Reviewer’s report
Title: 
Addressing the interaction between food insecurity, depression risk and
informal work: findings of a cross-sectional survey among informal women
workers with young children in South Africa.
Version: 
0 
Date: 
22 Jul 2020
Reviewer's report:
This paper is an important and carefully-constructed contribution to the
emerging field of social determinants and maternal mental health. The authors
are addressing a notable gap in knowledge pertaining to the relationships of
income generating conditions, food insecurity and maternal depressive
symptoms.
My critique includes mostly minor issues.
Title
The authors correctly state throughout the paper that as mental health screening
tools were used, they were assessing for symptoms or risk for depression. Thus, I
suggest the title similarly includes this cautious language.
Abstract
The nature of the study is only able to demonstrate associations. Thus, I suggest
that the concluding remark that low incomes and high rates of food insecurity
increases the risk for poor maternal health etc be phrased more cautiously. 
The
study has shown that some of these factors are associated with poor maternal
mental health. Further, the direction of association has not been demonstrated
nor has the potential bidirectional nature of these factors been considered. 
Also,
the study has not measured or reported on maternal physical health, child health
or child development outcomes and thus this should not be included in
concluding remarks. 
Similarly, if one is conjecturing that the relatively low depression risk among
informal workers may be linked to high levels of resilience, one would need to
consider the converse possibility - that innate resilience factors enable certain
women to generate income through informal work (in a job-poor economy) and
that having some income is protective against depressive symptoms.
The final statement seems to be missing a 'to' before 'care for their children'. 
The authors could consider that the interventions they suggest, may have value
for the mothers' wellbeing independently of, but in additional to, benefitting their
roles/functioning as caregivers.
Background
The term 'perinatal' generally refers to the period of pregnancy and up to the first
year after the birth of the baby. Thus, the term 'immediately' in the first sentence
is ambiguous. 
I would avoid citing prevalence data based on studies that have used screening
tools to assess for depressive symptoms. Citation 7 refers to a study that had a
small sample size, several methodological short-comings and used two screening
tools to determine the rate of 50%. Even though the cautionary phrase 'may be as
high as' is used, I suggest that other local work on postnatal depression also be
reflected and a bit more context is given for this prevalence data, e.g. based on
large or small samples, screening measure or diagnostic measures used etc.
Given the known comorbidity of depression and anxiety disorders and that the
authors mention the relationship between anxiety and food insecurity on a couple
of occasions throughout the paper, it would be useful to refer to any relevant
epidemiological data on perinatal anxiety.
Line 98 - suggest insert a comma after "In SA"
Line 108 - The reference to the Brazilian study which suggests informal work
may increase the risk of psychological symptoms - what is the increase
compared to?
Line 110 - the term 'largely invisible' is a rather vague and would benefit from
further explanation.
Recruitment and sampling
I suggest that rationale be explained for excluding participants based on working
fewer than three days a week or being in informal work for less than six months.
It strikes me that these two criteria each separately, and possibly through
different mechanisms, may confer particular risk for women in the perinatal
period. It is not clear whether the authors elected to sample such that these
potentially higher risk groups be excluded from the analysis for this reason.
It should also be made clear that no formally employed women were recruited
for the study and how this process of sampling took place.
The subgroup of participants with older children, is referred to variously as
'mothers of…. children aged 12-35 months (pg 6), between 12 and 39 months (pg
9), and 12-36 months' (table 2) - please standardize.
I do not believe that that there is scientific rationale for using two screening tools
as opposed to one. It is mentioned under 'strengths', that this enabled a validation
of data. However, simply comparing screen positive rates on one tool versus
another does not constitute a validation exercise. Rather, this would involve
Receiver Operating Curve, correlation analysis, factor analysis or some other
relevant method. Thus, it is not clear what was the utility of using both tools. 
Although it is likely that the EPDS scores were analysed on a continuous scale,
as opposed to the Whooley scores, this should be made explicit. 
I do not have adequate statistical expertise but was puzzled by the choice of the
unusual p value significance level of <0.3 (line 182). Is this a typo and meant to
read <0.03 as per table 6?
Results
For relationship characteristics, the categories do not seem logical to me. Were
all separated/divorced/widowed women without current partners? How were they
differentiated from the 'single' category? It is possible and likely, given SA
realities, that a substantive proportion of married women may also be living
separately from their partner. Were the two 'in a relationship' categories referring
to women not formally married? Given the focus of your work on partner
support, it would be relevant to explore cohabitation and formal relationship
status carefully to determine what sorts of relationships may be protective versus
those that may confer risk to mental health and food security.
HIV status - from the table, it appears that HIV status was based on self-report.
Thus, I suggest this be made clear whenever HIV status is subsequently
mentioned in the paper. It is possible, given the stigma associated with HIV, that
this may be an under-representation of true HIV prevalence among your
participants. Thus, this would need to be borne in mind for all analyses using this
variable.
The 'short' duration of leave around the time of childbirth should be defined.
