The Relationship Between Illusory Health Beliefs, Recommended Health Behaviours, and Complementary and Alternative Medicine: An Investigation Across Multiple Time Points

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. The study addresses a timely and important topic related to adolescents' mental health literacy and help-seeking intentions in the context of an educational intervention. 

However, while the study is framed within a contemporary and socially significant issue, its theoretical positioning and conceptual justification remain underdeveloped. For instance, the manuscript references Bandura’s self-efficacy theory and constructs related to mental health literacy but stops short of elaborating on how these constructs interact within a coherent model. There is a noticeable lack of critical engagement with competing frameworks or relevant recent scholarship, such as dual-process theories of behavior or other models of health behavior change, which might offer valuable explanatory dimensions for help-seeking intentions. Moreover, the rationale for focusing specifically on the mediating role of self-efficacy—rather than, for example, attitudes, perceived norms, or emotional coping—is not sufficiently defended. This weakens the conceptual sharpness of the study and raises questions about the specificity and novelty of the proposed model.

The manuscript outlines a quasi-experimental pre-post design with a short time interval and utilizes validated scales to measure mental health knowledge, self-efficacy, psychological distress, and help-seeking intentions. While the selection of these instruments is appropriate, the articulation of research questions and hypotheses is overly concise and somewhat ambiguous. Notably, the directionality and expected relationships among the variables are not made fully explicit in the text. The authors refer to mediation analysis but do not clearly specify the theoretical rationale behind choosing self-efficacy as a mediator between knowledge and help-seeking intentions, nor do they account for potential covariates or confounding factors.

In addition, the rationale for using repeated measures ANOVA and bootstrapped mediation should be more clearly justified, especially considering the small sample size (n=102) and the absence of a control group. The short interval between measurements may also be insufficient to capture meaningful changes in psychological constructs, particularly in educational or behavioral interventions of this nature.

Clearly formulate and number the research questions and corresponding hypotheses. Explicitly state the expected direction of the effects.

Justify the choice of self-efficacy as a mediator in more depth. Why is it considered the central mechanism of change? Could other constructs be equally relevant?

Discuss the limitations associated with the absence of a control group and how this affects causal inference.

Reconsider whether the short time frame allows for meaningful changes in internal variables such as psychological distress or intentions, or at least acknowledge this limitation explicitly.

Provide more detailed information on how assumptions for ANOVA and bootstrapping were tested and met, including treatment of missing data and potential outliers.

The results section is generally well-structured and includes appropriate statistical tests. The authors clearly report model fit indices, path coefficients, and standard errors, which speaks to a competent understanding of advanced quantitative methods. However, several issues merit further attention. First, while statistical output is comprehensive, interpretation remains overly descriptive in places. The theoretical significance of key findings—such as the negative predictive path from illusory health beliefs to recommended health behaviours is insufficiently unpacked. The finding that IHBs decrease over time and are negatively associated with RHBs could have substantial theoretical implications for models of health behaviour, yet the discussion lacks critical depth on this point. Second, the presentation of cross-lagged effects would benefit from visual summarization. The complex relationships among multiple variables across time points may overwhelm readers without the support of conceptual diagrams or summarized models. Additionally, while the authors mention measurement invariance, the results of these tests are not sufficiently detailed. Readers are left unsure whether the constructs are fully comparable across waves. Given the importance of longitudinal consistency, this omission weakens confidence in the temporal conclusions drawn.

Move beyond statistical reporting and engage more deeply with the theoretical implications of key effects. For example, what does the weakening of IHBs over time suggest about their cognitive structure? How might this relate to real-world health messaging or resistance to pseudoscientific beliefs?

Clarify whether full or partial measurement invariance was established across time points. Provide model comparisons or fit statistics (e.g., ΔCFI, RMSEA) to support this claim.

Incorporate at least one path diagram or simplified visual summary of the cross-lagged model to support interpretation.

