Exploring issues surrounding mental health and wellbeing across two continents: A preliminary cross-sectional collaborative study between the University of California, Davis, and University of Pretoria.

Mental health and wellness research continue to be a topic of importance among veterinary students in the United States of America (US). Limited peer reviewed literature focusing on South African veterinary students is available. South African veterinary medical students might benefit from approaches to improve mental health and wellness similar to those recommended in the US. However, these recommendations may not address the underlying risk factors for mental health and wellness concerns or mismatch resources available to South African veterinary medical students. The purpose of this collaborative study was to compare the mental health and wellness among veterinary students enrolled at the University of California, Davis (UCD), and the University of Pretoria (UP), the only veterinary school in South Africa. Our primary research question was; Are the measures of mental health and wellness for students at similar stages in the veterinary curriculum different between the two schools? We hypothesized that mental health and wellness as determined by assessment of anxiety, burnout, depression, and quality of life between the two schools is different. A cross-sectional study of 102 students from UCD and 74 students from UP, at similar preclinical stages (Year 2 for UCD and Year 4 for UP) of the veterinary curriculum was performed. Anxiety, burnout, depression, and quality of life were assessed using the Generalized Anxiety Disorder (GAD-7), Maslach Burnout Inventory (MBI), Patient Health Questionnaire (PHQ-9), and Short Form-8 (SF-8), respectively. Students from both schools had moderate levels of anxiety, high levels of burnout, mild to moderate levels of depression, poor mental health, and good physical health. Our results suggest that similar mental health and wellness concerns in South African veterinary students is comparable with concerns in veterinary medical students in the US. Recommendations and resources to improve mental health and wellness in US veterinary medical students might be applicable to South African veterinary medical students.

Introduction

Several universities educating veterinarians in the United States have recently undergone curricular revision. The University of California, Davis, School of Veterinary Medicine (UCD) completed its curricular revision for its Doctor of Veterinary Medicine (DVM) in 2011, graduating its first class from the revised curriculum in 2015 [1]. The UCD’s revised integrated block design curriculum was anticipated to reduce student and faculty stress and burnout by focusing learning material to fundamental “Day One Skills” necessary for graduates [1]. The revised curriculum was student-centered, inquiry-based, and included teaching and assessing methods that promoted critical thinking, such as case analysis and veterinary practice applications [1]. The University of Pretoria's Faculty of Veterinary Science (UP) completed a major curricular revision in 2016 [2]. While the UP’s driving forces for change were programmatic and educational, the UCD identified student and faculty stress and burnout as an additional impetus for curricular change. While the UP did not specifically identify mental health and wellness as a factor for change, the concerns for student mental health and wellness recently became prominent in the South African higher education sector [2]. The concerns for mental health and wellness were compounded by student protests prompted by persistence of powerful symbols of colonial history of tertiary institutions, lack of gender and racial diversity, and financial pressures on students during the curricular revision process [2]. Therefore, student mental health and wellness among veterinary students is associated with design, modification or change of curriculum. The similarities between drivers for curricular changes between UCD and UP programs included emphasis on core learning material for entry level veterinarians (Day One Skills), and recognition of the influences of external forces such as licensing accrediting bodies, and other stakeholders [1, 2].

There is a significant body of literature on mental health and wellness available for students in US veterinary schools [3-5]. In one study across three consecutive semesters at a US school, proportions as high as 49%, 65%, and 69%, respectively, of veterinary students reported depression levels above the clinical cut-off [4]. Furthermore, a cross-sectional study of 1,245 students from 33 US veterinary colleges reported that 66% of students had symptoms of mild to moderate depression, and these levels were higher compared to college students in other programs (41%) or medical students (23%) [5]. Factors associated with increased scores of anxiety and depression among US veterinary medical students include transitional stress (difficulty fitting in), academic stress (heavy workload), and homesickness [3, 4]. Female veterinary students have been reported to have higher scores for depression compared to males [4, 5].

In contrast, little peer reviewed information is available describing factors associated with mental health and wellness among South African veterinary medical students. However, factors associated with anxiety and depression in non-veterinary students and the general South African adult population include cultural differences [6, 7] and race [6, 8, 9]. Furthermore, social, and economic factors such as higher number of household members, lower education attainment, gender, lower social status, multiracial race, and less income stability also have been associated with depression and anxiety in South African adults [10]. Thus, some factors that are negatively associated with optimal mental well-being among veterinary students on the two continents might be different. For instance, anecdotal perceived important stressors negatively associated with optimal mental well-being in South African students include loneliness due to the geographical isolation of the veterinary school, and electrical power failures (thereby reducing study time). In contrast, perceived poor health and unclear curriculum expectations are major stressors negatively associated with optimal mental well-being in US veterinary students [3-5]. Furthermore, the resources available to support veterinary students’ mental health and wellness are different between US and South African schools of veterinary medicine. Despite these potential differences in resource availability, South African veterinary students may adopt approaches to improve mental health and wellness similar to those recommended in the US. This is because some of the perceived stressors associated with poor mental health in veterinary students such as increased academic workload, and lack of racial diversity in class composition are common to South African and US veterinary schools. However, these recommendations may not address the underlying risk factors for mental health and wellness concerns or mismatch available resources in South Africa. Consequently, collaboration between schools of veterinary medicine on two different continents will not only promote collaboration amongst educational researchers in veterinary medicine but enhance communication and provide research data that advances the knowledge of mental health and wellness issues in veterinary students.

Current mental health and wellness support for veterinary students

The University of California Davis and UP provided the following onsite mental health and wellness programs (excluding campus-wide, state, or national resources) at the time of study:

University of California Davis

The UCD wellness program had one full time and one part-time professional counselors on staff to provide psychotherapy. The Wellness Center was equipped with individual quiet rooms for sleeping, resting, and relaxation massage chairs. The Wellness Center was located within a walking distance from lecture rooms and the teaching hospital. A wellness initiative referred to as ‘Wake up for Wellness’ was held several times a semester to promote self-care and wellness, boost morale, and built a sense of community. A veterinary student-run Health and Wellness Club provided opportunities for self-care and promoted mental, physical and emotional health, and wellbeing through activities such as organizing presentations and webinars related to mental health and wellness, and physical activities such as yoga (along with faculty), meditation, wine-tasting, cooking, and hiking.

