Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENAT region: A systematic review and meta-analysis protocol

Maryam Kazemitabar; Kate Nyhan; Natalie Makableh; Rebecca Minahan-Rowley; Malak Ali; Mayyada Wazaify; Jeanette Tetrault; Kaveh Khoshnood

doi:10.1371/journal.pone.0292535

. 2023 Oct 5;18(10):e0292535. doi: 10.1371/journal.pone.0292535

Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENAT region: A systematic review and meta-analysis protocol

Maryam Kazemitabar ^1,^2,^*, Kate Nyhan ^3,⁴, Natalie Makableh ⁵, Rebecca Minahan-Rowley ¹, Malak Ali ⁶, Mayyada Wazaify ⁶, Jeanette Tetrault ¹, Kaveh Khoshnood ⁵

Editor: Amin Nakhostin-Ansari⁷

PMCID: PMC10553213 PMID: 37797050

Abstract

Background

Understanding the epidemiology of substance use disorders (SUDs) and mental health disorders (MHDs) among forced migrants from the Middle East and North Africa and Türkiye (MENAT) region is of utmost importance given their distinct challenges and vulnerabilities. Existing research on the topic is substantial; however, comprehensive systematic reviews are limited. We aim to conduct a systematic literature review to bridge this gap, providing a thorough understanding of SUDs and MHDs epidemiology among this population.

Methods

The systematic review will include original, peer-reviewed research articles published in English or Arabic between 2013 and 2023. It will encompass qualitative, quantitative, and mixed-methods studies focusing on SUDs and/or MHDs among forced migrants from the MENAT region. A Medline (via Ovid) search strategy was developed and will be translated into databases of EMBASE (via Ovid), Web of Science Core Collection (as licensed at Yale), and CINAHL. Risk of Bias in the included studies will be assessed using the Joanna Briggs Institute (JBI) checklist for observational studies and the Cochrane Risk of Bias (ROB) 2 tool for intervention studies. Meta-analysis using random-effects models will be conducted and subgroup analyses based on studies’ data will be performed. The systematic review will be conducted based on the framework introduced by the Joanna Briggs Institute. Additionally, the PRISMA-P extension for systematic reviews was used to report the present protocol. The present systematic review protocol has been registered with PROSPERO, an international prospective register of systematic reviews. The review’s registration ID is CRD42021286882.

Discussion

The systematic review aims to explore, identify and synthesize the evidence to reveal the epidemiology of SU and/or MH of forced migrants of the MENAT region as described in this protocol. In sum, the review will provide evidence to fill the gap in the literature and help the stakeholders, policymakers, and health providers to expand current knowledge of the prevalence and risk factors of SU and/or MH in humanitarian settings.

Introduction

Substance use disorders (SUDs) and mental health disorders (MHDs) are among the leading causes of fatal ailments [1]. A report by “Our World in Data” estimates that about 11.8 million people lose their lives annually due to substance use and related disorders worldwide [2]. Aside from health issues, SUDs, and MHDs can lead to various problems such as homelessness, criminal legal involvements, incarceration, transmission of HIV due to injecting drugs, high-risk sexual behaviors, unemployment, and dependence on welfare [3, 4]. Additionally, SUDs and MHDs limit an individual’s average performance in activities and might even lead to suicide and death [5]. The exorbitant costs associated with SUDs and MHDs is an economic burden for governments [6, 7].

According to the United Nations Human Rights Council, over 84 million people were forcibly displaced in mid-2021 due to persecution, war, or violence [8, 9]. Many of whom are likely struggling with MHDs and/or SUDs. The Middle East and North Africa and Türkiye (MENAT) region has experienced lots of unrest in the last several decades, resulting in forced migration for numerous people. Forced migrants in this region are forcibly displaced due to persecution, war, violence, and natural disasters such as floods and storms [10]. The Arab Spring protest and the subsequent state crackdowns, coups, and wars that followed the initial protests played a significant role in the displacement, such that caused more than 3.5 million people to get internally displaced; ever since, the numbers have increased to more than three times. Moreover, the MENAT region had approximately more than 7.8 million internally displaced people seeking asylum by 2021 [11].

Forced migrants have potentially high risks of SUDs and MHDs since they are exposed to challenging conditions that could have a lifelong impact. Forced migration, availability of illicit drugs in refugee camps, exposure to conflict, exploitation and mental, physical, and sexual abuse, trafficking, difficult living conditions, loss of resources, division of family, separation anxiety, isolation, stress of relocation, challenges associated with learning a new language, and unemployment are among common challenges that forced migrants encounter. Such events can trigger mental health disorders such as posttraumatic stress disorder (PTSD), anxiety, and depression [12, 13]. In addition, struggling with consequences and stress from forced displacement can lead individuals to use substances. Studies show that SUDs and MHDs frequently occur among forced migrants, such that about 50% of the individuals who experience a mental health disorder during their life will also experience a substance use disorder and vice versa [14, 15]. This population uses substances to cope with acculturation challenges, social and economic inequalities as well as traumatic experiences due to loss of livelihood, torture, and family separations [16].

Studying the epidemiology of SUDs and MHDs among forced migrants from the MENAT region is crucial due to their unique challenges and vulnerabilities. There is a substantial body of research on SUDs [16, 17] and especially MHDs [18–22] from the MENAT region. However, the availability of systematic reviews that comprehensively collect and analyze this data is limited. Conducting a systematic literature review will help bridge this gap by providing a comprehensive synthesis of the existing research, allowing for a more thorough understanding of the epidemiology of SUDs and MHDs among this population. In this systematic review protocol, we aim to fill this gap in the literature and help the stakeholders, policymakers, and health providers to expand their knowledge of the prevalence and risk factors of substance use and mental health disorders in humanitarian settings. As a result, we aim to find the answers to the following questions:

Primary review questions

What is the prevalence of SUDs and/or MHDs among forced migrants displaced from the MENAT region?

Expected outcome: The proportion or rate of individuals among forced migrants displaced from the MENAT region who have been diagnosed with SUDs and/or MHDs. Examples of specific disorders include but are not limited to depression, anxiety, PTSD, substance dependence, or substance abuse.
What are the causes and risk factors of SUDs and/or MHDs among forced migrants displaced from the MENAT region?

Expected outcome: Factors, circumstances, or events contributing to the development or increased risk of SUDs and/or MHDs among forced migrants displaced from the MENAT region. This may include factors such as exposure to conflict, trauma, displacement, loss of resources, social isolation, or environmental stressors.
What prevention and intervention considerations are provided to forced migrants with SUDs and/or MHDs displaced from the MENAT region?

Expected outcome: Strategies, approaches, or interventions to prevent or address SUDs and/or MHDs among forced migrants displaced from the MENAT region. This includes preventive measures, mental health support, treatment options, psychosocial interventions, access to healthcare services, or policy considerations.

Secondary review questions

What types of substances do forced migrants with SUDs and/or MHDs displaced from the MENAT region use?

Expected outcome: The specific substances, such as alcohol, opioids, stimulants, or other drugs, used by forced migrants with SUDs and/or MHDs who have been displaced from the MENAT region.
What types of mental disorders are prevalent among forced migrants with SUDs and/or MHDs displaced from the MENAT region?

Expected outcome: The specific mental disorders, such as depression, anxiety disorders, PTSD, or other psychiatric conditions, among forced migrants with SUDs and/or MHDs who have been displaced from the MENAT region.