Where applicable, discuss practical significance—not just statistical significance—especially in regard to the potential behavioral outcomes linked to CAM use and trust in medicine.

The discussion summarizes key findings but lacks depth in theoretical interpretation and practical implications. Explanations of mechanisms (e.g. cognitive rigidity) are mentioned without anchoring in established theories. The potential policy relevance is asserted but remains vague, and limitations are only briefly acknowledged.

Integrate established theoretical frameworks to support interpretations (e.g., dual-process models, belief persistence).

Clarify how findings could inform public health strategies, particularly in countering pseudoscientific beliefs.

Expand discussion of limitations and provide concrete directions for future research.

I hope these comments will be of assistance in strengthening the manuscript’s conceptual clarity and deepening its academic impact.

Author Response

Reviewer Comments

1. Thank you for the opportunity to review this manuscript. The study addresses a timely and important topic related to adolescents' mental health literacy and help-seeking intentions in the context of an educational intervention. 

However, while the study is framed within a contemporary and socially significant issue, its theoretical positioning and conceptual justification remain underdeveloped. For instance, the manuscript references Bandura’s self-efficacy theory and constructs related to mental health literacy but stops short of elaborating on how these constructs interact within a coherent model. There is a noticeable lack of critical engagement with competing frameworks or relevant recent scholarship, such as dual-process theories of behavior or other models of health behavior change, which might offer valuable explanatory dimensions for help-seeking intentions. Moreover, the rationale for focusing specifically on the mediating role of self-efficacy—rather than, for example, attitudes, perceived norms, or emotional coping—is not sufficiently defended. This weakens the conceptual sharpness of the study and raises questions about the specificity and novelty of the proposed model.

The manuscript outlines a quasi-experimental pre-post design with a short time interval and utilizes validated scales to measure mental health knowledge, self-efficacy, psychological distress, and help-seeking intentions. While the selection of these instruments is appropriate, the articulation of research questions and hypotheses is overly concise and somewhat ambiguous. Notably, the directionality and expected relationships among the variables are not made fully explicit in the text. The authors refer to mediation analysis but do not clearly specify the theoretical rationale behind choosing self-efficacy as a mediator between knowledge and help-seeking intentions, nor do they account for potential covariates or confounding factors.

In addition, the rationale for using repeated measures ANOVA and bootstrapped mediation should be more clearly justified, especially considering the small sample size (n=102) and the absence of a control group. The short interval between measurements may also be insufficient to capture meaningful changes in psychological constructs, particularly in educational or behavioral interventions of this nature.

Clearly formulate and number the research questions and corresponding hypotheses. Explicitly state the expected direction of the effects.

Justify the choice of self-efficacy as a mediator in more depth. Why is it considered the central mechanism of change? Could other constructs be equally relevant?

Discuss the limitations associated with the absence of a control group and how this affects causal inference.

Reconsider whether the short time frame allows for meaningful changes in internal variables such as psychological distress or intentions, or at least acknowledge this limitation explicitly.

Provide more detailed information on how assumptions for ANOVA and bootstrapping were tested and met, including treatment of missing data and potential outliers.

Response:

Thank you for these comments. However, after thorough review, we believe that these may relate to another study? Specifically, the current paper under review did not focus on self-efficacy nor use ANOVA.

2. The results section is generally well-structured and includes appropriate statistical tests. The authors clearly report model fit indices, path coefficients, and standard errors, which speaks to a competent understanding of advanced quantitative methods. However, several issues merit further attention. First, while statistical output is comprehensive, interpretation remains overly descriptive in places. The theoretical significance of key findings—such as the negative predictive path from illusory health beliefs to recommended health behaviours is insufficiently unpacked. The finding that IHBs decrease over time and are negatively associated with RHBs could have substantial theoretical implications for models of health behaviour, yet the discussion lacks critical depth on this point.