University of Pretoria

The UP had a one full-time faculty advisor providing student support on issues such as life-balancing, time management, motivation, and stress management. A part-time professional counselor was available to provide psychotherapy to veterinary students. A part-time physician (general medicine) and a part-time nurse were also available through the Faculty Medical Services. All professionals providing mental health and wellness support to the students could refer cases to a comprehensive campus service (University of Pretoria Counselling Services). The Onderstepoort Paraveterinary and Veterinary Student Committee, which was a professionally trained peer group provided opportunities and support for students through workshops and presentations on approaches to manage stress, anxiety, and depression.

Current study

This study provides an opportunity to examine mental health and wellness issues in programs of veterinary medicine in two countries potentially providing more information about the drivers and risk factors of mental health and wellness in schools of veterinary medicine. Specifically, this study focuses on the mental health and wellness aspects of students in terms of anxiety, burnout, depression, and quality of life. This preliminary, collaborative, cross-sectional study compared the mental health and wellness among students enrolled at UCD, United States of America, and UP, South Africa. Our primary research question was; Are the measures of mental health and wellness for students at similar stages in the veterinary curriculum different between the two schools? We hypothesized that mental health and wellness as determined by assessments of anxiety, burnout, depression, and quality of life would be different between the two schools.

Study design methods

Sampling and data collection

Sampling consisted of a non-probability sampling method via the use of a voluntary and convenient sample of students enrolled at the end of their second and fourth year of the DVM programs at UCD, and UP, respectively. While the DVM program is a 4-year curriculum at UCD requiring a bachelor’s degree for a student to be eligible, the Bachelor of Veterinary Science (BVSc) program is a 6-year curriculum at UP where students complete their first year of basic natural sciences education at the Hatfield campus in the Faculty of Natural and Agricultural Sciences, then transfer into the veterinary portion of the curriculum to complete the second through sixth years of education at the Onderstepoort campus in the Faculty of Veterinary Science. The UCD begins its academic year in August, while UP commences in February. Data were collected in May 2018 for UCD and in November 2018 for UP, prior to the onset of the end of year examinations. Both data collection periods utilized the Qualtrics online survey tool where students were informed that the data collected were confidential but not anonymous as responses were tracked via individual emails to ensure each student responded only once to the survey. This data collection tool also allowed for follow-up reminders. Consent by students to participate in the study was requested via email. Consent by students was electronically written. The study was approved by the UCD Institutional Review Board (Decision HRP 503) and the UP-Research Ethics Committee (#GW20181001).

Instrumentation

The following instruments were used to assess anxiety, burnout, depression, and quality of life of students at both schools.

Anxiety

The Generalized Anxiety Disorder (GAD-7) [11] was a self-administered patient questionnaire used as a screening tool and severity measure for generalized anxiety disorder. The GAD-7 consisted of seven questions where students indicated the frequency they experienced designated problems. Scores were calculated by assigning a value of 0, 1, 2, or 3, to the response categories of 'not at all', 'several days', 'more than half the days', and 'nearly every day', respectively, and the sum was calculated for the seven questions for a total score ranging from 0 to 21. Scores of 5, 10, and 15 were considered the cut-off points for mild, moderate, and severe anxiety, respectively. The GAD-7 had established internal and test-retest reliability and criterion, construct, factorial and procedural validity with sensitivity and specificity scores of 89% and 82%, respectively [11]. The GAD-7 was selected to assess anxiety over other instruments, including the Mental Health Inventory [12], the Zung Self-Rating Anxiety Scale [13], the State-Trait Anxiety Inventory [14], and the Trimodal Anxiety Questionnaire [15] because of its efficiency (short length of 7 items), good reliability, criterion construct, factorial and procedural validity [11].

Burnout

The Maslach Burnout Inventory (MBI) [16] was an instrument that measures individual burnout levels through the subscales of emotional exhaustion, depersonalization, and personal accomplishment which are identified as the key aspects to burnout, thereby providing a context for why burnout has possibly occurred [16]. The emotional exhaustion subscale assessed feelings of overextension and exhaustion from schoolwork with total scores of ≤ 18, 19–26 and ≥27 indicating low, average, and high levels of burnout, respectively. The depersonalization subscale measured an impersonal response to other students with total scores of ≤ 5, 6–9 and ≥10 indicating low, average, and high levels of burnout, respectively. Total personal accomplishment subscale measured students’ feelings of competence and success with scores of ≥40, 39–34 and ≤33 indicating low, average, and high levels of burnout, respectively.

Depression

The Patient Health Questionnaire (PHQ-9) [17] included a depression module that is part of the self-administered version of the PRIME-MD (Primary Care Evaluation of Mental Disorders) diagnostic instrument for common mental disorders. The PHQ-9 scored nine depressive symptom criteria present during the previous 2 weeks as 0 (not at all) to 3 (nearly every day) resulting in a severity measure ranging from 0 to 27. Total scores of 0–4, 5–9, 10–14, 15–19, and 20–27, indicated none, mild, moderate, moderately severe, and severe levels of depression, respectively. The PHQ-9 had demonstrated construct validity for use in primary care yielding a test-retest reliability of 0.84, sensitivity of 88% and specificity of 88% for major depression. The PHQ-9 was used to monitor the severity of depression and response to treatment as it is not a screening tool for depression. While several instruments are available to assess depression, including the Zung Depression Rating Scale [18], various versions of the Beck Depression Inventory [19, 20], and the Center for Epidemiological Studies Depression Scale [21], the PHQ-9 was selected for our study because of its ability to assess severity of depression, along with its acceptable reliability and validity coefficients [17].

Quality of life

The Optum Short Form-8 Health Survey (SF-8) was an 8-item self-reported Likert scale instrument that assessed health related quality of life with established reliability and validity for the health domain scales of general health perception (GH), physical functioning (PF), role limitations due to physical health problems (role physical, RP), bodily pain (BP), energy/fatigue (vitality, VT), social functioning (SF), role limitation due to emotional problems (role emotional, RE), and psychological distress and well-being (mental health, MH) [22]. Two summary measures were determined, namely the physical component summary (PCS) and the mental component summary (MCS). Alternate-form reliability for a 4-week recall for the subscales ranged from 0.70 to 0.88. Responses were standardized into scores for the eight dimensions using Optum Pro CoRE software (Optum Pro CoRE, Eden Prairie, MN). Scores below 50 points (mean score = 50, standard deviation = 10) correspond to deviations from normality and indicated a poorer quality of life, whereas scores above 50 points represented a better quality of life than that of the average adult American population [22].

