Reviewer ’s report  
 
Title: Loneliness among mothers raising children under the age of 3 years and predictors with  
special reference to the use of SNS: A community -based cross -sectional study  
 
Version: 4 Date: 08 Mar 2018  
 
Reviewer: Colleen Fisher  
 
Reviewer's report:  
The manuscript addresses the issue of loneliness among mothers of infants (0 -3 years) in Japan 
using a cross sectional questionnaire.  The topic is interesting but the manuscript requires 
considerable re -working to m ake it suitable for publication in BMC Women's Health.  Of central 
importance is consistency in the aims of the study.  
  The following issues should be addressed:  
 
1. Lack of clarity of the aim of the study and hence, focus of the manuscript.  
There is inco nsistency throughout the manuscript regarding the aim of the study.  This lack of 
clarity has, I believe, resulted in the results and discussion lacking focus and being a barrier to a  
detailed and analytical discussion of the results in relation to releva nt literature.     
To explain:  From the title, the expectation is that the use of social networks and its association 
with loneliness would be the focus of the manuscript.  This is reiterated in the abstract "......few 
studies have assessed the associatio n between loneliness in mothers raising infants and their social 
connections to the internet", yet this comprises only a small part of the manuscript.  Social and 
personal factors are also addressed.  Further, on page 7 Lines 24 -30, the aim of the research  is 
described as "....to measure the prevalence of SNS use for obtaining child care information 
compared with other sources and to examine social relationships among mothers raising infants in 
Japan by assessing SNS use and other factors including attachme nt styles, that influence 
loneliness".   
Once the research aim is determined, the manuscript can then be more focussed to specifically 
address this aim.  
The following items are highlighted as needing to be addressed.  
Methodological issues;  
a. Can prevalence in a country (Japan) be ascertained from a study of 523  in one Japanese 
city? (as per final aim as described in the  previous section)?  
 
b. It is unclear how from the manuscript how social relationships among mothers can be 
assessed by l ooking at SNS use and the other factors listed (as per the first 2 aims as described in 
the previous section).  
 
c. Is there a cut off score for 'loneliness' or does the Loneliness scale measure ''perceived 
sense of loneliness'.  This needs clarity and cons istency throughout the manuscript.  To explain.  
At various stages of the manuscript one or the other is implicit.  (eg, the introduction notes 
"....social and personal factors associated with loneliness" (Page 7) and "...The primary outcome 
was loneliness " (Page 10).  Both these indicate there is a cut off score where an individual is 
considered 'lonely. It I's noted in the description of the Loneliness Scale, however, that  scores can 
range between 20 and 80 with higher scores meaning a stronger sense of loneliness.    What is 
being measured by the scale (ie, 'loneliness' per se, or perceived 'sense of loneliness') needs to be 
explicit and then consistent throughout the manuscript  
 
d. What is an ''infant''?  Is this the most appropriate term to use to desc ribe 0 -3 year olds? If 
so, support from the literature for this would be useful.  It also needs to be defined early in the 
manuscript.  To explain:  in global institutions such as the WHO and in related research, an ''infant 
is typically aged between 1 mon th and 12 months old.    
 
e. How many health checkups occurred?   To explain, on page 7 it is noted that "... Total of 
28 infant/health check -ups were held at two local ......"  How can 28 check -ups result in a sample 
size of 523?  
 
f. Development of the qu estionnaire.  It is noted on page 8 that the questionnaire was 
developed from results of an interview and from previous loneliness studies.  Details of this 
interview are needed.  For example, who was it with?  What was asked? How was the interview 
analyse d to arrive at items for the questionnaire?  References for the studies that informed the 
questionnaire needed as well as some details about the respective studies including the level of 
evidence they provided.   
 
g. Is the pretest described on Page 8 (lin e 45) in fact a pilot study of the questionnaire?  How 
many women were included in the 'pretest'?   It is noted that revisions were made.   A very brief 
description of these would be useful.  
  
h.  It is noted that no personal information was collected, but  in the tables there is clear 
evidence of the collection of demographic information.  Clarity required.  
 
i.  There is lack of clarity around the attachment pattern that was included in the questionnaire 
(e, IWMS).  The IWMS is referred to as a model (page  9, line 15).  Is this correct?  What is mean 
by "the distinctive characteristics of attachment patterns"? (Pae 9 line 30).   
 
j. The justification provided for only including the 'secure' scale only that it is "the most basic 
of attachment patterns".  A m ore robust justification is needed.   
 
k. The K6 was used measure psychological distress.  What are the cut off scores to suggest 
the presence of psychological distress?   
 
l. Does the current study have sufficient power to undertake the statistical techni ques 
performed?  The inclusion of a power analysis would be beneficial.  
  
m. Issues related to information sought from participants.  
 
n. Number of children: It is noted that over half (58.7%) of mothers had 2 or more children.  
Dif all children have to be  under 3 for inclusion in the study?  Or just one?  Clarity is important 
because the study is described as ''examining loneliness in mothers with children under 3''. Does it 
make a difference if one (or more) of the children was older?  For example, with a n older child',  
the mother may have a wider range of activities to undertake by virtue of the activities of the older 
child and so impact on her perceived level of loneliness?  She may also have a wider range of 
social networks (although this is probably accounted for in 'mom networks').   
 
o. Employment:   Almost 50% of mothers were in 'employment'.  Was this further broken 
down into part time, full time or casual?  Would the level of employment make a difference on the 
mother's perceived level of loneliness?  
   
p. Attendance at Day care:  i t is noted at 41.5% of mothers had at least one child attending 
day care?  Which child was this?  Is there an index child and if so does it relate to that child?  Does 
it relate to all the mothers' children being in day care?  How often did s/he/ they atte nd?  And 
would this make a difference to the results?  
 
q. The label 'Health condition' does not really describe what is being reported (a health 
çondition'  normally refers to a 'disease').    Can another title be given to this - eg ''health status" or 
''perceived health status''.  The label "consultation partner'" is not particularly useful, moreso 
because in the body of the manuscript it is merely described as ''consultation'.  
 
r. Not all the participants were 'married''. (Table 1:  7 were single, 3 divo rced and 2 'no 
answer').  It is unclear however, whether the 'help from spouse'(Table 2 - yes or no) only includes 
those who identified as being 'married''.  If not, then no could include those who were single or 
divorced.  Perhaps they received support fr om someone else - eg, mother, friend etc at a similar 
level as a spouse?  Does this impact on results?  Does the level of 'help' from spouse make a 
difference?  Does it matter if the 'help' is with the ínfant''?  Or could it include 'help' with household 
chores?  Emotional ''help'' for the mother?   
 
Other Issues  
 
The discussion as it is written lacks  focus and depth, but as discussed above, this is probably by 
virtue of lack of clarity of the aim of the research.  Once the aim is clear, it will necessitat e a 
rewriting of the discussion and, as such, its structure and adequacy can be reviewed at that time.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
Yes 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
Unable to assess  
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
No 
Are you able to assess any statistics in the manuscript or would you recommend an additional 
statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
I recommend additional statistical review  
Quality of written English  
Please indicate the quality of language in the manuscript:  
Needs some language corrections before being published  
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
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3. Do you hold or are you currently applying for any patents relating to the content of the 
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