Caregiver Burden, Emotional Distress, and Coping Strategies in Romanian Parents of Children with Autism Spectrum Disorder: An Exploratory Cross-Sectional Comparative Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Many thanks to the authors for their text, which is the result of an interesting and relevant study.
As this is the first review, I will provide feedback on each of the sections of their article

1. The title is clear and adequately represents the overall focus of the study. However, it could be more accurately phrased as a comparative exploratory or pilot study. This would help align the reader's expectations with the actual strength of the data.
2. The abstract presents the core components of the article: sample, instruments, analysis, and main findings. However, it should more clearly state that most of the main results are non-significant trends or small effects. It would also be advisable for the abstract to mention the existence of significant differences between groups in education and marital status, as these differences directly affect the interpretation of the results.
3. The introduction is well contextualized and reviews relevant literature on the burden on parents of children with ASD, emotional distress, the role of support systems, and coping strategies. However, the introduction could be improved in three areas. First, the specific research gap that justifies this study in Romania needs to be defined more precisely. Studies from various cultural contexts are mentioned, but it is not sufficiently clear what this local case contributes to the existing literature. Second, the introduction is somewhat lengthy and, at times, repetitive. Third, the objective could be formulated with greater analytical precision, clearly differentiating between comparisons between groups and exploratory analyses within the ASD group or the total sample.
4. The methodology is one of the sections that requires the most attention.
   1. First, the description of recruitment is confusing. It is noted that the participants were recruited from the same pediatric neurology and psychiatry clinic, but it is unclear how the controls were selected or whether they truly represent parents of typically developing children without health problems.
   2. Second, no sample size calculation or statistical power analysis is reported. This is important because several central results are non-significant or borderline. With 46 participants per group, the study may be underpowered to detect small or moderate differences.
   3. Third, the instruments are described in a basic way, but no internal reliability indicators are reported for the current sample. Since the CBI, DASS-21, and SACS were used, the authors should report at least Cronbach's alpha or omega for the scales and subscales used. This is especially important in the case of the SACS and its multiple subscales.
   4. Fourth, the statistical strategy is insufficient for the questions posed. t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests were used depending on the data distribution, but multivariate models were not applied. Since the groups differ significantly in education and marital status, the analyses should be adjusted for at least these variables. Without such adjustment, it is not possible to clearly attribute the observed differences to having a child with ASD.
   5. Fifth, there is a problem with the multiple comparisons. The study examines numerous associations between sociodemographic variables and coping subscales, but no control for type I error is reported. The authors themselves acknowledge this risk in the limitations section, but this should have clearer implications for the interpretation of the results.
5. Regarding the results, they are understandable, but present inconsistencies and problems of interpretation.
   1. Table 1 should be revised because there is an error in the t-value for the sex variable.
   2. There are scale inconsistencies in the DASS-21 results.
   3. Furthermore, the use of terms like "borderline higher anxiety" should be moderated. It can be described as an exploratory trend, but not as a conclusive finding.
   4. In the coping section, some results are problematic. For example, it is stated that parents with ASD reported less seeking of social support than controls, but the means are 49.26 ± 10.47 and 50.22 ± 11.45, respectively. The absolute difference is less than one point, making it difficult to understand how it achieves statistical significance with t(90) = 2.581. This result should be verified, as it appears statistically inconsistent.
   5. The figures also require improvement. The graphs on pages 7 and 8 are visually unprofessional and do not provide sufficient analytical information. In particular, Figures 2 and 3 show columns with intense colors, but these do not facilitate the understanding of proportions, intervals, or effect sizes.
6. Regarding the discussion, it sometimes exceeds the strength of the findings. The authors acknowledge that some interpretations are speculative, but they should further reduce the explanatory tone and emphasize the exploratory nature of the work. More discussion is also needed on the effect of educational level. This variable can affect access to resources, coping strategies, understanding of the diagnosis, institutional support, and self-perception of burden. The discussion does not sufficiently explore this limitation.
7. The conclusions make clinical statements that should be softened.
8. Please review the references, as there are errors in bibliographic style and several are incomplete.

Comments on the Quality of English Language

The manuscript is written in generally understandable academic English. However, it requires linguistic and technical editing before publication. There are some repetitive phrases, a few punctuation problems, and unnecessary spaces before parentheses. In addition, the titles of tables, notes, and figures should be reviewed to improve accuracy and presentation.

Author Response

We sincerely thank the reviewer for the careful, generous, and highly constructive evaluation of our manuscript.

