Determinants of Inequalities in the Exposure to and Adoption of Multiple Health Risk Behaviors among Brazilian Adolescents, 2009–2019
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe manuscript focuses on socioeconomic inequalities in risk behaviors among adolescents in Brazil. This is an interesting and important topic. Nonetheless, there are some aspects in the manuscript that need clarification. For instance, I am not familiar with the conducted analysis regarding concentration indexes. Based on the description in the manuscript, I was not able to understand it and this may be the same for other readers.
In the following, please find my additional comments that may help to further strengthen the manuscript:
· It is not described in detail in the manuscript, whether the participants received a reimbursement for their time and whether parents had to agree for the participation of their children.
· Please clarify at the beginning of the manuscript, that you report trend data and not longitudinal data, as readers may think that you followed the individual over years after having read the introduction.
· Please include the case numbers per year in the methods section and in each table.
· Please clarify in the manuscript whether data were weighted to reach representativeness. Do the characteristics of participants correspond to the actual distribution of students in Brazil based on official statistics? (“representative at population level” (line 13))
· The analysis conducted in Table 2 are not clear and they are not described in the methods section (focus is on concentration and inequality indexes). Please include more information in the methods section and in the table’s legend.
· From my point of view, Table 2 does not show clear trends. There are ups and downs and the overall p-value does not give information on the changes between the single years. Here, post-hoc tests would be necessary. I suggest to include confidence intervals for each proportion reported in Table 2.
· In addition, some behaviors decreased over time (fighting with gun, fighting with weapon, alcohol consumption). Therefore the “worrying trends in exposure and adoption” (line 202) are not totally supported. Moreover, this is an interpretation of the findings that should be included in the discussion. The findings should be written in neutral language.
· For me it is not clear, what Table 3 shows. I do not know what kind of numbers are reported. The reader needs more information on what the numbers mean. Here, interpretation support in the legend may be helpful. The same applies to Figure 1, which I also do not understand.
Author Response
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Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsA few comments about the study design:
1) were all the participants the same age - page 2 line 69 notes that students were sampled in the last year of elementary school
2) if participants were followed longitudinally, and therefore explaining the various age groups, then data should have been analyzed longitudinally instead
3) page 3 lines 104 to 110 - two points in this section: why three of more experiences, not two or more, and why 30 days instead of once in life?
Pages 9 and 10 - I believe that the results would be more easily understood if they were summarized based on risky behavior categories rather than on the trend found. For example, page 9 lines 273 and 274 combines results about illicit drugs and unsafe sex, which are quite different behaviors
Overall, I do not believe that this manuscript adds to the literature in its current state, as the main conclusion (older male adolescents in minority ethnic groups with lower educational attainment are at higher risk) is one that is well-known and already a great concern worldwide.
Comments on the Quality of English LanguageOverall, the manuscript was difficult to understand due to the poor wording and sentence structure. A few keywords (evolution, adherence to risk behaviors, and inequality) were repeatedly used in a manner that did not clearly make sense in the context of the manuscript.
As well, the use of the term 'skin color' is not typically used, instead the words 'race' or 'ethnicity' are often used. Similarly, for adolescents the term 'gender' instead of 'sex' is used.
Throughout the manuscript there were prepositions missing as well.
Author Response
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Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsDear authors. I appreciate the opportunity to review your manuscript. I would like to send you some comments/suggestions that I think could improve your manuscript.
- I believe that the risk behaviors referred to in the study should be better explained in the introduction. From my point of view the introduction is too general.
- For what purpose did you want to investigate these inequalities?
- Why the range 2009-2019?
- What ages were the participants? It indicates that it is an elementary school but I don't know what ages it corresponds to.
- More information is necessary about the questionnaires used for data collection.
- The information contained in table 3 is not understood correctly, I recommend that it be reviewed.
- For what purpose have you carried out this research? They identify the factors and behaviors, why? Is there any intention to implement any changes after carrying out this research? Who are they going to share the data with?
- I have not seen the limitations of the study or the strengths and I consider it important.
Thank you.
Author Response
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Author Response File: Author Response.pdf
Reviewer 4 Report
Comments and Suggestions for AuthorsThis is very strong work. It is evident that the authors took great care with the preparation of the manuscript.
The topic is of critical importance, especially as we see more and more inequality on a global basis.
