Health Conditions of Immigrant, Refugee, and Asylum-Seeking Men During the COVID-19 Pandemic

Round 1

Reviewer 1 Report

A very interesting article that addresses a current and highly important topic. It presents a well-founded theoretical framework. The methodology used is well described and robust, consisting of a scoping review followed by lexical analysis. The discussion is in-depth and the results are well described and presented.
However, there is some repetition of information that could be avoided. 

Minor suggestions that will help simplify the reading of the article:
- Lines 122 to 129: clarify the relationship between the scoping review and the lexical analysis, as the latter may be perceived as a second study when in fact it is a complementary analysis. 
- Pay attention to repetitive descriptions, for example in Figures 2 and 3 (lines 160-207), perhaps placing the more detailed information in the discussion? 

 

Author Response

Dear Reviewer,

We are grateful for the thorough review of our manuscript, "Health conditions of immigrant, refugee, and asylum-seeking men during the COVID-19 pandemic". We appreciate the insightful comments and constructive suggestions, which have significantly improved the clarity, rigor, and impact of our work. We have carefully considered each point raised and revised the manuscript accordingly. Our detailed responses to each comment are provided below. The adjusted text in the manuscript is highlighted in green.

 

Comment: Lines 122 to 129: clarify the relationship between the scoping review and the lexical analysis, as the latter may be perceived as a second study when in fact it is a complementary analysis.

Response: We agree that the relationship between the scoping review and the lexical analysis needed further clarification to avoid the perception of it being a separate study. We have explicitly stated that the lexical analysis is a complementary layer of analysis.

Changes made in the manuscript:

• Materials and Methods (Etapa 2): We added the following sentence: "This lexical analysis does not constitute a separate study; rather, it is a complementary analytic layer applied to the textual syntheses derived from the scoping review to enhance thematic integration and interpretability of the mapped evidence."
• Results (opening paragraph): We further clarified the two-layered approach by stating: "Results are reported in two complementary layers: (i) the scoping review evidence map and (ii) a lexical analysis applied to standardized study syntheses to support thematic integration."

 

Comment: Pay attention to repetitive descriptions, for example in Figures 2 and 3 (lines 160-207), perhaps placing the more detailed information in the discussion?

Response: We acknowledge the concern regarding repetitive descriptions of Figures 2 and 3. We have condensed the descriptions in the Results section to focus on the key findings presented visually, reserving more detailed interpretation and discussion for the Discussion section.

Changes made in the manuscript:

• Results (description of Figures 2 and 3): The descriptive text for these figures has been significantly condensed to avoid re-explaining the visual content. For instance, for Figure 2, the description now focuses on the prominence of key terms, and for Figure 3, it highlights the co-occurrence structure without detailing every connection.
• Discussion: Interpretive insights derived from these figures are now integrated into the thematic categories, where they contribute to the broader analytical narrative.

 

We believe that these revisions have substantially strengthened the manuscript, addressing all concerns raised.

Thank you once again for your time and valuable feedback.

Reviewer 2 Report

This scoping review addresses an important and timely topic—the health conditions of immigrant, refugee, and asylum-seeking men during the COVID-19 pandemic. The study is well-structured, methodologically sound, and clearly written. It provides a valuable synthesis of existing literature and identifies critical gaps, particularly regarding asylum seekers. The use of both scoping review and qualitative lexical analysis (IRaMuTeQ) is a strength, allowing for both breadth and depth in analysis. However, some areas require clarification, expansion, or correction before publication.

please see the attached file

Comments for author File: Comments.pdf

Author Response

Dear Reviewer,

We are grateful for the thorough review of our manuscript, "Health conditions of immigrant, refugee, and asylum-seeking men during the COVID-19 pandemic." We appreciate the insightful comments and constructive suggestions, which have significantly improved the clarity, rigor, and impact of our work. We have carefully considered each point raised and revised the manuscript accordingly. Our detailed responses to each comment are provided below. The adjusted text in the manuscript is highlighted in yellow.

