Sociodemographic Factors Associated with Emotional Distress, Transactional Sex and Psychoactive Substance Use during the First Wave of the COVID-19 Pandemic

Round 1

Reviewer 1 Report

The proposal about “Sociodemographic factors associated with emotional distress among people who transacted sex and used psychoactive substances during the first wave of the COVID-19 pandemic” sounds well. However, to improve, you need the next questions:

-Title. It is right, but too much long. Try to shorten it.

-Abstract. It is right.

-Theoretical framework. Check if some references can be updated. To be prudent, try to update some new references if you find.

-Methods. The used Method is right. Moreover, I suggest to complete the paper with other qualitative sources, for example in-deep interviews or a Delphi. It means it is positive to do a triangulation to support the obtained data. Perhaps in-deep interviews are not possible in this moment, but expert brief interviews (a Delphi) can allow an added value. It is a recommendation.

-Results. Results are improvable for the explained reasons.

-Conclusion and discussion. Try to enlarge it if you include another method.

-Although the statistical data are right, and it follows the quantitative standards, in this kind of works, attending the improvable "n" (426 people who transacted sex and 630 persons who used 28 psychoactive drugs during the COVID-19 pandemic) and the heterogeneity of the database and countries, it is recommendable to incorporate a qualitative reinforcement of the results, because correlation not always means causality. Due to the actual status of the research, the most operative way is to include some interviews in a Delphy spirit. With 3 Delphi interviews, to be faster, the researchers can achieve more security and experts validations of the results. Logically, the paper, depending on the journal, can go ahead with the quantitative flow, but this qualitative improvement will allow more consolidation. 

Author Response

Thanks for the constructive feedback provided. This has helped improve the quality of the manuscript. Below is a point-by-point response to the issues raised by the reviewers.

Thanks for the constructive feedback provided. This has helped improve the quality of the manuscript. Below is a point-by-point response to the issues raised by the reviewers.

The proposal about “Sociodemographic factors associated with emotional distress among people who transacted sex and used psychoactive substances during the first wave of the COVID-19 pandemic” sounds well. However, to improve, you need the next questions:

RESPONSE: Thanks for the positive feedback

-Title. It is right, but too much long. Try to shorten it.

RESPONSE: Thanks for the suggestion, we have shortened the title to: Sociodemographic factors associated with emotional distress, transactional sex and psychoactive substance use during the first wave of the COVID-19 pandemic

-Abstract. It is right.

RESPONSE: Thanks for the positive feedback

-Theoretical framework. Check if some references can be updated. To be prudent, try to update some new references if you find.

RESPONSE:  Thanks for the suggestions. We had reviewed the references. Our original reference to theory dates back to 1975 because this seminal work is relevant to the study. We also agreed to retain the overview that was written in 2005 due to its importance to this study. We updated reference 19. We included a new reference 26 that supports the assessment of the study variables. We added: negative automation of thoughts and biases in attention, interpretation, and memory that informs the cognition associated with emotional distress [27].

-Methods. The used Method is right. Moreover, I suggest to complete the paper with other qualitative sources, for example in-deep interviews or a Delphi. It means it is positive to do a triangulation to support the obtained data. Perhaps in-deep interviews are not possible in this moment, but expert brief interviews (a Delphi) can allow an added value. It is a recommendation.

RESPONSE: Thanks for the excellent suggestion. The team considered this valuable suggestion but also realized the complexity of doing this. We will need to get a fresh ethics approval, and also ensure we recruit IDI interviews that represent a diversity of the geographical spread of the study populations. While this is very possible, this was not the purpose of the current study and collection of qualitative data and subsequent analysis is beyond the scope of the aims of this study. We therefore considered adopting this suggestion for a major related manuscript and continue to process this manuscript exclusively as a quantitative study, which is what it was intended.

-Results. Results are improvable for the explained reasons.

RESPONSE: Thanks once again. Please see response to previous comment.

-Conclusion and discussion. Try to enlarge it if you include another method.

RESPONSE: Thanks once again. Please see response to comment above.

-Although the statistical data are right, and it follows the quantitative standards, in this kind of works, attending the improvable "n" (426 people who transacted sex and 630 persons who used 28 psychoactive drugs during the COVID-19 pandemic) and the heterogeneity of the database and countries, it is recommendable to incorporate a qualitative reinforcement of the results, because correlation not always means causality. Due to the actual status of the research, the most operative way is to include some interviews in a Delphy spirit. With 3 Delphi interviews, to be faster, the researchers can achieve more security and experts validations of the results. Logically, the paper, depending on the journal, can go ahead with the quantitative flow, but this qualitative improvement will allow more consolidation. 

RESPONSE: Thanks once again. Please see response to this suggestion above.

Author Response File: Author Response.docx

Reviewer 2 Report

Dear colleagues, I hope this message find you well.

Thank you for giving me the opportunity of reading the work “Sociodemographic factors associated with emotional distress among people who transacted sex and used psychoactive substances during the first wave of the COVID-19 pandemic”, it has been a very big pleasure to collaborate reviewing this manuscript. The topic of this paper is very interesting and it seems necessary to delve it. However, there are several questions to improve before to publish it. I would suggest some changes: 

Title and abstract

·        Abstract: I recommend to eliminate all the numbers included (except sample information). This information could be found at the main document.

Introduction

·        Dear colleagues, the structure of the introduction is not clear. I recommended to divide it into several subsections. For example, creating a specific subsection where describe each group of variables/factors involved.