Data analysis

Descriptive statistics were reported for response rate, gender, marital status, and age. Normality check of the data was performed by the Shapiro-Wilk test. When data were normally distributed, mean ± standard deviation (SD) was reported, whereas median and 95% confidence interval (95% CI) was reported for not normally distributed data. Overall reliability (internal consistency) of each instrument was performed by calculation of Cronbach’s alpha coefficient. Cronbach’s alpha values of ≥ 0.7 were considered to indicate acceptable reliability [23]. A one-way between-groups multivariate ANOVA (MANOVA) was performed to determine significant differences between the scores for the survey instruments between UCD and UP students. Independent variables considered were group (UCD or UP), gender, marital status, and age. Correlations between the subscales for the survey instruments were also calculated. Commercial software was used for analyses (GraphPad Prism Version 8.1.2, GraphPad Software, San Diego, CA; JMP Pro Version 14, SAS Institute Inc., Cary, NC). P <0.05 was considered significant.

Results

Response rates were 68% and 51% for UCD and UP, respectively. A total of 102 students (101 females and 1 male) from a class of 150 at UCD completed all instruments. Results of the 1 male student enrolled from the UCD cohort was excluded from further analysis of comparisons between the 2 schools. Seventy-four (52 females, 21 males, 1 non-binary) students from a class of 145 from UP, completed all instruments. Sixty-one (82%) and 13 (18%) students were aged 20–25, and 26–30 years respectively, at UP. At UCD, 101 (99%) and 1 (1%) students were aged 20–25, and 26–30 years, respectively. Further analysis of age comparisons between the schools excluded the 1 student from UCD aged 26–30. Three students (4%) at UP indicated they had a spouse/partner, whereas 70 (96%) were single. Nineteen (19%) students at UCD indicated they had a spouse/partner whereas 83 (81%) were single. The ethnic composition for UCD students was 82 White/Caucasian, 30 Asian, 24 Multi-ethnic, 7 Hispanic, Latino or Spanish origin, and 1 African American/Black. The ethnic composition of UP students was 104 White/Caucasian, 17 Black African, 17 Indian, and 7 colored (in the South African population the colored ethnicity is synonymous to the mixed-race ethnicity in the US). Standardized reliability (internal consistency) as indicated by Cronbach’s alpha for MBI, GAD-7, PHQ-9 and SF-8 instruments were 0.73, 0.91, 0.85, and 0.84, respectively and were considered acceptable.

Based on whole model analysis with MANOVA, group (UCD or UP) was a significant predictor (P <0.0001; Wilks’s Lambda <0.0001) influencing the scores on the survey instruments. Gender (P = 0.264), age (P = 0.189), and marital status (P = 0.969) were not significant predictors of scores on the survey instruments.

Anxiety, burnout, and depression

Scores for GAD-7 were not different (P = 0.126) between UCD (score = 8; 95% CI, 7, 10) and UP (score = 9; 95% CI, 7, 12). The GAD-7 scores for both schools indicated moderate levels of anxiety. Score comparisons for the MBI between the two schools are summarized in Table 1. Students from UCD reported higher emotional exhaustion scores (33 vs 25; P <0.0023) compared to UP students. Scores for depersonalization (P = 0.931) and personal accomplishment (P = 0.123) were not different between the two schools. Scores for personal accomplishment for both schools indicated high levels of burnout whereas scores for depersonalization and emotional exhaustion indicated average to high levels of burnout. Scores (95% CI) for PHQ-9 were 8 (6, 9) and 10 (7, 12) for UCD and UP students, respectively. The PHQ-9 scores were not different (P = 0.233) between the two schools and indicated mild to moderate levels of depression. Strong correlation (r = 0.74) was present between GAD-7 and PHQ-9 scores.

Table 1

Comparison of scores (median and 95% confidence interval) of burnout with Maslach Burnout Inventory (MBI) between University of California (UCD) and University of Pretoria (UP) veterinary medical students.

	UCD (N = 102)	UP (N = 74)	P-value
Emotional exhaustion (EE)	33 (29, 35)	25 (20, 28)	<0.0023
Depersonalization (DP)	7 (5, 9)	7 (6, 9)	0.931
Personal accomplishment (PA)	30.0 (28, 32)	29.5 (27, 31)	0.123

EE scores of ≤ 18, 19–26 and ≥27 indicate low, average, and high levels of burnout, respectively.

DP scores of ≤ 5, 6–9 and ≥10 indicate low, average, and high levels of burnout, respectively.

PA scores of ≥40, 39–34 and ≤33 indicate low, average, and high levels of burnout, respectively.

Row score comparisons between the 2 schools with P <0.05 are different.

Quality of life dimension scores are summarized in Table 2. Scores for quality of life dimensions were below 50, except for the bodily pain dimension for UCD students. Similarly, scores for quality of life dimensions for UP students were below 50, except for the physical functioning dimension. The score for physical functioning dimension was higher (P = 0.039) in UP compared to UCD students. Students from UCD (50.3 ± 7.3) had higher scores (P = 0.02) for the bodily pain dimension compared to UP (48.5 ± 8.3) students. Mental component summary scores were below 50 for both UCD (36.5 ± 11.5) and UP (34.5 ± 12.3) but scores were not different (P = 0.418). Physical component summary score for UCD students was 49.8 ± 7.6 and was not different (P = 0.727) from UP students (50.8 ± 8.4). Strong correlations were present between mental component score summary and PHQ-9 scores (r = -0.765), and between mental component score summary and GAD-7 scores (r = -0.728).

Table 2

Comparison of quality of life dimensions scores (mean ± standard deviation) with Short Form-8 (SF-8) scores between University of California (UCD) and University of Pretoria (UP) veterinary medical students.

	UCD (N = 102)	UP (N = 74)	P-value
Role emotional (RE)	38.7 ± 10.0	35.6 ± 10.6	0.114
Mental health (MH)	40.0 ± 7.7	42.0 ± 8.2	0.09
Social functioning (SF)	42.6 ± 9.4	39.6 ± 9.2	0.179
Vitality (VT)	45.0 ± 8.3	45.6 ± 7.6	0.795
General health perception (GH)	43.2 ± 9.9	44.4 ± 8.5	0.554
Role physical (RP)	47.8 ± 7.0	48.8 ± 7.3	0.443
Physical functioning (PF)	47.7 ± 7.1	50.2 ± 7.5	0.039
Bodily pain (BP)	50.3 ± 7.3	48.5 ± 8.3	0.020
Mental component summary (MCS)	36.5 ± 11.5	34.5 ± 12.3	0.418
Physical component summary (PCS)	49.8 ± 7.6	50.8 ± 8.4	0.727

Scores below 50 points (mean score = 50, standard deviation = 10) corresponded to deviations from normality and indicate a poorer quality of life, whereas scores above 50 points represented a better quality of life than that of the average adult American population [22]. Row score comparisons between the 2 schools with P <0.05 are different.

