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. 2021 Jan 28;16(1):e0245873. doi: 10.1371/journal.pone.0245873

Parental migration and psychological well-being of left-behind adolescents in Western Nepal

Madhu Kharel 1, Shibanuma Akira 1, Junko Kiriya 1, Ken Ing Cherng Ong 1,*, Masamine Jimba 1
Editor: Gracia Fellmeth2
PMCID: PMC7842897  PMID: 33507904

Abstract

Introduction

International migration is increasing rapidly around the world mostly to obtain a job. International migrant workers usually leave their children back in their country of origin, and among family members, adolescents may experience greater psychological distress from parental separation. However, limited evidence is available on the relationship between parental international migration and psychological well-being of left-behind adolescents. Nepal has a relatively higher and increasing number of international migrants, and this study was conducted to examine the association between parental international migration and the psychological well-being of left-behind adolescents in Nepal.

Methods

A school-based cross-sectional study was conducted among 626 adolescents in two districts of Western Nepal, where international migration is common. Adolescents were recruited through random sampling. Pre-tested “Strengths and Difficulties Questionnaire” was used to measure their psychological well-being and simple and multiple linear regression were used to examine the association between parental international migration and the psychological well-being of left-behind adolescents.

Results

Adolescents with none of the parents living abroad were more likely to have higher total difficulties score compared to those with one of the parents living abroad (B: 1.02; 95% CI: 0.18, 1.86; p = 0.017). Adolescents with the following factors were more likely to have higher total difficulties score in comparison to their counterparts: adolescents in their late adolescence period, female adolescents, adolescents from ethnicities other than Brahmin and adolescents studying in private schools.

Conclusion

In rural districts of Nepal, where international migration is common, adolescents living with the parents were more likely to have poorer psychological well-being compared to those with one of the parents living abroad. Adolescents’ adaptation mechanism for the absence of parents for international migration might be explored in the future studies.

Introduction

International migration is increasing rapidly around the world. In 2019, for example, around 272 million people were estimated to live in a foreign country, accounting for 3.5% of the world's population [1]. Employment is the most common reason for international migration and migrant workers accounted for nearly two-thirds of the world's 258 million international migrants in 2017 [2].

Many migrants go abroad for employment and leave their children in their country of origin under the care of the remaining partner or other family members or relatives. Among them, children and adolescents, who are at the critical stage of growth and development, are anticipated to experience greater psychological distress from parental separation compared to other family members [3]. Precise data on the number of children left-behind is not available, but the number is thought to be in the hundreds of millions [4].

Despite such family problems, international migration is important in Nepal because remittance plays a vital role in the Nepalese economy. It accounted for about 31% of the Gross Domestic Product (GDP) in 2016, and Nepal ranked the second among the top five countries in the world with the highest share of remittance on GDP [5].

Nepal, a low-income country (recently upgraded to a lower-middle-income country [6]) in South Asia, is a labour exporting country. Due to the lack of employment opportunities in the country, people are forced to go abroad for work [7]. According to the National Census of 2011, one-fourth of the households had at least one member living in a foreign country [8]. Labour migration gained popularity among Nepalese after the restoration of democracy in 1990 when Nepal adopted liberal economy and opened up labour migration to countries other than India. Since that time, the number of people going abroad for work has increased significantly. A total of 3,554,683 foreign employment permits were issued between 2008/09-2016/17 for 153 countries by the Department of Foreign Employment [7]. Labour migration will increase in the future as the government is trying to make the labour migration process smooth, safe and transparent. The majority of Nepalese migrant workers leave their children in Nepal when they go abroad. The children are looked after by the remaining family members in Nepal, mostly their grandparents as joint families are still common in Nepal.

As labour migration will not decrease in the coming years in Nepal and other resource limited settings, research has been conducted on the impact of parental migration on the mental health of left-behind children [9–11]. However, a large proportion of these studies were conducted in China and mainly focused on internal migration [4, 12, 13]. Compared to internal migration, international migration of parents could have a much bigger impact on the mental health of children and adolescents left-behind. This is because it can increase geographical distance and limit the frequency of parent-child meeting and communication. Apart from the studies in China, studies have been conducted in some parts of Asia and Africa to see the impact of parental international migration on the mental health of left-behind children and adolescents [9, 10, 14]. However, these studies have produced mixed results, with some reporting negative effects of parental migration [9, 10, 14] while others reporting no difference in the psychological well-being of adolescents [9, 14]. Moreover, only a few studies have focused on adolescents.

Adolescents are in a crucial period of physical, sexual, and psychological development [3] and they may need more parental support during this period. If the parents are absent during this period, they might face various challenges including psychological distress. However, few studies have focused on them, and more evidence is necessary on how the absence of parents due to international migration could affect the mental health of left-behind adolescents. Therefore, this study examined the association between parental international migration and the psychological well-being of left-behind adolescents in Nepal.

