Sun Protective Behaviors and Attitudes of Runners

Round 1

Reviewer 1 Report

Author Response

Thank you for your comments. We agree that highlighting this is the value our report adds to the literature on this topic.

Reviewer 2 Report

Thank you for the opportunity to read and review this manuscript. The authors conducted their online survey among US American recreational runners to study their sun protection behaviors and attitudes. The authors described a research gap regarding this topic and succeeded at providing general information about sun protective measures as reported by the respondents. However, there are some issues with the manuscript. As stated by the authors, their study is “the largest (…) to understand health behaviors in recreational runners in the United States.” Because of its potentially major contribution to the relevant literature, the authors should improve the transparency and reproducibility of their study design. Especially the Materials and Methods as well as Results paragraphs lack some important information regarding sampling, survey instruments, the justification for choosing the empirical methods used for the analysis. The manuscript could be also improved by choosing different data visualization tools.

The major shortcoming of this manuscript, in my view, is the outdated database: The data are over 10 years old. To what extent can the identified research gap be closed with the outdated data? Can it be assumed that the sun protection behavior of runners has not changed over this time? It is important discussing these aspects in the manuscript.

Please also consider following minor comments.

Abstract:

• I suggest restructuring the abstract as follows for better readability: Please provide a clear objective for your manuscript in the abstract and describe the methods you used (In the current version, the authors mention the regression analysis in line 24 after part of the results have already been presented). Only after that the presentation of the results should come followed by a short conclusion.

Introduction

• General remark: please consider inserting spaces before all references (square brackets) throughout the manuscript to increase readability
• page 1, line 33: Skin cancer as the most common malignancy in the U.S. - please include a reference for this statement
• page 2, line 53: I recommend inserting an introductory sentence before mentioning the studies from Portugal, Switzerland, and Spain; introducing them as evidence from Europe emphasizes the lack of U.S. data even more
• page 2, line 62: Please mention (also in the title of your manuscript) that your focus was on recreational runners (if it was actually so)

Materials and Methods:

• Please report some more detail on the procedures of the study conduct: How were potential participants recruited and contacted? Were they all members of the Association? Please briefly describe the Association, its goals, and outreach (non-U.S. readers are unfamiliar with this organization). How did the authors define the “runners” (Marathon runners? Recreational runners? If recreational, how was this defined?)
• Page 2, lines 73-77: Sun protection behavior probably varies depending on the season (rather in summer, and less in winter). For which season has the behavior been asked? Did you used validated scales to gather sun protective behaviors? Did you pretested used questions (e.g., cognitive pretesting?). If not, these aspects should be addressed as one of the limitations of the study.
• Page 2, line 76: What is meant with sun protection overall (global question)? Can you please provide the exact wording of the question here?
• Page 2, lines 78-79: Please add that single answers (no multiple answers) were possible for these questions
• Page 2, lines 82-83: Please describe in more detail what composite variable was? Was it a sum score? How many categories/levels does the composite variable have? What is the direction of the composite variable’s values, i.e. what do lower vs. higher values indicate? Why was it necessary to use this variable in analyses? Why did you choose principal components analysis for creating this variable?
• Page 2, line 83: I recommend including a brief explanation of what principal components analysis is and what it did to your data/variables
• Page 2, line 86: Although it might seem obvious, I recommend including the specific reasons for choosing these statistical methods.

Results:

• Please stay consistent and report proportions with one decimal throughout the manuscript and in all tables. Please also be consistent when reporting p-values throughout the manuscript (3 or 4 decimals, and .00X or 0.00X)
• Page 3, line 93: Was the sample size defined a priori? Did it result from the sampling method?
• Table 2 and table 3: please unify spelling of "vitamin D”
• Heading of the table 3: Shouldn't it rather be "overall sun protection habits" here?
• Page 4, lines 116-117 “When we created a composite measure ...” please move this sentence to the method section
• Page 4, line 119: I think it should read “between” instead of “bewteen”, line 127 à “variable”
• Page 4, lines 119-120: could you please specify if “overall use of sun protection” and “use of any sun protection” mean the same thing?
• Page 4, line 118: Although mentioned in the Methods section, I recommend repeating the specific measure which was used to assess the level of correlation
• Table 4: Why was it necessary to make the same evaluations with two different outcome variables (variable for "overall sun protection" and "composite variable"?) Please consider presenting results in a table, e.g. in Appendix
• Table 4: It is not quite clear what you present in in the table. On the one hand absolute and relative numbers, yet the p-values are from ordinal logistic regression analysis? It is very misleading. I recommend to create a separate table to show the results from the regression analyses. Please explain in the footnote what bold print of p-values means. The title of the table is too long, please consider to move some parts of the title into the footnote.

Discussion:

• Page 5, lines 170-175: I recommend elaborating more on the study’s limitations instead of just listing them, e.g. why self-reports might limit the study’s implications?

