Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

First, I believe this article has merit, though there are some issues with typos, spacing, acronyms, and consistency of terms and language, etc. that hopefully a copy editor can support with. There are also many long sentences and paragraphs throughout the manuscript that should be revised.

 

Second, there is a lot of assuming on the part of the authors of existing knowledge among their readers. Suggest defining terms and methodologies more clearly.

 

Third, regarding the methods section, it is unclear why both a CPAR and phenomenological approach were needed. There is no clear justification of why each and both were needed for this study.

o   Additionally, it is unclear why the authors chose an RPA approach. RPA appears to be targeted for very short-term research projects, whereas the authors appear to have had more time to collect data. Thus, some justification is needed to rationalize why this was an appropriate methodology. The description of RPA could also be clearer.

 

o   In reading the background information of the study team (pg. 7) it does not appear that any actual IDP community members were part of the research team, which essentially means that this was perhaps not actually a CPAR or RPA project. Additionally, it states in the description of RPA that external experts were brought in, which again is not traditional for CPAR or RPA, as the point of both is to directly involve study participants as research team members and put them in the driver’s seat of the study. The authors should reflect on this and clarify and/or justify.

 

Fourth, the section detailing the background information of the study team (pg. 7) should be in a separate sub-section titled “Positionality” and should also include information and identity-markers related to race, gender, IDP status, language, etc. and address how these factors may have influenced or biased data collection and analysis/interpretation, and how they may have contributed to power hierarchies between the research team and study participants. This will be especially important if the authors want to continue to claim that they successfully executed a CPAR and RPA approach.  

 

Fifth, the title for section 2.1 is not appropriate as it is not related to the content provided, which essentially just gives an overview of the location of data collection. Rather informed consent is discussed in the following section and the ethics statement and there is no discussion about screening processes.

 

Sixth, the results section is quite thin, with most of the data reflecting experiences of women and girls and their families, rather than a whole community experience. This article may benefit from readjusting the literature review/theoretical framework section to focus on gendered experiences of displacement and trauma, and specifically the experiences of women and girls.

 

Seventh, the evidence provided in the results section does not justify everything brought up in the discussion section as there are many new terms and concepts brought up in the discussion section that are not mentioned previously in the article, such as “talk-based” vs. “action-based” interventions and preferences of private communication among Ethiopians.

 

Eighth, there is a general disconnect between the literature review/theoretical framework, results, and discussion. The discussion section reads as if the authors already knew what they were going to propose irrespective of the evidence they collected, as the evidence they provide does not speak to everything that is proposed in the discussion section and the framework.

 

Lastly, the “so what” is missing from the article. Culturally responsive and trauma-informed mental health practices are common practice with displaced and non-displaced communities. Therefore, what are the authors contributing to further the knowledge base on this topic? Are culturally responsive and trauma-informed practices not the norm in Ethiopia? And who is the framework aimed at, mental health practitioners in Ethiopia specifically or more broadly? If  more broadly, then are they advocating for this framework to be generalizable and replicated elsewhere?

Author Response

We sincerely appreciate the reviewer’s valuable time and insightful comments, which have significantly strengthened our manuscript. We have carefully revised the manuscript to address the reviewers’ concerns, as outlined below. Once again, thank you for your thorough evaluation of our work.

While we have submitted the clean copy through the portal, we have also attached a version with tracked changes highlighted in different colors to facilitate the review process.

Comment 1: I believe this article has merit, though there are some issues with typos, spacing, acronyms, and consistency of terms and language, etc., that hopefully a copy editor can support. There are also many long sentences and paragraphs throughout the manuscript that should be revised.

Response 1: Thank you for the insightful comments that strengthened our manuscript. We have thoroughly reviewed the manuscript to address typographical errors, formatting inconsistencies, and language clarity. Acronyms and terms have been defined upon first use, and lengthy sentences and paragraphs have been revised for readability.

Comment 2: Second, there is a lot of assuming on the part of the authors of existing knowledge among their readers. Suggest defining terms and methodologies more clearly.

Response 2:  Thanks for this thoughtful comment. Key terms such as "trauma-informed care," "community-based participatory action research (CBPAR)," and "rapid participatory appraisal (RPA)" have been clearly defined in the revised Introduction and Methods. We have also added explanations of how these methodologies align with the goals of this study. Page 2,4

Comment 3: Third, regarding the methods section, it is unclear why both a CPAR and phenomenological approach were needed. There is no clear justification of why each and both were needed for this study.

a)Additionally, it is unclear why the authors chose an RPA approach. The RPA appears to be targeted for very short-term research projects, whereas the authors appear to have had more time to collect data. Thus, some justification is needed to rationalize why this was an appropriate methodology. The description of RPA could also be clearer.

