Title: FACTORS ASSOCIATED WITH DEPRESSION AMONG YOUNG FEMALE
MIGRANTS IN ETHIOPIA
Version: 2 Date: 15 Nov 2021
Reviewer's report:
Thank you for the opportunity to review this manuscript. It is my belief that these are very
important data that are provide novel and unique descriptions and provide new understandings
of mental health and depression of young people in Ethiopia. In light of this belief, I sincerely
hope that  the authors will consider the comments that I have on the current manuscript. Some of
my comments are merely request for additional information and clarification. More importantly
however, are my relatively few comments about the parts of the manuscript that deal with the
methodology that, in my view, deserve additional attention in order to reach valid and reliable
conclusions. In my view, the most interesting and novel findings in the manuscript relates to
the insight into how mental health is related to the causes and consequences of first, migration
and second, involvement in sex work. It is my belief that further insight into these causes and
consequences can be obtained with these important data.
1. I would like to see a little more clarification about why the sample sizes and descriptors are
different in this manuscript as compared to the report that the authors refer to (Erulkar, Girmay
and Negeri, 2017: Table 4).
2. The manuscript would improve by a more careful use of terms. The term sex work in particular
need careful attention. Sometimes it is “commercial sex work” at other times it is “sex work”
and once (at least) it is “bar sex workers”. Most researchers use the term “sex worker” as a label
to describe a person who makes income from selling sexual services. Avoid using “migraters”
to describe migrants. The definition of “migrant” would benefit from clarification.
3.  I would like to learn a little more about the methodology. In particular, the authors describe
some novel administration of the PHQ-9. Their revisions are unclear to me and only describe
six of the nine questions. What about the other three?
4. The sampling strategy is unclear to me as is the categorization of work. I would like to
learn a little more about how the work status and occupations of participants were categorized.
It is common for people to have several income earning activities in particularly within low
prestige service occupations. How did the researchers categorize participants viz occupation?
Please clarify this statement: “approaching potential respondents for interview.” Did the
interviewers approach all individuals whom they identified as being women? Or did they
approach individuals selectively? If so, how did they select individuals?
5. The variable forced sexual initiation is not well described in the reference supplied (Erulkar,
Girmay and Negeri 2017). Please clarify.
6. The report referred to above state that an inclusion criteria for many participants were that
they had “dropped out of school before age 16”. It is very important to inform the reader of this
inclusion criteria and emphasize that all findings only apply to individuals who “dropped out
of school before age 16”. Some estimates indicate that the findings only apply to about 50% of
young people in Ethiopia based on this inclusion criteria. (https://www.epdc.org/sites/default/
files/documents/Ethiopia_OOSC_Profile_2.pdf).
7. Please avoid using the word “common” to describe frequencies: “depression was common
among commercial sex workers” , “mental health disorders are common”. In both instances, the
characteristic only apply to a minority of people whereas the reader may assume that it applies
to the majority of people.
8. “making migrating populations markedly young and female.” It may be appropriate to point
out that this is by far the most common pattern in the history of rural to urban migration.
9. Please clarify the apparent contradiction between the statements that “Several facility#based
studies have validated PHQ#9 in Ethiopia [14, 15].” and “Three statements used in the standard
PHQ#9 battery of questions were separated into two items. This is because, during pretest of the
questionnaire, respondents found some of the statements confusing, overly complex, or difficult
to understand.”
10. While admirable, it is unclear to me that the ownership of a blanket or a bed is a good
indicator of wealth: “exception of domestic workers, among whom only 23 percent owned two
or more of the mentioned assets, likely reflecting a much lower economic status among this
category of respondents.” According to the report referred to above, many domestic workers
live in a setting provided by their employer.
11. My most important two concerns have to do with the multivariate analysis.
a. In particular, non-migants are excluded from the analysis without a strong justification.
It would seem to me that the relationship between migration and mental health could be
investigated by including this group in the multivariate analysis.
b. Importantly, the authors create two different multivariate models without a clear justification.
Based on these two models, the authors reach a conclusion that sex workers are different. This is
the justification for the two different models: “Because commercial sex workers were a distinct
group in terms of mental health profile, we conducted a sub#group analysis with commercial
sex workers as a stand#alone category.” It is not clear to me that the profile is different. All I see
is that the frequency of depression is different and the minor differences in table 3 (incidentally,
it is not clear to me how the authors tested for statistical significance here). In my mind, this
does not justify a separate analysis for sex workers. Alternatively, find empirical tests to justify
separate analyses.
c. Thus, if possible, I think that the analysis would be much more illuminating if rural people
and sex workers were included in the analysis as additional covariates.
12. I have two more small comments regarding the analysis.
a. How did the researchers deal with missing data?
b. The sexual history variable is illogical to me because I do not see the variable “sexual
initiation: yes/no” as one category in the same variable as “forced sexual activity”. Perhaps try
to the dichotomy “forced sexual activity: yes/no”.
13. Please reconsider the sentence “This suggests that the conditions of work that are in conflict
with one’s religion or values may undermine one’s mental health, in addition to the well#known
physical and health risks faced by young women in commercial sex work.”
a. There are too many behavioral differences between different faiths that must be eliminated
before reaching the conclusion that values affect the causal link between work activity and
mental health.
b. There are much research that show only small differences in the physical and health risks
between low prestige service occupations including the report referenced above. In this report
I read many instances of abuse faced by domestic workers. Of course, there are big differences
within occupations depending on the work situation.
14. A revised analysis may illuminate further the important impact of life changes such as
divorce and social support on mental health, controlling for income earning activities (and vice
versa).