The literature review is very good, relying upon 56 references.
The Materials and Methods section is strong. There is a clear description of the study design. The datasets are well-described. I do recommend that the authors put in the narrative the number of respondents, in addition to having this information in the tables.
I am not a research methodologist/statistician and I hope another reviewer can be helpful here.
I am impressed by the number of adolescent risk behaviors that are addressed in this work.
The Discussion section is strong in elucidating the complicated relationship between socioeconomic inequalities and risk behaviors. The authors do a very good job of of discussing the study limitations.
The Conclusions section nicely offers some important recommendations for prevention practices.
Author Response
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Author Response File: Author Response.pdf
Reviewer 5 Report
Comments and Suggestions for AuthorsDear authors:
congratulation to your article:
Evolution and determinants of inequalities in exposure and adherence to multiple risk behaviors among Brazilian adolescents.
AIM: The study analyzes the evolution and the factors associated with inequalities in exposure and adoption of multiple risk behaviors in Brazilian adolescents
Important explanation:
The analyses of inequalities performed in the present study identify differences in 2 exposure and adoption of multiple health risk behaviors among Brazilian students according to socioeconomic strata and year, allowing to verify changes in the proportion of adolescents declaring co-occurrence of behaviors from 2009 to 2019.
The results showed: an intensification in socioeconomic inequalities referring to the incidence of multiple risk behaviors, shifting from higher concentration among wealthier individuals in 2009 to lower socioeconomic strata in the following periods.
WELL STRUCTURED ARTICLE.
Important conclusion:
Contextual issues referring to lifestyle choices, household, and school environments showed an important role in the occurrence and inequalities towards adolescents’ experience or adoption of multiple risk behaviors.
Excellent article with very good ideas and reflections.
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Questions: important articles:
1.
How important is : relationships between parents and adolescents,
Tkacova, H. et al. OVERSHARING OF CONTENT ONLINE BY CHILDREN DURING THE HOLIDAYS AND PARENTAL CONTROL . Acta Missiologica 2023, 2, pp. 60-74
https://www.actamissiologica.com/sub/am_2_2023.pdf
https://www.researchgate.net/publication/376515593_Oversharing_of_content_online_by_children_during_the_holidays_and_parental_control_Acta_Missiologica#fullTextFileContent
How important is religion?
http://www.ejst.tuiasi.ro/Files/79/7_Zalec%20&%20Pavlikova.pdf
Zalec Pavlíková, M. Civic virtues and functions of religion in public life European Journal of Science and Theology, 2019, 15(6), pp. 75–84
Author Response
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Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsEspecially the section on results has improved but important content from the answers to the comments of the three reviewers have not been included in the manuscript. From my point of view, the information given in the answers is not only important for the reviewers but also for potential readers. Readers may have the same questions as reviewers raised. In addition, there are methodic flaws (e.g., p=0.000 instead of p<0.001).
Author Response
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Author Response File: Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThank you for all the changes you made to the manuscript. It is much improved; though there are a few minor comments left to be addressed:
1) I continue to have concern about the ethnicity labels; as the labels currently included are skin colour, which is not ethnicity
2) page 11 line 403- I'm unclear why the data was not included for this result
3) there are various comments that imply causation or vast conclusions which do not seem appropriate, including page 12 lines 448/449 most of those individuals would be above adolescent age range, page 12 line 476 - cigarette use is not an affect of suicidal ideation, and page 13 line 497/498 - unhealthy diet does not cause risk behaviours
Comments on the Quality of English Language1) a review of the English would be helpful as in some sentences words such as 'a' and 'the' are missing and/or words seem to be incorrectly sequenced
Author Response
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Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsDear authors. I appreciate your time and effort in responding to each of the questions I have raised. I believe that, with great success, they have been able to include the reviewers' comments in their work and that it has improved.
I congratulate you for your work and encourage you to continue working on this line of research.
Best regards
Author Response
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Round 3
Reviewer 2 Report
Comments and Suggestions for AuthorsMy only remaining comment is about the demographic table; referring to individuals as "yellow" is not typical in most western countries so I would recommend changing that term.
Comments on the Quality of English Languageit seems to have been improved within the most recent revision, which is great.
Author Response
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Author Response File: Author Response.pdf
