Title: Adolescent girls’ explanations of high rates of low mood and anxiety in their population:
A co-produced qualitative study
Version: 0 Date: 19 Sep 2024
Reviewer's report:
The manuscript provides an original and important contribution to the literature on adolescent
girls’ mental health, particularly as qualitative research on this topic among young females is
limited. The co-produced design utilised as part of the research is a key strength of the study.
That said, the manuscript could be strengthened with some revisions, most notably in terms of
clarity in the introduction/background section of the manuscript and the rationale for the study,
the study aims, and the discussion. In particular, the introduction/background and discussion
sections need improvement in the structure of paragraphs, including linking sentences between
paragraphs and more clear and succinct language. Some additional information in the methods
section would also aid in the replicability of the study and provide readers with more context.
I have provided further explanation below:
Abstract:
• Background sub-section – the background could be more succinct and clearer e.g. the second
sentence refers to ‘such disparities’ what disparities? The preceding sentence implies that girls
are at greater risk of experiencing low mood and anxiety compared to some other group but who
– is it males/boys of the same age or older females? State this here.
• Aims sub-section - omit ‘rather than relying on researcher hypotheses’, this is not needed –
you can just clearly state ‘the aim of this study was to qualitatively explore adolescent girls’
perceptions of…’
• Methods sub-section – This needs to be split into two sentences. E.g. second sentence could
focus on analysis ‘Data were analysed using reflexive thematic analysis.’
• Analysis sub-section – This is not an ‘analysis’ sub-section, it should be titled Results or
Findings. Your approach to analysis is reported in Methods.
• Line 39 - if ‘normal’ in this sentence is a participant quote, it should be in double inverted
commas e.g. “normal”.
• Lines 42, 43 – This sentence needs editing, it is not clear. e.g. Throughout discussions (or focus
groups) and is it meant to be ‘complexities related to individual differences, sociodemographic
and societal contexts as influencing low mood and anxiety?’ As it reads currently, this sentence
does not tell the reader what these complexities are related to.
• Conclusions sub-section – Again, this sentence could be split into two sentences. Further,
this sub-section needs to state how the study offers a critically important contribution e.g. the
interwoven and complex nature of girls’ lives as influencing low mood and anxiety
Introduction/background:
• Overall, I believe significant revision is required to improve the structure of this section. There
is currently limited logical flow to the presentation of concepts and reviews of the literature,
and limited linking between sentences within paragraphs and between paragraphs. It is not
always clear what point the authors are trying to convey in building the rationale for the study.
Frequently throughout this section the authors start new sentences and paragraphs with ‘this’ or
‘these’ rather than with transitional words or phrases, assuming the reader automatically knows
what ‘this’ or ‘these is referring to. The rationale for the need for this study can be implied but
the way this section is written does not provide a clear and convincing rationale at the standard
required for publication.
• Line 68 – unsure how policy highlights drivers and patterns of mental health among girls and
women? Please include explanation if this is to remain.
• Line 68 – what uniqueness? Provide an explanation.
• Lines 69-70 – what possible pandemic effects? Describe them in reference to the literature.
This paragraph in general could also benefit from talking about adolescence as a development
stage of increased vulnerability for the onset of mental health issue among girls.
• Lines 74-75 – what does ‘limited school emphasis on low mood and anxiety provision’ mean?
If this is meant to be referring to mental health education and promotion and/or support services
for low mood and anxiety in schools, this needs to be described, as it currently reads as though
a school would be providing low mood and anxiety.
• Lines 76-77 – What are the ‘considerable societal shifts in mental health discourses’ referred
to here? Please describe. How have these shifts (once described) led to potential increased
willingness to report and what research is there to evidence this?
• Line 78 – An example of where a new paragraph is started with ‘these’. What are ‘these’?
Assumes the reader should know this paragraph contains content linked to the previous
paragraph and requires a rewrite to use transitional language.
• Line 78 – This whole sentence needs a re-write to be more succinct. It is currently unnecessarily
convoluted.
• Lines 78-87 - The whole paragraph is unclear and doesn’t provide sufficient detail or rationale.
• Line 88 –What are the ‘such explanations’? A new paragraph needs to start with linking and
transitional language not an assumption that the reader has retained ‘such explanations’ from
the preceding paragraph.
• Lines 88-94 - This paragraph lacks references to substantiate the claims made e.g. ‘explanations
have come from researchers without clear input from adolescent girls, limiting capacity to
meaningfully explore and address inequalities’ what evidence is there that you can refer to here?
Have other researchers also stated this?
