Review: Mental Health and Social Isolation among Sub-Saharan African Migrants in Tunisia: A Cross-Sectional Quantitative Study {under peer review}

 

Reviewer: Mariia Mezhenska

 

Completed: 02-09-2025 02:27

 

Recommendation: Resubmit for Review

 

 

	Yes	No	N/A
Is the research question clearly defined?		+
Are the methods appropriate and sufficiently detailed?		+
Is the data analysis robust and replicable?		+
Are the conclusions supported by the results?		+
Is the manuscript well organised and clearly written?		+
Are tables, figures, and supplementary material informative and necessary?		+
Is the abstract an accurate summary of the study?	+
Does the manuscript contribute meaningfully to the field?		+
Is it relevant to the field of mental health or related disciplines that are connected to the scope of the Journal?	+
Are ethical approvals and participant consents adequately described?	+
Have competing interests, funding, and data availability been transparently declared?	+

 

Comments for the authors:

 

This manuscript addresses an important and underexplored topic: the mental health of Sub-Saharan African migrants in Tunisia. The study makes a valuable contribution by drawing attention to psychosocial distress, isolation, and resilience among a marginalized group. However, in its current form, the manuscript suffers from significant conceptual, methodological, and analytical and interpretive limitations.

Major Concerns

The literature review (introduction part) presents only broad ideas without engaging deeply with relevant empirical studies on similar populations. The mention of Engel’s (1977) biopsychosocial model provides a general lens, but the manuscript fails to link this framework with current debates or recent research findings (the author mentioned a general theory without connecting it to the research questions and hypotheses). The discussion of acculturative stress is cursory, with only Berry (1997) and Nguyen et al. (2024) being relevantly cited; Hajak et al. (2021) did not explore acculturative stress. The evidence base is underdeveloped. Overall, the introduction part reads more like a background summary than a critical synthesis that positions the current study within existing scholarship. The introduction part requires refinement by narrowing the broad framing to the specific constructs under investigation, integrating prior empirical evidence more systematically for each idea that is mentioned further, and explicitly articulating how the study advances novelty in this field, not in general terms.

The stated objectives are overly broad and insufficiently aligned with the analyses actually conducted. For example, the aim to “explore the direct and intersecting relationships” is left undefined, with no accompanying hypotheses or analytic models. Similarly, the objective to “identify the main demographic, migratory, and contextual factors associated with psychological distress, considering the country's role as a transit area” lacks operational clarity and specificity. To enhance coherence, the manuscript would benefit from the inclusion of a dedicated current study section that explicitly articulates the research questions and hypotheses, derived logically from the preceding rationale and literature review. The objectives should be refined, made specific, and directly connected to the methodological choices and statistical analyses undertaken.

In the Methods section, the decision to conduct face-to-face interviews with a structured questionnaire offered in French, Tunisian Arabic, or English is presented descriptively, but the rationale for this approach is not provided. Why were interviews selected over potentially less intrusive or bias-reducing methods, such as anonymous self-administered surveys? Moreover, while it is stated that “we personally conducted the majority of interviews, occasionally assisted by community mediators to help translate cultural nuances or allay particular concerns,” the procedures remain unclear. Did the one author conduct all interviews, or was the team included? Were all interviews conducted under standardized conditions? Did the author possess fluency in all three languages, or were mediators essential for certain participants? If mediators were involved, were they trained in research ethics and confidentiality, or could their presence have introduced social desirability or translation bias?

Measurement validity issues. The manuscript claims to use “standardised composite scales,” but in fact, the items appear to be ad hoc sets of six questions each. There is no evidence that these are validated measures of depression, anxiety, and acculturative stress. Were items derived from existing scales? Were they changed/adapted/ modified? If so, which ones? Without this information, construct validity is highly questionable. Reporting Cronbach’s alpha for six-item sets does not resolve the issue; internal consistency does not establish validity. The absence of validated scales (e.g., BDI-II, BAI, GAD-7, HSCL-25) is a major flaw.