Author Response

Thank you for the opportunity to read and review this manuscript. The authors conducted their online survey among US American recreational runners to study their sun protection behaviors and attitudes. The authors described a research gap regarding this topic and succeeded at providing general information about sun protective measures as reported by the respondents. However, there are some issues with the manuscript. As stated by the authors, their study is “the largest (…) to understand health behaviors in recreational runners in the United States.” Because of its potentially major contribution to the relevant literature, the authors should improve the transparency and reproducibility of their study design. Especially the Materials and Methods as well as Results paragraphs lack some important information regarding sampling, survey instruments, the justification for choosing the empirical methods used for the analysis. The manuscript could be also improved by choosing different data visualization tools.

Response: thank you for your comments. We do recognize the strengths and have attempted to identify limitations in our paper including drawing from one geographic region, convenience sample, and self report. We have offered to publish our data for transparency in the published manuscript with goal to improve reader access to visualize raw data.

The major shortcoming of this manuscript, in my view, is the outdated database: The data are over 10 years old. To what extent can the identified research gap be closed with the outdated data? Can it be assumed that the sun protection behavior of runners has not changed over this time? It is important discussing these aspects in the manuscript.

Response: we recognize this in our limitations. Despite the delay in reporting these findings, our findings remain novel in the current published literature.

I suggest restructuring the abstract as follows for better readability: Please provide a clear objective for your manuscript in the abstract and describe the methods you used (In the current version, the authors mention the regression analysis in line 24 after part of the results have already been presented). Only after that the presentation of the results should come followed by a short conclusion.

Response: thank you for these suggestions. We have presented our objectives as they were implied in prior version. We present the prevalence and ordinal logistic regression later as these were two separate presentations of the data and key findings. Our final statement does conclude the key take away message. We defer to the editorial office if a formatted abstract would be preferred.

Introduction

General remark: please consider inserting spaces before all references (square brackets) throughout the manuscript to increase readability

Response: we have modified as recommended

page 1, line 33: Skin cancer as the most common malignancy in the U.S. - please include a reference for this statement

Response: modified to reflect a common form of malignancy

page 2, line 53: I recommend inserting an introductory sentence before mentioning the studies from Portugal, Switzerland, and Spain; introducing them as evidence from Europe emphasizes the lack of U.S. data even more

Response: excellent suggestion and added

page 2, line 62: Please mention (also in the title of your manuscript) that your focus was on recreational runners (if it was actually so)

Response: the population was a mix of recreational and elite

Materials and Methods:

Please report some more detail on the procedures of the study conduct: How were potential participants recruited and contacted? Were they all members of the Association? Please briefly describe the Association, its goals, and outreach (non-U.S. readers are unfamiliar with this organization). How did the authors define the “runners” (Marathon runners? Recreational runners? If recreational, how was this defined?)

Response: unfortunately we do not have these specifics. As noted in the limitation, our participants came from a convenience sample.

Page 2, lines 73-77: Sun protection behavior probably varies depending on the season (rather in summer, and less in winter). For which season has the behavior been asked? Did you used validated scales to gather sun protective behaviors? Did you pretested used questions (e.g., cognitive pretesting?). If not, these aspects should be addressed as one of the limitations of the study.

Response: we agree these are limitations and have added this - our survey tool is included in the paper for transparency

Page 2, line 76: What is meant with sun protection overall (global question)? Can you please provide the exact wording of the question here?

Response: the questions are included in the appendix. We have clarified in brackets the overall question and removed term global to avoid confusion

Page 2, lines 78-79: Please add that single answers (no multiple answers) were possible for these questions

Response: we have added as recommended

Page 2, lines 82-83: Please describe in more detail what composite variable was? Was it a sum score? How many categories/levels does the composite variable have? What is the direction of the composite variable’s values, i.e. what do lower vs. higher values indicate? Why was it necessary to use this variable in analyses? Why did you choose principal components analysis for creating this variable?

Response: we included this detail to address the concern about quality of responses and whether the responses were consistent. Line 118-120 describes our key finding but this is not discussed in greater detail as not a primary objective of the study.

Page 2, line 83: I recommend including a brief explanation of what principal components analysis is and what it did to your data/variables

Page 2, line 86: Although it might seem obvious, I recommend including the specific reasons for choosing these statistical methods.

Response: respectfully, these details may detract from the key aspects of this study purpose and key findings. We hope our explanation earlier helps explain use of the PCA

Results:

Please stay consistent and report proportions with one decimal throughout the manuscript and in all tables. Please also be consistent when reporting p-values throughout the manuscript (3 or 4 decimals, and .00X or 0.00X)

Response: we have limited to 3 decimals as recommended

Page 3, line 93: Was the sample size defined a priori? Did it result from the sampling method?

Response: we used a convenience sample as stated in limitations

Table 2 and table 3: please unify spelling of "vitamin D”

Response: we have modified as recommended

Heading of the table 3: Shouldn't it rather be "overall sun protection habits" here?

