Growing Forward: Exploring Post-Traumatic Growth and Trait Resilience Following the COVID-19 Pandemic in England
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsI would like to thank you for the opportunity to review the manuscript entitled "Growing Forward: Exploring post-traumatic growth and trait resilience following the COVID-19 pandemic in England". It is very impactful and it can improve our knowledge of this issue. Despite its scientific relevance, the manuscript has several flaws which cannot overcome with major revisions.
First of all, an abstract is a sort of businness card of the manuscript, summarized the most relevant aspects of the study. It must be easy to read and understandable. For a reader who read the abstract for the first time, it could be confusing: there is not a clear explanation about research it has been reported parameters of PTG without a clear explanation of these. Moreover, the main statistically significant results are lacking, as well as conclusion. Whilst the introduction is fine and can be improved including some epidemiological aspects, the materials and methods require a deeper revision (study design, questionnaires, covariates, outcomes). The statistical analysis section is lacking (both descriptive and inferential statistical analysis) and some analysis should be considered (e.g. factor analysis). The calculation of sample size is lacking. In the results section, the description of the sample is lacking. Before performing any tests, it is necessary to understand wheter variable values has a normal distribution in order to choose the most suitable. Therefore, all the analyses must be revised. The discussion section must be improved making comparisons with the current literature. Biases are not faced at all.
I would like to wish the Authors can revise their manuscript better and submit it afterwards because the manuscript cannot be published in this way.
Author Response
We thank Reviewer 1 for their time and points of feedback regarding our study. These have been addressed below.
Point 1: “First of all, an abstract is a sort of businness card of the manuscript, summarized the most relevant aspects of the study. It must be easy to read and understandable. For a reader who read the abstract for the first time, it could be confusing: there is not a clear explanation about research it has been reported parameters of PTG without a clear explanation of these.”
Response: We thank Reviewer 1 for this feedback. The parameters of PTG have been added to the abstract to improve clarity.
Point 2: “The main statistically significant results are lacking, as well as conclusion. Whilst the introduction is fine and can be improved including some epidemiological aspects, the materials and methods require a deeper revision (study design, questionnaires, covariates, outcomes).”
Response: The methodology has been reviewed to ensure that all key information is in fact provided, much of this information is also reiterated in the results section to clearly explain the variables used in each analysis and how they relate to the specific study aims. We outline the study design (cross sectional survey design) and explain the questionnaires in detail. Covariate and outcome variables can be discerned from a review of the materials, but these are explicitly highlighted within the results section as well.
Point 3: “The statistical analysis section is lacking (both descriptive and inferential statistical analysis) and some analysis should be considered (e.g. factor analysis). The calculation of sample size is lacking.”
Response: We are unsure what analyses the reviewer is referring to as lacking, as all descriptive data and inferential tests pertaining to each aim are presented in the results section. Some of the inferential and descriptive work is presented in tables to allow for a coherent narrative within the text. Factor analysis was not used in the present study because it did not relate to any of the study’s aims (we were not looking to validate a scale or identify a patter of dispositional constructs).
We have now included both power calculations and alternative sample size frameworks in our methodology.
Point 4: “In the results section, the description of the sample is lacking.”
Response: We thank Reviewer 1 for bringing this to our attention. We have inputted an additional table (Table 1) containing all demographic data collected within this study to bring clarity.
Point 5: “Before performing any tests, it is necessary to understand whether variable values has a normal distribution in order to choose the most suitable. Therefore, all the analyses must be revised.”
Response: Preliminary normality assessments were carried out but not reported for conciseness. We apologise for this omission and have now included information that details the normal distribution of the PTG variables to justify parametric testing (please note that we use inspections of Kurtosis and Skewness indices as they are favoured within large data analyses [i.e., over 100 respondents]). Additionally, the assumption requirements for regression analyses were already presented.
Point 6: “The discussion section must be improved making comparisons with the current literature”.
Response: We thank Reviewer 1 for this feedback. The discussion section has been significantly revised and additional supporting literature has been added.
Point 7: “Biases are not faced at all.”
Response: We thank Reviewer 1 for this feedback. In response we have added addition acknowledge of potential biases within this research to the limitations section. Our address of potential biases includes brief reflection on the potential perceived bias of our ‘oppositional’ stance regarding the current conduction of PTG literature. We acknowledge our ideas are novel/contrary to the norm but believe our critiques are rooted in leading theoretical literature and that change is positive. Our specific ideas for reform hold unique value and our discussion of the invalidity and poor reliability of much of current PTG researcher is supported by very recent research written by leading authors within the field – (Infurna et al., 2024).