 

Comment: The introduction does not explicitly state what is missing in the existing literature. It describes the context (pandemic, inequalities, vulnerability) but does not clearly articulate how prior studies have failed to adequately address the health conditions of immigrant, refugee, and asylum-seeking men from an intersectional and gendered perspective.

Response: We agree that a more explicit statement of the research gap and how previous studies have fallen short was necessary. We have revised the Introduction to clearly articulate this.

Changes made in the manuscript:

• Introduction: We added a dedicated paragraph explicitly stating the research gap: "Despite a growing body of COVID-19 research on migrant populations, the literature remains fragmented regarding men’s health conditions across migration statuses (immigrants, refugees, and asylum seekers) and seldom integrates a gender- and intersectionality-informed lens. Existing syntheses frequently focus on migrants in general or emphasize legal/administrative vulnerability without systematically examining how masculinities, work-related exposure, and intersecting social positions (e.g., race and class) shape health risks, access to care, and vaccine uptake during the pandemic. Therefore, a global scoping review focusing specifically on immigrant, refugee, and asylum-seeking men is needed to map what is known, identify blind spots (notably for asylum seekers), and generate actionable implications for health systems and policy."

 

Comment: The literature review is context-setting rather than critical. It explains why the population is vulnerable but does not critique how existing research has addressed (or failed to address) this vulnerability.

Response: We have incorporated a more critical perspective on how existing research has addressed (or failed to address) the vulnerability of this population, highlighting methodological and conceptual shortcomings in the literature.

Changes made in the manuscript:

• Introduction: We added a critical perspective within the gap statement, noting that existing syntheses often focus on migrants generally or emphasize legal/administrative vulnerability without systematically examining gendered and intersectional aspects. We also included a statement in the Limitations section about the heterogeneity in definitions and potential biases in the existing evidence base.

 

Comment: While relevant, the introduction heavily references Brazilian policies and data (e.g., National Policy for Men’s Health, asylum seeker demographics in Brazil). This may imply a geographic bias in the review’s focus, which is not explicitly stated as a limitation of the existing literature.

Response: We acknowledge the concern about a potential geographical bias due to references to Brazilian policies and data in the Introduction. We have repositioned these specific examples to the Discussion section, where they serve as illustrative cases for policy recommendations, and ensured that the global scope of the review is maintained in the Introduction.

Changes made in the manuscript:

• Introduction: Specific references to Brazilian policies and data have been removed from the Introduction.
• Discussion (Category 4): The discussion of the National Policy for Comprehensive Men's Health Care (PNAISH) now includes an explicit caveat regarding its transferability: "Although PNAISH is Brazil-specific, its underlying principles (gender-sensitive primary care and active outreach) are transferable; however, implementation requires adaptation to country-specific governance arrangements, financing capacity, and legal frameworks."

 

Comment: The introduction does not clearly state how this scoping review will differ from existing ones. It mentions a "scarcity of national studies" but does not position this review as a systematic global synthesis that fills that void.

Response: We have revised the Introduction to clearly articulate how this scoping review differentiates itself from existing literature, emphasizing its unique focus and methodological approach.

Changes made in the manuscript:

• Introduction: The revised gap statement explicitly positions this review as a "global scoping review focusing specifically on immigrant, refugee, and asylum-seeking men" and highlights its contribution in mapping what is known and identifying blind spots. We also clarified that the lexical analysis provides an integrative thematic structure.

 

Comment: The research question (“what were the health conditions of… men during the COVID-19

pandemic?”) emerges abruptly. The introduction does not build a case for why this question hasn’t

been answered yet.

Response: We have ensured that the research question is now logically introduced, following the articulation of the research gap and the justification for why this question remains inadequately addressed in the existing literature.

Changes made in the manuscript:

• Introduction: The research question is now presented after the detailed discussion of the research gap and the unique contribution of this review, providing a clear rationale for its inquiry.