Response 3 (a): We provided additional justification for employing both CPAR and a phenomenological approach. This combined approach captures both subjective lived experiences and collective input when co-constructing culturally responsive interventions. We acknowledge the longer timeline of this study and have clarified that the RPA was adapted for ongoing feedback and iterative input across multiple phases rather than short-term data collection. This rationale is explained in the revised "Methods" section. Page 4 (Line 186-191)

Comment 3.b)In reading the background information of the study team (pg. 7) it does not appear that any actual IDP community members were part of the research team, which essentially means that this was perhaps not actually a CPAR or RPA project.

Response 3 (b): We now clarify that although IDP community members did not formally join the research team, their input actively shaped each phase of the study, which aligns with the participatory research principles. We have added a subsection highlighting the community’s role and how they guided the research process. Please see Pages 7 &8

Comment 3.c) Additionally, it states in the description of RPA that external experts were brought in, which again is not traditional for CPAR or RPA, as the point of both is to directly involve study participants as research team members and put them in the driver’s seat of the study. The authors should reflect on this and clarify and/or justify.

Response 3(c): We have revised the statement to refer to external experts and clarify the collaboration between the research team and community in co-creating the data. Community leaders and IDP representatives play a primary role in guiding the process. Page 7&8

Comment 4: Fourth, the section detailing the background information of the study team (pg. 7) should be in a separate sub-section titled “Positionality” and should also include information and identity-markers related to race, gender, IDP status, language, etc. and address how these factors may have influenced or biased data collection and analysis/interpretation, and how they may have contributed to power hierarchies between the research team and study participants. This will be especially important if the authors want to continue to claim that they successfully executed a CPAR and RPA approach.  

Response 4:  We appreciate the insightful comment here. A separate subsection titled ‘Positionality and community engagement’ (pg. 7) has been included in the Methods section to detail the demographics of the research team, including race, gender, language proficiency, and prior relationships. This section also discusses potential biases and how power dynamics were addressed (e.g., co-identified research priorities and validated key themes through co-facilitated workshops and town hall meetings). Page 8

Comment 5: Fifth, the title for section 2.1 is not appropriate as it is not related to the content provided, which essentially just gives an overview of the location of data collection. Rather informed consent is discussed in the following section and the ethics statement and there is no discussion about screening processes.

Response 5: The section title has been changed to ‘Study Location and Community Overview’ to reflect the content better.  Page 4. We have also added a revision to the participant screening process, including criteria for participation and informed consent procedures. Page 5 

Comment 6: Sixth, the results section is quite thin, with most of the data reflecting experiences of women and girls and their families, rather than a whole community experience. This article may benefit from readjusting the literature review/theoretical framework section to focus on gendered experiences of displacement and trauma, and specifically the experiences of women and girls.

Response 6: We agree with the reviewer’s observation that the data primarily reflect the experiences of women and girls due to their heightened vulnerability in the IDP center. The literature review and theoretical framework were adjusted to foreground the gendered dimensions of trauma and displacement. This ensures the discussion aligns with the gendered experiences highlighted in the results. See pages 2 and 3 in the introduction section, the revisions in the discussion on pages 12 and 13, and the conclusion section on page 17.

Comment 7: Seventh, the evidence provided in the results section does not justify everything brought up in the discussion section as there are many new terms and concepts brought up in the discussion section that are not mentioned previously in the article, such as “talk-based” vs. “action-based” interventions and preferences of private communication among Ethiopians.

Response 7:  We revised the Discussion section to ensure all the concepts introduced were grounded in the results. Additionally, terms such as “talk-based” versus “action-based” interventions and “private communication preferences” private communication preferences’ have been introduced earlier in the results to ensure alignment. Please see the discussion section revised paragraph on Pages 13, 14, &16

Comment 8: Eighth, there is a general disconnect between the literature review/theoretical framework, results, and discussion. The discussion section reads as if the authors already knew what they were going to propose, irrespective of the evidence they collected, as the evidence they provide does not speak to everything that is proposed in the discussion section and the framework.

Response 8: We revisited the Discussion section to ensure that it reflected the findings and did not introduce unsupported claims. For example, existing studies on communal healing have framed Ethiopian coffee ceremonies and religious gatherings. The discussion now explicitly references the themes presented in the results section, ensuring a clear connection between the data and the discussion section. Please see the added and revised paragraph on Pages 13, 14, &16

Comment 9: Lastly, the “so what” is missing from the article. Culturally responsive and trauma-informed mental health practices are common practice with displaced and non-displaced communities. Therefore, what are the authors contributing to further the knowledge base on this topic? Are culturally responsive and trauma-informed practices not the norm in Ethiopia? And who is the framework aimed at, mental health practitioners in Ethiopia specifically or more broadly? If  more broadly, then are they advocating for this framework to be generalizable and replicated elsewhere?

