Round 1

Reviewer 1 Report (Previous Reviewer 1)

Thank you for the opportunity to review this manuscript again. I feel the authors did a much better job in this version framing the study and its goals. They also greatly improved the description of the methods. It now reads as a cohesive and interesting paper with some important clinical implications. 

A final proof with an eye toward the English language would be sufficient. 

Author Response

Please see the attachment

Author Response File: Author Response.docx

Reviewer 2 Report (New Reviewer)

The situation of young people who are dealing with close relatives who have serious health problems can certainly be grim.  As they are searching for their place in life and spending much of their energy preparing for adulthood through engaging in education, young people who have to deal with RHSC experience many challenges.  Your study has addressed some of the struggles that they may be encountering in a paper that focuses the attention of readers on the family issues that may produce a decline in the young people’s own mental health.  You have also indicated the factors that can have a serious impact on their ability to deal with these challenges.  Some specific comments follow regarding possible revisions that might clear up some issues and answer a few questions that arose.

Title: Suggest you revise so it is clear from the title that the paper focuses on youth mental health.  Perhaps you might revise to read “The association between adolescents’ experiences of close relatives having severe health conditions and their own mental health—a population-based school study.

Abstract

Lines 27-28.  Consider revising to read “…those with several RSHC experiences and few protective factors. When meeting adolescents with RSHC experiences, supporting their key protective factors may play an important role…”

Introduction

Line 34-35. It would be helpful for you to indicate with whom you are comparing the young persons’ vulnerable life situation. Perhaps those without RSHC challenges?

Lines 45-46.  Suggest your revise for clarity, perhaps. “Evidence has shown that young people experiencing either somatic symptoms and/or internalizing problems such as depression and anxiety is associated with the presence of…”

Line 54.  Please clarify what you mean by “major health promotion areas.”

Line 75.  You might revise to read, “…the impact of protective factors preventing poor mental health”

Line 78-80.  Do you mean “...positive factors related to an adolescent’s situation at school…may influence this association in a protective way.” ?

Materials and Methods

Lines 117-118.  Please say more about “The Life and Health in Youth” surveys.

Line 132.  Suggest you consider changing this to: “The questions were used to identify adolescents with different RSHC experiences.”

Results

Lines 270-272. The results reported here do not appear in Table 1.

Pages 6-8.  Please revise Table 1 so that the spacing is more regular, and the sections are more clearly distinct.

Table 2. Please indicate how the adjustments referred to in footnotes were made.

Discussion

Line 349.  Suggest you revise to read “…showed significantly increased odds…”

Line 380-388.  Strongly urge you to include what is now Supplementary Table 1 in the text of the report.

Strengths and Limitations section

Line 450-452.  It would be helpful for you to give more detail about the comprehensibility testing either in the methods section or here in the discussion.

Conclusions

Suggest that you discuss more about the stakeholders that can increase the mental wellbeing of these vulnerable youth. What should be their “supportive holistic approach”?

In this generally clearly written paper, the authors have been able to set forth a well -developed abstract and introduction, carefully present the materials and methods, and report the results in a logical and coherent section.  The discussion that follows does a generally logical job of setting forth major findings and implications. The comments that follow include some specific suggestions for editing some of the writing to improve clarity in several passages of the paper, but in general the writing is commendable.

Author Response

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Author Response File: Author Response.docx

Reviewer 3 Report (New Reviewer)

Thank you for the opportunity to review this paper. Whilst it is largely of high quality, there are a few clarifications or edits needed before publication:

I think it would be useful to describe in the paper how you decided to include questions regarding these specific protective factors e.g. is this based on previous literature/stakeholder involvement, or just some things you decided as a research team?

In the discussion, you define 'few' protective factors as any up to 7. "Adolescents with few (0–7) protective factors" However, 7 is over half of the 11 protective factors you identified, so I'm not sure how this can be categorised as 'few' - this needs more explaining, including how you decided on 0-7 to be 'few' protective factors.

Unsure of this distinction from 'strengths and limitations' "deaths of natural causes and death due to severe illness" - an illness like cancer is a severe illness but also a 'natural cause'?

 

Author Response

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Author Response File: Author Response.docx

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

1) The introduction seems to jump around and would benefit from improved flow and structure. For example, authors could first operationalize ‘relatives with health conditions’ and discuss how many youth are living with such relatives, then move on to discuss the impact this might have on mental health, then discuss potential protective factors, then conclude with a “current study” section in which aims and hypotheses are clearly stated, in addition to what makes this study novel. Also of note, the research gap that this study addresses is not currently evident. In sum, the Introduction needs to do a much better job clearly setting up what this study is about, and why it is novel and important.

