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Thank you for revising your manuscript to address the concerns of the reviewers, both of whom are satisfied with the revisions you have made in response to their comments. The manuscript is now ready for acceptance.
[# PeerJ Staff Note - this decision was reviewed and approved by Jafri Abdullah, a PeerJ Section Editor covering this Section #]
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Title & Abstract
Title
The title is succinct, well-written and capture the content and focus of the manuscript which is: “to map the quality of life in Norway through a psychometric evaluation and network analysis”.
Abstract
The Abstract is structured and fairly well written. The Background section covered the growing interest in assessing self-reported health (SRH) and Quality of Life (QoL) outcomes. It also has a well-written objective which is: “to assess the psychometric properties of NQoLS measures and applied network analysis to explore the structural relationships among outcome variables”.
The Methods section briefly captured the study participants and study period as well as the study instrument and psychometric evaluation measures. There is now an adequate description of the study design and participants.
The Results section is fairly well written capturing the objectives of the study.
The Conclusion section highlighted the overall findings of the study and its implications for health policy.
In the revised manuscript, the authors have provided a brief description of the study design, selection of the study participants as well as inclusion and exclusion criteria in the Methods section of the Abstract as recommended. Also, the authors have satisfactorily addressed all other issues raised in this section of the manuscript
Introduction
The authors provided a detailed review of the literature and addressed an important public health challenge i.e. the assessment of self-rated health and QoL based on the Norwegian perspectives. Although a tool (NQoLS) has been developed and used for the survey on SRH and QoL, psychometric limitations of the tool may affect cross-group comparisons; affecting the validity of the findings. Therefore, there is a need to ensure that the tool is psychometrically sound and suitable for SRH and QoL assessments. However, early experience with the NQoLS indicates underrepresentation of physical health domain and biological and medical factors in the tool - necessitating further attention. In addition, the authors noted that there are no comprehensive psychometric evaluations of the Norwegian versions of the scales used to design the NQoLS. Therefore, the authors adequately reviewed the literature and provided clear justification for the present study. In addition, the study has a clear objective which is: “to evaluate the psychometric properties of the measures/tools included in the NQoLS, and to explore structural relationships among the outcome variable using a network analysis”.
Figures & Tables
All the Tables and Figures are clear, well-labelled and cited in the text
Material and Methods
The Materials and Methods section is fairly detailed and well-written. The author provided adequate description of the study design and study period, which is a cross-sectional descriptive online survey carried out from March 7th to April 6th 2022. In addition, the authors provided clear details of the consent process and the fact that ethical approval for the use of the anonymized data was waved by the Institutional Review Board. Furthermore, the authors provided a detailed description of the study participants, including the inclusion and exclusion criteria as well as the data collection process. The authors also provided details of the various instruments/measures that constituted the NQoLS including “General Health”, “Satisfaction with physical or psychological health”, “Pain and Discomfort”, “Satisfaction with life scale”, “Hopkins symptoms checklists”, “Positive and Negative Affect Schedule” and “UCLA loneliness scale”. Furthermore, the authors provided details of the statistical analysis which is well written. Overall, the authors have provided adequate details to enable replication of the study.
In the Methods, the authors have provided a satisfactory response to the linguistic concerns and model fit of the tools used in the manuscript as recommended. Also, the authors have satisfactorily addressed all other issues raised during the previous review in this section of the manuscript.
Results
The paper makes a meaningful contribution to the growing interest of assessing SRH and QoL outcomes. The Results section provided a detailed description of the key findings, which is succinct, clear and captures the study objectives. The authors provided a detailed description of the demographic characteristics of the participants. In addition, they also provided a fairly detailed description of the Cleary model which identified three measures of overall QoL, one for growth health, two for physical health, seven for psychological health, and one for social health. The psychometric properties of the seven single-items measures were appropriate. However, some of the tools had large ceiling effects. In addition, the Tables and Figures were all well-labeled, informative and cited in the texts.
In the Results, the authors have satisfactorily addressed all the issues raised during the previous review in this section of the manuscript.
Discussion
The Discussion is fairly well-written. The authors discussed the key findings of the study in the context of SRH and QoL. The authors highlighted that the single- and multi-item scales used in the NQoLS were generally robust, with acceptable score distribution and psychometric properties. The authors argued that the high ceiling effects noted for some of the scales may reflect genuine high levels of mental well-being without providing other satisfactory reasons. Also, they discussed and compared their findings with previous studies highlighting that the SRH and QoL were interlinked. Furthermore, the authors provided a detailed paragraphs on the strengths and limitations of the study.
In the Discussion, the authors have satisfactorily addressed all other issues raised during the previous review in this section of the manuscript
Conclusion
The Conclusion section is fairly well written, highlighting the key findings of the study and its implications for policy – in particular, established instruments may offer more robust and nuanced evaluations of physical functioning and symptoms, aligning the survey more closely with integrative health frameworks.
The authors have satisfactorily addressed all issues raised during the previous review in the Conclusion section of the manuscript.
