-->PONE-D-25-47479-->-->A systematic review and meta-analysis on the epidemiology of work-related musculoskeletal disorders among nurses in Ethiopia-->-->PLOS One

Dear Dr. Demeke,

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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Sohel Ahmed, MPT, MDMR

Academic Editor

PLOS One

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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

Reviewer #3: Partly

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

Reviewer #1: I Don't Know

Reviewer #2: N/A

Reviewer #3: Yes

**********

-->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: No

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: 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: Reviewer comment and suggestions

Title and Abstract

Strengths

• The objective is clear: estimating pooled prevalence and associated factors of WMSDs among nurses in Ethiopia.

• Key results (prevalence, associated factors) are concisely summarized.

Limitations

• The abstract may be overly long; it reads more like a truncated full manuscript than a standard abstract.

• Key elements like registration of the review (e.g., PROSPERO number) are missing.

• No statement about the certainty of evidence or grading (e.g., GRADE approach).

Introduction

Strengths

• Identifies a clear knowledge gap: lack of compiled meta-analytic evidence on WMSDs in Ethiopian nurses.

• Provides justification due to high vulnerability of nurses.

Limitations

• Insufficient context: Does not explain global WMSD prevalence or compare Ethiopia to other regions.

• Does not explicitly state a theoretical framework guiding which factors were expected to be associated.

Methods

Strengths

• Multiple reputable databases searched (PubMed, ScienceDirect, HINARI, Google Scholar).

• Inclusion of published and unpublished studies reduces publication bias.

• Use of standard analytical elements: random-effects model, heterogeneity assessment (I²), funnel plot, Egger’s test, trim-and-fill, sensitivity analysis.

Limitations and Concerns

a. No PRISMA Compliance Mentioned

The description should explicitly state adherence to PRISMA 2020 guidelines, including a flow diagram.

b. Search Strategy Not Fully Described

Missing:

o Search string(s)

o Language restrictions

o Search date ranges (only end date given)

o Screening process (number of reviewers, resolution of disagreements)

Without these details, replication is difficult.

c. Study Quality Assessment Not Reported

• No mention of quality or bias assessment tools (e.g., Newcastle–Ottawa Scale).

• The robustness of included studies cannot be evaluated.

d. Lack of Data Extracted Variables

The description does not specify:

o How WMSD was defined across studies

o Whether data extraction was done independently by two reviewers

o Adjusted vs. crude effect sizes

e. No Handling of Variation Between Studies

• WMSD definitions, measurement tools, and anatomical regions may differ widely.

• No subgroup analyses (e.g., by region, measurement tool, year of study), which could help explain heterogeneity.

Results

Strengths

• Provides pooled sample size and number of included studies.

• Reports pooled prevalence with confidence intervals.

• Identifies significant associated factors with pooled odds ratios.

Limitations

a. High Heterogeneity Likely

• Although I² is mentioned, its value is not reported.

• Prevalence studies typically show high heterogeneity; without subgroup/exploratory analyses, results may be unreliable.

b. No Visuals Reported

• Forest plot, funnel plot, trim-and-fill output, and PRISMA flow diagram are essential but not mentioned or described.

c. Limited Examination of Associated Factors

• Only four factors identified; unclear if others were tested (e.g., BMI, working hours, shift work, patient-handling practices).

d. No Sensitivity Analysis Results Reported

• Stated as conducted but results not summarized.

Discussion

Strengths

• Conclusion aligns with findings.

• Suggests practical implications (e.g., focus on reducing stress and standing time).

Limitations

• Does not compare pooled estimates with global or African data.

• Does not address:

o Potential reverse causation (cross-sectional designs dominate this field).

o Measurement bias (self-reported outcomes).

o Differences in workplace ergonomics across studies.

Conclusion

Strengths

• Acknowledges high prevalence and identifies actionable factors.

Limitations

• Recommendations are generic and lack specificity (e.g., ergonomic programs, workload redesign, staffing ratio improvement).

• Does not address research implications, such as the need for longitudinal or intervention studies.

