Skip to main content
PLOS Medicine logoLink to PLOS Medicine
. 2021 Jul 12;18(7):e1003512. doi: 10.1371/journal.pmed.1003512

Psychological distress, resettlement stress, and lower school engagement among Arabic-speaking refugee parents in Sydney, Australia: A cross-sectional cohort study

Jess R Baker 1,*, Derrick Silove 1, Deserae Horswood 1, Afaf Al-Shammari 1, Mohammed Mohsin 1, Susan Rees 1, Valsamma Eapen 1
PMCID: PMC8312975  PMID: 34252076

Abstract

Background

Schools play a key role in supporting the well-being and resettlement of refugee children, and parental engagement with the school may be a critical factor in the process. Many resettlement countries have policies in place to support refugee parents’ engagement with their children’s school. However, the impact of these programs lacks systematic evaluation. This study first aimed to validate self-report measures of parental school engagement developed specifically for the refugee context, and second, to identify parent characteristics associated with school engagement, so as to help tailor support to families most in need.

Methods and findings

The report utilises 2016 baseline data of a cohort study of 233 Arabic-speaking parents (77% response rate) of 10- to 12-year-old schoolchildren from refugee backgrounds across 5 schools in Sydney, Australia. Most participants were born in Iraq (81%) or Syria (11%), and only 25% spoke English well to very well. Participants’ mean age was 40 years old, and 83% were female. Confirmatory factor analyses were run on provisional item sets identified from a literature review and separate qualitative study. The findings informed the development of 4 self-report tools assessing parent engagement with the school and school community, school belonging, and quality of the relationship with the schools’ bilingual cultural broker. Cronbach alpha and Pearson correlations with an established Teacher–Home Communication subscale demonstrated adequate reliability (α = 0.67 to 0.80) and construct and convergent validity of the measures (p < 0.01), respectively.

Parent characteristics were entered into respective least absolute shrinkage and selection operator (LASSO) regression analyses. The degree of parents’ psychological distress (as measured by the Kessler10 self-report instrument) and postmigration living difficulties (PLMDs) were each associated with lower school engagement and belonging, whereas less time lived in Australia, lower education levels, and an unemployed status were associated with higher ratings in relationship quality with the schools’ cultural broker. Study limitations include the cross-sectional design and the modest amount of variance (8% to 22%) accounted for by the regression models.

Conclusions

The study offers preliminary refugee-specific measures of parental school engagement. It is expected they will provide a resource for evaluating efforts to support the integration of refugee families into schools. The findings support the need for initiatives that identify and support parents with school-attending children from refugee backgrounds who are experiencing psychological distress or resettlement stressors. At the school level, the findings suggest that cultural brokers may be effective in targeting newly arrived families.


Jess Baker and co-workers study engagement of Arabic-speaking refugees with their children’s schools in Australia.

Author summary

Why was this study done?

  • Current measures of parent school engagement do not consider the unique experiences of families from refugee backgrounds.

  • This study was undertaken to develop appropriate measures of refugee parents’ engagement with school.

  • It is expected that specific measures to ascertain refugee parents’ engagement will help support the development and evaluation of school-based refugee programs.

What did the researchers do and find?

  • Using data from a cohort study of 233 Arabic-speaking refugee families, the study developed and validated 4 self-reports tools to assess parent school engagement and their sense of belonging.

  • The study also explored the quality of the relationship between parents and the bilingual officer employed by schools to act as a cultural broker.

  • Our findings suggest that parents who were experiencing psychological distress or postmigration living difficulties (PLMDs) were less engaged with their child’s school.

What do these findings mean?

  • These new refugee-specific measures of parent engagement are expected to assist in evaluating programs aimed at supporting the integration of refugee parents and their children into schools.

  • The cross-sectional design precludes causal interpretations.

  • Nonetheless, the findings highlight a need to consider the identification and capacity building of parents who are experiencing psychological distress or resettlement stressors.

Introduction

Global refugee numbers are at a record high, of which school aged children make up over 52% [1]. In high-income countries of resettlement, school attendance is mandatory. This provides an opportunity to engage with parents from refugee backgrounds, in order to promote the well-being and community integration of refugee families as a whole [24]. In that regard, refugee parents’ relationship with the school may be a critical factor in the successful adaptation of refugee students [5,6]. Robust evidence suggests that across ethnic groups and sociodemographic backgrounds, parent engagement with schools is positively correlated with children’s well-being. More specifically, children whose parents participate in school activities are more engaged in their learning and more successful in terms of achievement, attendance, motivation, school completion, emotional adjustment, prosocial behaviour, and peer interactions [714].

Several countries such as the United Kingdom, United States of America, Canada, Australia, Sweden, and Germany have government policies and programs in place to support the integration of refugee families into schools. Targeted measures that capture the distinct ways in which refugee parents might engage with schools are needed to monitor the success of these initiatives. Specialised measures may also generate data to better advance efforts to improve refugee parents’ engagement in their children’s schooling in a tailored way that is most valuable to the family. Teasing out the nuances of refugee parent school engagement relative to non-refugee families has the additional benefit of avoiding any cultural biases, including misguided findings that refugee families might be less invested in their children’s education. Several theories of parent school engagement have been proposed [1517]. The most common and comprehensive framework proposed is Epstein’s 6 different types of parent engagement [16]. The first type of engagement is parenting and discusses the school’s role in educating families on how to create a positive home environment. The second type of engagement is centered on effective communication between home and school. The other types include recruiting parents to volunteer at the school, involving parents in school decision-making, home learning, and community collaborations.

These traditional definitions of parental school involvement may not adequately capture engagement as it applies to refugee families [18]. Refugee parents’ limited English proficiency [1923] may interfere with volunteering at the school and supporting their child’s learning at home. This issue may be exacerbated by time constraints related to work, family, and economic survival [19,20,23,24]. Disruptions in schooling during displacement and limited family experience with school systems in countries of resettlement may also challenge typical parent engagement [24,25]. Qualitative research also suggests cultural dissonance between expectations of parents and the school. For instance, culture of origin may influence refugee parents’ belief that it is inappropriate to “interfere” with the work of teachers and that keeping one’s distance may be deemed to show respect for the school and its staff [26].

Indeed, the high value refugee parents place on their child’s education may be expressed in different ways [23]. While not focused on refugee children, a large national study of students in the US found that academic achievement among white American children was positively associated with parent engagement in school-based activities; however, for Asian American families, the relationship was inverse [27]. In another study, ethnicity was found to influence the relationship between different types of parent engagement categorised within Epstein’s typology and student achievement [28]. For instance, volunteering was a better predictor of achievement for white students than for Asian, Hispanic, and black students, while contact with the school was more important for explaining achievement effects for Hispanic and white students than for Asian and black students.

Moreover, an emphasis on behavioural indicators of parent engagement [1517] may undervalue the relational or more affective components of parental engagement, such as how close or connected a parent feels to the school or school community. The well-being of refugee parents is affected by historical factors such as past trauma and displacement [29] and learned distrust of authorities based on exposure to persecution and discrimination [30]. Establishing parental trust and safety may therefore be foundational to effective engagement with schools. For example, in a study of Hmong refugees in the US, a school ethos of inclusion was found to assist parents to overcome expectations of deference towards “authority” [23].

Numerous case studies have showcased how adept certain schools and their staff have become at engaging with refugee families [31,32]. Current measures of parent school engagement may not capture these specific activities attuned to refugee families [33]. For instance, schools have been found to play an instrumental role in guiding parents to local support agencies and helping them navigate unfamiliar and often overwhelming government systems [31,34]. Similarly, reports of social activities at the school, such as breakfast clubs and diversity days, have been posited to connect parents with each other, while school-initiated parent classes to support acculturation in the region’s primary language have been documented to improve cultural competency [35]. A key piece in the literature is the consistent role that bilingual school liaison officers play in facilitating these processes [6,23,26,36]. These persons are employed by the school, specifically tasked with brokering the relationship between refugee families and the school, as well as the wider community. To date, no measure exists to capture the quality of the relationship between the cultural broker and parents.

The primary aim of the present study was to develop and validate self-report tools to measure refugee parents’ engagement with school. We draw on Epstein’s framework and extend it to include specific elements of engagement that foster families’ social and cultural capital [31,32]. We also aimed to develop and validate a novel self-report tool that includes an affective index of engagement—namely parents’ sense of belonging or feelings of connectedness to the school. Further, we aimed to include an assessment of the relationship between refugee parents and the schools’ cultural broker. An established measure of teacher–home communication, a robust facet of parent engagement, was selected as a distal measure of convergent validity [3739].

The secondary aim of the present study was to identify refugee parent characteristics associated with these new measures of parent engagement. While some refugee families may engage readily and easily with school and not require special assistance, other families may have the opposite tendency and require more active assistance. Identifying refugee parents at “risk” of low levels of engagement can help schools to individualise or tailor their support to families most in need. It was reasoned that these factors would likely mirror some of the barriers to traditional engagement described earlier [1924]. For instance, in the migrant literature, low socioeconomic status, less education, and time preoccupation with daily environmental stressors have been associated with lower parent engagement [4046].

Specifically, it was hypothesised that countervailing parental factors such as length of time lived in the host country, employment and visa status, psychological health, English language proficiency, trauma experience, and postmigration stressors would be associated with school engagement and belonging.

Method

Design

The present report is based on the baseline cross-sectional data of a longitudinal cohort study exploring school climate and refugee student well-being.

Ethics statement

The study was approved by the University’s Human Research Ethics Committee (HC15833) and the equivalent body of the State Department of Education (SERAP 2016056) (see S1 Prospective Protocol). The bilingual research team was trained in working with refugee families using sensitive interviewing techniques and received ongoing supervision by author JB throughout the study. The principles governing recruitment were implemented according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (see S1 STROBE Checklist).

Setting

The study was conducted at 5 primary schools in a low socioeconomic multicultural geographical area of Sydney, Australia in 2016. The urban region receives a substantial portion of Australia’s refugee intake each year. For example, over 12% of Australia’s 73,833 refugee intake was settled in the catchment area between 2010 and 2015. An additional 12,000 Syrians were also resettled as a special intake in the area between 2016 and 2017 [47]. Given several years of experience working with refugee families, the schools had many well-established support initiatives, such as new family orientations, small support classes for refugee students, events to celebrate cultural diversity, homework clubs, English language and computer literacy classes for parents, and parent cafes and breakfast clubs.

Participants

Refugees speaking Arabic were the largest group entering the country at the time. Confining the study to one participant language limited the risk of transcultural measurement error and small cell sizes that would eventuate if multiple ethnic groups were included. Participants were Arabic-speaking parents of Year 5 and 6 students comprising 10- to 12-year-old children, who entered Australia on a humanitarian (refugee) visa, and had attended the school for at least 3 months. Selection criteria permitted either mother or father to participate at the family’s choosing. Assuming that the maximum standard deviation would not exceed 15 for the largest subscale total score for the project, and applying a 95% confidence interval along with a 3% margin of error, a sample size of 96 was deemed sufficient to reject the null hypothesis at the 0.05 probability level.

A nominated bilingual cultural broker at the school invited eligible families to participate, passing on the contact details of assenting families to the bilingual field team. At the point of further contact, the study process and objectives were explained fully in Arabic and, if the parent provided written informed consent, the family was included in the study (see flow diagram in Fig 1). Families received a $30 gift voucher for their participation. The design involved a rolling recruitment strategy of all eligible students attending or joining the school over a 2-year time frame, with the largest intake occurring at the start of each school year.

Fig 1. Flow diagram of parent participant recruitment.

Fig 1

Measures

Participants completed an extensive demographic survey followed by a provisional set of items for the school engagement measures (see a description hereafter), and then lastly, Arabic versions of the established measures below. All translations were checked for local cultural appropriateness and accuracy. To circumvent any literacy or comprehension issues, the measures were completed in an interview style, with the questions read aloud to participants in Arabic.

Item development and pilot for new measures

Items were developed from 2 main sources: (i) a desk review of the refugee school literature and existing school engagement scales [48,49]; and (ii) themes emerging from a preliminary qualitative study exploring the school experiences of refugee families (to be published elsewhere). The informing qualitative study included two 10 to 12 year olds (and their parents) from refugee backgrounds from each of the 5 schools of the present study, plus one other school that opted out before the quantitative stage of the current study (n = 12 dyads). In addition, focus groups were held with staff at each school. These typically comprised a Year 6 Teacher, School Counsellor, an English as an Additional Language or Dialect (EAD/L) Teacher, and one bilingual cultural broker. In total, 26 staff members participated.

