Self-Management Predicts Lower Post-Traumatic Symptoms and Greater Post-Traumatic Growth among Older Adults in Residential Care Homes in the Wake of the COVID-19 Pandemic

Round 1

Reviewer 1 Report

Thanks to the authors for the opportunity to review their manuscript! I would like to draw the authors' attention to the following points:

1.       It seems to me that the direction of the predictions in the title should be clearer: «Self-management predicts <lower> PTSD symptoms and <greater> post-traumatic growth among older adults in residential care homes in the 3 wake of COVID-19 pandemic».

2.       The authors do not describe the criteria for inclusion and exclusion of respondents, although this seems very important given the specifics of the sample. Was there a minimum and maximum age? Were there any restrictions on the mental and physical state and cognitive functioning of the respondents? It would be good to describe all these points in the manuscript.

3.       I am confused by the sample size of the study, given that the data were analyzed by regression analysis. Did the authors do a sample size calculation considering the statistical power of the analysis? It would have been nice to present the results of this analysis in the description of the study procedure.

4.       The authors do not specify in what language the questionnaire was. If the instruments were presented in a language other than English, references to adaptations should be given.

5.       I would note the limitations of the study's small sample size and gender imbalance.

6.       Technical note: In the discussion, some parts of the text have a smaller font than the main text (lines 342-349, 352-355, etc.).

Author Response

09 – June 2023 (initially, 15-November-2020

Liviu Oprea, PhD, University of Medicine and Pharmacy "Grigore T. Popa",

Daniela Cojocaru, Prof. PhD , Alexandru Ioan Cuza University,

Guest Editors, Special issue: Health-Related Sustainable Development Though Lifestyle and Self-Care. Sustainability Journal.

MS Ref Number: ID: sustainability-2423253

Title: "Self-management predicts PTSD symptoms and post-traumatic growth among older adults in residential care homes in the wake of COVID-19 pandemic"

New Title as suggested by reviewer #1 first remark and including the suggestion of reviewer #2 third remark: "Self-management predicts lower Post-Traumatic symptoms and greater post-traumatic growth among older adults in residential care homes in the wake of COVID-19 pandemic"

 

We wish to thank the editors, and both reviewers for reading and evaluating the manuscript, and for all the valuable observations. Clarifying and integrating the referees' comments was an enriching as well as demanding process. We have rethought and rearranged some of the conceptual and statistic measures and statistical analysis yielding a more precise manuscript. We worked thoroughly to assure the manuscript will contribute to the journal as expected.

In revising the manuscript, we addressed each point raised by the referees. 

All our changes are described below and marked in the manuscript.

 

 

Reviewer #1

Thanks to the authors for the opportunity to review their manuscript! I would like to draw the authors' attention to the following points:

1. It seems to me that the direction of the predictions in the title should be clearer: «Self-management predicts <lower> PTSD symptoms and <greater> post-traumatic growth among older adults in residential care homes in the 3 wake of COVID-19 pandemic». Thank you for the suggestion. The title was rewritten accordingly.
2. The authors do not describe the criteria for inclusion and exclusion of respondents, although this seems very important given the specifics of the sample. Was there a minimum and maximum age? Were there any restrictions on the mental and physical state and cognitive functioning of the respondents? It would be good to describe all these points in the manuscript. Thank you for the remark. Somehow, we missed describing these criteria in the first version of the manuscript. Done.
3. I am confused by the sample size of the study, given that the data were analyzed by regression analysis. Did the authors do a sample size calculation considering the statistical power of the analysis? It would have been nice to present the results of this analysis in the description of the study procedure. Thank you for the remark, indeed the sample size - as the reviewer suggested to add - is a limitation of the current study. As explained in the procedure, this study was a part of a broader study on the contribution of self-management to the improvement of well-being among older adults living within the community and in a residential care home. The initial study aimed at comparing these two different communities. Since the Covid-19 outbreak took place we had the opportunity to study new effects of self-management on psychological aspects which were not part of the initial study. Indeed, since the number of participants was present and finite, we were not sure that we would have sufficient participants. According to our pre-study power calculations, for a power of 0.90, and medium effect size of 0.15, for the delta in self-management variable, the last variable added to the hierarchical regressions. We needed a sample size of 73 participants; for a small to medium effect size of 0.10, we needed a sample size of 108 participants, and for a small effect size of 0.05, we needed a sample size of 213 participants. However, due to previous exploratory studies we made and were not published, we expected to see a medium to high effect size, between 0.15 and 0.20, equivalent to a sample size between 55 to 73 participants.

