Dear Dr. Eshetie,

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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?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: No

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

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Reviewer #1: Manuscript Number: PONE-D-24-46926

Manuscript Title: Magnitude of workplace violence and associated factors among health professionals in East Africa. Systematic review and meta-analysis

Congratulations dear authors on your scholarly work based on a priori protocol registered in PROSPERO; you have brought an important study problem with good findings that have public health importance in optimizing health care professional safety and well-being in work place. However, there few methodological issues that I want you to address before considering the manuscript for publication.

Comments

Abstract

Introduction: This section needs to tell the reader about overview of burden of the problem, gap justification/ reason/aim of study.

Methods: better to remove the aim of the study from this part and add to introduction section. Please add sub group analysis, sensitivity analysis, study period etc…

Result: you need to reduce, make it short and precise (instead of writing associated variable and AOR separately write like (Emergency department (95%CI: 3.22, 5.39; I2 =93.71%, p = 0.00).Please write total study participants and included studies.

Conclusion: “The magnitude of workplace violence in the region was high” do you have benchmark to say high?

Your conclusions need to be based on your finding. I recommend you to place your Prospero registration here (Abstract)

Introduction (main): I feel it is well stated and organized except first write the full term before abbreviation, see your grammatical and language usages. In addition, you better to state the known factors/ variables, the attempted solution taken and planed strategies.

Methods: do you think that PIOC mnemonic is suitable for this review? Please revise it.

Please operationalize “workplace violence”

Result: Under “Characteristics of the included studies” be consistent write all in words or number (4, eighteen, 7)

It is better to narrate your result in intelligible, short and conclusive manner (revise it)

Discussion: I recommend you to revise your discussion section critically.

• Please use reference for your justification,

• Make it short and clear to transfer your message well to the reader

• There are some sentences which placed unwisely like “As primary articles revealed that……?

• The flow of idea is not smart

• Please use paragraph for distinct idea

• Generally it needs deep revision

Your conclusion should base your result

General comments

� There are several typological and grammar usage errors that need extensive proof reading for revisions.

� Don’t use the conjunction ‘or’ to illustrate more, just one phrase or sentence is enough

Good luck!!

Reviewer #2: Thank you for the opportunity to review this manuscript. This meta-analysis estimates the prevalence of life-long workplace violence among healthcare workers in East Africa, understanding workplace violence as having suffered at least once an aggression from a client or user. The meta-analysis is generally well perfomed and contains thorough analyses. I have one major comment which I hope will help improve this manuscript.

The meta-analysis 25 studies in its main analysis and obtains a robust estimation of the workplace violence prevalence. However, when it comes to analyzing moderator variables, the manuscript's approach is suboptimal in the sense that it does not take all of the possible studies. For instance, let me take the example of the analysis of sex as a potential variable. The manuscript only take those studies where men and women were compared and use the OR as a size effect. However, it is also possible to take the proportion of men and women in every study and perform a meta-regression, using the prevalence as the effect size, and thus taking all of the studies instead of only some of them. Same logic could be applied to age, and years of experience, and perhaps other moderating variables as well.

The manuscript also mentions that the autohrs searched on databases like PubMed, Google Scholar, and Google. Is this the complete list of databases?

As a minor comment, regarding abbreviations and their use, it is customary that, the first time a term appears, both the expanded term and its abbreviation are mentioned, and in subsequent apprearances only the abbreviation is used. I suggest the manuscript to abide to this custom. For instance, the first time the term appears is in the first sentence: there I would say "Workplace violence (WPV) is a violent...", and use only the abbreviation WPV afterwards. Same rule may be applied to the abbreviation AOR.

Last, in the last paragraph of the Methods, it is said that p-value "<0.05% was used". Do you mean a significance threshold of 0.05?

Reviewer #3: In a meta-analysis, this paper deals with the questions of how high workplace violence is in East African countries and which predictors were found. It is a methodologically sound study. This and the results found are the strength of the work. However, I do see a some weaknesses in the work. Apart from a few points at the end, the introduction is good, but a chapter with related studies is missing. I am thinking in particular of systematic reviews and meta-analyses on the issues relating to East Africa, but also worldwide for comparison. For this reason, the discussion also suffers because there is no holistic reference to that existing literature. The methods section is complete in itself, but some more precise explanations are missing, and it could generally be more detailed. In my view, a very important question is why 70% of the studies were excluded due to unavailability before the full text review. It is very important to assess whether these could have an influence on the results.

