Title: Mental health of clinic-attending Syrian refugee women in Jordan: associations between
social ecological risks factors and mental health symptoms
Version: 1 Date: 09 Jul 2021
Reviewer's report:
First of all, in the background are exposed aspects of methodology, although in the background
I would have expected the authors to talk about the issues addressed, namely the mental health
of refugee women, possibly aspects of their addressability and access to adequate services, the
concept of needs health services, types of political, institutional arrangements designed to cover
the needs of services for refugee women in Jordan.
The phrase on lines 110-111, I think should be removed or moved from the Background anyway.
The background usually presents what is known, what has been proven about the topic studied.
If you specify what is not known, it is necessary to study yourself in the current study.
The same is true for the statement in line 118. "but emphasized the need for more and better
quality research [21]"
And the same goes for line 132-133: "but mentioned that rigorous methods are needed to
examine these stressors in depth [32]."
Regarding the terms used, please define: multivariable versus multivariate regression,
multivariable findings, social ecology.
Line 121: Please either explain or eliminate “negative coping skills such as justification and
acceptance of IPV to cope difficult living conditions”. You have to explain what “justification
and acceptance of IPV” means - I suspect that it is about the fact that the victim legitimizes the
partner's violence by giving his behavior various “reasons”.
Please also explain the Social-Ecological Framework / The ecological model of refugee distress,
specify if it is adapted and what phases it went through from the initial version formulated by
Bronfenbrenner.
For figure 1 please mention if it is original or adapted.
Please specify the connection between the variables in the scheme and those studied by you.
More precisely in your Figure 1 you mention concrete aspects of access (practices), while in
your questionnaire you ask about fears, opinions (rather attitudes, perceptions).
As for the wording, “social ecological framework” is written 2 times (line 93, 438) and twice
with a hyphen (social-ecological framework). Line 28, 189,
On line 572, you use “An ecological framework”. Is it the same with “the Ecological model of
refugee distress” and “the Social-Ecological framework”?
Please, in paragraph 86-88, explain the difference between vulnerability, risk factor, stressors.
As for the phrase line 88-89, please rephrase it. (Understanding how these vulnerabilities
and stressors impact mental health is crucial, as sex and gender differences in mental health
conditions exist [9, 10].)
You often use the term “unique”.
Line 58: unique social ecological risk factors
Lines 128-129: how postmigration living difficulties uniquely impact mental health
Lines 145-146: Understanding the unique social ecological risk factors associated with mental
health conditions of Syrian refugee women
Line 365: Our study provides a unique opportunity to examine mental health service needs
Lines 378-379: the unique contextual factors faced by Syrian refugees in different countries
Please reconsider the term “unique” and its translation as it is not clear that it would be an
appropriate term. What are the arguments for uniqueness?
In table 3, in the Individual Category risk factors mention age, marital status - but in the text
you interpret it as (older age) line 42 or being married / engaged (Line 43)
In fact, you commit this type of inaccuracy several times: when you talk about associations
between risk factors and certain outcomes, sometimes you cite the variable in general, sometimes
a certain level of the variable, sometimes in the same sentence both variants – generic variable
and/or level, imprecise and precise.
Lines 28-29: individual (age, marital status, children under 18, ability to read / write)
It is not specified for these variables what is the level at which they become risk factors
Lines 100-101: Several individual level risk factors have been associated with refugee mental
health, including age, educational level, marital status and number of children. ((you do not
specify at what level, for which category they are risk factors)
Lines 105-106: These studies suggest younger age to be associated with greater resilience and
education to be linked to economic opportunity (It is specified for age “younger” but is not
specified for education – I suppose it is about “higher”)
Lines 117: low education level, legal status, age and certain relationship factors
(for education the low level is specified - it is clear; “certain” is not clear and for legal status
and age nothing is specified)
Lines 126-127: income, employment, housing, language skills, asylum-seeking process, social
support and isolation, as well as discrimination [27]
The level at which these variables become risk factors is not specified at all.
Lines 131, 132: postmigration stressors such as finance, housing, employment, loss of social
support to exacerbate psychological distress
Apart from the social support, which states that his loss is a risk factor, the others do not specify
at all.