 

Comment: The title refers broadly to “immigrant, refugee, and asylum-seeking men,” but the results indicate a strong bias toward immigrants (75.3% of studies), with limited representation of refugees (16.1%) and especially asylum seekers (1.1%). This should be explicitly acknowledged as a limitation and reflected in the title or abstract to avoid overgeneralization.

Response: We fully agree with this observation. We have explicitly recognized this bias in the Abstract, Results, and Limitations section to prevent overgeneralization. We opted to maintain the current title, as the comprehensive acknowledgment of this limitation within the manuscript adequately addresses the concern.

Changes made in the manuscript:

• Abstract: We added the sentence: "Most studies focused on immigrants, with limited evidence for refugees and especially asylum seekers; therefore, conclusions should be interpreted cautiously for these groups."
• Results: We already had quantified the distribution: "There was a concentration of research focused on immigrants (75.3%), compared to refugees (16.1%) and asylum seekers (1.1%)."
• Limitations and Contributions: We already had reiterated this limitation: "Furthermore, there was an asymmetry in the representativeness of the populations investigated, with a predominance of studies focused on immigrants, to the detriment of refugees and, above all, asylum seekers, which limits the generalization of the findings to the latter group, which is known to be more exposed to extreme vulnerabilities."

 

Comment: The PRISMA-ScR flowchart (Fig. 1) is helpful, but the exclusion criteria could be more clearly detailed. For example, “not related to the topic” is vague.

The use of IRaMuTeQ is appropriate but would benefit from a brief justification of why this software

was chosen over other text analysis tools.

Response: We have significantly detailed the exclusion criteria and provided a clear justification for the selection of IRaMuTeQ.

Changes made in the manuscript:

• Materials and Methods (Eligibility Criteria): We replaced the vague "not related to the theme" with specific exclusion criteria: "We excluded reviews, editorials, and study protocols; studies not focused on immigrant/refugee/asylum-seeking men (or not reporting sex-disaggregated data); studies not conducted in the COVID-19 pandemic context; and studies that did not report health outcomes/conditions relevant to the PCC (clinical, mental health, access to care, or vaccination-related outcomes)."
• Materials and Methods (Etapa 2): We added the justification for IRaMuTeQ: "IRaMuTeQ was selected because it enables reproducible, corpus-based lexical analyses (e.g., similarity analysis and Descending Hierarchical Classification) grounded in established textual statistics, facilitating transparent identification of co-occurrence structures and lexical classes in a large multilingual corpus."

 

Comment: It is unclear how the “93 syntheses” were derived from the 93 studies. Were these author-generated summaries? Clarify the process.

Response: We have clarified the process of deriving the "93 syntheses" from the 93 included studies, detailing how they were generated and the quality control measures.

Changes made in the manuscript:

• Materials and Methods (Etapa 2): We added a detailed explanation: "For each included article, we produced one standardized textual synthesis (one per study; n = 93) by extracting and condensing the main conclusions and implications reported by the original authors (e.g., conclusion section and/or concluding statements from the abstract). These syntheses were prepared by two reviewers using a predefined template to preserve meaning while ensuring comparability across studies. Each synthesis was treated as one Initial Context Unit (ICU) in IRaMuTeQ (C_1 to C_93). Disagreements in synthesis extraction were resolved by consensus."

 

Comment: The five lexical classes and four thematic categories are logically presented, but the transition between them could be smoother. Explain more explicitly how the four categories were synthesized from the five classes.

Response: We have improved the fluidity of the transition between the lexical classes and thematic categories by explicitly explaining the interpretive synthesis process.

Changes made in the manuscript:

• Results (transition to Discussion): We added the following sentence: "We subsequently performed an interpretive synthesis by grouping lexically proximate classes (as indicated by CFA proximity and thematic overlap) into four higher-order categories to support a clearer public health narrative and reduce redundancy across findings."

 

Comment: The discussion sections are thorough but occasionally repetitive. Consider condensing overlapping points, especially in Categories 1 and 3 regarding barriers to access.