Overall Strengths of the Study

• Addresses an important occupational health issue.

• Uses meta-analysis to synthesize evidence valuable for policymaking.

• Includes multiple databases and unpublished studies.

• Demonstrates methodological awareness (heterogeneity, publication bias).

Overall Limitations and Areas for Improvement

Methodological Limitations

• Insufficient reporting on search strategy and risk-of-bias assessment.

• Unclear adherence to PRISMA guidelines.

• No subgroup or meta-regression analyses.

• Unclear handling of inconsistent definitions of WMSD.

• High heterogeneity likely undermines pooled prevalence reliability.

Analytical Limitations

• Effect estimates may be confounded due to lack of adjusted ORs.

• No weighting or discussion of study quality.

Interpretation Limitations

• Overgeneralizes findings without accounting for workplace variability across Ethiopia.

Summary

The study provides useful pooled estimates of WMSDs among nurses in Ethiopia, showing a high prevalence (61.47%) and identifying significant associated factors. However, methodological weaknesses especially incomplete reporting of search strategy, lack of study quality assessment, unclear heterogeneity handling, and limited discussion of contextual factors reduce confidence in the pooled estimates. Strengthening transparency, performing subgroup analyses, and adhering strictly to PRISMA standards would significantly improve the study’s rigor and credibility.

Reviewer #2: For the authors:

• Although a PROSPERO registration number is provided, the manuscript does not clearly describe whether the review was conducted strictly according to the registered protocol. Pls. clarify deviations from the registered protocol and explicitly state adherence to the PROSPERO plan.

• The authors report searching multiple databases; however, the manuscript lacks: Full electronic search strategies, Search strings for each database, Justification for the use of Google Scholar and screening limits

pls. provide complete search strategies (preferably as supplementary material) to ensure reproducibility, as required by PRISMA 2020.

• While observational studies were included, the methodology does not sufficiently describe: the specific quality appraisal tool used and How risk of bias influenced interpretation of pooled results. Pls. clarify the tool used and discuss how study quality may have affected the meta-analysis findings.

• Substantial heterogeneity is expected in prevalence meta-analyses; however, the manuscript does not adequately explore potential sources of heterogeneity beyond reporting I². pls. consider additional subgroup or meta-regression analyses (e.g., by region, study setting, or assessment tool) or explicitly justify their absence.

• The manuscript reports pooled odds ratios for associated factors; however, the language occasionally implies causality. Pls. revise interpretations to clearly reflect associations, acknowledging the limitations of cross-sectional observational data.

• The discussion could better contextualize findings within: Broader Sub-Saharan African data and differences in working conditions across regions of Ethiopia. Pls expand the discussion on contextual and structural factors affecting WMSDs among nurses in low-income settings.

• Language and grammar require minor revision throughout the manuscript.

• Ensure consistent use of terms (e.g., WMSD vs. WMSDs).

• Tables and figures should be checked for consistency in formatting and labeling.

• Confidence interval formatting should be standardized.

• The PRISMA flow diagram should strictly follow PRISMA 2020 terminology.

Revise the abstract to:

• Briefly mention the quality appraisal method

• Rephrase novelty claims

• Ensure associations are not interpreted causally

Introduction

• Strengthen the rationale for a country-specific meta-analysis.

• Explicitly distinguish how this review adds to existing global or African reviews.

Methods

• Explicitly report any deviations from the registered protocol.

• Provide full search strings for each database as supplementary material.

• Clearly state language and date restrictions.

• Describe how Google Scholar results were screened and limited.

• Clarify how WMSDs were operationally defined and handled across studies.

• Explore sources of heterogeneity where possible.

• Clearly justify pooling of odds ratios from observational studies.

Results

• Revise figures and tables for clarity and PRISMA compliance.

Discussion

• Emphasize observational nature and avoid causal language.

• Expand limitations section.

• Discuss implications within healthcare system constraints.

• Expand and deepen the limitations section.

• Align conclusions more closely with the observational evidence.