In table 2, a lot of granular detail is provided on infant feeding, time off work,
and child care arrangements. However, these issues are not adequately woven
into the background nor the discussion of the paper to explicate their relevance
to maternal depression or food security. Nor is it clear how work type or no work
may link with these issues.
The term 'informal enterprises' (line 238) may be misleading. It appears for some
types of work you have included under 'informal', i.e. administrators, call centre
workers, factory workers, that the enterprises themselves may indeed be formally
constituted. Rather, the informality lies in the conditions of employment. This is
relevant because, for these enterprises, the responsibility vis a vis good labour
practice and protection of vulnerable workers, rests squarely with the enterprise
owners/employers. It may be useful to highlight this in your discussion and refer
to relevant labour legislation, which is in this regard in SA. Are these enterprises
flagrantly disobeying labour law with respect to employing women on contract
with UIF and other relevant benefits? If so, this may need to be highlighted in
the discussion. You do allude (line 390 onwards) to policy frameworks for
employers (among other stakeholders), but this could be expanded upon.
The word 'women' is redundant, and possibly confusing in the title on line 250.
Given the many challenges faced by poor women in SA in accessing the Child
Support Grant, it would be relevant to note whether any of your participants
were eligible for grants and were not receiving these, e.g. had grants from some,
but not all children; or had no grants, but had children eligible. This information
would strengthen the later recommendation related to CSG with respect to
accessibility matters.
It is a limitation of the study that there was no assessment of the proportion of
support from the father of the children or other family members. It follows that a
father (or other source of support) may provide very minimal or occasional
contributions but would still be categorised as providing support or 'sharing
costs'. Some form of graded categorisation of contribution amount would have
allowed for more nuanced analysis of the associations of support with the other
outcomes of interest. Further, this data would enable evidence based
recommendations to be made on maintenance law implementation.
Line 289, suggest add comma after 'analysis'.
The factors included in both multivariable models should be stated.
Table 6 heading should include 'symptoms' after 'depression' to reflect the fact
that a screening tool was used.
Discussion
Line 336 - The phrase 'all the individuals needs' should be reworded for clarity.
Lines 339-344 - the argument does not flow coherently. Initially, the authors
report their own findings. A linking phrase or concept is then needed prior to the
statement about food insecurity being a source of anxiety and determinant of
poor mental health from a Ugandan study. 
There is no evidence from this study
and no citations offered to support the statement that starts 'As a result,…' In fact
the time off work matter is poorly developed through this paper and the collected
data on this does not seem to have been analysed or interpreted with respect to
time off work for women in formal employment, nor with respect to food
security or depressive symptoms.
Line 345 - The peri-partum period is a 'vulnerable time' for several reasons
additional to the economic. The language here should reflect this.
For the first time, in line 347, the authors mention women's reporting on the
helpfulness of the CSG. It is not mentioned in the methods section how this was
assessed. Nor was this information reported in the results section.
Line 355 -356 - The term 'perinatal' is confusing. It is not clear whether you are
advocating for the CSG to extend to the antenatal period or not. Currently, by
law, covers the postnatal period but there are barriers with with processing and
access during the first few weeks after the birth. Are you suggesting that these be
addressed?
Line 359 - the term 'confirmed' is inappropriate given that screening tools, and
not diagnostic instruments were used in your study. 
The discussion on resilience appears to have ignored the possibility that having
any income from work (versus being unemployed) - rather than resilience factors
- may confer protection for mental health conditions. This is borne out in the
poverty-mental health literature. The following paper may be of interest: Lund,
Crick, et al. "Social determinants of mental disorders and the Sustainable
Development Goals: a systematic review of reviews." The Lancet Psychiatry 5.4
(2018): 357-369."
Lines 373-374 - I assume the phrase 'especially after childbirth' is based on
results shown in Table 5. However, it is not clear from these results, how this
interpretation was reached.
Line 385 - a reference is required for the statement 'childcare is often
considered…'. 
Line 386 'Encouraging…' to end of paragraph - this statement is vague, does not
follow from the previous comments on the role of fathers. Gender issues could
be explored more carefully in the discussion.
As per above, the non-compliance with labour law by some employers also bears
more careful discussion and associated recommendations could be made.
Line 401 - grammatical error on sentence starting with 'Thereby..'
The practical suggestions pertaining to adaptations of the health systems and the
role of health providers are excellent. 
Suggestions for further research may include qualitative enquiry into the
complex and often inter-related variables under investigation. Further, analysis
that includes assessment of moderating and mediating factors would also add to
the knowledge base. Further research may also importantly explore food
insecurity and mental health status for women who have formal work and those
who have no work as comparison groups with each other and with women
working informally.
The following paper on the syndemic framework may be of interest: Laurenzi,
Christina, Sally Field, and Simone Honikman. "Food insecurity, maternal mental
health, and domestic violence: a call for a syndemic approach to research and
interventions." Maternal and child health journal (2020): 1-4.
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No
Are the methods appropriate and well described?
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Yes
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authors.
Unable to assess
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Yes
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I recommend additional statistical review
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Acceptable
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