Response 9: The Introduction and Conclusion have been revised to emphasize the novelty of our framework. We highlight that while culturally responsive trauma-informed care is recognized globally, it is not yet a standard practice in Ethiopia. Our study addresses this gap by providing an adaptable framework that integrates cultural rituals and participatory approaches tailored to Ethiopian communities. The revised conclusion clarifies that the framework is aimed primarily at mental health practitioners working in Ethiopia but can be adapted to other contexts involving displaced populations, particularly in resource-limited settings. Please see the added paragraph on the Conclusion, now revised as “Conclusion and Implication for practice “ section  on Page 17

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

 

I have read the article "Assessment of Cultural and Contextual Factors in Trauma-Informed Interventions for Internally Displaced People in Ethiopia" with interest. 

This article is a significant contribution to the field of trauma-informed care, specifically in the context of Ethiopia’s internally displaced populations (IDPs). By focusing on community-based participatory action research (CBPAR), the study offers a framework that emphasizes the integration of local rituals and values into mental health support. This focus is particularly relevant in Ethiopia, where internal displacement due to ethnic violence, conflict, and natural disasters has reached alarming levels. 

I have, however, some observations such as the findings are highly specific to Ethiopia, limiting their applicability to other settings without similar cultural and contextual adaptations.

While the article discusses cultural responsiveness, it could benefit from clearer definitions of key terms such as “trauma-informed care” and how they apply to diverse contexts.

The thematic analysis, though robust, occasionally lacks deeper exploration of some emergent themes, such as gender dynamics in trauma recovery.

The study relies on a purposive sampling method, which may introduce bias and limit the diversity of perspectives included.

Conducting interviews in Amharic and translating them into English risks losing nuances and meaning, despite efforts to ensure accurate translation.

Although the study outlines its adherence to ethical guidelines, it lacks detailed discussion of how potential power dynamics between researchers and participants were mitigated.

There should be clear statements on how these above have been addressed.

The references cited are relevant and include notable works on trauma-informed care, such as Brown et al. (2020) and Heim & Kohrt (2019). However, additional relevant and more recent references could strengthen the theoretical grounding.

While it has some methodological limitations and could benefit from broader theoretical integration, its emphasis on community participation and cultural alignment makes it a noteworthy resource for researchers and practitioners alike. This could be accepted after major revisions.

 

Comments on the Quality of English Language

Acceptable 

Author Response

We sincerely appreciate the reviewer’s valuable time and insightful comments, which have significantly strengthened our manuscript. We have carefully revised the manuscript to address the reviewers’ concerns, as outlined below. Once again, thank you for your thorough evaluation of our work.

While we have submitted the clean copy through the portal, we have also attached a version with tracked changes highlighted in different colors to facilitate the review process.

Reviewer Comment 1: the findings are highly specific to Ethiopia, limiting their applicability to other settings without similar cultural and contextual adaptations.

Response 1:  We expanded the Discussion and Conclusion sections to highlight the transferability of the framework by identifying universal themes, such as the role of cultural rituals and community-based resilience. We provided examples from global studies (e.g., in conflict zones such as Syria and Sudan) to emphasize the relevance of our findings in other contexts. Please see the added paragraph on the Conclusion, now revised as “Conclusion and Implication for practice “ section  Pages 13,14 and 14, 17

Reviewer Comment 2: While the article discusses cultural responsiveness, it could benefit from clearer definitions of key terms such as “trauma-informed care” and how they apply to diverse contexts.

Response 2: We have added a detailed definition of "trauma-informed care" in the introduction. We explicitly describe how this concept applies to displaced populations in Ethiopia, incorporating cultural and contextual aspects such as the community’s collective understanding of trauma and the need to avoid re-traumatization. Page 2, lines 88-91

Reviewer comment 3 The thematic analysis, though robust, occasionally lacks deeper exploration of some emergent themes, such as gender dynamics in trauma recovery.

Response 3: We agree with the reviewer’s observation that the data primarily reflect the experiences of women and girls due to their heightened vulnerability in the IDP center. The literature review and theoretical framework were adjusted to foreground the gendered dimensions of trauma and displacement. We provided narratives illustrating how stigma affects women’s help-seeking behavior and emphasized the importance of gender-sensitive group interventions in the results. This ensures the discussion aligns with the gendered experiences highlighted in the results. In the introduction section (page 2, lines 63-67, 112)  and revisions to the discussion and conclusion sections. Page 13,14 and Page 17

Reviewer comment 4: The study relies on a purposive sampling method, which may introduce bias and limit the diversity of perspectives included.