Infurna, F.J.; Jayawickreme, E.; Woods-Jaeger, B.; Zalta, A.K. Understanding adaptive responses to adversity: Introduction to the special issue on rethinking resilience and posttraumatic growth. American Psychologist 2024, 79, 989.
Reviewer 2 Report
Comments and Suggestions for AuthorsI thoroughly enjoyed reading the manuscript and here are some key suggestions to improve the quality of the paper.
Introduction:
1. Clear Research Gaps: The introduction lacks clarity on gaps in PTG-COVID-19 research. Highlight specific gaps and add in more studies if no studies then mention it, such as the long-term effects or overlooked populations like healthcare workers.
2. Unsubstantiated PTG Claims: The introduction suggests PTG follows trauma but doesn’t explain inconsistencies in studies, particularly during the pandemic. A more detailed literature review could clarify why outcomes differed and address study design flaws, sample sizes, or timing.
3. Inconsistent Focus on Resilience: The discussion on resilience is not well-integrated into the broader PTG theme. Strengthen this section by explaining the role of resilience in PTG outcomes during COVID-19, using relevant studies for support.
4. Better explanation of what is "Higher levels" of trauma: The hypotheses are vague, particularly in defining trauma levels. Refine them to be more measurable and specific, using clear criteria for “higher levels” of trauma and PTG.
5. Timing of Research: The critique of early pandemic studies isn’t adequately justified. Explain why post-pandemic research is more suitable for measuring PTG, emphasizing long-term psychological effects.
6. Control Variables: There’s no mention of potential control variables, such as socioeconomic status or mental health history, that could influence PTG and resilience. Address these confounders and explain how the study will control for them.
7. Simplified View of Trauma and PTG: The introduction oversimplifies the trauma-to-growth relationship. Discuss psychological and social factors—such as coping mechanisms or cultural differences—that could influence PTG outcomes.
Materials and Methods:
The sample is skewed towards females (70.7%), with limited representation from other genders, which may affect the generalizability of the findings. Please add in the limitations. Additionally, the measurement of trauma is based on self-reports without clear criteria, which may lead to inconsistent reporting. The study lacks consideration of control variables, such as pre-existing mental health conditions, which could influence resilience and PTG. While the psychometric properties of most measures are strong, the "Spiritual Change" domain of the PTGI has a relatively low internal consistency (α = .71), needing further validation.
Results:
Firstly, while the presentation of traumatic event percentages is clear, there is a lack of context regarding their impact on mental health and well-being. For example, frequent events like "Loss of control over life" and "Social isolation" are presented without commentary on their implications. A brief analysis following the descriptive statistics would help explain which experiences were most impactful and what they suggest about pandemic stressors. The comparison of post-traumatic growth (PTG) scores between pre- and post-pandemic samples also lacks interpretation. For instance, why participants reported lower "Relating to Others" scores but higher scores for "New Possibilities" and "Personal Strength" is not explained. Discussing possible reasons, such as the impact of social distancing on relationships and the potential for personal growth through adversity, would improve the paper. The regression models present predictors and coefficients but offer little discussion on the implications. For example, younger age predicting higher PTG is mentioned without elaboration. Explaining why younger people may experience more growth—perhaps due to greater adaptability during the pandemic—would add valuable context. Similarly, the "Spiritual Change" model, which explains only 12.9% of the variance (R² = .129), suggests a weak model fit, but this limitation is not acknowledged. Lastly, some predictors, like "Fear" in the "New Possibilities" model, are statistically significant but only briefly mentioned. Expanding on why predictors like fear might contribute to growth, especially since fear is generally seen as a negative emotion.
Discussion:
The connection between fear and PTG is mentioned but lacks thorough explanation; elaborating on how fear may drive positive coping mechanisms in the context of the pandemic is necessary.
Comments on the Quality of English Language
There are also issues with language precision, such as repetitive phrasing like "that that participants," in line 218 which could be revised for clarity.
Author Response
We thank Reviewer 2 for their time reviewing our study and their useful points of feedback. These have been addressed below.