As can be seen in table 1, in the current study the effect size ranged between 0.11 to 0.20. For a power of .90, and the current results of effect size, a sample size of 96 participants is needed for the covid-19 PTSD variable; 56 participants for Anxiety; 66 participants for Covid-19 Growth; 59 for the satisfaction with life variable and 58 participants for the negative general mood variable. Our sample size in the current study is 64 participants which is not enough for a power of .90 for covid-19 PTSD variable, and almost sufficient for Covid-19 Growth. There for according to the reviewer remark we added to table 1 the current calculated effect size as well as the post-hoc power analysis for the current sample size of 64 participants. Most of the results for post-hoc power analysis are quite satisfactory: Anxiety - .93; satisfaction - .99; negative general mood - .93; Covid-19 Growth is reasonably satisfactory (.87). The results for Covid-19 PTSD are .75, which is lower than .80. For this specific variable repeating the study with a larger sample size could have been essential and results should be taken with caution.

The above calculation and description were added to Materials and Methods, Data analysis sub section, to the end of the results and, to the limitations.

4. The authors do not specify in what language the questionnaire was. If the instruments were presented in a language other than English, references to adaptations should be given. Thank you, done.
5. I would note the limitations of the study's small sample size and gender imbalance. Thank you, done.
6. Technical note: In the discussion, some parts of the text have a smaller font than the main text (lines 342-349, 352-355, etc.). Thank you, done.

 

Reviewer 2 Report

Dear authors and editor,

The manuscript titled "Self-management predicts PTSD symptoms and post-traumatic 
growth among older adults in residential care homes in the wake of COVID-19 pandemic" aimed to compares psychological outcomes including traumatic stress symptoms, post-traumatic growth (PTG), anxiety, life satisfaction, and general mood among older adults who performed a set of self-directed physical exercises independently during the pandemic compared with a group that did not perform the exercises.

There are many minor and major issues I'd like the authors resolve.

Abstract

1-Add the study design to the abstract. Also, the authors can choose to add the study design to the title of the manuscript.

2-Change the keywords.  Not found in the MeSH (Medical Subject Headings):aging management; PTSD; PTG.

3-Abbreviations are not recommended in the title of the manuscript.

Introduction

4- The introduction is excessively long and provides information that is not relevant to this section. Example "This paper offers two main contributions. First, we show that independent physical exercise based on individuals’ own planning and self-reflection can contribute to the improvement of aging management. Second, while many older adults suffer regularly from loneliness, there is extra value to being able to predict psychological outcomes – including the development of traumatic stress symptoms and post-traumatic growth – and to offer relevant aid during periods such as the Covid-19 pandemic, when social gatherings are banned for public health reasons. 

In what follows, we first briefly review background information about Covid-19 as a traumatic event and aging management. We then introduce the present study and present our hypotheses. Following this, we describe our method and present our results. We conclude with a general discussion, limitations, and suggestions for future research"

5- Moving from the introduction to the methodology. It is recommended to reduce this section."For this research, we took advantage of a broader study on the contribution of self-management to older adults’ well-being that was underway as the pandemic began. As part of this study,care home residents in Israel provided data about their self-management in the autumn of 2019. They then underwent about six months of weekly training in chair exercises physical exercises performed while seated in a chair, designed to engage all parts of the body and to improve strength, balance, and mobility. The initial training phase was planned to last 24 weeks, with one training session per week. Due to the onset of the Covid-19 pandemic and Israel’s first lockdown, the training was halted after 22 weeks, and residents were instructed to stay isolated in their apartments within the care home. 

The first two months of lockdown were confusing and emotionally demanding for both residents and caregivers. Accurate information regarding the virus – its transmissibility, mortality rates, effective means of prevention, etc. – were lacking. Likewise, nobody knew how long the pandemic might last, and when restrictions on residents’ movements and social interactions would be lifted. 

During this period, participants in the original self-management study were not in structed to follow any physical routine. However, some participants, of their own initiative, continued to practice the exercises on their own. This situation naturally created two study groups, one which engaged in independent self-training, and one which did not. 

The present study reports on psychological outcomes collected eight weeks after the pandemic’s outbreak among members of these two groups."

