PONE-D-23-37675Prevalence, Predictors, and Economic Burden of Mental Health Disorders Among Asylum Seekers, Refugees and Migrants from African Countries: A Scoping ReviewPLOS ONE

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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: Partly

Reviewer #2: Partly

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

Reviewer #1: N/A

Reviewer #2: N/A

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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: Yes

Reviewer #2: Yes

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

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Reviewer #1: Yes

Reviewer #2: Yes

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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: To the authors:

Thank you for the opportunity to review this piece of work. This is an important area, and there is a need for research on the mental health needs of these the communities, and the larger impacts that they have. Congratulations, too, as you mention in the manuscript that this work was carried out as part of an MSc. This is a needed area of research, and the paper presents some important findings. There are some areas which could be strengthened, which I provide suggestions for below.

Abstract

Background:

I would encourage the authors to think about wording when describing migrant populations to ensure the article is not stigmatizing. For example, rather than “Inflows of migrants, asylum seekers, and refugees from African countries pose significant health and economic burdens” consider something like “Migrants, asylum seekers, and refugees from African countries may have significant health needs, with economic implications for receiving countries globally.” I would also reconsider ‘economic burden’ as a key word.

Similarly, these populations are very heterogeneous and not all migrants are more likely to experience mental health needs (and not all of these needs are ‘disorders’) so you may consider rephrasing the second sentence as: These communities may experience mental health needs due to factors such as…”.

Objective:

In your objective I might consider using a different word than ‘determine’ as you are not doing a systematic review and meta-analysis, for example ‘examine’ or ‘explore’.

Methods:

It would be helpful to have more information about the selection criteria (inclusion/exclusion) in the abstract.

Conclusion:

I would reconsider the first sentence, as the findings don’t imply mental health disorders are a major public health problem – rather, I would say something like “the findings of this scoping review suggest that many migrants from African countries experience mental health needs.” (This avoids stigmatizing the mental health needs of these communities by labeling them as problems).

Introduction

As an overall point, it would be helpful to define the terminology you are using for these communities early on. For example, how are you distinguishing asylum seekers, refugees, and migrants? Other terms I noticed in the paper included forced migrant, immigrants, non-forced migrant populations. It would be useful to have any terms used defined, and then used consistently.

Some of your citations (e.g. 2) are nearly ten years old, so I would consider updating with more current information (particularly as migrant patterns have also changed in the context of covid).

I would consider adapting some of your wording to avoid stigmatizing these communities. For example, rather than “The ability to cope with stress, work productively and fruitfully, and contribute to society is significantly impaired…” something like “Asylum seekers, migrants, and refugee groups may experience barriers to coping with stress, working productively and fruitful, and contributing to society” as not all migrants will be affected, many can contribute meaningfully, and it is the barriers placed before them (not their fault).

Methods

Spell out acronyms (like LJMU, AIR, PTSD) the first time they are used.

Regarding the selection criteria, it would be helpful to clarify whether any publications with mixed populations (both from Africa and elsewhere) were excluded, or just those where African populations could not be disaggregated. If it is the former, this should be addressed as an important limitation as there are likely to be numerous papers that do report on African populations that thus aren’t considered, which may bias the findings.

There is a section that reads “To chart the data, the first step was to review the abstracts” – I wasn’t sure if you were talking about data extraction here or screening. I do see that you have a separate section ‘data charting’ later on. Is this section perhapsmeant to be about screening? (e.g. you mean that to screen yielded papers for relevant texts an abstract screening was carried out before a full text screening?) If so, this language is probably more typical to use than “to chart the data”.

Looking at the search terms, it appears that the population terms you used were just relevant to refugees and asylum seekers. If this is the case, then the search would just have been focused on yielding papers on asylum seekers and refugees (not other migrant groups). Is this review specifically focused on these populations only? If so, this needs to be made clear throughout, including the abstract, introduction, methods (e.g. inclusion criteria) etc. In the list of search terms I also note that terms for depression, ptsd etc are not included. I would encourage the authors to consider revising the search strategy and updating the search before publication to include a broader range of mental health terms (and migrant terms if the review is intended to include individuals outside of asylum seekers and refugees). I also think there are limitations to having included search terms for Africa. I appreciate this is the population focus of the review, but the limitation in including this in the search strategy is that if, for example, a paper is specifically on refugees from South Sudan, the word Africa may not be used, but rather South Sudan. As a result, this paper may not get picked up. In my experience, thus, it is best practice to hand search by country/region. An alternative is to include all African countries and other terms (e.g. sub-saharan) in the search strategy.

For me, this guidance also applies to the use of economic terms, as it is challenging to have a comprehensive enough search strategy to identify papers that include data on economic impact, and is better to do through hand searching. In addition, my other concern is that the structure of the search strategy means that papers would have to include both mental health and economic terms to be picked up, but there is likely a wider range of literature that reports on one or the other. As a result, I think there is a risk you have missed papers. This is a challenge of trying to create one search strategy for multiple outcomes, and typically multiple search strings might be used then the results all pooled before screening.

You note that you use a modified version of the Appraisal Tool for Cross-Sectional Studies (AXIS). Is being a cross-sectional study one of the inclusion criteria? I don’t see this mentioned in the methods, so it would be helpful to clarify what study designs were included and whether only cross-sectional studies were included. If other study types were not excluded, then it raises the question of how quality was assessed for those study types. I can see in the results, for example, that qualitative research was included. This needs to be mentioned in the methods, and appropriate quality appraisal carried out.