Response: We have reviewed the Discussion section for repetitiveness, particularly in Categories 1 and 3, and condensed overlapping points to improve conciseness and flow.

Changes made in the manuscript:

• Discussion (Categories 1 and 3): We refined the content to ensure distinct focuses. For instance, in Category 1, the discussion on PNAISH now includes a cross-reference to Category 4 for further details on transferability, avoiding full repetition. In Category 3, the opening sentence was revised to avoid re-describing the lexical analysis output, focusing directly on the challenges.

 

Comment: While 35 countries are represented, it is unclear how many studies focused on low- vs. high-income countries. Given the emphasis on structural inequalities, a breakdown by country income level or region would strengthen the analysis.

Response: We have incorporated an analysis of the distribution of studies by country income level, which strengthens the discussion on structural inequalities.

Changes made in the manuscript:

• Results: We added the following information: "Using the World Bank income classification, studies were predominantly conducted in high-income settings (67.7%), with fewer studies from low- and middle-income countries (32.3%)."
• Limitations and Contributions: We also noted this as a limitation: "Evidence concentration in high-income contexts may further limit inference for low-resource settings."

 

Comment: The discussion on masculinity and health-seeking behavior is a strength, but it could be more critically engaged. For example, how do intersecting identities (e.g., race, class, sexual orientation) further shape these men’s experiences? This intersectional lens is mentioned but could be deepened.

Response: We have deepened the critical analysis of masculinity and health-seeking behaviors by explicitly integrating an intersectional perspective, discussing how various identities  further shape the experiences of migrant men.

Changes made in the manuscript:

• Discussion - Category 4: We expanded on this in the paragraph (highlighted in blue): "A central implementation challenge is that men’s health behaviors in migrant contexts are shaped by gendered social roles and expectations, which may intensify vaccine hesitancy and delay care-seeking when vaccination is perceived as compro-mising short-term work capacity (e.g., side effects, lost wages) or as conflicting with norms of endurance and self-management. These pressures interact with intersecting positions (e.g., race/ethnicity, class, housing precarity, and legal status), increasing vulnerability among men in essential or high-exposure occupations and reinforcing the “invisibility” of men in care pathways discussed above."

 

Comment: The review maps the evidence well but provides minimal critique of study quality, potential biases (e.g., over-representation of high-income settings, reliance on administrative data), or heterogeneity in definitions of “immigrant/refugee/asylum-seeker.”Recommendation: Add a brief subsection on evidence limitations/quality (common in scoping reviews) and discuss how over-focus on immigrants vs. refugees/asylum-seekers may skew conclusions.

Response: We have added a comprehensive discussion on the limitations of the included evidence, addressing potential biases, heterogeneity in definitions, and the quality of studies, as is common in scoping reviews.

Changes made in the manuscript:

• Limitations and Contributions: We expanded this section to include: "Additionally, heterogeneity in how primary studies defined migration status (immigrant/refugee/asylum seeker) and reliance on administrative datasets in some settings may have introduced comparability challenges and selection biases. Evidence concentration in high-income contexts may further limit inference for low-resource settings. Finally, although the literature mapping was comprehensive, the scoping review, by methodological definition, does not include an assessment of the quality of the primary studies, making it impossible to draw conclusive inferences about the risk of bias and the robustness of the estimates of morbidity, mortality, and clinical outcomes reported during the COVID-19 pandemic."

 

Comment (Minor): The abstract mentions “93 studies from 35 countries” but does not specify the date range of included studies. Add “(2020–2023)” for clarity.

Response: We have added the period of included studies to the Abstract.

Changes made in the manuscript:

• Abstract: The sentence now reads: "The results identified 93 studies conducted between 2020 and 2023, from 35 countries..."

 

Comment (Minor): The phrase “qualitative lexical analysis” may be too technical for some readers; consider simplifying or briefly explaining.

