Perceptions of Climate Change and Health Risks Among Urban Older Adults in Mexico City: A Pilot Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Sir or Madam,
please find some comments and suggestions attached regarding the manuscript.
I would suggestion to revise (i) the description of the methods (more information on recruitement strategy), (ii) the results (description of population; description of responses in more detail) as well as the (iii) discussion (I am not sure, if the tool measures what it is inteded to measure, and this should be discussed in more detail.

INTRODUCTION
2/13-56: "Recent official reports also show a 67% increase in mortality associated with heat- waves in Mexico between 2000–2009 and 2021–2022 [7]."
=> the methodology does not show an increase in mortality; as it is not based on real world data and does not take adaptation into account.
=> Suggestion: indicate instead of show or another weaker formulation? Or use another study as reference? 
2/13: Potential to condense the text and thereby shorten the introduction 

METHODS: 
4/13 Figure 1. Not necessary. Suggestion to remove it. 
4/13 154f: "This setting provided access to a representative sample of older adults with diverse sociodemographic and health profiles, ideal for exploring perceptions related to climate change and health vulnerability."
=> Representative for what? The patients in the hospital? The in-patients on the wards? The Metropolitan area of Mexico? 
=> And representative based on what characteristics: Age? Sex? Socioeconomic status?
==> Suggestion: (slightly shorten description of Hospital) and provide much more information on how participants of the survey were selected. Where were they drawn from? How were they approached
Methods overall: missing and should be added: Eligibility criteria for participation in the surey (partly provided, expand if possible), sampling frame, recuitement strategy/process/methods, recruitement period, incentives
4/13 168ff CCPAS tool: could you report some more on the translation process and how you ensured, that participants understand the same under the questions as in the english version? (validation of the spanish tool) Espcially words such as "environment" in english are tricky to translate in other languages

5/13 table 1: the tool is a bit strange to me; with some questions, I am not sure how the link to climate change can be done with some of the questions: 
"I feel that animals are suffering a lot" => this question does not seem to indicate climate change. I would answer yes, and think about factory farming.
"I feel angry / that we have failed / upset about how the environment is changing" => This question could indicate anger about pollution or deforestation, or even anger about renaturalization of rivers (which would be positive, from a climat adaptation perspective). I am not sure, if one can derive a perception of climate change from this question - unless you tested this somehow?
=> I guess, for a pilot study this is fine. For a future larger study I would suggest to use another survey tool

5/13 176-182f: the description of the population should be moved to the results section. 

RESULTS:

Results overall: What is the overall population the sample was drawn from (e.g., when the population was patients on the wards in the period xx to yy); how many people were in the ward How many people were appraoched and declined?
Results overall: See comment above; the description of the population should be moved from the methods to the results section.  Here (or in the discussion) it would be useful to have more information about a comparison between the population in the survey and the population it is intended to represent (e.g., what is the distribution of age, sex, years of education,(potentially of the disorders) in Mexico / the Valley of Mexico Region) 
=> this would allow readers to estimate some level of representativeness of the sample. 
Results Overall // 6/13: Please provide the distribtuion of responses to the question items (those from table 1) in the results section. For example, in the form of a table with 7 (or 5, if responses are clustered) columns, indicating (A the question; number / proportion of resonses: Never, Rarely, Occasionally, Frequently, Very Frequently ; overall number of participants / missing responses. 

DISCUSSION:
OVerall: in the study, the responses are interpreted in a way that the perceived changes to the environment are attributed by the participants to climate change. Based on the way the questions are formulated, I would not be sure about this (unless explicitly primed in this direction)
Overall: discuss potential biases in recruitement process and how this could influence the results
9/13-287:"Recent official reports also show a 67% increase in mortality associated with heat- waves in Mexico between 2000–2009 and 2021–2022 [7]."
=> the methodology does not show an increase in mortality; as it is not based on real world data and does not take adaptation into account.
=> Suggestion: indicate instead of show or another weaker formulation? Or use another study as reference? 
9/13 298: "These patterns speak to the sensory accessibility of climate impacts such as hat, drought, and smoke. Heat can be felt, drought can be seen, and wildfire smoke can be smelled – making them perceptually available phenomena even for older adults with limited access to scientific information or digital technologies." 
Not sure, if I agree with this statement. => There is limited sensory accessibility of climate change impacts, as it is statistical phenomenon. There have been heatwaves and wildefires before. What has happend is that their frquency has changed, with a change in frequency that can be best explained by anthorpogenic CO2 emissions after subtracting the effects of e.g. solar activities or land use change. Without scientific information or digital technologies (i.e., the media), it would be very challenging to attribute changes in the environment to anthropogenicGHG-emission caused climate change?

