PGPH-D-22-01853

Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: a cross-sectional, population-based, multi-level analysis in a German federal state

PLOS Global Public Health

Dear Dr. Amir Mohsenpour,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’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 February 4, 2023. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ 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 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'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Oliver Mendoza-Cano, Sc. D.

Academic Editor

PLOS Global Public Health

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1. Please amend your detailed Financial Disclosure statement. This is published with the article. It must therefore be completed in full sentences and contain the exact wording you wish to be published.

a. Please clarify all sources of funding (financial or material support) for your study. List the grants (with grant number) or organizations (with url) that supported your study, including funding received from your institution. 

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Additional Editor Comments (if provided):

Reviewer 1

The evaluated manuscript aimed to analyze contextual effects of post-migration housing environment on their mental health.

Congratulations to the authors because I consider that it is an interesting manuscript and of great public health relevance, however I must make the following observations and suggestions:

1. In the abstract, the authors list the results of the ORs that the model yielded, however none of these show a statistically significant result. I consider that it is useless to place these values and it would be more appropriate to describe the results of the variables corresponding to the second level of analysis and finally mentioning that none had effects on the mental health of the population analyzed in this study.

2. What does it mean for the authors that a tendencies were found? I suggest avoiding this phrase in the presence of statistical results without significance. It is prudent to point out that the frequencies and proportions are higher in a group with depression or anxiety, but the word “tendencies” is ambiguous.

3. The methods are appropriately described and the use of multilevel analysis is adequately presented, some doubts about the variables that characterize each level arise when reading them are

a. Why was a sample size not calculated?

b. Why were the centers dichotomized into ≥50 people per center? Could you explain what is the usual population that exists in these centers on average?

c. The region of origin definition that is analyzed is very broad and perhaps does not reflect the factor that could really be influencing, for example, coming from a low-income country or at war.

d. Why was 20 minutes considered as the time to calculate the remoteness index? What is the optimal time for these transfers in Germany?

4. Regarding the results, in Table 3 "Sample description", where the frequencies and proportions for the variables of each level are described, the number of participants do not coincide with the total sample size shown in Table 2

5. The titles of the tables do not adequately inform their content

6. Figures must have their own caption containing the explanation found in the text.

7. The discussion of this work is very limited and I consider it its greatest weakness, the authors do not compare their results with those found in other populations, they do not consider that in reality the post-migration housing environment has no effect on depression or anxiety and what would be the possible explanations for this in this population of Germany.

8.The conclusion must be rewritten because it is ambiguous and the results of the analysis are clear.

Reviewer 2

The authors abide to the truth and are honest about the absence of significant differences, which should be praised. However, and due to its limited findings, this manuscript should be submitted only as a short communication, which could be useful to other scientists in the designing of similar studies.

Reviewer 3

This original article explored the effect of post-migration on anxiety and depression symptoms (and other sociodemographic aspects) in asylum seekers and refugees in a German federal state. The proposed results show a clear need for improvement of well-being of this population. Some recommendations are presented below.

-If possible, the symptoms of anxiety and depression (GAD-2, PHQ-2) could be further explored if descriptive data are presented on each item analyzed in the study participants .

-It is required not to generalize to "mental health" only with the presence of anxiety and depression. In line 120 it could be clarified in a more detailed way.

-I recommend adding a univariate analysis of Table 2, to identify the associations between the presented variables .

-The discussion section requires further analysis of all the variables analyzed. It is required that the results obtained be hypothesized and compared with those of other authors.

-I recommend reducing the extension of the analysis of the generalized linear models, since most of the results did not have statistical significance and/or the confidence intervals presented do not have enough statistical power to take them as valid.

-Place the corresponding abbreviations at the foot of tables 2 and 3.

PGPH-D-22-01853R1

Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: a cross-sectional, population-based, multi-level analysis in a German federal state

PLOS Global Public Health

Dear Dr. Mohsenpour,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’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.

Your manuscript has been evaluated by three reviewers, including two of the previous reviewers plus one new reviewer; their comments are appended below.

While all reviewers are overall positive towards publication, Reviewer #3 has provided comments recommending further revisions to clarify some matters in the Methods and Discussion sections. You may also want to consider responding to the comment from Reviewer #2 regarding future studies into the generalizability of the findings in this study.

Please submit your revised manuscript by Jul 07 2023 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 globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ 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 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'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Hugh Cowley

Staff Editor

PLOS Global Public Health

Journal Requirements:

Additional Editor Comments (if provided):

[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: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #4: (No Response)

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2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. 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

Reviewer #2: Yes

Reviewer #4: No

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

PLOS Global Public Health 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: Yes

Reviewer #2: Yes

Reviewer #4: Yes

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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 have adequately responded to the comments, I consider that now the manuscript can be published in the present form

Reviewer #2: I find very intriguing the finding about a "protective" effect of deprivation before depression; however, despite the study recognizes its limitations, its findings warrant future studies to determine if the tendencies found are consistent among ASR, not only in Germany, but in other countries.