Response: We have provided a brief explanation for "qualitative lexical analysis" in the Abstract.

Changes made in the manuscript:

• Abstract: The phrase now reads: "a qualitative lexical analysis (text-mining of standardized study syntheses) of the corpus was performed..."

 

Comment (Minor): The introduction is well-written but slightly long. Some paragraphs could be merged for conciseness.

Response: We have reviewed the Introduction for conciseness and unified some paragraphs to improve flow and reduce length.

Changes made in the manuscript:

• Introduction: Paragraphs have been reviewed and adjusted for conciseness.

 

Comment (Minor): Reference to Brazilian policy is relevant but should be contextualized within global policy gaps.

Response: We have contextualized the reference to Brazilian policy within broader global policy gaps, as detailed in our response to the major comment on geographical bias.

Changes made in the manuscript:

• Introduction: Specific Brazilian policy references have been removed.
• Discussion (Category 4): The PNAISH example is now presented with a clear statement on its transferability and the need for adaptation to local contexts.

 

Comment (Minor): Clarify how “impact on health conditions” was operationalized. Was it self-reported, clinically measured, or both?

Response: We have clarified how "impact on health conditions" was operationalized.

Changes made in the manuscript:

• Materials and Methods (PCC framework): We specified: "The concept (C) comprised impacts on health conditions, operationalized as biological/clinical outcomes, psychological/mental health outcomes, and social or health-system outcomes (e.g., access barriers, information barriers, vaccination uptake/hesitancy)."

 

Comment (Minor): Mention any gray literature searched, if applicable.

Response: We have explicitly mentioned the search for grey literature.

Changes made in the manuscript:

• Materials and Methods (Search Strategy): We added: "Grey literature was searched in Brazilian Digital Library of Theses and Dissertations (BDTD), CAPES Theses and Dissertations Catalog, and Open Access Scientific Repositories from Portugal, using the same eligibility criteria."

 

Comment (Minor): Figure 2 and Figure 6 are referenced as “word clouds,” but the captions are generic. Label them clearly as word clouds for easier interpretation.

Response: We have clarified the captions for Figures 2 and 6 to explicitly label them as word clouds.

Changes made in the manuscript:

• Figure 2 (Caption): Now reads: "Figure 2. Contextual analysis of the corpus of summaries on the impacts of the pandemic on the health of immigrants, refugees, and asylum-seeking men using a word cloud."
• Figure 6 (Caption): Now reads: "Figure 6. Word cloud (contextual analysis) of the corpus of summaries on the impacts of the pandemic on the health of immigrants, refugees, and asylum-seeking men."

 

Comment (Minor): In the similarity analysis (Fig. 3), some terms are cut off in the PDF. Ensure all labels are fully visible.

Response: We revised the layout/export of Figure 3 to ensure that all labels are fully visible in the compiled PDF. Specifically, we re-exported the similarity graph at higher resolution and adjusted margins/canvas size to prevent truncation of terms, while preserving the original structure generated by the analysis software.

Changes made: Figure 3 was re-exported and reformatted to avoid label cut-offs in the final PDF.

 

Comment (Minor): The connection between findings and policy recommendations is strong, but some recommendations (e.g., extending Brazil’s PNAISH) may not be directly transferable to other

contexts. Acknowledge this.

Response: We have recognized that some recommendations, such as extending Brazil's PNAISH, may not be directly transferable and require contextual adaptation.

Changes made in the manuscript:

• Discussion (Category 4): We added the caveat: "Although PNAISH is Brazil-specific, its underlying principles (gender-sensitive primary care and active outreach) are transferable; however, implementation requires adaptation to country-specific governance arrangements, financing capacity, and legal frameworks."

 

Comment (Minor): The limitation about linguistic exclusion of non-Portuguese/English/Spanish studies is importante and should be reiterated in the conclusion.

Response: We have reiterated the limitation regarding linguistic exclusion.