Based on the desk review and qualitative study, authors JB and DH generated a pool of potential items written in English aimed at measuring school engagement. These were reviewed and edited for content and cultural appropriateness by a local primary school teacher and author AA (an active member of the local Arabic-speaking community with excellent English language skills). Author AA translated the items into Arabic, which were assessed for comprehension and cultural congruence by Arabic members of the research team. The items were piloted with sequential parents enrolled in the study. Items were deleted if they proved difficult to understand, required excessive explanation, or were interpreted differently by parents. This iterative process, involving feedback and research group discussion, led to a final consensus regarding a provisional set of school engagement items, a provisional set of items pertaining to the cultural broker–parent relationship, and a provisional set of items pertaining to the parent sense of school belonging, as detailed below. The initial set of items can be found in supporting file Table A in S1 Data Tables.

Refugee parent school engagement items

The 23-item measure followed 5 themes identified in the preliminary qualitative study (to be published elsewhere). The themes were (i) ease of communication between the school and parent (5 items, e.g., “It would be difficult for me to find a way to discuss an issue with school staff”); (ii) practical assistance provided by the school such as accessing services or provision of food or uniforms (5 items, e.g., “School staff direct me to services I need or that might be helpful to access”); (iii) degree of parent participation in school activities (6 items, e.g., “I regularly attend school events”); and the ways in which the school facilitates (iv) social capital (4 items, e.g., “Through the school, I have met and made friends”); or (v) acculturation (3 items, e.g., “This school helps me feel like I belong in Australia”). To maintain consistency with the Teacher–Home Communication (THC) scale, items were rated on a 4-point Likert scale from 1 (disagree a lot) to 4 (agree a lot). Negatively worded items were reverse scored. Higher scores reflected greater school engagement.

Cultural broker–parent relationship items

Six items pertained to the relationship between the parent and an identified bilingual cultural broker at the school employed to support newly arrived culturally and linguistically diverse (CALD) families in the transition to school and foster engagement between the school and broader CALD community [6,23,26]. Example items include: “XX has been important in making me feel secure in the school because xx understands my family’s religious and cultural backgrounds” and “XX helps me with my family’s wellbeing.” Items were rated on a 4-item Likert scale. For parents unable to identify a cultural broker, items were coded as “Not Applicable” and excluded from any analysis. Higher scores reflected a higher-quality relationship with the cultural broker.

Refugee parents’ sense of school belonging items

Distinct to the measures above, parent sense of school belongingness items were based on an adaptation of the well-established student-rated Psychological Sense of School Membership (PSSM) scale [50]. Items measured feelings of belonging and engagement with the school and were rephrased to ensure relevance to parents (e.g., “I am treated with as much respect as other parents in the school”). Two irrelevant items concerning school performance were excluded. The resulting 16-item scale was rated and scored in accordance with the PSSM scoring procedure on a 5-point Likert scale (1 “Not at all true” to 5 “Completely true”). Negatively worded items were reverse scored. Higher scores reflected a greater sense of belonging.

Established measures

Teacher–Home Communication subscale of the Delaware School Climate Survey

The Delaware School Climate Survey measures parent perceptions of the “quality and character of school life” across several domains utilising a 4-point Likert scale (1 “Disagree a lot” to 4 “Agree a lot”). For the study purpose, the 4-item THC subscale was summed, with higher scores reflecting more positive communication. The parent survey has shown excellent internal consistency across ethnicity, sex, and grade-level groups, and correlations with academic achievement, bullying victimisation, and school suspensions demonstrate concurrent validity [52]. The current sample demonstrated adequate internal consistency for the THC (Cronbach α = 0.69).

Kessler Psychological Distress Scale (K10)

The K10 is a 10-item self-report measure of nonspecific psychological distress for adults (e.g., “How often did you feel nervous?”). Participants rated their experience of distress in the preceding 30 days on a 5-point Likert scale (1 “None of the time” to 5 “All of the time”). Items were added to produce a total score; the higher the score, the greater the level of distress. Arabic NAATI-accredited translations were obtained from the state government health body. Normative data have been established for Australia [53], and high internal consistency demonstrated with refugee groups (α = 0.86) [54]. The total score obtained from the present sample demonstrated excellent internal consistency (Cronbach α = 0.89).

Postmigration Living Difficulties Scale (PMLD)

The PMLD scale consisted of 28 items reflecting levels of distress caused by daily living difficulties related to postmigration adaptation over the previous 12 months (e.g., “separation from family” or “delays processing your visa application”). Items are rated on a 5-point scale (0: “not a problem” to 4: “a very serious problem”). The scale has consistently been identified as a predictor of psychopathology among displaced populations [55]. The Arabic translation was obtained with permission from the lead author of the scale [56]. The total PMLD counts were summed to create a continuous total score. Internal reliability for PMLD items for the study sample was 0.79.

The Harvard Trauma Questionnaire (HTQ)—Iraqi version

The HTQ is the most widely used measure of trauma exposure and posttraumatic stress disorder in the refugee field [57,58]. The initial section includes a checklist of potentially traumatic events (PTEs), including exposure to combat, forms of warfare, and separations and losses. The list was modified to reflect the experiences of the refugee populations being studied. Participants reported on their lifetime exposure to 23 events (Yes/No). Items were coded “1” for yes, and “0” for no for lifetime exposure. The items were summed to generate a total trauma count ranging from 0 to 23.

Data analysis

Refinement and psychometric testing of the new measures

Confirmatory factor analysis (CFA) using MPLUS 7.1 was conducted on the 3 provisional measures above, with the aim to identify component scales and relevant item loadings. The threshold was set at p < 0.05. Items with lowest loadings were deleted serially to test for improved model fit based on a composite comparative fit index (CFI), Tucker–Lewis index (TLI), and standardised root mean square residual (SRMR) [51]. The final sets of items were aggregated, and transformations used to generate mean scores.

Reliability and validity tests were conducted using IBM SPSS Statistics Version 25 [59] and MPLUS 7.1 [51]. For reliability estimates, Cronbach alpha (α) was calculated for each scale. Positive correlations between items within each scale and with the single total score as indicated in a CFA were used to indicate construct validity. As an indicator of convergent validity, the data were examined for positive correlations among each derived scale, as well as the THC subscale.

Predictive analyses with developed measures

Firstly, descriptive statistics were presented for all parental level characteristics. Next, variance inflation factor (VIF) and tolerance statistics examined the multicollinearity among predictors accounting for each outcome factor. The original intention was to conduct linear or stepwise regression analyses. However, this was changed at the peer review stage, to LASSO (forward) regression analyses. Accordingly, parental level characteristics were entered into separate LASSO (forward) regression analyses with each newly developed scale as the outcome variable. The LASSO regressions were performed with SAS 9.4 software, PROC GLMSELECT with selection = forward (select = SL stop = predicted residual sum of squares (PRESS). To adjust for school effects, school was entered as a predictor variable. Based on the 5 sampled schools A, B, C, D, and E (designated letters for confidentiality), 4 indicators were created considering the fifth school (school E) as the reference group. Differences in measurement units of predictor variables meant that standardised LASSO regression coefficients were presented.

Results

Sample characteristics

The anticipated resettlement of 12,000 refugee families into the local area was delayed, thus the sample size was lower than prospective estimates. Of the 303 families identified by the schools to take part, 283 families assented to be contacted by the research team, and a final 233 parents (77% of those identified) consented to participate—see flow diagram of parent participant recruitment in Fig 1. Parent characteristics are provided in Table 1. Most participants were married women, born in Iraq (consistent with Australia’s refugee intake at the time), and spoke little or no English. Around a third were educated beyond high school, and few participants were currently employed. Around half met criteria for a mental health disorder based on the K10, and almost all endorsed experiencing at least one traumatic event (TE).

Table 1. Parent characteristics.

Parents’ characteristics Number % of total
All# 233 100.0
Sex
 Male 39 16.7
 Female 194 83.3
Parents’ age
 <35 years 62 27.0
 35–44 108 47.0
 45 and older 60 26.0
Mean (SD) 39.7(6.8)
Marital status
 Married 201 86.3
 Divorced/Separated/Widowed 32 13.7
Current parent visa category in Australia
 Humanitarian refugee/Family sponsored 178 76.4
 Permanent resident or Citizen 55 23.6
Duration of living in Australia
 Under 2 years 66 30.1
 2 to 5 years 90 41.1
 More than 5 years 63 28.8
Mean (SD) 3.8(3.0)
Country of birth
 Iraq 189 81.1
 Syria 26 11.2
 Other 18 7.7
Spoken language at home
 Arabic 161 69.1
 Others 72 30.9
English proficiency
 A little/Not at all 174 74.7
 Well/Very Well 59 25.3
Highest level of education attained
 Up to high school 152 65.2
 Diploma and University degree 81 34.8
Employment status
 Unemployed and others 216 92.7
 Employed 17 7.3
Family income (annual)
 up to $37,000 79 33.9
 $37,001 and above 154 66.1
Parent received any counselling or psychological therapies in Australia
 No counselling or therapy 129 58.1
 NGO service 55 24.8
 GP 10 4.5
 Private practice psychologist/counsellor 25 11.3
 Others 3 1.4
Number TEs experienced: Mean (SD) 9.9(4.0)
Number of PMLDs: Mean (SD) 5.4(0.3)
Psychological distress categories (measured as K10): Mean (SD) 21.3(9.9)
Child’s enrolled school
 School A 46 19.7
 School B 43 18.5
 School C 60 25.7
 School D 33 14.2
 School E 51 21.9

#The numbers do not always add up to 233 due to missing data. The number of missing observations for “Parents duration of living in Australia” was 14 (6%) and for “Parent received any counselling or psychological therapies in Australia” was 11 (4.7%). Else, the number of missing cases ranges from 0 to 3 (0 to 1.2).

GP, general practitioner; K10, Kessler Psychological Distress Scale; NGO, nongovernment organisation; PMLD, postmigration living difficulty; TE, traumatic event.

Confirmatory factor analysis

Please see Fig 2 showing the process of measure development.

Fig 2. The process of measure development.

Fig 2

Refugee parents school engagement

The CFA examined the correlations between the 5 predefined themes of communication between home and school, practical assistance provided by the school, parent participation in school activities, school as facilitating social capital, and school as enabling acculturation. The dimensions of communication, assistance, parent participation, and social capital correlated significantly with each other (r = 0.25 to 0.96, p-values ranged from 0.037 to 0.001). Acculturation did not show a correlation with the communication or assistance dimensions (p > 0.0.05) but significantly correlated with the social capital dimension (r = 0.68, p < 0.001) (see Table B in S1 Data Tables). Based on these findings, the items were aggregated into 2 notional and statistically distinct scales: (i) refugee parent engagement in relation to communication, assistance, and participation within the internal school system—named the School Internal Engagement Scale-Refugee Parent (SIES-RP) (16 items); and (ii) broader refugee parent engagement within the school community in which the school facilitates social capital and acculturation—named the School Community Engagement Scale-Refugee Parent (SCES-RP) (7 items). A CFA was performed on each separate scale. After item reduction as described above, the final CFA model fitness indices are presented in Table 2. Eleven of the original 16 items were retained for the SIES-RP, while all 7 items of the SCES-RP were retained (see Tables C and D in S1 Data Tables, respectively).

Table 2. Values of CFI, TLI, SRMR, AIC, sample size–adjusted BIC, and Cronbach α for each CFA model with number of items included in CFA.