Materials and Methods

5-It is recommended to add a section that includes the design of the study.

6-It is also recommended to add ethical permissions.

7-Study size: Explain how the study size was arrived at.  The sample size is very important.

Results

8-Poner "p valor" cuando se hace comparación entre los grupos. Uniformidad en la expresión de los datos(no poner n.s) "We first checked whether the two study groups differed in their self-management at the start of the study. We 278 found no significant difference in self-management between the groups before the be- 279 ginning of the training phase (M = 4.10, SE = .50, and M = 3.92, SE = .75, for the self-practicing and non-self-practicing groups, respectively), t(63)=1.11, n.s. However, after the outbreak of the pandemic a significant difference in self-management between the groups was found (M = 4.51, SE = .83, and M = 3.68, SE = .94, for the self-practicing and 283 non-self-practicing groups, respectively), t(63)=3.39, p < 0.005)."

9-It is recommended to assess whether both groups start from identical conditions. In this way biases can be identified. Only the initial differences in self-management have been assessed.

10-In Figure 1 the p value is indicated with an asterisk, however this p value is not shown in the figure.

11-It is recommended to put at the bottom of Table 1 the meaning of the symbols and/or letters.

12-In the regression model, the sex variable is included; however, there is no homogeneity in this variable. 11 Men versus 53 women.

Discussion

13-Adequate, the authors include the most important findings and limitations of the study.

Conclusión

14-Adequate.

Referencia:

15-Adequate

Author Response

09 – June 2023 (initially, 15-November-2020

Liviu Oprea, PhD, University of Medicine and Pharmacy "Grigore T. Popa",

Daniela Cojocaru, Prof. PhD , Alexandru Ioan Cuza University,

Guest Editors, Special issue: Health-Related Sustainable Development Though Lifestyle and Self-Care. Sustainability Journal.

MS Ref Number: ID: sustainability-2423253

Title: "Self-management predicts PTSD symptoms and post-traumatic growth among older adults in residential care homes in the wake of COVID-19 pandemic"

New Title as suggested by reviewer #1 first remark and including the suggestion of reviewer #2 third remark: "Self-management predicts lower Post-Traumatic symptoms and greater post-traumatic growth among older adults in residential care homes in the wake of COVID-19 pandemic"

 

We wish to thank the editors, and both reviewers for reading and evaluating the manuscript, and for all the valuable observations. Clarifying and integrating the referees' comments was an enriching as well as demanding process. We have rethought and rearranged some of the conceptual and statistic measures and statistical analysis yielding a more precise manuscript. We worked thoroughly to assure the manuscript will contribute to the journal as expected.

In revising the manuscript, we addressed each point raised by the referees. 

All our changes are described below and marked in the manuscript.

 

 

Reviewer #2

dear authors and editor,

The manuscript titled "Self-management predicts PTSD symptoms and post-traumatic 
growth among older adults in residential care homes in the wake of COVID-19 pandemic" aimed to compares psychological outcomes including traumatic stress symptoms, post-traumatic growth (PTG), anxiety, life satisfaction, and general mood among older adults who performed a set of self-directed physical exercises independently during the pandemic compared with a group that did not perform the exercises. We wish to thank the reviewer for reading, evaluating, and contributing to manuscript his observations and thoughts.

There are many minor and major issues I'd like the authors resolve.

Abstract

1-Add the study design to the abstract. Also, the authors can choose to add the study design to the title of the manuscript. Thank you. The study design was added to the Abstract and to the Materials and Methods sections. Since the title currently is quite long, after considering and reconsidering the issue we decided to leave the title as it is without adding the study design.

2-Change the keywords.  Not found in the MeSH (Medical Subject Headings): aging management; PTSD; PTG. Thank you, done.

3-Abbreviations are not recommended in the title of the manuscript. Thank you. This was corrected.

Introduction

4- The introduction is excessively long and provides information that is not relevant to this section. Example "This paper offers two main contributions. First, we show that independent physical exercise based on individuals’ own planning and self-reflection can contribute to the improvement of aging management. Second, while many older adults suffer regularly from loneliness, there is extra value to being able to predict psychological outcomes – including the development of traumatic stress symptoms and post-traumatic growth – and to offer relevant aid during periods such as the Covid-19 pandemic, when social gatherings are banned for public health reasons. 

