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

Reviewer: Dimitar Karadzhov

Completed: 07-07-2026 19:47

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?	+

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Comments for the authors:

Thank you for the opportunity to review this work. This an exploratory observational study of the mental health profiles and psychosocial stressors and their correlates in a sample of sub-Saharan migrants in Tunisia. The focus on this underrepresented population is certainly welcome, not least because Tunisia, we are being told, is often seen as a transit country on the way to Europe. This therefore represents a potentially crucial intervention setting to prevent the development of more serious mental health difficulties and further depletion of psychosocial resources. To that end, the cluster analysis is particularly intriguing.

While the ms has a number of strengths, there are several concerns around methodological rigour and interpretation of findings that need addressed.

Specific Comments:

Introduction:

The BPS model is not convincingly applied to the mental health of migrants. Provide examples of biological factors and their interactions.

Methods:

It is not stated where the various instruments were derived from. Explanations should be provided.

The full scales should be provided in Appendices.

Did the authors consider also measuring PTSD levels? Why not?

State which version of SPSS was used.

Given that the cluster analysis is presented as one of the study's chief contributions, one expects considerably more methodological detail. For example, why was K-means selected?

How were the four profiles arrived at? What variables were put in the model?

Statistical power: While adequate power is claimed for the primary analyses, this is likely not the case for the mediation analyses. In light of this, why were these carried out...?

Relatedly, the qualifying statement under 'Table 4' is neither necessary, nor warranted: '[...] indicating a direct and robust link between isolation and depressive symptoms.'

It is noted that no formal ethics review was in place, with the author explaining they followed institutional and national guidelines. However, for further reassurance, an ethics exemption statement or equivalent should be cited.

Results:

Several areas for improvement.

Is resilience the same as social resources (Table 2)? There is a tendency to use 'resilience' and 'resources' interchangeably (e.g. Table 8), which causes confusion.

Why wasn't the relationship between social isolation and anxiety measured? RQ2 indicates it should be.

Be careful not to overinterpret non-significant findings due to issues of power as stated above - for example, 'Psychological distress and resources remained stable regardless of how long people had been in the country'.

Similarly, rephrase 'non-significant trends'.

Table 8: No consistency in how the terms 'symptoms' and 'distress' are used.

Cluster analysis (Table 8): The differentiation between severe (M=20) and high (M=19) levels of distress seems highly arbitrary and perhaps not clinically significant. Please explain.

It is not clear how age was included in the analysis to support the claims regarding different profiles in younger versus older participants.

The interpretation after Figure 1 should be moved to Discussion.

The qualitative component is not well described and does not seem to have been systematically implemented. It is therefore advisable to remove it from the report.

As per the above, this statement in Abstract should be reconsidered: 'These profiles also reflected variations in age, migration trajectories, and the perception of Tunisia as a transit country to Europe, a view frequently expressed by participants in informal discussions during fieldwork.'

Discussion & Limitations:

'Social isolation and mental health: a confirmed link' - This section requires strengthening by a more considerate use of evidence and clearer expressions (e.g. 'unlike an earlier version') and structure.

Regarding gender differences in depression, it is worth reinstating the effect size was only moderate.

'Effects of length of stay: persistent vulnerability': Avoid reporting new analyses in Discussion.

This interpretation of non-significance is problematic: 'This suggests simply staying longer in Tunisia does not improve or worsen average psychological health.'

Clinical and policy implications could be elaborated on and be more context-specific.

Some appropriate recommendations for future research are made.