Dear Dr. Muthuri,

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.

==============================

Having reviewed both the manuscript and the referee reports, I largely concur with the point raised by referees 1 and 3 that the findings for the adult population are hard to interpret and should probably be excluded.  First, we do not know if these individuals were displaced as chidlren.  Second (and more importantly), the various risk and protective factors are measured contemporaneously (in adulthood), not retrospectively (at the time of the abuse), and thus the findings cannot be interpreted as evidence that any particular characteristic had a protective effect vis-a-vis polyvictimization: the victimization could have occurred long before any particular characteristic was determined.  I suggest you drop these findings.  I also concur with multiple points raised by the referees noting that a more robust defense of the definition of polyvictimization is required; and I also find that the differences between males and females seem somewhat overemphasized in the text (or at least, are overemphasized without any clear conceptual framework for understanding these differences).  Please respond carefully to all of the comments provided by all three referees.

==============================

Please submit your revised manuscript by Dec 20 2025 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.

• 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,

Jessica Leight, PhD

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. Please include a complete copy of PLOS’ questionnaire on inclusivity in global research in your revised manuscript. Our policy for research in this area aims to improve transparency in the reporting of research performed outside of researchers’ own country or community. The policy applies to researchers who have travelled to a different country to conduct research, research with Indigenous populations or their lands, and research on cultural artefacts. The questionnaire can also be requested at the journal’s discretion for any other submissions, even if these conditions are not met.  Please find more information on the policy and a link to download a blank copy of the questionnaire here: https://journals.plos.org/plosone/s/best-practices-in-research-reporting. Please upload a completed version of your questionnaire as Supporting Information when you resubmit your manuscript.

(2) Please describe in your methods section how capacity to provide consent was determined for the participants in this study. Please also state whether your ethics committee or IRB approved this consent procedure. If you did not assess capacity to consent please briefly outline why this was not necessary in this case.

3. Thank you for stating the following in the Funding Section of your manuscript:

“This study was funded by the United Kingdom (UK) government through the Baobab Research Program Consortium (RPC).”

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

“This study was funded by the United Kingdom (UK) government through the Baobab Research Program Consortium (RPC), with the Population Council Inc as the primary awardee under contract number PO8612.

The funder did not play any role in the

design of the study, collection, analysis and interpretation of the data, writing of the manuscript, or the decision to submit the manuscript for publication.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

**********

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

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #1: The paper is well-written and focuses on interesting issues that are prevalent in conflict-affected countries. My specific comments based on my review of the paper are provided below:

(i) The paper indicates a number of studies that focus on the prevalence of polyvictimisation in developing countries. The contributions of the paper to the existing literature could have strengthened to go beyond – undertaking another study in that focuses on humanitarian settings (Uganda and Ethiopia). The justifications provided for another study isn’t sufficient to warrant publishing the paper in a reputable journal like PLOS ONE.

(ii) In the discussion of the data sources, there are some repetitions in the discussions of the data between line 138-145, and 161-164.

(iii) In addition to using an additive index for polyvictimisation, the study could conside the use of Principal Component Analysis (PCA) or Multiple Correspondence Analysis (MCA) to generate an index for polyvictimisation.

(iv) In the description of mental health measure, the study generates a threshold for less severe mental health score if the mental health score is less than 13, and moderate to severe mental health stress for scores of 13 points or higher. How did the study arrive at this threshold? Please provide evidence to lend credence to the cut-off adopted.

(v) In the empirical analysis, in addition to using chi-square (X2), the paper could have used test of mean difference to obtain difference in outcomes between polyvictimisation, and non-polyvictimisation.

(vi) It would have been nice to present the econometric model used in the empirical analysis of the multivariate regression model. The econometric model should be presented such that the outcome (dependent variable), and the regressors are indicated.

(vii) The empirical analysis could have gone beyond multivariate logistic regression to include a further empirical analysis such as propensity score matching (PSM) method that use matching of observable characteristics to obtain robust results compared to multivariate logistic regression.

Reviewer #2: Review of the paper titled

“Prevalence of childhood polyvictimization, mental health outcomes, and associated risk and protective factors in Ethiopia and Uganda refugee settings”

by Muthuri et al., 2025

Question and Motivation

The paper seeks to understand whether polyvictimization is prevalent among children in humanitarian settings and to identify its associated risk and protective factors. This is a highly relevant topic, given that children in refugee contexts face multiple vulnerabilities that may differ substantially from those in non-humanitarian environments.

Contribution to the Literature

Polyvictimization during childhood has been linked to adverse mental-health and social outcomes later in life. While several studies have examined this issue in low- and middle-income countries, there is limited evidence from humanitarian contexts, where mechanisms and exposure dynamics may differ.

By focusing on refugee populations in Uganda and Ethiopia, this paper contributes new empirical evidence and provides useful insights into how risk and protective factors operate in displacement settings.

