PONE-D-24-15468A Systematic Review of Military to Civilian Transition: The Role of GenderPLOS ONE

Dear Dr. Smith,

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.

Please submit your revised manuscript by Jul 18 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Darrell Eugene Singer, M.D., M.P.H.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following financial disclosure: 

"This project was supported by a grant from the Forces in Mind Trust (FiMT) 2202"

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." 

If this statement is not correct you must amend it as needed. 

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

3. Thank you for stating the following in your Competing Interests section:  

"No competing interests"

Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now 

 This information should be included in your cover letter; we will change the online submission form on your behalf.

4. We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. [Available for preprint on medRxiv (MS ID#: MEDRXIV/2024/303195)] Please clarify whether this [conference proceeding or publication] was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.

5. In the online submission form, you indicated that [All underlying data is available upon request from researchers. The search strategy, including the exact search terminology will be provided in supplementary data.]. 

All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information.

This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 

6. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. 

7. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

Additional Editor Comments:

I concur with the reviewers that this is an important study and compliment you and your co-authors on your efforts. It is a privilege to edit your submission.

I have attempted to summarize the reviewers’ comments and provide specific guidance for a revision, however, there are several questions on the focus and methodology that may generate further discussion. Please also review and address the comments made by each reviewer that were not addressed in the summary. As this manuscript requires a major revision, the subsequent version may require additional reviews and/or edits.

1. Grammar, syntax, and formatting:

1a. Please insert page and line numbers (continuous) into the manuscript. https://journals.plos.org/plosone/s/submission-guidelines#loc-page-and-line-numbers

1b. The manuscript contains grammatical, syntax, and formatting errors that must be corrected. PLOS ONE does not copy-edit accepted manuscripts and directs Academic Editors not to provide copy-edits, however, Academic Editors and reviewers may point out some examples to assist the authors. https://journals.plos.org/plosone/s/submission-guidelines. Examples include the use (or not) of hyphens: “military to civilian transition” versus “military-to-civilian transition” and “post transition” versus “post-transition.” The overall article requires light editing on the use/absence of articles and prepositions.

1c. Consistency in terminology/references is helpful: examples include “gender discrimination” vs “gender-based discrimination.” The first two sentences of the second paragraph of the background section are somewhat clunky- the first sentence mentions increases in the “number of women” and the second sentence mentions prevalence. The two could be merged and streamlined. A similar sentence is contained in the conclusions section states “As women continue to enter the AF in greater numbers over the coming decades, research must advance our understanding of the barriers to a successful transition for female service personnel, particularly beyond the US context.” Suggest the consistent use of prevalence or proportion.

1d. Please review reference formatting and font use.

2. Introduction:

2a. Please provide an expanded description of why the military-civilian transition is an important aspect of military and veteran population studies. This could include the magnitude of the problems or build on the authors’ statements regarding the increasing prevalence of women in the military. A brief discussion of the definitions and use of the terms “female” and “woman” may be applicable.

2b. The introduction section should include an overview of similar studies (systematic reviews or meta-analyses) of qualitative studies and discuss any findings and/or gaps not answered by previous studies. What will your study add to the discussion? The last sentence in the second to last paragraph of the introduction provides a hint; possibly this should be combined with the last sentence of the section. “However, there remains ample room for improvement in policies and programs to support female veterans and in order to do this effectively we need further understand how women’s military experiences and post transition experiences may differ compared to those of men.”

2c. Please mention why the review is limited to the Five Eyes nations.

3. Methodology:

3a. Please include the study’s registration # in the manuscript.

3b. Seven databases were listed in the manuscript and Appendix C. Were other databases queried? From the methodology section: “A multi-database search was conducted, including Medline, Embase, PsycINFO, Pubmed, Global Health, Web of Science, and EBSCO.” If not, I recommend editing for specificity, e.g. “A multi-database search was conducted of Medline, Embase, PsychINFO….” If other databases or literature sources were accessed, please expand the methodology to include how these were addressed.