• PRISMA checklist should be submitted.

• Data availability statement should clarify extracted data access.

Reviewer #3: The background section provides a comprehensive and well-structured overview of work-related musculoskeletal disorders (WMSDs), clearly defining the concept and presenting its various synonymous terms. However, the background could be further strengthened by improving clarity and conciseness, as some sections contain repetitive information regarding prevalence and risk factors. In addition, although the authors state that no prior meta-analyses have been conducted on WMSDs among nurses in Ethiopia, this claim would benefit from a more explicit justification or citation to reinforce its validity. The final paragraph could more explicitly articulate how this study will advance existing knowledge, particularly in terms of informing policy, ergonomic interventions.

The methods section is clearly structured and transparent, registration of the study protocol in PROSPERO enhances the credibility and methodological rigor of the research, while adherence to the PRISMA 2020 guidelines further supports the study’s transparency and reproducibility. The methods would benefit from a more explicit presentation of complete search strings and whether reference list screening or manual searching was performed, which would strengthen reproducibility. The application of the PECOs framework for eligibility criteria is appropriate. However, the exclusion of gray literature beyond unpublished studies (e.g., theses or institutional reports) is not fully clarified, which may introduce publication bias. The use of the Joanna Briggs Institute (JBI) critical appraisal checklist for quality assessment is appropriate for observational studies. However, the critique notes that classifying all studies as low risk of bias may warrant further justification, as observational studies commonly exhibit at least moderate risk in certain domains.

The statistical analysis section demonstrates a strong methodological foundation and appropriate use of advanced meta-analytic techniques. The use of STATA version 17 and application of a random-effects meta-analysis model (DerSimonian and Laird method) are appropriate.

The results section is clearly organized, logically sequenced, and consistent with PRISMA reporting standards. However, there appears to be a numerical inconsistency in the reporting of excluded studies (the number excluded at the title/abstract stage exceeds the number remaining after duplicate removal), which should be clarified to avoid confusion and ensure internal consistency. The characteristics of the included studies are presented comprehensively, with clear reporting of geographic distribution, study design, sample size, measurement tools, and prevalence estimates. However, notable variation in measurement tools (NMQ, DMQ, SSQ, VAS) introduces methodological heterogeneity that could affect prevalence estimates and should be more explicitly acknowledged as a limitation.

The analysis of associated factors is a valuable addition to the study and enhances its practical relevance. The identification of sex, job stress, prolonged standing, and work experience as significant predictors aligns with existing occupational health literature. However, several concerns should be noted. First, the high heterogeneity observed in some pooled associations (e.g., prolonged standing and sleep disturbance) raises concerns about the reliability of these estimates. Pooling results with I² values exceeding 75% should be interpreted cautiously, and subgroup or sensitivity analyses specific to these variables would strengthen the findings. Second, the use of adjusted odds ratios pooled across studies with different covariate adjustments may compromise internal validity. Differences in confounding control across studies are not adequately addressed and may bias the pooled estimates.

The discussion section demonstrates a clear understanding of the study findings and effectively situates the results within the context of existing international and regional literature.

The comparative analysis with findings from other countries and global systematic reviews is a major strength. However, the discussion would benefit from a deeper exploration of contextual factors, such as healthcare infrastructure, staffing ratios, ergonomic practices, and resource availability, which may explain observed differences in prevalence across countries.

The association between job stress and WMSDs is well-articulated and supported by international evidence. The authors provide a coherent explanation linking psychological stress to musculoskeletal symptoms through fatigue and pain perception mechanisms. However, the discussion would benefit from acknowledging the high heterogeneity observed in this association and cautioning readers about overgeneralization.

Similarly, the interpretation of work experience as a risk factor is logical and consistent with existing studies. However, the discussion could further differentiate whether increased risk is due to cumulative exposure, aging, or prolonged exposure to poor ergonomic conditions, which are not mutually exclusive explanations.

