Review Reports - Understanding Family Experiences: A Study on Mental Health Literacy in Adolescent Eating Disorder Diagnoses

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors.

Thank you for the opportunity to review this paper, that I find interesting and relevant to ED audience. I have a few comments that I think would improve the paper:

- Overall, you should improve the language to make it more clear and concise.

- In the Abstract, it is not necessary to include location (Madrid, Spain)

- Introduction: Broadly speaking, I think the Introduction would benefit from a thorough revisison to sharpen the statements, and make sure that the arguments are clear and supported by the right references.

- I would change the start of the introduction (lines 41-43), as this probably is not the most common way to frame the seriousness of EDs. Reference no 3 (Jowik et al.) is secondary, and I would encourage you to find more updated references.

- In lines 56-58, you state that EDs are particularly prevalent in adolescents and young adults, and refer to Yu. I can’t find this information in the reference, and I also disagree about the prevalence. Age of onset is typically in adolescent age, but BED, e.g., is more prevalent for adults.

- Since you also mention BED in the Introduction, you should add a line about BED prevalence.

- In line 91, you state the importance of nursing professionals. This depends very much on the context. In a hospital setting, yes, but in other settings, other professionals – and family as you mention – are equally and sometimes more important. The setting should be more clear.

- Lines 116-118: How do you mean that the researchers’ position was “determined based on their beliefs”, ..? And which beliefs? How did this affect the study?

- Section 2.3.: You need to be more specific about the setting – where did you recruit the family members? Was it a treatment facility? How were they approached?

- Section 2.4. Were the interviews individual? Where did the interviews take place? Were the interviews recorded and transcribed verbatim?

- Lines 160-161: Add a reference for the computer program

- Lines 163-166: I don’t understand the purpose of these sentences.

Result section: In general, you should try to use a clearer and more concise language in the result section, as the results can be difficult to read.

- I would not underscore the categories.

- Lines 261-262: It is unclear to me what “structured nuclei and constrasting situations” means here.

- I like Figure 1 but it is unlcear to me where the Mental Health Nurse Practicioner (1 or 2 words?) comes from.

- Discussion and Conclusions: These sections could also benefit from restructuring. You quickly move to the importance of MHL and the nurse, but I think you should elaborate more on the themes that you find. You should align the discussion section more to the aim of the paper: “...seeks to explore family perspectives on the diagnosis of adolescent EDs, offering a qualitative approach to deep understanding the experiences, challenges, and emotional needs of families in this process.”

- Be careful about over-interpretation. I agree that the nurse is very important, but I think that it takes up too much space in the discussion and conclusions compared to the other themes.

Comments on the Quality of English Language

The quality of the language should be improved.

Author Response

Dear authors.

Thank you for the opportunity to review this paper, that I find interesting and relevant to ED audience. I have a few comments that I think would improve the paper:

- Overall, you should improve the language to make it more clear and concise.

First of all, I would like to thank you for your interest in the topic and your suggestions, which we will take into account in the article.

We proceed to revise the English through MDPI Author services for better understanding and clarification of the manuscript.

- In the Abstract, it is not necessary to include location (Madrid, Spain)

Thank you very much for the suggestion, the location will be removed from the abstract.

- Introduction: Broadly speaking, I think the Introduction would benefit from a thorough revisison to sharpen the statements, and make sure that the arguments are clear and supported by the right references.

Thank you very much for your suggestion, we will proceed to further review the assertions and references to improve the arguments.

Thank you very much for your suggestion, we will modify the beginning of the introduction section by removing reference 3 and adding the interesting and novel reference 5.

Thank you very much for the suggestion, the introduction will be changed for better understanding and clarification.

- Since you also mention BED in the Introduction, you should add a line about BED prevalence.

Totally agree, this will give more scientific rigor to the manuscript. Thank you very much for the suggestion. It will be added on lines 77-79.

Thank you very much for the suggestion, it does indeed depend on the context, we are proceeding to clarify this in the manuscript.

- Lines 116-118: How do you mean that the researchers’ position was “determined based on their beliefs”, ..? And which beliefs? How did this affect the study?

Thank you very much for the suggestion, what we are referring to is that the theoretical framework of this qualitative research, as well as the researchers' views and their reasons for carrying out the study, were defined before starting the research, so we proceed to clarify this in the manuscript.

