Review Reports - Stakeholder Consensus on Strategies for Collaboration Between Traditional and Biomedical Mental Health Services in Post-Conflict Tigray, Ethiopia

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Firstly, I would like to congratulate the authors for addressing such an important issue that has a significant impact on the study population and is relevant to health policies.

The description of the context is good, and a qualitative tool such as the Nominal Group Technique has been used, but we cannot consider this to be qualitative research. For this, there must be a theoretical framework from which to evaluate the data and perspective, something that has not been found in this work. Likewise, to ensure its scientific rigour, the qualitative study should be complemented with other techniques and analyses (triangulation, external audit, several sessions). For NTG to be part of solid research, the session is not enough; validation, transparency and reflexivity in the process are necessary.

The topic is very interesting and the work has been done, so I encourage you to improve this research with other techniques and resources (interviews with affected groups, greater depth of analysis, external auditors) that can guarantee the scientific rigour of your work.

Kind regards,

Author Response

Reviewers Comments

The description of the context is good, and a qualitative tool such as the Nominal Group Technique has been used, but we cannot consider this to be qualitative research. The qualitative study should be complemented with other techniques.

Responses

Thank you for the suggestion. While we acknowledge the importance of complementing qualitative research with other techniques, we did not consider that qualitative research necessarily requires multiple instruments, triangulation, or primary data collection methods. Although qualitative and quantitative approaches may share some philosophical overlap, the distinction lies mainly in their purpose and analytic outcomes. We therefore used the Nominal Group Technique to build consensus among stakeholders and prioritise strategies.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript addresses a relevant and timely topic, particularly in relation to mental health service delivery in post-conflict settings and collaboration between traditional and biomedical systems. The study is of clear interest and aligns well with current public health and global mental health priorities. However, both the Introduction and especially the Results sections are overly long and, at times, difficult to follow. This is particularly noticeable given the relatively small size of the stakeholder group (n = 14) involved in the Nominal Group Technique workshop. The authors are therefore encouraged to streamline these sections, reducing descriptive redundancy and focusing more clearly on the key findings, in order to improve clarity and readability.

While the use of an adapted Nominal Group Technique is appropriate, an important limitation of the study is the absence of patients’ family members or caregivers among the participants. Families and caregivers often play a central role in mental health care pathways, particularly in low-resource and post-conflict settings, and their perspectives could have added relevant insights into the feasibility and acceptability of the proposed strategies. The authors are encouraged to acknowledge and justify this exclusion in the limitations section and briefly discuss its potential impact on the findings.

The manuscript suggests that the proposed strategies may be transferable to other post-conflict settings. Given the context-specific nature of the study and the limited number of participants, a more cautious wording regarding transferability would be appropriate. Clarifying that these findings require contextual adaptation would strengthen the Discussion

Author Response

Reviewers Comments

Some statements in the Introduction and the Results sections are overly long and, at times, difficult to follow. The authors are therefore encouraged to streamline these sections and reduce descriptive redundancy.

Responses

Thank you for pointing this out. We agree with this comment. Therefore, we have conducted the final review to improve the repetition and shorten long statements. It is highlighted using track changes in the revised manuscript.

Reviewers Comments

Families and caregivers often play a central role in mental health care pathways, particularly in low-resource and post-conflict settings.The authors are encouraged to acknowledge and justify this exclusion in the limitations section and briefly discuss its potential impact on the findings.

Responses

Additional descriptions have been mentioned and reviewed:

The exclusion of caregivers and people with lived experience was another limitation of this study. However, although people with lived experience of mental health problems were not directly involved in the NGT workshop, they participated in preceding studies whose preliminary findings informed the current NGT phase. In particular, people with lived experience who had sought care from both traditional and biomedical services took part in a previously published study [65]. Therefore, the proposed list of collaborative care strategies presented to stakeholders at the NGT workshop was partly derived from these participants' perspectives.

See Page 16 (Line 621 - 629)

Reviewers Comments

The limited number of participants needs to be described in the discussion section.

Responses

Thank you for this comment. The primary aim of the NGT was to achieve structured consensus and prioritisation among a specific and relevant group of stakeholder experts, rather than to produce findings that are statistically generalisable to a wider population. However, we acknowledge the limitation and stated below:

In line with typical Nominal Group Technique practice, a small number of experts were recruited purposively, which may have limited the diversity of perspectives represented in the findings. This was due to the study’s focus on expert consensus and prioritisation, the post-conflict setting, and practical constraints related to time and resources, including transport costs, as stakeholders were geographically dispersed and difficult to contact. This approach may therefore have limited the range of perspectives represented. The NGT was conducted in a single session, which was considered appropriate for the study objective and context.