• The second sentence starting in line 90 comes out of nowhere and is unnecessarily long – this
needs to more clearly relate to the point the authors are trying to get across in the paragraph.
After re-reading the paragraph several times, I am still unclear on what the key concepts are
in this paragraph.
• Line 95 – ‘some factors explored above’ needs to be removed from this sentence – the authors
need to clearly outline here what they are referring to. The factors can be re-listed without
duplication of the preceding sections.
• Lines 97-98 – reference the few peer-reviewed studies you are referring to. Also, why the need
to say ‘peer-reviewed’? are there specific non-peer-reviewed studies the authors are alluding to
here that need brief explanation?
• Line 107 - Another new paragraph is started based on assuming the reader knows to link to
the previous e.g. ‘data in these studies’ what studies?
Aims:
• As mentioned in feedback to the Abstract, omit ‘rather than relying on ‘top down’ researcher
hypotheses, this is not required. It is not related to the aims or purpose of a qualitative study.
• The theoretical framework used should be in the Methods section of the paper, not this
section. Once moved to the Methods section, the description could also be broken down into
two sentences, instead of trying to fit so much content within one sentence.
• The aim needs to be stated clearly e.g. ‘the aim of this study was to explore adolescent girls’
perceptions of factors related to low mood and anxiety among girls their age’ or similar. The way
the aim is stated currently, and the main question asked, is also quite leading and not a neutral
standpoint with which to explore these issues/topics with girls which should be addressed in the
limitations section of the manuscript, as responses may have differed if this question was asked
using neutral language or about low mood and anxiety in general.
Methods:
• What is a co-produced qualitative design? Describe this approach for readers who might not be
familiar with this design and explain why it was a suitable method for your study, referencing
methodological literature. The information provided in the Supplementary materials is useful
from a procedure point of view but there needs to be a brief explanation of why this method
was chosen.
• Further, related to the co-produced design, missing from the Methods and/or section seven
young women as co-researchers? related to this method in the supplementary materials is the
‘how’ and ‘who’ – how did you recruit them? Where were they recruited from? What ‘diverse
backgrounds’ warranted their inclusion?
• Participants and sampling sub-section – what do you mean by diverse adolescent girls? What
were you looking for specifically in terms of diversity - ethnicity, socioeconomic status, sexual
orientation etc? Please describe how this was defined and how you tried to achieve this in your
recruitment.
• For international readers it would be useful to describe what post-16 education settings are
briefly. I note there are examples provided but sixth forms, colleges and vocational training
centres all refer to different settings even among English-speaking countries.
• Who are the frequently referred to ‘gatekeepers’? please describe. Are these principals, other
staff in the education settings, who?
• Who contacted the education settings and youth organisations and what information were they
given? How did they then indicate their interest for the advert to be shared with them?
• Some sentences start with numeric – e.g. line 166 ’13 identified’ correct to written e.g.
‘Thirteen’
• Line 168 - The footnote is not needed. This needs to be included as part of the semi-structured
focus group guide used (add to already included guide provided in Box 1 if that’s when it was
asked or provide a copy of the demographic survey questions participants completed if that’s
where it was asked)
• Lines 169-170 – You don’t need to report on ‘none shared that they were disabled’ and ‘none
shared that they were transgender’, this is included in your strengths and limitations section
already.
• Data generation sub-section – lines 175-176 interviews can also be used to gain participant
perceptions, not just focus groups. The way this is written currently as a rationale for focus
groups is not accurate and can be omitted. The rationale for focus groups is included in the
second part of the sentence - to enable contrasting and clarification of participants’ views e.g.
the group interactions that focus groups facilitate.
• Lines 176-177 - This sentence needs clarity. Do you mean that the facilitators co-led sessions
to draw out insights from participants’ perspectives? Currently reads as ‘from their’ perspective
and implies the perspective of the university researcher and co-researcher.
• Line 179 – The sentence is not clear. Should it be ‘we brought together participants who were
unknown to each other’?
• Lines 180-181 – what is meant by ‘to limit existing relationships’? whose existing
relationships?
• Lines 180-181 – this sentence needs clarity. Could also be more succinct e.g. ‘We conducted
focus groups online using Zoom’
• Lines 183-184 - what is ‘consistent with guidance’ referring to? And ‘active discussion’ – as
opposed to inactive discussion?
• Line 186 – Box 1 needs to be relabelled as Figure 1, as per journal guidelines for labelling
figures and tables.
Findings/Results:
• The heading for this section is incorrect, reading as ‘Analysis’. This should be Results or
Findings, as you are presenting the findings/results of the study. Data analytical methods have
been described in the preceding Methods sections as the Data Analysis sub section.