Response 4: We clarified the rationale for purposive sampling and highlighted the measures taken to ensure diverse participant pools (see Page 4). In the "Strengths and Limitations of the Study" section, we address this by acknowledging that while purposive sampling may inherently limit generalizability, it was selected deliberately to ensure the inclusion of participants with in-depth knowledge and lived experiences relevant to the research objectives. This approach was essential in a context where logistical and ethical considerations, such as the availability of community members who felt safe sharing their experiences, necessitated a strategic selection process. We balanced this limitation by ensuring a diverse participant pool, which included internally displaced individuals, service providers, community leaders, and government representatives. We also elaborated on the triangulation methods used to validate the findings and triangulation methods, such as cross-checking data from focus groups, interviews, and field observations, which helped mitigate potential bias and enrich the robustness of the findings. Page 16, 

Reviewer comment 5: Conducting interviews in Amharic and translating them into English risks losing nuances and meaning, despite efforts to ensure accurate translation.

Response 5: We have described our rigorous translation and back-translation process involving bilingual experts to maintain the fidelity of the data. We have included a discussion of potential linguistic nuances and cultural idioms, with examples illustrating how context-sensitive interpretations were maintained. See Page 16&17  

Reviewer comment 6: Although the study outlines its adherence to ethical guidelines, it lacks detailed discussion of how potential power dynamics between researchers and participants were mitigated.There should be clear statements on how these above have been addressed

Response 6: The method section includes a separate subsection titled "Positionality and community engagement" (pg. 7) to detail the research team's demographics, including race, gender, language proficiency, and prior relationships with the community. This section also discusses potential biases and how power dynamics were addressed (e.g., co-identifying research priorities and validating key themes through co-facilitated workshops and town hall meetings). 

Reviewer comment 7: The references cited are relevant and include notable works on trauma-informed care, such as Brown et al. (2020) and Heim & Kohrt (2019). However, additional relevant and more recent references could strengthen the theoretical grounding.

Response 7: Thanks for this comment. We integrated recent literature on trauma-informed care and cultural adaptation, including studies by Kaminer et al. (2024) and Nguyen et al. (2023), to support our conceptual framework and more. Page 15,16,&17

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I believe the authors did address many of my previous comments. Though, I still am uncomfortable at the lack of content in the results section and the large amount of content in the discussion and conclusions sections. It still feels that there is not sufficient evidence to back up the claims in the discussion section or the proposed framework. More data in the results section would likely help to address this issue, though I am unsure if such data is available to the authors. 

Author Response

Comment 1:

 I believe the authors did address many of my previous comments. Though, I still am uncomfortable at the lack of content in the results section and the large amount of content in the discussion and conclusions sections. It still feels that there is not sufficient evidence to back up the claims in the discussion section or the proposed framework. More data in the results section would likely help to address this issue, though I am unsure if such data is available to the authors. 

Response 1: 

We appreciate the reviewer’s feedback and have expanded the results section to provide additional evidence supporting our discussion and proposed framework. Specifically, we have made the following additions:

• We included additional participant testimonies and quantitative data on the frequency of distress, food insecurity, and safety concerns among IDPs (Page 10, lines 372-379, 398-403).
• We elaborated on gender-based barriers to trauma disclosure and the impact of literacy differences on intervention accessibility (see p. 10, lines 405-408, 416-417).
• We expanded on how cultural norms shape trauma disclosure, particularly regarding sexual violence, and added insights from service providers on culturally appropriate communication strategies (see p.11, lines 448-452).
• We also added a summary table on page 12. This table provides a concise overview of key themes, findings, and supporting data, helping better illustrate the connection between the results and our discussion. We hope these revisions enhance the empirical foundation of our discussion while maintaining the integrity of our qualitative approach. We appreciate the reviewer’s constructive critique and welcome any additional suggestions.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This looks much improved now. However, the figures could be adjusted and refined further to ensure they appear polished and visually appealing when printed.

Author Response

Comment 1: This looks much improved now. However, the figures could be adjusted and refined further to ensure they appear polished and visually appealing when printed.

Response 1: Thank you for your valuable feedback and for recognizing the improvements in the manuscript. We appreciate your suggestion regarding the figures and will carefully refine them to enhance their clarity, polish, and visual appeal for print Pages 9 and 16. We will ensure that they are properly formatted and optimized for readability and professional presentation

Author Response File: Author Response.pdf

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

N/A