3c. Please provide a deeper description of the inclusion/exclusion criteria. Specifically, the availability of full text and the first screener’s criteria for inclusion/exclusion into the study. Details could include what topics (medical, psychological, etc.) and when those experiences occurred (During service, post service, either, both)?

3d. Please provide an expanded description/definition of the framework analysis elements: transcription of verbal data to text; familiarisation; coding; developing an analytical framework; applying the analytical framework; charting data into the matrix; interpreting the data so that the study could be replicated. Why was a seventh element not included?

3e. Systematic reviews are recommended to have multiple reviewers, but the recommendations regarding the timing and use of the additional reviewers are inconsistent. Please describe how bias was avoided in your study, particularly the single screener and how possible discordancy between the two reviewers was handled.

4. Results:

4a. How do “results” vs “study findings” differ to require separate headers? Please provide a rationale for why. The difference is apparent- one appears to present descriptive findings; the second appears to present the qualitative analysis; however, both are “results.” Suggest a header of “Results” with sub-headers of “descriptive results vs. synthesized” or the like.

4b. The experiences occurring during a female/woman’s service experience are important and certainly contribute to their post-service health condition. Please provide an expanded description of how the “In-Service Military Experience” section contributes to the study’s transition objectives.

4c. Please provide an expanded discussion of the qualitative appraisal and thematic information. Did the investigators assess inter-nation differences?

5. Discussion:

5a. The discussion seems to repeat the results section. Please provide an expanded discussion on whether the findings of your study confirm, support, or counter previous studies and/or findings. Are there differences in transitioning populations (gender, age, race, other)?

Again, thank you for your work and patience with the editorial process. I look forward to your response.

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: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: N/A

**********

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: Yes

Reviewer #2: Yes

**********

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

**********

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: This systematic review aimed to identify and synthesize qualitative findings exploring the impact of gender during the military-civilian transition. The military-civilian transition is a time period of vulnerability for military service members, thus is a noteworthy area of inquiry across multiple countries. The abstract is clear and concise and results reported are within the scope of the aim of the review. However, there are noteworthy limitations in other sections of the manuscript.

Introduction

1. Need additional information on why the military-civilian transition is a transition that should be a focus when studying military and veteran populations.

2. No specific policies mentioned across countries considered in the review.

3. Does not provide and overview other scoring reviews to identify additional gaps in other publications using this methodology. Mentions only one review.

Methods

1. Include registration #.

2. Was grey literature considered in the review? If so, how was it addressed?

3. Explain why availability in full text was an inclusion criteria considering interlibrary loan and other strategies are available to access publications. Consider availability at institutions of the large group of authors of this manuscript.

4. Explain Framework Analysis and rationale for use in this review.

Results

1. How do "results" and "study findings" differ? One heading with limited subheadings seems appropriate to guide the reader.

2. The In-Service Military Experience section is beyond the aim of the review. It is not military-civilian transition focused. Seems more appropriate for the introduction to provide a rationale for the focus of the review. The space used by this section can be better used to include more elements of the manuscript related to framework analysis.

3. Qualitative appraisal discussed minimally as well as thematic information in supporting documentation.

4. Are there differences by country?

Discussion

1. Limit number of subheadings

2. Seems repetitive of the results and themes

3. Does not link findings of this review to the larger literature (i.e., both qual and qual) related to military-civilian transition focused on gender and/or focused on the military and veteran population in general.

4. Does the review findings confirm, support, and/or extent prior findings? Suicide theories? Military-civilian transition frameworks given the themes related to sense of belonging, loss of purpose, loss of military identity?

5. Link to to military research findings on gender discrimination instead of "workplace harassment" in general.

6. Is the major gaps section supposed to be one paragraph?

7. Qualitative methods such as grounded theory have specific outcomes related to theorizing. Do included studies with specific qualitative methodology contribute to theory or other outcomes related to women military service members and veterans?

