Revision Summary: Wounded Healers as Agents of Change: A Comparative Study on Stress and Work Satisfaction of Accompaniers worked with Families of Missing Persons in Nepal {under peer review}

Reviewers’ Comments and Response from the Authors

Reviewer 1: Selin Tanyeri Kayahan

Comments	Reply	Changes in the paper
Are the methods appropriate and sufficiently detailed? No	Indeed, the pilot testing and psychometric data of the tools used to collect quantitative data was not applied and available.	Included in the limitation section of the paper.
Kindly provide more information on the context of the conflict in Nepal and why people go missing.	As the research paper does not focus much on the context and conflict in Nepal, a detail report on the Hateymalo Accompaniment Program outlines such elements and is included in that report for the interested reader to refer on this topic.	Reference of the report is added. The details on the conflict, context, programme and results in which this research respondents were mobilized are available on the final project report ‘Hateymalo accompaniment programme: ICRC's comprehensive psychosocial support programme to the families of missing persons in Nepal (2010-2016, ICRC, 2016)’. See changes.
Kindly write the full forms of abbreviations in their first use in the main text: ICRC, FoMP, LMIC, UNHCR etc.	Thank you for highlighting this, adjusted accordingly.	Adjusted
The abstract methods and results should elaborate on the 3-step process of the lay counselors’ work, in terms of recruiting, training and service provision.	Thank you for your advice. Revised with details on the capacity building efforts.	Revised.
The methodology should be explained in detail, both quantitative and qualitative parts.	The research methodology chosen, both quantitative and qualitative methods, tools and implementation are adequately described in the methods section. Suggestions in this regard were not specific so no changes are made in the paper.	No changes
Please indicate how the validation of the locally developed 13 question self-administered perceived-impact scale was made, along with the development process in detail. Also kindly explain why there was not a validated questionnaire used.	As mentioned above, the tool was locally developed and tested for the first time in a small sample, future research is needed for the validation. The authors/implementors also did not find any existing validated tool for this purpose. The closest one, Professional Quality of life (ProQol), does not measure what we wanted to measure. Recommendations are added in the future directions of the research section and limitations on the tools are also described.	See limitation section, the acknowledgement on the limitation of the locally developed tool is outlined, and future research required on the validation is also added.
Please indicate how and by whom the semi-structured interview guidelines were developed, with which prompts and how those were selected	Thanks to this relevant comment, semi structured interview guide was prepared based on the themes derived from the literature review and research gap on the wounded healer’s wellbeing and distress. Authors have described well in the methods section. See changes.	Described in detail under the ‘qualitative method’ section of the paper.
Kindly explain how the focus group participants were selected and who conducted the focus groups.	Thanks to this feedback, it is described in detail under the ‘qualitative method’ section of the paper.	Described in detail under the ‘qualitative method’ section of the paper.
The reporting of the findings should be systematized.	The findings of qualitative findings were interpreted and analysed as per the themes and presented.	There is no clear comment on ‘what and how it should be systematized? Thus, no revisions were made.
Kindly explain how the statement “The program was perceived as a source of company, social recognition, and social support, with access to opportunities.”	Thanks to this relevant feedback, the sentence was vague and not clear to be kept in the abstract, so authors decided to remove it.	Removed.
- Kindly discuss gender-related outcomes in particular.	As per the design of this research, there was no aim to analyze the gender perspective of distress and wellbeing of accompaniers, rather it was focused on the accompaniers from FoMPs and Non-FoMPs. Thus, the findings were not interpreted based on the gender related factors.	A line in the limitation section is added.
- Kindly add the part “A five-day-long training on topics such as rapport-building, communication skills, responding skills, problem-solving, counselling skills, conducting household surveys and resource-mapping for referrals were provided to accompaniers immediately after their recruitment through adult learning methodologies, including role-plays for each set of skills.” to the methodology section briefly.	Thanks to your advice, a paragraph is included under the introduction of the title. Capacity building was the part of the project implementation rather than this research. The details of this component can also be found in the detailed report on the Hateymalo Accompaniment Program, mentioned above.	Included in the introduction section.

Overall response:

Thanks to your invaluable feedback Dr Selin Tanyeri Kayahan, your insights and comments were relevant. Your advice helped us to critically evaluate our manuscript and revisions were made accordingly.

