Cyberchondria, Health Literacy, and Perception of Risk in Croatian Patients with Risk of Sexually Transmitted Infections and HIV—A Cross-Sectional Study

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

The authors have correctly addressed my concerns. I believe the current version has been improved and is suitable for publication in this journal.

Author Response

Dear reviewer,

thank you for reviewing our paper (again) and giving us a positive opinion. We have used MDPI language editing services. 

Sincerely,

Ksenija Bazdaric

Author Response File: Author Response.pdf

Reviewer 2 Report (Previous Reviewer 4)

Comments and Suggestions for Authors

Thank you for revising your manuscript accordingly.

After going through the revision, I have no further comments to add.

Looking forward to seeing this published.

Best

Author Response

Dear reviewer,

thank you for reviewing our paper (again) and giving us a positive opinion. We have used MDPI language editing services. 

Sincerely,

Ksenija Bazdaric

Author Response File: Author Response.pdf

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

Overall, this is an interesting paper. However, significant changes are needed to render this manuscript suitable for publication. Additionally, extensive editing of English language and grammar is needed across the manuscript.

1. In line 41, "positively" is misspelled. 

2. Please rephrase line 39 in the abstract as it is not clear. 

3. Line 91-93, references are missing.

4. The introduction needs re-structuring. It would benefit from being divided into sub-sections with headings.

5.  The methods also needs re-structuring. The intervention is described towards the end of the methods section which makes it harder to follow. Inclusion and Exclusion criteria for each of the intervention and control group should have a paragraph on its own. Please elaborate on what the informed consent included in terms of information.

6. Line 414-417 is written as an assumption rather than being supported by the literature. 

7. What about social desirability bias as a limitation?

 

Comments on the Quality of English Language

Grammatical errors are widely apparent across the manuscript. Extensive editing is needed.

Author Response

Overall, this is an interesting paper. However, significant changes are needed to render this manuscript suitable for publication. Additionally, extensive editing of English language and grammar is needed across the manuscript (we attach the certificate)

 

Thank you for your review. We have tried to answer all your comments and we have used MDPI author services for language and academic editing and spelling and grammar are checked by native speakers.  

 

Comment 1. In line 41, "positively" is misspelled. 

 

Response 1. Spelling and grammar are now checked in all text by native speakers. The word "positively" is now in line 44. 

 

Comment 2. Please rephrase line 39 in the abstract as it is not clear. 

Response 2. The sentence: There was no difference in health literacy between the groups and it was average. Was changed into: There was no difference in the health literacy scores between the STI and control group, heaLth literacy score was average in both groups (l 41-42).

 

Comment 3. Line 91-93, references are missing.

Response 3. Reference is added as requested. (l 100-102)

 

Comment 4. The introduction needs re-structuring. It would benefit from being divided into sub-sections with headings.

Response 4. Thank you for your comment, we have now added subheadings in the Introduction.

 

Comment 5. The methods also needs re-structuring. The intervention is described towards the end of the methods section which makes it harder to follow. IInclusion and Exclusion criteria for each of the intervention and control group should have a paragraph on its own. Please elaborate on what the informed consent included in terms of information.

Response 5. We have now restructured the methods as requested and described the intervention earlier in the text.

We have added separate paragraphs for inclusion and exclusion groups in each group.

We have added a new paragraph (Ethics) and explained.

 

Comment 6. Line 414-417 is written as an assumption rather than being supported by the literature. 

Response 6. The sentence was editeda and a reference was added.

This finding may be connected to the fact that the survey was performed during the COVID-19 pandemic. Namely, people worldwide were confronted with medical information that was changing rapidly on a daily basis, increasing doubt in the organization and effectiveness of healthcare services and strengthening fear and uncertainty, especially regarding vaccination. 

 

Comment 7. What about social desirability bias as a limitation?

Response 7. We have added social desirability as bias in the limitations. (l 561-570)

 

 

Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

A well-written manuscript.

I noticed that you didn't mention any thing about pilot study.

You also mentioned that a professor (who you didn't mention her affiliation or specialty) did the translation of both questionnaires. You should test the translation by an expert in the language and then retranslate again into English to be sure that it was appropriate.

In lines 163 and 167 you mentioned that each participant was asked to fill out 4 questionnaires, while in line 178 you mentioned that 3 questionnaires were used in the research, kindly explain. 

Author Response

Reviewer 1

 

A well-written manuscript.

I noticed that you didn't mention any thing about pilot study.

