Mental Health Symptoms and Alcohol Counseling Among Young Adults: Implications for Equitable Preventive Care

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I would like to thank the authors for the opportunity to review this manuscript. The topic addressed is both relevant and timely, contributing to the understanding of patient–provider communication and its relationship with mental health indicators among young adults, including those identifying as plurisexual. The manuscript demonstrates conceptual and empirical value. However, several areas require clarification and improvement to strengthen its overall coherence, methodological transparency, and alignment across sections.

Specific Comments

Title

1. I suggest revising the title to better reflect the overall focus of the study rather than emphasizing implications for plurisexual individuals. The manuscript covers broader content and does not primarily focus on implications for this population.

Abstract

1. The abstract appears somewhat disconnected from the title, as it highlights results without sufficiently contextualizing the focus on plurisexual individuals. Greater alignment between the title, objectives, and abstract would improve coherence.

Introduction

1. Line 65: Please clarify whether the term “gender” refers to gender identity, as these are distinct constructs.

2. The study’s aims or hypotheses are not clearly stated. Their inclusion is essential to evaluate the logical consistency and adequacy of the following sections.

Methods

1. The design of the secondary data analysis is not described. 

2. Line 112: I recommend using the term monosexual instead of mono- to avoid confusion, as the abbreviated term is not widely recognized.

3. For consistency, consider formatting all section subtitles in uppercase letters.

Results

1. The introduction of ethnicity in the results section is confusing, as ethnicity and its intersections were not described or contextualized in earlier sections. Clarifying this addition or integrating it throughout the manuscript would improve conceptual consistency.

Discussion

1. The discussion introduces topics on ethnic and racial disparities that were not mentioned in the introduction. This weakens the internal coherence of the manuscript. I recommend aligning the discussion with previously defined concepts and study aims.

Figures

1. The figures should be provided in higher resolution to ensure readability and professional presentation.

The inclusion of clearly defined study aims or hypotheses is a critical component of any empirical manuscript. The aims serve as the conceptual foundation that connects the introduction, methods, results, and discussion. Without them, it becomes exceedingly difficult for reviewers or readers to evaluate the consistency, relevance, and scientific rigor of the study. The absence of explicit aims not only limits interpretability but also weakens the overall logical flow between sections. Clear articulation of the study’s objectives would therefore significantly enhance the clarity and impact of this work.

Author Response

Reviewer 1

Comments and Suggestions for Authors

COMMENT 1: I would like to thank the authors for the opportunity to review this manuscript. The topic addressed is both relevant and timely, contributing to the understanding of patient–provider communication and its relationship with mental health indicators among young adults, including those identifying as plurisexual. The manuscript demonstrates conceptual and empirical value. However, several areas require clarification and improvement to strengthen its overall coherence, methodological transparency, and alignment across sections.

RESPONSE 1: We thank the reviewer for their thoughtful and constructive feedback. We appreciate the recognition of the manuscript’s conceptual and empirical contributions to understanding patient–provider communication and its relationship with mental health among young adults. In response to the reviewer’s comments, we have carefully revised the manuscript to improve clarity, strengthen methodological transparency, and ensure greater alignment and coherence across all sections. We believe these revisions have enhanced the overall quality and readability of the paper.

Specific Comments

COMMENT 2:

Title

1. I suggest revising the title to better reflect the overall focus of the study rather than emphasizing implications for plurisexual individuals. The manuscript covers broader content and does not primarily focus on implications for this population.

RESPONSE 2: Thank you for your comment. To incorporate the findings of the broader content, the title has been revised as: “Mental Health Symptoms and Alcohol Counseling among Young Adults: Implications for Equitable Preventive Care”.

COMMENT 3:

Abstract

1. The abstract appears somewhat disconnected from the title, as it highlights results without sufficiently contextualizing the focus on plurisexual individuals. Greater alignment between the title, objectives, and abstract would improve coherence.