Discussion

Contrary to our hypothesis, study findings suggest that students from UCD and UP had comparable levels of anxiety, burnout, depression, and quality of life. Our findings are consistent with studies in US veterinary schools [5, 24] but there are no comparable studies available for South African veterinary students. In the US schools of veterinary medicine, risk factors associated with anxiety and depression are perceived poor physical health, unclear expectations in the curriculum, difficulty fitting in with peers, heavy academic workload, and homesickness [3, 4, 25, 26]. In contrast, the most frequent perceived contributors to student stress identified at UP during a recent study included academic pressure and heavy academic workload, electrical power failures, and isolation due to the remote location of the veterinary campus (unpublished data). Furthermore, UP has the only faculty of veterinary medicine in South Africa, a country with a population of > 55 million people (United Nations, World Population Prospects 2019, Office of the Director, DESA/Population division, New York, NY), thereby adding more scrutiny on its role in public service. Consequently, UP must justify the current and future resources to maintain and improve mental health and wellness for veterinary students.

The similarities in mental health and wellness concerns between the schools might be due to common stressors in any veterinary curriculum, including heavy academic workload. The results of our study indicate that recommendations and resources to improve mental health and wellness in the US might be applicable to South African veterinary medicine students. Specific strategies for improving mental health and wellness include curricular changes [3, 4], providing on-site resources for students' mental health [4], increasing awareness of mental health among students and faculty [4], and inclusion of mindfulness-based stress reduction intervention programs in the curriculum [27-31]. Although no comparable studies using the GAD-7 in veterinary students are available, the moderate levels of anxiety reported in our study is consistent with previous studies [3]. It should be noted that our study did not evaluate other potential risk factors for anxiety and depression including cultural [6, 7], social-economic [10], and racial factors [6, 8, 9], which have been reported in non-veterinary students and adult South Africans. Thus, further studies examining these risk factors for anxiety and depression are warranted in the South African veterinary student population.

Our study yielded levels of burnout consistent with previous studies at UCD [32]. Female students at UP (only one male student responded from UCD but was excluded) were likely to have higher scores of emotional exhaustion, indicating higher levels of stress consistent with previous studies in veterinary medical students at UCD [5]. It is important to note that the scores for personal accomplishment indicated high levels of burnout for students enrolled at both schools. The personal accomplishment subscale assesses feelings of competence and successful achievement in a student’s schoolwork. Personal accomplishment and depersonalization determine emotional exhaustion [33], in contrast to studies by Maslach [34], which focused on emotional exhaustion. Thus, focusing on early signs of emotional exhaustion is not recommended because when the signs of emotional exhaustion appear, the burnout process is already underway [33]. To increase the sense of personal accomplishment and counteract burnout, specific training programs were recommended for employees in various fields [35]. These training programs include role-playing to provide success experiences (enactive mastery), models of performances (vicarious experiences), coaching and encouragement (verbal persuasion) [35]. Of these recommendations, coaching and encouragement are two approaches that can be incorporated into stress management classes in the veterinary curriculum.

The mild to moderate levels of depression reported in our study is consistent with previous studies in veterinary students. Gender was not a significant predictor of levels of depression, which is in contrast to previous studies that indicated that that female students experienced higher levels of depression compared to male students [4, 5]. A likely reason for this difference is the fewer number of male students (1 at UCD who was excluded, and 21 at UP) in our study. Thus, the results of this study only reflected the analysis of gender for the UP cohort. Although not significant predictors of mental health in our study, we had hypothesized that older or married students would report higher scores of depression due to additional stressors from responsibilities in their personal life. However, older students or married students might be more resilient in adapting to stressors from schoolwork as they rely on personal experiences.

Assessment of quality of life allows identification of the most compromised dimensions of well-being and therefore, the ability to intervene by providing resources for students. Quality of life assessments allow comparison of the students in our study to a reference US adult population, and therefore are interpreted as deviations from normality. Our study yielded lower quality of mental health in veterinary students which may be related to the stressors associated with being enrolled in veterinary school. In contrast, students from both schools exhibited better physical health likely due to the young age of our study population (<30 years). The physical component summary scores decrease with age [36]. The nature of the veterinary curriculum which includes physical and outdoor activities and working with animals may also have contributed to the better physical health. General factors found to decrease quality of life in medical students which are applicable to veterinary students include peer competition, unprepared teachers, excessive learning activities, harsh social realities, frustrations with the medical program, and insecurity regarding professional future [37]. In contrast, good teachers, classes with good didactic approaches, active learning methodologies, efficient time management, and meaningful relationships with family members, friends, and teachers are associated with improved quality of life [37]. While these factors can be addressed with curricular changes, quality of life in veterinary medical students may also be improved by inclusion of mindfulness-based stress reduction intervention programs [38].

Implications of this study for collaborative future studies

The broader implications of this study include the importance of collecting data on mental health and wellness in veterinary programs during curricular implementation. Student mental health and wellness assessment will increase awareness among students and instructors of the impact of curricular revision, implementation, and evaluation. Furthermore, veterinary colleges should consider sharing resources and information on improving mental health and wellness during curricular revision and implementation.

Although our study is a preliminary study, the results serve to facilitate collaborative research between the two schools. Specific future large, longitudinal, research studies will focus on assessing social, racial, cultural, and economic factors associated with anxiety and depression. Furthermore, studies on impact of implementation and monitoring of mindfulness-based stress reduction intervention programs for veterinary students across all stages of the curriculum are warranted.