Thank you, we did not have a pilot study as the questionnaires were previously validated in Croatian language.

 

You also mentioned that a professor (who you didn't mention her affiliation or specialty) did the translation of both questionnaires. You should test the translation by an expert in the language and then retranslate again into English to be sure that it was appropriate.

Thank you. We have now included a text and reference in which the Cyberchondria severity score was previously tested in Croatian language ( ref. 18. Jokić-Begić N, Mikac U, Čuržik D, Sangster Jokić C. doi:10.1007/s10862-019-09744-z).

We have also calculated reliability for our sample. We have explained in section 3.3: Cyberchondria scale had excellent reliability of α=0.95. Most of the subscales also showed excellent reliability: Compulsion (α=0.92), Distress (α=0.95), Excessiveness (α=0.84), Reassurance (α=0.87) except for the Mistrust factor (α=0.45), The reliability of health literacy scale was excellent α=0.93.

Prof Jokić begić is a clinical psychology from the University of Zagreb, Croatia. (https://scholar.google.com.tw/citations?user=lH-19l0AAAAJ&hl=en)

 

In lines 163 and 167 you mentioned that each participant was asked to fill out 4 questionnaires, while in line 178 you mentioned that 3 questionnaires were used in the research, kindly explain. 

We have corrected the number. Thank you.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you very much for giving me the opportunity to review this interesting article which deals with a very interesting and little studied topic: cyberchondria and health literacy.

Overall it is a very well written article and the methodology is correct. I have no major concerns, but minor comments with the intention of improving the quality of the article.

 

GENERAL COMMENTS:

- I suggest the authors consider changing the term ‘Sexually Transmitted Diseases (STDs)’ and use ‘Sexually Transmitted Infections (STIs)’ instead. For years there has been a tendency to use the acronym STI, as disease does not always occur when infection occurs. This change of concept was coined by the World Health Organisation (WHO) in 1998 and is based on the fact that the term ‘disease’ is inappropriate to designate those infections that are asymptomatic and go unnoticed by people, with sometimes irreversible consequences.

- They could round all data to one decimal place. I think it makes it much simpler to read and helps to make calculations faster.

 

ABSTRACT

This section is perfect, it summarises correctly the research carried out. However, there is a small flaw in the distribution of the groups, they are switched. The test group was 134 and the control group was 171, and not the other way round as the authors reflect (lines 27-29).

 

INTRODUCTION

The first paragraph (lines 44-52) correctly summarises the HIV situation globally and in Croatia. However, epidemiological information on other STIs of interest is missing. Perhaps the authors could add this information in a summarised form, even if only focusing on the global level.

Line 76, I do not understand what you mean by ‘regular PAPA test’. This should be clarified or the acronym should be broken down.

Line 85, this sentence needs a supporting quote, ‘It was mentioned for the first time in 1999’.

Lines 87-88, before publication I suggest repeating the search to make it as up to date as possible. I found 170 results (02/06/2024).

Line 105, the authors indicate that Begić et al. carried out the translation and validation of the scale into the Croatian version, however, it seems that the reflected citation is not correct as the author of citation 14 is another one: McElroy et al.

 

MATERIALS AND METHODS

This section is correct, I have no real comments. The methodology used is correct and allows replication of this study.

Perhaps it would be good to expand a little on the information about the control group (lines 138-142).  What do they really mean by ‘everyday epidemiologic practice’? Do they have a database of patients who were randomly called? Which infectious diseases do you monitor and follow up?

 

RESULTS

Lines 254-255, this statement is not reflected in table 1. It could be added as a variable of interest.

In table 1, which risk behaviours are included under ‘other’?

Within the variable ‘risk behaviours’ I would consider changing the label of the category ‘promiscuity’ as it can be stigmatising. The same applies to the category ‘Homosexual contact’. Homosexual contact does not necessarily imply a risk behaviour, I suggest rewording these concepts to avoid conveying a stigmatising message.

To improve the readability of table 3, I suggest bolding the line ‘Total Cyberchondria’ to differentiate it from the other categories. Another option would be to indent the 5 items of the scale. It would also help to remember in the table legend the values defined in the methodology for the interpretation of the results. I suggest adding to the legend: ‘Low results were considered 1-2.33, average 2.34-3.67 and high 3.68-5.00’.

 

DISCUSSION

I have no comments for this section. They synthesise the findings of the study well and make comparisons with other studies. They address all issues well and acknowledge the limitation of overlapping fieldwork with COVID-19.

