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Additional Editor Comments (if provided):

The authors raised an important topic and it addresses War related-Vicarious Trauma among Healthcare providers in the War-Torn Tigray,Northern Ethiopia. see specific comments below;

Abstract

• Avoid third-person writing “the”

• VT seems difficult to understand so it is better to define it in the abstract as well as in one sentence.

• “ we estimated “ third person writing the whole sentence needs rephrasing

• The burden of war and its impact especially on those with health providers, what is the need to do especially health care workers

• Interventions such as aftercare and addressing vulnerable groups

• I would put AOR of the factors significantly associated

• Sensitive topic more clarification on ethical consideration

Introduction

• Line 3-5 can you quantify the material or human damage with reference

• Citation for the “deliberate targeting of war on health care system causing disruption

• Paragraph 3; why healthcare professionals; are at risk needs rephrasing and synthesis

• Rather than listing all studies to connect ideas and flow in paragraphs 3 and 4

• First discussing issues in Western then Africa rather than shifting back and forth

Methodology

• You need to describe the desire why you used p 50 % inside the text and te design effect 2 ; need justification.

• If you put a diagram and the specific numbers when doing multi-stage sampling and proportional allocation

• What other tools or factors are assed other than VT which is not put in the methodology

• Why do you use a p-value 0.05 for bivariate logistic regression and put the justification as well

Result

• You can also put the reliability of the tools of outcome and validation in Ethiopia.

• The footnotes a, b,c are confusing as you only used p-value 0.05 as statically significant in your methodology.

• Why you did not asses the type of traumatic content disclosed to health providers

• “Consequently, medical personnel were forced to treat a high volume of patients with the potentially dangerous physical and psychological effects of the conflict on a regular basis. Another explanation could be that many medical experts and dangerous medical supplies needed for treatment and therapy have been forced to leave underfunded, damaged, and robbed healthcare institutions. This places a great deal of strain on the remaining employees, who are already probably overburdened and worn out, making them even more susceptible to vicarious stress. The Tigray war, which was characterized by ethnic violence and the targeting of civilians, which medical professionals may see personally while tending to patients, this could be because the victims have experienced personal loss, have lost loved ones or families, or have been uprooted themselves. This may exacerbate their inability to detach themselves from their traumatized patients and heighten their sense of helplessness and hopelessness.” This concept needs to be back up by citation and references

• The discussion needs to be improved as it does not compare or give appropriate citations for the explanation of the discussion points.

• I would add a specific and better recommendation.

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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: Yes

Reviewer #4: Partly

Reviewer #5: Yes

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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

Reviewer #5: Yes

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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

Reviewer #4: No

Reviewer #5: Yes

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: Yes

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Reviewer #1: Date: November 12, 2020

Dear Editor,

I hereby submit a review report of the manuscript, entitled ‘War related -Vicarious Trauma among Healthcare providers in the War-Torn Tigray, Northern Ethiopia.”. I acknowledge the efforts of the authors for performing a good job and writing evidence which is highly needed. Since, it needs further amendment, I suggested to be accepted with Major revision. I believe, this manuscript will be very helpful in passing better evidence for decision making in rebuilding the human resource development.

For the sake of simplicity, it would be good to create line numbers of the manuscript which would be easier for the authors to trace the comments and revised changes.

Abstract:

On the method section of the abstract a statement is described as “VT was assessed using a 7-item standard tool with likert scale…”, a phrase in a new line statement shall be written with full words of the phrase, otherwise, authors are advised to write Vicarious Trauma instead of VT.

On the second line of the result section of the abstract, authors need to rephrase the “was found to be”.

The conclusion of the abstract seems overlooked.

Introduction

On the first and second paragraphs: Authors have verified about the war in Tigray and its effects on the vulnerability of the health workers referring three peer reviewed articles. Ample literature written by humanitarian organizations have proven the health workforce traumatic experiences, so authors are requested to justify their statements from the perspective of humanitarian agencies.

Third and fourth paragraph, the piece of evidences from Gaza, Poland, Eastern Maynemar, Kenya, USA, Japan and findings from University of Ottawa needs to be consolidated, refined and synthesized. At this level, it would be good if the information could convey precise and concise message, otherwise it would be redundant. Authors are requested to revise the paragraph in a suitable manner for readers.