**PeerJ Staff Note:** Please ensure that all review, editorial, and staff comments are addressed in a response letter and that any edits or clarifications mentioned in the letter are also inserted into the revised manuscript where appropriate.
**PeerJ Staff Note:** It is PeerJ policy that additional references suggested during the peer-review process should only be included if the authors agree that they are relevant and useful.
I read with great interest the manuscript titled "Mapping quality of life in Norway: Psychometric evaluation and network analysis of 15,148 responses from a public health study." The title of the paper is clear, and the research approach is well-structured. However, the language expression in certain sections could be more concise. For instance, the descriptions of international and domestic policies in the introduction could be streamlined. Additionally, the grammar and word choice in some sentences could be further refined to enhance comprehension for international readers. For example, the sentence structure in lines 57-59 could be simplified to avoid repetitive use of "and."
In terms of research design, the data collection methods are detailed, the sample size is sufficient (15,148 participants), and the sample is nationally representative. The authors clearly describe the survey implementation process, including the timing and methods of data collection, as well as information related to ethical approval. The methods section provides a clear description of the steps for psychometric evaluation and network analysis, making it easier for other researchers to replicate the study.
In lines 130-132 of the methodology, it is recommended to add references for the sociodemographic variables. The following modification is suggested: "Referring to prior literature focusing on survey data [doi: 10.1139/apnm-2023-0550; doi: 10.1016/j.jesf.2025.03.004], additional demographic and socioeconomic data were sourced from various national registers, including those for education, employment, income, and living conditions, to minimise the respondent burden."
Although the overall research design is rigorous, there are some potential issues. For example, the survey response rate was 38%, which is acceptable for large-scale public health studies, but the authors did not sufficiently discuss the potential impact of non-response bias on the results. In particular, the lower response rates among older adults and those with lower education levels may limit the generalizability of the findings. It is recommended that the authors supplement the discussion with an analysis of non-response bias and explore its potential implications for the results.
In line 174, it is suggested to add references to this sentence with the following modification: "Referring to previous population-based studies [doi: 10.3389/fimmu.2022.1080782; doi: 10.1038/s41514-025-00217-0], correlations between variables were displayed using Pearson correlation coefficients."
The psychometric analysis shows that most measurement tools demonstrate good reliability and validity. However, some single-item measures (e.g., "General Health" and "Pain and discomfort") exhibit notable ceiling effects, which may limit their discriminative power at higher score ranges. The authors address this issue in the discussion and recommend the use of multi-item tools in future research, which is an important point. The results of the network analysis reveal the structural relationships between psychological and physical health variables, with psychological health variables (e.g., "Satisfaction with life scale" and "Hopkins Symptom Checklist-5") occupying central positions in the network, while physical health variables are relatively peripheral. This finding supports the main conclusions of the study but also raises questions about the adequacy of physical health measurements in the NQoLS survey. The authors acknowledge this issue in the discussion and recommend incorporating more comprehensive physical health measurement tools (e.g., PROMIS-29 or RAND-36) in future studies, which is a reasonable suggestion.
However, the stability analysis of the network analysis shows that weaker correlations exhibit high variability in bootstrap analyses, indicating lower reliability of these relationships. While the authors mention this in the discussion, they could further emphasize the limitations of these results and suggest that future studies validate these findings with larger samples or more stable analytical methods.
The discussion section provides a comprehensive interpretation of the results and compares them well with existing literature. The authors highlight the limitations of the study, such as the cross-sectional design preventing causal inferences, non-response bias, and the variability of weaker relationships in the network analysis. This discussion demonstrates the authors' clear awareness of the study's limitations.
The conclusion section summarizes the main findings and offers recommendations for policymakers and future research, particularly regarding the need to enhance physical health measurement tools. The conclusions align with the research objectives and are logically presented.
Additional minor suggestions: The labeling of figures and tables could be more detailed. For example, Figure 1's network structure diagram could include more detailed explanations of nodes and edges to aid reader comprehension. Statistical indicators in Tables 3 and 4 (e.g., RMSEA and CFI) could be accompanied by brief explanations to help non-specialist readers understand their significance. The reference formatting is generally consistent, but it is recommended to ensure all citations fully comply with the journal's requirements.
**PeerJ Staff Note:** It is PeerJ policy that additional references suggested during the peer-review process should only be included if the authors are in agreement that they are relevant and useful.
Title & Abstract
Title
The title is succinct, well-written, and captures the content and focus of the manuscript, which is: “to map the quality of life in Norway through a psychometric evaluation and network analysis”.
Abstract
The Abstract is structured and fairly well written. The Background section covered the growing interest in assessing self-reported health (SRH) and Quality of Life (QoL) outcomes. It also has a well-written objective: “To assess the psychometric properties of NQoLS measures and apply network analysis to explore the structural relationships among outcome variables”.
The Methods section briefly captured the study participants and study period as well as the study instrument and psychometric evaluation measures. There is a limited description of the study design and participants.
The Results section is fairly well written, capturing the objectives of the study, but could be better described.