Limitations of the study

The non-probability convenient sample size was relatively small consisting of a single class from each school; therefore, the results of this study cannot be generalized to populations other than those included in the sample because the sample is not representative of all veterinary students in the United States or Africa. The non-probability voluntary sample may produce a voluntary response bias as students who were more interested in the topic self-selected to participate in the study. Consequently, a nonresponse bias may also be produced where students choosing not to participate may have differed from the sample in several ways. This may result in an over or under representation of students from particular groups. External validity of the results in our study may be limited as data were self-reported and are prone to response bias, honesty and image management, introspective ability, understanding questions, rating scales, ordinal measures, and control of sample [39, 40]. Response bias is when a student responds in a particular way to an item regardless of what is assessed. Honesty and image management refers when a student may not respond honestly due to the nature of the question in order to manage how he/she will be perceived. Introspective ability addresses a student’s lack of ability to reflect accurately on one’s self. Students may also vary in their ability to understand and interpret questions especially when dealing with abstract concepts, such as perceived level of stress. The value of each interval of a rating scale may be interpreted differently among students, as well as the distance between ordinal measures in a scale. Finally, students complete the survey at their own convenience, and the environment cannot be controlled. While our study did allow students to respond only once by soliciting surveys via individual emails, there is no control over the attention given to the survey by the student or if the indicated student completed the survey, thus we relied on the honesty of individual students.

Design, modification or change of the curriculum has an impact on student mental health and wellness. The effect of the curricula changes on mental health and wellness were not evaluated at both schools in our study to allow sufficient time for adjustments to the revised curricula. Holistic curricula evaluation, including assessment of mental health and wellness are planned for 2021 and 2022 academic years for UCD and UP, respectively.

Although the UP cohort had 13 students >26 years, age distribution in the 2 cohorts consisted of a higher proportion of students aged 20–25. Thus, the results from our study might be limited to this age group. Male participants were fewer for both schools with only 1 male respondent from UCD. Thus, analysis of gender comparisons was only applicable to the UP cohort. Further studies are required to evaluate the association between gender or age and scores of instruments assessing mental health and wellness in veterinary students from the two continents.

Conclusion

Instruments for assessing anxiety, burnout, depression, and quality of life had acceptable reliability. Students from both schools in our study had moderate levels of anxiety, high levels of burnout, mild to moderate levels of depression, poor mental health, and good physical health. The results suggest that mental health and wellness concerns in South African veterinary students is comparable with concerns in the US. Recommendations and resources to improve mental health and wellness in the US might be applicable to a South African school of veterinary medicine.

26 Jun 2020

PONE-D-20-09786

Exploring issues surrounding mental health and wellbeing across two continents: A preliminary cross-sectional collaborative study between the University of California, Davis, and University of Pretoria

PLOS ONE

Dear Dr. Chigerwe,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I received extensive feedback and I have carefully reviewed the manuscript as well. Overall, we thought that this manuscript presented an important, understudied topic that may generalize more broadly. Our reviewer offered some points of clarification and suggestions for edits that I would ask you to please address in a revision. I also suggest clarifying the statistical analyses and the choice to run univariate followed by multivariate tests. It seems like solely using a multivariate approach like MANOVA would be more appropriate for reducing the number of comparisons and capturing the likely correlations between subscales.

Please submit your revised manuscript by Aug 10 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Rachel A. Annunziato, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. During our internal checks, the in-house editorial staff noted that you conducted research or obtained samples in another country. Please check the relevant national regulations and laws applying to foreign researchers and state whether you obtained the required permits and approvals. Please address this in your ethics statement in both the manuscript and submission information.

3. Thank you for stating in your Funding Statement:

"The study was funded in part by the University Capacity Development Grant of the Department of Higher Education and Training (DHET) of South Africa."

Please provide an amended statement that declares *all* the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now.  Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement.

Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf.

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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

Reviewer #1: Yes

**********

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

Reviewer #1: Unsure

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

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

Reviewer #1: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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

Reviewer #1: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This preliminary research study examines and compares the mental health and wellness between veterinary students at the University of California Davis (UCD) and University of Pretoria (UP). Through measurements of anxiety, burnout, depression, and quality of life of students at comparable stages of their veterinary education, the authors found similar concerns for mental health and wellness between both schools. As such, they conclude that the recommended implementations to increase mental health and wellness in North American veterinary schools may be applicable to the University of Pretoria in South Africa. While these results were inconsistent with the authors’ original hypothesis, I expect that further research assessing the different cultural, social, racial and economic risk factors between North American and South African veterinary students will most likely have different implications for the recommendations that would be most effective for South African students.

The major strengths of the paper are contingent on the authors’ extensive knowledge of the topic and the pertinent existing research. The overall paper and conclusion are strengthened by the authors’ explication of their reasoning behind the choices of the data instruments and methods, as well as providing definitions and explanations for concepts that may not be familiar to individuals outside this specialty, such as those discussed in the “Limitations of the study” section (pages 17-18). This is important as it may help increase collaboration and attention to this topic from a cross-disciplinary perspective. Furthermore, it improves readability and reader comprehension. Another strength of the study is their extensive and honest section outlining the limitations of their research study and design and the implications of these for future studies.

However, with this being said, the extensive limitations of the study are what I perceive to be the major weakness of this paper. The various flaws of the study design, including the generalizability and external validity of results, most likely significantly impact the results and conclusions of this study. This may weaken its reproducibility and significance. Other major and minor issues are discussed below.

Major Issues

• The authors identify that mental health and wellness research is a topic of importance in North American veterinary schools (line 36). However, they fail to explain why it is important for this specific discipline. With a brief explanation of the importance of this and future research, the authors will provide readers and future researchers with a stronger impetus to perform further research studies, such as those recommended at the end (“Implications of this study for collaborative future studies” section on page 17).

• In the Introduction (lines 59-76), the authors identify certain curricular revisions that have been implemented in North American veterinary schools, with specific attention to those at UCD. To strengthen the association the authors make between mental health and wellness in veterinary students with modifications to and change of curriculum, a brief discussion of the success of current curriculum reforms would be helpful. Furthermore, the authors should consider briefly describing the similarities between the curriculum changes implemented at UCD and UP. Failure to describe the curriculum changes that have been implemented at UP is a significant issue that should be addressed to increase the strength of the authors’ conclusion.

Minor Issues

• While the authors exemplify extensive knowledge of the topic, there are many grammatical errors that make certain sections difficult to read and comprehend, specifically the common occurrence of run-on sentences. Specific attention should be given to the Introduction section.

• The authors identify the independent variables of the study, which are group, gender, marital status, and age. While they reference previous studies that found significant differences by gender in North America, further explanation for their choice to include marital status and age should be briefly discussed. Additionally, race would have been an easy descriptive statistic to obtain and incorporate into the research. This is an important factor to consider as there is significant evidence of racial disparities in mental health.

• It is important that the authors included a section on the current mental health and wellness support for veterinary students at UCD and UP. However, positioning this section as part of the Study Design and Methods section is confusing as it is merely background information and not relevant to how the study was conducted. As such, I advise that the authors move this section to be included in the Introduction for coherency and improved flow of the paper.

