Effects of Cognitive Behavioral Stress Management Delivered by a Virtual Human, Teletherapy, and an E-Manual on Psychological and Physiological Outcomes in Adult Women: An Experimental Test

Round 1

Reviewer 1 Report

Thank you for the opportunity to review your manuscript, Effects of Cognitive Behavioral Stress Management delivered 2 by a virtual human, teletherapy, and an e-manual on psycho- 3 logical and physiological outcomes in stressed women: An ex- 4 perimental test. The manuscript presents the argument well and provides novel implications for current and future health options. 

I have provided some comments below for you to consider. 

For lines 69-70, please provide examples of what is meant by cognitive and behavioral techniques using an e.g. statement. 

For your hypotheses stated in lines 123-126, please disaggregate the statements as the first hypothesis does not impact or hinge on what happens in the second part. 

For all of the reported stress findings, please provide the ranges along with the M and SD. 

Please provide the demographic characteristics for this study. You mention there were no significant differences, however there was no table to reference for these values. 

Given research shows women to be more sensitive and emotionally connected compared with males, it would be critical to also understand whether this type of therapeutic technique would be beneficial for males as well. Please discuss this possibility and include it as a limitation that these findings can only generalize to females. 

What types of controls were used in your analyses? Please clarify and provide estimates. 

Did you assess time of day, day of week, and employment status? These might be critical indicators for findings. 

Author Response

Thank you for the opportunity to review your manuscript, Effects of Cognitive Behavioral Stress Management delivered by a virtual human, teletherapy, and an e-manual on psycho-logical and physiological outcomes in stressed women: An experimental test. The manuscript presents the argument well and provides novel implications for current and future health options. 

I have provided some comments below for you to consider. 

For lines 69-70, please provide examples of what is meant by cognitive and behavioral techniques using an e.g. statement. 

We have added a statement to this line to include some examples of the cognitive and behavioral techniques that are delivered as part of Cognitive Behavioral Stress Management.

For your hypotheses stated in lines 123-126, please disaggregate the statements as the first hypothesis does not impact or hinge on what happens in the second part. 

We have separated the hypotheses in lines 123-126 of the introduction.

For all of the reported stress findings, please provide the ranges along with the M and SD. 

All means and standard error values have been reported for the significant results. Please note that in some instances (e.g,. lines 254-256), the sentence does not contain the mean and standard error values because they are reported in the previous sentence. This was to avoid repetition of data already reported. We have refrained from adding the means and SEs for the non-significant results as this would result in adding several paragraphs of non-significant results which would reduce readability. We have added the ranges for the significant results.

Please provide the demographic characteristics for this study. You mention there were no significant differences, however there was no table to reference for these values. 

We have added a table to the supplementary material that shows the detailed results for the baseline demographic variables (Appendix B).

Given research shows women to be more sensitive and emotionally connected compared with males, it would be critical to also understand whether this type of therapeutic technique would be beneficial for males as well. Please discuss this possibility and include it as a limitation that these findings can only generalize to females. 

We have added to the limitations subsection of our discussion that because we had an all-female sample, our findings only generalise to females. However, CBSM has been shown to be beneficial for males in other research. More studies are needed in gender diverse persons.

What types of controls were used in your analyses? Please clarify and provide estimates. 

No control variables were included in our analyses. This is because at baseline, there were found to be no significant group differences in demographics or psychological variables. This was taken as evidence that these demographic and psychological variables did not need to be controlled for in our subsequent analyses.

Did you assess time of day, day of week, and employment status? These might be critical indicators for findings. 

We did not assess for the effects of time of day, day of week, or employment status in our analyses. Different participants took part in the study across all days of the week and at different times of day, thus any effects of these variables should have been counteracted. However, we have added a statement to the limitations subsection of our discussion that future research should be mindful of this variable. Employment status was measured and was not found to vary between groups at baseline, thus this was not included in our analyses.

Reviewer 2 Report

- typo in the title: psycho-logical

- Adult women (M age =43.21, SD=10.70). why is SD=10.70 still relevant and inclusive?

- line 123: the hypothesis seems to appear too sudden. suggest including more thorough description before throwing out the hypothesis. 

- what are the relationships between VH, DH, eHealth, mHealth, and teleHealth within CBSM? why are VH and/or DH the best approach? 

- how did the authors apply PSS, EDA, LOT-R, and POMS in an innovative way? 

- lines 253-262 and 293-315: make sure these data are correct.

- line 391: can the authors further discuss the application of this research procedure and results in other contexts, countries, and cultures? 

- the references seem old in general. suggest adding recent research (from MDPI),

Author Response

- typo in the title: psycho-logical

Thank you for pointing this out. We will change this to “psychological” in our online submission form. In the manuscript, “psychological” appearing as “psycho-logical” in the title is a function of the automatic document formatting.

- Adult women (M age =43.21, SD=10.70). why is SD=10.70 still relevant and inclusive?

The standard deviation (SD) is reported as a statistical reporting convention in studies of health interventions. Should our article be included in a future meta-analysis, the SD would be required.

- line 123: the hypothesis seems to appear too sudden. suggest including more thorough description before throwing out the hypothesis. 

We have edited the language surrounding the introduction of our hypotheses to better guide the reader.

- what are the relationships between VH, DH, eHealth, mHealth, and teleHealth within CBSM? why are VH and/or DH the best approach? 

We have outlined the advantages of VH and DH for delivering psychological interventions in parts of the introduction section (paragraphs 1-3, 7). However, we have added a statement to the beginning of paragraph 7 to explicitly summarise the possible advantage of VH relative to the other technologies (e.g.,  self-guided e-manual).

- how did the authors apply PSS, EDA, LOT-R, and POMS in an innovative way? 

These were the measures of perceived and physiological stress, optimism, and negative affect that were used to evaluate the effect of the intervention on psychological and physiological outcomes. The goal of the research was not to use these measures in an innovative way, but rather to use them in a conventional manner to evaluate the innovative delivery of CBSM (i.e., virtual human, telehealth, and an e-manual).

- lines 253-262 and 293-315: make sure these data are correct.

We have checked and can confirm that the results presented in lines 253-262 and 293-315 are correct.

- line 391: can the authors further discuss the application of this research procedure and results in other contexts, countries, and cultures? 

We have added a statement to the future research subsection of our discussion that although our study contained an ethnically diverse sample, future studies should evaluate whether the results generalise in other cultures and in other countries.

- the references seem old in general. suggest adding recent research (from MDPI),

We have checked our reference list and can confirm that 35 of 52 (67%) of our references were published in the last ten years (i.e., after 2012). Many of the foundational CBSM studies were published in the early 2000s, and the psychological measures we used were published in the 1980s – early 2000s, which we believe are the older references the reviewer refers to. Unfortunately these citations are essential to our manuscript therefore we cannot replace them. However, we have added a couple more recent references as indicated in our reference list (references 3 and 20). A search of virtual humans and telehealth in MDPI journals did not reveal any relevant results for our manuscript.