The strengths and limitations section is appropriately positioned and clearly articulated. However, the limitations section, while accurate, could be more comprehensive. The reliance on cross-sectional studies is appropriately acknowledged, as it limits causal inference. Additional limitations that warrant discussion include:

1- Reliance on self-reported measures, which may introduce recall and reporting bias.

2- Variability in measurement tools used across studies, potentially affecting prevalence comparability.

3- Presence of publication bias, which, although addressed statistically, may still influence pooled estimates.

4- Limited representation from certain Ethiopian regions, which may affect national generalizability.

The conclusions are concise, relevant, and directly aligned with the study objectives. However, the conclusion section appears incomplete, ending abruptly before fully summarizing all identified associated factors. Additionally, the conclusions could be strengthened by offering specific recommendations, such as ergonomic training, workplace redesign, and policy-level interventions tailored to the nursing workforce. Also, the conclusions would benefit from a brief mention of future research directions, such as the need for longitudinal studies, interventional trials, or qualitative research.

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Reviewer #1: Yes:  REHEMA ABDALLAH

Reviewer #2: No

Reviewer #3: Yes:  Dr. Lareen Magdi El-Sayed Abo-Seif

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-->PONE-D-25-47479R1-->-->A systematic review and meta-analysis on the epidemiology of work-related musculoskeletal disorders among nurses in Ethiopia-->-->PLOS One

Dear Dr.  Demeke,

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 May 09 2026 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:-->

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• 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Sohel Ahmed, BPT, MPT, MDMR

Academic Editor

PLOS One

Journal Requirements:

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2. 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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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

Reviewer #3: All comments have been addressed

**********

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #2: Yes

Reviewer #3: Yes

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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: The authors have made substantial and sincere efforts to address the reviewers’ comments. The revised manuscript demonstrates marked improvement in transparency, methodological reporting, and discussion depth. Many of the major concerns raised in the initial review particularly those related to PRISMA adherence, search strategy reporting, subgroup analyses, and contextual discussion—have now been addressed.

However, several important issues remain, mainly related to interpretation of heterogeneity, pooling of adjusted odds ratios, and internal consistency. These issues do not invalidate the study but should be addressed before final acceptance.

Major Comments

1. PRISMA Compliance and Reporting Transparency — Largely Resolved

✔ The authors now explicitly state adherence to PRISMA 2020, provide a flow diagram, and submit a PRISMA checklist.

✔ Search dates, databases, and inclusion criteria are clearer.

✔ Supplementary materials now include detailed search strategies.

Remaining issue:

• Although PRISMA compliance is stated, the manuscript would benefit from a brief explicit statement confirming that all PRISMA 2020 items were met, with reference to the submitted checklist.

Recommendation: Minor clarification only.

2. Search Strategy and Reproducibility — Mostly Resolved

✔ Full electronic search strategies are provided as supplementary material.

✔ Language and date restrictions are now explicitly stated.

✔ Justification for Google Scholar use is included.

Remaining issue:

• The authors explicitly state that reference list screening and manual searching were not performed. While acceptable, this should be acknowledged as a limitation, as it may affect completeness.

Recommendation: Add one sentence in the limitations section.

3. Study Quality Assessment and Risk of Bias — Partially Resolved

✔ Use of the JBI critical appraisal checklist is appropriate and clearly described.

✔ Independent assessment by multiple reviewers is reported.

Concern remains:

• All included studies are classified as “low risk of bias,” which is unusual for cross-sectional observational studies.

• The justification provided is brief and may not fully convince readers.

Recommendation:

• Temper the language to acknowledge that “low risk” reflects methodological adequacy within JBI criteria, but residual bias typical of cross-sectional designs cannot be excluded.

4. Heterogeneity and Subgroup Analyses — Improved but Interpretation Needs Caution

✔ Subgroup analyses by region, year, sample size, body areas, and measurement tool have been added and strengthen the analysis.

✔ Sensitivity analyses are reported.

Critical issue:

• Some pooled associations (e.g., prolonged standing, sleep disturbance) show very high heterogeneity (I² > 85–90%), yet are still presented as significant findings.