Though large number of health workforce population and civilians suffer in SSA countries due to war and conflict, the experiences and prevalence of vicarious trauma in sub Saharan African countries seem to be overlooked. So, authors are requested to provide SSA countries experiences.

On top of these comments, authors are advised to revise the flow and coherence of the paragraphs in the introduction section. It would be advisable to follow the writing style from global to local and general to specific.

Last paragraph of the introduction section: Authors noted “Despite our personal observations and experiences …….. the scope of the problem is not investigated”. The highlighted phrase seems overstated. Because, significant number of report reviews have been documented by MSF,

So, authors are advised to revise the phrase; instead of “not investigated” “the scope of the problem is not adequately investigated” might be an option. It would also be good to rephrase the valid evidence stated as “Except for the presence of vicarious trauma among the medical staff in the hemodialysis unit of the Ayder referral hospital published recently”.

Methods and materials

Study area

It is good that authors noted the number of health facilities and health workforce before the war. However, it seems inadequate information for this manuscript. On top of the information given the categories of the health workers, their speciality and the development of the health workforce and its contribution on the health outcome need to be highlighted.

Study design

The design is not only for the purpose of recruiting healthcare providers. It works for conducting the overall study. Authors are advised to omit the phrase “recruiting healthcare providers”.

Sample Size and Sampling Procedure

What was the reason for authors to choose simple random sampling technique after using multistage stratified sampling technique, while systematic random sampling technique is the easiest technique? It is from curiosity.

Authors noted “Twelve health professionals fluent in the local language (Tigrigna) were recruited.

Results

Socio-demographic characteristics of study participants

The first line statement reads “From the total of 2374 sampled healthcare providers, 2366 participants were included in the study”, I suggest to be corrected as “of 2374 participants, 2366 participated in the study” Authors are advised to revise their reports to be concise.

The first paragraph of the result section is with redundant phrases “two third is stated four times in a single paragraph”. Authors are advised to avoid redundant phrases and rephrase their result statements with eye-catching ideas to readers.

Besides authors interpreted “Nearly two-thirds of the study participants were from the Mekelle and Central zones” that mismatches with the figure on table 1 which is calculated as 26.7% for Mekelle and 15% for Central in total 41.7%. Authors are advised to make correction of the aforementioned result statement.

What standard do you for perceived economic classification?

In your result section table 2, the result of the odds ratio 0.7 [0.5, 0.9] by zone showed the protective effect of vicarious trauma among health workers in south East zone, do you have any clarification? Can you see back your data again for possible correction of the analysis?

Discussion

In the first paragraph of the discussion the word those is repeatedly stated, so authors are requested to avoid redundant words and revise the wording.

The comparison of similarities and variations in the discussion section is more skewed to the Western countries (USA, Europe and Canada). In order to make careful comparisons with sub-Saharan African countries, Authors need to revisit the discussion section.

It would be good if authors made an attempt to align some of their justifications with peer literature review.

Authors stated “Consequently, medical personnel were forced to treat a high volume of patients with the potentially dangerous physical and psychological effects of the conflict on a regular basis”. This statement is not clear. Is it part of the finding of this study, if not, Authors are requested to put a reference.

Authors stated “….. many medical experts and dangerous medical supplies needed for treatment and therapy have been forced to leave underfunded”, “What does dangerous medical supplies mean?” Authors are advised to provide clear statement on the highlighted phrase.

Many of the justifications stated on the discussion section lack references. Similar justifications are documented in various reports by humanitarian organizations including MSF, OCHA, ICRC and World Peace foundation led by Professor Alex Alex de Waal, so authors are advised to use the references for their justifications

Authors are duly requested to revisit the discussion section for further elaboration and amendment.

For the betterment of the manuscript, language revision is highly needed by native speakers.

Decision – Major revision

Reviewer #2: Dear authors,

The title is very interesting and timely to improve the healthcare service.