Reviewer 2: Dr. Zyed Achour

Comments	Reply	Changes in the paper
Title: It could be made more precise by specifying that the study focuses specifically on families of missing persons.	Excellent advice, we proposed to change the title.	New title: Wounded Healers as Agents of Change: A Comparative Study on Stress and Work Satisfaction of Accompaniers working with Families of Missing Persons in Nepal
Abstract: While it broadly reflects the content, it would benefit from more contextual precision (e.g., reference to the Nepalese armed conflict). Moreover, the conclusion remains general and does not specify the concrete implications for humanitarian programs	As the research paper does not focus much on the context and conflict in Nepal, a detail report on the Hateymalo Accompaniment Program outlines such elements and is included in that report for the interested reader to refer on this topic. Conclusion section is amended.	The details on the conflict, context, programme and results in which this research respondents were mobilized are available on the final project report ‘Hateymalo accompaniment programme: ICRC's comprehensive psychosocial support programme to the families of missing persons in Nepal (2010-2016, ICRC, 2016)’. See changes. In the conclusion section, the text is amended to make it more inclusive to humanitarian contexts. The engagement of FoMPs accompaniers has been of significant benefit not only to the accompaniers and families benefiting from humanitarian programmes, but also for the humanitarian programmes in post-conflict contexts.
The innovative positioning is noteworthy: the idea of recruiting victims as care providers is presented convincingly. However, the introduction would be strengthened by including epidemiological data (e.g., the total number of missing persons in Nepal) as well as more detailed information on the scale of the problem faced by affected families.	Thanks to this relevant suggestion, we adjusted the text with the inclusion of key statistics on the prevalence and need of psychological distress of FoMPs.	A paragraph on the results and outcomes of the program for the FoMPs in Nepal is added.
The article discusses key concepts (wounded healer, task-shifting, empowerment) with appropriate references. However, it lacks a true synthesis. Each section presents studies descriptively without critical analysis, and the article fails to clearly position the study within prior research. The transition from the abstract Jungian concept to its practical applications would benefit from greater theoretical rigor.	Indeed, the remarks are praiseworthy. It was a challenge for authors to balance between the theoretical evolutions and reflections of the respondents. Due to the unavailability of vast knowledge in this field on the humanitarian domain, the paper aimed more into the presentation of direct feelings, observations and experiences of the respondents. The Jungian concepts were merely introduced to illustrate that the concept of wounded healers existed long before now.	The authors added one sentence in the limitation section.
The mixed-methods approach is well justified, and the combination of quantitative and qualitative methods is appropriate for this type of research. However, several critical methodological shortcomings seriously compromise the validity of the conclusions: - Sampling not documented: no information is provided on the participant selection process. - Unvalidated instrument: the locally developed “perceived-impact” scale lacks psychometric validation (reliability, validity, internal consistency). - Inadequate statistical analysis: no statistical tests are used to compare groups. - Major selection bias: all participants are employees of the evaluated program, creating a potential conflict of interest. - Unjustified imbalance in the sample composition (32% men vs. 68% women). These methodological shortcomings require major revision, including the validation of measurement tools, the implementation of appropriate statistical tests, and the adoption of rigorous sampling strategies before the conclusions can be considered reliable for guiding humanitarian practice.	Thanks to your genuine feedback, we have acknowledged it and explained well in the limitation section. Thanks to this relevant feedback, the sampling, non-validated measures used in the research, selection and human response biases are elaborated clearly in the limitation section. The issue of lack of inferential statistical analysis and other statistical analysis are outlined in the report now. See, revised text in the data analysis section. As 72% staff were female, the inclusion of 68% of women is justifiable, we have included the demographic details of the accompaniers. Since 67% of the beneficiary (N = 1475) were females, the program implementors deliberately selected 72% of the accompaniers to be female to respect gender sensitivity and cultural norms of Nepal, i.e, a non-relative man cannot go to the house of a wife of a missing person (ICRC, 2016).	Addressed in the conclusion section. Conclusively, this research was primarily designed to get reflections and feedback on the subjective understanding and wellbeing of the accompaniers. The localized quantitative tools, locally prepared, non-validated and statistically not tested in various aspects of the results, indicated the stress and wellbeing in the five domains, additionally the qualitative findings narrated well on the direct experiences and reflections of the respondents on the observed variables. Although the quantitative part of the research seemed methodologically weak, the mix-methods on the findings can provide significant insights for program managers and supervisors working in the humanitarian sectors.
The conclusion should be rewritten to: - Explicitly acknowledge the major limitations, notably the risk of social desirability bias (employees evaluating their own program), which may compromise the reliability of the findings. - Moderate the claims by avoiding overinterpretation of results and by presenting the conclusions as exploratory, requiring further validation. Overall, while this study addresses an important and innovative topic, it requires substantial methodological revision.	We have outlined the biases in the responses from the staff, however this research is not an evaluation of the program. The evaluation and results of the program outcomes of the beneficiaries are published separately as report (see, ICRC, 2016 for details). This research is an effort on the documentation and sharing on the reflections, feelings and experiences of the accompaniers, who contributed to the program as ‘agents of change’ while being also ‘wounded and psychologically affected by the trauma and loss due to the disappearances of their loved ones.	The above-mentioned paragraph in the conclusion section addresses your concerns and remarks.

