Concerns Related to the COVID-19 in Adult Norwegians during the First Outbreak in 2020: A Qualitative Approach

Round 1

Reviewer 1 Report

Dear authors, 
It is an interesting work. I suggest the following modifications:

 Keywords: add "Coronavirus" and "Sars-cov-2". 

Introduction: Add at the end the research questions or the hypothesis of your work. I would also enrich the introduction with a background on qualitative research on covid-19 in Norway. I would also add a data visualization of the impact of covid-19 in Norway. Make the introduction more engaging and visual. 

Materials and methods: It would be interesting to include the web survey template and the link in Appendix A. You can include a screenshot of the webpage. 

Results: Please number the results, otherwise it is chaotic to follow a coherent reading. The same for all subsections of the paper. 

My recommendation is that you make a section with Discussion and another section with Conclusions. In the conclusions I would divide it into two sections: implications (in public health) and future lines of research. 

Best regards. 

 

Author Response

Please see the attachment

Author Response File: Author Response.docx

Reviewer 2 Report

Overall, the study is well conducted and clearly presented. 

 

ABSTRACT

“concerns related to the first outbreak of the COVID-19 pandemic in the Norwegian population is studied”.  I think the authors mean: “concerns .... are studied”

 

INTRODUCTION

 

“Personal and direct experience with the virus perceived higher risk.” May be the authors intended “People who experienced personal and direct experience with the virus perceived higher risk”. If so, they should provide a reference for this.

 

“Socio-cultural factors and knowledge explained some of the variance in concerns.” Please provide a reference for this.

"Pagnini et al. [12] found more resilience to worries and con-cerns relating to COVID-19 in people who were cognitively flexible and emotionally stable." This sentence sounds incomplete. Other studies found predictive positive effects in other stable traits, like coping styles, locus of control, etc. (i.e. Flesia L, Monaro M, Mazza C, Fietta V, Colicino E, Segatto B, Roma P. Predicting Perceived Stress Related to the Covid-19 Outbreak through Stable Psychological Traits and Machine Learning Models. J Clin Med. 2020 Oct 19;9(10):3350. doi: 10.3390/jcm9103350. PMID: 33086558; PMCID: PMC7603217). Other studies found the protective role of tolerance to uncertainty (i.e. Sauer KS, Jungmann SM, Witthöft M. Emotional and Behavioral Consequences of the COVID-19 Pandemic: The Role of Health Anxiety, Intolerance of Uncertainty, and Distress (In)Tolerance. Int J Environ Res Public Health. 2020 Oct 3;17(19):7241. doi: 10.3390/ijerph17197241. PMID: 33022993; PMCID: PMC7578938.). 

“Most studies of concerns are quantitative surveys with pre-categorized response op-tions, but a fixed list is probably not sufficient to cover all concerns people may have. There is a paucity of studies using open-ended or in-depth questions about concerns.” This sentence seems to be quite vague. As the authors list some literature results about quantitative research, and the aim of the work is to focus on qualitative research, I think it would be useful they provide a brief overview about qualitative literature about the issue of the paper.

 

MATERIALS AND METHOD

 

I would suggest to add in the supplementary material a version of the questionnaire.

 

Although the authors are going to focus primarily on the qualitative section of the questionnaire, they should at least provide a brief indication about the demographic section of the questionnaire, as they consider this aspect in the results section.

 

“CORONAPOP is a cross-sectional population-based survey, which include open-ended questions.” “include” should be changed with “includes”

 

“We provided five quantitative questions related to concerns with response alterna-tives yes/no:” . At this point the authors cannot change it and this is not about this paper, however, why didn’t they use a Likert scale instead of yes/no?

 

“The thematic analysis of the qualitative comments followed a six-step process devel-oped by Virginia Braun and Victoria Clarke; Familiarization; Coding; Generating themes; Reviewing themes; Defining and naming themes; Writing up”. I suggest to change the “;” between Clarke and Familiarization with a “:”.

 

 

“Some had been in quarantine or isolation (28.2%), 23.4% reported having risk factors for developing complications if infected (Table 2),”. Table 2 does not report these data. Please amend it.

 

Figure 2: What do they mean with “housing market”?

 

Figure 1 caption: “Figure 1. Themes and sub-themes from the quantitative analysis”. I think they mean Qualitative, rather than Quantitative

 

“Four sub-themes were identified in the thematic analysis; economy; contagion effects; vulnerable groups; and attitudes.” I suggest to change the “;” between analysis and economy with a “:”.

 

“Two hundred and fourteen comments on personal activities were reported. Two sub-themes were identified; isolation/loneliness; physical contact with family and friends”. I suggest to change the “;” between identified and isolation/loneliness with a “:”.

 

“Two sub-themes were identified; redundancy/unemployment; housing market.” I suggest to change the “;” between identified and redundancy/unemployment with a “:”.