Point 1: “Clear Research Gaps: The introduction lacks clarity on gaps in PTG-COVID-19 research. Highlight specific gaps and add in more studies if no studies then mention it, such as the long-term effects or overlooked populations like healthcare workers”.
Response: We thank Reviewer 3 for this feedback.
We acknowledge Reviewer 2’s suggestions regarding adding more research papers referencing both the long-term effects of PTG and populations such as healthcare workers. After careful consideration, we have chosen not to include further information regarding healthcare workers within our introduction as these samples have been subject to wide research (Li et al., 2024) so on this occasion we feel this does not present our study with any additional research gap. Furthermore, as our study aimed to explore PTG in a general population sample rather than specifically healthcare workers, we do not feel addressing potential research gaps regarding healthcare workers within our introduction would correspond validly with our research aims. Too, we have chosen not to discuss debates regarding the potential longevity of PTG or associated outcomes due to our utilisation of a cross-sectional design. We acknowledge that we compared the data of our study with a previous PTG study however this was with the intention of comparing a study which met the parameters of PTG regarding the COVID-19 pandemic with one which did not rather than considering longevity. This purpose has now been explicitly stated within the research.
Despite this, we recognise the useful feedback of Reviewer 2 regarding the clarity of our intended research aims. Therefore, the phrasing of the introduction section 1.2 has been edited to make the intended research gap targeted clearer and additional supportive research has been added to support these. A new introduction section (1.3) has been added regarding PTG and fear which too aims to make the targeted research gaps clearer.
Point 2: “Unsubstantiated PTG Claims: The introduction suggests PTG follows trauma but doesn’t explain inconsistencies in studies, particularly during the pandemic. A more detailed literature review could clarify why outcomes differed and address study design flaws, sample sizes, or timing.”
Response: We thank Reviewer 3 for this feedback. It is the stance of the authors that inconsistencies within PTG/COVID-19 pandemic studies are largely the result of, or indistinguishable from the result of, the failure of such studies to meet the parameters of PTG, causing invalid, unreliable and inconsistent results as such studies cannot be measuring PTG per definition. This theoretical invalidity surpasses the impact of individual study design and sample limitations and therefore we have chosen not to discuss these within our introduction, particularly as they would not be addressed elsewhere within the paper. However, we acknowledge the need for our stance to be clearer within our introduction and have edited this to make the intended point of address as parameter limitations (including poor timing of studies) clearer. We also acknowledge more recent attitudes questioning the requirement for trauma specifically to elicit PTG as well as differing definitions of trauma within modern literature. Therefore, language has been edited within the introduction to include the modern stance that it is an event of seismic intensity, and not necessarily a ‘trauma’, which is required to elicit PTG. Additional citations have been added to support this.
Point 3: “Inconsistent Focus on Resilience: The discussion on resilience is not well-integrated into the broader PTG theme. Strengthen this section by explaining the role of resilience in PTG outcomes during COVID-19, using relevant studies for support.”
Response: We thank Reviewer 2 for bringing this to our attention. Additional discussion and citations have been added to the discussion regarding resilience.
Point 4: “Better explanation of what is "Higher levels" of trauma: The hypotheses are vague, particularly in defining trauma levels. Refine them to be more measurable and specific, using clear criteria for “higher levels” of trauma and PTG.”
Response: We thank Reviewer 2 for bringing this to our attention. Reference to ‘higher levels of trauma’ has been removed from the paper. Hypothesis 1 has been reworded for clarity and specificity of measurement.
Point 5: “Timing of Research: The critique of early pandemic studies isn’t adequately justified. Explain why post-pandemic research is more suitable for measuring PTG, emphasizing long-term psychological effects.”
Response: We thank Reviewer 2 for this feedback. Our rationale is based upon the highly influential work of Tedeschi et al. (2018), whereby it is explicitly stated that PTG can only take place post trauma. In this way, when measuring the impact of the pandemic as an overall event as within this study (as opposed to researching specific events within the pandemic), post-pandemic (ie post trauma) research is the only option for measuring PTG. Edits have been made regarding the language used within the introduction to make our research rationale and aims clearer.
Tedeschi, R. G.; Shakespeare-Finch, J.; Taku, K. Posttraumatic growth: Theory, research, and applications, 1st ed.; Routledge: New York, USA, 2018.