• Lines 222-223 – this sentence needs an edit for clarity – what is meant by ‘attending to
agreement, nuances, and divergences in viewpoints’? If referring to participants’ agreement,
nuances and divergences in their viewpoints, then state this.
• It would be useful to include the age of each participant next to the pseudonym provided
with participant quotes, to provide readers with a sense of any differing views depending on
participant age.
• Lines 236-237 - Louise’s quote does not seem specific to adolescent girls, referring to
“teenagers”. If this is the case, it needs to be addressed in the discussion section of the paper.
E.g. some perceptions among participants indicate low mood and anxiety may not be perceived
as different between adolescent boys and girls but an issue for all adolescents.
• Line 238 – what is meant by normalisation of mental health – normalisation of talking about
mental health? The normalisation of mental health awareness? Something else? Please provide
more detail.
• Line 286 – another example of starting a paragraph and sentence with ‘this’. Please edit
throughout manuscript where this occurs. It is not immediately clear what ‘this’ is describing.
In this example, it could be as simple as changing to ‘The’ pervasive messaging… … or
‘Participants framed… …’ this is also a long sentence and I would encourage the authors to
consider breaking into two sentences.
• Page 12, lines 283 and 300. I would suggest removing the footnotes included here (Are
footnotes allowed in the journal guidelines, many state to not include footnotes) and instead
incorporate the content in the Discussion section (not as footnotes, but as content to be discussed
within the body text of the manuscript). Both footnotes on this page would add more depth to
the Discussion by providing broader context to the time that the study took place and would
demonstrate critical and analytic thinking about study findings.
• Line 304 – referring to ‘such pressures’ in a new paragraph does not make for clear flow when
reading the content for theme 3. Either include as part of the previous paragraph or describe the
pressures e.g. ‘participants explored how educational pressures may be communicated … …’
• Line 305 – some felt that ‘this’ pressure. Again, what is ‘this’? state rather than assume the
reader knows what you are referring to e.g. some felt educational pressure is greater for girls…
• Line 307 – ‘As in the previous theme’ – the name of the theme needs to be included here. The
reader will not remember what the previous theme was.
• The thematic map is missing content from Theme 4 about participants describing their
friendships as valuable mental health support sources.
• Lines 349-351 – be clear about whose quote this is and just name that one participant – readers
are not going to scroll further up within the manuscript to find a quote from Emmy. Alternatively,
repeat the quote and include both Emmy and Hanna’s quotes here.
• Line 377 – again, the reader is not going to scroll back up searching for Nazrin’s earlier
comment. Either repeat it here again or leave reference to the comment out.
• Line 383-384 ‘Participants’ needs adding to this sentence e.g. Some ‘participants’ emphasised.
Discussion:
• Line 399 – important to include here that low mood and anxiety was perceived normal – the
findings are adolescent girls who participated in the study’s perceptions.
• Lines 399-400 – what do you mean by both generally and particularly among current cohorts?
This needs clearer explanation.
• Line 411 – Starting a new paragraph with ‘some of these factors’ assumes readers remember
and can sum up the factors described in the preceding paragraph. What are ‘these factors’
referring to? When starting a new paragraph explicitly state what factors have been evidenced
as associated with adolescent low mood and anxiety.
• Lines 412-413 – This sentence states ‘Some evidence indicates a relationship between gender
norm perceptions and low mood and anxiety’ for who? Adolescent girls aged??
• There is a general overreliance on the word ‘evidence’ throughout the Discussion – can this be
edited to be more concise e.g. lines 419-421 the relationship between social media and mental
health remains unclear. This also needs to explicitly state for whom, adolescent girls specifically
or adolescents in general?
• Line 425 – This sentence is the first of a new paragraph and again states ‘this evidence base’
what evidence base? Describe and explain.
• Line 443 – Provide the name/title of the final theme where this sentence refers to ‘the final
theme’. Also what are the ‘various issues’ referring to in this sentence? Describe them.
Strengths and limitations:
• Overall, this was a clear and well written sub-section of the manuscript, accurately highlighting
the strengths and limitations of the study. However, I would add that there could be limitations
related to the age and location of participants in the study e.g. younger adolescent girls might
have different perceptions compared to the age group included in this study (Older adolescents),
and those located in countries other than England, particularly those that are non-English
speaking.
Conclusion and implications:
• Examining risk factors is mentioned here but what about the need to further explore protective
factors?
• Lines 509-511 – outline the key issues being referred to in this sentence and what the broader
concerns within the field of youth mental health are, as well as what the research priorities
referred to as having recently been established through co-produced transdisciplinary project
are – more description and explanation is needed.