See Page 15 to 16(line 612 – 618)

Reviewer 3 Report

Comments and Suggestions for Authors

This descriptive qualitative study used a Nominal Group Technique to develop a consensus and priority listing of strategies for collaboration between traditional and biomedical mental health services in post-conflict Tigray, Ethiopia. The report gives the reader insights into how successful collaborations may be promoted between traditional and biomedical mental health services in LMIC. The authors should consider the following:
1. What was the rationale for adopting the NGT approach to develop a consensus and prioritizing versus other approaches such as a Delphi Study?
2. A rationale was given for why Regulatory office delegates were excluded but what was the rationale for not including people with lived experience as participations?
3. Although the introduction mentioned the impact of ongoing conflicts in the region, the strategies for collaborative care do not appear to be targeting these impacts. Is there a requirement for more capacity building to deal with community members suffering with trauma-related disorders? Related to ongoing conflicts, are there safety issue barriers that will prevent joint collaborations?
4. The discussion should have indicated what are the next steps to be taken to implement the proposed strategies and how will these outcomes be evaluated going forward?

Comments on the Quality of English Language

A few minor edits may improve the readability.

Author Response

Reviewers Comments

What was the rationale for adopting the NGT approach to develop a consensus and prioritizing versus other approaches such as a Delphi Study?

Responses

We thank you for the suggestion to strengthen the rationale for selecting the NGT. We selected NGT because it was methodologically appropriate for the heterogeneous stakeholder groups of experts involved. including traditional healers, religious leaders, and biomedical mental health professionals, and it was contextually appropriate for a post-conflict, low-income setting. The detail is added in the manuscript highlighted using track changes as follows presented in red color:

The NGT is a structured, face-to-face consensus method for prioritising ideas within a feasible session. The method is important in fostering dialogue and understanding across stakeholders with differing cultural frameworks and professional backgrounds [44]. Because it is structured and all participants are provided the opportunity to air their idea(s), it helps mitigate the effects of power imbalances and dominant voices, and it is important to consider it when engaging stakeholders with differing levels of social and institutional authority[45]. Therefore, NGT was considered a reliable approach because it can be completed in a single face-to-face session, does not rely on online platforms, and reduces the risk of participant attrition in the disrupted communication context of post-conflict Tigray. As a qualitative methodology, NGT was useful in exploring different strategies and their levels of importance and feasibility through prioritisation.

See Methods- study design: Page 3 (line 116-127)

Reviewers Comments

A rationale was given for why Regulatory office delegates were excluded but what was the rationale for not including people with lived experience as participations?

Responses

See Page 16 (Line 621 - 629)

Reviewers Comments

The discussion should have more indicated what are the next steps to be taken to implement the proposed strategies and how will these outcomes be evaluated going forward?

Responses

Additional points of recommendations and implications are added under the conclusion section as follows:

Stakeholders underscore the importance of developing culturally responsive and contextually grounded strategies that can address the collaborative care gap. The NGT findings provide prioritised solutions to improve collaboration in resource-limited settings and to contribute to recovery in post-conflict settings. Moreover, our findings support these existing directions and policies, including the WHO Global Traditional Medicine Strategy 2014–2023, and the WHO Comprehensive Mental Health Action Plan 2013–2030, which recommend the integration of traditional healing into community-based interventions and primary health care. Therefore, the findings of this study indicate that mental health systems that operate exclusively within biomedical frameworks are unlikely to meet the pluralistic needs of the people in low-resource and conflict settings. In a post-conflict setting, the implementation of most activities should be integrated within existing post-conflict humanitarian coordination mechanisms involving international and local non-governmental organisations. These prioritised strategies implementation should begin with low-cost and high-feasibility actions, such as structured collaborative learning platforms, referral pathways, and clearly defined coordination mechanisms. These approaches can help build trust and shared understanding between practitioners. Concurrently, implementation of capacity-building activities, including joint training, resource sharing, and supportive supervision, can support the gradual development of collaborative intervention programs tailored to local mental health care needs. At the system level, engagement with policymakers, mental health leaders, religious authorities and professional associations is essential to ensure supportive regulatory frameworks and to recognise context-specific collaborative models.

See Page 16 (line 639-662)

Reviewer 4 Report

Comments and Suggestions for Authors

I am grateful for the opportunity to review the manuscript “Stakeholder consensus on strategies for collaboration between traditional and biomedical mental health services in post-conflict Tigray, Ethiopia”, submitted to the International Journal of Environmental Research and Public Health. I present my review, in which I evaluate the scientific quality, methodology, results, and relevance of the topic to the journal.