Reviewer #4: Dear Authors,

Thanks for sharing this manuscript. I enjoyed reading it.

Your manuscript provides an important overview of the effects of the post-migration housing environment on the mental health of asylum seekers and refugees in Germany. Housing situation is a determinant of health that is underreported in the context of migrant health. The study has many merits; however, I recommend the authors address the following points in their manuscript:

Methods:

- The authors referred to previously reported details about "Setting, sampling and recruitment". However, they should provide more details about their study's setting and data collection. This should include the data collection period, the languages into which the questionnaire was translated, and the rationale for choosing these languages.

- Did the authors involve the concerned population (asylum seekers and refugees) in the design and implementation of their study? If not, why? This should be reflected in the limitations.

- The length of stay in the collective accommodation centres is a potential confounder that has yet to be considered in the analyses. Authors should explain why they did not include this confounder and reflect on this in the limitations.

Discussion:

- How would this study's outcomes apply to other parts of Germany?

- Could the authors put their study in the context of the current situation of asylum seekers and refugees in Germany, considering the high number of people who fled Ukraine to Germany?

Best wishes for you resubmission.

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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.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #4: No

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[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.

PGPH-D-22-01853R2

Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: a cross-sectional, population-based, multi-level analysis in a German federal state

PLOS Global Public Health

Dear Dr. Mohsenpour,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’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 Oct 02 2023 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 globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ 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 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'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Jianhong Zhou

Staff Editor

PLOS Global Public Health

Journal Requirements:

Additional Editor Comments (if provided):

[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: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #4: (No Response)

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2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: (No Response)

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. 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

Reviewer #2: Yes

Reviewer #4: (No Response)

**********

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

PLOS Global Public Health 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: Yes

Reviewer #2: Yes

Reviewer #4: (No Response)

**********

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: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #4: Dear Authors,

Thanks for sharing your revised manuscript. It is great to see how you have addressed many of the questions I shared. There are still some concerns to be further addressed in your manuscript.

Best wishes for your resubmission.

- The length of stay in the collective accommodation centres is a potential confounder that

has yet to be considered in the analyses. Authors should explain why they did not include this

confounder and reflect on this in the limitations.

We have added details on the lack of data on length of stay in the limitations section

(lines323-324).

Great that you have added this statement to refer to this limitation of your study. This is not a minor limitation. Please refer to this limitation in your abstract and conclusion and try to reflect on how you think the following outcome of your study: “No significant clustering was found for symptoms of depression” would be influenced by including the length of stay in collective accommodation centres.

- Could the authors put their study in the context of the current situation of asylum seekers

and refugees in Germany, considering the high number of people who fled Ukraine to

Germany?

A direct comparison or contrasting of the different ASR populations is out of scope for this

manuscript. The current Ukrainian refugees arrive(d) in Germany with a protected status as

war refugees and do not need to apply for asylum in Germany. As such they are not part of

the usual trajectory in terms of housing, are not placed in the initial state-wide reception

centres, and have high residential mobility.

I am not suggesting comparing your study population with other populations. Some Ukrainian refugees are staying in some of the collective accommodation centres where you collected the data for your study. Any reflection on how did the arrival of high numbers of Ukrainian refugees to Germany impact the living conditions in collective accommodation centres?

Best wishes for you resubmission.

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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.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #4: No

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[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.

Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: a cross-sectional, population-based, multi-level analysis in a German federal state

PGPH-D-22-01853R3

Dear Mr. Mohsenpour,

We are pleased to inform you that your manuscript 'Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: a cross-sectional, population-based, multi-level analysis in a German federal state' has been provisionally accepted for publication in PLOS Global Public Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

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 globalpubhealth@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.

Best regards,

Julia Robinson

Executive Editor

PLOS Global Public Health

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Reviewer Comments (if any, and for reference):

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: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #4: All comments have been addressed

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2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. 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

Reviewer #2: Yes

Reviewer #4: (No Response)

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

PLOS Global Public Health 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: Yes

Reviewer #2: Yes

Reviewer #4: Yes

**********

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: My observations were addressed from previous versions, and I consider that residual observations made by another reviewer were addressed now

Reviewer #2: All corrections have been addressed. I recommend the manuscript to be published without further corrections.

Reviewer #4: Dear Authors,

Thanks for adequately addressing the comments I shared.

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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.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #4: No

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