Response: thank you for identifying this error. We have corrected to sunscreen use in the text.

Page 4, lines 116-117 “When we created a composite measure ...” please move this sentence to the method section

Response: we have modified as recommended

Page 4, line 119: I think it should read “between” instead of “bewteen”, line 127 à “variable”

Response: thank you, these have been corrected

Page 4, lines 119-120: could you please specify if “overall use of sun protection” and “use of any sun protection” mean the same thing?

Response: we have modified to avoid this confusion.

Page 4, line 118: Although mentioned in the Methods section, I recommend repeating the specific measure which was used to assess the level of correlation

Response: modified as recommended

Table 4: Why was it necessary to make the same evaluations with two different outcome variables (variable for "overall sun protection" and "composite variable"?) Please consider presenting results in a table, e.g. in Appendix

Response: the goal of presenting these data are to show overall protection and any protection. As stated earlier, we will publish the raw, deidentified data with the published manuscript.

Table 4: It is not quite clear what you present in in the table. On the one hand absolute and relative numbers, yet the p-values are from ordinal logistic regression analysis? It is very misleading. I recommend to create a separate table to show the results from the regression analyses. Please explain in the footnote what bold print of p-values means. The title of the table is too long, please consider to move some parts of the title into the footnote.

Response: we have added this as footnote per recommendations

Discussion:

Page 5, lines 170-175: I recommend elaborating more on the study’s limitations instead of just listing them, e.g. why self-reports might limit the study’s implications?

Response: we have modified the limitation section to include details requested.

Reviewer 3 Report

Thank you for the opportunity to review your research findings. For a brief report, I find the submission largely acceptable and as a runner myself, this is very interesting. My main concerns are around the age of both the data and the references. I appreciate that nothing can be done about the age of the existing data. However, it would be worth discussing how this is still relevant. Perhaps linking to more current literature, which could demonstrate that this information does not change much over time, or something to that effect. 

After conducting a brief literature search myself, I understand that there are not very many articles overall as discuss this specifically with runners. You may want to expand this search to other outdoor athletes. Alternatively, you could explain why that actually is NOT appropriate to do here. Not acknowledging this is the biggest concern I have.

Finally, I am also interested in a bit more discussion about the study population itself. Who makes up the Pacific Association of USA Track and Field? Is this org throughout the west? The CA Bay Area? What was your response rate to the survey request? Did the online nature of the survey impact those who responded? Answers to these questions all speak to the generalizability of these findings beyond what you already discussed. 

There is a typo on line 119; the word "between" is misspelled. I believe there is also a typo in the Acknowledgements section, re: Irene Herman. Is she part of the PA USA T&F? Should there be a period in there somewhere?

Author Response

Thank you for the opportunity to review your research findings. For a brief report, I find the submission largely acceptable and as a runner myself, this is very interesting. My main concerns are around the age of both the data and the references. I appreciate that nothing can be done about the age of the existing data. However, it would be worth discussing how this is still relevant. Perhaps linking to more current literature, which could demonstrate that this information does not change much over time, or something to that effect. 

Response: we agree the time of responses should be noted and have added this to limitation section.

After conducting a brief literature search myself, I understand that there are not very many articles overall as discuss this specifically with runners. You may want to expand this search to other outdoor athletes. Alternatively, you could explain why that actually is NOT appropriate to do here. Not acknowledging this is the biggest concern I have.

Response: we have added this point as recommended.

Finally, I am also interested in a bit more discussion about the study population itself. Who makes up the Pacific Association of USA Track and Field? Is this org throughout the west? The CA Bay Area? What was your response rate to the survey request? Did the online nature of the survey impact those who responded? Answers to these questions all speak to the generalizability of these findings beyond what you already discussed. 

Response: we added information about the survey and did address this as a convenience sample in our limitation section. We include our PCA analysis to suggest some internal consistency in responses. Details about the organization were added as recommended.

There is a typo on line 119; the word "between" is misspelled. I believe there is also a typo in the Acknowledgements section, re: Irene Herman. Is she part of the PA USA T&F? Should there be a period in there somewhere?

Response: thank you for identifying the typo. We have modified the acknowledgement section as we recognize this was confusing as written.

Round 2

Reviewer 2 Report

Dear authors,

Unfortunately, I find your revisions inadequate. In your rebuttal letter, you write that my comments were considered and changes were made in the text. In fact, most of the comments (on the central aspects of the manuscript) in the Methods and Results sections have not been implemented at all.

Author Response

My sincere apologies to the reviewer on behalf of co-authors and me. The prior manuscript attachment did not reflect the changes that had been made to methods, results or discussion due to not saving changes prior to upload. I have uploaded the correct file and highlighted the changes to make it easier to track responses to these excellent prior suggestions.

Author Response File: Author Response.docx