However, the following comments needs your attention

General comments:

• There is gloss editorial problem

• Less contextualized (context is war and war-related)

• The way research question is explored is not clear

Abstract:

• Background: Indicate clear gap

• Method does not indicate study area

• Result: show the p values for the factors

• Conclusion: disregard the conclusion about risk factors

Introduction:

• Look the detailed comments in the document

Method:

• The study setting is not clear... Conditions during the war are not indicated

• Show that your study takes place in health facilities under the study area and setting

• Specify your study population (if any inclusions and exclusions)

• Sampling procedure like stratification and proportional allocation should be clear (look the comments in detail in the document)

• Analysis method... way of reporting the OMLR... Comment in the document

Results:

• Reporting the result of ordinal logistic regression... comparison groups

• Inclusion of the zones for analysis... Concerns look comment

Discussion

• Need a huge work

• Justifications provided are not satisfactory and not supported by evidence

• Implications are not indicated

• All the narrative in the discussion should be based on scientific merit

• Strength and limitation... very shallow

Conclusion

• Has to emanate from the findings

• Conclusion: not repeating the result

Reference

• Journal articles should have year, volume, number, and page

• There are about 4 references with no year

Reviewer #3: First of all, i would like to say thank you dear plos one journal organizer for inviting me to this valuable manuscript and thanks Authors for well organized and systematically writtlng the manuscript. I moved through all parts of these manuscript and no doubt has been seen. It has acceptable comment and no more major errors are seen. Regards!

Reviewer #4: Review of War related-Vicarious Trauma among Healthcare providers in the War-Torn Tigray, Northern Ethiopia PONE-D-24-43464

This original research article is a cross sectional study of the prevalence of vicarious trauma among healthcare workers in war-torn Tigray, Northern Ethiopia. It reports highly significant levels of trauma, an important finding that could help to guide interventions to support health care workers living in this and other conflict zones with the aim of maintaining a functional health care system serving a population victimized by war. It also includes an empirically derived regression model of significant predictors of outcome that can generate hypotheses regarding the mechanism of vicarious trauma, which can help to guide intervention. I commend the authors for this important piece of research carried out despite extremely difficult circumstances. I believe it can be a very valuable addition to the peer reviewed scientific medical literature on this topic.

I believe the manuscript could be strengthened in the following specific ways prior to publication, and offer these suggestions in a supportive and constructive spirit:

1. In the title, the phrase “War related-Vicarious Trauma” should be: “War-Related Vicarious Trauma”

2. Please change “It has costed the physical, mental, economic, and psychological health of the people in Tigray in general and the healthcare providers in particular” to “It has taken a toll the physical, mental, economic, and psychological health of the people in Tigray in general and the healthcare providers in particular”

3. Please clarify the sentence: “The effect of conflicts provided a prominent example of this experience”

4. For the sentence “A systematic review revealed that 56% of health care providers had developed secondary trauma (10)” please clarify to be consistent with the other examples cited in this paragraph by briefly identifying the work setting and affected group.

5. “Maynemar” should be “Myanmar”

6. Please change “Despite our personal observations and experiences with such trauma among healthcare providers, in the war-torn Tigray region, the scope of the problem is not investigated. Except for the presence of vicarious trauma among the medical staff in the hemodialysis unit of the Ayder referral hospital published recently” to “Despite our personal observations and experiences with such trauma among healthcare providers in the war-torn Tigray region, the scope of the problem is not investigated except for a single recently published study on the presence of vicarious trauma among the medical staff in the hemodialysis unit of the Ayder referral hospital.”

7. Please define “health posts,” which is a term that may not be familiar to all readers.

8. Regarding the primary outcome measure, the “Crisis and Trauma Resource Institute's (CTRI) tool,” please specify in the text which tool was used (eg., title and if available the author(s), publisher, publication year, etc). Has the tool’s validity and reliabilty been measured and published in peer reviewed literature? If so, please cite using the publication information instead of the URL where it is found.

9. Also regarding the primary outcome measure, for the sentence stating that “After extensive revision of the English questionnaire, the final English version was translated into the local language by language experts” please briefly describe or summarize the descriptions. What needed revision?

10. In the sentence “Data collection location, accuracy, and completeness were monitored by the data manager by looking at the server-centered,” the meaning of the phrase “looking at the server-centered” is unclear. Please clarify.

11. For the sentence “The reliability of the item was measured by a Cronbach's alpha that ranged from 0.835 to 0.856” please clarify “The reliability of the item was measured by a Cronbach's alpha that ranged from 0.835 to 0.856.” Is this inter-rater reliability, something else?