RESPONSE 3: We appreciate the reviewer’s insightful observation regarding the need for stronger alignment between the title, objectives, and abstract. In response, we have revised the title to better reflect the overall study focus while still acknowledging sexual identity differences. The new title is: “Mental Health Symptoms and Alcohol Counseling among Young Adults: Implications for Equitable Preventive Care” and the abstract has been edited as follows:

“Young adulthood is a critical period for preventing alcohol-related harm, as heavy drinking and mental health challenges often peak, yet preventive counseling remains underused. This study examined associations between depressive and anxious symptoms and receipt of alcohol-related advice from healthcare providers among U.S. young adults aged 18–29, with attention to differences across sexual identity groups. Data came from the 2022 National Health Interview Survey (N=2,256). Weighted logistic regressions estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Overall, 49.0% of participants reported receiving alcohol advice. Odds were higher among lesbian/gay participants (aOR=1.81; 95% CI: 1.03–3.18) and those with severe anxiety symptoms (aOR=2.10; 95% CI: 1.11–3.94). Interaction effects indicated disparities by sexual identity, with plurisexual males showing the lowest predicted probability of receiving advice when meeting the clinical threshold for anxiety (20.9% vs. 62.4% for monosexual individuals). Findings underscore the need to strengthen alcohol-related counseling and integrate mental health screening in preventive care for diverse young adult populations.”

COMMENT 4:

Introduction

1. Line 65: Please clarify whether the term “gender” refers to gender identity, as these are distinct constructs.

RESPONSE 4: Thank you for catching this omission. The sentence now reads: “Recent extensions of the model incorporate structural stigma and intersectional marginalization, which posits that identities like sexual orientation and gender identity can create compounding, unique forms of disadvantage, as key drivers of SM health disparities.

COMMENT 5:

1. The study’s aims or hypotheses are not clearly stated. Their inclusion is essential to evaluate the logical consistency and adequacy of the following sections.

RESPONSE 5: We thank the reviewer for this helpful suggestion. We agree that the study’s aims and hypotheses should be clearly articulated to strengthen the logical flow and coherence across sections. We have therefore added this statement in paragraph at the end of the Introduction to explicitly state the study’s objectives and hypotheses:

“The present study aimed to examine associations between depressive and anxious symptom severity and receipt of alcohol-related advice from healthcare providers among U.S. young adults aged 18–29. A secondary aim was to explore whether these associations differed by sexual identity. We hypothesized that (1) higher levels of depressive and anxious symptoms would be associated with greater likelihood of receiving alcohol-related counseling, and (2) disparities would emerge by sexual identity, with plurisexual males being less likely to receive alcohol-related advice compared to monosexual peers.”

COMMENT 6:

Methods

1. The design of the secondary data analysis is not described. 

RESPONSE 6: We thank the reviewer for noting the need to clarify the study design. We have revised the Materials and Methods section to explicitly describe the study as a cross-sectional secondary data analysis using nationally representative data from the 2022 National Health Interview Survey (NHIS). The following sentence has been added to the beginning of the subsection now titled Study Design and Data:

“This study used a cross-sectional, secondary data analysis design based on the 2022 National Health Interview Survey (NHIS), a nationally representative dataset collected by the National Center for Health Statistics. The analysis examined associations between mental health symptom severity and receipt of alcohol-related advice from healthcare providers among U.S. young adults aged 18–29.”

COMMENT 7:

1. Line 112: I recommend using the term monosexual instead of mono- to avoid confusion, as the abbreviated term is not widely recognized.

RESPONSE 7: We thank the reviewer for this helpful clarification. We have replaced all instances of the abbreviated term “mono-” with the full term “monosexual” throughout the manuscript to enhance clarity and ensure consistency in terminology.

COMMENT 8:

1. For consistency, consider formatting all section subtitles in uppercase letters.

RESPONSE 8: We appreciate the reviewer’s attention to formatting consistency. We have revised the manuscript so that all main section subtitles are numbered and in uppercase letters as suggested and aligned with other articles in the journal.

COMMENT 9:

Results

1. The introduction of ethnicity in the results section is confusing, as ethnicity and its intersections were not described or contextualized in earlier sections. Clarifying this addition or integrating it throughout the manuscript would improve conceptual consistency.