I think this study is an important contribution to the documentation and prevention of workplace violence. I hope that you can revise this meta-analysis so that it can be published.

General comments

• In chapter 3 (methods), 3.1 Data analysis follows 2.4 Data extraction. I suppose it should be 2.5 Data analysis.

You have no chapter 3. After chapter 3. Methods chapter 4. Results follows, and the 4. Meta-Analysis.

• Please, let proofread your paper. There as some grammatical errors and stylistic issues.

Abstract

The abstract is comprehensible and contains the relevant information.

• There are mentioned findings of a WHO study on WPV that are not mentioned in the introduction.

• I recommend to mention all databases searched not “like PubMed, …”.

• Egger’s test (not egger’s test)

• AOR is used in the abstract. I would write out the abbreviation in the abstract and introduce the abbreviation at first use later in the paper.

• Do not reference to figures in the abstract (“fig.12”).

• The second part of the results (in the abstract) “Emergency room AOR was …” is not written in complete sentences.

Introduction

I see some issues in the last section of the introduction.

You write that WPV is “predominantly dangerous in Africa, especially in East African countries”. Why is that the case. You should explain this.

“they are almost similar in resource, health staff and technology usage, infrastructures, health care practice and environment.” -> similar to which countries.

You write that there is no comprehensive study on WPV in East Africa and that despite the importance there are few information. But then you write “It is therefore feasible to determine the magnitude workplace violence and its predictors in the region level.”

That is not logic to me. If there are few studies, few information, how can you conduct a meta-analysis?

• There are phrases that are not easy to understand for me (e.g. “having almost similar healthcare institutions and challenges in the region of this”)

• Introduce the abbreviation of workplace violence at it’s first use; not further down in the introduction.

• “the rest employees” -> the other employees

• Several times in the paper you mention to conduct “a systematic review and a meta-analysis”. I would only refer to meta-analysis. A meta-analysis is a kind of systematic review, but I would not mention both.

Related works

I miss a chapter with related works, especially systematic reviews and meta-analyses. You might use these studies to show the actual state of the art and make first conclusions about WPV worldwide, in Africa and East Africa. Then you can bring them and their results in relation to the results of your paper in the discussion section. I listed some systematic reviews and meta-analysis further below.

Methods

In the methods section all necessary information is there, even if mostly in a rather short way. I recommend integrating the subchapters 4.1, 4.2 and 4.3 into the methods section.

But there are some points to clear.

• mObjective: “to determine the overall pooled magnitude of workplace violence and identify associated factors among healthcare professionals in East Africa”

But in the next phrase you write “to evaluate the category and predictors of workplace violence in this area”. What do you mean with category? That seems to be a new element.

• PRISMA: I would very brief explain what these guidelines are for.

• In subchapter 2.1, I do not find the description of the study design. There is the objective and the reference to the PRISMA guidelines and the register of systematic reviews.

• 2.1.1: The details of the search strategy are not clear to me. Did you mention all databases or only a part of them (“like PubMed, …”)? Who was conducted the search for grey literature? In what databases? Did you find grey literature? How was “search complementary articles” done, by whom?

• Please explain shortly what the PIOC pursuing design is.

• “The explanation approach and quantity of rescued article to database has been given.» Where did you do this?

I recommend integrating the chapters below into the methods section, where there is the reference to fig. 1.

• Concerning data extraction, you write that you did extract “odds ratio of significantly associated factors”. Did you leave out non-significant factors? That would bias results. I suppose I am misunderstanding something.

• “The associated factors of workplace violence were also the second interest of this review”

correct: “The associated factors of workplace violence were the second interest of this meta-analysis.”

• Egger’s test (not egger’s test)

• “I2 value of 0, 25%, 50 and 75%” -> “I2 value of 0%, 25%, 50% and 75%”

• Figure 1: What are other reasons for exclusion before screening

I am a bit alarmed to read that 89 of 127 studies are excluded due to unavailability of a full text. What is the unavailability? Are they not open source? Did you find only a reference but no functioning link or they seem not to exist? This seems important to me.