Methods

Study design and settings

This study was a school-based, cross-sectional study conducted in two districts of Western Nepal, Baglung and Gulmi. These are basically rural districts. The two districts were selected as the proportion of households with at least one member living in a foreign country in these two districts was among the highest (Gulmi: 54.1% and Baglung: 47.4%) in Nepal [15]. Two municipalities, one from each district, with the high proportion of absent households (Galkot Municipality from Baglung and Musikot Municipality from Gulmi) were selected as the study sites. These two areas were declared municipalities by the government in March 2017, after merging several Village Development Committees.

Participants

The participants in this study were adolescents studying in grades from 8 to 10, and between the age of 11 and 17 years with both parents alive. Adolescents were excluded when they had severe mental health illnesses, or they were absent from school on the day of data collection, their parents were migrating internally, or divorced. Sample size was calculated using OpenEpi software based on the findings from a similar study in Angola in Africa (a lower-middle income country as Nepal) as studies from Nepal or other Asian countries were not found which had relevant information on adolescents' psychological well-being to calculate the sample size for the study. In Angola, the adolescents living with both parents had mean psychological well-being score of 13.0 and standard deviation (SD) of 5.6. These figures for the adolescents with both parents away were 15.1 and 5.9, respectively [14]. The design effect was calculated to be 2.56 assuming the average class size of 40 and the intra-class correlation coefficient of 0.04 [16]. Power was set at 80% and the significance level was set at 5%. Considering a non-response rate of 10%, the minimum required sample size was 685.

Sampling procedure

Four schools (two public and two private) per municipality were selected randomly from the list of public secondary schools and private secondary schools in each municipality. In total, four public schools and four private schools were selected for the survey. Adolescents in Grades 8, 9 and 10 filled the questionnaire. Grades are divided into two or more sections (e.g. 9A, 9B and so on for Grade 9) when the school have either large number of students or different teaching languages (Nepali or English) or different majors (such as Accounting, Agriculture, Computer, Education, Optional Maths) in a grade. Two randomly selected sections were included from each grade of a school when the particular grade in that school had more than two sections. In this study, 3 schools had 3 sections in Grades 9 and 10.

Measures

In this study, the exposure variable was parental migration status and the outcome variable was psychological well-being of adolescents. Information on adolescents' perceived relationship with their primary caretaker and other socio-demographic variables were also collected.

Parental migration status

The main exposure variable in this study was parental migration status. Adolescents were asked if their father and/ or mother was living abroad. The responses were categorised as none of the parents living abroad, only the father living abroad, only the mother living abroad and both parents living abroad.

Relationship with primary caretaker

Adolescents provided response on their perceived relationship with their primary caretaker. They had four options to choose from: "Very good", "Satisfactory", "Poor" and "Very poor".

Psychological well-being of adolescents

Psychological well-being of adolescents was the outcome variable, and it was measured using the Strengths and Difficulties Questionnaire (SDQ). It is widely used around the world to assess mental well-being of children and is translated into more than 80 languages, including Nepali [17, 18]. It is a 25 item scale consisting of 5 sub-scales: emotional symptoms, conduct problems, hyperactivity/ inattention, peer relationships problem and prosocial behaviour [19]. The five sub-scales contain five questions each. The first 4 sub-scales yield total difficulties score which ranges from 0 to 40. Use of broader scale score is preferred over the sub-scale scores in community samples with low-risk of mental health difficulties [20]. Therefore, the total difficulties score was used to measure the psychological well-being of adolescents in this study as done by similar studies in the past [14, 21]. Higher total difficulties score indicates poorer psychological well-being.

Sociodemographic characteristics

Sociodemographic variables included age, gender, ethnicity, religion, parents' educational status, economic status (wealth quintile) and school type. Age was categorised into "Early adolescence" (10–14 years) and "Late adolescence" (15–19) based on the definition given by the World Health Organization (WHO) [3].

Data collection

Self-administered questionnaire was used to collect information on exposure, outcome and other variables. The students filled out the questionnaire in their classrooms, in the presence of the researcher, who provided instructions on how to fill the questionnaire in the beginning and was available throughout the session to clarify any confusion or questions. It took around 40–45 minutes to complete the questionnaire. Data collection was facilitated through coordination with respective municipalities, their education sections and selected schools. The questionnaire was pre-tested among adolescents in similar settings. The instructions for filling the questionnaire were made clearer based on the results of the pre-test. Data were collected in August and September 2019.

Data analysis

One-way Analysis of Variance (ANOVA) was used to compare the mean total difficulties score between adolescent groups in different categories of each variable. Simple and multiple linear regression analyses were performed to examine the association between independent variables and psychological well-being of adolescents. Variance Inflation Factor (VIF) was calculated to check multicollinearity between independent variables. All analyses were performed using Stata version 15.1 (College Station, TX: StataCorp LLC).

Ethics

This study was approved by the Research Ethics Committee of The University of Tokyo (Serial Number: 2019067NI) in Japan as well as the Nepal Health Research Council (Reg. no. 615/2019) in Nepal. Participation in this study was voluntary. Written informed assent was collected from the adolescents and written informed consent was obtained from their guardians before data collection. The questionnaire did not include any personal identifiable information.