Methods

Design of the systematic review

This systematic review protocol has been registered with PROSPERO, a global database for prospective registration of systematic reviews. The review has been assigned the registration ID of CRD42021286882. The current study uses the framework introduced by the Joanna Briggs Institute (JBI). The JBI framework is a comprehensive approach to conducting systematic reviews of evidence. It includes nine stages to the review process [23]:

Defining the review question: This involves developing a well-defined research question or objective.
Developing inclusion and exclusion criteria: This involves identifying the specific criteria that will be used to determine which studies will be included in the review.
Search strategy: Develop a comprehensive search strategy to identify all relevant studies for the review.
Study selection: Screen the search results against the inclusion and exclusion criteria and select the studies that meet these criteria.
Quality appraisal: Assess the quality of the included studies to determine their validity and reliability.
Data extraction: Extract relevant data from the included studies.
Data synthesis: Analyze and synthesize the data from the included studies to identify patterns and draw conclusions.
Assessing certainty of evidence: Evaluate the overall certainty of the evidence and the strength of the conclusions that can be drawn from it.
Reporting: Report the results of the review clearly and transparently.

Besides the JBI framework, the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P; [24]) extension for systematic reviews was used to report the present protocol.

Eligibility criteria

Participants

The participants of the studies include forced migrants with SUDs and/or MHDs from one of the MENAT countries without any age or gender limitation. Forced migration involves refugees and displaced populations compelled to leave due to war, conflict, persecution, disasters, development-induced displacement, smuggling, human trafficking, and environmental factors [25]. We will include forced migrants such as refugees, asylum seekers, and internally displaced persons in our review.

The systematic review will include all qualitative, quantitative studies, and mixed-methods studies focusing on SUDs and/or MHDs among forced migrants displaced from the MENAT region. The quantitative prevalence estimates of SUDs and MHDs should be classified by the latest version of Diagnostic and Statistical Manual of Mental Disorders (DSM) [26] which is DSM-5-TR. Included studies must be original and peer-reviewed research articles. Studies must provide original data; therefore, commentaries, editorials, letters, and opinions are excluded. The studies’ language must be English or Arabic. We will include studies published from 2013 to 2023 (the last ten years). We use the United Nations Human Resources Office of the High Commissioner (HROHC) classification for included countries in the MENA region [27] plus Türkiye (MENAT). Countries include Algeria, Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Palestine, Oman, Qatar, Saudi Arabia, Syria, Tunisia, Türkiye, United Arab Emirates, and Yemen. Studies focused on people from the MENAT region who have been forcibly displaced by conflict, persecution, and/or natural disaster, including international displacement as well as internal displacement will be included.

Information sources

Database selection and search will be designed collaboratively by domain experts and a medical librarian. Electronic databases of MEDLINE, EMBASE (both via Ovid), Web of Science Core Collection, CINAHL COMPLETE, Global Index Medicus, and The Index Medicus for the Eastern Mediterranean Region (IMEMR) will be searched. A hand search through WHO regional database and Google Scholar will also be conducted. Additionally, research articles published in journals not covered by the databases we searched can still be located using citation chaining in this study. We will perform this process using the Citation Chaser tool [28] and the bibliographic database Lens. This database incorporates publication details from the OpenAlex database/dataset, known for its strong coverage of open-access journals in low- and middle-income countries [29]. Citation Chaser is an automated tool that streamlines the process of "citation chasing" in systematic reviews. It uses the Lens.org API to quickly retrieve lists of references from various studies and identify articles that cite a specific study. This eliminates the manual effort traditionally required for cross-referencing and enhances accuracy. The tool can generate lists of both referenced and citing records from sources like PubMed, PubMed Central, CrossRef, Microsoft Academic Graph, and CORE, making systematic review searches more efficient. The steps involved in conducting citation chaining are:

Identifying a relevant article or resource.
Looking at the references cited in the article to identify other potentially relevant sources.
Examining the reference list of each identified article to identify additional relevant sources.
Repeating this process until no new relevant sources are found.
Evaluating the relevance and qualifying of each identified source.
Incorporating the new sources into our research and citing them appropriately.

Search strategy

The research team members developed the search terms through a comprehensive list of search terms focused on substance use, mental health, forced migrants and MENAT region countries’ relevant terms and keywords. We conducted a preliminary search to find the appropriate terms and keywords. Table 1 represents the search strategy developed for the Medline Ovid database. The search strategy was peer-reviewed by an independent medical librarian.

Table 1. Search strategy for Medline Ovid from 1946 to July 12, 2023.