General Assessment

I found the paper well-written, well-motivated, and statistically rigorous. The analyses are transparent, and the presentation is clear and consistent. I recommend the paper for publication after the authors address the following key points of clarification and discussion.

Major Comments

1. Clarify the relevance of the refugee context

The paper would benefit from a stronger articulation of why the refugee context is analytically important. What mechanisms or structural conditions make victimization dynamics different from those in host communities? Without this framing, readers might assume that children in refugee camps face similar risks as other disadvantaged children.

- Where does the victimization primarily occur—within households, among peers, or through interactions with host-community members?

- If feasible, provide basic descriptive contrasts between the refugee sample and national statistics (e.g., share of female-headed households, poverty rates, school enrollment). Such comparisons would help contextualize the findings.

2. Clarify timing and setting of victimization

It is not entirely clear whether the episodes of polyvictimization occurred within the camps or prior to displacement. Because polyvictimization is defined as exposure before age 18, respondents aged 18–24 may have spent part of their childhood outside the camps.

- How long have these individuals been displaced?

- Could the higher prevalence among older respondents in Ethiopia reflect pre-displacement experiences rather than conditions in the camps?

This clarification is crucial for interpreting the age pattern in the results.

3. Disaggregate the forms of victimization and explore gender-norm mechanisms

Polyvictimization is defined as exposure to two or more types of victimization. The paper could benefit from disaggregating these experiences to show which combinations most commonly overlap (e.g., emotional–physical, physical–sexual). Such descriptive insights would deepen understanding of mechanisms behind the associations.

Moreover, the study surfaces a potentially important link between gender-norm attitudes (endorsement of IPVAW) and experiences of childhood victimization. The observed association between endorsing intimate-partner violence and being a polyvictim is intriguing yet counterintuitive. One might expect that individuals who normalize violence would under-report such experiences, yet the opposite pattern emerges. This tension might stem from the types of violence reported—certain forms (e.g., emotional or community-level) may be interpreted differently depending on gender-norm beliefs.

To probe this, the authors could:

- Produce a cross-tabulation between types of violence and respondent characteristics (gender, IPVAW endorsement, disability, household structure).

- Or, more ambitiously, replicate the analysis by defining polyvictimization as exposure to specific pairs of violence types (2 × 2)—for example, emotional + physical, physical + sexual, etc.

Either approach would enrich the discussion and clarify whether the IPVAW relationship reflects differences in perception, reporting, or actual exposure. I would be very interested in seeing these results.

4- Understanding the relationship between mental health and polyvictimization

The paper could more explicitly unpack what drives the association between mental health outcomes (e.g., self-harm, suicidal ideation or attempts) and polyvictimization. In Ethiopia, the point estimates drop by almost half once models are adjusted for gender, suggesting that compositional or mediating factors may be at play.

I encourage the authors to consider a sequential adjustment approach—adding individual-level factors first, then family-level, and finally community-level variables—to assess which dimension accounts for the observed attenuation. This would provide deeper insight into which factors most strongly mediate or confound the link between victimization and mental health and would strengthen the causal interpretation of the associations.

Minor Suggestions

- When reporting results, use neutral language such as “associated with higher/lower odds” instead of causal terms (“increased risk,” “reduced risk”).

- Visualization: The results section is dense with tables. Adding graphical summaries (e.g., bar charts or coefficient plots) would help readers grasp key patterns quickly. For instance, Table 2 contains more information than is discussed in the text; parts of it could be moved to an appendix while the main text features a concise visualization.

Reviewer #3: The exposition is generally good. It could be tightened in some places and expanded in others. The motivation and framing of the research question is area that requires attention. Some polishing and proof-reading could be beneficial, but is secondary. Please see attached report for more detailed comments.

**********

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: Yes: Dr Joseph Ajefu

Reviewer #2: No

Reviewer #3: 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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Attachments

Attachment

Submitted filename: Referee_Report_PLOS ONE.docx

Attachment

Submitted filename: Report_MuthuriEtAl_PLOSOne.pdf

Prevalence of childhood polyvictimization, mental health outcomes, and associated risk and protective factors in Ethiopia and Uganda refugee settings.

PONE-D-25-42079R1

Dear Dr. Muthuri,

Thank you for your thorough response to the request for revisions.  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. For questions related to billing, please contact billing support .

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,

Jessica Leight, PhD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

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

Reviewer #2: Partly

Reviewer #3: No

**********

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

Reviewer #2: Yes

Reviewer #3: No

**********

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

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: (No Response)

**********

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

Reviewer #2: No

Reviewer #3: (No Response)

**********

Reviewer #2: This revised version of the manuscript represents a clear improvement over the previous submission. The authors have addressed most of the comments raised in the first round in a careful and thoughtful manner.

Please find below my remaining comments regarding one issue that I believe would benefit from further consideration.

Reviewer #3: Unfortunately, the authors have not addressed the thoughtful comments raised by the editor and the reviewers. As a result, the results of the study are not reliable. Given the importance of the topic, the results must be extremely robust even for a correlation.

**********

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

**********