RESPONSE 9: We thank the reviewer for this valuable observation. We agree that the introduction of race and ethnicity variables in the Results section required clearer context earlier in the manuscript. To address this, we have revised the Introduction to include a brief discussion of known racial and ethnic disparities in preventive alcohol counseling and healthcare access among young adults. This addition provides conceptual grounding for the inclusion of ethnicity in the analyses and results.

“Previous research has also identified racial and ethnic disparities in preventive health counseling, with non-Hispanic Black, Hispanic, and multiracial adults less likely to receive alcohol screening or advice compared to non-Hispanic White peers  [11,15]. These inequities reflect broader patterns of differential access, provider bias, and systemic barriers in healthcare delivery. Including race and ethnicity in the present analysis allows for a more comprehensive understanding of how intersecting sociodemographic factors shape the likelihood of receiving alcohol-related advice.”

COMMENT 10:

Discussion

1. The discussion introduces topics on ethnic and racial disparities that were not mentioned in the introduction. This weakens the internal coherence of the manuscript. I recommend aligning the discussion with previously defined concepts and study aims.

RESPONSE 10: We thank the reviewer for this observation. We agree that introducing new concepts in the discussion can reduce coherence. To address this, we have revised the manuscript to better align with the concepts and study aims now presented in the introduction as noted above. Specifically, we now contextualize any mention of ethnic and racial disparities within the framework already established in the introduction, ensuring that all discussion points are consistent with the study’s objectives.

COMMENT 11:

Figures

1. The figures should be provided in higher resolution to ensure readability and professional presentation.

RESPONSE 11: We appreciate the reviewer’s feedback regarding figure quality. All figures have been regenerated at a higher resolution (600 dpi) to enhance clarity and ensure professional presentation. We verified that text labels, legends, and axis titles are fully legible in the revised versions. The updated high-resolution figures have been uploaded with the revised manuscript.

COMMENT 12: The inclusion of clearly defined study aims or hypotheses is a critical component of any empirical manuscript. The aims serve as the conceptual foundation that connects the introduction, methods, results, and discussion. Without them, it becomes exceedingly difficult for reviewers or readers to evaluate the consistency, relevance, and scientific rigor of the study. The absence of explicit aims not only limits interpretability but also weakens the overall logical flow between sections. Clear articulation of the study’s objectives would therefore significantly enhance the clarity and impact of this work.

RESPONSE 12: We thank the reviewer for emphasizing the importance of clearly defined study aims and hypotheses. In the revised manuscript, we have explicitly articulated the primary and secondary study aims in the introduction. The primary aim is to examine associations between depressive and anxious symptom severity and receipt of alcohol-related advice from healthcare providers among U.S. young adults aged 18–29. The secondary aim is to explore whether these associations differ by sexual identity. We also included two specific hypotheses: (1) higher levels of depressive and anxious symptoms would be associated with greater likelihood of receiving alcohol-related counseling, and (2) disparities would emerge by sexual identity, with plurisexual males being less likely to receive alcohol-related advice compared to monosexual peers. These explicit aims and hypotheses now provide a clear conceptual foundation that guides the methods, results, and discussion, enhancing the coherence, interpretability, and scientific rigor of the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

It would be worth listing somewhere exactly what your hypothesis or research question is. That would clarify for readers the gap in the literature you are trying to fill. Doing this would also make sure the authors can make their language consistent, whether they are looking at correlations, associations, causal relationships, etc. At the moment, that is not completely clear.

Is there any literature to support the way you handled sex assigned at birth and sexual identity? If so, it would be worth citing to show that this has been done before. If not, it would be worth stating that as well. I am guessing that transgender was not a question, since it is not mentioned, but that is something that could be addressed in the future research/limitations section.

Author Response

COMMENT 1: It would be worth listing somewhere exactly what your hypothesis or research question is. That would clarify for readers the gap in the literature you are trying to fill. Doing this would also make sure the authors can make their language consistent, whether they are looking at correlations, associations, causal relationships, etc. At the moment, that is not completely clear.