Point 6: “Control Variables: There’s no mention of potential control variables, such as socioeconomic status or mental health history, that could influence PTG and resilience. Address these confounders and explain how the study will control for them.”
Response: We thank Reviewer 2 for bringing this to our attention. The omission of current mental health disorders as a potential confounding variable has been added to the limitations section. Socioeconomic status is not evidenced to have a significant impact upon PTG in relation to the COVID-19 pandemic (ie Willey et al., 2022) and is not a well-researched area regarding trait resilience. The latter therefore may be an important area of differing further research. We do acknowledge socioeconomic status may be important demographic information. Due to this, further demographic information which was collected has been inputted as an additional table (see Table 1) to ensure a more accurate understanding of our sample.
Willey, B.; Mimmack, K.; Gagliardi, G.; Dossett, M.L.; Wang, S.; Udeogu, O.J.; ...Vannini, P. Racial and socioeconomic status differences in stress, posttraumatic growth, and mental health in an older adult cohort during the COVID-19 pandemic. EClinicalMedicine 2022, 45, 101343.
Point 7: “Simplified View of Trauma and PTG: The introduction oversimplifies the trauma-to-growth relationship. Discuss psychological and social factors—such as coping mechanisms or cultural differences—that could influence PTG outcomes.”
Response: We thank Reviewer 2 for this feedback. As researchers we acknowledge there are a plethora of confounding factors which can influence the trauma-PTG relationship, perhaps more than it is possible for us to explore or control for within our study.
We acknowledge that cultural differences can have a significant impact upon the understanding and manifestation of PTG (Tedeschi et al., 2018). Our study utilised a Western sample, similar to many other PTG/COVID-19 pandemic studies currently available, supporting comparability between studies to some degree.
As our individual sample was majorly white (78.3%) and all participants were living in England at the time of study (this was a condition of participation to ensure participants experienced the COVID-19 pandemic in England) we do not believe cultural differences between participants had a significant influence upon our findings on this occasion. We do however recognise the potential generalisability limitations of the ethnicity demographic of the sample and have added this to the limitations section.
In terms of coping styles, we acknowledge that differing coping styles can have an impact on PTG. However, as we did not collect any data to measure specific coping styles or data that may imply specific coping styles utilised by our sample, we cannot discuss how these may have impacted our results beyond speculation. We have added acknowledgement of the potential impact of coping styles upon our results within our discussion of PTG and age differences.
We do acknowledge coping styles may be an interesting area for future research, as few studies have looked specifically at coping styles during the pandemic and PTG and thank Reviewer 2 for this idea.
Point 8: “The sample is skewed towards females (70.7%), with limited representation from other genders, which may affect the generalizability of the findings. Please add in the limitations. Additionally, the measurement of trauma is based on self-reports without clear criteria, which may lead to inconsistent reporting. The study lacks consideration of control variables, such as pre-existing mental health conditions, which could influence resilience and PTG.”
Response: We thank Reviewer 2 for bring these points to our attention. The gender-based skew has been added to the limitations section.
We acknowledge that our Likert scale used to assess trauma was not a validated measure of trauma assessment. The limitations of this have been re-emphasised within the limitations section. Participants were provided with a definition of trauma relating to the destruction of previously held personal assumptions (which corresponds to the definition of trauma utilised by Tedeschi and Calhoun 1995, 1996 etc) alongside our trauma rating scale however we acknowledge we did not make this clear in the previous version of this manuscript. The nature of this definition as well as the citation presented on the digital questionnaire provided to participants (Janoff-Bulman, 2010) has been added to the measures section.
There appears to be very limited research investigating the impact of mental health conditions on trait resilience (as opposed to resilience on the development of mental health conditions). We consider this is likely as trait resilience is considered an innate personality trait rather than a developed phenomenon. We acknowledge this may be an interesting area of potential future research but have chosen not to include it within our study due to the lack of research supporting this as a confounding factor at present.
Point 9: “While the psychometric properties of most measures are strong, the "Spiritual Change" domain of the PTGI has a relatively low internal consistency (α = .71), needing further validation.”
Response: Whilst the reliability value for Spiritual Change was relatively lower than the values for the other constructs, both the research team and previous scholars argue that a score of .7 or greater is in fact an acceptable score. For instance, George & Mallery (2003) argued that an alpha score of .7 to .8 was acceptable, Nunnally & Bernstein (1994) state that a value of .7 or greater is generally acceptable, as does DeVellis (2012). Therefore, we believe that the reliability of all scales were good and not in need of further inspection.