Model summary
Scales measures CFI TLI SRMR AIC Sample size–adjusted BIC Cronbach α
SIES-RP
Model 1 (16 items) 0.47 0.38 0.09 9,971.0 9,984.1 0.63
Model 2 (11 items) 0.60 0.49 0.08 6,834.6 6,843.6 0.67
SCES-RP
Model 1 (7 items) 0.84 0.75 0.06 4,519.9 4,525.6 0.73
SBS-RP
Model 1 (16 items) 0.74 0.70 0.07 8,185.7 8,199.0 0.77
Model 2 (15 items) 0.76 0.72 0.07 7,435.3 7,447.7 0.80
CBRS
Model 1 (6 items) 0.79 0.65 0.08 2,820.5 2,824.3 0.53
Model 2 (5 items) 0.81 0.62 0.08 2,166.1 2,169.2 0.63

AIC, Akaike information criterion; BIC, Bayesian information criterion; CBRS, Cultural Broker Relationship Scale; CFA, confirmatory factor analysis; CFI, comparative fit index; SBS-RP, School Belonging Scale-Refugee Parent; SCES-RP, School Community Engagement Scale-Refugee Parent; SIES-RP, School Internal Engagement Scale-Refugee Parent; SRMR, standardised root mean square residual; TLI, Tucker–Lewis index.

Cultural broker relationship

Final CFA model fitness indices are presented in Table 2. Five of the original 6 items were retained. This was named the Cultural Broker Relationship Scale (CBRS) (see Table E in S1 Data Tables).

Refugee parents’ sense of school belonging

Final CFA model fitness indices are presented in Table 2. Fifteen of the original 16 items were retained. This was named the School Belonging Scale-Refugee Parent (SBS-RP) (see Table F in S1 Data Tables).

Final measures

In summary, the refinement procedures produced 4 scales: the SIES-RP, the SCES-RP, the CBRS, and the SBS-RP. Cronbach α and other summary statistics are shown in Table 2.

Reliability and validity testing of developed measures

Tables detailing the construct validity of the final developed measures are presented in Tables G-J in S1 Data Tables. Descriptive characteristics and Cronbach α (i.e., reliability) of the new measures, as well as their correlations with THC, are provided in Tables 3 and 4, respectively. All measures were significantly correlated with THC indicating convergent validity. The SBS-RP alpha score also indicated very good reliability. The SCES-RP and SBS-RP reported alpha scores of a minimally acceptable standard. The Cronbach α of the SIES-RP and CBRS did not meet the typically acceptable standard of 0.70, reported as 0.67 and 0.63, respectively.

Table 3. School scale measures with mean scale score and reliability coefficients Cronbach α.

Measures (number of items in the scale and sample size) Mean total scale score (SD) [range] Mean of scale score (SD) [range] Cronbach α
SIES-RP [11 items] (n = 231) 32.6 (5.4) [16–44] 2.9 (0.5) [1–4] 0.67
SCES-RP [7 items] (n = 231) 18.1 (4.7) [7–28] 2.6 (0.7) [1–4] 0.73
SBS-RP [15 items] (n = 232) 66.7 (6.5) [41–77] 4.4 (0.4) [1–5] 0.80
CBRS [5 items] (n = 216) 17.6 (2.5) [5–20] 3.5 (0.5) [1–4] 0.63
THC subscale [4 items, parent report] (n = 233) 14.7 (1.6) [7–16] 3.7 (0.4) [1–4] 0.69

CBRS, Cultural Broker Relationship Scale; SBS-RP, School Belonging Scale-Refugee Parent; SCES-RP, School Community Engagement Scale-Refugee Parent; SIES-RP, School Internal Engagement Scale-Refugee Parent; THC, Teacher–Home Communication.

Table 4. Correlation matrix of among scale school measures.

Measures (number of items in the scale and sample size) SIES-RP SCES-RP SBS-RP CBRS THC
SIES-RP 1.00
SCES-RP 0.30** 1.00
SBS-RP 0.53** 0.22** 1.00
CBRS 0.16* 0.01 0.28** 1.00
THC scale 0.51** 0.23** 0.60** 0.19** 1.00

*Correlation significant at p < 0.05.

**Significant at p < 0.01.

CBRS, Cultural Broker Relationship Scale; SBS-RP, School Belonging Scale-Refugee Parent; SCES-RP, School Community Engagement Scale-Refugee Parent; SIES-RP, School Internal Engagement Scale-Refugee Parent; THC, Teacher–Home Communication.

Predictive analyses with developed measures

The mean of the school measures by parent characteristics are presented in Table 5. Results of the standardised LASSO regression analyses coefficients (Beta, β) for significant predictors are presented in Table 6. Table 7 presents the forward LASSO regression selection summary for each outcome variable. The VIF for the predictor variables ranged from 1.14 to 2.25. Multicollinearity tolerance statistics ranged from 0.44 to 0.87. While some predictor variables were significantly correlated with one another, the maximum value of correlation coefficient r = 0.48 was less than <0.70; the maximum VIF value of 2.25 was less than 10, and the minimum tolerance statistic of 0.44 was greater than 0.10. This indicated that multicollinearity among predictors was sufficiently low to warrant entry into the LASSO regression.

Table 5. Mean of the school measures by parent characteristics.

Parental characteristics SIES-RP SCES-RP SBS-RP CBRS
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
All# 3.0 (0.5) 2.6 (0.7) 4.4 (0.4) 3.5 (0.5)
Sex
°Male 3.1 (0.4) 2.6 (0.6) 4.5 (0.4) 3.5 (0.4)
°Female 2.9 (0.5) 2.6 (0.7) 4.4 (0.4) 3.5 (0.5)
Marital status
°Married 3.0 (0.5) 2.6 (0.7) 4.5 (0.4) 3.5 (0.5)
°Divorced/Separated/Widowed 2.9 (0.5) 2.6 (0.8) 4.4 (0.5) 3.5 (0.5)
Current parent visa category in Australia
°Humanitarian refugee/Family sponsored 2.9 (0.5) 2.6 (0.7) 4.4 (0.4) 3.5 (0.5)
°Permanent resident or Citizen 3.1 (0.5) 2.6 (0.7) 4.5 (0.4) 3.4 (0.5)
Country of birth
°Iraq 3.0 (0.5) 2.6 (0.7) 4.4 (0.4) 3.5 (0.4)
°Syria 3.0 (0.5) 2.4 (0.7) 4.5 (0.3) 3.6 (0.7)
°Other 2.8 (0.5) 2.4 (0.7) 4.4 (0.4) 3.3 (0.6)
Spoken language at home
°Arabic 3.0 (0.5) 2.7 (0.7) 4.4 (0.4) 3.5 (0.5)
°Others 2.9 (0.5) 2.4 (0.6) 4.5 (0.4) 3.6 (0.5)
English proficiency
°A little/Not at all 2.9 (0.5) 2.6 (0.7) 4.4 (0.4) 3.6 (0.5)
°Well/Very Well 3.0 (0.4) 2.7 (0.7) 4.4 (0.4) 3.3 (0.5)
Highest level of education attained
°Up to high school 2.9 (0.5) 2.6 (0.6) 4.5 (0.4) 3.6 (0.4)
°Diploma and University degree 3.0 (0.5) 2.7 (0.7) 4.4 (0.5) 3.4 (0.6)
Employment status
°Unemployed and others 3.0 (0.5) 2.6 (0.7) 4.4 (0.4) 3.6 (0.5)
°Employed 3.1 (0.4) 3.0 (0.6) 4.6 (0.3) 3.1 (0.6)
Child’s enrolled school
°School A 2.9 (0.5) 2.6 (0.6) 4.4 (0.5) 3.6 (0.4)
°School B 2.8 (0.5) 2.4 (0.7) 4.5 (0.4) 3.5 (0.7)
°School C 3.1 (0.5) 2.6 (0.7) 4.4 (0.4) 3.5 (0.6)
°School D 3.2 (0.4) 2.7 (0.7) 4.6 (0.3) 3.6 (0.3)
°School E 2.8 (0.5) 2.6 (0.7) 4.4 (0.4) 3.5 (0.5)

CBRS, Cultural Broker Relationship Scale; SBS-RP, School Belonging Scale-Refugee Parent; SCES-RP, School Community Engagement Scale-Refugee Parent; SIES-RP, School Internal Engagement Scale-Refugee Parent.

Table 6. Standardised LASSO (forward) regression coefficients (Beta, β) for significant predictors.

Significant predictors# SIES-RP (n = 231) SCES-RP (n = 231) SBS-RP (n = 232) CBRS (n = 216)
Beta (β) Beta (β) Beta (β) Beta (β)
Current visa category in Australia 0.26** - - -
Duration in Australia −0.24** - −0.24**
Language spoken at home - −0.15*
Highest level of education completed - - −0.15* −0.17**
Employment status - 0.16** - −0.14*
Number of PMLDs - −0.18** −0.16* -
Psychological distress (K10 score) −0.22** - −0.23** -
School C# 0.24** - - -
School D# 0.27** 0.16**
Value of R-square 0.241** 0.118** 0.166** 0.124**
Value of adjusted R-square 0.223** 0.097** 0.147** 0.110**

Predictor variables used in LASSO regression analysis are coded as:

Sex: 0 = Male, 1 = Female;

Age (parent): individual age ranges 26 years to 63 years;

Marital status: 0 = Married, 1 = Divorced/Separated/Widowed;

Country of birth: 0 = Iraq, 1 = Syria and others;

Current visa category in Australia: 0 = Humanitarian/Family-sponsored Refugee, 1 = Permanent Resident/Citizen/Others;

Duration of living in Australia: 0 = Under 2 years, 1 = 2 to 5 years, 3 = More than 5 years;

Language spoken at home (parent): 0 = Arabic, 1 = Others;

Level of English efficiency (parent): 0 = A little/Not at all, 1 = Well/Very Well;

Highest level of education attained: 0 = Up to HSC, 1 = Diploma and University degree;

Employment category: 0 = Unemployed/others, 1 = Employed;

Family income (annual): 0 = up to $37,000, 1 = $37,001 and above;

Number of TEs: total counts of premigration traumatic events (0 to 23);

Number of PMLDs: total counts of PMLDs (0 to 25; treated as continuous);

Psychological distress (score): Total score of 10 individual items (K10 score) (10 to 46; treated as continuous);

#For 5 enrolled schools, 4 dichotomous dummy variable created: named as School A, School B, School C, School D where School E considered as reference category.

Outcome variables for each LASSO regression analysis are as follows:

SIES-RP subscale score;

SCES-RP subscale score;

SBS-RP subscale score;

CBRS subscale score.

*Significant at p < 0.05.

**Significant at p < 0.01.

CBRS, Cultural Broker Relationship Scale; HSC, xxxx; K10, Kessler Psychological Distress Scale; LASSO, least absolute shrinkage and selection operator; PMLD, postmigration living difficulty; SBS-RP, School Belonging Scale-Refugee Parent; SCES-RP, School Community Engagement Scale-Refugee Parent; SIES-RP, School Internal Engagement Scale-Refugee Parent; TE, traumatic event.

Table 7. LASSO regression calculation: Forward selection summary for each of the outcome variable.

Step number Scale and effect (parameter) entered Number effects in PRESS F Value Pr > F
SIES-RP
0 Intercept 1 52.3 0.00 1.0000
1 Psychological distress score (measured as Kessler 10) 2 49.92 12.45 0.0005
2 School C 3 47.78 11.30 0.0009
3 School D 4 46.67 17.05 <0.0001
4 Current visa category in Australia 5 43.73 6.70 0.0103
5 Duration of living in Australia 6 41.68* 12.59 0.0005
SCES-RP
0 Intercept 1 97.11 0.00 1.000
1 Number of PMLDs 2 93.57 10.44 0.0014
2 English proficiency 3 91.06 7.63 0.0062
3 Employment status 4 90.13* 3.99 0.0471
SBS-RP
0 Intercept 1 38.37 0.00 1.000
1 Psychological distress score (measured as) 2 35.45 21.59 <0.0001
2 Number of PMLDs 3 34.80 5.83 0.0166
3 School D 4 34.28 4.59 0.0333
4 Highest level of education 5 33.72* 5.62 0.0186
CBRS
0 Intercept 1 49.47 0.00 1.000
1 Duration of living in Australia 2 46.55 14.79 0.0002
2 Highest level of education 3 45.29 7.97 0.0052
3 Employment status 4 44.80* 4.18 0.0423

*PRESS, predicted residual sum of squares statistic (leave-one-out cross-validation).

CBRS, Cultural Broker Relationship Scale; LASSO, least absolute shrinkage and selection operator; PMLD, postmigration living difficulty; SBS-RP, School Belonging Scale-Refugee Parent; SCES-RP, School Community Engagement Scale-Refugee Parent; SIES-RP, School Internal Engagement Scale-Refugee Parent.