The manuscript makes an important contribution to the global mental health literature, particularly in post-conflict contexts. The adapted Nominal Group Technique methodology is well employed to elicit consensus among stakeholders, and the results are presented clearly, identifying five key strategies for collaboration between traditional and biomedical mental health services. The title is accurate, and the figures and tables are clear and well presented. However, some points in the manuscript require revision for methodological improvement.

1) The Introduction establishes the mental health problem in Tigray and the need for collaboration. However, it could be improved to provide a more robust contextualization of the state of the art of collaboration between traditional and biomedical medicine in mental health, especially in post-conflict contexts. I recommend expanding the approach to the challenges and opportunities of integrating mental health services in post-conflict contexts, citing examples and studies from other regions. This would help to position the research more solidly in the global scientific landscape and justify the chosen methodology.

2) The Methods section describes data collection and analysis, but the description of the adaptation of the NGT could be more detailed. I recommend detailing the “adaptation” of the NGT, explaining the specific modifications to the standard protocol and the rationale for these changes. In addition, clarify how the scores were aggregated and interpreted in each round of ranking (Tables 2, 3, and 4). For example, the description of the “Sum score Of the 1–5 Likert scale rating based on importance” (Table 2) could be better explained in the text.

3) The Discussion section summarizes the findings, but it is recommended to deepen the comparison and contrast with other studies (or the absence thereof). I recommend discussing, in each of the five prioritized strategies (collaborative learning, formalization of coordination, training, joint intervention programs, and regulatory support), how the findings align with or differ from previous research. If there are gaps in the literature, this should be highlighted as a contribution of the research.

4) The limitations section mentions the exclusion of families/caregivers and the regulatory office, as well as geographical limitations due to the conflict. I recommend further discussion on how these limitations may have impacted the results and the implications for the generalization of the findings.

5) I recommend adding a paragraph that articulates how the results can be translated into concrete actions, in addition to reinforcing directions for future research.

6) Conduct a final review to improve the fluidity and accuracy of the academic language. Also, check the formatting of the citations, which are in parentheses and should be in square brackets.

Author Response

Reviewers Comments

I recommend expanding the introduction by citing examples and studies from other regions on challenges and opportunities of integrating mental health services in post-conflict contexts

Responses

A preceding paper of a research project was published separately on the changes and opportunities of the collaborative care , which was presented its preliminary findings in the NGT workshop and it is stated under the NGT process page 4 and cited as [50].
The detailed NGT process was described as follows:
Introduction: A Summary of the suggested strategies was presented, focusing on traditional healing effectiveness [17], the need and influencing factors of collaborative care[50], and suggested strategies for collaborative care between traditional and biomedical services [51] based on preliminary findings of the published papers from a research project.

See Page 4 - line 169

Reviewers Comments

Clarify how the scores were aggregated and interpreted in each round of ranking (Tables 2, 3, and 4). For example, the description of the “Sum score Of the 1–5 Likert scale rating based on importance” (Table 2) could be better explained in the text.

Responses

Regarding the scoring of the NGT rounds, an additional statement has been added:
For each round of the Nominal Group Technique, the total score for each strategy was calculated by summing the 1–5 Likert-scale ratings provided by all participants, where 1 indicated very low importance or feasibility and 5 indicated very high importance or feasibility. In Rounds 1 and 2, strategies were rated based on importance, while in Round 3 they were rated based on feasibility.

See Page 7 (line 275 -279)

Reviewers Comments

It is recommended to deepen the discussion comparison and contrast with other studies. If there are gaps in the literature, this should be highlighted as a contribution of the research.

Responses

Yes, there is a gap in the literature, which is highlighted in the Introduction and the Discussion. We have also added an additional paragraph to the discussion as follows:
International guidance has long emphasised the importance of developing context-specific collaborative approaches to support progress towards universal health coverage, including the appropriate integration of traditional healing practices within formal health systems [12]. The strategies identified in this study are aligned with these recommendations by addressing key domains such as policy and regulation, education and training, research, and service delivery [5, 12]. In addition, the findings support broader global initiatives aimed at strengthening the integration of mental health into primary care in low-income settings [57]. The effective implementation of collaborative mental health services requires formalised coordination, alongside regular supervision, and structured discussions. Therefore, to ensure the sustainability of collaborative care, coordination needs to begin at the regional level and be decentralised to district areas, as suggested in this NGT study. Through better coordination, collaborative care can be strengthened and better aligned with the cultural preferences approach of service users [8, 58].