Results

A total of 763 adolescents completed the survey. All the children present on the days of the survey completed the questionnaire. However, for analysis, those with divorced, deceased and internal migrant parents were excluded. Therefore, final analysis was conducted among 626 eligible adolescents.

General characteristics of adolescents

Table 1 shows the demographic characteristics of the adolescents (n = 626). Their mean age was 14.3 years [Standard Deviation (SD) 1.2] and more than half of them were in their early adolescence (10–14 years). The proportion of female adolescents (52.1%) was slightly higher than that of male adolescents (47.9%). Majority of the adolescents followed Hindu religion. Chhetri was the largest ethnic group accounting for nearly one-third of the adolescents. More than two-thirds of the adolescents attended public schools. Majority of the adolescents said they had a very good relationship with their primary caretakers. Very few respondents said they had poor (n = 1) and very poor (n = 2) relationship with their primary caretaker. Therefore, the three categories "Satisfactory", "Poor" and "Very Poor" were collapsed into a new category—"Not very good".

Table 1. General characteristics of adolescents (n = 626).

Variables n %*
Age (years) Mean (SD) 14.3 (1.2)
Age group
Early adolescence (10–14 years) 354 56.6
Late adolescence (15–19 years) 272 43.5
Gender
Male 300 47.9
Female 326 52.1
Type of school
Public 457 73.0
Private 169 27.0
Religion
Hindu 607 97.0
Buddhist 11 1.8
Christian 6 1.0
Muslim 1 0.2
Other 1 0.2
Ethnicity
Brahmin 106 16.9
Chhetri 234 37.4
Janajati 173 27.6
Dalit 112 17.9
Muslim 1 0.2
Father's education
Did not complete primary level 113 18.1
Completed primary or secondary level 424 67.7
Completed higher than secondary level 89 14.2
Mother's education
Did not complete primary level 178 28.4
Completed primary or secondary level 385 61.5
Completed higher than secondary level 63 10.1
Parental migration status
None of the parents living abroad 383 61.2
One of the parents living abroad 166 26.5
Both parents living abroad 77 12.3
Relationship with primary caretaker
Very good 584 93.3
Satisfactory 39 6.2
Poor 1 0.2
Very poor 2 0.3
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SD, standard deviation.

* Total might not add up to 100 due to rounding off.

Parental migration status

More than half of the adolescents were living with both parents. One-fourth of the adolescents had one of their parents living abroad and around 1 in 10 adolescents had both of their parents living abroad. Among those with one of the parents living abroad, very few adolescents (n = 4) had their mother living abroad (not shown in the table). So, the two categories—"only the father living abroad" and "only the mother living abroad" were collapsed to form a new category—"one of the parents living abroad".

Total difficulties score

The tool used to collect information on the psychological well-being of adolescents had acceptable reliability (Cronbach's alpha = 0.69). Table 2 shows comparison of the mean total difficulties score between adolescent groups in different categories in each independent variable. Adolescents with both parents living abroad had higher total difficulties score compared to those with one of the parents living abroad (pairwise comparisons using Bonferroni correction not shown in the table). The following groups had higher total difficulties score compared to their counterparts: older adolescents, female adolescents, adolescents from ethnicities other than Brahmin and those studying in private schools. No significant difference was observed in the mean total difficulties score for religion, parents' education, wealth quintile and children's relationship with their primary caretaker.

Table 2. Total difficulties score by general characteristics (n = 626).

Variables n Mean SD p-value
All adolescents 626 9.6 4.7
Age group 0.001
Early adolescence 354 9.1 4.6
Late adolescence 272 10.3 4.7
Gender 0.046
Male 300 9.3 4.4
Female 326 10.0 4.9
Ethnicity 0.002
Brahmin 106 8.3 4.3
Chhetri and others 520 9.9 4.7
Religion 0.992
Hindu 607 9.6 4.7
Buddhist and others 19 9.6 4.9
Type of school <0.001
Public 457 9.2 4.3
Private 169 10.9 5.4
Father's education 0.387
Lower than primary level 113 9.8 3.9
Completed primary or secondary level 424 9.7 4.8
Completed higher than secondary level 89 9.0 5.2
Mother's education 0.638
Lower than primary level 178 9.7 4.3
Completed primary or secondary level 385 9.7 4.8
Completed higher than secondary level 63 9.1 5.3
Wealth quintile 0.576
Quintile 1 134 9.3 4.0
Quintile 2 115 9.3 4.5
Quintile 3 126 9.8 5.0
Quintile 4 133 10.1 4.9
Quintile 5 118 9.8 5.0
Parental migration status 0.025
None of the parents living abroad 383 9.7 4.7
One of the parents living abroad 166 9.0 4.3
Both parents living abroad 77 10.8 5.3
Relationship with primary caretaker 0.375
Very good 584 9.6 4.6
Not very good 39 10.3 5.4
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Results of one-way analysis of variance (ANOVA).

Association between parent's migration status and psychological well-being of left-behind adolescents

Table 3 shows the results of simple linear regression analysis for the association of each independent variable with psychological well-being of adolescents, without controlling for other independent variables. In simple linear regression, the following factors were associated with the psychological well-being of adolescents: parental migration status, age, gender, ethnicity and school type. Adolescents with both parents living abroad were more likely to have higher total difficulties score compared to those with one of the parents living abroad (B: 1.74; 95% CI: 0.48, 3.00; p = 0.007).