- Section 2.3.: You need to be more specific about the setting – where did you recruit the family members? Was it a treatment facility? How were they approached?

Thank you for your comment. Relatives were recruited through posters placed in a social-health centre and posts on social media. In addition, adolescents diagnosed with TCA were initially contacted through the health team that cared for them, who, with appropriate consent, facilitated contact with their relatives. To strengthen intentional snowball sampling, participants were asked to suggest other relatives in similar circumstances who might be interested in collaborating in the study until saturation was reached.

- Section 2.4. Were the interviews individual? Where did the interviews take place? Were the interviews recorded and transcribed verbatim?

Thank you very much for the suggestion, interviews were conducted individually to allow participants to express their thoughts and experiences freely without external influences. Interviews were conducted in person at a location and time of the participant’s choosing or via video call, depending on the participant’s preference. All interviews were audio-recorded with the participants’ consent and transcribed verbatim to ensure the accuracy and authenticity of the data. This process allowed for a detailed and faithful representation of the participants’ responses.

- Lines 160-161: Add a reference for the computer program

Thank you very much for the suggestion. Reference for the computer program is added.

- Lines 163-166: I don’t understand the purpose of these sentences.

Thank you very much for your comment, it will be clarified.

Result section: In general, you should try to use a clearer and more concise language in the result section, as the results can be difficult to read.

Thank you very much for your suggestion, the results section has been revised and we proceed to revise the English through MDPI Author Services for better understanding and clarification of the manuscript.

- I would not underscore the categories.

Thank you very much for your suggestion, we will remove the underlining of the categories.

- Lines 261-262: It is unclear to me what “structured nuclei and constrasting situations” means here.

Very interesting suggestion. In this case, “structured nuclei” refers to families that have a traditional and stable structure, while “contrasting situations” implies more complex or unstructured family situations, such as conflicts or significant changes in family dynamics. This is clarified in the manuscript to avoid confusion.

- I like Figure 1 but it is unclear to me where the Mental Health Nurse Practicioner (1 or 2 words?) comes from.

In Figure 1, the Mental Health Nurse Practitioner (also known as Advanced Practice Mental Health Nurse) is referred to as one word but in the figure it appears fractionated to fit in the figure, it refers to a professional who plays a key role in the treatment of eating disorders, especially in inpatient and outpatient settings. This professional works in multidisciplinary teams to provide comprehensive care and follow-up to patients with advanced knowledge in the field of mental health due to their training of several years and that in English-speaking countries is called “Mental Health Nurse Practitioner”.

- Discussion and Conclusions: These sections could also benefit from restructuring. You quickly move to the importance of MHL and the nurse, but I think you should elaborate more on the themes that you find. You should align the discussion section more to the aim of the paper: “...seeks to explore family perspectives on the diagnosis of adolescent EDs, offering a qualitative approach to deep understanding the experiences, challenges, and emotional needs of families in this process.”

- Be careful about over-interpretation. I agree that the nurse is very important, but I think that it takes up too much space in the discussion and conclusions compared to the other themes.

Thank you very much for suggesting a reformulation of the discussion and conclusions of the article. The structure will be modified to make it clearer, more scientifically rigorous and more understandable.

Comments on the Quality of English Language

The quality of the language should be improved.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Important paper, excellent methodology. Two suggestions, one on the info provided as background re AN, the other on study design. Re background, the recent letter in The Lancet by Hebebrand et al on the role of leptin in AN might be usefully cited - though we are far from using leptin in routine care, it is worth mentioning to illustrate the limitations of our knowledge of the biology of AN. Re method: interviewing individual family members was, as shown, very productive. But it does not include the role of family interactions - the focus of most family therapy - which might be mentioned.

Author Response

First of all, I would like to thank you for your interest in the topic and your suggestions, which we will take into account in the article.

It seems very pertinent to add in the citations the recent letter published in The Lancet by Hebebrand et al on the role of leptin in AN, something recent and novel that will undoubtedly give more scientific rigor to the manuscript. In relation to the design of the study, the role of family interactions is not directly included, which we consider important to take into account for future research and we add in the limitations section

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

It is an interesting issue, in particular doing interviews in family members: mothers, sisters, fathers. How was the Mental Health Literacy recorded, there is either a question nor an answer in the interview capturing this aspect?

