coherent, explaining the main concepts and relevance of the study. The study's objective should be the same in the abstract, introduction, and methodology.

Methodology:

Place Table 2 in the results section.

Discussion:

Redo the discussion according to the study's objective.

Overall, the article is written in a confusing manner, straying from its objective.

Significant reformulation is suggested given the relevance of the theme.

Comments on the Quality of English Language

Dear Editor and Reviewer,

The article could be interesting but requires significant revisions to be clear to the author, for which I suggest the following changes:

Title:

Why does the title only reflect Millennials when results from numerous generations are presented?

Abstract:

Introduction:

Methodology:

Place Table 2 in the results section.

Discussion:

Redo the discussion according to the study's objective.

Overall, the article is written in a confusing manner, straying from its objective.

Significant reformulation is suggested given the relevance of the theme.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for addressing the previous comments

Comments on the Quality of English Language

Author Response

Thank you for your time and effort!

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors!

Thank you for submitting a revised version of the manuscript with the title "Examining differences in health-related technology use between Millennial and older generations of caregivers“ I appreciate the changes made, and, in my opinion, the quality of the manuscript has improved significantly. You have addressed all of my comments in a satisfactory way. To sum up, I think that the manuscript has really improved through the revision, and it makes a nice contribution to the literature. In my opinion, the core contribution of the paper is now much clearer through the thorough revision of the Introduction. The (at least implicit) RQ runs like a golden thread throughout the manuscript. The rationale behind selecting the specific target group of Millennial caregivers is now reasonable, and shedding light on the technology use behavior of Millenials to be able to tailor interventions by the Internet for caregivers in this age cohort, in the long run, is reasonable. Thus, the revised Introduction raises curiosity and underlines the importance of the topic and its rationale for putting special emphasis on the group of Millenial caregivers. The Introduction now highlights what has been known so far as compared to what has not been known before. Nevertheless, I would recommend adding a sentence in the introduction phrasing a clear RQ similar to the one included in your (authors`) response, e.g., in the following form: “How do Millenial caregivers differ from other generations with regard to their technology use and which conclusions can be drawn thereof for assessing the feasibility of and acceptance of interventions related to their roles as caregivers?” Feel free to phrase the RQ on your own.

Furthermore, I appreciate the reference to the publicly available HINTS 6 data by revealing a link. I also appreciate including the variable IDs in Table 1, and the justification for the selection of variables included in the analysis. I also appreciate the thorough revision of the Discussion section.

From my point of view, I would only recommend including a specific RQ, as mentioned above. However, feel free to follow my recommendation or not. I always prefer including RQs explicitly instead of having them implicitly included to strengthen the golden thread for the target readership. Altogether, I think the manuscript is now publishable, as the revision round was very fruitful. Thus, I recommend the publication of the manuscript to the editor immediately after you have considered including an RQ. Please feel free to decide by yourselves. Well done!

No further annotations.

Good luck with your research!

Author Response

Thank you for the helpful feedback and encouragement. Your review significantly improved the quality and potential impact of this manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for the opportunity to review the article "Examining differences in health-related technology use between Millennial and older generations of caregivers."

I would like to express my sincere congratulations for the effort dedicated to the recent revisions and improvements made to the article. It is evident that the suggestions were carefully considered and addressed, resulting in a more robust and refined work.

However, I believe that some areas can still be improved.

Abstract:

· Specify the type of study in the method section.

· The objective is solely this and aimed to understand how Millennials may differ from other generations of caregivers regarding digital health-related technology use.

· "Compared to select older generations?" Who are these generations?

· "which has implications for intervention design and tailoring." It may have implications for intervention design and tailoring, although this is yet to be confirmed by the authors

In the discussion, integrate a final paragraph with study limitations. The study focuses only on a specific sample of the population, the data are self-reported, among others.

Good work.

Author Response

Comment 1: Abstract - Specify the type of study in the method section.

Response 1: Please see line 19.

Comment 2: Abstract - The objective is solely this and aimed to understand how Millennials may differ from other generations of caregivers regarding digital health-related technology use.

Response 2: See line 14; Objectives was changed to Objective.

Comment 3: Abstract - "Compared to select older generations?" Who are these generations?

Response 3: More detailed results were provided in lines 21-28.

Comment 4: Abstract "which has implications for intervention design and tailoring." It may have implications for intervention design and tailoring, although this is yet to be confirmed by the authors

Response 4: This has been changed. See line 29.

Comment 5: In the discussion, integrate a final paragraph with study limitations. The study focuses only on a specific sample of the population, the data are self-reported, among others.

Response 5: Study limitations are discussed in lines 314-326. We added that this study is comprised of self-report data.