Table 3. Factors associated with the psychological well-being of adolescents (simple linear regression analysis) (n = 626).

Variables B 95% CI p-value
Age group (reference: early adolescence)
Late adolescence 1.21 0.47, 1.95 0.001
Gender (reference: male)
Female 0.75 0.01, 1.48 0.046
Ethnicity (reference: Brahmin)
Chhetri and others 1.56 0.58, 2.53 0.002
Religion (reference: Hindu)
Buddhist and others -0.01 -2.16, 2.14 0.992
Type of school (reference: public)
Private 1.79 0.97, 2.60 <0.001
Father's education (reference: lower than primary level)
Completed primary or secondary level -0.74 -1.05, 0.90 0.881
Completed higher than secondary level -0.79 -2.10, 0.51 0.232
Mother's education (reference: lower than primary level)
Completed primary or secondary level -0.00 -0.84, 0.83 0.998
Completed higher than secondary level -0.59 -1.94, 0.76 0.390
Wealth quintile (reference: quintile 1)
Quintile 2 0.27 -1.14, 1.20 0.964
Quintile 3 0.50 -0.64, 1.64 0.390
Quintile 4 0.83 -0.30, 1.20 0.149
Quintile 5 0.49 -0.68, 1.65 0.413
Parental migration status (reference: one of the parents living abroad)
None of the parents living abroad 0.68 -0.17, 1.53 0.117
Both parents living abroad 1.74 0.48, 3.00 0.007
Relationship with the primary caretaker (reference: very good)
Not very good 0.66 -0.81, 2.13 0.375
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Table 4 presents the results of multiple linear regression analysis for the association of each independent variable with psychological well-being of adolescents, while controlling for other independent variables. The same variables as in simple linear regression analysis were associated with the psychological well-being of adolescents in multiple linear regression analysis. Adolescents living with both parents were more likely to have higher total difficulties score compared to those with one of the parents living abroad (B: 1.02; 95% CI: 0.18, 1.86; p = 0.017). Adolescents with both parents living abroad were also more likely to have higher total difficulties score than their peers with one of the parents living abroad (B: 1.28; 95% CI: -0.04, 2.60; p = 0.057). However, this association was not significant at 5% level of significance. Adolescents in their late adolescence period (B: 1.05; 95% CI: 0.32, 1.78; p = 0.005), female adolescents (B: 0.80; 95% CI: 0.05, 1.55; p = 0.037), adolescents from ethnicities other than Brahmin (B: 1.33; 95% CI: 0.30, 2.36; p = 0.011) and adolescents studying in private schools (B: 1.77; 95% CI: 0.73, 2.81; p = 0.001) were more likely to have higher total difficulties score in comparison to their counterparts. Multi-collinearity was not observed in the model as the VIF for all the variables was below 2.35.

Table 4. Factors associated with the psychological well-being of adolescents (multiple linear regression analysis) (n = 626).

Variables B 95% CI p-value
Age group (reference: early adolescence)
Late adolescence 1.05 0.32, 1.78 0.005
Gender (reference: male)
Female 0.80 0.05, 1.55 0.037
Ethnicity (reference: Brahmin)
Chhetri and others 1.33 0.30, 2.36 0.011
Religion (reference: Hindu)
Buddhist and others -0.33 -2.35, 1.69 0.747
Type of school (reference: public)
Private 1.77 0.73, 2.81 0.001
Father's education (reference: lower than primary level)
Completed primary or secondary level -0.23 -1.24, 0.78 0.655
Completed higher than secondary level -1.00 -2.56, 0.55 0.204
Mother's education (reference: lower than primary level)
Completed primary or secondary level -0.09 -1.01, 0.84 0.849
Completed higher than secondary level 0.16 -1.58, 1.91 0.856
Wealth quintile (reference: quintile 1)
Quintile 2 0.21 -0.88, 1.31 0.701
Quintile 3 0.32 -0.80, 1.45 0.571
Quintile 4 0.43 -0.83, 1.69 0.504
Quintile 5 -0.03 -1.40, 1.34 0.966
Parental migration status (reference: one of the parents living abroad)
None of the parents living abroad 1.02 0.18, 1.86 0.017
Both parents living abroad 1.28 -0.04, 2.60 0.057
Relationship with the primary caretaker (reference: very good)
Not very good 0.55 -1.04, 2.14 0.494
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Discussion

This study has the following major findings. Adolescents living with both parents were more likely to have higher total difficulties score and thus their psychological well-being was poorer compared to those with one of the parents living abroad. Older adolescents, female adolescents, adolescents from ethnicities other than Brahmin, and adolescents studying in private school were more likely to have poorer mental well-being.