1. Comment:

The title is clear and adequately represents the overall focus of the study. However, it could be more accurately phrased as a comparative exploratory or pilot study. This would help align the reader’s expectations with the actual strength of the data.

Response:

We revised the title to avoid implying a stronger inferential design than supported by the data.

The revised title is:

“Caregiver Burden, Emotional Distress, and Coping Strategies in Romanian Parents of Children with Autism Spectrum Disorder: An Exploratory Cross-Sectional Comparative Study.”

 

2. Comment:

The abstract presents the core components of the article: sample, instruments, analysis, and main findings. However, it should more clearly state that most of the main results are non-significant trends or small effects. It would also be advisable for the abstract to mention the existence of significant differences between groups in education and marital status, as these differences directly affect the interpretation of the results.

Response:

We revised the abstract to present the findings more cautiously and transparently. The abstract now states that several main findings were non-significant trends or small effects rather than definitive between-group differences. We also added that the groups differed significantly in educational level and marital status, as these baseline differences are important for interpreting the results.

In addition, we revised the conclusion of the abstract to emphasize that the findings should be interpreted as preliminary and hypothesis-generating because of the exploratory design, modest sample size, and multiple comparisons.

3. Comment:

The introduction is well contextualized and reviews relevant literature on the burden on parents of children with ASD, emotional distress, the role of support systems, and coping strategies. However, the introduction could be improved in three areas. First, the specific research gap that justifies this study in Romania needs to be defined more precisely. Studies from various cultural contexts are mentioned, but it is not sufficiently clear what this local case contributes to the existing literature.

Response:

We revised the Introduction to better define the rationale for conducting the study in Romania. We clarified that, although international evidence on caregiver burden, emotional distress, and coping among parents of children with ASD has increased, Romanian data remain limited. We also emphasized that caregiver experiences may differ across healthcare systems and cultural settings because access to diagnostic pathways, specialized interventions, family support structures, stigma, and service availability may vary locally.

4. Comment:

The introduction is somewhat lengthy and, at times, repetitive.

Response:

We shortened and refocused the Introduction. Redundant passages were removed, and the section was reorganized to focus more directly on caregiver burden, emotional distress, coping strategies, the Romanian context, and the specific study aims.

5. Comment:

The objective could be formulated with greater analytical precision, clearly differentiating between comparisons between groups and exploratory analyses within the ASD group or the total sample.

Response:

Thank you. We revised the aim of the study to make the analytical structure clearer. The revised objective now distinguishes between the main comparative aim and the exploratory aim.

6. Comment:

The methodology is one of the sections that requires the most attention. First, the description of recruitment is confusing. It is noted that the participants were recruited from the same pediatric neurology and psychiatry clinic, but it is unclear how the controls were selected or whether they truly represent parents of typically developing children without health problems.

Response:

The revised manuscript now states that participants were recruited between 2024 and 2025 from the Pediatric Neurology and Psychiatry Clinic in Târgu Mureș, Romania, using a non-probabilistic convenience sampling strategy. Parents/caregivers of children and adolescents with clinician-confirmed ASD were invited to participate during clinic visits. The control group consisted of parents/caregivers of typically developing children recruited from the same clinical setting during the same period.

We also clarified that controls were eligible if their child had no known diagnosis of ASD or other neurodevelopmental disorder, based on caregiver report and available clinical information at enrollment.

 

7. Comment:

No sample size calculation or statistical power analysis is reported. This is important because several central results are non-significant or borderline. With 46 participants per group, the study may be underpowered to detect small or moderate differences.

Response:

Thank you. We agree that the absence of an a priori sample size calculation is important for interpreting the non-significant and trend-level findings. We added a statement in the Statistical Analysis section acknowledging that no a priori sample size calculation was performed.

We also included this issue in the Limitations section, noting that the study may have been underpowered to detect small-to-moderate effects.

 

8. Comment:

The instruments are described in a basic way, but no internal reliability indicators are reported for the current sample. Since the CBI, DASS-21, and SACS were used, the authors should report at least Cronbach’s alpha or omega for the scales and subscales used. This is especially important in the case of the SACS and its multiple subscales.

Response:

Unfortunately, internal consistency indices could not be calculated for the present dataset. We now explicitly acknowledge this as a limitation of the study. The revised Limitations section states that the absence of internal reliability indices for the instruments/subscales in the present sample represents an additional limitation, particularly for the interpretation of SACS subscale findings.