• Although the Discussion section is strong in discussing the results and their implications, it is not coherently structured. It would be helpful too to consider broader implications.

**********

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

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

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Mackenzie Connelly

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10 Aug 2020

31 July 2020

Dr. Annunziato

Academic Editor- PLOS ONE

Dear Dr., Annunziato,

We are pleased to submit the revised version of the manuscript entitled:

“A preliminary cross-sectional collaborative study between the University of California, Davis, and University of Pretoria” to PLOS ONE.

Thank you for giving us the opportunity to revise and resubmit this manuscript. We appreciate the time the reviewer spent on this manuscript and the detailed comments that they have provided. The manuscript has been revised to reflect your suggestions and the reviewer’s comments and suggestions.

All authors have approved the final version of the revised manuscript.

We have responded specifically to each comment/suggestion below and highlighted any changes made to the manuscript in green (‘Manuscript with track changes’).

Academic Editor’s comments

I received extensive feedback and I have carefully reviewed the manuscript as well. Overall, we thought that this manuscript presented an important, understudied topic that may generalize more broadly. Our reviewer offered some points of clarification and suggestions for edits that I would ask you to please address in a revision. I also suggest clarifying the statistical analyses and the choice to run univariate followed by multivariate tests. It seems like solely using a multivariate approach like MANOVA would be more appropriate for reducing the number of comparisons and capturing the likely correlations between subscales.

AU Response: Thank you for the suggestion. We agree that analyzing the data using MANOVA is more appropriate compared to our previous approach that included adjustment of the P-values in the multiple comparisons.

We re-analyzed the data using a one-way MANOVA. As a result of performing MANOVA, the following summarizes the changes (or no changes) in the results/conclusions:

1. Gender was not a significant predictor of any of the survey instrument scores in this revised version of the manuscript. In our first submission, gender was a significant predictor for emotional exhaustion (for UP students only because only 1 male student completed the survey at UCD) because we had analyzed the data as separate multiple regression models. Similar to our first submission, marital status and age were not significant predictors of scores on the survey instruments.

2. Group (UCD or UP) was a significant predictor of scores in at least one survey instrument, consistent with our first submission results/conclusions. Emotional exhaustion scores were higher for UCD students compared to UP students. This conclusion is similar to our first submission results. The P-value was different but still significant (P<0.0001, in our first submission versus P = 0.0023 in this revised version). Scores for depersonalization (P =0.931) and personal accomplishment (P = 0.123) were not different between the two schools, consistent with our first submission results.

3. Conclusions for differences between PHQ-9 and GAD-7 scores between UCD and UP remained unchanged, but the P-values changed, though still not significant.

4. For SF-8: Social Functioning dimension score which was significantly different between the 2 schools was not significant (P = 0.179) with MANOVA. In contrast, Bodily Pain dimension (previously non-significant in the first submission) was significantly different (P=0.020) in this revised version.

The Physical Functioning (P = 0.039) was still significantly different between the two schools, consistent with the conclusion in the first submission.

Although the p-values changed, Role Physical (P = 0.443), General Health (P=0.554), Vitality (P = 0.795), Role Emotion (P = 0.114), Mental Health (P = 0.09), Mental Component Summary (P=0.418), and Physical Component Summary (P =0.727) were not different between the schools, consistent with the conclusion in our first submission.

5. We revised the results, included analysis from MANOVA, and deleted results from multiple regression analysis for each survey instruments from our first submission. Please see results.

6. We also included the significant relevant correlations between the subscales. Please see results.

PLOS ONE style requirements

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming

AU Response: We followed all the style requirements and identified the revised editions of the manuscript as suggested by the journal.

2. During our internal checks, the in-house editorial staff noted that you conducted research or obtained samples in another country. Please check the relevant national regulations and laws applying to foreign researchers and state whether you obtained the required permits and approvals. Please address this in your ethics statement in both the manuscript and submission information.

AU Response: We provided a project approval number by the University of Pretoria. Please see Materials and Methods.

3. Thank you for stating in your Funding Statement:

"The study was funded in part by the University Capacity Development Grant of the Department of Higher Education and Training (DHET) of South Africa."

Please provide an amended statement that declares *all* the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement.

Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf.

AU Response: We deleted the funding source statement from the Acknowledgments and included it in our cover letter as suggested. We provided information on all the funding sources and included the statement; “There was no additional external funding received for this study” as suggested. We included the following funding source statement: “The study was funded by the University Capacity Development Grant of the Department of Higher Education and Training (DHET) of South Africa, and the UC Davis Faculty Discretionary Support funds. There was no additional external funding received for this study.”

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

AU response: The data presented in our study potentially contain sensitive identifying personal information such as, mental health data which have psychological risks to the respondents. We have provided contacts (non-authors of this manuscript) to which data requests maybe send. The contacts are the respective institutional representatives for the ethics committees:

University of California Davis:

Office of Research

IRB Administration

1850 Research Park Drive

Davis, CA 95618-6153

Phone: (530) 754-7679

Fax: (530) 754-7894

Email: ORExecutiveMgtAsst@ad3.ucdavis.edu

University of Pretoria:

Deputy Dean, Postgraduate and Research Ethics

Faculty of Humanities

Email: PGHumanities@up.ac.za

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

AU response: Please see our response above, in 4(a).

Reviewer #1

General response: Thank you for taking time to review our manuscript. To make it easier for you to recognize the changes we made to the manuscript, we highlighted the changes in green.

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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

Reviewer #1: Yes

AU response: Thank you.

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

Reviewer #1: Unsure

AU response: We considered recommendations from the Academic Editor, specifically to consider MANOVA (multivariate analysis of variance) rather than assessing the difference in scores for each survey instruments as single multivariate regression analysis. We clarified this in the materials and methods. We changed the results accordingly.

3. Have the authors made all data underlying the findings in their manuscript fully available?

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

Reviewer #1: No

AU response: The data presented in our study potentially contain sensitive identifying personal information such as mental health data which have psychological risks for the respondents. We have provided contacts to which data requests maybe sent. The contacts are the respective institutional representatives for the ethics committees:

University of California Davis:

Office of Research

IRB Administration

1850 Research Park Drive

Davis, CA 95618-6153

Phone: (530) 754-7679

Fax: (530) 754-7894

Email: ORExecutiveMgtAsst@ad3.ucdavis.edu

University of Pretoria:

Deputy Dean, Postgraduate and Research Ethics

Faculty of Humanities

Email: PGHumanities@up.ac.za

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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

Reviewer #1: No

AU response: We revised the manuscript and checked for any grammatical errors to the best of our ability.