·        Secondly, when you explain the signs of psychological distress and mental health as a result of COVID-19, it is necessary to add more data and references. I recommend you to add this paper recently published (https://doi.org/10.3390/ijerph18147422), which offers a cognitive approach to COVID-19 and it proposes pandemic as a possible PTSD.

Method

·        The information regarding your sample could be added in a specific table.

Results

·        Have you assessed/controlled another variable in order to avoid interferences? Explain it please.

Discussion

·       More references are required in order to support your findings.

·       In my humble opinion, it could be useful to describe in more detail the practical and theoretical implications of this research. It would be useful they contextualize better the contribution within the framework of the issue explaining why the contribution is useful and enrich the impact.

·       Limitations are poorly described. For instance, you can explain how to reduce this inconveniences in the future.

Conclusions

·       Nothing to add. Good job.

Author Response

Thanks for the constructive feedback provided. This has helped improve the quality of the manuscript. Below is a point-by-point response to the issues raised by the reviewers

Dear colleagues, I hope this message find you well. Thank you for giving me the opportunity of reading the work “Sociodemographic factors associated with emotional distress among people who transacted sex and used psychoactive substances during the first wave of the COVID-19 pandemic”, it has been a very big pleasure to collaborate reviewing this manuscript. The topic of this paper is very interesting and it seems necessary to delve it. However, there are several questions to improve before to publish it. I would suggest some changes: 

RESPONSE:  thanks for the positive feedback. I hope the reviewer finds the edits have addressed their concern and improved the readability of the manuscript.

• Abstract: I recommend to eliminate all the numbers included (except sample information). This information could be found at the main document.

RESPONSE: Thanks for this suggestion. We considered this point and concluded that there are many advantages to keeping the figures in the abstract. This is important as it increases the likelihood of the manuscript being included in a systematic review. For this valuable reason and for the fact that we have kept within the word limit, we chose to leave the figures in the abstract.

Introduction. Dear colleagues, the structure of the introduction is not clear. I recommended to divide it into several subsections. For example, creating a specific subsection where describe each group of variables/factors involved.

RESPONSE: The introduction has been edited to improve clarify and we now think it reads much better.

Secondly, when you explain the signs of psychological distress and mental health as a result of COVID-19, it is necessary to add more data and references. I recommend you to add this paper recently published (https://doi.org/10.3390/ijerph18147422), which offers a cognitive approach to COVID-19 and it proposes pandemic as a possible PTSD.

RESPONSE:  Thanks for sharing the manuscript. It was really an interesting read with interesting study outcomes on PTSD and COVID-19 fear. Unfortunately, we could not find a fit for it within this manuscript so were unable to cite it in the current manuscript.

Method: The information regarding your sample could be added in a specific table.

RESPONSE: Thanks for this suggestion. All the information extracted about the sample has been included in Tables 1 and 2. We are conscious of the need to reduce the number of tables to a minimal.

Results: Have you assessed/controlled another variable in order to avoid interferences? Explain it please.

RESPONSE: Yes, we did assess for confounders. We wrote: Country income level obtained from publicly available data of the World Bank Data Bank [40]. Differences in the countries’ income level, affect the formulation of policies and the strength of the health care systems to address the COVID‐19 pandemic. Based on income level, countries were classified into low‐income countries (LICs) with a gross national income (GNI) per capita ≤1035 USD in 2019, lower middle‐income countries (LMICs) with GNI between 1036 and 4045 USD, upper middle‐income countries (UMICs) with GNI between 4046 and 12,535 USD, and high‐income countries (HICs) with GNI ≥12,536 USD.

Discussion: More references are required in order to support your findings.

RESPONSE: The discussion section contains 19 references and all issues that were identified from the analysis have now been discussed within the context of this literature.

• In my humble opinion, it could be useful to describe in more detail the practical and theoretical implications of this research. It would be useful they contextualize better the contribution within the framework of the issue explaining why the contribution is useful and enrich the impact.

RESPONSE: Thanks for this suggestion. We included this information in the last paragraph of the discussion section: The study findings indicates that there is a complex relationship between vulnerability status the risk for emotional stress and the role that known stress protective factors play. Progamming to reduce the risk of vulnerable populations to emotional stress during the pandemic will need to be designed specifically for each population to be able to adequately address the needs of affected populations.

Limitations are poorly described. For instance, you can explain how to reduce this inconveniences in the future.

RESPONSE: We strengthened this by adding: In addition, the questions on emotional distress were measured using single-item questions. Single-item questions for the measure of emotional distress have moderate levels of sensitivity, specificity, positive predictive values and high negative predictive values were [42-44]. This has implications for under-reporting emotional stress in this study. The use of validated instruments will support the objective evaluation of emotional distress.

Conclusions: Nothing to add. Good job.

RESPONSE: Thanks for the positive feedback.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Tha paper has improved. It can go ahead like now, although it would be interesting to include a qualitative tool (Delphi, for example). The authors must reviwex formal questions.

Author Response

Thanks for the suggestion on the minor review. We have add as a concluding statement that : Conducting a qualitative study to understand the study findings will also be of value for future studies.

Author Response File: Author Response.pdf

Reviewer 2 Report

Dear colleagues, 

The manuscript has been improved significantly. Congratulations. 

Author Response

Thanks for the feedback. We have had to make a minor edit. We included as a concluding statement - Conducting a qualitative study to understand the study findings will also be of value for future studies.

Author Response File: Author Response.docx