Profile of Self-Care Capacity and Alcohol Use in Elderly Brazilians during the COVID-19 Outbreak: An Online Study

Round 1

Reviewer 1 Report

The study aims to examine the relationship between alcohol use and the physical capacity to perform activities of the daily life of the elderly during the covid-19 out-break.  Data are drawn from a cross-sectional survey, a questionnaire was self-filled by 101 elderly attending the Open University for the Elderly of Sao Paolo Campus, Brazil.  Descriptive statistics and some tests have been used to corroborate the research hypothesis. Tables 3 and 4 show that none of the assumed associations were significant (with one exception). Discussion and study limitations are oriented to explain why this could happen.

This research has several weaknesses, related to each other.

The first, moreover expressed by the authors among the limitations of the study, is the composition of the convenience sample. This cannot be considered as a sample of the elderly population but, at the most, of the elderly population with a good level of education and income. It follows that the hypotheses made do not fit to be tested on a sample consisting only of elderly people with good education and income levels. The low variability of socio-demographic variables, due probably to the context of reference, as well as of the dependent variables (SASCA and MAST-G) makes any statistical analysis little or no use at all.

The title explicitly brings the reader to  the evaluation of the “Impact of a……”. This would imply a pre-post research design or, in sub-order, the inclusion in the questionnaire of questions that can measure possible changes (example: In comparison with a year ago, your physical capacity is improved, worsened, or the same). Both the SASCA and the MAST-G seem to report the score only at the moment of the self-completion of the questionnaire. So the collected data are not sufficient to test the research hypothesis. 

Based on these considerations a suggestion could be to extend the survey to a control group with the same structural profile (but not attending the program) and to compare the two groups to evaluate the impact of the formative program.

Author Response

Reviewer: 1

Concern 1 (C1): This research has several weaknesses, related to each other. The first, moreover expressed by the authors among the limitations of the study, is the composition of the convenience sample. This cannot be considered as a sample of the elderly population but, at the most, of the elderly population with a good level of education and income. It follows that the hypotheses made do not fit to be tested on a sample consisting only of elderly people with good education and income levels. The low variability of socio-demographic variables, due probably to the context of reference, as well as of the dependent variables (SASCA and MAST-G) makes any statistical analysis little or no use at all.

Answer (A1): The Universal Declaration of Human Rights establishes the universal protection of human rights, regardless of race, sex, nationality, ethnicity, religion, or any other status. Human rights include the right to life, liberty, work, education, and housing. According to the United Nations, they are founded on respect for the person. The Unified Health System (SUS) in Brazil was born with the Federal Constitution of 1988, in article 196, it says that health is everyone's right and a duty of the State. To achieve this aim, the SUS was created, in accordance with the guidelines of integral decentralization and popular participation, the principles of universal care, integrality and equality established in the Constitution itself. Therefore, this portion of the elderly population, with better income and education conditions, in addition to having the right to physical and mental well-being, also needs to be seen and cared for. Therefore, it is important to know the sociodemographic variables that were related or not with SASCA and MAST-G in a context as peculiar and perhaps unique in our historical moment as pandemic.

Although we mentioned that it was a convenience sample, we cannot choose the people who have access to the public health service offered or not. What happens in Brazil, as in other parts of the world, is that people with higher levels of schooling and education tend to take better care of their health. We agree with the reviewer, but we disagree that our data are not applicable, as our research was carried out in the real context of the Brazilian public health system and during a situation as specific as a pandemic. That is, our study has ecological validity. On the contrary, our data show how much the "abyss of social differences" can have an impact on self-management and health care. In this pandemic, one of the things that made a difference is that those who had more digital and technological literacy were able to have more access to health care and information.

C2: The title explicitly brings the reader to the evaluation of the “Impact of a……”. This would imply a pre-post research design or, in sub-order, the inclusion in the questionnaire of questions that can measure possible changes (example: In comparison with a year ago, your physical capacity is improved, worsened, or the same). Both the SASCA and the MAST-G seem to report the score only at the moment of the self-completion of the questionnaire. So, the collected data are not sufficient to test the research hypothesis.