12. The fact that “Variables having p ≤ 0.05 on the bivariate ordinal logistic regression analysis were candidates for the ordinal multivariable logistic regression analysis to control confounders” the fact that the ordinal logistic regression variables were derived empirically rather than from a pre-specified hypothesis means that the on average, 5% of the significance could be explained by Type I error. This should be acknowledged as a limitation of the study. This could also be addressed by use of an appropriate correction (eg., Bonferroni correction or its equivalent as statistically appropriate) in the analysis. Please either a>) re-run the data with this correction, or b.) acknowledge its absence as a further limitation. It should also be clarified that the estimated sample size and implied power analysis relate to measuring significance in the primary outcome of vicarious trauma only, not to the regression model (assuming this is the case; if not, please clarify).

13. The meaning of “than” is not clear in the sentence “When we report our results of multivariable ordinal logistic regression, we used the term ‘higher level vicarious trauma,’ which means extreme high than combined low, medium, and high; or combined ‘high and extreme high’ than combined low and medium; or combined ‘medium, high, and extreme high’ than low.” Instead of “than” do you mean “versus” (or an equivalent term such as “rather than” or “as opposed to”)?

14. By “orthodox religion” Do you mean the Christian Orthodox religion? Please clarify.

15. Regarding “The participants had a median (IQR) work experience of 8.0 (5.0, 12.0) years and a median annual income (IQR) of 8017 Ethiopian Birr (range: 7071.0–9056.0)” is this correct? I believe 7071.0–9056.0 Ethiopian Birr is equivalent to US$55.05-70.51, while the 2023 Gross Domestic Product per capita in Ethiopia was last recorded at US$890.35 US. Please confirm this is correct both in the foregoing sentence and also in Table 1.

16. Regarding “Table 2: Factors associated with vicarious trauma among healthcare providers in Tigray, Ethiopia, August to September, 2023” I suggest the authors consider making this Table 3, and adding a separate Table 2 in which data are presented on the prevalence of the different levels (low risk, moderate risk, high risk, and extreme high risk) of vicarious trauma in the sample as a whole. Alternatively, perhaps even better than a new Table 2 could be a new Figure 1 with this data represented graphically using a pie chart.

17. For the sentence “Another explanation could be that many medical experts and dangerous medical supplies needed for treatment and therapy have been forced to leave underfunded, damaged, and robbed healthcare institutions” please revise for clarity, eg: “Another explanation could be that underfunding of, damage to, and theft from healthcare institutions have led to critical shortages in medical experts and essential medical supplies needed for treatment.”

18. For the sentence, “The Tigray war, which was characterized by ethnic violence and the targeting of civilians, which medical professionals may see personally while tending to patients, this could be because the victims have experienced personal loss, have lost loved ones or families, or have been uprooted themselves” please revise for clarity, eg: “The Tigray war was characterized by ethnic violence and the targeting of civilians. Medical professionals who have experienced personal loss, have lost loved ones or families, or have been uprooted themselves may be re-traumatized when tending to patients who have also experienced such trauma.”

19. Please consider clarifying “This might mean healthcare providers working in these regions were exposed to more violence and trauma, heavy fighting during the war, shortages of medical supplies as a result of the war, may have lost colleagues, friends, or family members during the war, and may have met and provided care for people who had been injured by the crude troops of Eritrean and Amhara Milasha, like the of mass massacre in Tsion on November 29, 2020,” eg., “This might be because healthcare providers working in these regions were exposed to more violence and trauma, heavy fighting during the war, shortages of medical supplies as a result of the war, loss of colleagues, friends, or family members during the war, and/or may have met and provided care for people who had been injured by atrocities such as the of mass massacre in Tsion on November 29, 2020 by troops of Eritrean and Amhara Milasha.” Please also provide citation for this statement, eg: by human rights groups, journalists, etc.

20. Please clarify “This implication might indicate the life stage and responsibilities; this means care providers over 30 may have additional personal stressors like family obligations, more connectedness and responsibilities to nearby communities, financial concerns, or aging parents, making them less resilient to additional emotional burdens from work in addition to their traumatized clients or patients they met.” Eg., “This might be because of increasing life stage responsibilities and associated personal stressors among care providers over 30 such as family obligations, responsibilities to communities, financial obligations, or aging parents, making them less resilient to additional emotional burdens from work leading to increased risk of vicarious traumatization when caring for traumatized clients or patients.”