George, D., & Mallery, P. (2003). SPSS for Windows Step by Step: A Simple Guide and Reference (4th ed.). Allyn & Bacon.
Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric Theory (3rd ed.). McGraw-Hill.
DeVellis, R. F. (2012). Scale Development: Theory and Applications (3rd ed.). SAGE Publications.
Point 10: “Firstly, while the presentation of traumatic event percentages is clear, there is a lack of context regarding their impact on mental health and well-being. For example, frequent events like "Loss of control over life" and "Social isolation" are presented without commentary on their implications.”
AND
Point 11: “A brief analysis following the descriptive statistics would help explain which experiences were most impactful and what they suggest about pandemic stressors.”
Response: We thank Reviewer 2 for this feedback. We have edited the PTG/COVID-19 section of the introduction to make the intended purpose of the traumatic event list (an exploratory measure for indicative us for points of future research) clear. The impact of the reported traumatic events upon mental health and wellbeing is an interesting proposition and may be an area for important future research. However, as PTG and trait resilience are both constructs separate to both mental health and wellbeing (Lenzo et al., 2023; Leys et al., 2018) we have decided not to include this commentary within our revisions to maintain focus and validity within our conclusions. Discussion of how individual stressors may have influenced relevant results can be found within the discussion.
Point 12: “The comparison of post-traumatic growth (PTG) scores between pre- and post-pandemic samples also lacks interpretation. For instance, why participants reported lower "Relating to Others" scores but higher scores for "New Possibilities" and "Personal Strength" is not explained. Discussing possible reasons, such as the impact of social distancing on relationships and the potential for personal growth through adversity, would improve the paper.”
Response: We thank Reviewer 2 for this feedback. Whilst we acknowledge that discussing each domain individually may be of interest, we are also aware that discussing all results within the discussion would constitute great length. To keep our discussion succinct, we have chosen to instead discuss a selection of our most surprising/interesting results and therefore have chosen not to include this information. This may be a useful suggestion for future research focussing specifically upon intra and post pandemic PTG comparison and we thank Reviewer 2 for this suggestion. We have also edited language within the measures and discussion to improve clarity regarding the purpose of the intra and post pandemic comparison which supports why we have not discussed all differences demonstrated within domain data.
Point 13: “The regression models present predictors and coefficients but offer little discussion on the implications. For example, younger age predicting higher PTG is mentioned without elaboration. Explaining why younger people may experience more growth—perhaps due to greater adaptability during the pandemic—would add valuable context.”
Response: We thank Reviewer 2 for this feedback. Further discussion regarding the age differences found within our results have been added to the discussion.
Point 14: “Similarly, the "Spiritual Change" model, which explains only 12.9% of the variance (R² = .129), suggests a weak model fit, but this limitation is not acknowledged”.
Response: The authors do not feel that this is a limitation, rather an indication that age, trauma, resilience, stress and fear are not strongly associated with spiritual change. However, the weak model fit is now acknowledged in the results section and within the discussion.
Point 15: “Lastly, some predictors, like "Fear" in the "New Possibilities" model, are statistically significant but only briefly mentioned. Expanding on why predictors like fear might contribute to growth, especially since fear is generally seen as a negative emotion. The connection between fear and PTG is mentioned but lacks thorough explanation; elaborating on how fear may drive positive coping mechanisms in the context of the pandemic is necessary”.
Response: We thank Reviewer 2 for bringing our inconsistent consideration of fear to our attention. We have made significant revisions within the paper to address this. A dedicated section discussing COVID-19 related fear and PTG has been added to the introduction, a specific hypothesis relating to fear has been added to hypotheses section and a dedicated section discussing our resulting regarding pandemic related fear and PTG has been added to the discussion.
Point 16: “There are also issues with language precision, such as repetitive phrasing like "that that participants," in line 218 which could be revised for clarity.”
Response: We thank Reviewer 2 for bringing this to our attention. This typing error has been rectified.
Reviewer 3 Report
Comments and Suggestions for AuthorsThe topic of this manuscript is very important, and it contains relevant information about the post-traumatic growth and trait resilience following the COVID-19 pandemic in England. This is a very well written manuscript. Introduction, method, results, and discussion are well described with enough and wide information. Overall, the critical evaluation of the research within sections is very strong. The section of “Discussion” is excellent and described in detail. It includes a lot of greatly well interpreted information. The Conclusions states the problem and the purpose of review clearly.