This study found that adolescents living with both parents were more likely to have poorer psychological well-being compared to those with one of the parents living abroad. Parental migration is believed to have negative impact on the mental health of left-behind children and adolescents [4]. However, past studies also have shown that parental migration may not always be associated with poorer mental health among left-behind children and adolescents, and circumstances of parental migration and living arrangements for the left-behind children and adolescents might make a difference. For example, in Africa, no difference was observed for mental well-being between adolescents living with both parents and those with father or both parents living abroad in Ghana and Nigeria; however, adolescents with one or both parents living abroad had poorer psychological well-being compared to those living with both parents in Angola [14]. In our study, almost all of the adolescents with one of the parents living abroad had their father away and mother was there to take care of them. Therefore, they might have a sense of financial security from their father's earning as well as a sense of emotional support from their mother's presence at home. The majority of the migrant parents of the target population were living in Japan, one of the high-income countries and it might be a matter of pride for their children [22]. However, wealth quintile was not associated with psychological well-being of adolescents in this study. Joint families are quite common in Nepal, especially in rural areas, and the children are usually looked after by their grandparents. As the migrant parents mostly leave their children under the care of their grandparents, the left-behind children and adolescents might not have experienced much difference in the love and care they received before and after their parents migrate.

Generally, the school-going adolescents in Nepal support their families with household work though they are not engaged in direct income-generating activities. Agriculture is the primary occupation of the majority of the families in the study area. Families without foreign income may have to work more in the field to sustain their livelihoods. Accordingly, adolescents in such families might have to work extra hours to support their families. This extra burden on adolescents can affect their psychological well-being.

As anticipated, adolescents with both parents living abroad tended to show higher total mean difficulties score compared to those with none or one of the parents living abroad. However, this difference was not significant at 5% level of significance. Since the number of adolescents with both parents living abroad was low, this study might have failed to detect this difference.

In this study, adolescents in their late adolescence were more likely to have poorer mental well-being compared with those in their early adolescence. This concurs with previous studies in Nepal and Spain, too [23, 24]. This might be because the older adolescents are more likely to report lower life satisfaction, lower perceived family support, lower quality of communication with parents and increased school pressure [24, 25]. Being female was negatively associated with mental well-being in this study. This finding is consistent with results from previous studies in Nepal and other countries [23, 26–28]. In a multi-country study from Europe and North America, female adolescents had lower levels of satisfaction with life than their male counterparts, and they were more likely to report multiple health complaints [25]. Adolescents from ethnicities other than Brahmin were more likely to have poorer psychological well-being compared to Brahmin adolescents in this study. The caste-based hierarchy which is still existing in Nepalese society might have played a role in this ethnic difference in mental well-being [29, 30]. Studying in private school was associated with lower mental well-being among adolescents. School is the second home of children and the school environment plays a vital role in their development and psychological well-being. Private schools are generally believed to provide better quality education compared to public schools in Nepal and parents prefer to send their children to private schools [31]. However, private schools may not always be conducive to the emotional well-being of their students as observed in a study in the US [32]. This might be because of stricter school rules and higher academic pressure in private schools compared to public schools [33].

The finding from this study should be interpreted in consideration with the following limitations. First, this study used only the self-report version of SDQ although it would have been ideal to get information from different sources such as parents and teachers. However, it has been established from the past studies that the self-report version of SDQ could be used for the group of adolescents included in this study [34]. Second, this study used a self-administered questionnaire and some missing responses were observed despite clear instructions while filling the questionnaire. Those respondents had to be excluded from the analysis. Third, this study could not exclude adolescents with divorced parents, internal migrant parents and deceased parents during the survey due to ethical reasons. These could have caused selection bias. Fourth, the characteristics of primary caretakers, other than their relationship with the adolescents, were not captured in this study. Next, sub-group analysis could not be performed for adolescents' gender and age group as the study will not have enough power to detect the difference due to small sample size. Another limitation of this study is that the number of adolescents with both parents living abroad was relatively small compared to those living with both parents. Finally, due to the cross-sectional design of this study, causality cannot be established.

Despite these limitations, this study is one of the few studies examining the association between parental international migration and the psychological well-being of left-behind adolescents. This study also included information on adolescents' perceived relationship with their primary caretakers. The findings from this study might be useful in understanding the association between parental international migration and the psychological well-being of left-behind adolescents in settings where parental international migration is common.

This study highlights the need to prioritize adolescents with none or both parents living abroad, older adolescents, female adolescents, adolescents from ethnicities other than Brahmin and those attending private schools while enacting policies and interventions to promote the psychological well-being of adolescents.

Conclusion

In rural districts of Nepal, where international migration is common, adolescents living with the parents were more likely to have a poorer psychological well-being compared to those with one of the parents living abroad. Future studies could explore adolescents' adaptation mechanism for the absence of parents due to international migration.

Supporting information

S1 File. STROBE checklist.

(DOC)

Click here for additional data file. (102.5KB, doc)
S2 File. General characteristics by parental migration status.

(DOCX)

Click here for additional data file. (17.5KB, docx)
S3 File. Coding of study variables.