Recommendation:

• Interpret these pooled estimates more cautiously and explicitly state that high heterogeneity limits confidence in these specific associations.

• Avoid emphasizing these findings in the conclusion.

5. Pooling of Adjusted Odds Ratios — Still a Methodological Weakness

The manuscript pools adjusted odds ratios from studies with different covariate sets, which may compromise internal validity.

Although the authors now acknowledge this issue, the limitation remains methodologically important.

Recommendation:

• Explicitly state that pooled AORs should be interpreted as approximate summaries, not precise effect estimates.

• Consider adding a brief justification for why meta-regression was not feasible (e.g., limited number of studies per factor).

6. Language Suggesting Causality — Mostly Resolved

✔ The authors have revised much of the language to reflect associations rather than causation.

✔ The observational nature of the evidence is now acknowledged.

Minor remaining issue:

• A few phrases in the Discussion and Conclusion still imply risk reduction or prevention effects.

Recommendation: Final language polishing to ensure consistent non-causal framing.

Minor Comments

1. Internal consistency:

o Double-check numerical consistency between the PRISMA flow diagram and the Results text (earlier inconsistencies were corrected, but a final check is advised).

2. Terminology:

o Consistent use of WMSDs is improved; continue to ensure uniform usage across figures and tables.

3. Tables:

o Table 2 would benefit from a footnote reminding readers that pooled AORs are derived from heterogeneous adjustment models.

Reviewer #3: Regarding the introduction, strong epidemiological justification, clear research gap, comprehensive risk factor coverage, and strong contextual relevance. If possible, reduce the Redundancy.

Protocol registration, PRISMA adherence, rigorous statistical methods, dual-review processes are major strengths. Kindly, describe the methods for pooling adjusted odds ratios (e.g., log transformation, heterogeneity handling, model selection).

**********

-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #2: No

Reviewer #3: Yes:  Dr. Lareen Magdi El-Sayed Abo-Seif

**********

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-->PONE-D-25-47479R2-->-->A systematic review and meta-analysis on the epidemiology of work-related musculoskeletal disorders among nurses in Ethiopia-->-->PLOS One

Dear Dr.  Demeke,

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 Jun 02 2026 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 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'.

-->

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Reviewer #2: All comments have been addressed

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Overall assessment

The paper addresses an important occupational health issue and has several strengths: protocol registration, PRISMA-based reporting, multiple database searching, duplicate screening/quality appraisal, subgroup analysis, publication-bias assessment, and sensitivity analysis. The study also provides a useful pooled estimate for WMSDs among nurses in Ethiopia.

That said, the manuscript still has problems in four main areas:

• English language and grammar

• Overstatement of findings in some places

• Methodological inconsistency in interpretation of pooled adjusted odds ratios

• Need for tighter scientific writing, especially in Abstract, Discussion, and Conclusion

Major issues

1. Language needs substantial polishing

The manuscript still contains many grammatical and style problems that reduce readability and credibility.

Examples:

“no comprehensive meta-analysis have been done” should be “has been done.”

“Joana Brigg Institute” should be “Joanna Briggs Institute.”

“≥ 5 year of work experience of” is grammatically incorrect.

“The protocol … has been registered … codeCRD420251136383.We didn’t make an amendment…” is awkward and not journal-ready.

“two researchers independently evaluate” should be past tense.

This is not just cosmetic. The paper needs a full professional English edit.

2. The conclusion still overreaches

The paper repeatedly acknowledges that pooled AORs are only approximate summaries because studies adjusted for different covariates, and that some associations had high heterogeneity.

However, the conclusion still moves too far toward intervention language:

“Reducing job stress and prolonged standing…” in the abstract conclusion

“it may be important to improve staffing ratios…” in the final conclusion

For a review based entirely on observational studies, the wording should stay with:

“were associated with”

“may warrant attention”

“should be interpreted cautiously”

“may inform occupational health planning”

Not with implied preventive effect unless clearly framed as a recommendation rather than evidence of effect.