 

9. Comment:

The statistical strategy is insufficient for the questions posed. t-tests, Mann–Whitney U tests, chi-square tests, and Fisher’s exact tests were used depending on the data distribution, but multivariate models were not applied. Since the groups differ significantly in education and marital status, the analyses should be adjusted for at least these variables. Without such adjustment, it is not possible to clearly attribute the observed differences to having a child with ASD.

Response:

To address this issue, we added exploratory multivariable regression analyses adjusted for educational level and marital status. Caregiver burden and psychological symptom measures were analyzed as dependent variables, while group status, educational level, and marital status were included as independent variables.

These analyses were presented as exploratory rather than confirmatory, given the modest sample size and the observational design. The Discussion was also revised to emphasize that residual confounding remains possible because other relevant variables were not available or not included in the models.

 

10. Comment:

There is a problem with the multiple comparisons. The study examines numerous associations between sociodemographic variables and coping subscales, but no control for type I error is reported. The authors themselves acknowledge this risk in the limitations section, but this should have clearer implications for the interpretation of the results.

Response:

We agree that the number of exploratory comparisons increases the risk of type I error. We revised the Results, Discussion, and Limitations to make this implication clearer.

11. Comment:

Regarding the results, they are understandable, but present inconsistencies and problems of interpretation. Table 1 should be revised because there is an error in the t-value for the sex variable.

Response:

We revised Table 1 and corrected the erroneous value for the sex variable. The table now reports the appropriate p-value for the sex comparison between groups.

 

12. Comment:

There are scale inconsistencies in the DASS-21 results.

Response:

We reviewed the DASS-21 reporting to ensure consistency between the text, table, and statistical analyses. The revised manuscript now reports DASS-21 outcomes consistently according to the scoring approach used in the analysis.

We clarified that DASS-21 subscale scores were computed according to standard scoring procedures and revised the Results section to avoid inconsistencies between mean item-level values and total subscale values.

 

13. Comment:

The use of terms like “borderline higher anxiety” should be moderated. It can be described as an exploratory trend, but not as a conclusive finding.

Response:

 We agree and revised the wording throughout the manuscript. Terms such as “borderline higher anxiety” were replaced with more cautious formulations such as “trend-level difference,” “exploratory tendency,” or “non-significant trend.”

We also revised the Conclusions to avoid presenting non-significant findings as definitive.

 

14. Comment:

In the coping section, some results are problematic. For example, it is stated that parents with ASD reported less seeking of social support than controls, but the means are 49.26 ± 10.47 and 50.22 ± 11.45, respectively. The absolute difference is less than one point, making it difficult to understand how it achieves statistical significance with t(90) = 2.581. This result should be verified, as it appears statistically inconsistent.

Response:

We rechecked the SACS Seeking Social Support analysis and revised the reporting accordingly. We also moderated the interpretation of this result.

The revised text now emphasizes that, even where statistical significance is observed, the absolute mean difference is small and the clinical relevance should be interpreted cautiously. We also avoided drawing strong conclusions from this finding and framed it as exploratory.

 

15. Comment:

The figures also require improvement. The graphs on pages 7 and 8 are visually unprofessional and do not provide sufficient analytical information. In particular, Figures 2 and 3 show columns with intense colors, but these do not facilitate the understanding of proportions, intervals, or effect sizes.

Response:

We reviewed the figures and revised their presentation to improve clarity and professional appearance. The visual formatting was simplified, and figure citations were inserted in the appropriate locations in the main text.

We also ensured that the figures support the interpretation of the results rather than duplicating information already available in the text or tables.

 

16. Comment:

Regarding the discussion, it sometimes exceeds the strength of the findings. The authors acknowledge that some interpretations are speculative, but they should further reduce the explanatory tone and emphasize the exploratory nature of the work.

Response:

We revised the Discussion to better align the interpretation with the strength of the findings. Explanatory and causal language was reduced, and the exploratory nature of the study is now emphasized throughout the Discussion.

We also added a dedicated explanation of why several expected differences may not have reached statistical significance, including modest sample size, limited power, sample heterogeneity, recruitment from a clinical setting, multiple comparisons, and unmeasured child-level clinical variables.

 

17. Comment:

More discussion is also needed on the effect of educational level. This variable can affect access to resources, coping strategies, understanding of the diagnosis, institutional support, and self-perception of burden. The discussion does not sufficiently explore this limitation.

Response:

We expanded the Discussion to address educational level as a potential confounder and contextual factor.

The revised manuscript now acknowledges that educational level may influence access to resources, understanding of the child’s diagnosis, ability to navigate healthcare and educational systems, perceived institutional support, coping strategies, and self-perception of burden. We also added exploratory adjusted analyses including educational level as a covariate, while noting that residual confounding remains possible.