(DOCX)

Click here for additional data file. (14.7KB, docx)

Acknowledgments

We would like to express our heartfelt thanks to all adolescents for taking part in the study and to their guardians for allowing them to participate. Authorities in the two municipalities and the participating schools also deserve deep appreciation for their cooperation and support during data collection. We would also like to acknowledge and thank Pushkar Raj Silwal and Vishnu Prasad Sapkota for their inputs during proposal development and data analysis.

Data Availability

All data files are available in the Figshare Repository at: https://dx.doi.org/10.6084/m9.figshare.12301937.

Funding Statement

This study is funded by The University of Tokyo Fund to MJ. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

George Vousden

9 Sep 2020

PONE-D-20-14440

Parental migration and psychological well-being of left-behind adolescents in Western Nepal

PLOS ONE

Dear Dr. Ong,

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.

The manuscript has been evaluated by two reviewers, and their comments are available below. You will see the reviewers have commented on the potential impact of your work and interest it will attract once published. However, they have also raised a number of concerns that should be addressed before the manuscript can be accepted.

Please note that as per our publication criteria, PLOS ONE requires that all experiments, statistics and other analyses are performed to a high technical standard, described in sufficient detail and adhere to appropriate reporting guidelines and community standards. Conclusions must be presented in an appropriate fashion and be supported by the data (Please see http://journals.plos.org/plosone/s/criteria-for-publication).

The reviewers have requested further details regarding the statistical analysis and requested the further variables be included in your analysis. You should consider the requests made by the reviewers to ensure that the data presented in the manuscript support the conclusions drawn.

Please submit your revised manuscript by Oct 22 2020 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.

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We look forward to receiving your revised manuscript.

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George Vousden

Senior Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Many thanks for the opportunity to review this paper on the mental well-being of left-behind adolescents in Nepal. I apologise for the delay in submitting my review.

The research has been carried out to a high standard. The paper covers an important topic which has not received much attention to date in Nepal. The methods are rigorous and the authors have described them in detail. The conclusions are sound and of interest to a wide, global health audience.

I have some minor comments below for the authors' consideration.

Results, 1st paragraph: It may be clearer if you state that all children present on the days of the surveys completed the questionnaire. However, for analysis, those with divorced/deceased parents were excluded. At the moment it is slightly unclear from the way you have described it.

Results, Table 1. I would find it helpful to see these demographic characteristics according to parental migrant status. Would it be possible to add to this table (or in an additional table) the distribution of these characteristics by (a) whole sample; (b) one-parent migrant; (c) both parent migrants; (d) non-migrant?

Results, Table 3. It is interesting that you chose 1-migrant-parent as the reference group. PLease can you explain rationale for this? I would imagine it would make more sense to use non-migrant parent group as the reference, because it is the largest group and also it is most relevant to the overall research question - i.e. do children with migrnat parents have worse outcomes than those with no migrant parents. It is slightly more difficult to interpret when the reference category is 1-parent, and you are comparing those to either no-migrant or 2-parents.

Results, Table 3. I also cannot understand why in the simple linear regression, the order of scores changes. In Table 2, 1-parent group has the lowest SDQ scores, followed by non-migrant, and finally 2-parents. In Table 3, this has changed to lowest risk in non-migrant, followed by 1-parent, followed by 2-parents. What has changed, given that in the simple regression model you are (presumably) not controlling for any other factors yet?

Reviewer #2: Dear Authors,

I read your work with great interest and I commend you on focusing on left behind children on Nepal. Your study has a lot of potential to provide more insights into the existing literature on the psychological well-being left behind children. Below I provide you with comments to improve your work.

1. On page 4, line7, your paper argues that most studies focus on the left behind children in China in an internal migration context. However, there are now more studies on the psychological well-being of left behind children in Africa, Latin America and other parts of Asia (the Philippines, Indonesia). It is important that you acknowledge and get insights from these quantitative studies, which will help you in improving the choice of variables for your analysis and improving the key conclusions you can draw from this analysis.

2. In the Methods section,

a. the use of psychological data on the African adolescents is neither properly explained nor very well justified. It is not particularly clear for what purpose you use this data and what insight it can bring to the study, as well on what basis Nepalese and African Adolescents can be compared. Note: it is very important that you mention the exact country in Africa that this data represents as Africa is a continent covering many countries. If you are comparing continental average data, it is important to explicit about that.

b. The methods section should be explicit about what kind of information were collected in the survey.

c. It is important to add a supplementary table on the coding of the socioeconomic and demographic variables.

d. Because you are focusing on the left behind children, it is crucial that you account for the characteristics of the caregiver: is the caregiver employed, other than relationship with the caregiver. It is also important to control for the economic activities of these children (see #3 comment for more explanation). Please also consider variables such as household size if it is available.

e. In the analyses strategy, it is important to conduct further analyses to check the robustness of your results. Contrary to findings for Ghanaian and Angolan left behind children, your study finds that adolescents living with both their parents have lower psychological well-being. I suggest you conduct separate analyses for girls and boys to see whether this result persists. You can also conduct separate analyses for early adolescent and late adolescent groups as the effect of parental migration could differ between these groups.