9/13 323/324: "(5) The Urban and regional context of the study: An important finding of this study is that residents of the Valley of Mexico exhibited significantly greater awareness of phenomena such as drought."
=> This is not shown in the results. Pelase provide this data in the results

Comments on the Quality of English Language

I noticed some typos, e.g. hat instead of hot. A language check would be helpful .

Author Response

Resubmission of Manuscript: “Perceptions of Climate Change and Health Risks among Urban Older Adults in Mexico City: A Pilot Study”

Dear Reviewer,

We appreciate the opportunity to revise our manuscript. We are thankful for the constructive feedback provided by the reviewers, which has helped us significantly improve the quality and clarity of the paper. All suggestions were carefully considered and addressed.

Attached is a detailed point-by-point response to the reviewer comments (Doc Reviewer 1) and the manuscript with the changes. (Doc reviewer 1  Yellow)
We would also like to inform you that after revisions, authors decide to change the title of the article to better align content with findings.

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Overall Comments:

This study provides a valuable investigation into older adults’ perceptions of climate change and associated health risks in Mexico. The research design is appropriate, and the data collection methods are well-described. However, the study has notable limitations, including a small and geographically restricted sample, potential issues with the validation of the adapted survey instrument, and a cross-sectional design that limits causal inferences. Future research should expand the sample size, include more diverse regions, and validate the Spanish version of the CCPAS more rigorously. However, some aspects of the interpretation of results require further clarification and improvement. The authors are encouraged to address the comments below. With these revisions, the manuscript will be suitable for publication in Atmosphere.

 

Major comments:

1. The study was conducted at a single hospital (IMSS La Raza) in Mexico City, with 84% of participants residing in the Valley of Mexico. This urban bias may not reflect perceptions of older adults in rural or climatically distinct regions. The discussion should explicitly acknowledge this limitation and recommend broader geographic sampling in future studies.
2. The Climate Change Perceptual Awareness Scale (CCPAS) was adapted into Spanish but not fully validated for this linguistic and cultural context. The manuscript should clarify the translation process (e.g., forward-backward translation, pilot testing) or acknowledge the need for future psychometric validation.
3. While associations between chronic diseases (e.g., hypertension) and heightened emotional responses to climate change are noted, the study cannot establish causality. The discussion should avoid implying causation and instead suggest longitudinal or experimental designs for future research.

 

Minor comments:

1. Line 5: Remove the extra comma after "Citlali Fernández Vivar³,".
2. Line17: "Very limited research is available on the topic and this pilot study aims to..." to "Limited research exists on this topic; this pilot study aims to..."
3. Line 56: "67% increase in mortality" should specify whether it is relative or absolute (e.g., "a 67% relative increase").
4. Line 107: This subtitle is extraneous.
5. Table 1: "CCPAS Items and Categories" to "CCPAS Items and Their Categories" for clarity.
6. Line 176: "1,515 individual responses" should clarify if this is per participant (15 items × 101 participants).
7. Line 209: "53% of the responses" vs. "2% of responses" to standardize to "of the responses."
8. Line 434: References [14] and [17] cite the same study (Cipriani et al., 2024). Merge or remove redundancy.
9. Line 328: "These problems are especially pronounced in Mexico City, a megacity of over 20 million inhabitants, where infrastructural and ecological stress is a daily reality." to "These problems are pronounced in Mexico City, a megacity facing daily infrastructural and ecological stress."
10. Line 346: This subtitle is extraneous.
11. Line 395: "Data will be made available on request." to "Data are available upon reasonable request to the authors."
12. Expand the discussion on how findings could inform targeted climate-health communication for older adults.

Author Response

 

Resubmission of Manuscript: “Perceptions of Climate Change and Health Risks among Urban Older Adults in Mexico City: A Pilot Study”

Dear Editor,

We appreciate the opportunity to revise our manuscript. We are thankful for the constructive feedback provided by the reviewers, which has helped us significantly improve the quality and clarity of the paper. All suggestions were carefully considered and addressed.

Attached is a detailed point-by-point response to the reviewer comments. Doc 1 (general responses) Doc 2, (in Green) changes in the manuscript.
We would also like to inform you that after revisions, authors decide to change the title of the article to better align content with findings.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

1. Reviewer Comment (2/13):
Potential to condense the text and thereby shorten the introduction
Response:
Thank you for the suggestion. The Introduction section was carefully reviewed 
and revised to reduce redundancy and improve clarity. Several sentences were 
merged or shortened while maintaining the necessary background, especially 
the rationale for focusing on older adults and climate-health perception in 
Mexico.
==> There was no relevant reduction in the length of the revised mansucript.

1.2 Furthermore, in the revised version. Figure 1 is still included.
==> remove, as stated in your response

2. 2/15 56f => relative risk relative to what? Minimium mortality treshold? Median Temperature? Heat (i.e. 95th temperature percentile) or warmth+heat (any temperature above MMT)`?


3. p4/15 145ff. While the authors expanded on the study site and participants section was expanded, but still lacks relevant information.
Please ensure that all relevant reporting items are provided.
In particular: how did you arrive at 101 individuals over the 2 month period. Is this a convenient sample? Does this represent all patients at the ward? Is it a fraction of the patients of the ward, but only a sample sample was willing to participate? => please provide more information on the sampling strategy.
With no participant declining: were these ~20 outpatients and 80 inpatients all individuals treated in the clinic in this period`?
https://www.equator-network.org/wp-content/uploads/2015/10/STROBE_checklist_v4_cross-sectional.pdf

P10/15: 318f  According to the Lancet Countdown on Health and Cli- 318
mate Change, heat-related mortality in Mexico increased by 67% between 2000-2009 319
and 2021-2022, with older adults being severely affected
=> please check your responses to the reviewers and revise the section in accordance with your response. The lancet data did not estimate an increase in mortality. They assumed this increase, based on the assumption of not adaptation in the context of an increase in temperature. Depending on the underlying change in adpatation/vulnerability, this figure can deviate significantly.

Titel: Perceptions of Climate Change and Health Risks among Urban 2
Older Adults in Mexico City: A Pilot Study.
=> given that your survey focuses on the experience of the environment and only indirectly addresses climate change through some of the items, I the title may be misleading.

Author Response

Please see word attached for responses.

Regards

The Authors

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

I appreciate the authors' responses to the reviewers' comments. My concerns have been adequately addressed, and the quality of the paper has significantly improved. I recommend its publication.

Author Response

Reviewer 2 stated that no further changes were needed in round 2. All relevant concerns were addressed. 

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

The study describes a "pilot study" in which some patients in one Month in 2025 were asked to fill out a survey on the perception of the environment and the feeling of the environment. It is assumed, that these changes of the environment can/is attributed to climate change (as the title suggests) rather than non-climate change related changes of the environment (e.g., urbanization). By classifying the study as a pilot study, the low number of cases, the non systematic approach of recruitement , the lack of representativeness ( I assume, the relationsship between the study population and the overall population is not described properly) can be justified. The tool used does not seem appropriate to capture the intention of exploring participants views on climate change (rather than the environment, environmental change, and human-environment interaction in general). As written previously, the text could and should be condensed and shorten. In particular the introduction, It still contains a lot of irrelevant information and does not help the reader orient in the article. It seems to be shortended by 2 sentences since I recommended this the past revision. While some more information was added (including, a change in the recruitement period) I still have no clear picture how the recuitement process took place.

Author Response

Please find attached responses to reviewer.

Author Response File: Author Response.pdf