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PONE-D-21-37102How do international humanitarian aid workers stay healthy in the face of adversity?Is Sense of Coherence a mediator for health and work engagement?PLOS ONE

Dear Dr. de Jong,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.  You have received two strongly positive reviews, but with a suggestion from Reviewer 2 that you are likely to want to consider in preparing a final version of your report. Specifically, the instability of sense of coherence scores may reflect shifts in their general resistance resources, such as social and emotional support.  Consideration of this fact may help your interpretation to be more consistent throughout the manuscript.  The changes can be minor but I wanted you to have the opportunity to make changes that you agree improve the manuscript.

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this paper which is about International Humanitarian Aid Workers (iHAWs) and the fact that despite working under stressful and traumatic environments, they remain healthy. The authors used a stress-health model to test whether the concept of a Sense of Coherence (SOC) as a health mechanism would mediate the relationship between stressors related to the field work of iHAWs after they returned from their assignment.

I found this paper very interesting and very well written throughout. The background to the concept and components of SOC was clearly defined as was their rationale for choosing it to explore how and why iHAWs remain relatively healthy despite challenging work and conditions. Salutogenesis was sufficiently explained as the rationale for looking at the three components of SOC.

Methods were clear and I feel their choice of instruments was appropriate to provide the various indicators of health in their model.

Analyses seems comprehensive and appropriate. The number of participants is adequate for the analyses they performed. Although they noted some limitations to further analyses due to sample size. Although not an expert, overall, their statistical analysis performed, and their mediation analysis seems correct. They thoroughly tested the demographic variables, mainly sex, as they may impact on their findings.

The discussion again was clearly written and described the results while highlighting how certain variables were mediated by the three components of SOC. I found this very interesting and the I think they have strengthened the importance of considering the context in which any action and behaviour is observed. I feel this information could go beyond the promotion of better health for workers in difficult and challenging environments but can be applied more broadly to situations where the context is specifically unique and/or intense.

Reviewer #2: Dear authors, my only remark is regarding the last sentence on page 21. In it, you assume that the SOC may not be a stable construct over time, according to your results. I would like to emphasize that the SOC is a heterogeneous construct and this could lead to erroneous conclusions. Please keep in mind that this construct is identical to Generalized Resistance Resources (GRRs), which in practice remain undiscovered by the researchers who measure only the underlying trend for coherence, or SOC. Therefore, measuring pre- and post-assignment SOC in your study is not an indicator of construct instability. During this period, the participants in your study has experienced immeasurable dynamics of GRRs. In my opinion, this explains the discrepancy between pre- and post-assignment SOC in promoting health. I remind you that GGRs includes coping strategies, emotional closeness, knowledge and intelligence, and support system. Refer to: Mittelmark, M. B., Sagy, S., Eriksson, M., Bauer, G. F., Pelikan, J. M., Lindström, B., & Arild Espnes, G. (2017). The handbook of salutogenesis. Springer Nature.

In short, I urge you to rethink this sentence in your work. On page 24 of the manuscript, which describes the strengths and limitations, you yourself self-critically point out that the design does not allow for causal conclusions. That is enough !!!

I sincerely congratulate you on the idea of researching SOC in these samples, which are so presumptively focused on pathology!

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Reviewer #1: Yes: Diann S Eley

Reviewer #2: No

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How do international humanitarian aid workers stay healthy in the face of adversity?

PONE-D-21-37102R1

Dear Dr. de Jong,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Silva Ibrahimi, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: I agree with the positions the authors defend regarding my criticisms. I accept that the text and the research are sufficiently well-argued.

Reviewer #3: This is a highly significant argument and interesting research. It provides both an empirical and broad statistical view on such a issue as the humanitarian work and wellbeing. I would kindly suggest authors only to replace the word "analyses" to "analysis".

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

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