Lines 147-148: women who are older, unmarried, have more children under 18, have difficulty
reading / writing, report IPV, experience greater number of postmigration stressors.
Here the level at which the variables become a risk factor is specified. (older, unmarried, more
children, difficulty, greater number).
Lines 234-236: the association between individual (age, marital status, number of children
under 18, ability to read/write), interpersonal (IPV), community and societal level risk factors
(postmigration stressors)
Here the variables are specified but not the level at which they become risk factors.
But such anticipated precision appears unnatural – for a problem not very well study, for the
descriptive design - since in the background you spoke in vague, general terms.
Please make a difference between situations when you talk about variable/item and when you
talk about the level of the variable at which becomes risk factor.
Some inconsistencies
At line 43, you declare aOR: 1.04, 95% CI: [1.02,1.06] In table 3 the upper limit is 1.07
At line 47, you declare aOR PTSD: 5.49, 95% CI: [3.09,9.78] but in the table the upper limit
is 9.76
At line 48 you declare aOR: 1.36, 95% CI: [1.22,1.42] but in table 3 the point value of aOR
is 1.32.
About references.
Please provide link for the Reference 2
(possibly) https://reliefweb.int/report/jordan/jordan-response-plan-syria-crisis-2020-2022
I did not find the reference 14 quoted in the text.
In Reference 18, from the Reference list, please enter a space between persons and A Meta-
analysis.
It's a problem with your citation style. When the references are assembled in the list of references
in the order of citation, it would be normal for the figures in the text to come one after the other
at the first mention. Or you break the order a few times.
This is observed between lines 89-95 where the references come in the following order: [9,10],
[12], [11,13], reference 14 not being quoted at all. Basically, the reference 12 should receive the
number 11 and the reference 11 the number 12.
The same happens between lines 124-130 where the citations are the following: [25, 26, 27, 30],
[27], [31], references 28, 29, appearing for the first time only at line 403, 404.
Between lines 175 and 179, you quote as follows
[35], [33,34], [36].
Basically [35] appears before [34].
On lines 184-185 you quote the references: [35,36] [39] References 37, 38 are not quoted here
but only [38] on line 214.
References following reference [45] are not cited for the first time in order
Line 378 [45].
Line 396 [48]
Line 397 [47]
Line 417 [46]
Basically [48] should become [46] and [46] should become 48.
At line 141, please change “such” to “such as”.
At line 174 I think that instead of "added", the term “summed up” would be more appropriate.
Incomplete:
Please specify what time period CES-D, GAD-7, PCL-5 refer to.
The "less than 1 year" category of the covariate Time displaced in Syria is rather "1 month - less
than 1 year" (otherwise, it overlaps with the category "less than 1 month").
Please indicate in the table where exactly you used the chi-squared test, the t test or Fisher’s
exact test.
Interpretation:
Please comment what the cut off value versus the average score value in the women's group
implies: 4 vs 5.32 (3.65) for CES-D; 10 vs 10.5 (5.66) for GAD-7; 23 vs 32.7 (19.4) for PCL- 5.
Please rewrite the paragraph below, especially when specifying the last two categories. You
should add that both/each “less than one year” and “more than one-year” categories appear in
one-third of respondents.
Less than half (39.9%) of women were displaced in Syria for less than 1 month, with
approximately one-third being displaced for less than a year (29.2%) and more than 1 year
(30.9%).
On lines 270-272 it is unclear - please keep in mind: which variable is dependent, that
the percentages give one hundred percent (100%) per column. Actually, in all people with
depression and PTSD, the proportions of those who have been displaced in Syria "less than 1
year" and "more than 1 year" are higher than among those without depression and PTSD.
In contrast, among those with probable anxiety only the proportion of those who have been
displaced in Syria “more than 1 year” is higher than among those without anxiety.
With regard to paragraph lines 273-276, I believe that it needs to be completely reworded and
corrected at the same time.