Author Response

Reviewer 2

 

GENERAL COMMENTS:

- I suggest the authors consider changing the term ‘Sexually Transmitted Diseases (STDs)’ and use ‘Sexually Transmitted Infections (STIs)’ instead. For years there has been a tendency to use the acronym STI, as disease does not always occur when infection occurs. This change of concept was coined by the World Health Organisation (WHO) in 1998 and is based on the fact that the term ‘disease’ is inappropriate to designate those infections that are asymptomatic and go unnoticed by people, with sometimes irreversible consequences.

We have corrected the term STD into STI. Thank you.

 

- They could round all data to one decimal place. I think it makes it much simpler to read and helps to make calculations faster.

Thank you. All percentages and scale results were corrected in the text and in the tables. However, the results of the regression analysis are presented in a usual manner, with 2 decimal points for values and 3 decimal points for p values.

 

ABSTRACT

This section is perfect, it summarises correctly the research carried out. However, there is a small flaw in the distribution of the groups, they are switched. The test group was 134 and the control group was 171, and not the other way round as the authors reflect (lines 27-29).

Thank you, we have corrected the numbers.

 

INTRODUCTION

The first paragraph (lines 44-52) correctly summarises the HIV situation globally and in Croatia. However, epidemiological information on other STIs of interest is missing. Perhaps the authors could add this information in a summarised form, even if only focusing on the global level.

Thank you, we have included the data on other STIs.

 

Line 76, I do not understand what you mean by ‘regular PAPA test’. This should be clarified or the acronym should be broken down.

Thank you, we corrected the term into “Pap test”.

 

Line 85, this sentence needs a supporting quote, ‘It was mentioned for the first time in 1999’.

Thank you. The sentence is corrected and the reference is provided:

The term “cyberchondria” was used for the first time in an article in the “Business Wire” newspaper in the United Kingdom in 1996., while in scientific communication, in an article published in The Medical Journal of Australia in 2000.

Loos A. Cyberchondria: too much information for the health anxious patient?. J Consum Health Internet. 2013;17(4):439-45

 

Lines 87-88, before publication I suggest repeating the search to make it as up to date as possible. I found 170 results (02/06/2024).

Thank you, we have performed a new search and there are 171 results. We have corrected the text.

Line 105, the authors indicate that Begić et al. carried out the translation and validation of the scale into the Croatian version, however, it seems that the reflected citation is not correct as the author of citation 14 is another one: McElroy et al.

Thank you. We included the reference 18. Jokić-Begić et al, and corrected the reference list.

 

MATERIALS AND METHODS

This section is correct, I have no real comments. The methodology used is correct and allows replication of this study.

Perhaps it would be good to expand a little on the information about the control group (lines 138-142).  What do they really mean by ‘everyday epidemiologic practice’? Do they have a database of patients who were randomly called? Which infectious diseases do you monitor and follow up?

Thank you. It was corrected as follows:

The control group (N = 171) consisted of patients of the Department recruited from everyday epidemiologic practice: vaccinations (according to indications or commercial), passenger counselling related to vaccinations and measures to protect against infectious diseases during travel, health examinations of persons subject to mandatory health surveillance, anti-rabies treatment of persons (bitten/injured by animals), health surveillance of returnees from countries under increased risk of certain infectious diseases according to the current epidemiological situation or by order of the border sanitary inspection, and a number of other activities that depend on the current epidemiological situation.

 

RESULTS

Lines 254-255, this statement is not reflected in table 1. It could be added as a variable of interest.

We have commented this results in the Discussion section.

 

In table 1, which risk behaviours are included under ‘other’?

Any other risk behaviour not covered by the previous provided answers.

 

Within the variable ‘risk behaviours’ I would consider changing the label of the category ‘promiscuity’ as it can be stigmatising. The same applies to the category ‘Homosexual contact’. Homosexual contact does not necessarily imply a risk behaviour, I suggest rewording these concepts to avoid conveying a stigmatising message.

Thank you for your comment. However, these terms are used in the standard survey questionnaire Form for HIV testing and counselling (version 7), which is an official form issued by the Croatian Institute of Public Health and used by all centres in Croatia.

Nemeth Blažić T, ed. Priručnik za HIV savjetovanje i testiranje. Zagreb: Ministarstvo zdravstva i socijalne skrbi Republike hrvatske, Hrvatski zavod za javno zdravstvo; 2009.