3. High-heterogeneity associations are still emphasized too strongly

The manuscript appropriately notes high heterogeneity for job stress and especially prolonged standing.

But these factors are still emphasized in the abstract and conclusion almost as if they were robust effect estimates. That is too strong, especially for:

Prolonged standing: I² = 91.4%

Job stress: I² = 70.8%

These should remain in the results, but in the abstract and conclusion the authors should make clear that these associations were observed with substantial between-study variability.

4. The Discussion needs more scientific restraint Some explanatory statements are too assertive or simplistic.

For example, the sex explanation relies heavily on biological reasoning and muscle mass/testosterone differences.

That is possible, but it reads as overly deterministic. The discussion should also acknowledge:

• role differences and task allocation

• domestic workload

• ergonomics

• reporting differences

• workplace context

A more balanced interpretation would be stronger scientifically.

5. Some claims in the Introduction are overstated or awkwardly phrased

Examples:

• “This variability and scarcity of clear epidemiological understanding deterred the design of diagnostic criteria, the establishment of specialized services, and recruitment in intervention trials.”

This feels exaggerated and probably unsupported.

• “This study is a reliable, evidence-based basis…” should be rewritten more modestly.

The introduction should be tighter and more evidence-led.

Methodological concerns

6) Pooling adjusted odds ratios remains a limitation The authors now acknowledge that PAORs are approximate because covariates differed across studies. That is good.

Still, the manuscript should be even clearer that:

• pooled adjusted effects across heterogeneous models are not equivalent to pooled effects from harmonized adjustment sets

• this reduces comparability and internal validity

• these results are exploratory summaries, not precise quantitative causal estimates

This caution should appear not only in Methods and Table 2 footnote, but also briefly in the Abstract or Conclusion.

7) Some factor interpretations are statistically awkward For work experience:

• PAOR = 1.58 (1.08–2.31), I² = 38.6%, P = 0.196

This appears to mix the heterogeneity p-value with inferential interpretation. The result is statistically significant based on the confidence interval excluding 1, but the narrative should avoid confusing readers by presenting the heterogeneity p-value next to the effect without clarification.

Also, in Table 2 and surrounding text, formatting and presentation should be standardized to avoid ambiguity.

Internal consistency and reporting

8) Scope of outcome needs clearer wording

The paper is framed as WMSDs among nurses, but several included studies appear focused on single body regions, especially low back pain or ankle-foot pain.

The authors partly address this by subgrouping according to number of body areas assessed.

Still, they should state more explicitly that the pooled estimate combines studies with different anatomical scopes, which may affect comparability.

9. Reference and citation quality should be rechecked A few citations look weak or mismatched:

Reference 30 is a study among bank workers in Ethiopia, yet it is cited for work-related musculoskeletal disorder definition/associated factors in places where a more direct occupational health or nursing source would be stronger.

Some supporting statements in the discussion would benefit from more directly relevant sources and less generic explanation.

Minor issues

10)) Title and abstract wording

The title is acceptable, but the abstract needs line editing for grammar and flow.

For example:

• “Result” should be “Results”

• “its associated factors” should be “associated factors”

• avoid recommendation-style language in the conclusion

11. Tables need cleanup

Table 1 and Table 2 are useful, but formatting is rough and should be standardized for journal submission.

Examples:

• inconsistent spacing

• awkward variable labels

• inconsistent capitalization

• some row labels are not reader-friendly

12. Strengths and limitations

section should be rewritten The section is useful, but the language is weak and repetitive.

For instance:

• “intensifies transparency” is not natural scientific English

• “negate WMSDs” in the conclusion is incorrect usage

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Reviewer #2: Yes:  Dr. Ali Daifallah abousoliman

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Attachment

Submitted filename: New Microsoft Word Document (5).docx

A systematic review and meta-analysis on the epidemiology of work-related musculoskeletal disorders among nurses in Ethiopia

PONE-D-25-47479R3

Dear Dr. Abel Desalegn,

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,

Sohel Ahmed, BPT, MPT, MDMR

Academic Editor

PLOS One

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