I have some minor suggestions for the authors to improve this article.
· There is no need for a dot after the title of the subsections.
· -P.3, line142-145: ”Initially, 230 responses were collected, however, one participant was removed due to 142 failing to respond to the questions correctly leaving a usable sample of 229 respondents (Mean age = 31.79, Std Dev = 14.03), of which 162 were female (70.7%), 57 were male (25%) 144 and 10 (4.3%) identified as other (e.g., transgender and non-binary).” There are many more female participants than male. It may be necessary to include the data for women and men separately in separate tables (table 1, 2, 3).
· The bibliography is not uniform. In my opinion, it is not necessary to indicate the doi number. Correct the references.
Author Response
We thank Reviewer 3 for their time, their positive words regarding our study and their useful points of feedback. These have been addressed below.
Point 1: “There is no need for a dot after the title of the subsections”.
Response: We thank Reviewer 3 for bringing this to our attention; these have been removed.
Point 2: “P.3, line142-145: ”Initially, 230 responses were collected, however, one participant was removed due to 142 failing to respond to the questions correctly leaving a usable sample of 229 respondents (Mean age = 31.79, Std Dev = 14.03), of which 162 were female (70.7%), 57 were male (25%) 144 and 10 (4.3%) identified as other (e.g., transgender and non-binary).” There are many more female participants than male. It may be necessary to include the data for women and men separately in separate tables (table 1, 2, 3).”
Response: We value this suggestion, however after careful consideration, we have decided not to separate our results by gender as the focus of the current paper is not on gender differences in PTG. The skewed gender difference, although common within PTG literature (ie Chiang-Hanisko et al., 2024; Deitz et al., 2024; Demir et al., 2024), limits the generalisability of the findings and this is acknowledged in our limitations section now. We believe that the gender proportions of our sample are likely partially reflective of the greater female tendency to complete self-report studies online. We do however acknowledge that a female skew may impact the generalisability of our results and this comment has been added to the limitation section.
Chiang-Hanisko, L., Force, E., & Liehr, P. (2024). COVID-19 Pandemic and Posttraumatic Growth in Residents of a Continuing Care Retirement Community: A Mixed Methods Study. Journal of Gerontological Nursing, 50(6), 25-33.
Deitz, A. H. (2024). Self-compassion, childhood emotional neglect, and posttraumatic growth: Parental well-being during COVID-19. Journal of Affective Disorders, 350, 504-512.
Demir, Z. G. Y., Duru, H. A., & Yılmaz, M. Determination of Post-Traumatic Growth and Psychological Resilience Levels of Nurses Caring for Patients with COVID-19. Kırşehir Ahi Evran Üniversitesi Sağlık Bilimleri Dergisi, 8(1), 1-23.
Point 3: “The bibliography is not uniform. In my opinion, it is not necessary to indicate the doi number. Correct the references”.
Response: We thank Reviewer 3 for bringing this to our attention; these have been removed.
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsI congratulate the Authors for their efforts in improving their manuscript. I would like to add some comments:
- please, check all spaces and punctuation signs;
- all citations in the text have to be inserted before the first punctuation sign. Moreover, check the citation style, which has to be ;
- being an abstract like a business card, define better what lacks in the current literature (it is already written, but it has to be improved). Moreover, add the most statistically significant results;
- please, revise the materials and methods following this scheme: study design, study setting, study population, study period, tools for extracting data or creating the questionnaire, variables of this study, outcomes, and covariates. Moreover, add the minimum sample size and all the tests which was used for obtain the results.
- please, shift Table 1 in the results section and the related results description because they are the descriptive statistics;
- please, check the statistical analyses section and the results because all the tests and the related measures (for example, odds ratio) in the results section have to be mentioned in the statistical analyses section before;
- please, make comparisons between the findings and the current literature;
- please, add the common biases for study like this.
The quality of English is fine, but it requires minor editing for some synonyms.
Author Response
please see attachment
Author Response File: 
Author Response.pdf
Round 3
Reviewer 1 Report
Comments and Suggestions for AuthorsI would like to thank the Authors for addressing my comments. As regards synonyms, they are only little details in order to improve the manuscript, but it is fine.