School Internal Engagement Scale for Refugee Parents (SIES-RP)

Participants with children at schools C and D reported significantly greater internal school engagement as compared to school E (reference school). The LASSO regression analysis revealed that greater parent psychological distress and the longer the time lived in Australia were each related to lower internal school engagement. Parents on a permanent residency or citizenship visa (as opposed to a humanitarian visa) reported greater internal school engagement. Length of time lived in Australia and parent visa category exerted the largest influence on parents’ school engagement, followed by the index of psychological distress. The overall model was significant, accounting for 22.3% of the total variance.

School Community Engagement Scale for Refugee Parents (SCES-RP)

The LASSO regression analysis revealed that speaking a language other than Arabic, being unemployed, and endorsing more PMLDs were significantly associated with lower school community engagement. The overall model accounted for 9.7% of the total variance.

School Belonging Scale-Refugee Parent (SBS-RP)

The regression analysis revealed that lower level of education, more PMLDs, and greater psychological distress were significantly correlated with lower school belonging. School D had significant influence on parents’ higher school belonging. The overall model was significant and accounted for 14.7% of the total variance.

Cultural Broker Relationship Scale (CBRS)

The regression analysis revealed that parents who had lived less time in Australia, were educated at a high school or diploma level, or who were unemployed reported a significantly greater quality relationship with the school cultural broker, relative to parents who had lived longer in Australia, educated to a degree level, or who were employed. The overall model was significant and accounted for 11.0% of the total variance.

Discussion

This paper describes the development of 4 contemporary measures of refugee parents’ engagement with their child’s school, namely the SBS-RP, the CBRS, the SIES-RP, and the SCES-RP. The SBS-RP and SCES-RP demonstrated adequate to good reliability. The reliability of the SIES-RP and CBRS was below the acceptable threshold. All measures indicated sound construct validity, and convergent validity as based on positive correlations with the THC scale. Using these instruments, we studied a cohort of Arabic-speaking refugee parents in Australia. We report that parental factors associated with school engagement included time lived in Australia, psychological distress, PMLDs, visa status, employment status, education level, and speaking Arabic (the dominant language of the sample—69%) at home. Greater psychological distress was implicated in lower parental school engagement across both internal engagement and the more affective sense of belonging. Another factor to reliably emerge as a predictor of school engagement was PMLDs. Specifically, the greater the number of current living difficulties, the lower the parents’ reported community school engagement and sense of school belonging. Interestingly, English language proficiency did not show an association with parent school engagement, cultural broker relationship, or sense of belonging. Regarding the cultural broker scale, parents who had lived less time in Australia, were unemployed, or less educated endorsed a greater quality relationship with this school staff member.

It makes sense that the strongest correlations of the 4 self-report tools were between the SBS-RP and the SIES-RP, the 2 measures assessing sense of belonging and internal school engagement (SBS-RP and SIES-RP). The SCES-RP and CBRS encompass community factors outside of the school or independent of the relationship with the teacher or an ability to speak English and thus add more noise to the data.

The finding that parent psychological distress was related to lower internal engagement and sense of belonging also makes sense. A parent facing mental health issues may be less able to engage with their child’s school. They may also be harder to engage or feel more disconnected. This latter idea aligns with bidirectional research that family engagement is necessary for schools to be able to reach parents to help improve their and their child’s mental health [60,61]. Lower parental engagement may be one symptom of the more general finding that poor parent mental health, particularly among female caregivers, is a risk factor for negative child outcomes inclusive of refugee and war-affected communities [6265]. Nearly half of the current parent sample gave indications of a mild to severe mental health disorder. The high rates of mental health issues seen in the refugee population relative to native-born populations may be why psychological distress emerged as a particular risk factor for refugee parents [66].

It is understandable, too, that parents preoccupied with complex life circumstances may have limited capacity to prioritise school engagement. This is consistent with past research documenting a focus on economic survival as a barrier to engagement [19,20,23,24]. It is interesting that PMLD impacted on parents’ more affective sense of school belonging. Based on social and cultural capital theories, one might expect stretched resources to have more impact on the more resource-heavy behavioural or cognitive expressions of school engagement. Alternatively, it could be that stressors that challenge one’s sense of belonging within the host country more broadly—such as discrimination, communication difficulties, issues with government services, and fears of being sent home—necessarily impinge then on the sense of belonging within the smaller microsystems of that country, including school.

It was noteworthy that English language was not associated with any of the 4 measures of parent engagement. There is extensive literature citing language as a barrier to school engagement in minority populations [4045]. However, the schools under study were culturally diverse (over 90% of families did not speak English as a first language), with Arabic being one of the prominent languages. To this end, the schools were familiar with accommodating language needs perhaps more so than typically less culturally diverse schools.

Viewed collectively, the cultural broker scale findings are encouraging evidence that cultural brokers may be assisting target families most in need, i.e., newly arrived families who are not yet employed. This suggests sage use of school capacity. Families who have lived in Australia for longer and are employed and more educated likely have less need to engage with the school cultural broker, given their likely familiarity with the school and capacity to participate in the community.

However, the finding that the longer a parent had lived in Australia was related to lower internal school engagement is curious, especially given the almost opposite relationship in permanent residency or citizenship status (relative to humanitarian visa status) being associated with higher internal school engagement. One might expect a parent who had lived in Australia for longer to be more socially and culturally resourced and thus more able to engage with the school. One potential explanation, similar to the cultural broker reasoning detailed above, is that schools are so geared towards serving newcomers that long-term residents feel less engaged. The relationship between refugee health and time lived in the resettled country does appear to be a nonlinear one. There is some suggestion of a “honeymoon” period whereby refugee health improves significantly upon arrival in the host country, attributed in part to an acute sense of “relief” and an influx of government support, but once this favourable phase passes and government support ceases, refugee health can worsen [67].

The findings carry authenticity when considered that the refugee families were able to be interviewed in their native language. This diverges from many culturally diverse studies that often require English language proficiency, lending itself to a biased, potentially more acculturated, sample. However, the study encompasses many limitations, not least that the reliability of the measures is compromised with the omission of accredited translators and back translation. Some questionnaire items were also double barrelled and could have been interpreted ambiguously.

The most significant limitation of the study is the cross-sectional design. This hinders any casual interpretation and prevents ruling out any other confounding variable underlying the associations found. Moreover, Arabic-speaking families were almost in the majority in the current participating schools, which limits the generalisability of the findings to other schools where refugee families may subsume more of a minority presence or where the host country’s language is dominant. Another weakness is that parental engagement was assessed via only one (parent) informant, and there is a noted tendency for parents to inflate self-reports of their school engagement for understandable desirability motives [68]. Furthermore, the authors are careful that this paper does not assume a responsibility on refugee parents to engage, but rather note that parent engagement is a bidirectional relationship between school and the home.

Future research is required to separate out the nuances of each newly developed measure with distinct measures of validity, including predictive and divergent validity. The sociodemographic findings also need to be replicated in larger, longitudinal samples. For example, the number of employed parents in the study was very small, so any interpretation regarding this factor needs to be treated with caution. The small sample sizes across a wide duration of stay from 3 months to 21 years also unfortunately prohibited comparisons between recently arrived and long-term residents in Australia. This would be useful in interpreting the curious finding that the longer a parent had lived in Australia was related to lower internal school engagement.

Limitations of the emerging psychometrics acknowledged, it is hoped that the developed tools will enable a more targeted robust evaluation of the impact of school initiatives on refugee parent engagement, knowing how vital this is in relation to child outcomes. For example, this paper now provides a measure with which to quantitatively evaluate the quality of the important relationship between the school-based bilingual cultural broker and parent [6,23,26].

The current study forms the baseline data of a larger study that follows parent and child dyads from the last years of primary school across the transition into secondary school. This will enable us to explore the direction and magnitude of change in the different dimensions of parent engagement, and, importantly, meaningful longitudinal associations between different dimensions of parent engagement and child outcomes. Individual item predictor analysis would also be helpful in guiding interventions and pinpointing exactly which tangible dimensions of engagement schools should be focusing on. For instance, during the scale development, it was pertinent that items related to effective communication correlated strongly with parent engagement items, and items related to social capital correlated strongly with acculturation items. Consideration of online parent connectivity in terms of digital literacy, devices, and network may also be a fruitful future endeavour.

Strong family systems are an important protective factor in optimising refugee children’s well-being [34]. In terms of enhancing parent school engagement among refugee families, the study findings support the implementation of initiatives that consider the identification and capacity building of parents who are experiencing psychological distress and/or struggling with resettlement stressors. This invites improvements at both government and school levels. Within the school system, a refugee model of engagement that includes the employment of a bilingual cultural broker, in combination with parent outreach programs, is one seemingly positive way through which to provide targeted support to unemployed newly arrived refugee families [6,23,26,31]. At the macro level, the federal system needs to consider policies that minimise the economic and psychosocial challenges that may interfere with refugee parents’ capacity to engage with school.

Supporting information

S1 Prospective Protocol. Prospective protocol based on approved ethics submission (HC15833).

(DOCX)

S1 STROBE Checklist. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist.

(DOCX)

S1 Data Tables. Pertaining to the development and psychometrics of study scales.

(DOCX)

Acknowledgments

The authors would like to thank the supporting schools, all the parents who participated, and research team members, Sajia Faiz and Holya Hassan.

Abbreviations

CALD

culturally and linguistically diverse

CBRS

Cultural Broker Relationship Scale

CFA

confirmatory factor analysis

CFI

comparative fit index

EAD/L

English as an Additional Language or Dialect

HTQ

Harvard Trauma Questionnaire

K10

Kessler Psychological Distress Scale

LASSO

least absolute shrinkage and selection operator

PMLD

postmigration living difficulty

PRESS

predicted residual sum of squares

PSSM

Psychological Sense of School Membership

PTE

potentially traumatic event

SBS-RP

School Belonging Scale-Refugee Parent

SCES-RP

School Community Engagement Scale-Refugee Parent

SIES-RP

School Internal Engagement Scale-Refugee Parent

SRMR

standardised root mean square residual

TE

traumatic event

THC

Teacher–Home Communication

TLI

Tucker–Lewis index

VIF

variance inflation factor

Data Availability

The data that support the findings of this study will be made available to researchers who meet the criteria for access to study data, after permission from the relevant ethics body below has been sought. The Human Ethics Coordinator The University of New South Wales Email: humanethics@unsw.edu.au.

Funding Statement

This research was part funded by the National Health and Medical Research Council of Australia (NHMRC) program grant (APP1073041) awarded to DS (CI) and SR (AI). The NHMRC had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

  • 1.UNHCR. Global Trends: Forced Displacement in 2017. Geneva, Swizterland: UNHCR; 2018.
  • 2.UNHCR. The UNHCR Global Report 1999. New York; 2000.
  • 3.O’Toole Thommessen SA, Todd BK. How do refugee children experience their new situation in England and Denmark? Implications for educational policy and practice. Child Youth Serv Rev. 2018;85:228–38. doi: 10.1016/j.childyouth.2017.12.025 [DOI] [Google Scholar]
  • 4.Fazel M. A moment of change: Facilitating refugee children’s mental health in UK schools. Int J Educ Dev. 2015;41:255–61. doi: 10.1016/j.ijedudev.2014.12.006 [DOI] [Google Scholar]
  • 5.Matthews J. Schooling and settlement: Refugee education in Australia. Int Stud Sociol Educ. 2008;18(1):31–45. doi: 10.1080/09620210802195947 [DOI] [Google Scholar]
  • 6.McBrien JL. Educational needs and barriers for refugee students in the united states: A review of the literature. Rev Educ Res. 2005;75(3):329–64. [Google Scholar]
  • 7.Barnard WM. Parent involvement in elementary school and educational attainment. Child Youth Serv Rev. 2004;26(1):39–62. doi: 10.1016/j.childyouth.2003.11.002 [DOI] [Google Scholar]
  • 8.Miedel WT, Reynolds AJ. Parent Involvement in Early Intervention for Disadvantaged Children: Does It Matter? J Sch Psychol. 1999;37(4):379–402. doi: 10.1016/S0022-4405(99)00023-0 [DOI] [Google Scholar]
  • 9.Marcon RA. Positive relationships between parent school involvement and public school inner-city preschoolers’ development and academic performance. School Psych Rev. 1999;28(3):395–412. [Google Scholar]
  • 10.Izzo CV, Weissberg RP, Kasprow WJ, Fendrich MA. Longitudinal Assessment of Teacher Perceptions of Parent Involvement in Children’s Education and School Performance. Am J Community Psychol. 1999;27 (6):817–39. doi: 10.1023/a:1022262625984 [DOI] [PubMed] [Google Scholar]
  • 11.Hill NE, Castellino DR, Lansford JE, Nowlin P, Dodge KA, Bates JE, et al. Parent academic involvement as related to school behavior, achievement, and aspirations: demographic variations across adolescence. Child Dev. 2004;75(5):1491–509. doi: 10.1111/j.1467-8624.2004.00753.x . [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Jeynes WH. Parental involvement research: Moving to the next level. The School Community Journal. 2011;21(1):9–18. [Google Scholar]
  • 13.Jeynes WHA. Meta-Analysis: The Effects of Parental Involvement on Minority Children’s Academic Achievement. Educ Urban Soc. 2003;35(2):202–18. doi: 10.1177/0013124502239392 [DOI] [Google Scholar]
  • 14.Fan X, Chen M. Parental Involvement and Students’ Academic Achievement: A Meta-Analysis. Educ Psychol Rev. 2001;13:1–22. doi: 10.1023/A:1009048817385 [DOI] [Google Scholar]
  • 15.Grolnick WS, Slowiaczek ML. Parents’ Involvement in Children’s Schooling: A Multidimensional Conceptualization and Motivational Model. Child Dev. 1994;65(1):237–52. doi: 10.1111/j.1467-8624.1994.tb00747.x [DOI] [PubMed] [Google Scholar]
  • 16.Epstein JL, Sanders MG, Simon BS, Salinas KC, Jansorn NR, Van Voorhis FL. School, family, and community partnerships: Your handbook for action, 2nd ed. Thousand Oaks, CA, US: Corwin Press; 2002. xi, 379–xi, p. [Google Scholar]
  • 17.Ho E. Effects of Parental Involvement On Eight Grade Achievement. Sociol Educ. 1996;69. doi: 10.2307/2112802 [DOI] [Google Scholar]
  • 18.Bower HA, Griffin D. Can the Epstein Model of Parental Involvement Work in a High-Minority, High-Poverty Elementary School? A Case Study. Prof Sch Couns. 2011;15(2):2156759X1101500201. doi: 10.1177/2156759x1101500201 [DOI] [Google Scholar]
  • 19.Miller E, Ziaian T, Esterman A. Australian school practices and the education experiences of students with a refugee background: a review of the literature. Int J Incl Educ. 2018;22(4):339–59. doi: 10.1080/13603116.2017.1365955 [DOI] [Google Scholar]
  • 20.Ibrahim HH, Small D, Grimley M. Parent/school interface: Current communication practices and their implication for Somali parents. N Z J Educ Stud. 2009;44(2):19–30. [Google Scholar]
  • 21.Hughes N, Beirens H. Enhancing Educational Support: Towards Holistic, Responsive and Strength-based Services for Young Refugees and Asylum-seekers. Child Soc. 2007;21:261–72. doi: 10.1111/j.1099-0860.2007.00098.x [DOI] [Google Scholar]
  • 22.Blackmore J, Hutchison K. Ambivalent relations: the ‘tricky footwork’ of parental involvement in school communities. Int J Incl Educ. 2010;14(5):499–515. doi: 10.1080/13603110802657685 [DOI] [Google Scholar]
  • 23.Rah Y, Choi S, Nguyễn TST. Building bridges between refugee parents and schools. Int J Leadersh Educ. 2009;12(4):347–65. doi: 10.1080/13603120802609867 [DOI] [Google Scholar]
  • 24.Collignon FF, Men M, Tan S. Finding Ways In: Community-Based Perspectives on Southeast Asian Family Involvement With Schools in a New England State. Journal of Education for Students Placed at Risk (JESPAR). 2001;6(1–2):27–44. doi: 10.1207/S15327671ESPR0601-2_3 [DOI] [Google Scholar]
  • 25.UNHCR. Turn the Tide: Refugee Education in Crisis. Geneva, Switzerland: UNHCR, 2018.
  • 26.McBrien JL. The importance of context: Vietnamese, Somali, and Iranian refugee mothers discuss their resettled lives and involvement in their children’s schools. Compare: A Journal of Comparative and International Education. 2011;41(1):75–90. doi: 10.1080/03057925.2010.523168 [DOI] [Google Scholar]
  • 27.Mau W-C. Parental influences on the high school students’ academic achievement: A comparison of Asian immigrants, Asian Americans, and White Americans. Psychol Sch. 1997;34(3):267–77. doi: [DOI] [Google Scholar]
  • 28.Desimone L. Linking Parent Involvement with Student Achievement: Do Race and Income Matter? J Educ Res. 1999;93(1):11–30. [Google Scholar]
  • 29.Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012;379(9812):266–82. doi: 10.1016/S0140-6736(11)60051-2 [DOI] [PubMed] [Google Scholar]
  • 30.Hynes T. The issue of ‘trust’ or ‘mistrust’ in research with refugees: choices, caveats and considerations for researchers. Geneva: UNHCR, Evaluation and Policy Analysis Unit, 2003.
  • 31.Block K, Cross S, Riggs E, Gibbs L. Supporting schools to create an inclusive environment for refugee students. Int J Incl Educ. 2014;18(12):1337–55. doi: 10.1080/13603116.2014.899636 [DOI] [Google Scholar]
  • 32.Naidoo L. Developing social inclusion through after-school homework tutoring: a study of African refugee students in Greater Western Sydney. Br J Sociol Educ. 2009;30(3):261–73. doi: 10.1080/01425690902812547 [DOI] [Google Scholar]
  • 33.Watkins M, Noble G, Wong A. IT’S COMPLEX! Working with Students of Refugee Backgrounds and their Families in New South Wales Public Schools, New South Wales Teachers Federation 2019.
  • 34.Baker JR, Raman S, Kohlhoff J, George A, Kaplun C, Dadich A, et al. Optimising refugee children’s health/wellbeing in preparation for primary and secondary school: a qualitative inquiry. BMC Public Health. 2019;19(1):812. doi: 10.1186/s12889-019-7183-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Kim Y. Minority parental involvement and school barriers: Moving the focus away from deficiencies of parents. Educ Res Rev. 2009;4(2):80–102. 10.1016/j.edurev.2009.02.003 [DOI] [Google Scholar]
  • 36.Brar-Josan N, Yohani SC. Cultural brokers’ role in facilitating informal and formal mental health supports for refugee youth in school and community context: a Canadian case study. Br J Guid Counc. 2019;47(4):512–23. doi: 10.1080/03069885.2017.1403010 [DOI] [Google Scholar]
  • 37.Povey J, Campbell AK, Willis L-D, Haynes M, Western M, Bennett S, et al. Engaging parents in schools and building parent-school partnerships: The role of school and parent organisation leadership. Int J Educ Res. 2016;79:128–41. 10.1016/j.ijer.2016.07.005 [DOI] [Google Scholar]
  • 38.Murray KW, Finigan-Carr N, Jones V, Copeland-Linder N, Haynie DL, Cheng TL. Barriers and Facilitators to School-Based Parent Involvement for Parents of Urban Public Middle School Students. SAGE Open. 2014;4(4):10.1177/2158244014558030. Epub 2014/11/18. doi: 10.1177/2158244014558030 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Rattenborg K, MacPhee D, Walker AK, Miller-Heyl J. Pathways to Parental Engagement: Contributions of Parents, Teachers, and Schools in Cultural Context. Early Educ Dev. 2019;30(3):315–36. doi: 10.1080/10409289.2018.1526577 [DOI] [Google Scholar]
  • 40.Ramirez AYF. Dismay and Disappointment: Parental Involvement of Latino Immigrant Parents. Urban Rev. 2003;35(2):93–110. doi: 10.1023/a:1023705511946 [DOI] [Google Scholar]
  • 41.García Coll C, Akiba D, Palacios N, Bailey B, Silver R, DiMartino L, et al. Parental Involvement in Children’s Education: Lessons from Three Immigrant Groups. Parenting. 2002;2(3):303–24. doi: 10.1207/S15327922PAR0203_05 [DOI] [Google Scholar]
  • 42.Sohn S, Wang XC. Immigrant parents’ involvement in American schools: Perspectives from Korean mothers. Early Childhood Educ J. 2006;34(2):125–32. doi: 10.1007/s10643-006-0070-6 [DOI] [Google Scholar]
  • 43.Peña DC. Parent Involvement: Influencing Factors and Implications. J Educ Res. 2000;94(1):42–54. doi: 10.1080/00220670009598741 [DOI] [Google Scholar]
  • 44.Huss-Keeler RL. Teacher perception of ethnic and linguistic minority parental involvement and its relationships to children’s language and literacy learning: A case study. Teach Teach Educ. 1997;13(2):171–82. 10.1016/S0742-051X(96)00018-2 [DOI] [Google Scholar]
  • 45.Wong SW, Hughes JN. Ethnicity and Language Contributions to Dimensions of Parent Involvement. School Psych Rev 2006;35(4):645–62. . [PMC free article] [PubMed] [Google Scholar]
  • 46.Turney K, Kao G. Barriers to School Involvement: Are Immigrant Parents Disadvantaged? J Educ Res. 2009;102(4):257–71. doi: 10.3200/JOER.102.4.257-271 [DOI] [Google Scholar]
  • 47.Department of Social Services. Settlement Data Reports January to December 2016 http://data.gov.au/dataset/8d1b90a9-a4d7-4b10-ad6a-8273722c8628/resource/7fc5da75-0d24-4ec6-ad89-891aed7244ca/download/settlement-data-reports-january-to-december-2016.xlsx
  • 48.Jimerson SR, Campos E, Greif JL. Toward an Understanding of Definitions and Measures of School Engagement and Related Terms. Calif Sch Psychol. 2003;8(1):7–27. doi: 10.1007/bf03340893 [DOI] [Google Scholar]
  • 49.Horswood D, Baker J, Fazel M, Rees S, Heslop L, Silove D. School factors related to the emotional wellbeing and resettlement outcomes of students from refugee backgrounds: protocol for a systematic review. Syst Rev. 2019;8(1):107. doi: 10.1186/s13643-019-1016-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Goodenow C. The psychological sense of school membership among adolescents: Scale development and educational correlates. Psychol Sch. 1993;30(1):79–90. doi: [DOI] [Google Scholar]
  • 51.Muthén LK, Muthén BO. Mplus User’s Guide. 5th2007.
  • 52.Bear GG, Yang C, Pasipanodya E. Assessing School Climate:Validation of a Brief Measure of the Perceptions of Parents. J Psychoeduc Assess. 2015;33(2):115–29. doi: 10.1177/0734282914545748 [DOI] [Google Scholar]
  • 53.Slade T, Johnston A, Browne MAO, Andrews G, Whiteford H. 2007 National Survey of Mental Health and Wellbeing: Methods and key findings. Aust NZ J Psychiatry. 2009;43(7):594–605. doi: 10.1080/00048670902970882 PubMed PMID: ISI:000267012100003. [DOI] [PubMed] [Google Scholar]
  • 54.Sulaiman-Hill CM, Thompson SC. Selecting instruments for assessing psychological wellbeing in Afghan and Kurdish refugee groups. BMC Res Notes. 2010;3:237. Epub 2010/09/10. doi: 10.1186/1756-0500-3-237 ; PubMed Central PMCID: PMC2949661. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Schweitzer R, Melville F, Steel Z, Lacherez P. Trauma, Post-Migration Living Difficulties, and Social Support as Predictors of Psychological Adjustment in Resettled Sudanese Refugees. Aust N Z J Psychiatry. 2006;40(2):179–87. doi: 10.1080/j.1440-1614.2006.01766.x [DOI] [PubMed] [Google Scholar]
  • 56.Aragona M, Pucci D, Mazzetti M, Maisano B, Geraci S. Traumatic events, post-migration living difficulties and post-traumatic symptoms in first generation immigrants: a primary care study. Ann Ist Super Sanita. 2013;49(2):169–75. Epub 2013/06/19. doi: 10.4415/ANN_13_02_08 . [DOI] [PubMed] [Google Scholar]
  • 57.Kleijn WC, Hovens JE, Rodenburg JJ. Posttraumatic Stress Symptoms in Refugees: Assessments with the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist–25 in Different Languages. Psychol Rep. 2001;88(2):527–32. doi: 10.2466/pr0.2001.88.2.527 [DOI] [PubMed] [Google Scholar]
  • 58.Sigvardsdotter E, Malm A, Tinghög P, Vaez M, Saboonchi F. Refugee trauma measurement: a review of existing checklists. Public Health Rev. 2016;37(1):10. doi: 10.1186/s40985-016-0024-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.IBM Corporation. IBM SPSS Statistics for Windows. 25.0 ed. Armonk, NY: IBM Corp.; 2017.
  • 60.Kia-Keating M, Ellis BH. Belonging and connection to school in resettlement: Young refugees, school belonging, and psychosocial adjustment. Clin Child Psychol Psychiatry. 2007;12(1):29–43. doi: 10.1177/1359104507071052 [DOI] [PubMed] [Google Scholar]
  • 61.McNeely CA, Morland L, Doty SB, Meschke LL, Awad S, Husain A, et al. How Schools Can Promote Healthy Development for Newly Arrived Immigrant and Refugee Adolescents: Research Priorities. J Sch Health. 2017;87(2):121–32. doi: 10.1111/josh.12477 [DOI] [PubMed] [Google Scholar]
  • 62.Ekblad S. Psychosocial adaptation of children while housed in a Swedish refugee camp: Aftermath of the collapse of Yugoslavia. STRESS MED. 1993;9(3):159–66. [Google Scholar]
  • 63.Fox PG, Cowell JM, Montgomery AC. Southeast Asian refugee children: violence experience and depression. Int J Psychiatr Nurs Res. 1999;5(2):589–600. [PubMed] [Google Scholar]
  • 64.Thabet AA, Ibraheem AN, Shivram R, Winter EA, Vostanis P. Parenting support and PTSD in children of a war zone. Int J Soc Psychiatry. 2009;55(3):226–37. doi: 10.1177/0020764008096100 [DOI] [PubMed] [Google Scholar]
  • 65.Betancourt TS, Khan KT. The mental health of children affected by armed conflict: Protective processes and pathways to resilience. Int Rev Psychiatry. 2008;20(3):317–28. doi: 10.1080/09540260802090363 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.McFarlane CA, Kaplan I, Lawrence JA. Psychosocial indicators of wellbeing for resettled refugee children and youth: Conceptual and developmental directions. Child Indic Res. 2011;4(4):647–77. doi: 10.1007/s12187-010-9100-4 [DOI] [Google Scholar]
  • 67.Uribe Guajardo MG, Slewa-Younan S, Smith M, Eagar S, Stone G. Psychological distress is influenced by length of stay in resettled Iraqi refugees in Australia. Int J Ment Heal Syst. 2016;10:4. doi: 10.1186/s13033-016-0036-z . [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Nord CW, National Center for Education S. Home literacy activities and signs of children’s emerging literacy, 1993 and 1999: Washington, DC: National Center for Education Statistics; 2000.

Decision Letter 0

Emma Veitch

26 Apr 2020

Dear Dr. Baker,

Thank you very much for submitting your manuscript "Psychological distress and resettlement stress are associated with lower school engagement among refugee parents" (PMEDICINE-D-19-03661) for consideration at PLOS Medicine.

Your paper was evaluated by a senior editor and discussed among all the editors here. It was also discussed with an academic editor with relevant expertise, and sent to independent reviewers, including a statistical reviewer. The reviews are appended at the bottom of this email and any accompanying reviewer attachments can be seen via the link below:

[LINK]

In light of these reviews, I am afraid that we will not be able to accept the manuscript for publication in the journal in its current form, but we would like to consider a revised version that addresses the reviewers' and editors' comments. Obviously we cannot make any decision about publication until we have seen the revised manuscript and your response, and we plan to seek re-review by one or more of the reviewers.

In revising the manuscript for further consideration, your revisions should address the specific points made by each reviewer and the editors. Please also check the guidelines for revised papers at http://journals.plos.org/plosmedicine/s/revising-your-manuscript for any that apply to your paper. In your rebuttal letter you should indicate your response to the reviewers' and editors' comments, the changes you have made in the manuscript, and include either an excerpt of the revised text or the location (eg: page and line number) where each change can be found. Please submit a clean version of the paper as the main article file; a version with changes marked should be uploaded as a marked up manuscript.

In addition, we request that you upload any figures associated with your paper as individual TIF or EPS files with 300dpi resolution at resubmission; please read our figure guidelines for more information on our requirements: http://journals.plos.org/plosmedicine/s/figures. While revising your submission, please upload your figure files to the 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. 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 us at PLOSMedicine@plos.org.

We expect to receive your revised manuscript by May 15 2020 11:59PM. Please email us (plosmedicine@plos.org) if you have any questions or concerns.

***Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.***

We ask every co-author listed on the manuscript to fill in a contributing author statement, making sure to declare all competing interests. If any of the co-authors have not filled in the statement, we will remind them to do so when the paper is revised. If all statements are not completed in a timely fashion this could hold up the re-review process. If new competing interests are declared later in the revision process, this may also hold up the submission. Should there be a problem getting one of your co-authors to fill in a statement we will be in contact. YOU MUST NOT ADD OR REMOVE AUTHORS UNLESS YOU HAVE ALERTED THE EDITOR HANDLING THE MANUSCRIPT TO THE CHANGE AND THEY SPECIFICALLY HAVE AGREED TO IT. You can see our competing interests policy here: http://journals.plos.org/plosmedicine/s/competing-interests.

Please use the following link to submit the revised manuscript:

https://www.editorialmanager.com/pmedicine/

Your article can be found in the "Submissions Needing Revision" folder.

To enhance the reproducibility of your results, we recommend that you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see http://journals.plos.org/plosmedicine/s/submission-guidelines#loc-methods.

Please ensure that the paper adheres to the PLOS Data Availability Policy (see http://journals.plos.org/plosmedicine/s/data-availability), which requires that all data underlying the study's findings be provided in a repository or as Supporting Information. For data residing with a third party, authors are required to provide instructions with contact information for obtaining the data. PLOS journals do not allow statements supported by "data not shown" or "unpublished results." For such statements, authors must provide supporting data or cite public sources that include it.

We look forward to receiving your revised manuscript.

Sincerely,

Emma Veitch, PhD

PLOS Medicine

On behalf of Clare Stone, PhD, Acting Chief Editor,

PLOS Medicine

plosmedicine.org

-----------------------------------------------------------

Requests from the editors:

*I understand the paper was submitted for the journal's special Collection on Refugee and Migrant Health; that collection has now launched (https://collections.plos.org/refugee-health-special-issue) so the paper you've submitted is too late for the launch. However, it can still be considered for the journal and if it passes the journal's usual criteria, published; we'd also hope it can subsequently included in the collection's homepage as well.

*Please revise the title according to PLOS Medicine's style. Your title must be nondeclarative and not a question. It should begin with main concept if possible. Please place the study design in the subtitle (ie, after a colon) - eg, here, "xxyy: cross-sectional study".

*At this stage, we ask that you include a short, non-technical Author Summary of your research to make findings accessible to a wide audience that includes both scientists and non-scientists. The Author Summary should immediately follow the Abstract in your revised manuscript. This text is subject to editorial change and should be distinct from the scientific abstract. Please see our author guidelines for more information: https://journals.plos.org/plosmedicine/s/revising-your-manuscript#loc-author-summary

*Currently, the abstract states that one aim of the work is to "...measure the effectiveness of school-based parent

engagement initiatives" - I wasn't clear that this was something that the current study design was capable of doing (given that the study doesn't seem designed to assess the effects of an intervention(s) per se - eg, such as using RCT design) - perhaps this can be considered and the explanation of aims framed a bit more clearly?

*Ideally, please rework the in-text referencing style (this should be simple if referencing software is used) to use sequential numbering in square (not round) brackets. Many thanks

*Can you clarify in the Methods section if the study had a prospective protocol or analysis plan? Please state this (either way) early in the Methods section.

a) If a prospective analysis plan (from your funding proposal, IRB or other ethics committee submission, study protocol, or other planning document written before analyzing the data) was used in designing the study, please include the relevant prospectively written document with your revised manuscript as a Supporting Information file to be published alongside your study, and cite it in the Methods section. A legend for this file should be included at the end of your manuscript.

b) If no such document exists, please make sure that the Methods section transparently describes when analyses were planned, and when/why any data-driven changes to analyses took place.

c) In either case, changes in the analysis-- including those made in response to peer review comments-- should be identified as such in the Methods section of the paper, with rationale.

*At the moment, figure 1 is named (in the title and also the in-text callouts) as a CONSORT flow diagram. CONSORT is the reporting tool normally used for randomized trials; the actual figure is fine as it is, but I'd suggest renaming the flow diagram of recruitment, this could just simply say (in title and text) "Flow diagram of Parent/Participant recriutment".

*We would suggest ensuring that the study is reported according to the STROBE guideline (recommended for observational studies - case/control, cohort, and cross-sectional studies), and include the completed STROBE checklist as Supporting Information. Please add the following statement, or similar, to the Methods: "This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline (SChecklist)." The STROBE guideline can be found here: http://www.equator-network.org/reporting-guidelines/strobe/. When completing the checklist, please use section and paragraph numbers, rather than page numbers.

-----------------------------------------------------------

Comments from the reviewers:

Reviewer #1: I confine my remarks to statistical aspects of this paper. While the general approach is appropriate, I have a number of issues to resolve before I can recommend publication

Line 337 Why was 85% chosen? This may or may not be a good choice, depending on what it retains and eliminates. Sometimes it is good to have one or two items with a ceiling, as some respondents may respond "correctly" only to that item. ("Correctly" is not quite right, but really means "most positive way")

Line 338-340 Why remove these items before the CFA? The CFA ought to indicate that they are not useful.

Lines 356-358 This approach, known as bivariate screening, cannot be recommended. The resulting multiplle regression will be wrong in several ways: Standard errors will be too small and, as a result, p values will be too low and CIs too narrow. In addition, the parameter estimates will be biased away from 0. It is best to use substantive knowledge to build a model, but if the authors insist on using an automatic method, then LASSO is usable.

Line 358-359 What exactly does this mean? Categorizing continuous variables is a mistake; it leads to an increase in both type I and type II error.. If there are outliers in an IV, they can be dealt with by choice of method (e.g. robust regression).

Line 359=360 Colinearity can occur between more than two variables. What was done then?

Line 361-363 You cannot accept the null, only fail to reject. If the authors want to do equivalence testing, they can, but that would be a separate procedure.

Line 365-367 I don't understand this. What was done?

Peter Flom

-----------------------------------------------------------

Reviewer #2: Review of PMEDICINE-D-19-03661

Psychological distress and resettlement stress are associated with lower school engagement among refugee parents

The purpose of the paper is to develop culturally-valid measures of school engagement among refugee parents in Australia and to describe the association of school engagement with other sociodemographic characteristics and psychological states of refugee parents. I very much appreciate the careful attention these authors give to establishing measures appropriate to refugee populations. It is important to not impose etic constructs.

Theoretical and Framing Issues

The paper needs more theoretical development. I understand that the qualitative research findings are reserved for another paper. However, there needs to be a discussion of the literature on parental engagement, which is broader and more sophisticated than the authors' suggest with their statement that existing engagement measures focus primarily on behavioral engagement. Several dimensions of parental/family engagement have been identified in addition to behavioral supports of student learning as evidenced by participation (which I agree is the most common). These include perceptions that the school is a welcoming environment, effective communication with school staff, and sharing power an advocacy, among others. The paper needs a review of these existing constructs and describe how the qualitative data showed that additional dimensions of school engagement are relevant for Arab-speaking refugees or that existing measures do not adequately capture the construct for Arab-speaking refugees. The new measures should fill this void, and predictive and discriminant validity established by testing the association with existing engagement measures. This was done to a limited extent with the Delaware scale, but it all seemed a bit random because of the lack of a theoretical framework.

The items developed for the scales do not follow best practices. They include reverse-coded items. The questions are complex, which makes it difficult to interpret the answers. Some questions combine parental engagement and barriers to parental engagement in a single question. For example, "Despite the language restrictions I feel adequately informed about what happens at the school." This question assumes that parents experience language restrictions, whereas your data show that many do not. If I don't experience language restrictions, how do I answer this question? Other questions are double-barreled. For example, "XX has been important in making me feel secure in the school because XX understands my family's religious and cultural backgrounds." What if XX understands family background but does not make them feel secure in school? These should have been separate questions.

The scales contain items that on their face seem to measure distinct dimensions of parental engagement. For example, the individual engagement scale includes questions about financial support, parental behavioral involvement, communication, and language barriers. In the larger literature, as noted above, these are treated as separate dimensions of engagement. One of the limitations of the current research on parental engagement, which also suffers from this type of fuzzy measurement, is that it does not lend itself to guiding interventions. Which of these aspects should schools focus on? Which is foundational for the others to be present? Ken Bollen (1990) has an excellent discussion of how highly correlated items may still represent distinct dimensions of community engagement.

Concurrent validity, as measured by correlations with the THC, needed some discussion.

Finally, the latter part of the paper and the discussion is too causal in nature, even though it is acknowledged that the data are cross-sectional. It presumes a unidirectional association that poor parental mental health reduces family engagement. Research suggests a bidirectional relationship such that that family engagement is necessary for schools to reach parents to improve mental health of both children and parents. See, for example, McNeely et al. (2020; Journal of School Health) and Ellis and colleagues (e.g., Kia-Keating & Ellis, 2007; Clinical Child Psychiatry and Psychology).

Methodological Suggestions

The authors drop variables due to their data distribution or missing data. They did not say which variables were excluded or how many, and I was left wondering if these variables were conceptually important. Fortunately, Mplus can handle variables with missing data. The variables with ceiling effects can be treated as categorical variables in the CFA model. Given that the authors chose CFA over EFA, I suspect that all of the variables used to measure the latent constructs have theoretical importance and should be included if possible.

The authors also drop variables because they have low factor loadings. What are these variables? Do they form a different, also important dimension of social belonging or did they have low factor loadings due to measurement issues (e.g., confusing wording, reverse scoring)? This gets back to the issue of having a theoretical basis for selecting the items and an empirical basis for dropping them.

It would be valuable to test for factor invariance across groups, particularly between early arrivers and long-term residents/citizens in Australia. Not sure if there is enough statistical power, but could the authors explore this? This would be particularly useful given the unexpected finding that duration of time in Australia is associated with lower school engagement. One potential explanation is that the schools are so geared towards serving newcomers that long-term residents feel less engaged.

Presentation Suggestions

Title: Might you consider replacing the term "refugee parents" with "Arabic-speaking refugee parents" in the title. Refugees are an extremely heterogeneous group.

Essential information about some of the scales is missing in the measures section. How many items are on the Delaware school climate survey teacher-home communication subscale and the PMLD scale. Also, I'm not sure it makes sense to report the reliability of the number of trauma exposures because this is a count variable. Measures of reliability assume that all the variables in your scale measure the same underlying construct, which is not the goal in counting the frequency of different traumatic experiences to determine the level of adversity exposure.

Items of the new scales are only reported in the supplemental index, which will make it difficult for readers to access. These should be reported in the main paper.

The supplemental index is confusing. The first table, presenting a correlation matrix, looks really interesting. But you list scales that you never present in the paper. I'm wondering if these scales wouldn't be more appropriate since they seem to distinguish dimensions of engagement more clearly. They also show very interesting findings, which are consistent with qualitative research and would be useful for policy, e.g., that for refugee parents, perceived quality of communication is highly correlated with assistance from the schools. That kind of specificity is needed for schools to know what to do.

The supplemental tables showing item-to-item correlations uses the variable names instead of the variable labels, making it difficult to read. I had to assume the variables were listed in the same order as they were in the prior table. By "estimates from CFA," did you mean the factor loadings? In these tables it would also be interesting to have an additional column reporting the Chronbach's alpha for the scale if the item had been dropped.

-----------------------------------------------------------

Reviewer #3: This is a well-done study guided by theory with community implications. The lack of more details about the translation process is a weakness and should be expanded or listed as a weakness. Also the lack of analysis incorporating school as a cluster was disappointing. A statistician should review and make suggestions.

Other than those criticisms, it is a well-done, well-written study.

-----------------------------------------------------------

Any attachments provided with reviews can be seen via the following link:

[LINK]

Decision Letter 1

Clare Stone

18 Aug 2020

Dear Dr. Baker,

Thank you very much for submitting your manuscript "Psychological distress and resettlement stress are associated with lower school engagement among Arabic-speaking refugee parents: A cross-sectional cohort study" (PMEDICINE-D-19-03661R1) for consideration at PLOS Medicine.

Your paper was evaluated by a senior editor and discussed among all the editors here. It was also discussed with an academic editor with relevant expertise, and sent to independent reviewers, including a statistical reviewer. The reviews are appended at the bottom of this email and any accompanying reviewer attachments can be seen via the link below:

[LINK]

In light of these reviews, I am afraid that we will not be able to accept the manuscript for publication in the journal in its current form, but we would like to consider a revised version that addresses the reviewers' and editors' comments. Obviously we cannot make any decision about publication until we have seen the revised manuscript and your response, and we plan to seek re-review by one or more of the reviewers.

In revising the manuscript for further consideration, your revisions should address the specific points made by each reviewer and the editors. Please also check the guidelines for revised papers at http://journals.plos.org/plosmedicine/s/revising-your-manuscript for any that apply to your paper. In your rebuttal letter you should indicate your response to the reviewers' and editors' comments, the changes you have made in the manuscript, and include either an excerpt of the revised text or the location (eg: page and line number) where each change can be found. Please submit a clean version of the paper as the main article file; a version with changes marked should be uploaded as a marked up manuscript.

In addition, we request that you upload any figures associated with your paper as individual TIF or EPS files with 300dpi resolution at resubmission; please read our figure guidelines for more information on our requirements: http://journals.plos.org/plosmedicine/s/figures. While revising your submission, please upload your figure files to the 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. 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 us at PLOSMedicine@plos.org.

We expect to receive your revised manuscript by Sep 08 2020 11:59PM. Please email us (plosmedicine@plos.org) if you have any questions or concerns.

***Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.***

We ask every co-author listed on the manuscript to fill in a contributing author statement, making sure to declare all competing interests. If any of the co-authors have not filled in the statement, we will remind them to do so when the paper is revised. If all statements are not completed in a timely fashion this could hold up the re-review process. If new competing interests are declared later in the revision process, this may also hold up the submission. Should there be a problem getting one of your co-authors to fill in a statement we will be in contact. YOU MUST NOT ADD OR REMOVE AUTHORS UNLESS YOU HAVE ALERTED THE EDITOR HANDLING THE MANUSCRIPT TO THE CHANGE AND THEY SPECIFICALLY HAVE AGREED TO IT. You can see our competing interests policy here: http://journals.plos.org/plosmedicine/s/competing-interests.

Please use the following link to submit the revised manuscript:

https://www.editorialmanager.com/pmedicine/

Your article can be found in the "Submissions Needing Revision" folder.

To enhance the reproducibility of your results, we recommend that you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see http://journals.plos.org/plosmedicine/s/submission-guidelines#loc-methods.

Please ensure that the paper adheres to the PLOS Data Availability Policy (see http://journals.plos.org/plosmedicine/s/data-availability), which requires that all data underlying the study's findings be provided in a repository or as Supporting Information. For data residing with a third party, authors are required to provide instructions with contact information for obtaining the data. PLOS journals do not allow statements supported by "data not shown" or "unpublished results." For such statements, authors must provide supporting data or cite public sources that include it.

We look forward to receiving your revised manuscript.

Sincerely,

Clare Stone, PhD

Managing Editor

PLOS Medicine

plosmedicine.org

-----------------------------------------------------------

Requests from the editors:

Unfortunately 2 of the referees continue to have issues with the analysis and revision. Please address all points and note we will only consult once more with the referees.

Comments from the reviewers:

Reviewer #1: The authors responded to my suggestions.

Remaining issues:

The authors wrote

<<<

If a predictor is not found to be significant in bivariate analyses, then it is typically not found to be statistically significant in multiple regression models, in the presence of all other predictors in the model. As expected,

those predictors not found to be statistically significant in bivariate analyses, were not significant in the multiple regression analyses. The variables found to be significant in bivariate analyses are also significant (p<0.05) in the stepwise multiple regression analysis. This consistency of findings indicates that multiple regression analysis is appropriate for our

data.

>>>

This is not always the case and it overemphasizes statistical significance. The results of stepwise methods are wrong. As I said, p values are too low, standard errors too small, parameter estimates biased away from 0.

Results from stepwise and bivariate analyses should not be presented.

The fact that none switched from significant to non-sig., or vice versa, is not really important.

<<< In SPSS, stepwise forward linear multiple regression analysis technique is similar to LASSO (Least Absolute Shrinkage and Selection Operator) forward technique. Since the term Multiple Regression is more familiar to readers, relative to LASSO, we have stayed with stepwise forward multiple regression as the analysis of choice. (However, if the reviewers feel strongly about this, we are open to change the name to LASSO linear regression (forward).

>>>

It's not a question of the name, but the whole analysis. The results from LASSO should be presented. The fact that it is less familiar isn't really important -- maybe some readers will learn something.

<<<

To be consistent with other dichotomous and categorical predictor variables, we categorised continuous predictor variables. In bivariate analyses, categorisation of continuous

predictor variables is common, e.g. age group, income group, psychological distress, BMI index etc.

>>>

It's certainly common to do this but it is a mistake to do so.

<<<

In the revised manuscript, we have used stepwise forward multiple regression technique. During the estimation process this technique automatically removes the variable by considering the value correlation and collinearity statistics tolerance. We have revised thetext throughout to accommodate this change.

>>>

This is not correct. See e,,g this thread https://stats.stackexchange.com/questions/186081/is-multicollinearity-an-issue-when-doing-stepwise-logistic-regression-using-aic

What happens is that SPSS will make an essentially arbitrary choice among colinear variables. This won't affect prediction, but it can lead to very poor explanation and to wrong conclusions about which variables are important.

Peter Flom

Reviewer #2: Thank you for attending to my concerns about the lack of justification for the study and the lack of a theoretical framework. The revisions to the introduction helped to address these concerns. The rewriting of the discussion also helped.

Unfortunately, the methodological approach used still does no align with the new theoretical development presented and is still incomplete.

Content Design and Development of New Measures: I found the formatting of this section confusing. I think it is an easy fix. Isn't the determination of these measures the result of the paper? Yet you describe the measures as if they are already validated. I had expected to see a description of your process for organizing the multiple items on the master list into theoretically distinct constructs as laid out in the intro. This is a major part of the methods that you entirely skip over. Was EFA used for this? Another process? Please describe. Also, please provide information on whether the items were originally written in English or Arabic and, regardless, if they were translated and back-translated.

Line 309: What does it mean to selectively sum a scale?

The presentation of results is still confusing. It appears that you proposed a scale and called it SES-RP. You present no empirical or theoretical justification for it being a single scale, nor do you point to it being an extant scale in the existing literature. You then conduct a CFA of these items and group them into five subscales, but do not present the CFA results that led you to that decision. Finally, based on correlation analysis that doesn't appear to treat the scales as latent constructs, you group the five scales into two scales based on what appears to be your interpretation of what makes sense along with the correlation analysis. I get the sense that you are using CFA in an exploratory rather than a confirmatory manner, but there is insufficient documentation. Why did some items have high factor loadings (presumably) when they were part of one subscale but had a statistically insignificant factor loading when they were part of another subscale? Finally, the naming of a subscale as "parent engagement" when all the scales, collectively, are referred to as parent engagement scales is confusing.

A Cronbach's alpha of 0.67 for an 11-item scale is not typically acceptable, as the alpha is a function of both average inter-item correlation and the number of items—11 items is a large scale. This is also reflected in Supplemental Table 5, which shows that some of the items have low correlations with most of the other items and in Table 3's goodness of fit measures. It would be helpful to see estimates Cronbach's alpha with each item deleted one at a time to affirm that all items belong in the scale or to have a theoretical rationale for why these items should remain in the scale.

In short, the development of the scales still needs more empirical and theoretical justification. I cannot tell if the methods used in this version of the paper are sufficient because not all results were presented.