1	[peer-reviewed search date: 07/12/2023]
2	[medline]
3	[concept 1: MENA]
4	(Algeria* or Bahrain* or Egypt* or Iran* or Iraq* or Israel* or Jordan* or Kuwait* or Lebanon* or Lebanese or Libya* or Morocc* or Oman or Omani or Oman’s or Palestin* or Qatar* or Saudi Arabia* or Syria* or Tunisia* or Turkey* or United Arab Emirates or Emirat* or UAE or Western Sahara* or Yemen* or Middle East* or North* Africa* or MENA or "Middle East and North Africa" or Gaza* or Maghreb* or Persian Gulf).mp,jw.	416652
5	(Algiers or Manama or Cairo or Baghdad or Tehran or Amman or Kuwait City or Beirut or Tripoli or Rabat or Muscat or Ramallah or Jerusalem or Doha or Riyadh or Khartoum or Damascus or Tunis or Ankara or Abu Dhabi or Sana’a or Sanaa).mp.	37116
6	exp middle east/ or exp africa, northern/	200333
7	(Turkiye* or Kurd* or near east* or Turkish or Istanbul).mp,jw.	51343
8	or/4-7	456675
9	[concept 2: forced migrants]
10	refugees/ or refugee camps/	13360
11	(refugee* or asylum seeker* or migrant* or migration or immigra* or displac* or IDP or IDPs or "stateless person*" or "victims of persecution" or exiles or evacuees).mp.	601424
12	(asylee* or resettled or returnee*).mp.	1441
13	0r/10-12	601805
14	[concept 3: substance use or mental health disorders]
15	[starting from the basis of Kumar, N., Janmohamed, K., Nyhan, K., Martins, S. S., Cerda, M., Hasin, D., Scott, J., Sarpong Frimpong, A., Pates, R., Ghandour, L. A., Wazaify, M., & Khoshnood, K. (2022). Substance use in relation to COVID-19: A scoping review. Addictive Behaviors, 127, 107213. https://doi.org/10.1016/j.addbeh.2021.107213 ]
16	[substance use]
17	exp substance-related disorders/	310855
18	((substance* adj3 (abus* or dependen* or disorder* or addict* or misus* or "use" or "user" or "users" or "usage" or "using" or "used" or withdrawal)) or addiction* or addict*).mp.	260922
19	((opioid* or opiate* or heroin or amphetamine* or drug or drugs) adj3 (abus* or dependen* or disorder* or addict* or misus* or "use" or "user" or "users" or "usage" or "using" or "used")).mp.	328542
20	(OUD or IDU or PWID or SUD or SAT or MAT or OAT or AUD or PWUD or OTP or OST or PDM).mp.	57226
21	("injection drug use" or "intravenous drug use").mp.	6737
22	methadone/ or opiate substitution treatment/ or exp buprenorphine/	20292
23	harm reduction/	4130
24	[redundant]
25	exp smoking/	161200
26	smoking cessation/	32748
27	"tobacco use cessation"/ [check that quotation marks remain through launcher]	1454
28	vaping/	3558
29	Electronic Nicotine Delivery Systems/	7856
30	marijuana abuse/ or exp "marijuana use"/	12979
31	exp tobacco products/ or smokers/	15479
32	(smoking or smoker* or cigarette* or ecig* or e-cig* or tobacco or snuff or snus or cannabis or marijuana or vape or vaping or vaper or vapers or vaped or cigar*).mp.	465778
33	(alcohol* or "alcohol use" or alcohol abuse* or wine* or beer* or liquor* or spirits).mp.	534626
34	exp illicit drugs/	14063
35	aerosol propellant*.mp.	775
36	((sniff* or huff* or inhal) adj2 aerosol).mp.	3194
37	inhalant abuse.mp.	468
38	huffing.mp.	94
39	aliphatic nitrites.mp.	5
40	anabolic steroid*.mp.	4762
41	doping in sports/ and exp steroids/	931
42	performance-enhancing substances/	1285
43	(phencyclidine or PCP or angel dust).mp.	17553
44	Benzodiazepines/ or exp Morphine Derivatives/ or exp Naloxone/ or exp Cocaine/ or exp Fentanyl/ or fentanyl.mp. or Narcotic Antagonists/ or Hallucinogens/ or Ketamine.mp. or Catha.mp. or exp Cannabis/ or "Ecstasy".mp. or MDMA.mp. or exp Methamphetamine/ or Mescaline.mp. or Opium/ or Tramadol/ or exp Narcotics/	268826
45	benzodiazepine*.mp.	50109
46	cocaine.mp.	47081
47	(ecstasy or MDMA).mp.	6613
48	[redundant]
49	N-Methyl-3,4-methylenedioxyamphetamine/	4253
50	(GBH or GBL or gamma-hydroxybutyrate).mp.	2178
51	4-Butyrolactone/	4530
52	glue.mp.	12838
53	(hashish or heroin).mp.	21647
54	exp "hypnotics and sedatives"/	130569
55	hypnotics.mp.	34872
56	inhalant*.mp.	4797
57	(LSD or Lysergic Acid Diethylamide).mp.	9531
58	mescaline/	1067
59	mescaline.mp.	1319
60	exp amphetamines/	40260
61	methamphetamine*.mp.	16090
62	(amphetamine* or speed).mp.	252994
63	methylxanthine*.mp.	5832
64	nicotine.mp. or nicotine chewing gum/ or nicotine/	56553
65	(nitrous oxide or laughing gas).mp.	24027
66	((OTC or over the counter) adj1 (drug* or medication*)).mp.	3510
67	exp nonprescription drugs/	6695
68	(oxycodone or oxycontin).mp.	5272
69	paint thinner*.mp.	124
70	amyl nitrite.mp.	918
71	poppers.mp.	483
72	psilocybe.mp.	211
73	salvia divinorum.mp.	233
74	sedative*.mp.	47365
75	stimulant*.mp.	47065
76	tranquilizer*.mp.	3199
77	designer drugs/	1781
78	overdose*.mp.	31226
79	narcotic*.mp.	65858
80	needle-exchange programs/	1994
81	self medication/	4972
82	opioid*.mp.	147649
83	((medication-assisted or opiate-agonist or maintenance or replacement or substitution) adj1 (treatment* or therap*)).mp.	116297
84	[mental disorders]
85	exp mental disorders/ or depression/	1529266
86	mentally ill persons/	6431
87	mental health/	61802
88	(mental health or depression or depressive or anxiety or PTSD or posttraumatic stress or posttraumatic stress or MMD or GAD or panic disorder* or adjustment disorder* or mental illness* or mood disorder* or behavioral health or behavioural health or psychological or stress or stressor or stressors or distress or well-being or well-being or resilience).mp.	2560558
89	exp nonprescription drugs/ or exp drug misuse/	23935
90	(khat or qat or catha edulis or mairung* or miraa or hookah* or hooka* or narghile* or argila* or shisha or sheesha or waterpipe* or water pipe*).mp. or Catha/	4630
91	or/17-90	5079215
92	8 and 13 and 91	3877
93	limit 92 to yr = "2013 -Current"	2311
94	limit 93 to (arabic or english)	2227

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Screening process

A public health librarian (KN) was responsible for designing and testing the search queries and an independent medical librarian (TM) peer-reviewed the search strategies. Those results will then be exported from databases and imported to Covidence and duplicates will be removed. The titles and abstracts returned will be screened. Records will be screened for title and abstract by independent reviewers and then, the reviewers will read and screen the full texts of the selected studies to determine whether they meet the eligibility criteria for final inclusion (MK, NM, RM-R, MA). Screening will be done in duplicate. Conflicts will be resolved by authors with expertise in the relevant field (MW, JT, KK). PRISMA flowchart diagram [30] depicts the screening and selection process once the review is finalized (Fig 1).

If there are any disagreements among the main reviewers over the selection, a third reviewer will make the final decision, or the two main reviewers will convene to discuss and make a final decision. The reviewers will then extract data from the selected studies using a predetermined form. The data extraction form will include details about the authors, publication year, sources of funding, countries, language, population characteristics (age and gender), sample size, type of intervention, prevalence, causes and risk factors of SUDs and MHDs, types of substances and mental illnesses, comparison tools, follow-up period, and other key findings. Relevant papers written in languages other than English and Arabic as well as grey literature such as conference papers and preprints will be listed in the S1 Chekclist.

Risk of bias assessment

The risk of bias in the included studies will be assessed through multiple appraisal tools. Observational studies will be appraised with a revised version of JBI for systematic reviews of prevalence [31, 32], and intervention studies will be appraised by ROBINS-I [33, 34]. The studies pertaining to primary research question 1 (PQ1) will undergo appraisal, while those related to PQ2 and PQ3 as well as secondary research questions 1 (SQ1) and SQ2 will not be appraised. This is because the latter questions are of the scoping review type, where critical appraisal is not recommended.

Two reviewers will independently evaluate each study, and any discrepancies will be resolved through discussion and consensus. The tool assesses the risk of bias in several domains, including selection bias, performance bias, detection bias, attrition bias, reporting bias, and other sources of bias. Selection bias will be evaluated by assessing the adequacy of the randomization process and allocation concealment. Performance bias will be assessed by evaluating the blinding of participants and personnel. Detection bias will be evaluated by assessing the blinding of outcome assessors. Attrition bias will be evaluated by assessing the completeness of outcome data. Reporting bias will be evaluated by assessing the completeness of outcome reporting. Any other sources of bias will be evaluated based on the specific characteristics of each study. The risk of bias assessment will be used to inform the interpretation and synthesis of the study findings, and studies with high risk of bias will be considered in a sensitivity analysis.

Through sensitivity analysis, we will systematically exclude studies with methodological limitations or biases affecting internal validity, which have been appraised as high risk of bias using ROBINS-I. The specific methods and criteria for exclusion will be described to ensure transparency. The impact of the sensitivity analysis on the conclusions and the strength of the evidence will be discussed, enhancing the reliability and validity of the review.

Statistical analysis

The meta-analysis model will be chosen based on the study design. Given the expected variability among studies, a random-effects model will be considered due to its capacity to account for heterogeneity. If utilizing the ‘meta’ package, the ‘metagen’ function [35] will be applied. Alternatively, for the ‘metafor’ package, the ‘rma’ function [36] will be used. The selected function will be executed by inputting a structured data frame and defining relevant parameters including effect size, standard error, sample size, and study identifiers.

To quantify heterogeneity among the studies, I² statistic [37] will be employed to quantify the proportion of total variation in effect estimates that is due to heterogeneity rather than chance. Visual representations of study effect sizes and confidence intervals will be generated through the creation of forest plots, using functions like ‘forest()’ or ‘forest.rma()’. Potential publication bias will be explored and visualized using funnel plots and Egger’s test [38] considering a p-value < .05. These analyses will be facilitated through dedicated functions available in the chosen R package.

