Climate Change Anxiety Among Individuals with and Without Chronic Illnesses: The Roles of Exposure, Awareness, and Coping Strategies

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1- Summary and general concept comments:

The main objective of the paper is to assess the mental health implications of climate change, namely climate change anxiety, in people with chronic diseases (e.g., cardiovascular-CVD and respiratory diseases-RD) in contrast to those without chronic illnesses-CI. This study aims to investigate and examine factors predicting climate change anxiety, such as experience of climate-related events, perceived risks from climate change (i.e., climate change exposure and climate change awareness) and coping strategies (i.e., problem focused strategies, meaning focused coping, and de-emphasizing), and group-specific (i.e., CVD, RD and without CI) variances in these relationships.

This paper represents an important contribution to literature in this gap area on the psychological effects of climate change exposure, particularly climate change anxiety (breakdown of the recent contributions by population groups), in vulnerable populations who have chronic diseases, inadequately studied elsewhere.

Comparing across groups of individuals with CVD, with RD and without CI indicates how various health vulnerabilities may influence emotional reactions to climate threats. Moreover, the study highlights key predictors of climate change anxiety (exposure to climate-related events and coping strategies) in order to enhance how these variables are interrelated, and affect psychological distress.

Also, the application of Lazarus and Folkman's (1984) transactional theory of stress and coping supplies a theoretical template to understand how individuals evaluate and react to climate-related stressors and add depth to the discussion of coping strategies.

It is clear that the present findings have practical implications for public health intervention and clinical practice, pointing to the importance of providing targeted mental health support to individuals suffering from chronic diseases with the aim of reducing climate change anxiety.

Finally, I the emphasis on people with preexisting conditions in this research is, I think, a sorely needed, but often absent, focus of climate research, when we think about designing interventions for people in danger.

The research, overall, provides important perspectives on the psychological dimensions of climate change, at an individual level and for those with chronic illness, and have much to offer in relation to practical suggestions on how to work with climate change anxiety among these populations.

2 - Specific comments in each part :

The introduction is very informative; however, it can be better broken into paragraphs to help with readability. Try to have one theme or idea per paragraph. Check that the hypotheses are explicit and above all mentioned so that they are coming out of the text. This enables readers to quickly understand the aims of the study.

 Literature Review:

You reference literature but might want to consider more literature, especially on psychological impacts of climate change on various people. This may be a sturdier frame for your study. And talk about the implications of the results of the one study you did cite about climate change anxiety in people who have chronic diseases." Q: How does this study relate to your own research?

Theoretical Framework:

It is relevant to apply Lazarus and Folkman’s transactional theory of stress and coping; a little more on how the theory has been previously applied for research on climate change anxiety could help make a stronger case for its relevance.

 Methodology:

The method section is well written, however, a more detailed description of the demographic characteristics of the sample would be nice. For example, what is the demographic make-up of the sample relative to the Israelis more broadly? Address possible biases in the sampling of online panels as this may influence the generalizability of your results.

 Statistical Analysis:

Would be good if you could explain the rationale for controlling certain variables in your analyses. If the decision to include education as control, but not gender and age, is justified, it can make clear your methodological decision. Maybe you can write about what the high VIF values do to the data. This may indicate a stronger involvement with the statistics and potential consequences.

Results Interpretation:

The results section is well presented, but it would be useful to relate the results more explicitly to the hypotheses. Summing up: For each hypothesis, summarize briefly how much, if at all, it was supported, and by what, before tackling the implications. The focus on surprises and their interpretation could provide more substance and insight to your conclusions. Why would such type of coping (i.e., problem-focused coping) be related to increased anxiety, for example?

Discussion and Conclusions:

The discussion is good and summaries the findings well, but you may also wish to consider a clearer section where you discuss the implications of the findings for public health and clinical practice. In the end, summarize the importance of the study and its impact on the field. This can lead the reader to appreciate the significance of your results.

Author Response

Please see the attached file 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This study compared climate change anxiety levels between Israeli chronic disease patients (cardiovascular and respiratory diseases) and healthy individuals, and analyzed the impacts of exposure, awareness, and coping strategies (problem-focused, meaning-focused, and de-emphasizing) on anxiety. Although this study is very interesting, there are some obvious loopholes that need to be patched.

(1) Is the sample representative? Relying on members of the online survey panel may not represent a broader Israeli population (such as the digital divide, differences in willingness to participate), especially those with lower socioeconomic status or poorer health conditions may be overlooked. 

Age and gender themselves may affect anxiety levels and coping styles (studies have shown that men are more likely to use downplaying strategies, and age is positively correlated with anxiety). This seriously confuses the relationship between the variable of "cardiovascular disease" and the outcome (higher anxiety), making it impossible to determine whether it is the disease itself or age/gender factors that dominate the differences. In the study, only the years of education were controlled, and the two strongly correlated variables of age and gender were not adequately controlled or their confounding effects were not discussed.

Unemployment or retirement status may significantly affect anxiety levels, social participation and coping resources, which is also an important confounding variable that has not been fully considered.

（2）The definition of the respiratory disease group is rather vague. Some diseases in this group are triggered by climate factors, while others are caused by viral infections. It might not be appropriate to lump all related diseases together. For instance, asthma is more sensitive to air quality, whereas chronic obstructive pulmonary disease (COPD) is more susceptible to infection risks. Grouping them together may mask significant within-group differences and weaken the explanatory power of the results.

(3) The cross-sectional design limits the inference of causal relationships. Firstly, causality requires a clear sequence of events. However, since all variables are measured simultaneously, it's impossible to determine whether exposure to climate change events leads to increased anxiety or if pre-existing anxiety influences perceived exposure. Secondly, without tracking individuals over time, changes in variables cannot be observed. For example, how anxiety levels evolve with changing exposure or coping strategies remains unknown. Thirdly, other unmeasured variables could influence the observed relationships. For instance, social support or economic status might affect anxiety levels but aren't accounted for in a single-time assessment.

(4) When comparing the differences between groups in ANCOVA, only the years of education were controlled, while age or gender was not controlled (although it was known that they were related to the groups and study variables), the reason being that a high correlation with the groups would lead to collinearity. However, this might lead to the observed intergroup differences (especially the higher anxiety in the cardiovascular group) being partly attributed to age/gender rather than the disease itself.

(5) The study’s data collection at a single time point precludes establishing causality. For instance, it’s unclear whether heightened anxiety drives increased use of problem-focused strategies (e.g., constant environmental monitoring) or if these strategies themselves elevate anxiety.

Author Response

Please see the attached file 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thanks, I have no comments further more.