Second, the presentation of cross-lagged effects would benefit from visual summarization. The complex relationships among multiple variables across time points may overwhelm readers without the support of conceptual diagrams or summarized models. Additionally, while the authors mention measurement invariance, the results of these tests are not sufficiently detailed. Readers are left unsure whether the constructs are fully comparable across waves. Given the importance of longitudinal consistency, this omission weakens confidence in the temporal conclusions drawn.

Move beyond statistical reporting and engage more deeply with the theoretical implications of key effects. For example, what does the weakening of IHBs over time suggest about their cognitive structure? How might this relate to real-world health messaging or resistance to pseudoscientific beliefs?

Clarify whether full or partial measurement invariance was established across time points. Provide model comparisons or fit statistics (e.g., ΔCFI, RMSEA) to support this claim.

Incorporate at least one path diagram or simplified visual summary of the cross-lagged model to support interpretation.

Where applicable, discuss practical significance—not just statistical significance—especially in regard to the potential behavioral outcomes linked to CAM use and trust in medicine.

Response:

Thank you for these comments. Please note that we included a figure/conceptual diagram with the manuscript submission. In addition, longitudinal invariance was not assessed and would not be appropriate because constructs were not measured at multiple time points.

3. The discussion summarizes key findings but lacks depth in theoretical interpretation and practical implications. Explanations of mechanisms (e.g. cognitive rigidity) are mentioned without anchoring in established theories. The potential policy relevance is asserted but remains vague, and limitations are only briefly acknowledged.

Integrate established theoretical frameworks to support interpretations (e.g., dual-process models, belief persistence).

Clarify how findings could inform public health strategies, particularly in countering pseudoscientific beliefs.

Expand discussion of limitations and provide concrete directions for future research.

Response:

We have expanded on the theoretical links within the Discussion, including a subsection with references to dual-process theory, and public health strategies. Please note that this is a novel research area, and such links are exploratory. Additional suggestions for future research have also been included.

I hope these comments will be of assistance in strengthening the manuscript’s conceptual clarity and deepening its academic impact.

Response:

Thank you for your review and for the provided suggestions.

Reviewer 2 Report

Comments and Suggestions for Authors

This study explores the relationships between illusory health beliefs (IHBs), adoption of recommended health behaviors, and use of complementary and alternative medicine (CAM). The topic is within the scope of the journal and valuable in the fields of public health and psychology to understand individual’s decision making in health. The research design is solid by measuring at multiple time points and covering a large sample size, which ensure representativeness. A variety of established measurement scales, such as the IHBs Scale and the Multidimensional Health Locus of Control Scale (MHLOC), are used to illustrate reliability. The authors also conduct a comprehensive test using statistical modelling to analyze the direct and indirect relationships among variables. The methodology and research process are scientific and rigorous to support the results.

However, the Discussion section can be enhanced by considering the following: (1) clearly highlight the theoretical and practical implications of the research results. (2) Propose future research directions based on the research limitations. 

Author Response

Reviewer Comments

This study explores the relationships between illusory health beliefs (IHBs), adoption of recommended health behaviors, and use of complementary and alternative medicine (CAM). The topic is within the scope of the journal and valuable in the fields of public health and psychology to understand individual’s decision making in health. The research design is solid by measuring at multiple time points and covering a large sample size, which ensure representativeness. A variety of established measurement scales, such as the IHBs Scale and the Multidimensional Health Locus of Control Scale (MHLOC), are used to illustrate reliability. The authors also conduct a comprehensive test using statistical modelling to analyze the direct and indirect relationships among variables. The methodology and research process are scientific and rigorous to support the results.

However, the Discussion section can be enhanced by considering the following: (1) clearly highlight the theoretical and practical implications of the research results. (2) Propose future research directions based on the research limitations. 

Response:

Thank you for your review and for the provided suggestions. We have included a subsection within the paper referring to theoretical and practical implications. Please note that this is a novel research area, and such links are exploratory. Additional suggestions for future research have also been included.