So, the title of the paper might be changed in “Study on Understanding Family Experiences: Mental Health Literacy in Adolescent Eating Disorder Diagnoses”

In the abstract, the number of interview participants should be mentioned.

The literature review is excellent, the method well described. But the mentioned data satisfaction is not reached, when looking at the participants in more details.

There are 7 women, out of them 5 mothers, 2 sisters, there are 5 men, 4 fathers and 1 grandfather. We don’t know exactly whether all mothers, exception one, talked about their daughters and men talked about (grand)daughters or (grand)sons?

In general the advantage that interviews add new contents and insights additional to questionnaires was not utilized.

The notes transcribed from the interviews are in relation to the text of the authors, but all answers to the respective questions should be available – in a short form in a supplement.

Comparing answers of dads, they seem to feel more helpless than mothers – so looking at fathers answers and mothers answers and sisters answers would clarify whether they have different aspects in mind, when describing effects on them personally, the family and the health system. It was interesting to realize that most of the interviewees had not much knowledge about the role nurses play in the therapy of ED patients – and the need of involving the family as whole into the healing process is an important result.

Figure 1 should be described in more details and the meaning of Mental Health Nurse Practitioner in this context.

Author Response

Thank you very much for your suggestion. Although our study emphasizes the relevance of mental health literacy as a central theoretical axis, we recognize that the interviews conducted did not include specific questions aimed at assessing this concept directly. This is because the primary focus of the study was to explore family members' experiences and challenges with adolescent eating disorder diagnosis and treatment, leaving aspects of mental health literacy to emerge naturally in participants' narratives. However, we note that certain themes identified, such as the need for more information and educational support from health services, initial understanding of eating disorders, perception of the quality of information received, and skills needed to manage the situation reflect indirect elements linked to mental health literacy. We recognize that including specific questions aimed at measuring the level of mental health literacy would have allowed a more direct and in-depth assessment of this construct in the family context, and we propose this improvement as a recommendation for future studies.

So, the title of the paper might be changed in “Study on Understanding Family Experiences: Mental Health Literacy in Adolescent Eating Disorder Diagnoses”

I find very interesting the title you suggest we have proceeded to change it as you indicate but when sending to check the English to through MDPI Author services they have suggested another more specific title. Thank you very much for the suggestion.

In the abstract, the number of interview participants should be mentioned.

Thank you very much for the suggestion, the number of participants in the interview will be mentioned in the summary.

The literature review is excellent, the method well described. But the mentioned data satisfaction is not reached, when looking at the participants in more details.

In the participants description, the sex of adolescents with ED diagnosis is missing. Trying to ascribe the sex of adolescents by the notes of the 12 interviewees, for E3, E9, E11 and E12 it is not clear. For E4 once the adolescent is identified as “she” and once as “he”. It would be helpful to complete the participants characteristics and these of their relatives with ED diagnosis. There are 7 women, out of them 5 mothers, 2 sisters, there are 5 men, 4 fathers and 1 grandfather. We don’t know exactly whether all mothers, exception one, talked about their daughters and men talked about (grand)daughters or (grand)sons?

We appreciate the comments and acknowledge that the description of the participants did not specify the sex of the adolescents diagnosed with eating disorders (ED). we proceed to create an additional column in the table of participants that specifically details the sex of the adolescents diagnosed. This improvement will allow greater clarity in the characterization of the participants and will facilitate the analysis of the differences in family perceptions in relation to this variable.

In general the advantage that interviews add new contents and insights additional to questionnaires was not utilized.

Very interesting your suggestion, we will keep it in mind for future qualitative studies to get the most out of the interviews.

The notes transcribed from the interviews are in relation to the text of the authors, but all answers to the respective questions should be available – in a short form in a supplement.

Thank you for the suggestion. We have all the interviews recorded and transcribed, if you need them attached as a supplement please let us know and we will upload them.

Very interesting what you suggest, we proceed to add it in the manuscript to give more scientific rigor to the study.

Figure 1 should be described in more details and the meaning of Mental Health Nurse Practitioner in this context.

Thank you very much for your comment and you are right, figure 1 will be described in more detail for better understanding and clarification in the context of the article.