 

To improve the readability of table 3, I suggest bolding the line ‘Total Cyberchondria’ to differentiate it from the other categories. Another option would be to indent the 5 items of the scale. It would also help to remember in the table legend the values defined in the methodology for the interpretation of the results. I suggest adding to the legend: ‘Low results were considered 1-2.33, average 2.34-3.67 and high 3.68-5.00’.

Thank you, it was corrected.

 

DISCUSSION

I have no comments for this section. They synthesise the findings of the study well and make comparisons with other studies. They address all issues well and acknowledge the limitation of overlapping fieldwork with COVID-19.

Thank you.

 

Reviewer 3 Report

Comments and Suggestions for Authors

I am pleased to have the opportunity to review the manuscript titled "Cyberchondria, Health Literacy and Perception of Risk in Croatian Patients with Risk of Sexually Transmitted Diseases and HIV – A Cross Sectional Study." This study aims to examine the association between risk assessment of sexually transmitted diseases and HIV, cyberchondria, and health literacy. However, after a thorough review of the manuscript, I have identified several major issues, including some fundamental conceptual errors. Here are my detailed comments:

 

1-The title claims that this is a cross-sectional study, which inherently does not require the establishment of control groups. However, in both the abstract and the full text, the authors have divided participants into experimental and control groups. This division suggests that the samples come from two distinct populations rather than from a single population, which theoretically precludes meaningful comparative testing.

Methods Section:

 

2- The methods section should provide a detailed description of the study design and implementation procedures (this should be a separate section). It is crucial to clearly define the type of study being conducted (e.g., cross-sectional study). Typically, an experimental group refers to a group receiving a specific intervention, which does not align with the stated design.

 

3- The methods section should explicitly describe the sampling method and clarify why the current sample size is adequate for the study's needs. This necessitates a separate subsection explaining "sample size calculation."

 

4- What specific model was used in the multiple regression analysis? Were the assumptions of the model met? How were the independent variables included?

 

5- It is generally necessary to present adjusted odds ratios in epidemiological research.

Comments on the Quality of English Language

Moderate editing of English language required.

Author Response

Reviewer 3

I am pleased to have the opportunity to review the manuscript titled "Cyberchondria, Health Literacy and Perception of Risk in Croatian Patients with Risk of Sexually Transmitted Diseases and HIV – A Cross Sectional Study." This study aims to examine the association between risk assessment of sexually transmitted diseases and HIV, cyberchondria, and health literacy. However, after a thorough review of the manuscript, I have identified several major issues, including some fundamental conceptual errors. Here are my detailed comments:

 

1-The title claims that this is a cross-sectional study, which inherently does not require the establishment of control groups. However, in both the abstract and the full text, the authors have divided participants into experimental and control groups. This division suggests that the samples come from two distinct populations rather than from a single population, which theoretically precludes meaningful comparative testing.

 

Dear Reviewer, thank You very much for Your comments. Our study would be best characterized as a non-randomized controlled trial with cross-sectional study design since investigational and control group were evaluated and data were obtained at a single timepoint. These two terms describe different aspects of the study design and are not mutually exclusive and are now included in the text

 

Methods Section:

 

2- The methods section should provide a detailed description of the study design and implementation procedures (this should be a separate section). It is crucial to clearly define the type of study being conducted (e.g., cross-sectional study). Typically, an experimental group refers to a group receiving a specific intervention, which does not align with the stated design.

 

Thank You, we renamed the “experimental group” into “STI counselling group” throughout the manuscript to avoid confusion.

 

3- The methods section should explicitly describe the sampling method and clarify why the current sample size is adequate for the study's needs. This necessitates a separate subsection explaining "sample size calculation."

 

Convenience sampling was used with consecutive patients presenting in the STI counselling clinic and other epidemiological clinics were approached to participate in the study. Power analysis for estimation of required sample size was done prior to the study, with the assumptions of error type 1 of 0.05, 90% power, clinically significant difference in means of 10 points on Cyberchondria scale between groups, and standard deviation of 20 points in each group. The required sample size for obtaining statistically significant difference under these assumptions was calculated to be at least 86 patients per each group. The study enrolled higher number of patients to account for potentially missing data and sufficient power for additional analyses.

 

4- What specific model was used in the multiple regression analysis? Were the assumptions of the model met? How were the independent variables included?

 

We used linear multiple regression analysis to obtain presented models. Due to real-life clinical dataset all the models did not meet all the assumptions behind the multiple regression analysis, and thus we performed additional multivariate analyses using the logistic regression analysis to increase the robustness of our findings (supplement 1). These results were consistent with originally presented ones and allowed us to obtain odds ratios for these analyses.