Finally, I think the authors might have misunderstood the reviewers' request to take into account the clustering of students in schools. We were not asking for school fixed effects in the models (dummy variables for the schools), although the authors' justification that sample size did not allow for that doesn't really make sense (it is four variables). Rather, we were asking that the authors adjust the standard errors of the regression coefficients, which are underestimated due to the fact that the observations within schools are not independent (e.g., families in the same school work with the same cultural broker). The authors have two choices to address this. They can include school fixed effects (one indicator for four of the five schools, with the fifth one serving as the referent group), or they can adjust the standard errors using the complex samples general linear model option in SPSS (or another software). This probably won't change the results substantively, but since all reviewers requested it, I recommend the authors do it.

In addition, the paper uses terms loosely and vaguely, causing the reader to have to work too hard. Here are some examples in the beginning of the paper. Such examples continue throughout even though I do not note them.

The authors switch language between involvement and engagement (note title and first sentence of discussion) without explicitly defining either one. Please choose a single term, define it, and stick to it.

Line 76: take out the word "socio-demographic" and simply refer to "parent characteristics." Psychological distress is not a sociodemographic characteristic.

Lines 81-82: Low variance explained does not mean a set of variables isn't important. I recommend taking out this statement.

Lines 87-92: The stated conclusions are not based in the findings of this paper. You provide no evidence of effectiveness of cultural brokers in this study.

Lines 95-99: You say the study was done because schools integrate refugee families into communities, but there is nothing in your study about community involvement. You explain the connection well in the intro, but this edited-down version doesn't really make sense. Isn't the purpose to develop appropriate measures of school involvement for program development and evaluation?

Line 109: Casual or causal?

Lines 151-153: Sentence doesn't make sense. What is a refugee field? Current wellbeing is affected by past trauma. Not sure what it means to say it includes past trauma.

Lines 158-159. You say: "Current measures may not capture this." What is "this"? Unclear.

Line 169: What do you mean by "capture this relationship?" Do you mean measure the quality of this relationship? The content of interactions? Unclear.

Line 170: "The development of such measures is important." What measures? Throughout intro need to be very explicit about the constructs you are talking about, keeping the focus narrowly on the constructs you are proposing to measure. There is a tendency in this paper to keep broadening the scope, which ironically weakens the paper by diffusing the focus.

Line 174-175: "Context-specific measures also carry important implications for advancing efforts to improve refugee parents' engagement…" Unclear. What contexts are you talking about?

Line 181-183. Now you are talking about "traditional sense." Please, just use the names of the constructs this refers to, as you've never defined traditional constructs. Similarly, why call the new constructs "extras?" That minimizes their core importance.

Line 191: I suggest not using the word profiling. For U.S. audiences that has very negative connotations and is never something to be recommended.

Line 251: What are generic school engagement scales? You haven't defined these prior to now.

Lines 234-236: This sample size estimation is completely out of context. Statistical power must be estimated in the context of an intended analysis, and you haven't proposed one yet. What sort of coefficients are you referring to for what statistical model? This should be presented later in the data and analysis sections of the methods.

Lines 258-59: Don't need to state that qualitative data was transcribed or the software you used to analyze it. Not relevant or informative for this study. Better to cite the study so reader can find full details.

Line 264: Need a little more information on the qualitative pilot.

Reviewer #3: The authors have addressed my concerns.

Any attachments provided with reviews can be seen via the following link:

[LINK]

Decision Letter 2

Richard Turner

3 Dec 2020

Dear Dr. Baker,

Thank you very much for re-submitting your manuscript "Psychological distress and resettlement stress are associated with lower school engagement among Arabic-speaking refugee parents: A cross-sectional cohort study" (PMEDICINE-D-19-03661R2) for consideration at PLOS Medicine.

I have discussed the paper with editorial colleagues and our academic editor, and it was also seen again by 2 reviewers. I am pleased to tell you that, provided the remaining editorial and production issues are fully dealt with, we expect to be able to accept the paper for publication in the journal.

The remaining issues that need to be addressed are listed at the end of this email. Any accompanying reviewer attachments can be seen via the link below. Please take these into account before resubmitting your manuscript:

[LINK]

Our publications team (plosmedicine@plos.org) will be in touch shortly about the production requirements for your paper, and the link and deadline for resubmission. DO NOT RESUBMIT BEFORE YOU'VE RECEIVED THE PRODUCTION REQUIREMENTS.

***Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.***

In revising the manuscript for further consideration here, please ensure you address the specific points made by each reviewer and the editors. In your rebuttal letter you should indicate your response to the reviewers' and editors' comments and the changes you have made in the manuscript. Please submit a clean version of the paper as the main article file. A version with changes marked must also be uploaded as a marked up manuscript file.

Please also check the guidelines for revised papers at http://journals.plos.org/plosmedicine/s/revising-your-manuscript for any that apply to your paper. If you haven't already, we ask that you provide a short, non-technical Author Summary of your research to make findings accessible to a wide audience that includes both scientists and non-scientists. The Author Summary should immediately follow the Abstract in your revised manuscript. This text is subject to editorial change and should be distinct from the scientific abstract.

We hope to receive your revised manuscript within 1 week. Please email us (plosmedicine@plos.org) if you have any questions or concerns.

We ask every co-author listed on the manuscript to fill in a contributing author statement. If any of the co-authors have not filled in the statement, we will remind them to do so when the paper is revised. If all statements are not completed in a timely fashion this could hold up the re-review process. Should there be a problem getting one of your co-authors to fill in a statement we will be in contact. YOU MUST NOT ADD OR REMOVE AUTHORS UNLESS YOU HAVE ALERTED THE EDITOR HANDLING THE MANUSCRIPT TO THE CHANGE AND THEY SPECIFICALLY HAVE AGREED TO IT.

Please ensure that the paper adheres to the PLOS Data Availability Policy (see http://journals.plos.org/plosmedicine/s/data-availability), which requires that all data underlying the study's findings be provided in a repository or as Supporting Information. For data residing with a third party, authors are required to provide instructions with contact information for obtaining the data. PLOS journals do not allow statements supported by "data not shown" or "unpublished results." For such statements, authors must provide supporting data or cite public sources that include it.

Please note, when your manuscript is accepted, an uncorrected proof of your manuscript will be published online ahead of the final version, unless you've already opted out via the online submission form. If, for any reason, you do not want an earlier version of your manuscript published online or are unsure if you have already indicated as such, please let the journal staff know immediately at plosmedicine@plos.org.

Please let me know if you have any questions. Otherwise, we look forward to receiving the revised manuscript shortly.

Sincerely,

Richard Turner, PhD

Senior Editor, PLOS Medicine

rturner@plos.org

------------------------------------------------------------

Requests from Editors:

In order to comply with PLOS' data policy, https://journals.plos.org/plosmedicine/s/data-availability, we will need to ask that you provide a non-author contact for readers interested in inquiring about access to study data.

Please remove "are associated with" from your title so that it conforms to PLOS Medicine's style (i.e., non-declarative titles). Please mention the study setting in the title, e.g., "Psychological distress, resettlement stress and lower school engagement among Arabic-speaking refugee parents in Sydney, Australia: a cross-sectional study".

Please remove the information on funding and competing interests from the title page. In the event of publication, this information will appear in the article metadata via entries in the submission form.

Please adapt the "Methods and findings" subsection of your abstract to briefly describe the pilot phase of the study also, quoting quantitative details of the findings.

Please include study dates in the abstract; and add a few words to make it clear what the "Kessler10" is.

Please also quote aggregate demographic details for study participants in the abstract.

Please restructure the end of the "Methods and findings" subsection of your abstract so that the final sentence begins "Study limitations include ..." or similar.

Please avoid claims of "the first" and the like, e.g., at line 83. Where needed, please add "to our knowledge".

Please trim the "Conclusions" subsection of you abstract to no more than 3-4 sentences, and we ask you to focus the text more on the conclusions of the study and their immediate implications.

Please reformat the "author summary" so that each of the three subsections consists of 3-4 bulleted points, which should generally comprise a single sentence each.

Please add a heading to the Introduction.

We ask you to restructure the Discussion section. The first paragraph should provide a summary of the paper's main findings, and there should be a separate discrete paragraph discussing study limitations.

Please avoid "a couple of" at line 536.

Please ensure that all p values are quoted exactly, or for smaller values as p<0.001.

Where appropriate, please substitute "sex" for "gender" throughout the paper.

Please remove footnotes from your text: these can be integrated into the main text at suitable points. Acknowledgements to reviewers can appear in the acknowledgments section.

Please remove all reference call-outs from subheadings, e.g., at line 272.

Throughout the text, please remove spaces from the reference call-outs (e.g., ... refugee students [5,6].").

Please revisit your reference list to ensure that all citations contain full access information and comply with journal format. We note that reference 76, for example, appears to lack full access details.

Please reformat your supplementary material so that the study protocol and STROBE checklist are both separate supplementary documents, individually referred to in the Methods section (e.g., "See S1_STROBE_Checklist").

Comments from Reviewers:

*** Reviewer #1:

The authors have addressed my concerns and I now recommend publication.

Peter Flom

*** Reviewer #2:

The authors made some of the requested changes. I thank them for that.

I have some final suggestions.

p. 8. There seems to be a suggestion that the new measures could be used to identify individual parents at risk of low engagement. The authors need to be careful about making that claim because developing tools for monitoring is very different from developing screening tools. Be careful to frame the purpose of the multivariate analysis as identifying risk factors (vs. parents at risk) for low engagement.

p. 12. The description of the measure development is still confusing. This is primarily an organizational suggestion, but I think an important one. You are presenting the analytic strategy in the measures section. In measures section, I would have expected to see a statement describing the theoretical constructs you are testing with CFA and to be given examples of items that you believe measure each construct. This is missing from the methods section entirely. Then the CFA description should go in the analysis section, which you don't have. Consider adding a heading for Data Analysis (like you have for Measures) and putting all subsections starting with Measurement Development under that heading.

p. 16 - 18. All of the information in the section Item Development and Pilot should be put in the Measures section. I thank the authors for adding this important information. This is the information I was expecting to see on page 12. I would move it into the Methods section, since you are describing the methods of your paper, not the results.

Line 412 - you hypothesized 3 domains but said CFA identified 5. Need more context here on what happened. How did you get to five and how did you name them what you named them? And then you go back to four scales. It is impossible to follow your decision-making here. I've stated this same limitation multiple times now. It is starting to feel futile.

Which leads me to my final point. I hope that going forward in their careers, the authors respond less superficially to reviewer comments than they did in the case of his manusript. It is frustrating to keep saying the same changes are needed over and over. I am committed to this topic and the paper had potential, so I stuck it out. The authors would be better served and get their work published more quickly if they responded more fully to reviewer comments. I am not saying that the authors need to change their paper as the reviewer wishes -- a full response could include an explanation why the reviewer is incorrect in their assessment.

***

Any attachments provided with reviews can be seen via the following link:

[LINK]

Decision Letter 3

Richard Turner

17 Jun 2021

Dear Dr. Baker,

I am writing concerning your manuscript submitted to PLOS Medicine, entitled “Psychological distress, resettlement stress and lower school engagement among Arabic-speaking refugee parents in Sydney, Australia: a cross-sectional cohort study”.

We have now completed our final technical checks and have approved your submission for publication. You will shortly receive a letter of formal acceptance from the editor.

Kind regards,

PLOS Medicine

Associated Data

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

    Supplementary Materials

    S1 Prospective Protocol. Prospective protocol based on approved ethics submission (HC15833).

    (DOCX)

    S1 STROBE Checklist. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist.

    (DOCX)

    S1 Data Tables. Pertaining to the development and psychometrics of study scales.

    (DOCX)

    Attachment

    Submitted filename: ResponsetoEditors.PLOSMedicine.29.7.20.FINAL.docx

    Attachment

    Submitted filename: 2ndResponsetoReviewers.FINAL.27.9.20.docx

    Attachment

    Submitted filename: 3rdResponsetoReviewers_final.docx

    Data Availability Statement

    The data that support the findings of this study will be made available to researchers who meet the criteria for access to study data, after permission from the relevant ethics body below has been sought. The Human Ethics Coordinator The University of New South Wales Email: humanethics@unsw.edu.au.


    Articles from PLoS Medicine are provided here courtesy of PLOS

    RESOURCES