21. Regarding the sentence “It might also be because of their changes in coping mechanisms; this means that over time, coping strategies used earlier in a career may become less effective, and healthier coping mechanisms may not yet be developed, making individuals more vulnerable to the effects of vicarious trauma” it is not clear why coping would decrease with age.

22. Regarding the sentence “Limited personal time and reduced opportunities for self-care and emotional processing due to family commitments can exacerbate the impact of vicarious trauma” please either a.) provide a reference for this or b.) replace “can” with “might.”

23. Regarding “…but being hampered by the limited resources and seriousness of the war might lead to moral distress and feelings of helplessness, which can contribute to vicarious trauma.” Please either a.) provide a reference for this statement or b.) change “can contribute” to “might contribute.”

24. Please clarify “Additionally, it might be difficult to make decisions about resource allocation, staffing, and patient care under perilous circumstances. It might be exposed to a secret broader information about the healthcare system’s such as displaced staff, perilous medical supply, traumatized patients, and witnessing the overall impact of the war on healthcare delivery.” Eg., “Additionally, it might be difficult for managers to make decisions about resource allocation, staffing, and patient care under perilous circumstances, especially if they alone bear the burden of knowing traumatizing information about the healthcare system such as displaced staff, perilous medical supply, traumatized patients, and witnessing the overall impact of the war on healthcare delivery.”

25. Please clarify “This might be because of the nature of the war, which was totally besiege and siege.” Eg., “This might be because of the nature of the war, which involved working in areas under siege.”

26. Regarding the sentence “This would mean healthcare professionals see more critically ill patients to reach their facilities. and those whose conditions worsen due to a lack of timely treatment,” wouldn’t this traumatize all healthcare workers equally irrespective of their distance from work?

I again commend the authors for this important contribution to knowledge that can help respond to a pressing healthcare delivery service need. I thank them for their brave work, and wish them the best in their time of crisis.

Reviewer #5: This study is important in examining the vicarious trauma on the Tigray War.

Some concerns emerged.

Socio-demographic characteristics of study participants is better to be simple using Table 1.

The definition of the healthcare providers is better to be filled in the methods.

In the section of the factors Associated with Vicarious Trauma, on the aim of the analysis, what reason did the authors include the eight categories in the multivariable ordinal logistic regression mode? Are the explanations of the results is overlapping to the table 2 ?

**********

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Reviewer #1: Yes: Dr. Tesfay Gebregzabher Gebrehiwet

Reviewer #2: No

Reviewer #3: Yes: Beshir Mammiyo

Reviewer #4: No

Reviewer #5: No

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Submitted filename: Plos One review.docx

Dear Dr./Mr.  Hagos Degefa Hidru,

plosone@plos.org

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Guest Editor

PLOS ONE

Journal Requirements:

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):

Thank you for revising your paper with comments and suggestions. However, these areas need further editing.

Abstract

•The burden of war and its impact, especially on those with health providers, what is the need to do, especially for healthcare workers

•Interventions such as aftercare and addressing the vulnerable groups

•It would be better to add relevant recommendations on the conclusions based on the findings

Introduction

•It is good that you put references, but on lines 3-5, can you quantify in numbers the material or human damage?

•Paragraph 3; why health care professionals are at risk needs rephrasing and synthesis

•Rather than listing all studies to connect ideas and flow in paragraphs 3 and 4

•First discussing issues in western then Africa, rather than shifting back and forth.

•More details on the war in Ethiopia and its impacts, before going to the scarcity of data

Methodology

•You need to describe the reason why you used p 50 % inside the text, and the design effect 2; need justification; no justification in the revised version.

•Why did you use p p-value of 0.05 for bivariate logistic regression and put the justification as well.

•Sensitive topic, more clarification on ethical considerations

Result

•The footnotes a, b,c are confusing, as you only used p p-value of 0.05 as statistically significant in your methodology.

• Not including the type of traumatic limitations as well disclosed to health providers.

•The discussion needs to be improved as it does not compare or give appropriate citations for the explanation of the discussion points.

•It is good to add specific recommendations based on the findings.