Subgroup analyses will be conducted to find potential sources of heterogeneity by categorizing studies based on specific study characteristics. Variables anticipated to introduce heterogeneity will be considered for these analyses. Finally, for each variable, separate subgroups will be created, grouping studies with similar characteristics together. The meta-analysis model will then be applied within each subgroup to calculate the pooled effect estimate and associated confidence intervals. Comparing the effect estimates across different subgroups will allow for the identification of patterns or trends, revealing how each variable may impact the overall results. This process will provide valuable insights into the relative contribution of each characteristic to the observed heterogeneity.

Data synthesis

In the data synthesis section of the systematic review, the primary studies included in the analysis will be analyzed and reported according to the research questions. We aim to investigate a comprehensive range of research questions to gain a thorough understanding of the topic under study. The PQ1uncovers international evidence, necessitating a systematic review approach. By following a systematic review methodology, we will conduct a rigorous and exhaustive literature search, ensuring the inclusion of all relevant studies and providing a robust synthesis and analysis of the findings [31].

Additionally, we recognize that PQ2, PQ3, SQ1, and SQ2 might benefit from a scoping review approach due to their exploratory and broad-scope nature. Employing a scoping review methodology for these secondary questions will enable us to map the available evidence, identify key concepts, and offer an overview of the literature without necessarily assessing the quality of individual studies. This approach will provide a comprehensive understanding of the existing research landscape related to these questions and facilitate the identification of knowledge gaps and potential areas for future research [31]. Given that the outcomes for PQ2/3 and SQ1/2 will be scoping review questions and no risk of bias assessments will be completed, there will be no evaluation conducted to determine the overall certainty or strength of the evidence.

Discussion

The implications of this systematic review extend beyond research to practice and policy. By providing a more nuanced understanding of the prevalence and nature of SUDs and MHDs among forced migrants, the review may help inform the development of targeted interventions and services tailored to the specific needs of this population. For example, the review may suggest the need for culturally sensitive and linguistically appropriate services that take into account the unique experiences and challenges faced by forced migrants. Additionally, the review may help to identify gaps in existing policies and services, highlighting areas where further investment and resource allocation are needed to better support forced migrants with SUDs and MHDs.

Finally, it is important to note that this review is just one step towards improving our understanding of SUDs and MHDs among forced migrants. Ongoing research and investment in this area is crucial to better understand the complex interplay between forced migration, substance use, and mental health. Ultimately, we hope this research helps to improve the health and well-being of forced migrants, a population that is often underserved and marginalized in the context of global health.

Limitations

While we will endeavor to find all original articles aligned with our eligibility criteria through bibliographic database searches and citation chaining, we might miss some relevant studies. In addition, we may not be able to make policy recommendations due to the lack of high-quality studies. Last but not least, some authors we contact may not respond, and we may thus miss including those articles if the published documents lack important details.

Supporting information

S1 Checklist. PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: Recommended items to address in a systematic review protocol*.

(DOC)

Click here for additional data file.^{(99.5KB, doc)}

Acknowledgments

The authors would like to thank Tom Mead for his valuable contributions in peer-reviewing the search strategy employed in this study.

Data Availability

No datasets were generated or analyzed during the current study. All relevant data from this study will be made available upon study completion.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0292535.r001

Decision Letter 0

Amin Nakhostin-Ansari

29 Jun 2023

PONE-D-23-12703

Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENA region: a systematic review protocol

PLOS ONE

Dear Dr. Kazemitabar,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: No

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

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(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This protocol outlines a well-designed study and important study on the epidemiology of substance use and mental health disorders among MENA forced migrants. The authors motivate the study well and prose a technically sound study that should achieve their research aims. Notwithstanding these considerable strengths, the submission could be strengthened through several additional considerations:

1. Introduction:

a. It would be useful to add a few lines articulating exactly why the MENA population warrants further study, other than there being a literature gap. After all, if the state of the literature is so poor, then why conduct a systematic literature review and not something more exploratory, such as a scoping study? It would be worth providing a short review of the sizable literature on the mental health needs and experiences of the MENA population and to position this study in relation to other available reviews.

2. Inclusion/exclusion criteria:

a. The authors’ definition of “forced migrants displaced from the MENA region” could be sharpened. Taken at face value, this wording suggests that the authors will only include studies on people that have been displaced from the region entirely, which would exclude the steep majority, who have been displaced within the region. From the search terms, I don’t believe this is the authors’ intention, but it would be worth stating in the inclusion/exclusion criteria section exactly what they intend. For instance: studies focused on people from the MENA region who have been forcibly displaced by conflict, persecution, and/or natural disaster, including international displacement as well as internal displacement. Relatedly, the authors’ definition of the MENA region is a little fuzzy, since UNOCHA responds to both places producing displacement (e.g., Syria) and places receiving displaced people (e.g., Jordan). Often, for example, Turkey is not included in definitions of the MENA region (for instance, in OHCHR), but UNOCHA includes it because of its Syrian response. Some related questions: Is there a minimum/maximum length of time for the length of displacement that the authors will include? For instance, will they include resettled refugees, who are technically no longer displaced? Will they include people who fled a natural disaster for a month, only to return? Will they include returnees more generally?

b. Will the authors include studies that include participants from other regions, or only studies that focus exclusively on migrants from the MENA region?

c. The authors justify the 2013-2023 period with a parenthetical reference to the Arab Spring, but it’s unclear how this fits exactly. The Conventional periodization of the Arab Spring is 2010-2012, so is the goal to include only studies that followed the Arab Spring? Why not also include 2010-2012? As an aside, the introduction section attributes displacement to the Arab Spring protest, rather than to the state crackdowns, coups, and war that followed. I would consider reframing.

d. Will the authors include qualitative, quantitative studies, and mixed-methods studies, or only quantitative studies?

3. Search strategy:

a. Concept 1: Consider adding: Türkiye (official name), Kurdistan, and Near East

b. Concept 2: Depending on your responses to the above, consider adding asylee, resettled, and returnee

c. Concept 3: Consider adding regionally specific substances, such as khat/qat, hookah/narghile/argila/shisha/waterpipe

d. Consider adding search terms in Arabic

Thank you for the opportunity to read and review this protocol.

Reviewer #2: Thank you for inviting me to review the protocol “Epidemiology of substance use and mental health disorders among forced migrants 2 displaced from the MENA region: a systematic review protocol”. Overall, I believe that the review topic itself has merit, but this manuscript would benefit from major revisions, and perhaps even the assistance of an editor for help with writing as there is awkward phrasing throughout the paper. I have provided my comments as both a topic expert (migrant health) and as a systematic review methodologist. I hope the authors find my comments useful in preparing their next version.

ABSTRACT

The abstract requires substantial revisions – I suggest that the authors review the PRISMA 2020 for Abstracts Checklist (http://prisma-statement.org/Extensions/Abstracts) to help with the overall reporting and structure. Importantly, the authors should provide an explicit statement of the main objective(s) or question(s) the review addresses in the background and define all acronyms at their first mention (e.g., “SU”, “MH”, “MENA”). The Methods should describe the inclusion criteria and the planned approach for synthesis.

INTRODUCTION

Major:

- Please review the UNHCR statistics and verify if more recent stats are available (2022? 2021?).

- Many statements are provided without in-text citations (e.g., Lines 51-52; 63-71). Please provide supporting references.

Minor:

- Lines 77 and 78 are repetitive.