The Conclusion section highlighted the overall findings of the study and its implications for health policy.
i) Line 39 - 43: The authors need to provide a brief description of the study design, selection of the study participants, as well as inclusion and exclusion criteria.
ii) Line 44: “Measures generally demonstrated acceptable psychometric properties”.
Comment: Please include the findings of these “acceptable psychometric properties” in the Results section.
Introduction
The authors provided a detailed review of the literature and addressed an important public health challenge, i.e., the assessment of self-rated health and QoL based on the Norwegian perspectives. Although a tool (NQoLS) has been developed and used for the survey on SRh and QoL, psychometric limitations of the tool may affect cross-group comparisons, affecting the validity of the findings. Therefore, there is a need to ensure that the tool is psychometrically sound and suitable for SRH and QoL assessments. However, early experience with the NQoLS indicates underrepresentation of the physical health domain and biological and medical factors in the tool, necessitating further attention. In Addison, the authors noted that there are no comprehensive psychometric evaluations of the Norwegian versions of the scales used to design the NQoLS. Therefore, the authors adequately reviewed the literature and provided clear justification for the present study. In addition, the study has a clear objective, which is: “to evaluate the psychometric properties of the measures/tools included in the NQoLS, and to explore structural relationships among the outcome variable using a network analysis.”
Figures & Tables
All the Tables and Figures are clear, well-labelled, and cited in the text.
Materials and Methods
The Materials and Methods section is fairly detailed and well-written. The author provided an adequate description of the study design and study period, which is a cross-sectional descriptive online survey carried out from March 7th to April 6th, 2022. In addition, the authors provided clear details of the consent process and the fact that ethical approval for the use of the anonymized data was waived by the Institutional Review Board. Furthermore, the authors provided a detailed description of the study participants, including the inclusion and exclusion criteria as well as the data collection process. The authors also provided details of the various instruments/measures that constituted the NQoLS including “General Health”, “Satisfaction with physical or psychological health”, “Pain and Discomfort”, “Satisfaction with life scale”, “Hopkins symptoms checklists”, “Positive and Negative Affect Schedule” and “UCLA loneliness scale”. Furthermore, the authors provided details of the statistical analysis, which is well written. Overall, the authors have provided adequate details to enable replication of the study.
i) Line 128 - 130: “The questionnaire was available in the two major Norwegian language (Bokmål and Nynorsk) and English, the median completion time was 20 minutes"
Comment: The authors distributed a questionnaire containing several instruments or measures in three different languages; yet, they combined the findings of the questionnaires filled in different languages to analyze and report their findings. The authors assumed that the questionnaire administered in these languages have undergone cultural adaptations, including assessment of cultural, semantic, item, and linguistic equivalence of the scales included in the NQoLS questionnaire to ensure that the language, cultural and contextual factors were aligned with the target population's cultural patterns, meaning, and values. This is the biggest limitation of this study. If this (cross-cultural adaptation of the scales) was not done, this should be stated in the Methods section and its impact briefly discussed in the limitations section of the manuscript.
Results
The paper makes a meaningful contribution to the growing interest in assessing SRH and QoL outcomes. The Results section provided a detailed description of the key findings, which is succinct, clear, and captures the study objectives. The authors provided a detailed description of the demographic characteristics of the participants. In addition, they also provided a fairly detailed description of the model, which identified three measures of overall QoL: one for growth health, two for physical health, seven for psychological health, and one for social health. The psychometric properties of the seven single-item measures were appropriate. However, some of the tools had large ceiling effects. In addition, the Tables and Figures were all well-labeled, informative, and cited in the text.
Discussion
The Discussion is fairly well-written. The authors discussed the key findings of the study in the context of SRH and QoL. The authors highlighted that the single- and multi-item scales used in the NQoLS were generally robust, with acceptable score distribution and psychometric properties. The authors argued that the high ceiling effects noted for some of the scales may reflect genuine high levels of mental well-being without providing other satisfactory reasons. Also, they discussed and compared their findings with previous studies, highlighting that the SRH and QoL were interlinked. Furthermore, the authors provided a detailed paragraph on some of the strengths and limitations of the study.
i) Line 265-269: The authors need to highlight that it is also possible that the lack of contextual understanding of the scales administered in languages that were not culturally validated affected the choice selected by the participants and the sensitivity of the analysis.
ii) Lines 339 to 367: The authors did not attempt to undertake validation of any of the scales used in the NQoLS. Therefore, future studies need to undertake concurrent validity, convergent, and divergent validity of the scales used in the NQLoS for the Norwegian population.
iii) Line 339 -367: There is a need to undertake cross-cultural adaptation of the scales to ensure cultural equivalence of the scale and items before being administered at the population level in three different languages.
Conclusion
The Conclusion section is fairly well written, highlighting the key findings of the study and its implications for policy. However, some of the claims of the authors in the Conclusion section regarding the validity of the NQoLs are not correct.
Line 140: “The NQoLS demonstrated acceptable validity and reliability in capturing SRH and QoL across a broad and heterogeneous population.”
This seems incorrect because validity assessment of the scales was not carried out, and the tools were administered in three different languages without undertaking cross-cultural adaptations. Please clarify.
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