RESPONSE 1: We appreciate the reviewer’s suggestion to explicitly state the study hypotheses and research questions. In the revised manuscript, we have clearly listed the study’s primary and secondary aims in the introduction. The primary aim is to examine associations between depressive and anxious symptom severity and receipt of alcohol-related advice from healthcare providers among U.S. young adults aged 18–29. The secondary aim is to explore whether these associations differ by sexual identity. Corresponding hypotheses are also now explicitly stated: (1) higher levels of depressive and anxious symptoms will be associated with a greater likelihood of receiving alcohol-related counseling, and (2) disparities will emerge by sexual identity, with plurisexual males being less likely to receive alcohol-related advice compared to monosexual peers. Including these explicit aims and hypotheses clarifies the gap in the literature the study addresses and ensures consistent language regarding associations rather than causal claims throughout the manuscript.

COMMENT 2: Is there any literature to support the way you handled sex assigned at birth and sexual identity? If so, it would be worth citing to show that this has been done before. If not, it would be worth stating that as well. I am guessing that transgender was not a question, since it is not mentioned, but that is something that could be addressed in the future research/limitations section.

RESPONSE 2: We thank the reviewer for this insightful comment. The NHIS 2022 dataset did not include items on gender identity beyond sex assigned at birth, and therefore transgender, nonbinary, and other gender-diverse populations could not be identified in this analysis. Regarding the handling of sex assigned at birth and sexual identity, our approach follows prior research in population-based surveys examining sexual minority health, where collapsing small categories into monosexual versus plurisexual groups is a common strategy to ensure sufficient cell sizes for meaningful analyses. We have now added citations to support this approach in the Methods section: “As the number of categories produced small cell sizes, these identities were further reduced to monosexual, including those who identified as lesbian, gay, or straight, and plurisexual, bisexual males and bisexual females consistent with previous literature noting these terms and distinctions [24].”

Additionally, we have clarified in the Limitations that the absence of gender identity items constrains our ability to examine the experiences of transgender and other gender-diverse young adults, and we suggest this as an area for future research with the following:

“Fifth, the SM categories in NHIS do not capture the full complexity of sexual orientation, gender identity, or expression, potentially obscuring important nuances in healthcare experiences among transgender, nonbinary, and other individuals not captured in these categories due to the evolving refinement of these items in population survey research including the problematic use of the term “straight” for monosexual, heterosexual individuals.”

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript is conceptually rich and empirically rigorous. Nonetheless, I recommend addressing the intersection between mental health, sexual identity, and access to preventive healthcare, a crucial yet often underexplored area.

To strengthen the manuscript further: Firstly, the discussion could more explicitly link intersectionality and minority stress frameworks to the observed disparities, showing how structural and provider-level biases intersect. Secondly, a more detailed reflection on how clinicians and policymakers can operationalize these findings (e.g., through SBIRT adaptation, inclusive training) would enhance the applied relevance. Thirdly, the decision to collapse sexual identity categories is understandable but warrants further justification and acknowledgment of potential oversimplifications of identity diversity. Finally, given the distinct disadvantage experienced by plurisexual males, discussing how masculinity norms and provider perceptions intersect with sexual identity would deepen the sociopsychological interpretation.

Overall, this is a valuable, original, and socially significant contribution that will interest readers in public health, gender studies, and social psychology.

Author Response

COMMENT 1: The manuscript is conceptually rich and empirically rigorous. Nonetheless, I recommend addressing the intersection between mental health, sexual identity, and access to preventive healthcare, a crucial yet often underexplored area.

To strengthen the manuscript further: Firstly, the discussion could more explicitly link intersectionality and minority stress frameworks to the observed disparities, showing how structural and provider-level biases intersect. Secondly, a more detailed reflection on how clinicians and policymakers can operationalize these findings (e.g., through SBIRT adaptation, inclusive training) would enhance the applied relevance. Thirdly, the decision to collapse sexual identity categories is understandable but warrants further justification and acknowledgment of potential oversimplifications of identity diversity. Finally, given the distinct disadvantage experienced by plurisexual males, discussing how masculinity norms and provider perceptions intersect with sexual identity would deepen the sociopsychological interpretation.

These revisions aim to enhance the conceptual clarity, applied relevance, and interpretive depth of the manuscript while maintaining the empirical rigor of our analysis.