METHODS

Major:

Given the broad nature of the review questions presented by the authors, and the descriptive planned synthesis and presentation of the results, I strongly recommend the authors to consider whether a scoping review is more appropriate review choice. The authors should justify their choice in their protocol. There are resources available on making this decision, as well as guidance for conduct and reporting:

- Munn, Z., Peters, M. D., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC medical research methodology, 18, 1-7. https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-018-0611-x

- JBI MANUAL FOR EVIDENCE SYNTHESIS: SCOPING REVIEWS CHAPTER: https://jbi.global/scoping-review-network/resources

- Tricco, AC, Lillie, E, Zarin, W, O'Brien, KK, Colquhoun, H, Levac, D, Moher, D, Peters, MD, Horsley, T, Weeks, L, Hempel, S et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018,169(7):467-473. doi:10.7326/M18-0850. http://www.prisma-statement.org/Extensions/ScopingReviews

Under “Participants”, the authors should define the term “forced migrants”. For example, will the authors include migrants who cross a border (refugees, asylum seekers) and those who don’t (IDPs?). What types of migrant populations would be excluded (e.g., economic migrants, international students, other?).

If the authors choose to conduct a systematic review, then they must specify interventions and outcomes eligible for inclusion.

Under “Risk of Bias Assessment” – the authors have selected the Cochrane RoB 2.0 tool to assess intervention studies, however this tool it specifically designed for RCTs and does not adequately assess other non-randomized study designs. The authors should consider ROBINS-I. Given that the studies addressing review question #1 are likely to be observational and reporting prevalence, the authors should also consider whether the JBI critical appraisal checklist for prevalence studies would be beneficial. Additional guidance for reporting such evidence is available:

- Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and incidence data. Int J Evid Based Healthc. 2015;13(3):147–153.

Under “Data synthesis” it’s not clear why the authors have not described a synthesis approach for the pooling of prevalence estimates, which would be expected in a systematic review addressing question #1. The charting approach described by the authors would be better suited to a scoping review.

The authors previously described that “studies with high risk of bias will be considered in a sensitivity analysis”, but the methods for this analysis are not described in this section.

Given the explicit decision not to pool outcomes, the authors will find it challenging to conduct GRADE assessments, as there may be a large number of single-study estimates. Additionally, the authors have not explicitly defined any outcomes in their eligibility criteria or analysis plan, and so it is unclear what types of outcomes will be assessed using GRADE. Notably, there is currently no GRADE guidance available for the assessment of the certainty of evidence of prevalence data. The authors should describe how they plan to assess the evidence for review question 1.

Minor:

- Line 97 – it is not necessary to describe PROSPERO and cite Booth et al., your reference should include the citation information necessary to locate your registration.

- There is a word missing, Line 99: “The current ___ uses the framework…”

- The headings “study selection criteria” and “inclusion and exclusion criteria” are redundant – The PRISMSA-P Checklist uses the language “Eligibility criteria” – the authors should review PRISMA-P and ensure that they are adequately reporting all items.

- Under “screening”, the authors should specify that screening will be done in duplicate

**********

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Reviewer #1: Yes: Cyril Bennouna

Reviewer #2: No

**********

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PLoS One. 2023 Oct 5;18(10):e0292535. doi: 10.1371/journal.pone.0292535.r002

Author response to Decision Letter 0

3 Aug 2023

Dear Reviewers,

I extend my sincere gratitude to the reviewers for their valuable comments and feedback, which greatly improved my revised manuscript. Your input was instrumental in enhancing the quality of our work, and I appreciate the time and effort you dedicated to the review process. Thank you for your invaluable contributions to this research.

Sincerely,

Maryam Kazemitabar

Please see our responses to the reviewers’ comments below. My responses to the reviewers' comments are in bold black and when I directly referred to the manuscript contents in bold blue.

1. Introduction:

Response to the reviewer’s comment: Thank you for your helpful comment. I revised it, you can see the changes on pages 3 and 4 lines 77-83: “Studying the epidemiology of SUDs and MHDs among forced migrants from the MENA region is crucial due to their unique challenges and vulnerabilities. There is a substantial body of existing research on the topic of SUDs [12, 13] and especially MHDs [14-18] from the MENA region. However, the availability of systematic reviews that comprehensively collect and analyze this data is limited. Conducting a systematic literature review will help bridge this gap by providing a comprehensive synthesis of the existing research, allowing for a more thorough understanding of the epidemiology of SUDs and MHDs among this population.”

2. Inclusion/exclusion criteria:

Response to the reviewer’s comment: Thank you for your valuable feedback. We intended to include both internationally and internal displacement, so we included this sentence per your suggestion. Please see page 6, lines 140-142: “Studies focused on people from the MENA region who have been forcibly displaced by conflict, persecution, and/or natural disaster, including international displacement as well as internal displacement will be included.”.

Relatedly, the authors’ definition of the MENA region is a little fuzzy, since UNOCHA responds to both places producing displacement (e.g., Syria) and places receiving displaced people (e.g., Jordan). Often, for example, Turkey is not included in definitions of the MENA region (for instance, in OHCHR), but UNOCHA includes it because of its Syrian response.

Response to the reviewer’s comment: Thank you for your insightful comment. We used United Nations Human Resources Office of the High Commissioner (HROHC) classification for included countries in MENA region plus Türkiye (MENAT).

Some related questions: Is there a minimum/maximum length of time for the length of displacement that the authors will include? For instance, will they include resettled refugees, who are technically no longer displaced? Will they include people who fled a natural disaster for a month, only to return? Will they include returnees more generally?

Response to the reviewer’s comment: There is no specific length of time for displacement in this study. All refugees resettled or not resettled will be included since even after resettlement they might struggle with SUDs and/or MHDs, we decided to include them all.

b. Will the authors include studies that include participants from other regions, or only studies that focus exclusively on migrants from the MENA region?

Response to the reviewer’s comment: Only studies on forced migrants from the MENA region. Expanding the inclusion criteria to encompass forced migrants from other regions would significantly increase the number of extracted articles, making the process of data extraction and synthesis unmanageable. Furthermore, there already exists a substantial body of research focusing on MHDs among forced migrants specifically from the MENA region.

Response to the reviewer’s comment: We aim to include the studies conducted in the last ten years not more to make the process of data extraction and synthesis manageable. The introduction section is reframed per your suggestion. Please see page 3, lines 59-62: “The Arab Spring protest and the subsequent state crackdowns, coups, and wars that followed the initial protests played a significant role in the displacement such that caused more than 3.5 million people to get internally displaced; ever since the numbers have even increased to more than three times.”

d. Will the authors include qualitative, quantitative studies, and mixed-methods studies, or only quantitative studies?

Response to the reviewer’s comment: All qualitative, quantitative studies, and mixed-methods studies will be included. We added this information to the methods section. Please see page 6, lines 133-134: “The systematic review will include all qualitative, quantitative studies, and mixed-methods studies focusing on SUDs and/or MHDs among forced migrants displaced from the MENA region.”

3. Search strategy:

a. Concept 1: Consider adding: Türkiye (official name), Kurdistan, and Near East

b. Concept 2: Depending on your responses to the above, consider adding asylee, resettled, and returnee

c. Concept 3: Consider adding regionally specific substances, such as khat/qat, hookah/narghile/argila/shisha/waterpiped. Consider adding search terms in Arabic

Response to the reviewer’s comment : Thank you for these suggestions about additional search terms. We have added them all, as well as demonyms for Turkish and Kurdish people, and some additional synonyms/spellings for the regionally specific substances.