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This preliminary research study examines and compares the mental health and wellness between veterinary students at the University of California Davis (UCD) and University of Pretoria (UP). Through measurements of anxiety, burnout, depression, and quality of life of students at comparable stages of their veterinary education, the authors found similar concerns for mental health and wellness between both schools. As such, they conclude that the recommended implementations to increase mental health and wellness in North American veterinary schools may be applicable to the University of Pretoria in South Africa. While these results were inconsistent with the authors’ original hypothesis, I expect that further research assessing the different cultural, social, racial and economic risk factors between North American and South African veterinary students will most likely have different implications for the recommendations that would be most effective for South African students.

The major strengths of the paper are contingent on the authors’ extensive knowledge of the topic and the pertinent existing research. The overall paper and conclusion are strengthened by the authors’ explication of their reasoning behind the choices of the data instruments and methods, as well as providing definitions and explanations for concepts that may not be familiar to individuals outside this specialty, such as those discussed in the “Limitations of the study” section (pages 17-18). This is important as it may help increase collaboration and attention to this topic from a cross-disciplinary perspective. Furthermore, it improves readability and reader comprehension. Another strength of the study is their extensive and honest section outlining the limitations of their research study and design and the implications of these for future studies.

However, with this being said, the extensive limitations of the study are what I perceive to be the major weakness of this paper. The various flaws of the study design, including the generalizability and external validity of results, most likely significantly impact the results and conclusions of this study. This may weaken its reproducibility and significance. Other major and minor issues are discussed below.

AU response: Thank you for your succinct summary of the strength and weaknesses of our study. We agree with your comment that further longitudinal studies results might differ from this current study particularly when cultural, social, racial, and economic factors are considered. While all these factors have a potential influence on the mental health, the degree to which they affect mental health among veterinary students might be different between the schools. We plan to pursue longitudinal studies with intervention strategies at both schools.

Major Issues

1. The authors identify that mental health and wellness research is a topic of importance in North American veterinary schools (line 36). However, they fail to explain why it is important for this specific discipline. With a brief explanation of the importance of this and future research, the authors will provide readers and future researchers with a stronger impetus to perform further research studies, such as those recommended at the end (“Implications of this study for collaborative future studies” section on page 17).

AU response: We added relevant statistics from recent studies to provide more context on mental health and wellness in North American veterinary students compared to peers in other programs, such as medical students. We added the information in the introduction and cited relevant references. Please see the introduction.

2. In the Introduction (lines 59-76), the authors identify certain curricular revisions that have been implemented in North American veterinary schools, with specific attention to those at UCD. To strengthen the association the authors make between mental health and wellness in veterinary students with modifications to and change of curriculum, a brief discussion of the success of current curriculum reforms would be helpful. Furthermore, the authors should consider briefly describing the similarities between the curriculum changes implemented at UCD and UP. Failure to describe the curriculum changes that have been implemented at UP is a significant issue that should be addressed to increase the strength of the authors’ conclusion.

AU response: The revised curricula were implemented in 2011 and 2016, at UCD and UP, respectively. As you pointed out, the revised curricula will have an impact on student mental health and wellness. Curricular evaluation at UCD is planned in 2021 (5 years after the first class on the new curriculum graduated) and 2022 at University of Pretoria. In response to your comment, we added the lack of data regarding the impact of the curricular change on mental and wellness as limitation of our study. Please see changes under ‘Limitations of the study’.

While not numerous, we included the similarities between the drivers for curricular changes between UCD and UP. Please see introduction.

Minor Issues

1.While the authors exemplify extensive knowledge of the topic, there are many grammatical errors that make certain sections difficult to read and comprehend, specifically the common occurrence of run-on sentences. Specific attention should be given to the Introduction section.

AU response: We revised the introduction and split the run-on sentences where necessary but did our best to maintain flow of the manuscript.

2. The authors identify the independent variables of the study, which are group, gender, marital status, and age. While they reference previous studies that found significant differences by gender in North America, further explanation for their choice to include marital status and age should be briefly discussed. Additionally, race would have been an easy descriptive statistic to obtain and incorporate into the research. This is an important factor to consider as there is significant evidence of racial disparities in mental health.

AU response: As indicated in our first submission, most students from UCD are 25 years and younger (at this stage of the curriculum) and this is expected in North American veterinary schools. Only 1 student was aged 26-30 from UCD 13 students from UP were aged 26-30 hence no comparison was made between the schools. In response to your comment, we did the following:

1. Discussed potential reasons why we included marital status and age variables for predicting scores. Please see Discussion.

2. We provided descriptive statistics of the racial composition of the 2 classes included in this study. Please see Results.

3. It is important that the authors included a section on the current mental health and wellness support for veterinary students at UCD and UP. However, positioning this section as part of the Study Design and Methods section is confusing as it is merely background information and not relevant to how the study was conducted. As such, I advise that the authors move this section to be included in the Introduction for coherency and improved flow of the paper.

AU response: Thank you for the suggestion. We moved the material on mental and health support for UCD and UP to the introduction. We provided sub-titles in the introduction to improve the flow of the manuscript. Please see changes in the introduction.

4. Although the Discussion section is strong in discussing the results and their implications, it is not coherently structured. It would be helpful too to consider broader implications.

AU response: We expanded the discussion to include broader implications of the study. Specifically, we discussed the impact of the study results relating to the following:

1. The importance of collecting data and monitoring mental health and wellbeing to increase awareness by students and faculty.

2. Sharing and provision of resources between schools to monitor mental health and wellness.

To improve the flow of the Discussion, we included this information under “Implications of the study for future studies”. We think the information fits better in this part of the discussion as it summarizes the practical implications of the study.

Please see Discussion for the additions.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

18 Sep 2020

PONE-D-20-09786R1

Exploring issues surrounding mental health and wellbeing across two continents: A preliminary cross-sectional collaborative study between the University of California, Davis, and University of Pretoria

PLOS ONE

Dear Dr. Chigerwe,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 02 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Rachel A. Annunziato, Ph.D.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

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

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

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

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

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

Reviewer #1: Yes

**********

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

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

Reviewer #1: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors made many revisions that have significantly strengthened their paper. Aside from the strengths discussed in their first submission, one strong addition was the inclusion of past studies that explicate the importance of studying mental health and wellness in veterinary school students. This will provide a further impetus for future studies to be conducted. The manuscript is further strengthened by the addition of the “Data Analysis” subsection, format changes to improve the paper’s readability, as well as the explanation of the specific independent variables that were studied.