Overall, this is a valuable, original, and socially significant contribution that will interest readers in public health, gender studies, and social psychology.

RESPONSE 1: We sincerely thank the reviewer for the thoughtful and constructive feedback. In response, we have substantially revised the Discussion to enhance the manuscript’s conceptual clarity, applied relevance, and interpretive depth while maintaining empirical rigor. Specifically, at the end of the discussion we:

1. Integrated intersectionality and minority stress frameworks to clarify how structural and provider-level biases intersect to produce disparities.
2. Expanded the applied implications by discussing how clinicians and policymakers can operationalize these findings through culturally responsive SBIRT adaptations, inclusive provider training, and equity-oriented policies.
3. Acknowledged limitations of collapsing sexual identity categories and discussed potential oversimplifications of sexual identity diversity, emphasizing the need for future disaggregated analyses.
4. Elaborated on the disadvantages among plurisexual males, linking masculinity norms and provider perceptions of sexual identity to healthcare inequities.

We sincerely appreciate the reviewer’s thoughtful and constructive feedback. We have carefully addressed each comment to strengthen the manuscript’s conceptual clarity, applied relevance, and interpretive depth while maintaining the integrity and rigor of our empirical analysis. We are grateful for the recognition of the study’s originality and social significance and for the reviewer’s acknowledgment of its relevance to public health, gender studies, and social psychology. These insights have been invaluable in refining the manuscript and enhancing its contribution to the literature.

Reviewer 4 Report

Comments and Suggestions for Authors

Dear authors.

I hope you are fine. Thank you for the opportunity to review your manuscript. The study addresses a highly relevant topic in youth. The text is well written. Congratulations for your work. Nevertheless, some aspects could be refined.

 

/ Abstract:

• Please, include the final sample (N).
• It is not necessary to report all the statistics values.

 

/ Introduction:

• The Minority Stress Model is well explained. However, its connection to the study´s aim should be strengthened to clarify its theoretical implications.
• In the final paragraph, the study´s aim and research gap are adequately presented. However, the hypotheses should be stated in alignment with the existing literature. Moreover, the original contribution is important (mental health and plurisexual populations) but not showed.

 

/ Method:

• It is recommended to include a sample item from both GAD-7 and PHQ-8. Furthermore, it would be valuable to report the Cronbach´s alpha coefficient for each measure.
• Provide more details on how missing data were handled, the criteria of exclusion, and any imputation procedures were considered.

 

/ Results:

• Please ensure that a space is included between the statistical symbol and its value (e.g. p < 0.001; aOR = 0.76).
• It is suggested to write “Figure 1/2”, instead of “Fig. 1/2” for consistency with the journal’s formatting style.
• It appears Table 2, but is not discussed in the main text. Ensure all tables are referenced.

 

/ Discussion:

• The text is well structured. However, it would be Benefit from a more analytical integration of the findings with prior studies. Some sections are more descriptively than interpretatively.
• The practical and policy implications could be presented in an explicit manner. Please, consider to add a short paragraph that outlines examples of how these results can support clinical practice or health policy.
• The final of Conclusion could be reinforced to better highlight the originality and social relevance of the findings.

 

/ References:

• The references should be revised to ensure alignment with the journal´s guide.

 

I hope these suggest are helpful.

Best regards.

Author Response

COMMENT 1: / Abstract:

• Please, include the final sample (N).
• It is not necessary to report all the statistics values.

RESPONSE 1: We appreciate the reviewer’s helpful suggestions. We have now clarified that the N reflects the final analytic sample based on the age inclusion criterion, as follows:

“Data were drawn from the 2022 National Health Interview Survey, with a final analytic sample of participants aged 18–29 (N = 2,256).”

In addition, we streamlined the Results section of the abstract by retaining only the key statistics necessary to convey the main findings, removing excessive statistical detail to improve readability and focus.

 

COMMENT 2: / Introduction:

• The Minority Stress Model is well explained. However, its connection to the study´s aim should be strengthened to clarify its theoretical implications.
• In the final paragraph, the study´s aim and research gap are adequately presented. However, the hypotheses should be stated in alignment with the existing literature. Moreover, the original contribution is important (mental health and plurisexual populations) but not showed.