 

18. Comment:

The conclusions make clinical statements that should be softened.

Response:

We revised the Conclusions to avoid overstatement. The conclusions now emphasize that the findings are preliminary and hypothesis-generating, rather than definitive.

Clinical implications are now framed cautiously, suggesting that caregiver screening may be useful in ASD-related services, while acknowledging that larger longitudinal studies with multivariable adjustment and detailed child-level clinical characterization are needed before stronger conclusions can be drawn.

 

19. Comment:

Please review the references, as there are errors in bibliographic style and several are incomplete.

Response:

We revised the reference list according to the journal’s bibliographic style. Incomplete references were completed where possible by adding missing bibliographic details, DOI links, URLs, and access dates for online sources.

We also checked the in-text citations against the final reference list to improve consistency.

 

20. Comment:

The manuscript is written in generally understandable academic English. However, it requires linguistic and technical editing before publication. There are some repetitive phrases, a few punctuation problems, and unnecessary spaces before parentheses. In addition, the titles of tables, notes, and figures should be reviewed to improve accuracy and presentation.

Response:

We revised the manuscript for language, punctuation, repetition, spacing, and technical presentation. Table titles, figure titles, notes, and formatting were also reviewed to improve clarity and consistency.

The revised manuscript was edited to improve readability and to ensure a more polished academic style.

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. Prior to reading the manuscript, I had guessed that parents of kids with autism would evidence a greater burden across your measures. The absence of significant results disaffirms my pre-reading guess, and I'm curious as to why? Rather than treating a trend as almost significant event , I would have welcomed a discussion of why the trends failed to achieve significance. Obviously sample size and reliability of the instrumentation are possible contributors. Perhaps sample heterogeneity was a contributor.  I'd welcome a slight revision/addition to explore the failure to detect significance. 

I would suggest increased caution in interpreting trends in data that fail to reach statistical significance.

Given the breadth of the classification category of autism, I would welcome a more complete description of the children with autism in this study. How many had significant behavior problems? How significant was the issue of cognitive impairment? Etc.

Author Response

Thank you for this thoughtful and constructive comment. We agree that the absence of statistically significant between-group differences requires a more cautious and explicit interpretation, rather than treating trend-level findings as almost significant results. We revised the Results, Discussion, and Conclusions to avoid overstatement and to frame non-significant findings as preliminary observations requiring confirmation.

We also expanded the Discussion to address possible explanations for the failure to detect statistically significant differences. Specifically, we now discuss the potential contribution of the modest sample size, limited statistical power, sample heterogeneity, clinical recruitment context, baseline sociodemographic differences between groups, and the lack of detailed child-level clinical variables. We agree that heterogeneity within the ASD group may have reduced the ability to detect stronger group differences, particularly because ASD includes a wide range of cognitive, behavioral, communicative, and functional profiles.

In response to your comment regarding the characterization of children with ASD, we acknowledge that the present dataset did not include detailed information regarding ASD severity, intellectual functioning, significant behavioral problems, language level, comorbidities, therapy intensity, or time since diagnosis. We have therefore added this as an important limitation and have explicitly recommended that future studies include more detailed child-level clinical characterization.

Reviewer 3 Report

Comments and Suggestions for Authors

• The number of participants is not mentioned in the abstract.
• The results are purely descriptive with no inferential statistics, which weaken the study findings impact and conclusion.
• The introduction section is lengthy and required to be more focused.
• The rationale for conducting the study in Romania is not highlighted.
• Exclusion criteria are not sufficiently described.
• Sample size calculation is not available; which is important to determine the statistical power of the study estimates.
• Please provide flowchart for the study sample.
• Please provide details how did you recruit the study participants, highlighting the sampling technique and any matching approaches employed.
• The study design is not clear to me, is it cross-sectional or case-control study?

Author Response

Thank you for these important methodological and structural comments. We revised the manuscript to improve clarity regarding the study design, sample, recruitment procedure, exclusion criteria, statistical approach, and rationale for conducting the study in Romania.

First, we revised the abstract to include the total number of participants and the group distribution. The abstract now states that the study included 92 parents/caregivers: 46 parents/caregivers of children/adolescents with clinician-confirmed ASD and 46 parents/caregivers of typically developing children.

