Review Reports - Weaker Association Between Financial Security and Health in the Global South

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This Reviewer commends the authors for a very informative study. The following are a few minor recommendations for the authors to consider:

Abstract: This Reviewer found the abstract to be very well-written as it provides an enticing summary of the manuscript. Well done!

Page 5, Table 1: The columns in the table are mis-aligned with the headers on the tables making it (initially) difficult to comprehend. Recommend aligning the columns with the headers for clarity.

Page 6, Table 2: Same recommendation as above.

Page 6, Table 3: Same recommendation as above.

Page 8, Table 5: Same recommendation as above.

Concluding comments: This Reviewer commends the Authors for a very thorough and interesting study. The data presented in this analysis fully support the Authors’ conclusions and recommendations. The conclusions drawn by the Authors are accurate and the description of study limitations and recommendations for future study were descriptive and much appreciated. This Reviewer looks forward to these minor revisions as well as to follow-on studies. Thank you.

Author Response

Table: Reviewer 1 Comments and Author Responses

Reviewer 1 Comment	Author Response
Abstract: Well-written and effectively summarizes the manuscript.	Thank you. We appreciate the positive feedback and have retained the abstract as originally submitted.
Table 1 (Page 5): The columns are misaligned with the headers, making it initially difficult to read.	We have revised Table 1 to ensure column alignment with headers. This should improve clarity and ease of interpretation.
Table 2 (Page 6): Same issue with alignment.	Table 2 has been corrected. All columns now properly align with their respective headers.
Table 3 (Page 6): Same alignment issue.	Table 3 has been reformatted to ensure column-header alignment and consistent spacing.
Table 5 (Page 8): Same alignment issue.	Table 5 has been revised for consistency and improved readability. All formatting issues have been addressed.
Conclusion and Overall Comments: Commends the study's thoroughness and the clarity of conclusions and limitations. Encourages minor revisions and future research.	Thank you for the thoughtful and supportive comments. We have made the recommended formatting corrections and appreciate the encouragement for further work.

Table: Reviewer 2 Comments and Author Responses

Reviewer 2 Comment	Author Response
Novelty Concern: The research question may appear familiar; please reframe for novelty.	We have revised the introduction to better highlight the novelty of this work, specifically the application of MDR theory across a global sample using subjective SES and combined self-rated health outcomes—an approach not previously taken in international studies.
Clarify Mechanisms of Subjective SES Effects: Clarify and cite how subjective SES affects physical and mental health.	We added a paragraph in the discussion explaining proposed pathways linking subjective SES with health, including chronic stress, perceived control, and social comparison processes. Supporting citations (e.g., Adler et al., 2000; Singh-Manoux et al., 2005) have been added.
Combined Health Outcome Justification: Justify merging mental and physical SRH.	We added a justification to the methods and discussion. The high correlation and Cronbach’s alpha > 0.7 supported the internal consistency. Additionally, literature suggests that individuals often apply a unified evaluative framework when rating different health domains. Citations have been added to support this decision.
Lack of Confounder Control: No adjustment for education, income, urbanicity, etc.	We acknowledge this limitation and have expanded the discussion to note the potential confounding effects of these omitted variables. This limitation is now clearly stated with implications for interpretation.
Binary Global North/South Critique: The classification is too broad.	We agree and now explicitly acknowledge this limitation. The discussion has been updated to note that multilevel or country-specific models would better capture heterogeneity, though our sample size limited this approach.
Speculative Claims in Discussion: Structural explanations not tested; frame more cautiously.	We revised speculative statements to use more cautious language and added citations where structural explanations are mentioned. These include references on inequality, institutional quality, and healthcare disparities.
Define “Marginalized” and “Disadvantaged”: These terms are vague across countries.	We now define these terms early in the manuscript and clarify their context-specific usage, particularly when discussing international differences.
Missing Citations in Discussion: Add evidence on racism, inequality, MDRs, etc.	We added several references to support discussion points regarding structural inequality, MDRs, and contextual effects. These include prior studies applying MDR theory in U.S. and international settings.
Data Quality and Table Comments: Tables are clear; caution not to overstate correlations.	Thank you. We now note explicitly in the discussion that correlations were modest and should be interpreted with caution. The cross-sectional design has also been flagged more clearly as a limitation.

Reviewer 2 Report

Comments and Suggestions for Authors

The research question addressed by the manuscript is already known fact that is known from previous research. What is novel here? It can be reconsidered after reframing the research question to something novel.

What is the main question addressed by the research?

The study investigates whether the association between subjective socioeconomic status (SES)—measured via perceived financial and basic needs security—and self-rated mental and physical health differs between countries in the Global North and Global South. The authors hypothesize that the strength of this association is systematically weaker in Global South countries, reflecting a global pattern of "diminished returns" on perceived SES.

What parts do you consider original or relevant to the field? What specific gap in the field does the paper address?