See Page 14 to 15 (line 554 -566)

Reviewers Comments

The limitations section mentions the exclusion of families/caregivers and the regulatory office, as well as geographical limitations due to the conflict. I recommend further discussion on how these limitations may have impacted the results and the implications for the generalization of the findings.

Responses

People with lived experience of mental health problems and caregivers were not directly included in the NGT workshop because this phase of the study was designed to elicit expert opinion and prioritise strategies for collaboration between traditional and biomedical mental health services. However, more description is added to the revised manuscript:
The exclusion of caregivers and people with lived experience was another limitation of this study. However, although people with lived experience of mental health problems were not directly involved in the NGT workshop, they participated in preceding studies whose preliminary findings informed the current NGT phase. In particular, people with lived experience who had sought care from both traditional and biomedical services took part in a previously published study [65]. Therefore, the proposed list of collaborative care strategies presented to stakeholders at the NGT workshop was partly derived from these participants' perspectives.

See Page 16 (Line 621 - 629)

Reviewers Comments

I recommend adding a paragraph that articulates how the results can be translated into concrete actions, in addition to reinforcing directions for future research.

Responses

Additional points of recommendations and implications are added under the conclusion section as follows:
Stakeholders underscore the importance of developing culturally responsive and contextually grounded strategies that can address the collaborative care gap. The NGT findings provide prioritised solutions to improve collaboration in resource-limited settings and to contribute to recovery in post-conflict settings. Moreover, our findings support these existing directions and policies, including the WHO Global Traditional Medicine Strategy 2014–2023, and the WHO Comprehensive Mental Health Action Plan 2013–2030, which recommend the integration of traditional healing into community-based interventions and primary health care. Therefore, the findings of this study indicate that mental health systems that operate exclusively within biomedical frameworks are unlikely to meet the pluralistic needs of the people in low-resource and conflict settings. In a post-conflict setting, the implementation of most activities should be integrated within existing post-conflict humanitarian coordination mechanisms involving international and local non-governmental organisations. These prioritised strategies implementation should begin with low-cost and high-feasibility actions, such as structured collaborative learning platforms, referral pathways, and clearly defined coordination mechanisms. These approaches can help build trust and shared understanding between practitioners. Concurrently, implementation of capacity-building activities, including joint training, resource sharing, and supportive supervision, can support the gradual development of collaborative intervention programs tailored to local mental health care needs. At the system level, engagement with policymakers, mental health leaders, religious authorities and professional associations is essential to ensure supportive regulatory frameworks and to recognise context-specific collaborative models.

See Page 16 (line 639-662)

Reviewers Comments

Conduct a final review to improve the fluidity and accuracy of the academic language. Also, check the formatting of the citations, which are in parentheses and should be in square brackets.

Responses

Thank you for pointing this out. We agree with this comment. Therefore, we have conducted the final review to improve the academic language, and it is highlighted using track changes in the revised manuscript. Also, the formatting of the citations has changed from parentheses to square brackets.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Once again, as when I first reviewed this document, I would like to congratulate the authors on proposing such an interesting topic. Although some points have been improved in the revised version sent to me by the authors, I still find several shortcomings that should be reviewed again before publication.

Overall, the theoretical framework underpinning this qualitative research is still lacking.

152–205. They should report how they dealt with ties and whether the vote was anonymous. They should also explain what the categories of analysis were and whether coding was used. They should also state how it was done and whether triangulation was used. They should state the content analysis approach and quality procedures (e.g. double coding, consensus, memos and member checking where appropriate).

When they refer to 'the preliminary findings of the published papers of a research project', they do not provide a bibliography to support this information.

178–192. It would be useful to include a list of the strategies on which their work is based, either in the text or as an appendix. The research process lacks the clarity and detail required to understand and replicate the research.

I see that you have included the researcher's position and reflexivity prior to the study, which was lacking in the first version. However, it would be good to add one or two specific examples of how reflexivity was managed in facilitation and coding, and what impact this had, or whether it helped to mitigate.

Several important points have been included in the discussion, which enriches the text. However, the text would benefit from a more orderly reorganisation and rewording: key findings; comparison with evidence; implications (CFIR/RE-AIM/WHO); limitations; future agenda.

It is appropriate to comment on the limitation of the study in not including all those involved, such as carers and patients themselves. It would be beneficial to address potential biases (e.g. anchoring, power, language), justify the exclusion of regulators or users, and propose Delphi or regional NGTs for external validation. Expand 'Limitations' and 'Validation plan'.