Second, we expanded the statistical analysis and results reporting. In addition to descriptive comparisons, we now report inferential statistics, including t-tests, Mann–Whitney U tests, chi-square tests, Fisher’s exact tests, relative risks with 95% confidence intervals where applicable, and exploratory multivariable regression analyses adjusted for educational level and marital status. These additional analyses were included because educational level and marital status differed significantly between groups.

Third, we shortened and refocused the Introduction. We removed redundant text and focused the section on caregiver burden, emotional distress, coping strategies, and the need for local Romanian data. We also highlighted the rationale for conducting the study in Romania, emphasizing that evidence from Romania remains limited and that local data are needed to better understand caregiver needs and inform feasible family-centered interventions in the national clinical context.

Fourth, we clarified the study design throughout the manuscript. The study is now consistently described as an exploratory cross-sectional comparative study, rather than a case-control study.

Fifth, we expanded the recruitment section. The manuscript now states that participants were recruited between 2024 and 2025 from the Pediatric Neurology and Psychiatry Clinic in Târgu Mureș, Romania, using a non-probabilistic convenience sampling strategy. Parents/caregivers of children/adolescents with clinician-confirmed ASD were invited during clinic visits. The control group was recruited from the same clinical setting during the same period and included parents/caregivers of typically developing children. We also clarified that no individual matching procedure was performed; however, the two groups were compared statistically for key sociodemographic characteristics.

Sixth, we expanded the eligibility criteria. The revised manuscript now specifies exclusion criteria for both groups, including refusal or withdrawal of informed consent, insufficient questionnaire data, inability to understand the study procedures or complete the questionnaires, and duplicate participation. For the control group, additional exclusion criteria included having a child with a known diagnosis of ASD, intellectual disability, attention-deficit/hyperactivity disorder, developmental delay, or another neurodevelopmental disorder.

Seventh, we added a statement regarding sample size calculation. Because no a priori sample size calculation was performed, this is now explicitly acknowledged in the Statistical Analysis section and in the Limitations section. We also state that the study may have been underpowered to detect small-to-moderate effects.

Finally, we added a participant flow description and included a study flow diagram to improve transparency regarding sample selection and final analytic sample size.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Many thanks to the authors for their attention to the comments.

The second version shows real progress, but it is not yet ready for acceptance, as the feedback was only partially addressed.

The first major problem is in the DASS-21 report. The methodology indicates that the subscales were calculated by summing the seven items and multiplying by two, as per the standard procedure. However, the results text shows values ​​such as 1.80 ± 1.39 for depression and 1.75 ± 1.14 for anxiety, while Table 2 reports much higher values, such as 25.20 ± 19.46 and 24.50 ± 15.96. This suggests that the text and the table are not using the same scoring scale. The authors stated that they had corrected this inconsistency, but the problem remains in the revised version.

The second critical problem is in the SACS subscale for seeking social support. The manuscript states that there is a statistically significant difference between groups, with t(90) = 2.581 and p = .0115. However, the reported means are 49.26 ± 10.47 for parents of children with ASD and 50.22 ± 11.45 for controls. A difference of less than one point, with standard deviations of more than ten points and groups of 46 participants, can hardly produce that t-value. This should be verified because it appears to be a calculation error, transcription error, or misidentification with the wrong variable.

The third problem lies in the adjusted analyses. The authors added exploratory regressions controlling for education and marital status, which responds to a relevant observation, since both groups differed significantly in these variables. However, the presentation of these models is incomplete. Table 4 does not include confidence intervals, R², F-statistic, sample size per model, variable coding, or a diagnosis of assumptions. Furthermore, it is stated that stress was not associated with the variables after adjustment, but the stress model is not clearly reported in the table.

There is also a significant internal contradiction. The discussion notes that the analyses were adjusted for education and marital status, but the limitations section still states that the analyses were not adjusted for these variables. This phrase belongs to the previous version and should be removed or corrected. Retaining it weakens the review's coherence.

Another point requiring correction is the ethical approval. The methodology section reports approval No. 8318/26.06.2025, while the institutional statement lists approval No. 8318/26.10.2023.

Author Response

We sincerely thank the reviewer for the careful re-evaluation of our manuscript and for the constructive follow-up comments. Our point-by-point responses are provided below.

1. The first major problem is in the DASS-21 report. The methodology indicates that the subscales were calculated by summing the seven items and multiplying by two, as per the standard procedure. However, the results text shows values ​​such as 1.80 ± 1.39 for depression and 1.75 ± 1.14 for anxiety, while Table 2 reports much higher values, such as 25.20 ± 19.46 and 24.50 ± 15.96. This suggests that the text and the table are not using the same scoring scale. The authors stated that they had corrected this inconsistency, but the problem remains in the revised version.