 

5- It is generally necessary to present adjusted odds ratios in epidemiological research.

Please see point 4 above.

 

Reviewer 4 Report

Comments and Suggestions for Authors

Thanks for this important work. Please find my comments below:

1. Can the authors revise the first two sentences of the introduction?

2. In sentence 3 of the introduction, the authors ascribed 630 000 [480 000–880 000]  to “AIDS” instead of “HIV” Please note that AIDS is not technically the same as HIV. Consider revising this where necessary in the rest of the manuscript.

3. In the Methods, there are two subsections with the same title. Consider merging these to avoid any confusion or giving different titles.

4. Consider stating whether consent or its lack is part of the inclusion/exclusion criteria.

5. Regarding the questionnaires used to evaluate the three study outcomes, please state whether you adapted or adopted these, and indicate whether they have been validated in the Croatian population.

6. Under the analysis section, the authors have yet to state whether they have evaluated model fitness and, if so, how they did it.

7. Have bivariate comparisons been done? And what approach to logistic regression modeling was employed for the multivariate analysis. Please give all these and more details regarding your analysis to make the work reproducible.

8. In describing the results in the abstract, the authors compare the examined group (for which they did a multivariate analysis) with the control group for which they have not done a multivariate analysis. So how did they arrive at these comparisons?

9. Why have the authors also not applied multivariate analysis to examine the Cyberchondria items for the control group?

10. Off not, the Mistrust item of the cyberchondria scale was not included in your multivariate analysis for the examined group. Could you explain to your reader why this is so?

 

I look forward to reading the revised version of this manuscript.

Author Response

Reviewer 4

Thanks for this important work. Please find my comments below:

1. Can the authors revise the first two sentences of the introduction?

In sentence 3 of the introduction, the authors ascribed 630 000 [480 000–880 000]  to “AIDS” instead of “HIV” Please note that AIDS is not technically the same as HIV. Consider revising this where necessary in the rest of the manuscript.

Thank you, the revision has been made.

1. In the Methods, there are two subsections with the same title. Consider merging these to avoid any confusion or giving different titles.

Thank you, the revision has been made.

1. Consider stating whether consent or its lack is part of the inclusion/exclusion criteria.

Thank you, the revision has been made.

1. Regarding the questionnaires used to evaluate the three study outcomes, please state whether you adapted or adopted these, and indicate whether they have been validated in the Croatian population.

Thank you. We have now included a text and reference in which the Cyberchondria severity score was tested in Croatian language ( ref. 18. Jokić-Begić N, Mikac U, Čuržik D, Sangster Jokić C. doi:10.1007/s10862-019-09744-z). We have also calculated reliability for our sample. We have explained in 3.3: Cyberchondria scale had excellent reliability of α=0.95. Most of the subscales also showed excellent reliability: Compulsion (α=0.92), Distress (α=0.95), Excessiveness (α=0.84), Reassurance (α=0.87) except for the Mistrust factor (α=0.45), The reliability of health literacy scale was excellent α=0.93.

1. Under the analysis section, the authors have yet to state whether they have evaluated model fitness and, if so, how they did it.

Thank You, all the models have been evaluated using the R squared and overall model P value which are included in the tables.

1. Have bivariate comparisons been done? And what approach to logistic regression modeling was employed for the multivariate analysis. Please give all these and more details regarding your analysis to make the work reproducible.

 

We included logistic regression analysis in the revised version of the manuscript as a supplement 1. We synchronously analyzed all included variables in the model using the “enter“ method and have revised the text in the statistical analysis section.

 

7. In describing the results in the abstract, the authors compare the examined group (for which they did a multivariate analysis) with the control group for which they have not done a multivariate analysis. So how did they arrive at these comparisons?

 

Both groups are included in the regression analyses, to control for confounders regarding observed differences between STI counselling and control group.

 

1. Why have the authors also not applied multivariate analysis to examine the Cyberchondria items for the control group?

See point 7 above.

 

1. Off not, the Mistrust item of the cyberchondria scale was not included in your multivariate analysis for the examined group. Could you explain to your reader why this is so?

We omitted the Mistrust factor from the presentation due to non-significant associations, however, we now include it in the revised version of the manuscript.

 

 

 

 

Round 2

Reviewer 4 Report

Comments and Suggestions for Authors

Thank you for responding to the comments adequately and so promptly.

Looking forward to seeing the published version.