Changes made in the manuscript:

• Limitations and Contributions: The first limitation explicitly states: "First, the linguistic restriction to Portuguese, English, and Spanish may have resulted in the exclusion of relevant evidence published in other languages, especially those from countries with intense migratory flows."

 

Comment (Minor): Some references in the text do not have corresponding entries in the reference list (e.g., Ref 19 in the discussion cites Medrado et al., but the reference list jumps from 18 to 20). Please check consistency.

Response: Thank you for this careful observation. We performed a full audit of in-text citations against the reference list to ensure consistency and continuous numbering. In the revised manuscript, all cited references have corresponding entries in the reference list, including Reference 19 (Medrado et al.), and the numbering has been verified throughout.

Changes made: Reference list and in-text citations were cross-checked and corrected for completeness and numbering consistency.

 

Comment (Minor): Abbreviations (e.g., PNAISH, CFA) are well-defined, but consider adding a list of abbreviations earlier in the paper.

Response: We appreciate the suggestion. All abbreviations are defined at first mention in the text. In addition, we provide a dedicated Abbreviations section to support readability. We maintained the Abbreviations section in the location required by the journal template, ensuring compliance with the journal’s formatting standards.

 

Comment (Minor): Ensure all figures are cited in the text in numerical order. Figure 4 is referenced but not included in the provided PDF. The dendrogram (Fig. 4) and factor analysis (Fig. 5) are described but not visually present in the excerpt. Ensure they are included and clearly labeled in the final version.

Response: Thank you for noting this. We verified figure inclusion and ordering in the revised manuscript. Figure 4 (Dendrogram) and Figure 5 (Correspondence Factor Analysis) are included with complete captions, and all figures are cited in the text in numerical order. We also ensured that all figures are properly embedded and displayed in the final output.

Changes made: Figure set and Results section were revised to ensure Figures 4 and 5 are included, clearly labeled, and correctly cited.

 

We believe that these revisions have substantially strengthened the manuscript, addressing all concerns raised.

Thank you once again for your time and valuable feedback.

Reviewer 3 Report

I enjoyed reading your manuscript and profited from doing so. My judgement overall is that, as you suggest, your principal contribution lies in your focus especially on male immigrant, refugee and asylee health experiences during the COVID 19 crisis. I also found your research design fascinating and well executed. 

 

I can offer perhaps two broad comments for your consideration. First, as noted, I found your research design and methodology nuanced and well done. Second. I was struck that most of your conclusions are well known,but for the reasons you articulate, many governments did not respond in the ways for which you appropriately call. That is, many clearly did not accept the ethical imperative of providing adequate care or did so fitfully (or, in Brazil's case, by even blaming favela residents for the epidemic). In addition, how, even with sufficient political will, many of the concerns you raise can be addressed remains practically challenging.  As such, it might be helpful, if you have the data, to share more on the specifically male role-related issues linked to increased vaccine hesitancy, greater vulnerability and to employment related concerns and what governments can do to address them and how they might be persuaded to bear the cost of doing so would be helpful. Such palliatives as you suggest-public information campaigns and reaching kinship networks in multiple languages depend on the availability of care in the first instance. In addition, many, if not most, are relatively expensive and their success has been notably uneven in any case. 

Author Response

Dear Reviewer,

We are grateful for the thorough review of our manuscript, "Health conditions of immigrant, refugee, and asylum-seeking men during the COVID-19 pandemic." We appreciate the insightful comments and constructive suggestions, which have significantly improved the clarity, rigor, and impact of our work. We have carefully considered each point raised and revised the manuscript accordingly. Our detailed responses to each comment are provided below. The adjusted text in the manuscript is highlighted in blue.