Whenever possible you should select these studies for full text review. If this is not possible you should estimate with the existing information (title, abstract) if these papers would change your findings.

Results

As mentioned above I recommend integrating chapter 4.1 to 4.3 into the method section.

• 4.3: the first sentence is a repetition (methods section)

Meta-analysis

When placing the chapters 4.1-4.3 into to method section, I would rename chapter 4. Meta-analysis in 4. Results.

All in all, the results are presented clear and understandable. Even if an editorial question, I would reflect about the integration of the figures within the text. Thirteen figures are a lot and most of them might be rather large compared to their contained information.

• When writing about the analysed papers I would use the word studies (not articles).

Discussion

Principally, the discussion is ok. But as there are only view related studies are cited in the introduction, I miss a broader discussion in relation to existing literature (especially systematic reviews and meta-analyses).

• I would integrate numbers (results of other studies) into the discussion, e.g. “which is higher than the findings of studies conducted in Nepal[10], in France[43].» I would add there the lower values of the referred studies.

• Alcohol and substance consumption. Reflection about cause and effect: Alcohol or substance consumption could be a consequence of WPV not a cause.

• Women face more WPV. What about sexual harassment? That’s not WPV per se, evtl. one version of it. Could it be that this is one reason for the higher values.

• This finding is supported with the result of other studies[45]. I would mention that [45] is a meta-analysis; else it seems strange to mention other studies and refer only to one.

• “This insecurity feeling of professionals directly affect the healthcare service provided and the outcome of institutions. .” -> Two points at the end of the sentence.

Meta-analyses and systematic reviews about WPV (worldwide)

no comprehensive literature research

Afolabi, A. A., Ilesanmi, O. S., & Chirico, F. (2024). Prevalence, pattern and factors associated with workplace violence against healthcare workers in Nigeria: A systematic review. Ibom Medical Journal, 17(2), 166-175.

Ayalew, E., Workineh, Y., Semachew, A., Woldgiorgies, T., Kerie, S., Gedamu, H., & Zeleke, B. (2021). Nurses' intention to leave their job in sub-Saharan Africa: A systematic review and meta-analysis. Heliyon, 7(6).

[-> Highest value in East Africa. That could be a consequence of WPV.]

Ayyash¹, S., Ruziqat, E., Alsmadi, A., Al Melhem¹, A., Eshah, N., Khalifeh, A., & Al Helou, D. (2023, September). Check for updates Violence Against Health Care Workers in Health Care Services: A Literature Review. In Proceedings of the Second International Nursing Conference" Nursing Profession in the Current Era"(INC 2023) (Vol. 67, p. 182). Springer Nature.

Ekpor, E., Kobiah, E., & Akyirem, S. (2024). Prevalence and predictors of workplace violence against nurses in Africa: A systematic review and meta‐analysis. Health Science Reports, 7(4), e2068.

[cited in your discussion]

Edward, K. L., Ousey, K., Warelow, P., & Lui, S. (2014). Nursing and aggression in the workplace: a systematic review. British journal of nursing, 23(12), 653-659.

Haleem, S. E. A. A., El Bingawi, H. M., Haleem, S. A., & El Bingawi, H. (2024). An international review of workplace violence against healthcare providers: Sudan as a case study. Cureus, 16(1).

Hallett, N., Gayton, A., Dickenson, R., Franckel, M., & Dickens, G. L. (2023). Student nurses' experiences of workplace violence: A mixed methods systematic review and meta-analysis. Nurse education today, 128, 105845.

Karatuna, I., Jönsson, S., & Muhonen, T. (2020). Workplace bullying in the nursing profession: A cross-cultural scoping review. International journal of nursing studies, 111, 103628.

Li, Y. L., Li, R. Q., Qiu, D., & Xiao, S. Y. (2020). Prevalence of workplace physical violence against health care professionals by patients and visitors: a systematic review and meta-analysis. International journal of environmental research and public health, 17(1), 299.

Liu, J., Gan, Y., Jiang, H., Li, L., Dwyer, R., Lu, K., ... & Lu, Z. (2019). Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occupational and environmental medicine, 76(12), 927-937.