•Thorough edition of grammar and spelling

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

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

Reviewer #1: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #1: Yes

Reviewer #4: Yes

Reviewer #5: 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 #1: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #1: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #1: Dear Academic Editor and authors

I am very glad to re-review the manuscript “War-related Vicarious Trauma among Healthcare providers in the War-Torn Tigray, Northern Ethiopia”

I re-reviewed the revised manuscript and it is well written except few typographic and editorial errors. The revised version of the manuscript showed much improvement. Since the evidence is highly needed for decision making and restoration of the human resource development, I suggest this revised manuscript to be accepted after the minor errors are corrected.

Minor comments that need to be considered are below:

Line 41: Authors need to edit word spacing.

Line 51-52: Method of the abstract section: Authors wrote: “Statistical significance was reported whenever the 95% confidence interval for odds ratio did not include one and the p-value was less than 0.05”. This statement contradicts with their finding on line 235-236 Table 2: Factors associated with vicarious trauma among healthcare providers in Tigray; for instance in table 2, the variable age in years “age group 20-29 is reference, then the vicarious trauma for the age groups 30-39, 40-49 and >50 showed results of AOR and CI 1.3 [1.1, 1.6], 1.5 [1.1, 2.0] and 2.3 [1.7, 3.0]. In this case the confidence intervals include 1 which contradicts to the statement reported by authors. Therefore, Authors need to reconsider their statement related to statistical significance based on the valid and scientific description.

Line 95 and 99: Authors need to edit word spacing.

Authors wrote sometimes VC in abbreviation and others in full words; please check Line 98, 100, 101, 104, 105, 110. Authors are advised to be consistent in writing the phrase.

Line 114: Authors need to state “health post” in plural form as “health posts”.

Line 199-200: Authors stated: 66.1%, of the 200 respondents were living with their parents. It is uncommon to start with numbers in the new line statement, so authors are advised to rewrite the statement: of the 200 respondents, two third/or 66.1% were living with their parents.

Line 328: Authors wrote “………………consequence of the Tigary war among healthcare professional”. The bolded word should be written in plural form. “professionals”

Reviewer #4: (No Response)

Reviewer #5: (No Response)

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Reviewer #1: Yes: Dr. Tesfay Gebregzabher Gebrehiwet

Reviewer #4: No

Reviewer #5: No

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Attachments

Attachment

Submitted filename: Re-review of Vicarious trauma manuscript PLOS One.docx

Dear Dr. Hidru,

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,

Selamawit Alemayehu Tessema

Guest Editor

PLOS ONE

Journal Requirements:

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #6: (No Response)

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

Reviewer #6: Yes

**********

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

Reviewer #6: Yes

**********

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

The PLOS Data policy

Reviewer #6: Yes

**********

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

Reviewer #6: No

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Reviewer #6: Thank you for writing this important article of vicarious trauma among Healthcare providers in the War-Torn Tigray, Northern Ethiopia. My comments are provided below:

1. Check grammar on line 72-75.

2. Typo word "involvement" in line 89

3. Typo word "similarly" in line 103

4. Line 157 - use it is instead of "it's" in formal writing

5. Methodology: there is no report of the validity value of the tool used

6. Typo word "prevalence" in line 236

7. Sometimes the word "moderate" is used (line 237), sometimes the word "medium" is used (Table 2): make sure the term used is consistent.

8. Typo "agencies" line 279

9. Improve grammar and comprehension in line 288-293.

10. Line 324-350 must have references to justify the claims

11. There is no consistency in the format of the references, font sizes across the texts

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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 #6: No

**********

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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

War-related Vicarious Trauma among Healthcare providers in the War-Torn Tigray, Northern Ethiopia

PONE-D-24-43464R3

Dear Dr. Hagos Degefa,

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,

Selamawit Alemayehu Tessema

Guest Editor

PLOS One

Additional Editor Comments (optional):

Authors have addressed all the suggestions made by reviewer.

The manuscript may benefit from  proof reading and make edits only.

Authors need to work on this issues before publication;

-editing this sentence in the abstract to be meaningful "Due to the lack of evidence regarding the level of vicarious trauma in this population"

-need to put citation on the lines 106-110

- need to support the last two paragraphs of the discussion with other literature in lines 337-363

Reviewers' comments: