Title: Mental health of clinic-attending Syrian refugee women in Jordan: associations between
social ecological risks factors and mental health symptoms
Version: 2 Date: 21 Sep 2021
Reviewer's report:
The authors took a serious look at the comments and suggestions.
They made the required changes and when they did not incorporate the suggestions, they
explained why they did not.
They also indicated very disciplined what changes they made and ensured the traceability of
the changes.
However, there are still some issues that require correction or development before the article
is published.
I'll start with the ones I consider essential.
I will indicate the lines in the document in which I accepted all the changes - in the document
with track changes otherwise it was very difficult to understand the final form of the text.
It is about what the authors call the rate of (probable) depression, anxiety, PTSD) or prevalence.
The authors speak correctly about prevalence rates when referring to the values 62.92%
(depression), 57.46% (anxiety) and 66.21% (PTSD) lines 41-42, lines 381-385 (although in these
lines they do not explicitly mention the values - should!)
However, they do not talk about prevalence in the text referring to Table 1.
In table 1 and the related text they talk about the percentage frequency distribution / proportion
in which the risk factors are distributed in the 2 groups (with mental illness and without mental
illness). It is something other than the prevalence rate.
As such, the authors are asked to redo the wording in 230-233, 277-283 and probably 142-143.
Lines 41-42 rates of probable depression to be 62.92%; anxiety 57.46%; and PTSD 66.21%.
Lines 142-143 First, we examine the rates of depression, anxiety, and PTSD among our sample
of Syrian refugee women
Lines 381-385 We found rates of probable mental health conditions among our sample of Syrian
refugees to be high when comparing them to prevalence rates from a recent systematic review
of Syrian refugees displaced in 10 different countries globally: depression (20-44.1%), anxiety
(19.3-31.8%), and PTSD (23.4-83.4%) [45]. One possible explanation for these high rates is
because our sample focused exclusively on women.
Lines 386 – 389 Higher rates of mental illness among women was suggested in a study of Syrian
refugees residing in a tent city in Turkey, where estimated probability of PTSD within their
sample was 71% if they were female gender, diagnosed with a psychiatric disorder in the past,
having a family history of psychiatric disorder, and experiencing 2 or more traumas [46].
The Prevalence
Lines 230-233
…. to examine the prevalence of probable depression, anxiety, and PTSD. Chi-square test or
Fisher’s exact test was used to calculate significant differences in categorical variables between
two groups, while t-test was used to calculate significant mean differences for continuous
variables between two groups.
Lines 277-283
Bivariate findings of covariates and mental health conditions in Table 1 demonstrate significant
differences in the prevalence of depression based on the time displaced in Syria (p=0.007),
clinic location (p<0.001), and Syrian region of origin (p=0.002). Significant differences in the
prevalence of anxiety were also found in bivariate analyses of years in Jordan (p=0.0129), time
displaced in Syria (p=0.026), clinic location (p<0.001), and Syrian region of origin (p=0.005).
Significant differences in the prevalence of PTSD were found in bivariate analyses of time
displaced in Syria (p=0.050), clinic location (p<0.001) and Syrian region of origin (p=0.001).
Also in table 3, the proportion of the two layers of perceived exposure (big / very big problem
compared to no / moderate problem) is calculated within those with disease and those without
disease.
I think that the authors should check and clarify for what kind of differences they tested the
statistical significance.
In contrast, in Table 2, the authors practically calculated the prevalence of probable mental health
conditions but did not report this.
Another important reproach I make to the authors is that they limited the interpretation of odds
to a description of the values in the table but did not go further.
I am convinced that they know how to interpret odds as shown in lines 412-413 on Table 4.
Lines 412-413 At the community and societal level, we found that each additional postmigration
stressor increased odds of experiencing a probable mental health condition by approximately
30-50%.
They also do not make a clear interpretation of the meaning of the similarities or differences
between unadjusted and adjusted OR. (See similarities for community and societal risk factors
(for depression, anxiety and PTSD) and Interpersonal risk factors, for age (anxiety and PTSD),
married (PTSD).
And so on for tables 4 and 5.
I would also have expected the authors to comment on what broad CI versus narrow CI means
(the difference between lower and upper limits).
For the effect of age on outcomes, I would have expected them to point out that odds are higher
by 4% (and between 1% -6% or 7%) for each year of age.
I was surprised that they did not figure the increase or decrease of odds in the adapted
figure. Thus, they could have made a more eloquent and meaningful plea for possible lines of
intervention for those less familiar with statistics.
For example, the fact that poor access to psychological services increases unadjusted odds for
depression by 99% (24% -290%) and adjusted odds by 71% (5% -180%) seems very inspiring
to me for possible policies.
And so on for all other situations.
Perhaps the authors could make a staggering, an ordering of the results according to the biggest
odds, at least in the part of the conclusions.
I think they should also differentiate between odds and probability/likelihood - because they are
two notions with different meanings and are calculated differently. See below.
… odds is the ratio of the probabilities of an event happening to that of it not happening
while likelihood is the probability of a specified outcome; the chance of something happening;
probability; the state of being probable.
Now I will list a few minor remarks.
The abstract still lacks a beginning phrase to describe the importance of the problem /
phenomenon studied.
The authors talk about Mental health outcomes (9 times from which 2 with “probable”), mental
health conditions (21 times), adverse mental health (2 times), probable case for depression,
generalized anxiety disorder, PTSD…. (3 times). Probable depression (once), probable mental
health conditions (twice), probable depression, anxiety, and PTSD (4 times) and so on. It seems
to me a great diversity if it is about the same thing.
There are some passages where English does not sound good or sounds confusing. A rewording
would be welcome.
Lines 105-106, line 120, line 128 (conflict-affected women) (war or family?)
Gendered inequities in line 157. Only women are studied.
Amman or Sweileh region?
Lines 224-225 - in which of the categories were included those with exactly one year of time
displaced in Syria?
There are several repetitive formulations that could be synthesized. (About Cronbach’s alpha
in lines 179, 185, 191)
Please check the bibliographic list. Some names are capitalized. (Reference 41) Instead in
reference 39, PTSD, DSM-5, PCL-5 are written in lower case.