RESPONSE 2: We appreciate the reviewer’s insightful feedback. In the revised Introduction, we strengthened the connection between the Minority Stress Model and the study’s aims by elaborating on how minority stress processes, such as internalized stigma, expectations of rejection, and discriminatory healthcare experiences, may shape the likelihood of receiving alcohol-related counseling among sexual minority (SM) young adults. We now explicitly explain that this framework provides the theoretical foundation for examining how intersecting stressors related to mental health and sexual identity influence preventive care engagement.

We also revised the final paragraph to align the hypotheses more closely with prior literature and to highlight the study’s novel contribution. Specifically, we emphasize the gap in understanding how depressive and anxious symptom severity interact with sexual identity to affect alcohol-related advice receipt, particularly among plurisexual males, a group shown in previous research to face unique barriers to care and invisibility within both heterosexual and sexual minority populations. The revised text now reads:

“Guided by the Minority Stress Model, this study examined how depressive and anxious symptoms relate to receiving alcohol-related advice from healthcare providers among U.S. young adults aged 18–29, with attention to differences across sexual identity groups. We hypothesized that (1) higher levels of depressive and anxious symptoms would be associated with greater likelihood of receiving alcohol-related counseling, and (2) disparities would emerge by sexual identity, with plurisexual males being less likely to receive such advice compared to monosexual peers. This study extends existing literature by integrating minority stress theory into the context of preventive care engagement, providing new insights into mental health and alcohol-related counseling disparities among plurisexual young adults.”

COMMENT 3: / Method:

• It is recommended to include a sample item from both GAD-7 and PHQ-8. Furthermore, it would be valuable to report the Cronbach´s alpha coefficient for each measure.
• Provide more details on how missing data were handled, the criteria of exclusion, and any imputation procedures were considered.

In response to the suggestion, a sample item from each scale has been added, and reliability statistics are now reported:

RESPONSE 3: “The GAD-7 assesses core symptoms of generalized anxiety such as excessive worry, restlessness, and difficulty relaxing (e.g., “How often have you been bothered by feeling nervous, anxious, or on edge in the past two weeks?”). The PHQ-8 measures depressive symptoms including loss of interest or pleasure and low mood (e.g., “How often have you been bothered by feeling down, depressed, or hopeless in the past two weeks?”). Scores on both scales were categorized as none/minimal, mild, moderate, or severe, based on established clinical cut-points. Internal consistency was high for both instruments: GAD-7 (Cronbach’s α = .86) and PHQ-8 (Cronbach’s α = .90), indicating strong reliability and supporting the use of total scale scores.”

 

Missing data were handled using listwise deletion; participants with missing responses on any of the GAD-7 or PHQ-8 items were excluded from the respective analyses. No imputation procedures were applied, as the proportion of missing data was minimal (<5%).

COMMENT 4: / Results:

• Please ensure that a space is included between the statistical symbol and its value (e.g. p < 0.001; aOR = 0.76).
• It is suggested to write “Figure 1/2”, instead of “Fig. 1/2” for consistency with the journal’s formatting style.
• It appears Table 2, but is not discussed in the main text. Ensure all tables are referenced.

RESPONSE 4: Thank you for these helpful formatting and clarity suggestions. All statistical symbols have been revised to include a space between the symbol and its value (e.g., p < .001; aOR = 0.76) for consistency. References to figures have been updated to “Figure 1” and “Figure 2” throughout the text in accordance with the journal’s preferred style. In addition, Table 2 is now explicitly discussed in the Results section to ensure that all tables are referenced in the main text.

COMMENT 5: / Discussion:

• The text is well structured. However, it would be Benefit from a more analytical integration of the findings with prior studies. Some sections are more descriptively than interpretatively.
• The practical and policy implications could be presented in an explicit manner. Please, consider to add a short paragraph that outlines examples of how these results can support clinical practice or health policy.
• The final of Conclusion could be reinforced to better highlight the originality and social relevance of the findings.