2) The fact that this data was collected at the very outset of the Covid-19 pandemic is notable. It was only mentioned once. It seems like an important contextual factor to discuss, especially given that the medical conditions suffered by relatives may have been related to Covid?

3) I’m curious about the authors’ decision to include relatives who have passed away in this study. The way the measure is written, it asked about relatives current struggles with health conditions. The timeframe of a relative passing away, however, is much less clear (i.e., could it have been at any point in a the youth’s life?). Plus, it seems the psychological implications of these two categories could be very different (e.g., a relative with a chronic ongoing condition may lead to stress, a relative who has died may contribute to grief). So, authors would do well to either spell out these distinctions better, or perhaps eliminate the question about a relative who has died.

4) Authors should provide the names of each measure used, and relevant psychometric information (e.g., # items, internal consistency).

5) How was the decision made about which covariates to include?

6) I am particularly curious about whether the index of ‘poor mental health’ has been used in other studies. In my area of research, for example, bullying is an indicator of peer relationships, not mental health, and anxiety and depression and loneliness are related but distinct construct. I am concerned this measure confounds many distinct variables. More information is needed, and this should also be discussed as a limitation/future direction.

7) Authors note that a limitation of the study is the missing data, but it is unclear how missing data was handled. Did participants with and without missing data differ on key variables? Was it deleted listwise or imputed? I am also wondering about other preliminary data analyses; I would encourage authors to present information on skew/kurtosis, outliers, and other potentially important differences (e.g., did the Y9 and Y2U participants differ on key variables?)

8) Overall the article would benefit from editing, with an eye to the English language.

9) Another minor but important note is that authors use interchangeably the terms children and adolescents, when this study is very specific to adolescents. Because adolescents and children have unique developmental considerations, authors may consider framing the study with a bit more developmental context. 

Author Response

Please see the attachment

Author Response File: Author Response.docx

Reviewer 2 Report

Dear authors,

Many thanks for allowing me to contribute to your review. As chronic illness and co-morbidities continue to grow in our populations, the impact on young people's mental health and wellbeing, especially if they take on caregiving roles, will only increase in importance. Your paper is a clear, easy to digest contribution to this conversation. 

That said, I would encourage some reflection on a couple of items:

1) Past year mental health was only explored through a single measure - what are the pros and cons of this as the yardstick by which we assess youth mental health outcomes?

2) In exploring promotive factors, I feel readers would benefit from a more nuanced breakdown to understand the difference between those youth with no factors, very few, compared to the majority of promotive factors being endorsed as present. Can a breakdown more detailed (i.e. more categories) than 0-7 and 8-11 tell us anything about what really can start to bring down risk of past-year mental health difficulties? 

3) Limitations of not knowing about relatives' health challenges - were deaths from natural causes or not (we know suicide/homicide in families has a distinct impact on youth versus losing a parent to cancer), and is there a difference for young people with relatives experiencing mental/substance misuse challenges versus physical illnesses? This could help us better understand whether there may be other layers to attend to e.g., stigma, self-blame, etc. for youth.

It is really useful to present to readers the limitations then of what the data can and cannot tell us and perhaps you can add your recommendations for future research in terms of strengthening research on youth mental health in the context of family illness.

More comments are threaded throughout the attached document.

Best wishes for strengthening the nuance and depth of this work.

 

Comments for author File: Comments.pdf

Author Response

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Author Response File: Author Response.docx

Reviewer 3 Report

It is a well-written and clear brief research report on a less analyzed but no less relevant topic. The introduction is sufficient to justify the questions raised, and the research methodology and data analysis strategy are described adequately and clearly.
One of my main comments to this article would be to add a little more to the discussion of the results about the fact that adolescents' mental health is determined by many factors, not only those examined in the study.

Author Response

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Author Response File: Author Response.docx

Reviewer 4 Report

 

Comments for author File: Comments.pdf

Author Response

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Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

It appears that the authors made a good faith attempt to address some of the prior suggestions and concerns. There are some things that are better, such as addressing the timing of the study and COVID-19, and some things that are more confusing, such as adding in implications that are very underdeveloped (e.g., with regards to identity development). Ultimately, my overall impression of this paper remains the same. Aside from several of my past suggestions not being addressed (e.g., the introduction seems to jump around, unclear how missing data were handled, unclear how the different promotive factors were identified and measured), my biggest concern remains that that the study aims and hypotheses are still not spelled out clearly, consistently, or thoroughly enough. This is a critical problem because, if the reader cannot clearly ascertain the aims and hypotheses, they also cannot ascertain if the method was appropriate to testing them, and if the results are supportive or not. I do think the authors might have an interesting and important paper on their hands, but based on this critical issue I do not feel that I can make this determination. 

Author Response

Please see the attachment

Author Response File: Author Response.docx