3. To explain the results you find, it might be wise to look into childhood and youth studies, which study these groups in non-migratory contexts. It is also worthwhile to include some background information about Nepal’s socioeconomic and adolescent labor conditions to understand the emigration context better. That could for instance help to nuance why adolescents living with both parents could be in a worse situation. It could be that they may themselves need to work to support their families’ livelihood.

**********

6. 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: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Decision Letter 1

Gracia Fellmeth

25 Nov 2020

PONE-D-20-14440R1

Parental migration and psychological well-being of left-behind adolescents in Western Nepal

PLOS ONE

Dear Dr. Ong,

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.

Please submit your revised manuscript by Jan 09 2021 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'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Gracia Fellmeth

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Associate Professor Ong,

Many thanks for submitting your revised manuscript. I have taken on the role of editor for your manuscript, having previously reviewed your original submission (my comments were those of "Reviewer 1" in the original submission).

I have now had a chance to read your revised version and feel it is much improved. Thank you for addressing the points raised by myself and the second reviewer. Both the second reviewer and I feel there are still some issues remaining which need to be addressed before this is suitable for publication. Please see these listed below.

We look forward to receiving another revised version.

Sincerely,

Dr Gracia Fellmeth

(Guest Editor)

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Dear Authors,

In general the motivation for such kind of research is nicely presented. The text is written in a clear and precise way.

Having said this, there are four major issues that need your attention.

1. It is not clear why you call Table 3 a simple linear regression analyses and Table 4 a multiple linear regression analyses. A simple linear regression is when you only have one variable in your analyses. By this logic, Table 3 is rather a multiple linear regression table. It is also not clear why and how Table 3 and Table 4 differ. I can see that the regression results on the parental migration status variable are not the same in the two tables even though the control variables used are the same. Table 4 shows that children living with both parents in Nepal have a higher SDQ compared to those with one of their parents abroad whereas Table 3 shows that an increased SDQ for children with both parents abroad. What is your explanation for these two opposite findings?

2. It might be worth discussing whether adolescents girls' and boys' SDQs respond differently due to their parent(s)' migration. To do that my suggestion is to run separate regressions for the girls' and boys' sub-samples. Alternatively, you may choose to see the interaction effect of gender and the parental migration status variable. This could give your analyses more nuance.

3. Your conclusion focuses a lot on general discussions on other control variables. It is best if your conclusion dedicates more time contemplating on the result on the parental migration status variable by using some contextual information to explain the result.

4. Suggestion: if you make the conclusion section succinct, then you can have more space to include some background information about parental migration in Nepal either in the introduction section or as a separate section and come back to this in the conclusion section.

**********

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 #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Jan 28;16(1):e0245873. doi: 10.1371/journal.pone.0245873.r004

Author response to Decision Letter 1

21 Dec 2020

Response to Reviewer #2:

1. It is not clear why you call Table 3 a simple linear regression analyses and Table 4 a multiple linear regression analyses. A simple linear regression is when you only have one variable in your analyses. By this logic, Table 3 is rather a multiple linear regression table. It is also not clear why and how Table 3 and Table 4 differ. I can see that the regression results on the parental migration status variable are not the same in the two tables even though the control variables used are the same. Table 4 shows that children living with both parents in Nepal have a higher SDQ compared to those with one of their parents abroad whereas Table 3 shows that an increased SDQ for children with both parents abroad. What is your explanation for these two opposite findings?

We call Table 3 a simple linear regression analyses because in Table 3, we present the results of bivariate analyses between each independent variable and the dependent variable (i.e. psychological well-being), without controlling for other independent variables. We call table 4 a multiple linear regression analyses because we have controlled for other independent variables while looking at the association between each independent variable and the dependent variable. [UCLA, 2020]

Table 4 is different from Table 3 in that the Table 3 presents the results of a crude association between each independent variable and the dependent variable while Table 4 shows the results after controlling for potential confounders.

Results from the simple linear regression analyses (Table 3) show that adolescents living with both parents tend to have a higher SDQ compared to those with one of their parents living abroad. However, when we controlled for potential confounders (Table 4), adolescents living with both parents tend to have a higher SDQ compared to those with one of their parents abroad. Therefore, the different results are due to confounding.

We have removed Table 3 and presented only Table 4 (as Table 3 in the revised manuscript).

Reference:

UCLA Institute for Digital Research and Education Statistical Consulting. Regression with STATA Chapter 1 - Simple and multiple regression [Internet]. California: UCLA Institute for Digital Research and Education; [cited: 2020 Dec 19]. Available from: https://stats.idre.ucla.edu/stata/webbooks/reg/chapter1/regressionwith-statachapter-1-simple-and-multiple-regression/

2. It might be worth discussing whether adolescents girls' and boys' SDQs respond differently due to their parent(s)' migration. To do that my suggestion is to run separate regressions for the girls' and boys' sub-samples. Alternatively, you may choose to see the interaction effect of gender and the parental migration status variable. This could give your analyses more nuance.

Thank you for your suggestion. We ran multiple regression analysis including the interaction term for gender and parental migration status. However, the interaction term was not statistically significant. Therefore, we did not include it in the final model.