 

DISCUSSION

 

“A larger proportion were more concerned of infecting family/friends, colleagues or patients than being infected themselves. This is in line with results from a rapid literature review including 36 papers, where Barello et al. [17] found that health care professionals reported frequent fear of infecting family, patients and colleagues.” I think this reference does not fit so good. Barello et al.’s review regards health care workers, that are a specific population, working in contact with infected people. It is different from the present study sample, belonging to the general population. I would suggest to mention findings from studies indicating higher levels of distress among people living with others, compared to people living alone (i.e. Flesia L, Monaro M, Mazza C, Fietta V, Colicino E, Segatto B, Roma P. Predicting Perceived Stress Related to the Covid-19 Outbreak through Stable Psychological Traits and Machine Learning Models. J Clin Med. 2020 Oct 19;9(10):3350. doi: 10.3390/jcm9103350. PMID: 33086558; PMCID: PMC7603217).

 

“A proportion of pregnant women in the present study expressed concerns related to giving birth or for the newborn child.” Did the questionnaire’s quantitative section included information about pregnancy status?

                               

“There were substantially fewer comments related to the other themes, indicating that there may be less concerns about social activities, personal economy, and duration of the pandemic at the early stage of the pandemic.” This result may depend on the demographic characteristics of the sample, especially of respondents to open questions that, as the authors wrote in the Results section, were highly educated and, likely, medium-high income respondents.

 

Author Response

Please see the attachment

Author Response File: Author Response.docx

Reviewer 3 Report

 

First of all, I would like to congratulate the authors for their hard work in analyzing a large number of responses. The work seems to me to be relevant and necessary and addresses a field that, although it has been widely worked on, has hardly been studied from this perspective and methodology. Moreover, it includes a large number of participants and the results may be of interest to the scientific community. I think it could be published with some modifications, mainly suggestions involving the inclusion of more information and   clarifying different points.

 

 

1. TITLE, ABSTRACT AND INTRODUCTION.

 

• I think the title is appropriate, simple and pertinent, but I suggest changing the hyphen to a colon.It is important to specify characteristics of the participants in the abstract, such as age or gender.
• The length of the abstract must be reduced to comply with the rules of the journal (maximum 200 words).
• The conclusion of the abstract should be rewritten, it is not really clear the scope or the main conclusions of the study.
• After full review of the manuscript, the abstract should be adjusted to the changes suggested in the other sections.
• In general, I think the introduction should be restructured. Details that are necessary to understand the study should be included and others that are perhaps not the target of this work should be removed. Examples may include the following:
• In the introduction, the following sentence can be deleted as it is not directly connected to the content of the paper. “A clear and transparent communication from the authorities is recommended to establish trust and high degree of compliance [6], and the authorities’ call to join a collective effort seems to have created a strong team spirit in Norway [2].”
• In the introduction, it is necessary to highlight more clearly the mental health impact of this health crisis. If possible, it would be interesting to reference a study carried out in the population under study.
• I think it would be relevant to highlight the strengths of the study or the need to conduct it in this way. For example, as the authors have done by pointing out that previous studies had been carried out with surveys, and that none (or few, and point out which ones) had done so qualitatively and in the context in which it was carried out. These studies should be cited and referenced.
• In general, I miss a solid theoretical contribution to the study. For example, what theoretical model have the authors based themselves on? Some ideas about this appear more clearly in the discussion section.
• In addition, the results discuss variables that are not mentioned in the introduction, e.g. social support? COVID-19 status? risk factors for complications? If these variables have been discussed in the literature, they should be mentioned in the introduction. Did these people in previous studies show more or less concern than the rest?
• The aim of the study seems clear to me, I would only add "adult population".
• The hypothesis(es) put forward by the authors should be stated.

 

 

 

2. METHOD.

 

• The method section should start with the sub-section on participants.
• In the participants section you need to expand the information about the participants: how many were there in the end, what was their gender, what were their ages (range, mean, standard deviation...)? I suggest moving the information from the results section to the participants section.
• I consider the lack of inclusion and exclusion criteria to be a major limitation of the study. For example, the authors state that the participants had to be 18 years old or older (this is an inclusion criterion), and it is also possible that they were selected on the basis of their origin, mother tongue... This aspect should be expanded.
• After the participants the authors can point out the variables to be assessed and the instruments. Information about the instrument needs to be applied.
• I fail to understand how this sentence "Two papers have previously been published on symptom-defined PTSD [11] and self-reported mental and global health in optimists/pessimists [14]. " has to do with the previous one.
• What statistical analyses did the authors carry out?
• Although the authors point out that the "quantitative" data are in another article, I would be interested to see that information included here as well for completeness. In this way it is possible to talk in the text about the use of these 4527 participants (instead of the 1491). This aspect is a great potential of the study, which I think should also be pointed out in the discussion.
• If the authors have followed criteria of rigour and credibility, this should be pointed out. For example (I quote an article by Póstigo and collaborators from 2019, http://dx.doi.org/10.6018/analesps.35.2.301201) In terms of the rigour and credibility criteria proposed for qualitative studies, triangulation of researchers (two researchers), methods (sociometric and qualitative), coding (two analysts), and theoretical triangulation (review and discussion of previous studies) were used, which increases the reliability and validity of this study (Denzin & Lincoln, 2008; Twining, Heller, Nussbaum & Tsai, 2017).
• It would be appropriate to assess the rate of agreement between respondents using the Kappa index and Cohen's.
• Cohen's Delta index, and to show whether there was adequate coding reliability or not (the following references can be consulted in this regard:
• Cohen, J. (1960). A Coefficient of Agreement for Nominal Scales. Educational and Psychological Measurement, 20, 37-46. Femia, P., Martín, A., & Álvarez, M. (2012). The Delta Model to evaluate the degree of agreement between two observers [El Modelo Delta para evaluar el grado de acuerdo entre dos observadores]. In García, Bouza, & Covarrubias (Eds.), Modelación de fenómenos del Medio Ambiente, Salud y Desarrollo Humano: estudios medio ambientales. (pp. 125-144). Universities of Guerrero (Mex) and Havana (Cuba)).
• Were the evaluators blinded during the process? This would be a strength of the study.