RESPONSE 5: We appreciate the reviewer’s thoughtful feedback on strengthening the Discussion and Conclusion sections. The revised Discussion now includes a more analytical integration of the findings with prior literature, emphasizing how the observed disparities align with and extend existing evidence on preventive counseling, minority stress, and intersectional health inequities. We have reduced overly descriptive passages and expanded interpretative commentary to highlight underlying mechanisms and theoretical implications.

Additionally, we have added a new paragraph that explicitly discusses the practical and policy implications of our results, including examples of how these findings can inform clinical training, targeted screening protocols, and equity-focused health system interventions. Finally, the Conclusion has been revised to more clearly emphasize the originality and social relevance of the study, underscoring its contributions to understanding how sexual identity and mental health intersect to shape access to preventive care among young adults.

COMMENT 6: / References:

• The references should be revised to ensure alignment with the journal´s guide.

RESPONSE 6: Thank you for the feedback. The reference list has been carefully reviewed and revised to ensure full compliance with the journal’s formatting guidelines, including citation style, punctuation, ordering, and use of italics as specified in the author instructions.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have thoroughly addressed all of my prior recommendations, and the revised manuscript reflects substantial improvement in clarity, rigor, and organization. The revisions strengthen both the conceptual framing and the methodological reporting, and the manuscript now meets the journal’s standards for publication. I have no further concerns.

Author Response

Comment 1: The authors have thoroughly addressed all of my prior recommendations, and the revised manuscript reflects substantial improvement in clarity, rigor, and organization. The revisions strengthen both the conceptual framing and the methodological reporting, and the manuscript now meets the journal’s standards for publication. I have no further concerns.

Response 1: We sincerely thank the reviewer for their thoughtful feedback and for recognizing the revisions made to improve the clarity, rigor, and organization of the manuscript. We are grateful for the reviewer’s time and valuable insights throughout this process.

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Authors.

Thank you for thoughtfully addressing my previous comments. The manuscript has improved considerably in both quality and content.

I have just a few minor recommendations for further improvement, which are primarily related to formatting:

• Abstract: Please insert a space in "aOR = 1.81" (to read "aOR = 1.81").
• p-values: Some p-values are not consistently italicized. Please check this, for example, in the captions for Figures 1, 2, 3, and 4.
• References: The reference list does not yet fully adhere to the journal´s guidelines. For example, journal names should be abbreviated and italicized, and the publication year should be in bold in articles. Please, review the journal´s guidelines.

 

I hope you find these final suggestions helpful.

Best regards.

Author Response

Comment 1: Thank you for thoughtfully addressing my previous comments. The manuscript has improved considerably in both quality and content.

Response 1: We appreciate the reviewer’s thoughtful reassessment of our manuscript. Thank you for recognizing the improvements made in response to your previous comments. Your feedback greatly strengthened the quality and clarity of this work.

I have just a few minor recommendations for further improvement, which are primarily related to formatting:

Comment 2: Abstract: Please insert a space in "aOR = 1.81" (to read "aOR = 1.81").

Response2: Thank you for pointing this out. We have added the space so that the text now reads “aOR = 1.81” and “aOR = 2.10” in the Abstract.

Comment 3: p-values: Some p-values are not consistently italicized. Please check this, for example, in the captions for Figures 1, 2, 3, and 4.

Response 3: Thank you for this observation. All figure titles were italicized consistent with APA formatting, but we have specifically moved the p-value from the figure title to a note below the figure with the corrected format for p-values for consistency.

Comment 4: References: The reference list does not yet fully adhere to the journal´s guidelines. For example, journal names should be abbreviated and italicized, and the publication year should be in bold in articles. Please, review the journal´s guidelines.

Response 4: Thank you for this helpful feedback. We have thoroughly revised the reference list to ensure full adherence to the journal’s formatting guidelines. Specifically, we have:

• Abbreviated and italicized all journal names according to the journal’s requirements.
• Reformatted all article citations so that the publication year appears in bold.
• Updated punctuation, ordering, and styling to maintain consistency throughout.
• We have carefully reviewed each reference against the journal’s style guide and corrected all remaining inconsistencies.