Major Revisions

• The authors state that the factors associated with good mental health and well-being are different between the two countries. They hypothesize that the levels of mental health and wellness would be different between the two schools. However, in the introduction, the authors also hypothesize that the approaches to improve mental health and well-being in North America may be applicable South African veterinary schools. The authors should include a brief explanation as to why they hypothesized this despite the many differences.

• The authors state that they are assessing differences between North American and South African veterinary school students. However, all of the data provided, as well as the study conducted, are only applicable to the United States. Therefore, I recommend revising this inaccuracy by replacing “North America(n)” with “the United States of America” or “America(n),” unless the authors can provide statistics that indicate there are comparable mental health and wellness concerns in both Canada and Mexico.

• Throughout the paper, the authors switch between “South Africa(n)” and “Africa(n).”

Minor Revisions

• I recommend moving the primary research question stated in lines 141-143 to the abstract.

• The “Current mental health and wellness support for veterinary students” section is important. While they discuss the UCD “Wellness Center” and the programs it offers, the pathway to UP Counselling Services is less clear. I suggest briefly stating the programs it offers, if the information is available, to demonstrate consistency.

• To improve flow, readability and comprehension of the “Results” section, I suggest putting each school’s information consecutively. For example, state ages of respondents for UP followed by the ages of respondents for UCD. Or create separate paragraphs for each school.

• Although very minor, I suggest creating a new paragraph on line 93 to separate the background information discussion of North American and South African veterinary schools.

• The authors made many corrections to grammatical errors present in their first submission. However, there are still many run-on sentences and misuses of commas. I recommend revising these grammatical errors to improve readability and comprehension.

**********

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

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

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

5 Oct 2020

Reviewer #1: The authors made many revisions that have significantly strengthened their paper. Aside from the strengths discussed in their first submission, one strong addition was the inclusion of past studies that explicate the importance of studying mental health and wellness in veterinary school students. This will provide a further impetus for future studies to be conducted. The manuscript is further strengthened by the addition of the “Data Analysis” subsection, format changes to improve the paper’s readability, as well as the explanation of the specific independent variables that were studied.

Response

Thank you for taking time to review our manuscript. We responded point-by-point to your suggestions and comments. To make it easier for you to recognize the changes we made in the manuscript, we highlighted the changes in green where necessary.

Major Revisions

• The authors state that the factors associated with good mental health and well-being are different between the two countries. They hypothesize that the levels of mental health and wellness would be different between the two schools. However, in the introduction, the authors also hypothesize that the approaches to improve mental health and well-being in North America may be applicable South African veterinary schools. The authors should include a brief explanation as to why they hypothesized this despite the many differences.

Response

We hypothesized that the levels of mental health and wellness would be different based on the different stressors for being in veterinary school between the two different continents. Different stressors that will make approaches to mental health and wellness different between the schools maybe be stressors like powercuts (reducing study time), and isolation of the veterinary school in South Africa (there is only one veterinary school in South Africa); whereas perceived poor physical health and unclear expectations of the curriculum maybe be major stressors at North American schools. However, approaches to improving mental health maybe similar for stressors that are common to being in veterinary school such as heavy academic workload, and lack of racial diversity in class composition.

In response to your comment we clarified the statement in the introduction to indicate that although there are different stressors between the schools, improvement of mental health and wellness maybe applicable towards stressors that are common to both veterinary school.

• The authors state that they are assessing differences between North American and South African veterinary school students. However, all of the data provided, as well as the study conducted, are only applicable to the United States. Therefore, I recommend revising this inaccuracy by replacing “North America(n)” with “the United States of America” or “America(n),” unless the authors can provide statistics that indicate there are comparable mental health and wellness concerns in both Canada and Mexico.

Response

Thank you. We changed the phrase from “North America” to the “United States of America (US)” throughout the manuscript.

• Throughout the paper, the authors switch between “South Africa(n)” and “Africa(n).”

Response

We changed the phrase to “South African” throughout the manuscript because our study focused on South African students.

Minor Revisions

• I recommend moving the primary research question stated in lines 141-143 to the abstract.

Response

We added the primary research question to the abstract. To maintain flow of the manuscript, we left the primary research question in the introduction under the sub-title “Current Study” as well.

• The “Current mental health and wellness support for veterinary students” section is important. While they discuss the UCD “Wellness Center” and the programs it offers, the pathway to UP Counselling Services is less clear. I suggest briefly stating the programs it offers, if the information is available, to demonstrate consistency.

Response

The information indicated in the manuscript for UP Counselling Services is how the program is set-up currently and there is no additional information regarding its organization. Most of the staff administering the program are part-time except the full-time faculty advisor. However, the full-time faculty advisor provides mentoring and life coaching, but is not qualified/licensed to provide psychotherapy. The program at UP is still growing at the moment.

• To improve flow, readability and comprehension of the “Results” section, I suggest putting each school’s information consecutively. For example, state ages of respondents for UP followed by the ages of respondents for UCD. Or create separate paragraphs for each school.

Response

Thank you. We re-organized the results as suggested. Please see the results.

• Although very minor, I suggest creating a new paragraph on line 93 to separate the background information discussion of North American and South African veterinary schools.

Response

We created a new paragraph to separate background information on US veterinary schools and the South African school. Please see introduction.

• The authors made many corrections to grammatical errors present in their first submission. However, there are still many run-on sentences and misuses of commas. I recommend revising these grammatical errors to improve readability and comprehension.

Response

Thank you for the comment. We revised the manuscript and divided the run-on sentences when necessary. We also removed inappropriate commas when necessary using Microsoft Word grammar and spell-check.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

13 Oct 2020

Exploring issues surrounding mental health and wellbeing across two continents: A preliminary cross-sectional collaborative study between the University of California, Davis, and University of Pretoria

PONE-D-20-09786R2

Dear Dr. Chigerwe,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Rachel A. Annunziato, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

15 Oct 2020

PONE-D-20-09786R2

Exploring issues surrounding mental health and wellbeing across two continents: A preliminary cross-sectional collaborative study between the University of California, Davis, and University of Pretoria

Dear Dr. Chigerwe:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Rachel A. Annunziato

Academic Editor

PLOS ONE