 

Comment: I was struck that most of your conclusions are well known,but for the reasons you articulate, many governments did not respond in the ways for which you appropriately call. That is, many clearly did not accept the ethical imperative of providing adequate care or did so fitfully (or, in Brazil's case, by even blaming favela residents for the epidemic). In addition, how, even with sufficient political will, many of the concerns you raise can be addressed remains practically challenging.  As such, it might be helpful, if you have the data, to share more on the specifically male role-related issues linked to increased vaccine hesitancy, greater vulnerability and to employment related concerns and what governments can do to address them and how they might be persuaded to bear the cost of doing so would be helpful. Such palliatives as you suggest-public information campaigns and reaching kinship networks in multiple languages depend on the availability of care in the first instance. In addition, many, if not most, are relatively expensive and their success has been notably uneven in any case.

Response: We appreciate this critical and highly relevant comment, which highlights the practical challenges of implementing equitable policies despite known conclusions. We expanded the discussion of category 4 to directly address the issues of implementation, political feasibility, the specific role of masculinity in health behaviors, and strategies for persuading governments to invest in these interventions.

Changes made in the manuscript:

• Inclusion of the following paragraphs, expanding the discussion of category 4:

Beyond mapping barriers and impacts, these findings also have implications for implementation and political feasibility. Implementing gender- and equity-sensitive responses for immigrant, refugee, and asylum-seeking men during and after large-scale health emergencies requires moving beyond information campaigns and addressing the practical conditions that shape exposure, service use, and compliance.

Across the included evidence, barriers were not merely individual (knowledge deficits), but were strongly mediated by legal insecurity, language and health-system navigation barriers, precarious employment conditions, and mistrust linked to dis-crimination—consistent with this Category’s emphasis on documentation-related ex-clusion and the need to ensure access regardless of migration status. Therefore, policy implications should be articulated as an integrated package of service availability, ef-fective access, and institutional legitimacy, rather than as isolated communication in-terventions.

A central implementation challenge is that men’s health behaviors in migrant contexts are shaped by gendered social roles and expectations, which may intensify vaccine hesitancy and delay care-seeking when vaccination is perceived as compro-mising short-term work capacity (e.g., side effects, lost wages) or as conflicting with norms of endurance and self-management. These pressures interact with intersecting positions (e.g., race/ethnicity, class, housing precarity, and legal status), increasing vulnerability among men in essential or high-exposure occupations and reinforcing the “invisibility” of men in care pathways discussed above. Political feasibility can be strengthened by complementing rights-based arguments with a pragmatic risk-management framing (reducing outbreaks in essential sectors and avoidable late-stage care), supported by intersectoral arrangements that distribute costs while preserving accountability for equity outcomes. Finally, because messaging rarely translates into uptake without enabling conditions, social protection (paid leave for vaccination/isolation, protection against workplace retaliation, and reduced adminis-trative barriers) should be treated as a core component of emergency preparedness for migrant men’s health. Future research should test which combinations of service de-sign, protection, and community engagement most improve outcomes, considering the limitations of the evidence base (uneven representation of statuses and settings).

 

We believe that these revisions have substantially strengthened the manuscript, addressing all concerns raised.

Thank you once again for your time and valuable feedback.

Round 2

Reviewer 2 Report

minor revision 

They not only addressed each point individually but also exceeded reviewer expectations in several aspects, particularly in clarifying research gaps, enhancing methodological transparency, deepening intersectional perspectives, and frankly acknowledging limitations. The academic quality of the revised manuscript has significantly improved and it now possesses strong potential for publication in a high-quality journal.

Suggestion: The author should maintain this rigorous academic approach and conduct a final comprehensive language proofread and format check before final submission to ensure consistency in all figures, citations, and terminology.

1.Optimization of Figure Visualization

Although the author indicated re-exporting figures, it is advisable to double-check the display of all figures in the final PDF before submission to ensure complete and clear labeling.

2.Further Refinement of Language

While the author has attempted to merge paragraphs, the Introduction could be further streamlined to better highlight the core argumentative thread.

3.Contextual Adaptability of Policy Recommendations

Although it is stated that the PNAISH policy needs adaptation to specific national contexts, future work could consider providing a broader framework for discussing cross-context policy adaptation to enhance global applicability.