Lu, L., Dong, M., Wang, S. B., Zhang, L., Ng, C. H., Ungvari, G. S., ... & Xiang, Y. T. (2020). Prevalence of workplace violence against health-care professionals in China: a comprehensive meta-analysis of observational surveys. Trauma, Violence, & Abuse, 21(3), 498-509.

Nelson, S., Ayaz, B., Baumann, A. L., & Dozois, G. (2024). A gender-based review of workplace violence amongst the global health workforce—A scoping review of the literature. PLOS global public health, 4(7), e0003336.

Njaka, S., Edeogu, O. C., Oko, C. C., Goni, M. D., & Nkadi, N. (2020). Work place violence (WPV) against healthcare workers in Africa: A systematic review. Heliyon, 6(9).

Spector, P. E., Zhou, Z. E., & Che, X. X. (2014). Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: a quantitative review. International journal of nursing studies, 51(1), 72-84.

Tee, S., Özçetin, Y. S. Ü., & Russell-Westhead, M. (2016). Workplace violence experienced by nursing students: A UK survey. Nurse education today, 41, 30-35.

Worke, M. D., Koricha, Z. B., & Debelew, G. T. (2020). Prevalence of sexual violence in Ethiopian workplaces: systematic review and meta-analysis. Reproductive health, 17, 1-15.

[in relation to WPV against women]

Yusoff, H. M., Ahmad, H., Ismail, H., Reffin, N., Chan, D., Kusnin, F., ... & Rahman, M. A. (2023). Contemporary evidence of workplace violence against the primary healthcare workforce worldwide: a systematic review. Human resources for health, 21(1), 82.

Reviewer #4: Dear editor,

Thank you for providing me with the opportunity to review this interesting work. The authors present a systematic review and meta-analysis of the prevalence of workplace violence among healthcare workers in East Africa and of factors that moderate its prevalence. The topic is certainly of interest, but I have strong reservations against the paper in its present form. I address only the most pressing points for now. Further issues would need to be discussed after any revision.

1) The text is sometimes difficult to understand. I suggest the authors use ChatGPT or similar to improve the grammar and readability of their manuscript.

2) Out of 127 publications selected for full text review, 89 (i.e., about 75%) could not be accessed. I fully understand that access to research papers is limited at some institutions. However, a review that misses about three quarters of the relevant literature is not very useful. I suggest that the authors look for a collaboration partner who can provide them with access to the missing papers or find some other means to access these publications.

3) It remains unclear how the prevalence of workplace violence was assessed across studies. It is therefore unclear if the results can be pooled or compared. Imagine two studies that find 50% workplace violence. One study asked: “Did you experience workplace violence throughout the past 12 months?". The other asked “Have you heard of a colleague who experienced workplace violence throughout their career?” It would be misleading to assume that both studies found the same result. Please provide information how the experience of workplace violence was assessed in each study.

I wish the authors all the best for their project and hope that they further build on the substantial work they have undertaken so far.

Johannes Hönekopp

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes:  Johannes Hönekopp

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Submitted filename: Comments to the Authors.pdf

Dear Dr. Eshetie,

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.

The reviewers have different opinions on this manuscript. The author is requested to make major revisions to the fourth reviewer's suggestion, because this manuscript does have the problems he raised. The author is asked to reasonably explain the third reviewer's recommendation, especially since he listed four articles to refute the author's argument.

Please submit your revised manuscript by Aug 31 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.

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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.

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We look forward to receiving your revised manuscript.

Kind regards,

De-Chih Lee, Ph.D.

Academic Editor

PLOS ONE

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The reviewers have different opinions on this manuscript. The author is requested to make major revisions to the fourth reviewer's suggestion, because this manuscript does have the problems he raised. The author is asked to reasonably explain the third reviewer's recommendation, especially since he listed four articles to refute the author's argument.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: (No Response)

**********

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

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Partly

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

Reviewer #2: The manuscript considerably improved after this revision. I have no further comments. I congratulate the authors for their well done work.

Reviewer #3: The authors have incorporated most of the reviewers' suggestions for improvement or explained why they have not done so. The paper has improved significantly since the revision and might be ready for publication with minor revisions if two points are clarified.