Regarding the suggestion of adding search terms in Arabic: we considered this approach, but we decided not to implement it. We are confident that we can nevertheless expect to identify relevant Arabic-language papers with the current approach, through three pathways. First, many Arabic-language papers in the databases we are searching have English-language abstracts, through which our search strategy will retrieve them. Second, Arabic-language papers in the databases which we are searching with controlled vocabulary will be retrieved by our use of subject headings and our use of the Ovid multipurpose field (as opposed to the Ovid textword field). Third, papers (in any language) in journals that are not indexed in any of the databases which we searched can still be identified in this project through citation chaining, which we will conduct with the tool Citation Chaser (Haddaway 2022), using the bibliographic database Lens, which includes publication metadata from the database/dataset OpenAlex (https://about.lens.org/release-8-5/), which is recognized as having particularly good coverage of open access journals based in LMIC countries (Khanna 2022). Via these pathways, we hope to identify relevant papers in Arabic, even if they are from journals not indexed in any of the bibliographic databases we are searching. What’s more, we intend to create a supplemental table of relevant articles in other languages – Persian, French, Turkish, any other language – that we identify during the screening process, for use by other researchers studying this topic in the future.

Khanna, S., Ball, J., Alperin, J. P., & Willinsky, J. (2022). Recalibrating the Scope of Scholarly Publishing: A Modest Step in a Vast Decolonization Process. Quantitative Science Studies, 1–43. https://doi.org/10.1162/qss_a_00228

Haddaway, N. R., Grainger, M. J., & Gray, C. T. (2022). Citationchaser: A tool for transparent and efficient forward and backward citation chasing in systematic searching. Research Synthesis Methods, n/a(n/a). https://doi.org/10.1002/jrsm.1563

ABSTRACT

Response to the reviewer’s comment: Thank you for your constructive feedback. The Abstract is revised and improved now.

INTRODUCTION

Major:

- Please review the UNHCR statistics and verify if more recent stats are available (2022? 2021?).

Response to the reviewer’s comment: Data is updated from UNHRC.

- Many statements are provided without in-text citations (e.g., Lines 51-52; 63-71). Please provide supporting references.

Response to the reviewer’s comment: References added.

Minor:

- Lines 77 and 78 are repetitive.

Response to the reviewer’s comment: Thank you for noticing that. This sentence is modified.

METHODS

Major:

Response to the reviewer’s comment: We appreciate the reviewer's thoughtful consideration of the review questions and the recommended resources. We have thoroughly reviewed the suggestions and have reevaluated the appropriateness of the review type for each question.

After careful consideration, we agree that the primary question (PQ1) has a broad nature and requires a systematic review approach. We will conduct a comprehensive and methodical search of the literature to identify all relevant studies, followed by a rigorous synthesis and analysis of the findings. A systematic review will allow us to address PQ1 with a high level of evidence and ensure a robust and reliable conclusion.

Regarding the secondary questions, SQ1 and SQ2, and primary question 2 (PQ2) we acknowledge that they might benefit from a scoping review approach due to their exploratory and broad scope nature. A scoping review will enable us to map the available evidence, identify key concepts, and provide an overview of the literature without necessarily assessing the quality of individual studies. This approach will help us gain a better understanding of the existing research landscape related to these questions.

In our protocol, we will explicitly specify the review type for each question and provide a clear justification for our choice. We will also refer to the recommended resources, such as the Munn et al. (2018) paper on choosing between systematic and scoping reviews and the PRISMA-ScR checklist by Tricco et al. (2018), to ensure that our review follows best practices for conduct and reporting.

Please see page 14, lines 240-252: “We aim to investigate a comprehensive range of research questions to gain a thorough understanding of the topic under study. The primary question (PQ1) has been identified as having a broad nature, necessitating a systematic review approach. By following a systematic review methodology, we will conduct a rigorous and exhaustive search of the literature, ensuring the inclusion of all relevant studies and providing a robust synthesis and analysis of the findings.

Additionally, we recognize that PQ2, SQ1, and SQ2 might benefit from a scoping review approach due to their exploratory and broad scope nature. Employing a scoping review methodology for these secondary questions will enable us to map the available evidence, identify key concepts, and offer an overview of the literature without necessarily assessing the quality of individual studies. This approach will provide a comprehensive understanding of the existing research landscape related to these questions and facilitate the identification of knowledge gaps and potential areas for future research.”.

Response to the reviewer’s comment: The definition added per your suggestion.

If the authors choose to conduct a systematic review, then they must specify interventions and outcomes eligible for inclusion.

Response to the reviewer’s comment: Thank you for your comment. This systematic review is a systematic review of prevalence and incidence. Including interventions and outcomes is not applicable; it is more applicable for Cochrane-style systematic review of interventions.

Response to the reviewer’s comment: Thank you for your suggestion. Edited!

Given that the studies addressing review question #1 are likely to be observational and reporting prevalence, the authors should also consider whether the JBI critical appraisal checklist for prevalence studies would be beneficial. Additional guidance for reporting such evidence is available:

Response to the reviewer’s comment: Thank you for your helpful comment. We will use the JBI critical appraisal checklist for prevalence study that you mentioned. The manuscript’s content edited accordingly.

Response to the reviewer’s comment: The approach to synthesizing prevalence studies is added to the manuscript per your suggestion: “The ‘best evidence synthesis’ will be used to synthesizing prevalence estimates. In implementing a best evidence synthesis approach, this study will prioritize higher-quality studies or those with more robust methodology to guide the synthesis process [29]. Greater weight will be assigned to studies with larger sample sizes, rigorous study designs, or lower risk of bias when summarizing prevalence estimates. By employing this approach, we aim to provide a more reliable and valid synthesis of prevalence data that will be informed by studies of the highest quality and methodological rigor.”

29- Slavin, R.E., Best-Evidence Synthesis: An Alternative to Meta-Analytic and Traditional Reviews. Educational Researcher, 1986. 15(9): p. 5-11.

The authors previously described that “studies with high risk of bias will be considered in a sensitivity analysis”, but the methods for this analysis are not described in this section.

Response to the reviewer’s comment: We appreciate the reviewer's comment. We added a description about methods for sensitivity analysis.

Response to the reviewer’s comment: Thank you for your comment. We will use ‘best evidence synthesis’ to synthesizing prevalence estimates as mentioned above.

Minor:

- Line 97 – it is not necessary to describe PROSPERO and cite Booth et al., your reference should include the citation information necessary to locate your registration.

Response to the reviewer’s comment: We have included registration ID under the “Design of the systematic review” section. Citation for PROSPERO removed.

- There is a word missing, Line 99: “The current ___ uses the framework…”

Response to the reviewer’s comment: Edited! Thank you.

- Under “screening”, the authors should specify that screening will be done in duplicate

Response to the reviewer’s comment: Added.

Attachment

Submitted filename: Rebuttal Letter.docx

Click here for additional data file.^{(38.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0292535.r003

Decision Letter 1

Amin Nakhostin-Ansari

15 Aug 2023

PONE-D-23-12703R1Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENAT region: a systematic review protocolPLOS ONE

Dear Dr. Kazemitabar,

==============================

Please submit your revised manuscript by Sep 29 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Amin Nakhostin-Ansari

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

Reviewer #2: No

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

primary question (PQ1) has been identified as having a broad nature, necessitating a systematic review approach." This is further confused by the fact that the authors also justify a *scoping* review for PQ2, SQ1, and SQ2 on the basis of their "broad scope nature." I disagree that "having a broad nature" is what warrants a systematic review, for PQ1, and I believe Reviewer 2 actually suggested a *scoping* review (rather than a systematic review) specifically "given the broad nature of the review questions." This is in keeping with the Munn et al. article on deciding between a systematic and scoping review, where they note that "A key difference between scoping reviews and systematic reviews is that in terms of a review question, a scoping review will have a broader “scope” than traditional systematic reviews..." That said, I agree with the authors that a systematic review is appropriate for PQ1—given the question's focus on synthesizing evidence of prevalence—but I would suggest articulating the justification more clearly. For example, using the same Munn et al. article, the authors could argue that PQ1 meets the systematic review indication for "uncover[ing] the international evidence." My second small comment is that some of the edits have introduced new grammatical errors (e.g. page 3, line 75), so I would recommend a comprehensive copy edit before publishing.