Response: We carefully rechecked the DASS-21 reporting and confirmed that the discrepancy arose from inconsistent presentation of platform-derived output values in the text versus standard subscale scores in the table. In the revised manuscript, we have now fully harmonized the DASS-21 reporting so that the text and Table 2 use the same scoring framework throughout. We also clarified the description of DASS-21 scoring in the Methods section to avoid any ambiguity regarding how the reported values were obtained and interpreted.

2. The second critical problem is in the SACS subscale for seeking social support. The manuscript states that there is a statistically significant difference between groups, with t(90) = 2.581 and p = .0115. However, the reported means are 49.26 ± 10.47 for parents of children with ASD and 50.22 ± 11.45 for controls. A difference of less than one point, with standard deviations of more than ten points and groups of 46 participants, can hardly produce that t-value. This should be verified because it appears to be a calculation error, transcription error, or misidentification with the wrong variable.

Response: After rechecking the dataset and statistical outputs, we confirmed that this was due to an error in the reporting of the group means for the “seeking social support” subscale. The values previously reported in the text were incorrect and did not correspond to the test statistic shown. We have now corrected the means and aligned the text, Table 3, and the interpretation in the Discussion.

3. The third problem lies in the adjusted analyses. The authors added exploratory regressions controlling for education and marital status, which responds to a relevant observation, since both groups differed significantly in these variables. However, the presentation of these models is incomplete. Table 4 does not include confidence intervals, R², F-statistic, sample size per model, variable coding, or a diagnosis of assumptions. Furthermore, it is stated that stress was not associated with the variables after adjustment, but the stress model is not clearly reported in the table.

Response: In the revised manuscript, Table 4 has been expanded and clarified. We now report the stress model explicitly, together with the other adjusted models. In addition, we have added model-level information and clarifying notes regarding variable coding. We also added reporting on multicollinearity diagnostics and clarified in the Methods/Results that the adjusted models were exploratory.

4. There is also a significant internal contradiction. The discussion notes that the analyses were adjusted for education and marital status, but the limitations section still states that the analyses were not adjusted for these variables. This phrase belongs to the previous version and should be removed or corrected. Retaining it weakens the review's coherence.

Response: This sentence was inadvertently retained from the previous version. It has now been corrected in the Limitations section

5. Another point requiring correction is the ethical approval. The methodology section reports approval No. 8318/26.06.2025, while the institutional statement lists approval No. 8318/26.10.2023.

Response: The inconsistency resulted from an editing error in one section of the manuscript. We have now corrected the ethical approval statement so that the same protocol number and date are reported consistently throughout the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

none

Author Response

Thank you for revising our manuscript and providing valuable suggestions.

Reviewer 3 Report

Comments and Suggestions for Authors

• The number of participants is not sufficent.
• The results are purely descriptive with no inferential statistics, which weaken the study findings impact and conclusion.
• The rationale for conducting the study in Romania is not highlighted.
• Sample size calculation is not available; which is important to determine the statistical power of the study estimates.
• The methodology section is confusing, and the study design is not clear to me, is it cross-sectional or case-control study.

Author Response

Thank you for these important observations. Below you can find our point-by-point response:

• The number of participants is not sufficent.

Response: We acknowledge that the sample should be considered modest . We have now stated this explicitly in the Limitations section and emphasized that the findings should be interpreted cautiously, particularly with regard to generalizability and the detection of small effects.

• The results are purely descriptive with no inferential statistics, which weaken the study findings impact and conclusion.

Response: In addition to descriptive statistics, the manuscript reports inferential analyses, including between-group comparisons and exploratory adjusted regression models. To make this clearer, we revised the Results and Methods sections to better describe the statistical approach and to distinguish descriptive findings from inferential analyses.

• The rationale for conducting the study in Romania is not highlighted.

Response: We expanded the Introduction and Discussion to highlight the relevance of examining this issue in an Romanian adult sample, particularly given the limited data from Eastern European contexts.

• Sample size calculation is not available; which is important to determine the statistical power of the study estimates.

Response: We acknowledge that no a priori sample size calculation was performed, which limits the precision and statistical power of the study estimates. We have now explicitly reported this in the revised manuscript as a methodological limitation.

• The methodology section is confusing, and the study design is not clear to me, is it cross-sectional or case-control study.

Response: We have revised the Methodology section to make the study design clearer. The manuscript now explicitly describes the study as an exploratory cross-sectional comparative study