Title: Women’s alcohol Consumption During The Restriction Phases of the COVID-19
Pandemic in Brazil: a Phone Based Survey
Version: 6 Date: 06 Nov 2023
Reviewer's report:
Comments
The COVID-19 pandemic has led to an increase in mental health disorders.  This study entitled
“Women’s Alcohol Consumption During the Restriction Phases of the COVID-19 Pandemic
in Brazil: A Phone-Based Survey” has investigated an important factor, alcohol consumption
which his use may increase during the pandemic as a way to cope with mental health disorders.
This study may contribute to the understanding of women's alcohol use over the pandemic
restriction. However, some methodological aspects need to be addressed in order to make the
study suitable for publication.
In the abstract section, I do not understand why you say “The independent variable was the
timing of the COVID-19 pandemic’s restriction phases”? Explain. I thought that the independent
variables are those used to describe the outcome (AUDIT-C scores).
When we have our outcome as a continuous variable and normally distributed, we often use
a t-test for estimating the mean within groups. Otherwise, we used other alternatives. In this
study, I think that the AUDIT-C scores were not normally distributed and for this reason, the
authors used the Brunner-Munzel test and Kruskal-Wallis test to estimate the central tendency
parameter. Therefore, in my opinion, the best estimation to be estimated would be the median
of AUDIT-C score and respective interquartile internal, and not the mean of AUDIT-C scores.
Was Negative binomial regression used to model multivariate analysis? They need to specify
it in the methods section and remember that the negative binomial regression is used with
a count outcome variable. Also, in Table 5 the authors say that they used the Generalized
Linear Regression model. This model does not estimate the incidence rate ratio, it estimates
the difference in mean between groups. Maybe they mean “negative binomial regression. If so,
correct it. Also, in the abstract section, you say that the model used was “negative binomial
distribution and zero inflation” and this needs to be clearly explained in the methods section
since it is confusing and difficult to understand the actual model used.
With negative binomial regression, it seems that the authors performed multivariate analysis to
identify associated factors to AUDIT-C scores. If so, did the authors use a hierarchical model
to include the independent variables in the model? If yes, a detail about variables included in
the model from each level needs to be specified. Also, which value of p value did they consider
maintaining variables in the model?
The authors mentioned in the statistical analyses section the following: “The effect of the
independent variable on the dependent variable was evaluated through the Incidence Rate Ratio
(IRR).” I think they are referring to multivariate analysis and they used negative binomial
regression for it. However, as the study design is cross-sectional, Incidence Rate Ratio cannot
be estimated since IRR can just be estimated for the longitudinal study. With this study, they
are estimating the Prevalence Ratio (PR). So, they need to correct it in the methods and results
sections, and in Table 5 as well.
If they performed a multivariate analysis in Table 5 in order to identify the associated factor to
AUDIT-C, in the same Table 5 a crude PR needs to be presented. In this way, the reader can
clearly see after including the independent variables how the estimated PR changes.
The descriptive Tables 1 and 2 should be put together as one Table since they describe the
participants' characteristics.
One potential limitation may be the sub-estimation of alcohol consumption since it was an
interview not self-applied. The interview was by phone call and the participants may be
uncomfortable to report to the interviewer the true amount of alcohol they used during the time
investigated.
One of the limitations that needs to be highlighted is the fact that mental health disorders
(anxiety, depression, and others…) were self-reported by the participants, a misclassification
of these disorders may occur since they have not been screened in the study with existing
screen instrument tools making some women who actually have some of the disorders without
diagnostic since they did not visit a professional for a mental health issues.
Please include how the limitations that you have highlighted impact on the study results.