Reviewer #2: Thank you for addressing my previous comments and for inviting me to review the revised paper. I appreciate the efforts the authors have made in their protocol. Below, I have a few additional comments that should be addressed prior to publication.

1) The abstract states that you will use the Newcastle-Ottawa Scale and Cochrane RoB, but the methods have been revised to the JBI checklist for prevalence studies an d ROBINS-I. This needs to be consistent.

2) More details are needed regarding how you plan to analyze the data for PQ1. For example, do you plan to conduct a meta-analysis of prevalence estimates? If yes, will you use a random or fixed effects model? Will these estimates be stratified by MH condition? Will you conduct any assessments for publication bias? You do describe the best evidence synthesis approach to weight studies in your analyses, but it is still necessary to describe the analytic approach. I would consider reviewing the paper by Blackmore et al. below as an example of the type of analyses that could be possible. If the authors choose not to conduct a meta-analysis (or other regression analyses), this choice needs to be justified in the protocol.

Citation: Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM, Fitzgerald G, et al. (2020) The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Med 17(9): e1003337. https://doi.org/10.1371/journal.pmed.1003337

3) The authors have still not addressed the issue with planning to use GRADE methods. Given that the outcomes for PQ2 and SQ1/2 will be scoping review questions and no risk of bias assessments will be complete, no GRADE assessment will be possible for these questions. Additionally, there are no current methods for GRADE assessments for prevalence data (PQ1). My suggestion would be for the authors to acknowledge these limitations and state that no assessment for the overall certainty/strength of the evidence will be performed.

4) In response to reviewers #1's comments, the authors described "papers (in any language) in journals that are not indexed in any of the databases which we searched can still be identified in this project through citation chaining, which we will conduct with the tool Citation Chaser (Haddaway 2022), using the bibliographic database Lens, which includes publication metadata from the database/dataset OpenAlex (https://about.lens.org/release-8-5/), which is recognized as having particularly good coverage of open access journals based in LMIC countries (Khanna 2022)."

These details (such as your planned use of the tool citation chaser) should be described in the protocol and referenced appropriately. You should list the software you plan to use for your analysis (e.g., RevMan, STATA, R) and any planned visualizations.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Cyril Bennouna

Reviewer #2: No

**********

PLoS One. 2023 Oct 5;18(10):e0292535. doi: 10.1371/journal.pone.0292535.r004

Author response to Decision Letter 1

15 Aug 2023

28th July, 2023

Dear Editorial Board,

We extend our sincere appreciation for the valuable and insightful feedback provided by the reviewers regarding our manuscript titled "Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENA region: a systematic review protocol". We are pleased to submit the revised version of our manuscript to PLOS ONE journal.

The reviewers' comments have significantly contributed to the enhancement of our manuscript. Below, we have addressed each comment raised and incorporated the necessary revisions accordingly. Furthermore, we affirm that the present work has not been published in any journal previously, nor is it under consideration for publication elsewhere.

Sincerely,

Maryam Kazemitabar, Ph.D.

Department of Internal Medicine, Yale University

Email: maryam.kazemitabar@yale.edu

Please see our responses to the reviewers’ comments below.

1. Introduction:

2. Inclusion/exclusion criteria:

b. Will the authors include studies that include participants from other regions, or only studies that focus exclusively on migrants from the MENA region?

d. Will the authors include qualitative, quantitative studies, and mixed-methods studies, or only quantitative studies?

3. Search strategy:

a. Concept 1: Consider adding: Türkiye (official name), Kurdistan, and Near East

b. Concept 2: Depending on your responses to the above, consider adding asylee, resettled, and returnee

c. Concept 3: Consider adding regionally specific substances, such as khat/qat, hookah/narghile/argila/shisha/waterpiped. Consider adding search terms in Arabic

ABSTRACT

Response to the reviewer’s comment: Thank you for your constructive feedback. The Abstract is revised and improved now.

INTRODUCTION

Major:

- Please review the UNHCR statistics and verify if more recent stats are available (2022? 2021?).

Response to the reviewer’s comment: Data is updated from UNHRC.

- Many statements are provided without in-text citations (e.g., Lines 51-52; 63-71). Please provide supporting references.

Response to the reviewer’s comment: References added.

Minor:

- Lines 77 and 78 are repetitive.

Response to the reviewer’s comment: Thank you for noticing that. This sentence is modified.

METHODS

Major:

Response to the reviewer’s comment: The definition added per your suggestion.

If the authors choose to conduct a systematic review, then they must specify interventions and outcomes eligible for inclusion.

Response to the reviewer’s comment: Thank you for your suggestion. Edited!

29- Slavin, R.E., Best-Evidence Synthesis: An Alternative to Meta-Analytic and Traditional Reviews. Educational Researcher, 1986. 15(9): p. 5-11.

The authors previously described that “studies with high risk of bias will be considered in a sensitivity analysis”, but the methods for this analysis are not described in this section.

Response to the reviewer’s comment: We appreciate the reviewer's comment. We added a description about methods for sensitivity analysis.

Response to the reviewer’s comment: Thank you for your comment. We will use ‘best evidence synthesis’ to synthesizing prevalence estimates as mentioned above.

Minor:

- Line 97 – it is not necessary to describe PROSPERO and cite Booth et al., your reference should include the citation information necessary to locate your registration.

Response to the reviewer’s comment: We have included registration ID under the “Design of the systematic review” section. Citation for PROSPERO removed.

- There is a word missing, Line 99: “The current ___ uses the framework…”

Response to the reviewer’s comment: Edited! Thank you.

- Under “screening”, the authors should specify that screening will be done in duplicate

Response to the reviewer’s comment: Added.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(38.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0292535.r005

Decision Letter 2

Amin Nakhostin-Ansari

16 Aug 2023

PONE-D-23-12703R2Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENAT region: a systematic review protocolPLOS ONE

Dear Dr. Kazemitabar,

==============================

ACADEMIC EDITOR: The response letter remains unchanged from the previous version of the manuscript, and the new comments from the reviewers have not yet been addressed in the revised manuscript (R2 version). Please thoroughly address the reviewers' comments and submit the revised version along with the response letter for further consideration.

==============================

Please submit your revised manuscript by Sep 30 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Amin Nakhostin-Ansari

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2023 Oct 5;18(10):e0292535. doi: 10.1371/journal.pone.0292535.r006

Author response to Decision Letter 2

5 Sep 2023

September 5, 2023

Dear Reviewers,

Thank you for your insightful comments and feedback on our manuscript which resulted in improving it. We addressed your comments and incorporated them in this revised version. Please see below our responses to your comments.

Sincerely,

Maryam Kazemitabar

Please see our responses to the reviewers’ comments below. My responses to the reviewers' comments are in bold black and the contents in bold blue are those that directly refer to the manuscript.