A2: We agree with the considerations made by the reviewer regarding the title of the manuscript. Therefore, we changed the title of the manuscript to "Profile of self-care capacity and alcohol use in elderly Brazilians during the COVID-19 outbreak: an online study". In fact, the proposed title was not reflecting what was done. It should be noted that our study contributed to the knowledge about alcohol use, abuse and dependence among elderly users assisted by a community program. Education and health promotion programs such as the "Open University for the Elderly" (UAPI), which is a national reference throughout Brazil, in the context of the Unified Health System (SUS), can be an effective strategy for the adoption and/or or maintenance of health self-care in the elderly population. The effort to maintain UAPI activities online during the COVID-19 pandemic was essential to minimize social isolation and social/psychological stressors that negatively impacted the health status of the elderly. Although there is no association between self-care and abusive use of alcohol by the elderly at the UAPI, this may denote the contribution of the community program to the adoption of a positive lifestyle, better self-care and non-abusive use of alcohol in the elderly population. In addition, it is fair to assume that the contact of health professionals with the elderly, even online, has contributed to better mental and physical health.

C3: Based on these considerations a suggestion could be to extend the survey to a control group with the same structural profile (but not attending the program) and to compare the two groups to evaluate the impact of the formative program. Impact of a Remote and Online Program on Older People's Daily Activities and Alcohol Consumption during the Coronavirus Outbreak.

A3: In the period in which the study was carried out, August 2020 to February 2021, unprecedented physical and social distancing measures were introduced worldwide, including Brazil, to mitigate the spread of SARS-CoV-2. At the time this research was conducted, the initial public health response for the population focused on social distancing with the aim of reducing exposure and easing the burden on public health services. The protection of the elderly was a priority strategy, given that they were the group at greatest risk of complications and death from COVID-19. People over 60 years of age in Brazil, as they are the most vulnerable, were advised to stay at home whenever possible, restrict their movements to perform strictly necessary activities, avoid using public transport and not frequent crowded places. Therefore, it would not be feasible to comply with the reviewer's suggestion of extending the research to a control group with the same structural profile (but not attending the program) and comparing the two groups to assess the impact of the applied program, since the measures and Sanitary recommendations, currently adopted in Brazil and in the world, are not the same as at the time the study was carried out. Today in Brazil, the elderly is on the fourth dose of the vaccine against COVID-19, there is no longer the orientation of social distance, and the health and sanitary recommendations are very different from the study collection period. Companies, schools, commerce, cultural activities were reopened and the recommendation to wear a mask is restricted to hospitals, laboratories, pharmacies, and public transport. This includes the elderly. We understand the reviewer's concern about our data and its possible outcomes, but we understand that the limitations of our study are not fatal and serve as a guide for possible future scenarios such as what we are experiencing and are currently experiencing. Around the world, all studies were carried out at specific times, in terms of the timeline of the pandemic, as this is a unique and dynamic situation. The reviewer proposes a laboratory and controlled study. Our proposal was to carry out a study in a real situation and outside the laboratory context and with greater ecological validity.

Reviewer 2 Report

The article is a classic example of research in which the null hypothesis (H0) is the statistical analysis, conducted with rigour, that does not support the hypotheses put forward by the researchers. The sample used is adequate and the data collected has been subjected to appropriate statistical analysis correctly illustrated. The only significant difference observed concerns the higher percentage of males of alcohol abuse, although the figure is lower than that of the Brazilian population as a whole.

Author Response

Reviewer: 2

Comments and Suggestions for Authors

C1: The article is a classic example of research in which the null hypothesis (H0) is the statistical analysis, conducted with rigor, that does not support the hypotheses put forward by the researchers. The sample used is adequate and the data collected has been subjected to appropriate statistical analysis correctly illustrated. The only significant difference observed concerns the higher percentage of males of alcohol abuse, although the figure is lower than that of the Brazilian population.

A1: As reviewer 2 points out, our article is a classic example of research in which the H0 does not support the hypotheses put forward by the researchers. Our statistical analysis was conducted by a professional statistician and based on in-depth discussion, as acknowledged by Reviewer 2. We thank Reviewer 2 for the insight of our article. Our study contributes to knowledge about alcohol use, abuse and dependence among users assisted by a community program and how this use could impact the performance of self-care activities. Education and health promotion programs such as the UAPI have proved to be an effective strategy for the adoption and/or maintenance and improvement of self-care in the elderly population. Online maintenance of UAPI activities during the COVID-19 pandemic was essential to minimize social isolation and the psychological stressors. Although there was no association between self-care and alcohol abuse by the elderly at the UAPI, this may contribute to the adoption of a positive lifestyle and health habits, such as self-care and non-abusive use of alcohol in the elderly population and denotes efficiency of the UAPI program. This study shows that the sample studied follows the same trend as the general population of greater abuse of alcohol by men.

Round 2

Reviewer 1 Report

The new title of the manuscript is in line with the paper's contents, so it can be accepted in its actual version. Please note that the pre-print release still shows the old title in the citation.