8. Are there international implications? Adoption of policy and procedures for military women and veterans internationally?

Overall

1. Focus results and discussion within the scope of the review. Identify gender differences and differences among women (e.g., age and racial differences, military service branch, active vs reserve).

2. Edit more carefully to address missing articles (e.g., a, and the) and prepositions.

3. Review reference formatting to be consistent with authors' instructions.

4. Correct use of two different fonts and use terminology consistently throughout the manuscript (e.g., gender discrimination vs gender-based discrimination.

Reviewer #2: Outstanding work, and thank you for allowing me to review this study.

This paper is a scoping review regarding the experiences of female veterans through the military to civilian transition. The review employs a framework analysis to collect general themes and subthemes from the accepted literature, and then synthesizes the findings within those overarching theme groups. Examples of these themes include loss of purpose and discordance of gender norms. Author(s) conclude that the women face significant stresses and disparities compared to male counterparts, especially post-service.

The overall methodology appears appropriate for the research question and what the authors are looking for. The “Inclusion/Exclusion Criteria” properly fits, considering the general nature of experiences of military to civilian transition. The process of study selection and screening is adequately noted. Data extraction, synthesis, and results are appropriate and work well within the overall scoping review. The supplemental charts and the JBI critical appraisal are properly completed and there are no issues regarding those features. The articles are well summarized and themes are well presented.

In essence, the article is almost acceptable. However, I do advise a couple of revisions or explanations, not only for a complete research article, but also for duplication purposes.

Major Revisions/Comments

1. I do advise more details for inclusion/exclusion factors, especially for purposes of study duplication. Although the details of participants, study type, and theme of search are presented, there should be specific mentioning for what qualifies during the screening process. For instance do these experiences need to be regarding a certain topic (medical, psychological, etc.) and when can those experiences have occurred (During service, post service, either, both)?

2. There is a notable inquiry as to why only one reviewer conducted initial screenings of titles and abstracts - Many scoping review studies often utilize multiple reviewers throughout the entire screening process. In any case, it may be worth mentioning potential bias/lack of consensus during initial screening.

Minor Revisions/Comments

1. First sentence of “Inclusion/Exclusion Criteria” - May want to break up the sentence a bit. This is mostly to reduce ambiguity of inclusion factors.

2. “Results” section - Please add the study methods within the included studies (interview, focus group, etc.) to detail more about what current literature is available

3. I do think there is a lack of consistency of themes/subthemes are worded within appendix B, which may provide difficulty in navigation.

**********

6. 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 #1: No

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

A Systematic Review of Military to Civilian Transition: The Role of Gender

PONE-D-24-15468R1

Dear Dr. Smith,

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.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Darrell Eugene Singer, M.D., M.P.H.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thanks to you and your fellow authors for your collective patience and persistence- congratulations and well done.

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: (No Response)

Reviewer #3: (No Response)

**********

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

**********

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

Reviewer #2: Yes

Reviewer #3: N/A

**********

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: Yes

Reviewer #3: Yes

**********

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

**********

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 thank the authors for their resubmission of their systematic review.

The authors adequately addressed my previous comments - The paper's methodology appears technically sound, and all inclusion/exclusion factors and potential for bias biases are properly explained.

The paper's new discussion section appears to properly describe the results in relation to current literature, properly expanding upon the military-to-civilian transition.

Please review paper for grammar and formatting, such as:

Missing periods line 115, line 469 line 567

Reference formatting Line 440

No other significant/major changes are noted.

Reviewer #3: I enjoyed reading the article. It is a well written article of original research on a topic of interest within the realm of military/veteran well-being among Five Eyes nations. The article is technically sound. The analysis, discussion and conclusion are appropriate given the findings presented and the acknowledged limitations. The authors have sufficiently addressed the feedback from the previous reviewers.

**********

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

**********