Reviewer #1: The authors have thoroughly addressed my comments and produced an improved submission. I have two small remaining notes: First, I find the justification for the systematic review for PQ1 somewhat confusing. In response to Reviewer 2, the authors note that "After careful consideration, we agree that the primary question (PQ1) has a broad nature and requires a systematic review approach." They then write in the body of the text that "The primary question (PQ1) has been identified as having a broad nature, necessitating a systematic review approach." This is further confused by the fact that the authors also justify a *scoping* review for PQ2, SQ1, and SQ2 on the basis of their "broad scope nature." I disagree that "having a broad nature" is what warrants a systematic review, for PQ1, and I believe Reviewer 2 actually suggested a *scoping* review (rather than a systematic review) specifically "given the broad nature of the review questions." This is in keeping with the Munn et al. article on deciding between a systematic and scoping review, where they note that "A key difference between scoping reviews and systematic reviews is that in terms of a review question, a scoping review will have a broader “scope” than traditional systematic reviews..." That said, I agree with the authors that a systematic review is appropriate for PQ1—given the question's focus on synthesizing evidence of prevalence—but I would suggest articulating the justification more clearly. For example, using the same Munn et al. article, the authors could argue that PQ1 meets the systematic review indication for "uncover[ing] the international evidence." My second small comment is that some of the edits have introduced new grammatical errors (e.g. page 3, line 75), so I would recommend a comprehensive copy edit before publishing.

Response to the reviewer’s comment: Thank you for your helpful comment. It is edited according to your suggestion. Please see page 15 line 276. We also reviewed and edited the whole manuscript for English proficiency.

Response to the reviewer’s comment: Good catch! Thank you for reminding us to edit this in the Abstract.

Response to the reviewer’s comment: Thank you for your valuable suggestion. We considered a meta-analysis for PQ1, focusing on SUDs and MHDs prevalence per your suggestion. Please see pages 14-15, lines 249-271:

“Statistical analysis

The meta-analysis model will be chosen based on the study design. Given the expected variability among studies, a random-effects model will be considered due to its capacity to account for heterogeneity. If utilizing the ‘meta’ package, the ‘metagen’ function [1] will be applied. Alternatively, for the ‘metafor’ package, the ‘rma’ function [2] will be used. The selected function will be executed by inputting a structured data frame and defining relevant parameters including effect size, standard error, sample size, and study identifiers.

To quantify heterogeneity among the studies, I² statistic [3] will be employed to quantify the proportion of total variation in effect estimates that is due to heterogeneity rather than chance. Visual representations of study effect sizes and confidence intervals will be generated through the creation of forest plots, using functions like ‘forest()’ or ‘forest.rma()’. Potential publication bias will be explored and visualized using funnel plots and Egger's test [4] considering a p-value < .05. These analyses will be facilitated through dedicated functions available in the chosen R package.

We also updated the abstract to reflect these changes.

Response to the reviewer’s comment: Thank you for your feedback. We appreciate your input and have taken it into consideration. As per your suggestion, we have included the following sentence to address the issues you mentioned (page 14, lines 251-253):

“Given that the outcomes for PQ2/3 and SQ1/2 will be scoping review questions and no risk of bias assessments will be completed, there will be no evaluation conducted to determine the overall certainty or strength of the evidence.”

Response to the reviewer’s comment: Thank you for your insightful comments. We appreciate your attention to detail. We added the following information to the protocol per your suggestion:

“Additionally, research articles published in journals not covered by the databases we searched can still be located using citation chaining in this study. We will perform this process using the Citation Chaser tool [5] and the bibliographic database Lens. This database incorporates publication details from the OpenAlex database/dataset, known for its strong coverage of open-access journals in low- and middle-income countries [6]. Citation Chaser is an automated tool that streamlines the process of "citation chasing" in systematic reviews. It uses the Lens.org API to quickly retrieve lists of references from various studies and identify articles that cite a specific study. This eliminates the manual effort traditionally required for cross-referencing and enhances accuracy. The tool can generate lists of both referenced and citing records from sources like PubMed, PubMed Central, CrossRef, Microsoft Academic Graph, and CORE, making systematic review searches more efficient.”

27- Haddaway NR, Grainger MJ, Gray CT. Citationchaser: A tool for transparent and efficient forward and backward citation chasing in systematic searching. Research Synthesis Methods. 2022 Jul;13(4):533-45.

28- Khanna S, Ball J, Alperin JP, Willinsky J. Recalibrating the scope of scholarly publishing: A modest step in a vast decolonization process. Quantitative Science Studies. 2022 Dec 22:1-9.

The statistical analysis and the software and packages used to conduct meta-analysis described in details as explained in response to your previous comment.

References

1. Viechtbauer, W., Conducting meta-analyses in R with the metafor package. Journal of statistical software, 2010. 36: p. 1-48.

2. Viechtbauer, W. The R package metafor: Past, present, and future. in Research Synthesis 2019 incl. Pre-Conference Symposium Big Data in Psychology, Dubrovnik, Croatia. 2019. ZPID (Leibniz Institute for Psychology Information).

3. Higgins, J.P., et al., Measuring inconsistency in meta-analyses. Bmj, 2003. 327(7414): p. 557-560.

4. Egger, M., et al., Bias in meta-analysis detected by a simple, graphical test. Bmj, 1997. 315(7109): p. 629-634.

5. Haddaway, N.R., M.J. Grainger, and C.T. Gray, Citationchaser: A tool for transparent and efficient forward and backward citation chasing in systematic searching. Research Synthesis Methods, 2022. 13(4): p. 533-545.

6. Khanna, S., et al., Recalibrating the scope of scholarly publishing: A modest step in a vast decolonization process. Quantitative Science Studies, 2022: p. 1-19.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(31.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0292535.r007

Decision Letter 3

Amin Nakhostin-Ansari

25 Sep 2023

Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENAT region: a systematic review and meta-analysis protocol

PONE-D-23-12703R3

Dear Dr. Kazemitabar,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Amin Nakhostin-Ansari

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #1: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #1: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have done a great job reviewing the manuscript and I wish them all the best with their study.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Cyril Bennouna

**********

PLoS One. doi: 10.1371/journal.pone.0292535.r008

Acceptance letter

Amin Nakhostin-Ansari

27 Sep 2023

PONE-D-23-12703R3

Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENAT region: a systematic review and meta-analysis protocol

Dear Dr. Kazemitabar:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Amin Nakhostin-Ansari

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: Recommended items to address in a systematic review protocol*.

(DOC)

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Data Availability Statement

No datasets were generated or analyzed during the current study. All relevant data from this study will be made available upon study completion.

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PERMALINK

Epidemiology of substance use and mental health disorders among forced migrants displaced from the MENAT region: A systematic review and meta-analysis protocol

Maryam Kazemitabar

Kate Nyhan

Natalie Makableh

Rebecca Minahan-Rowley

Malak Ali

Mayyada Wazaify

Jeanette Tetrault

Kaveh Khoshnood

Roles

Abstract

Background

Methods

Discussion

Introduction

Primary review questions

Secondary review questions

Methods

Design of the systematic review

Eligibility criteria

Participants

Information sources

Search strategy

Table 1. Search strategy for Medline Ovid from 1946 to July 12, 2023.

Screening process

Fig 1. PRISMA flow diagram.

Risk of bias assessment

Statistical analysis

Data synthesis

Discussion

Limitations

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Amin Nakhostin-Ansari

Roles

Author response to Decision Letter 0

Decision Letter 1

Amin Nakhostin-Ansari

Roles

Author response to Decision Letter 1

Decision Letter 2

Amin Nakhostin-Ansari

Roles

Author response to Decision Letter 2

Decision Letter 3

Amin Nakhostin-Ansari

Roles

Acceptance letter

Amin Nakhostin-Ansari

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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