In what follows, we first briefly review background information about Covid-19 as a traumatic event and aging management. We then introduce the present study and present our hypotheses. Following this, we describe our method and present our results. We conclude with a general discussion, limitations, and suggestions for future research".

Thank you. This part was removed.

5- Moving from the introduction to the methodology. It is recommended to reduce this section."For this research, we took advantage of a broader study on the contribution of self-management to older adults’ well-being that was underway as the pandemic began. As part of this study,care home residents in Israel provided data about their self-management in the autumn of 2019. They then underwent about six months of weekly training in chair exercises physical exercises performed while seated in a chair, designed to engage all parts of the body and to improve strength, balance, and mobility. The initial training phase was planned to last 24 weeks, with one training session per week. Due to the onset of the Covid-19 pandemic and Israel’s first lockdown, the training was halted after 22 weeks, and residents were instructed to stay isolated in their apartments within the care home. 

The first two months of lockdown were confusing and emotionally demanding for both residents and caregivers. Accurate information regarding the virus – its transmissibility, mortality rates, effective means of prevention, etc. – were lacking. Likewise, nobody knew how long the pandemic might last, and when restrictions on residents’ movements and social interactions would be lifted. 

During this period, participants in the original self-management study were not in structed to follow any physical routine. However, some participants, of their own initiative, continued to practice the exercises on their own. This situation naturally created two study groups, one which engaged in independent self-training, and one which did not. 

The present study reports on psychological outcomes collected eight weeks after the pandemic’s outbreak among members of these two groups."

Thank you. This part was removed.

 

Materials and Methods

5-It is recommended to add a section that includes the design of the study. Done.

6-It is also recommended to add ethical permissions. Done.

7-Study size: Explain how the study size was arrived at.  The sample size is very important. Thank you for the remark. Please see specific explanations in the Materials and Methods, Data analysis sub section, in the end of the results and in the limitations. 

Results

8-Poner "p valor" cuando se hace comparación entre los grupos. Uniformidad en la expresión de los datos(no poner n.s) "We first checked whether the two study groups differed in their self-management at the start of the study. We 278 found no significant difference in self-management between the groups before the be- 279 ginning of the training phase (M = 4.10, SE = .50, and M = 3.92, SE = .75, for the self-practicing and non-self-practicing groups, respectively), t(63)=1.11, n.s. However, after the outbreak of the pandemic a significant difference in self-management between the groups was found (M = 4.51, SE = .83, and M = 3.68, SE = .94, for the self-practicing and 283 non-self-practicing groups, respectively), t(63)=3.39, p < 0.005)." Done.

9-It is recommended to assess whether both groups start from identical conditions. In this way biases can be identified. Only the initial differences in self-management have been assessed. Since self-management is the most important variable for the current design it was crucial for us to tell wheatear any initial differences between the group existed. As for the other interfering variable the random assignment to the two groups should eliminate any interfering variable. As for the psychological variables. These were collected only at the end of the current study. Since the initial aim of the large study was to compare the physiological condition of the participants we did not collected data for these measurement at the beginning of the study.   

10-In Figure 1 the p value is indicated with an asterisk, however this p value is not shown in the figure. That you for the remark. The p value was added to the figure.

11-It is recommended to put at the bottom of Table 1 the meaning of the symbols and/or letters. We are sorry but we did not understand to which symbols and/or letters the reviewer was referring.

12-In the regression model, the sex variable is included; however, there is no homogeneity in this variable. 11 Men versus 53 women. Thank you for the accurate observation. Indeed, it is generally recommended to exercise caution when including variables that violate the homogeneity assumption. However, comparing the dependents variable between the gender sub groups assuming inequal variances was not significant for any of the dependent variables [Covid-19 PTSD t(63)=1.2, p = 0.23; Anxiety t(63)=0.46, p = 0.64; Covid-19 Growth t(63)=0.54, p = 0.59 satisfaction with life t(63)=0.37, p = 0.53 and negative general mood t(63)=1.2, p = 0.22]. Taking in mind the importance of this issue for the validation of the results, the gender imbalance variable was added as a limitation to the current study.

Discussion

13-Adequate, the authors include the most important findings and limitations of the study.

Conclusión

14-Adequate.

Referencia:

15-Adequate

 

 

Round 2

Reviewer 1 Report

Thanks to the authors for improving the manuscript, I think the edits are sufficient.