PONE-D-24-42534 Improving Spaces for Women First Responders: A grounded theory on gender equity PLOS ONE

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Comments from PLOS Editorial Office: We note that one or more reviewers has recommended that you cite specific previously published works. As always, we recommend that you please review and evaluate the requested works to determine whether they are relevant and should be cited. It is not a requirement to cite these works. We appreciate your attention to this request.

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: N/A

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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: Yes

Reviewer #2: No

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

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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: Abstract

Comment 1, Page 4, Line 1: Consider rephrasing “designed”. Emergency response work is not necessarily gendered in its design.

Introduction

Comment 1: Please be consistent with your language, public safety vs. first responder.

Comment 2: A definition of what a first responder is would be helpful to focus the reader on the cohorts your are specifically commenting on. There is a lot of back and forth in the introduction between FF, PO etc, so it would be help to define the groups you are presenting on.

Comment 3: It is worth mentioning the increased risk for adverse mental health outcomes among these groups, of which are further elevated among women. EMS and fire, specifically, are noted to have increase depression, anxiety, substance abuse, and even suicide. This speaks volumes when it comes to advocating for more research among these cohorts. Please consider including some of the citations below.

McCann-Pineo M, Keating M, McEvoy T, Schwartz M, Schwartz RM, Washko J, Wuestman E, Berkowitz J. The Female Emergency Medical Services Experience: A Mixed Methods Study. Prehospital Emergency Care. 2024 May 18;28(4):626-34.

Huang G, Chu H, Chen R, Liu D, Banda KJ, O’Brien AP, Jen HJ, Chiang KJ, Chiou JF, Chou KR. Prevalence of depression, anxiety, and stress among first responders for medical emergencies during COVID-19 pandemic: A meta-analysis. Journal of global health. 2022;12.

Stanley IH, Hom MA, Joiner TE. A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and paramedics. Clinical psychology review. 2016 Mar 1;44:25-44.

Stanley IH, Boffa JW, Smith LJ, Tran JK, Schmidt NB, Joiner TE, Vujanovic AA. Occupational stress and suicidality among firefighters: Examining the buffering role of distress tolerance. Psychiatry research. 2018 Aug 1;266:90-6.

Lebeaut A, Tran JK, Vujanovic AA. Posttraumatic stress, alcohol use severity, and alcohol use motives among firefighters: The role of anxiety sensitivity. Addictive Behaviors. 2020 Jul 1;106:106353.

Comment 4: What was the author’s justification for not including EMT’s? The literature suggest that they experience significant occupational and mental health burdens alongside their paramedic counterparts. There needs to be a firm rationale for their exclusion.

Comment 5: Has there been any efforts to collect the demographic distribution among the professions? What is the reason for not collecting it? Time, funding? Might be something to comment on.

Methods

Comment 1: Please refer to and utilize the Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist., There are numerous items that are missing and not included in the main text.

More detail is need on the recruitment methodology: how many agencies/institutions were provided with the recruitment poster? Besides being active/on leave/retired <3 years, was there any other inclusion/exclusion criteria?

Who developed the interview guide? Was it reviewed or tested prior to use?

Were the ZOOM sessions just audio recorded, or video as well? If video was used, please state. Further, if video was used, do you think that responses among those who opted for video/ZOOM may have been biased? Less confidentiality with video, which may have prevented participants from being 100% forthcoming.

Please indicate how long each interview session was.

There is no justification for the sample. Was saturation among themes met at 20? How did the authors decide to stop enrollment/interviews?

Who was responsible for the coding of the transcripts? How do you think the author’s own personal experiences may have influenced the coding? Reflexivity in qualitative research has become increasingly important.

Results:

Comment 1: are you able to present the demographic information by profession? This would be helpful for the readers. Further, is there any information on the EMS/fire agency type? Such as EMS agency vs. Fire agency with EMS? This distinction is meaningful and can directly impact participant experiences.

Comment 2: The presentation of the four themes is less than to be desired.

Firstly, it appears that there many subthemes within each of the overall themes. For example, ‘Changing Professional Environments’ appears to have subthemes of increases accessibility (uniforms, stair chairs, mobile stretchers, etc), workplace culture (sexism, harassment, women focused policies. This reviewer suggests that you consider reorganizing the presentation of the data to group quotes and ideas by subthemes. It is disjointed as it is currently presented.

Secondly, it may help focus and streamline things if you put all participant quotes within one large table. This would also cut down on the word count.

Comment 3: There are numerous occasions where expletives are included in the participant quotes. This review understands “fidelity” of the quotations; however, it is suggested to remove the curse words and replace with something like [expletive].

Comment 4: Under the ‘Facing resistance” theme, additional participant quotations are need to support the subthemes presented. Specifically, quotes commenting on pregnancy/maternity leave in its relation to career advancements, promotions (particularly being unearned), and social acceptance are needed. These are large paragraphs of text with no supporting quotation.

Discussion:

Comment 1: Please include Contursi et al 2018 as an in-text citation.

Comment 2: As mentioned previously, presenting demographic data by profession is necessary to support the claims in your last paragraph of the Discussion.

Comment 3: While this Review appreciates and agrees with the recruitment and retention recommendations presented in Table 1, many of them are anticipated to have low feasibility, particularly among EMS and EMS/Fire agencies with limited funding (i.e rural). At least within the US, the pay discrepancies across the three professions are profound—with EMS receiving a fraction of the salaries of their law and fire counterparts. This generates significant difficulties in instituting any organizational changes that would benefit women directly (i.e scheduling, childcare, etc). Perhaps providing some information on how the Canadian EMS system compares to other major nations would be helpful. Or, maybe provide an example as how the authors envision implementing these recommendations? On paper they are great, but to anyone in operations would see many of these as seemingly impossible to enact.

Secondly, perhaps separating the key recommendations by profession is also needed. Yes, all these recommendations will benefit women in each of the 3 professions, however, there are others that could be specifically tailored for EMS vs Fire vs. Law.

Limitations:

Comment 1: This may no longer be necessary after addressing the comment about saturation, but if saturation was not met this needs to be included as a limitation

Conclusion

There is no conclusion section. Please include.

Reviewer #2: This study set out what it aimed to do: to analyze information from women first responders and develop ideas to advance gender equity in the professions. Study significance is supported by the cited literature and using grounded theory to generate new knowledge was effective. The description of the grounded theory process was succinct.

A “major” issue is the abrupt ending of the paper. I wonder if the “Recruitment & Retention” and “Limitations” sections could come earlier in the Discussion section, so there can be a conclusion to wrap up the paper.

For clarity, restate the total number of participants in the “Results” section as you begin to describe the population sample. Additionally, defining the term “sexual minority” for your reader would be helpful.

Diving into the topic of first responders who identify as women is important in supporting the increased number of them in these historically masculine professions. I support the publication of this article with the suggested revisions above. Thank you for the opportunity to submit this review.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-24-42534R1 Improving Spaces for Women First Responders: A grounded theory on gender equity PLOS ONE

Dear Dr. Gregory,

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 Sep 01 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.

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,

Saravana Kumar

Academic Editor

PLOS ONE

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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

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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

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

Reviewer #2: N/A

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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: 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

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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: This revision has increased the impact of this work for publication. Please note some typos in the following lines for correction:

233-234: "both" does not reference two like things in order. Revise for clarity.

379: Replace "loose" with "lose"

503: Replace "bullshit" with "[expletive]"

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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

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Improving Spaces for Women First Responders: A grounded theory on gender equity

PONE-D-24-42534R2

Dear Dr. Gregory,

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.

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Kind regards,

Saravana Kumar

Academic Editor

PLOS ONE