In all, three points remain unclear to me:

1. Proofreading is still required.

Examples: The first sentence in the introduction is still incorrect, or rather, an error has been inserted (WPV occur instead of WPV occurs). Interestingly, the same sentence is better formulated in the abstract (even before the revision). ‘Towards the staff’ (abstract) or ‘toward the staffs’ (introduction) may be correct, but I would write ‘against employees’. There are other examples such as: ‘the impact of predictors on outcome variable’ (that is ‘variables’?). In the abstract, the list of moderators is not integrated into a correct sentence (‘... with the outcome variable. Emergency department ...’).

All this makes reading somewhat more difficult and leads to misunderstandings.

2. Studies with no full text

I understand the explanation for the exclusion of studies lacking “full texts” (still written this way on page 5), but I am still not convinced. I apologize for being so suspicious and persistent here. I might be a question of language, or expression that I don’t understand correctly. But I cannot exclude that your explanation is a way to save the paper for publication.

The sentence ‘During full-text review, 89 studies with no accessible full text were removed’ is a clear and easily understandable statement that says that 89 studies were not accessible. The new wording ‘During full-text review, 89 studies were excluded due to the full-text articles did not report the outcome of interest’. This is a completely different statement. You excluded the studies because they did not meet the inclusion criteria.

3. Most studies from Ethiopia

Of the 25 studies analysed, 18 (72%) are from Ethiopia. I wonder whether there are really no studies on WPV from other East African countries such as Tanzania, Mozambique or Madagascar. In the revised version, this weakness is mentioned in the discussion: ‘Therefore, based on the subgroup analysis, we can conclude that the source of the heterogeneity may be the inclusion of studies from Ethiopia, Rwanda and Sudan.’ I understand the sentence, although it is not a clear statement: ‘we can conclude that [...] may be’.

However, in my view, there are studies on the subject from other East African countries: e.g.

- Patricio et al. (2022): https://doi.org/10.1002/hpm.3506

- Shimoda et al. (2020): https://doi.org/10.1186/s12884-020-03256-5

- El Ghaziri et al. (2014): https://doi.org/10.1016/j.jana.2013.07.002

If it is indeed the case that most of the studies are from Ethiopia, then this requires a plausible explanation or in-depth discussion.

If studies were indeed excluded because they were not accessible, and if there are indeed further studies from other East African countries, then I would not publish the paper. It would be better to complete data collection, reanalyse, adapt the text and resubmit the paper.

I apologize again for my mistrust, and I recommend speaking with the editor.

Reviewer #4: I find the manuscript much improved, and I like the clear focus on applied consequences in the discussion. A number of problems still need to be addressed, though.

1. P7, “13 studies were also removed due to study design differences”. What does this mean? Is this related to the exclusion of studies due to poor quality mentioned earlier? Please clarify.

2. Regarding the proportion of staff experiencing violence, you present a test of publication bias (p7). I don’t think that the concept of publication bias applies here. Whichever proportion of violence a study finds, applying any test of statistical significance does not make sense. It is just a single estimate, and there is no benchmark against which it could be sensibly tested against. Consequently, there cannot be bias against statistically non-significant studies. I therefore suggest you drop the test of publication bias.

3. The sensitivity analysis (p7/8) is very difficult to understand; please rephrase.

4. Given the high heterogeneity observed, I understand the motivation to look for moderators. However, your sub-group analyses are not very convincing. To test whether there is time trend strikes me as a good idea. However, what you should do is include publication year (or even better: year of data collection, if available) as a moderator in the meta-analysis. You can then check if this moderator is statistically significant. This would indicate that reported violence systematically increased or decreased over the time period studied. Similarly, the comparison of countries fails to address if the level of violence differs significantly across countries. Only if that is the case should country be considered a moderator. Alternatively, you might simply drop Figures 7 and 8 and the respective text.

5. “Similarly, inadequate staffing was statistically associated with workplace violence” (p8): In that case the confidence interval should not include 1, but you report it as “95% CI: 0.90, 3.97” (p8). Note, if a result is statistically significant at .05 the 95% CI should exclude the value that indicates ‘no effect’, i.e. 1 for OR. Please address this contradiction. If staffing proves statistically non-significant, the discussion and conclusion need to change accordingly.

6. Table 2: It is essential that you indicate for each study, what measure of workplace violence was used (or that relevant information is missing). If we don’t know what the studies asked, we don’t know what the overall prevalence means. If the studies assessed the prevalence of workplace violence in different ways, this might have contributed to the large observed heterogeneity.