Regarding Probable anxiety: There are differences between text (txt) and table (tb) for the value
of p.
lived in Jordan longer (p<0.05) (txt) while p=0.0129 (tb)
Time displaced in Syria (p=0.05) txt while p=0.026 (tb)
Clinic location p<0.01 (txt) while p<0.001 (tb)
Different regions in Syria p<0.01 (txt) while p=0.005 (tb)
For Time displaced in Syria, probable anxiety, denote by lower case p instead of uppercase P.
What exactly is the conclusion that "women who were older had a significantly higher proportion
of having probable depression, anxiety and PTSD"? Table 1 shows only the average ages for
those with and without a condition. Age group distribution should be viewed to support your
comment.
Same question for “children under 18 in household”. I think that the proportions of those with
more than 3 children should be compared and not the average children.
The line 284 needs to be corrected -
Actually, the proportion of married / engaged is higher for those WITHOUT a condition than
for those with a condition.
The proportion of the NOT married is higher for all 3 conditions for those with condition
compared to those without condition.
For lines 285-286:
There are differences between the p value in the text and the tables and for all 3 conditions, In
table 1 Probable depression Marital status p<0.044 (txt) p=0.044 (tb)
Probable PTSD more children under 18 p=0.005 (txt) while p=0.434 (tb)
There are some results that are not included in the tables - I think it should be mentioned by the
expression Data not shown.
These are the percentages from lines 264-266, the range 18-74 from line 279, the number of
postmigration stressors from line 303-307.
As for the statement in lines 305-307, it is somewhat inaccurate.
For probable PTSD there are 12 postmigration stressors for which p <0.001,
For probable depression there are 9 stressors for which p <0.001 and 2 for which p = 0.001.
For anxiety there are 10 stressors for which p <0.001 and for others 2, p = 0.002 and p = 0.015
respectively.
That's because I adopted your formulation because I think you could more simply say that some
stressors are statistically significant and only indicate the range for the value of p.
I think it would be worth interpreting the fact that for the first stressors among those who have
a certain mental condition, the proportion of those who declared that stressor as a big / very big
problem is higher than the proportion of those who declared it absent or moderate, while for
another 4, this ratio is reversed (many of the stressors remaining significant).
At line 325, the upper limit of the confidence interval for unadjusted PTSD is 0.82 (txt) while
it is 0.81 in the table.
Please reformulate at line 327-328. Actually, the epidemiological association exists and is tested
between variables, not between people and outcomes and people end up presenting a risk.
The same goes for the statement in lines 385-386, you need to refer to exposure and effect
variables. You refer to associations between women (persons) with certain characteristics and
health outcomes. The association between variables is tested, the risk/likelihood is a ratio, the
persons/individuals within subgroups present certain risk.
At line 337, the aOR for depression is 1.36 in the text while in the table it is 1.32.
Basically, you could say: We did not find associations between having more children under 18,
difficulty reading / writing and/with mental health outcomes.
At line 339, the upper limit of the confidence interval for PTSD is 1.69 in the text but 1.60 in
the table.
As for the statement in lines 391-392, I assume you are referring to Table 3 and the point value
of uOR and aOR.
I think for the variables in Table 3, you should specify what the reference value is, what the
compared categories are.
Please rewrite line 416-417. "This importance" is not very clear. In general, these models,
frameworks are based on interconnectedness.
Please also review the sentence on line 430-432. Please do not change the meaning of the
measured variables. You have measured and tested “worry no treatment for health problem” not
“not getting treatment for health condition”. There is a difference between fear of not having
access and not having proper access.
There is also a difference between “unable to return home in an emergency” and “unable to
return home”.
In the text, in line 54 you use the wording “treatment worry for health” and in tables 2, 4 “worry
no treatment for health’
Regarding the conclusions, please specify the audience, the group of professionals, the
institutions, the organizations, the refugees to whom you make one recommendation or another.
Personally, I am against the wording "should". This verb has a sententious character but almost
never has a clear subject. It does not allow the clear formulation of an objective. You could
replace "should" with "it is necessary", “it is proven”, "it is necessary” to incorporate in the
design of interventions, programs objectives such as: raising awareness of the mental health of
refugees among professionals, policy makers, and so on.
When you measure needs, you can later afford to formulate objectives of interventions,
programs, and this would involve specifying who, when, how, and what to do.