Statistical Analysis Issues. First, descriptive statistics are presented as if they yield inferential conclusions. While descriptives are a necessary preliminary step, they cannot serve as the basis for drawing scientific inferences about associations or group differences. Relying on them in this way represents a weak analytic approach.

Second, the inferential analyses are poorly introduced and insufficiently motivated. For example, the decision to divide participants into length-of-stay groups emerges only in the statistical analysis section, without prior justification in the rationale, objectives, or hypotheses. Similarly, analyses comparing participants by legal status and religion were not anticipated in the stated objectives, creating a disconnect between the aims of the study and the statistical procedures undertaken. The absence of clear hypotheses or guiding research questions for these comparisons undermines the coherence of the analytic strategy.

Finally, the clustering analysis is particularly problematic. With a sample size of N = 98, extracting four clusters is statistically unstable, and no validation is reported. Treating these clusters as “clinical profiles” substantially overstates the robustness and interpretability of the findings. At best, these results should be presented as exploratory and interpreted with extreme caution.

Specific recommendations for analytical strategy. In this case, the ANOVA tests did not yield statistically significant results, which reduces immediate concern about inflated Type I error. However, the analytic strategy remains limited in its interpretive value. Even if no spurious positives were detected, the approach of running multiple independent ANOVAs across outcomes is not the most justifiable or rigorous. To strengthen the methodological coherence of the study, I would recommend replacing these analyses with a MANCOVA (with appropriate follow-up ANCOVAs if the overall multivariate test is significant) or a multivariate regression framework. Such an approach would allow the authors to test the influence of key predictors (length of stay, gender, legal status) on the full constellation of outcomes simultaneously, while accounting for intercorrelations among variables and including relevant covariates (e.g., age, education).

Furthermore, I recommend presenting a single comprehensive table that includes all study variables with their descriptive statistics (means, standard deviations, ranges) alongside a correlation matrix. This would allow readers to see the interrelationships among depression, anxiety, social isolation, acculturative stress, and psychosocial resources in one place, rather than dispersed across sections. Such a table would both improve transparency and facilitate comparison with prior studies.

Results and discussion structure. The presentation of results suffers from a lack of clear separation between reporting and interpretation. The results section frequently incorporates explanatory commentary, making it difficult to distinguish empirical findings from the authors’ interpretations. For instance, informal comments from participants are inserted into the results without being subjected to systematic qualitative analysis. Without a rigorous methodological framework for analyzing narrative data, it is inappropriate to use these anecdotal observations as explanatory evidence. In particular, certain claims, such as those regarding gender differences and the influence of Tunisia’s role as a “transit country,” are speculative and insufficiently supported by the data presented. These interpretations require either stronger empirical grounding or a more cautious framing as tentative observations.

The discussion section is overly broad and ambitious in tone but underdeveloped in substance. Rather than critically engaging with the findings, it largely reiterates well-established insights, such as the negative impact of social isolation and structural barriers, without positioning the study within existing regional or international literature. This limits the contribution of the paper to advancing current debates.

The statement that “the high average scores across all dimensions show a notable prevalence of psychological distress” is misleading. Prevalence requires the use of validated instruments with established diagnostic thresholds or cut-offs, not simply elevated mean scores. Because this study relies on ad hoc composite measures, prevalence cannot be inferred. At most, the results may be described as indicating elevated symptom levels or higher mean scores. However, even this phrasing requires a point of reference - higher in comparison to what? Without normative data, validated cut-offs, or comparison groups, the interpretation of “high” scores is ambiguous.

Minor Concerns

The manuscript frequently employs rhetorical phrasing (e.g., “compelling practical reasons,” “rigorous statistical approach,” “from a psychological perspective”) that reads more like persuasive writing than scholarly reporting. Such language does not align with academic standards, where methodological claims should be supported by evidence, precision, and clear justification rather than by rhetorical emphasis.

In sum, the manuscript addresses an important and timely topic. However, significant revisions are needed in the areas of theoretical framing, methodological rigor, measurement validity, statistical analysis, and interpretation. Strengthening the literature review, refining the objectives, justifying methodological choices, using validated measures, and aligning analyses with hypotheses would substantially improve the quality and credibility of the work.