In the ‘data charting’ section you outline what information was extracted on measurement of mental health, however you don’t mention what (if any) information was extracted on economic outcomes. If this is a key focus (which it seems to be from the aims, selection criteria, and search string) it would be good to include a description of this as well.

In the data quality assurance section you talk about selection criteria, and screening to some extent. It would be useful to have separate sections for this (see comment above about ‘screening), which presumably would precede the data extraction/charting section.

In the data analysis and synthesis section you describe generating themes. However, it seems that you were excluding qualitative studies (e.g. just including cross-sectional studies), so it raises the question of why qualitative data were not included. In addition, since your research questions are in part focused on prevalence, I feel further justification is needed for why this analysis approach was used.

Results

The results begin by describing the screening process - this content might be more suitable for the methods section (the steps used, not the numbers).

Overall, the results provide a good summary of the mental health needs identified, and key predictors, as well as highlighting the lack of data on economic impact. The tables and figures support the findings well. However, in the methods you mention that you identified themes in your analysis. I don’t see themes presented here in the results, so it may be beneficial to slightly rethink how the methods describes the process of synthesizing the information across the studies if themes were not identified and are not presented in your results.

Discussion:

The discussion highlights some important areas. Some of this could perhaps be brought out more in the results, for example differences in rates of mental illness between children and adolescents from migrant backgrounds compared to native-born populations, differences between accompanied and unaccompanied minors, and the content around families. These findings are important, and only mentioned in the discussion, so a section in the results could be beneficial.

In a few places, the discussion could be strengthened by engaging with more of the wider literature. For example, how do the rates in African migrant/refugee/asylum seeker populations compare with rates in other migrant/refugee/asylum seeker populations? It might also be useful to include some more of the literature around acculturation, and the healthy migrant hypothesis vs the migration morbidity hypothesis.

The section in the discussion around the instruments used is good. It could be further strengthened by including a discussion of the critiques of the use of wester/biomedical instruments and mental health disorders in migrant populations, as well as critiques around normative distress vs the over medicalization of these communities (see Derek Summerfield’s writing for example).

It is great you have highlighted key strengths and limitations. Typically these are written out (rather than bullet points), but this is a stylistic issue the journal can decide on. The last ‘strength’ could also be reworded to avoid stigmatizing these communities – I think it is problematic to say that these communities pose a ‘global public health threat’ – perhaps something instead like ‘these communities experience important mental health needs’. In the limitations you might also touch on the limitations of the use of these instruments in these populations.

The recommendations provide some great ideas. I would encourage the authors, though, to ensure the recommendations stem directly from what is presented in the results section. If any do not, then either remove them, tweak them, or add the relevant content that supports them to the results section.

There are some places throughout the abstract and full text where minor editing/grammar can be corrected.

Reviewer #2: Dear Authors,

Interesting research topic, but the review study needs a bit more in-depth analysis to enhance its impact. It could also benefit from reorganising the text and proofreading, as certain parts were hard to follow and lacked justifications.

Introduction

Provide a description of “forced migrants”.

Line 91- Provide more context about this “increasing the challenge of screening health conditions efficiently.” The influx of migrants is not the direct factor affecting screening efficiency.

Paragraph 2 is a bit hard to follow. The first three lines can be revised to make the point more straightforward.

Line 104-106; supporting references required.

Line 120-122: Is the scoping reviewed referred to here about general or forced migrant populations?

Lines 122-123; supporting references required.

Methodology

Why was the search date started on 1 January 2000? Provide justification.

Table 1: The search terms used in 1-4 are limiting and would have missed other papers mentioning just mentioning “immigrants” or “asylum” as a word (e.g. “people seeking asylum”).

Also, words in 19-21 would miss out on studies mentioning “finance” and “income” related terms etc, but not “economics”.

This section should clearly define the core terms “Prevalence, Predictors, and Economic Burden” in the context of this work, so it is clear precisely what you are looking into.

AXIS appraisal is for cross-sectional studies (a quantitative study design); although this was modified to 5 questions, I do not think it is appropriate to have used for the qualitative studies.

Results

Line 255 – Did all the quantitative studies use a cross-sectional design? Make this clear.

When mentioning authors in-text, you do not need to include their initials.

Paragraph 3, line 6: what comorbid conditions?

Analysis of your findings is quite limited and contrary to the extended relevance presented in the discussion. Also, there are several contextual repetitions, especially about PTSD. Further analysis by population groups (e.g. Children and adolescents) would improve the summarisation.

It is possible that the lack of relevant papers on the economic burden of MH disorders might be due to the search terms being too narrow. Most papers may not have used the word “economic.”

Discussion

Most of the information in the section “What do the review's findings mean for host countries?” is not entirely relevant to the focus of your review. The section also does not emphasise much on the relevance of your findings to host countries.

Several claims in this section do not come through clearly in your results. I recommend reanalysing your data and mapping your discussion to reflect that.

Conclusion

Ideally, the end of a journal paper ends with a conclusion statement/paragraph, not a list of recommendations. Also, the recommendations should come before the conclusion and could be placed in a text box to provide clearer emphasis.

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Reviewer #1: Yes: Laura B. Nellums

Reviewer #2: No

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Prevalence, Predictors, and Economic Burden of Mental Health Disorders Among Asylum Seekers, Refugees and Migrants from African Countries: A Scoping Review

PONE-D-23-37675R1

Dear Dr. OSMAN,

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.

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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

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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

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

Reviewer #1: N/A

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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

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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: 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: Thank you for all of the time and effort you have put into this. I can see how thoughtfully you addressed my comments. Well done!

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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: Laura B Nellums

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