This paper is original in applying the theory of Marginalization-related Diminished Returns (MDRs) at a global scale, moving beyond race or ethnicity within single countries to compare structural outcomes across geopolitical regions. The focus on subjective SES and its health implications in cross-national data fills an underexplored gap in global public health and social determinants research.

What does it add to the subject area compared with other published material?

The paper uses data from the Global Flourishing Study (n ≈ 207,000) across 23 countries to empirically show that perceived SES is associated with self-rated health worldwide, but that this association is stronger in the Global North. This supports the idea that broader contextual factors may limit the health benefits of perceived financial and social security in lower-resource settings.

What specific improvements should the authors consider regarding the methodology?

Clarify the mechanism by which subjective SES is proposed to influence both mental and physical health, particularly the latter. Include relevant citations to support these pathways.
Justify the use of a combined outcome variable that merges self-rated mental and physical health. These are conceptually and empirically distinct domains, and combining them risks obscuring specific associations. Provide validation or literature to support this approach.
The analysis does not control for key potential confounders—such as education, employment, household income, urban/rural location, social norms, political context, or healthcare access—which could bias results. These should be discussed as limitations.
The binary Global North/South classification is overly broad and masks substantial heterogeneity. Acknowledge this in the limitations or consider multilevel or country-specific models.

Are the conclusions consistent with the evidence and arguments presented? Were all the main questions posed addressed? By which specific experiments?

The statistical results support the paper's primary claim: subjective SES is positively associated with self-rated health, and this relationship is weaker in the Global South. However, the conclusions rely heavily on speculative explanations (e.g., weak institutions, structural inequality) that are not directly tested. These claims should be framed more cautiously and supported by literature. Additionally:

The terms “marginalized” and “disadvantaged” should be clearly defined, as their meaning varies across countries.
The discussion references factors like racism, segregation, and inequality in relation to minority groups, but lacks citations. Statements such as "racial and ethnic minorities often experience weaker protective effects..." must be backed by evidence.

Are the references appropriate?

The references cited in the introduction and methods are mostly appropriate and relevant. However:

The discussion section lacks sufficient citations to support many of its claims, particularly those concerning structural inequality, political instability, and social adversity in the Global South.
The authors should also cite literature justifying the use of subjective SES, combined health outcomes, and the concept of diminished returns across international settings.

Any additional comments on the tables and figures and the quality of the data

Tables are clearly organized and generally easy to interpret.
The data quality is high due to the large and diverse sample, but the cross-sectional nature of the data limits causal inference. This should be emphasized more strongly in the discussion.
Table 3 (correlations) is informative, but relationships are modest. The authors should be careful not to overstate them.

Author Response

Table: Reviewer 2 Comments and Author Responses

Reviewer 2 Comment	Author Response
Novelty Concern: The research question may appear familiar; please reframe for novelty.	We have revised the introduction to better highlight the novelty of this work, specifically the application of MDR theory across a global sample using subjective SES and combined self-rated health outcomes—an approach not previously taken in international studies.
Clarify Mechanisms of Subjective SES Effects: Clarify and cite how subjective SES affects physical and mental health.	We added a paragraph in the discussion explaining proposed pathways linking subjective SES with health, including chronic stress, perceived control, and social comparison processes. Supporting citations (e.g., Adler et al., 2000; Singh-Manoux et al., 2005) have been added.
Combined Health Outcome Justification: Justify merging mental and physical SRH.	We added a justification to the methods and discussion. The high correlation and Cronbach’s alpha > 0.7 supported the internal consistency. Additionally, literature suggests that individuals often apply a unified evaluative framework when rating different health domains. Citations have been added to support this decision.
Lack of Confounder Control: No adjustment for education, income, urbanicity, etc.	We acknowledge this limitation and have expanded the discussion to note the potential confounding effects of these omitted variables. This limitation is now clearly stated with implications for interpretation.
Binary Global North/South Critique: The classification is too broad.	We agree and now explicitly acknowledge this limitation. The discussion has been updated to note that multilevel or country-specific models would better capture heterogeneity, though our sample size limited this approach.
Speculative Claims in Discussion: Structural explanations not tested; frame more cautiously.	We revised speculative statements to use more cautious language and added citations where structural explanations are mentioned. These include references on inequality, institutional quality, and healthcare disparities.
Define “Marginalized” and “Disadvantaged”: These terms are vague across countries.	We now define these terms early in the manuscript and clarify their context-specific usage, particularly when discussing international differences.
Missing Citations in Discussion: Add evidence on racism, inequality, MDRs, etc.	We added several references to support discussion points regarding structural inequality, MDRs, and contextual effects. These include prior studies applying MDR theory in U.S. and international settings.
Data Quality and Table Comments: Tables are clear; caution not to overstate correlations.	Thank you. We now note explicitly in the discussion that correlations were modest and should be interpreted with caution. The cross-sectional design has also been flagged more clearly as a limitation.