Overall response:

Dear Dr Zyed Achour, we are extremely grateful for your excellent and through review of our paper and providing us with significant insights and suggestions to enhance the understanding and clarity in this research article. We highly appreciate your critical review and made efforts in addressing most of your concerns and equally revised the manuscript after incorporating your valuable feedback. We thank you again for your support in revisiting them. Lots of regards from the authors.

Reviewer 3: Dr. Ope Atanda

Comments

Reply

Changes in the paper

Thanks for the opportunity to review this article. It was a highly pertinent topic and one that contributes to the existing body of knowledge on the subject. There are some concerns, particularly around the methodologies used in the study. Whilst the authors have identified the use of a non-validated scale as a limitation of the study, it would be helpful to obtain further details on how the scale items were developed.

Thanks to your review and relevant comments.

The process of development of tools, and use of locally developed non-validated tool is well elaborated now in the methods and limitation sections. Kindly revisit the updated text.

Refer to the methods and limitation section of the revised manuscript.

Some clarity is also needed on the form of qualitative data utilised in your study; there appears to be some confusion regarding whether a focus group approach or an interview approach was employed. Data analysis for both quantitative and qualitative outputs need to be reconsidered. The choice of using descriptive data or the phenomenological approach was either robust or justified. Generally, the structure of the qualitative outputs was difficult to follow.

It is now elaborated well in the methods sections on the selection of FGDs and interviews.

We could understand the difficulties in understanding the flow of the qualitative data. It is straightforward that the researchers used five themes in both quantitative and qualitative process of data of data collections and presented the findings in the similar fashion. The ‘theme centric approach of ‘phenomenological’ research process was used as the research focuses on subjective experiences, reflections and perceptions on the stress and wellbeing. The authors have elaborated more in the methods section in this regard,

Refer the methods section of the revised manuscript.

Authors provided six key findings in summarized manner, see under the ‘discussions and qualitative findings section’.

It was also difficult to understand how the findings from both quantitative and qualitative elements contributed to the conclusions you have made from your findings.

The conclusion refers on the overall findings from both qualitative and quantitative results. The results indicated that ‘the perceived concerns of possible revictimization of the victims of trauma when recruited and mobilized to support other victims’ did not seem true from this preliminary finding of this research. Furthermore, the ‘wounded healers’ who got the opportunity to support others felt empowered and transformed in their life and felt rewarded in their work to support similar people like them. Thus, the conclusion is simple and straightforward.

Nevertheless, we may disagree on the format and presentation of the findings as the same research findings can be presented in a different way.

No revisions in text were made.

Overall Response:

Dr. Ope Atanda, we thank you for your critical review of the proposed manuscript and providing us many important elements to enhance it quality and presentation. We went through the comments you have made in the manuscript, and we addressed them adequately. We kindly request you to review the changes text again as other reviewers had also highlighted similar weaknesses or recommended to make changes. Thus, the revision of the manuscript was done collectively. We believe that the revised manuscript with adjustment of the critiques, concerns and suggestions (some of them outlined in the track changes mode), are directly inserted in the manuscript are sufficient in addressing your concerns. We would like to again provide our gratitude for your invaluable inputs for the revision of this paper.