The conclusions are more in line with the study than in the other version. However, some of them, such as the involvement of local policies and religious orders, do not seem to me to be conclusions that can be drawn from the present work. They should be formulated in a more specific way with a simpler, clearer narrative.

In general, I would like to make the following recommendations:

- Use the same terminology for the same concepts, such as 'holy water sites', 'traditional healers' and 'biomedical rehabilitation centres'.

- Review the numbering of tables and figures. Avoid using 'below'; use 'in Table X/Figure Y' instead.

Correct any grammatical or spelling errors (e.g. participants, prioritisation/prioritization, emerged, to rate).

- Provide supplementary materials (e.g. operational definitions, a Likert sheet, a script, a codebook, a translation protocol and a table showing the rounds with W).

We sincerely appreciate the team's efforts on this highly relevant study for the integration of mental health in low-resource and post-conflict settings. With the above improvements, I am confident that the manuscript will be a valuable resource for decision-makers and clinical-community teams.

Author Response

We, the authors, greatly appreciate the reviewers’ second-round feedback. Our point-by-point responses are provided in the cover letter attachment.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

I appreciate the opportunity to reevaluate the revised version of the manuscript “Stakeholder consensus on strategies for collaboration between traditional and biomedical mental health services in post-conflict Tigray, Ethiopia.” After reviewing the original document and the authors’ responses to the recommendations from the previous review, I believe that the authors have satisfactorily addressed the main suggestions presented, demonstrating their commitment to improving the manuscript.

Regarding the clarification on the aggregation and interpretation of scores in the ranking rounds (Tables 2, 3, and 4), the authors provided a clear and technical explanation in the revised text, detailing how the scores were added based on the Likert scale from 1 to 5, and distinguishing between criteria of importance (rounds 1 and 2) and feasibility (round 3). This addition improves methodological transparency, making the process reproducible and accessible to scientific readers, which is essential for qualitative-quantitative studies such as this one. The change demonstrates pragmatic attention to technical details, aligning with best practices in public health research.

The recommendation to deepen the discussion, comparing and contrasting with other studies and highlighting gaps in the literature, has been convincingly addressed. The authors added a paragraph in the discussion section that aligns the findings with international guidelines, such as the WHO Global Strategy on Traditional Medicine (2014-2023) and the WHO Comprehensive Mental Health Action Plan (2013-2030), emphasizing the need for context-specific approaches. They also highlight gaps, such as the scarcity of evidence on collaborative strategies in low-income and post-conflict settings, positioning the study as an original contribution. This argumentative approach reinforces the strategic value of the work, inspiring future research and practical applications.

Regarding limitations, the authors satisfactorily addressed the exclusion of families/caregivers, the regulatory office, and geographical restrictions resulting from the conflict. They explained that although people with lived experience did not directly participate in the NGT workshop, their insights were indirectly incorporated through published preliminary studies [65]. This clarification mitigates concerns about selection bias, discussing implications for the generalization of findings, such as the need for validation in similar contexts. The response is accessible and evidence-based, demonstrating critical reflection on the ethical and methodological challenges in conflict settings.

The addition of a paragraph on translating results into concrete actions, in addition to reinforcing directions for future research, was a pragmatic and inspiring improvement. The authors suggest low-cost and highly feasible actions, such as collaborative learning platforms, referral pathways, and coordination mechanisms, in addition to engaging key actors such as policymakers and religious authorities. This transforms the study into an actionable guide, aligning with global initiatives and encouraging sustainable implementation in resource-limited settings.

The final revision to improve the fluidity and accuracy of academic language, as well as the correction of parenthetical citation formatting to square brackets, was performed as requested. These changes elevate the editorial quality of the manuscript, making it more cohesive and professional.

However, there is room for additional refinements that could further strengthen the study's scientific contribution.

The authors responded appropriately to the recommendation to expand the introduction with citations of examples and studies from other regions on the challenges and opportunities of integrating mental health services in post-conflict contexts. They incorporated references to their own preliminary study [50] and described the Nominal Group Technique (NGT) process, including preliminary findings from previous publications. Although this enriches the local context, the response could be more robust by including explicit citations from comparable international studies, such as those conducted in post-conflict regions in sub-Saharan Africa or Asia, to illustrate global patterns. This gap does not compromise the validity of the work, but it limits its ability to engage more broadly with the existing literature and may reduce the argumentative impact of the introductory section.

Author Response

We, the authors, greatly appreciate the reviewers’ second-round feedback. Our point-by-point responses are provided in the cover letter attachment.

Author Response File: Author Response.pdf