A minor point: It should be “Likewise” instead of “Like ways” on p10.

Johannes Hönekopp

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Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes:  Johannes Hönekopp

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Dear Dr. Eshetie,

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.

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We look forward to receiving your revised manuscript.

Kind regards,

De-Chih Lee, Ph.D.

Academic Editor

PLOS ONE

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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. 

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

There are still some minor problems with this manuscript. The authors are requested to make minor revisions based on the first reviewer's comments.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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??>

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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: Thank you for the opportunity to review the new version of this manuscript. I have two minor comments from this new version and the responses provided to the reviewers.

1. The manuscript says that "this review included all quantitative and mixed-methods observational studies". This is an inclusion criterion. Later, explaining the included and excluded articles, the manuscript says that 13 studies were excluded because the design did not align with inclusion criteria. However, I understand that those 13 studies reported the desired outcome, which is a prevalence, and thus I also understand that those 13 studies were quantitative. Of couse, I do not know which studies were excluded for this reason, but I can not help but wonder how were those studies performed to have the desired prevalence and yet not being included.

2. I agree with a comment formerly made by another reviewer that meta-regression using year as the independent variable would be a good idea. First, perhaps re-ordering the studies in Figure 2 by year would allow us to see possible time trends in the prevalence of workplace agressions; I must admit I do not see how studies in Figure 2 are currently ordered and perhaps a different order could be more helpful, but I would not be very insistive on this. Second, and more importantly, the authors divided the studies in two groups: before 2022 and after 2022, but there is still much heterogeneity. I would suggest treating the year as a quantitative variable in the meta-regression, instead of dichotomizing it.

Reviewer #3: The current version of the paper reads better and has improved in quality once again. Conducting a meta-analysis is a time consuming and hard work - I am very aware of this.

There are a few minor improvements that I recommend below.

The authors have argued well why they had to exclude many studies. The explanations for the three studies I mentioned have shown me this in an exemplary manner.

I would like to thank the authors for their great patience in responding to my objections with the relevant explanations and apologise once again for my mistrust.

From the studies included in the meta-analysis and their composition in terms of the countries in which they were conducted, I conclude that there is a significant lack of high-quality studies on the topic of WPV in the healthcare sector in most East African countries. This could be a conclusion from your study.

Points for improvement:

- You write: "20% to 38% of healthcare workers have experienced physical violence at some point during their careers, compared to employees in other sectors."

This concerns this sentence in the abstract and a similar sentence in the introduction.

I am missing the comparison. I would add some values of WPV from other areas here.

- In the abstract, you list the associated factors three times in a row, once in the same sentence (with and without AOR values) and then again in the conclusion.

I recommend rephrasing the sentence and the conclusion.

- Result section: ‘An extensive search was conducted, and a total of 1,243 studies were retrieved from databases such as Google’

better: ‘An extensive search was conducted, and a total of 1,243 studies were retrieved from the databases Google, ...’

- Publication bias: ‘The p-value from Egger's regression test (p < 0.03), along with the asymmetric distribution of the included primary studies on the funnel plot (Fig 3a), and suggests the presence of publication bias.’

-> ‘The p-value from Egger's regression test (p < 0.03), along with the asymmetric distribution of the included primary studies on the funnel plot (Fig 3a), suggests the presence of publication bias.’

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what does this mean? ). If published, this will include your full peer review and any attached files.

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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

Reviewer #3: No

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<p>Magnitude of workplace violence and associated factors among healthcare professionals in East Africa: A Systematic Review and Meta-Analysis.     .

PONE-D-24-46926R3

Dear Dr. Eshetie,

A few minor errors (see review comments) need to be revised.

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,

De-Chih Lee, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewer #2:

Reviewer #3:

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: (No Response)

Reviewer #3: Thank you for accepting my propositions.

The paper again improved.

I found only some tipos:

- page 10, line 14: all age group -> all age groups

- page 13, paper 6: the link contains spaces and misses a character ("-"; violence-against)

https://www.who.int/activities/preventing-violenceagainst-health-workers

-> https://www.who.int/activities/preventing-violence-against-health-workers

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #2: No

Reviewer #3: No

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