 

 

 

3. RESULTS.

• “Some identified a single concern; others identified two or more concerns” . Include percentages.
• “A significantly higher proportion with higher education was found among respondents to the open-ended question, compared to non- respondents (86.2% vs 83.4%, respectively), p = 0.022.” If there were differences only in this aspect, point it out. If not, include information on this.
• How did the authors control for confounding variables? The literature has pointed out that women or people with previous mental health problems showed more concerns. I think the direction of the work could be improved by statistical comparisons of the results according to these variables. For example: do the themes differ according to the group of origin? Contingency table or chi-square analyses could be carried out.

 

4. DISCUSSION.

• I appreciate that the authors have pointed out the possible limitations of the study in an honest way. Nevertheless, limitations could be expanded upon in the discussion section. For example, throughout the process, independent analysts were not consulted to ensure as much objectivity as possible in both the selection and coding of the textual analysis units.
• Since one of the concerns was infection in pregnant women. It should be noted in the limitations of the study that the authors did not take into account whether people were pregnant, and point this out as a point for improvement in future studies.
• The authors note this information in the discussion: “The themes about concerns in the present study are in line with the domains from WHO COVID-19 Snapshot Monitoring project (health, economic, emotional, work, and future). They are also in line with most of the addressed concerns Sabat et al. [6] studied: losing a close person, becoming unemployed, health system becoming overloaded, closed school, small companies running out of business, recession, and society getting more egoistic.". Perhaps it could be used in the introduction as part of the theoretical framework.
• The authors note this information in the discussion: " The study had a mixed methods design". The nature of the questions does not determine the research design.
• Need to include reference to implications.

 

5. OTHER ASPECTS

• The term covid-19 needs to be replaced by COVID-19 throughout the text.
• I suggest modifying the formatting of table 1 (justify the text in rows 2 onwards so that it is centred).
• In Figure 2, the "personal economy" lines are missing. I recommend authors to put the figure within the same handwriting as in the manuscript.
• It is not clear to me that Figure 1 refers to a quantitative analysis.

 

Again, I congratulate the authors for their hard work and effort and encourage them to improve the manuscript 

Author Response

Please see the attachment

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Go ahead. 

Author Response

Rev 1

English language and style

( ) Extensive editing of English language and style required
( ) Moderate English changes required
(x) English language and style are fine/minor spell check required
( ) I don't feel qualified to judge about the English language and style

 

Reply: Minor spell check has been performed

Reviewer 3 Report

Dear authors, thank you for your attention to the suggestions. Your clarifications facilitate the correct understanding of the study and its great potential can be clearly visualised. That is why I am proposing minor revisions.

Title: thank you for the change in the title. However, I think that a space between the colon and the following A is missing.

Abstract: reduce the abstract to comply with journal guidelines (maximum 200 words). Also, change the number of total participants (as noted in the method section). It is confusing, as you are actually analysing 1961 people.

Introduction: please include the place of extraction of the data from the figure.

Method: it remains unclear to me the actual number of participants, it would be interesting if you could mention that all 4527 people participated in the total survey, but only 1961 people were considered for this study, as an inclusion criterion for your work was the completion of the open response.

Although the authors answer in the response letter about the inclusion criteria, it is necessary to point out what these criteria were in the text. (age, answering the open question, living in confinement in Norway...).

Discussion: It would be interesting for me if they would add in the discussion that in future studies the work will be done in a blinded way and inter-rater agreement rates will be calculated. As well as that they will take into account other confounding variables such as the presence of a physical or mental health problem prior to (or during) confinement.

In the last sentence of the strengths and limitations "This" should be "this".

Thanks again for considering the suggestions, congratulations on your great work.

 

Author Response

Dear editor and reviewers

The revised manuscript, with your suggestions, have resulted in a clearer and improved version.

Editor – you asked us to provide a short cover letter with detailed changes and citing the line number. There were no line number in the provided manuscript and thus, not possible to cite the line number. We have deleted prior changes and highlighted the new changes with green color. In addition, we have provided numbers for each chapter (IMRaD).

Author Response File: Author Response.pdf