Title: Examining Educational Attainment and Allostatic Load in Non-Hispanic Black Women
Version: 2 Date: 07 Oct 2021
Reviewer's report:
- The background in the abstract (co-examining Black identify and education attainment of
predictors of allostatic load) would suggest that an interaction between these two was being
proposed but they authors really intend to just examine the impact of education attainment
on allostatic load among Black women, so might rephrase to make that more clear with the
background sentence.
- After reading the introduction, I also expected the authors to focus on a few other factors and
how they impact allostatic load for Black women, including pregnancy/parity, student status,
professional achievement, social stress, etc. While the authors raise important points about the
experiences of Black women that could all independently contribute to allostatic load, these
points are conceptually distinct from educational attainment (or at least not tied together in the
introduction) and they don’t really articulate why this study (more narrowly focused on the
impact of educational attainment) is unique and needed. They reference another study that seems
to have already established this when comparing Black women to other race-gender subgroups
so what does this study specifically add?
- If BMI was a marker of allostatic load (pg 7), why is it listed as a covariate (pg 8)? Also waist
circumference is listed as a covariate when it is also sometimes considered a marker of allostatic
load. Can authors please reconcile these variables? It is not appropriate to include variables as
covariates if they were included in the creation of your outcome variable
- Why was diabetes (or other conditions available in NHANES) not included in the comorbidity
measure?
- When using weighting procedures on a subsample, analysts need to include a domain statement
where they include the weighted/strata/cluster for sampled individuals that were included in the
initial sample in order to obtain the correct standard errors. Unclear if the authors did this and
if not, unfortunately all of their analyses will need to be redone.
- Please consider referring to the income variable as income relative to FPL as this is the standard
way this variable is referenced in the literature (rather than PIR)
- Why were the covariates for prevalence models different than those for the AL score?
Conceptually, if you think a covariate affects one than it should obviously affect the other.
Models should be updated accordingly
- Suggest as a sensitivity analysis authors consider evaluating the relationship between education
and AL among a more narrow age range where all women should have had similar time to
achieve their highest desired educational attainment (eg an 18 yo with a high school degree is
not the same as a 40 yo with a high school degree). Adjusted for age only might not be sufficient
to adjust for educational opportunity. (Also likely to be period/cohort effects)
- Why are SE shown for all the descriptive stats? This isn’t especially useful for either prevalence
or mean (better to show SD for mean). This goes for tables and results section of the paper
- I’m not a fan of the use of the word “moderated” in the first sentence of the discussion as
moderation is a statistical concept implying effect modification which is not what the authors
did. Please chose a more appropriate word. Actually see use of “educational attainment as a
moderating variable” again later after the authors reference a limitation of a prior study being
that the study only looked an independent effects and not interaction but again, these authors
did not evaluate moderation. They absolutely could have and IMO their paper could be made
stronger if they did but since they did not evaluate moderation, please consider a more accurate
way to describe findings.
- Authors claim they are revealing “intersectional” differences but they only evaluated one
subgroup of an identity so I am unclear as to what they are referring to here? Given extremely
limited covariate adjustment, the authors don’t sufficiently address many of the structural factors
that this population could be exposed to as potential risk factors for AL.
- The discussion is not particularly well organized or cogent in the discussion of the implications
of their findings. Rather it reads as a laundry list of the perceived strengths of the study and with
an over-extension of the importance of the findings by suggesting that authors have adequately
captured all of the many structural/institutional forces that may adversely affect Black women
when analyses only controlled for age, income, education, and a subset of available chronic
conditions.
- You evaluated educational attainment and allostatic load so to claim that it confirms a statement
about education and prosperity is an overreach.
- I conceptually agree with many of the points made in the discussion but nearly all points made
are quite far removed from the actual findings of this work. I think major edits are needed to
best address the actual study findings.