3. Your conclusion focuses a lot on general discussions on other control variables. It is best if your conclusion dedicates more time contemplating on the result on the parental migration status variable by using some contextual information to explain the result.

Thank you for your suggestion. In the revised manuscript, we have discussed more about the parental migration status variable, and shortened the discussion on other control variables.

Please refer to page: 16-18, line: 238-288.

4. Suggestion: if you make the conclusion section succinct, then you can have more space to include some background information about parental migration in Nepal either in the introduction section or as a separate section and come back to this in the conclusion section.

Thank you for your suggestion. We have separated the conclusion section to make it clear. We have also added background information about parental migration in Nepal in the introduction section.

Conclusion Section:

(Page 19, Line: 314-318)

Conclusion

In rural districts of Nepal, where international migration is common, adolescents living with the parents were more likely to have a poorer psychological well-being compared to those with one of the parents living abroad. Future studies could explore adolescents' adaptation mechanism for the absence of parents due to international migration.

Introduction Section:

(Page: 4, Line: 56-58)

"Nepal, a low-income country (recently upgraded to a lower-middle-income country [6]) in South Asia, is a labour exporting country. Due to the lack of employment opportunities in the country, people are forced to go abroad for work [7]."

(Page: 4, Line: 66-68)

The majority of Nepalese migrant workers leave their children in Nepal when they go abroad. The children are looked after by the remaining family members in Nepal, mostly their grandparents as joint families are still common in Nepal.

(Page: 5, Line: 91)

This study was a school-based, cross-sectional study conducted in two districts of Western Nepal, Baglung and Gulmi. These are basically rural districts.

(Page: 6; Line: 96-97)

Two municipalities, one from each district, with the high proportion of absent households (Galkot Municipality from Baglung and Musikot Municipality from Gulmi) were selected as the study sites. These two areas were declared municipalities by the government in March 2017, after merging several Village Development Committees.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (23.5KB, docx)

Decision Letter 2

Gracia Fellmeth

5 Jan 2021

PONE-D-20-14440R2

Parental migration and psychological well-being of left-behind adolescents in Western Nepal

PLOS ONE

Dear Dr. Ong,

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.

Please submit your revised manuscript by Feb 19 2021 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'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Gracia Fellmeth

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Authors,

Many thanks for submitting your revised manuscript. I am happy that you have addressed all of the reviewers' comments. However, I ask if you can make one final change: in response to one of the reviewer comments, you removed what was previously Table 3 (simple linear regression). In the previous version, it was not clear that Table 3 was indeed a simple regression as it appeared that other factors were being controlled for. However, given your response and clarification, I feel it is important to include the simple regression as well as the multiple regression results. I would be very grateful if you could re-instate the deleted Table 3.

I sincerely apologise for any confusion caused by the reviewer comment - I think it was clarification that was sought, rather than removal of the table.

Many thanks for your understanding and I look forward to seeing your resubmission.

With best wishes,

Gracia Fellmeth

(Guest editor)

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

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Jan 28;16(1):e0245873. doi: 10.1371/journal.pone.0245873.r006

Author response to Decision Letter 2

8 Jan 2021

Response to comments from the Editor:

I ask if you can make one final change: in response to one of the reviewer comments, you removed what was previously Table 3 (simple linear regression). In the previous version, it was not clear that Table 3 was indeed a simple regression as it appeared that other factors were being controlled for. However, given your response and clarification, I feel it is important to include the simple regression as well as the multiple regression results. I would be very grateful if you could re-instate the deleted Table 3.

Thank you for your suggestion. We have re-instated Table 3 (simple linear regression) in the revised submission, and we have slightly modified the text to make it clearer.

Page: 14 Line: 215-217

"Table 3 shows the results of simple linear regression analysis for the association of each independent variable with psychological well-being of adolescents, without controlling for other independent variables."

Page: 15 Line: 225-227

"Table 4 presents the results of multiple linear regression analysis for the association of each independent variable with psychological well-being of adolescents, while controlling for other independent variables."

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (18.2KB, docx)

Decision Letter 3

Gracia Fellmeth

11 Jan 2021

Parental migration and psychological well-being of left-behind adolescents in Western Nepal

PONE-D-20-14440R3

Dear Dr. Ong,

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.

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Kind regards,

Gracia Fellmeth

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Gracia Fellmeth

20 Jan 2021

PONE-D-20-14440R3

Parental migration and psychological well-being of left-behind adolescents in Western Nepal

Dear Dr. Ong:

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.

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Kind regards,

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on behalf of

Dr. Gracia Fellmeth

Guest Editor

PLOS ONE

Associated Data

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

    Supplementary Materials

    S1 File. STROBE checklist.

    (DOC)

    Click here for additional data file. (102.5KB, doc)
    S2 File. General characteristics by parental migration status.

    (DOCX)

    Click here for additional data file. (17.5KB, docx)
    S3 File. Coding of study variables.

    (DOCX)

    Click here for additional data file. (14.7KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (28.8KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (23.5KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (18.2KB, docx)

    Data Availability Statement

    All data files are available in the Figshare Repository at: https://dx.doi.org/10.6084/m9.figshare.12301937.

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