Nursing Interventions in Primary Care for the Management of Maladaptive Grief: A Scoping Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This article addresses a topic of great interest to nursing, being both innovative and current. The choice of the research area—interventions in grief and the risk of maladaptive grief—stands out as one of its strengths. The methodology adopted is appropriate, though it warrants some comments.

The title of the article reflects the content discussed, but it is overly long, exceeding 15 words. It is recommended to consider revising it to make it more concise.

Although the research question follows the PIO methodology, the authors focus solely on nursing interventions carried out in the home setting. Therefore, I suggest that the research question be adjusted to "Which interventions nurses implement in the PHC context by means of an individual approach to reduce maladaptive grief or maladaptive grief risk in adults?

In the articles analyzed and included in the results, the importance of monitoring the grieving process is emphasized. Additionally, it is noted that the environment where the person lives (rural versus urban) influences the grieving process. It would be interesting to see these two aspects discussed in the article's discussion section.

Author Response

REVIEWER 2:
- This article addresses a topic of great interest to nursing, being both innovative and current. The choice of the research area—interventions in grief and the risk of maladaptive grief—stands out as one of its strengths. The methodology adopted is appropriate, though it warrants some comments.

The authors are grateful for the interest and comments of reviewer 2 on this point.
The title of the article reflects the content discussed, but it is overly long, exceeding 15 words. It is recommended to consider revising it to make it more concise.
We agree with this comment of reviewer 2, which is why we have shortened the title without losing informative content, as follows: Nursing interventions in Primary Care for the management of maladaptive grief: A scoping review

- Although the research question follows the PIO methodology, the authors focus solely on nursing interventions carried out in the home setting. Therefore, I suggest that the research question be adjusted to "Which interventions nurses implement in the PHC context by means of an individual approach to reduce maladaptive grief or maladaptive grief risk in adults?

Although we consider that the proposed modification of the question does not affect the development of the methodology or the results of the review, the question has been implemented as suggested by reviewer 2.

- In the articles analyzed and included in the results, the importance of monitoring the grieving process is emphasized. Additionally, it is noted that the environment where the person lives (rural versus urban) influences the grieving process. It would be interesting to see these two aspects discussed in the article's discussion section.
To discuss these aspects, the following paragraph (in italics) has been added to the discussion, including 4 new references (ordered according to the corresponding reference number):
In addition, other factors have been described; Zhou et al [27] highlighted that younger parental age, being a mother, living in a rural location, lower monthly capital income, shorter time since loss and more comorbid chronic physical conditions were associated with more severe PGD symptoms. Regarding the differences between rural and urban areas, in contrast to our results, Dorsey et al [28] have studied the use of cognitive behavioural therapy (CBT) versus usual care for children in the context of Africa (Kenya and Tanzania) showing that in all groups (rural and urban) CBT was more effective (rural Kenya Cohen d= 1.04 [95% CI, 0.72-1.36]), urban Kenya

Cohen d= 0.56 [95% CI, 0.29-0.83]), and urban Tanzania Cohen d= 0.45 [95% CI, 0.10-0.80]). At 12-month follow-up, TCC remained more effective than usual care in both rural (Cohen d= 0.86 [95% CI, 0.64-1.07]) and urban (Cohen d= 0.99 [95% CI, 0.75-1.23]).
On the other hand, according to Xiong et al [29], los padres con apoyo social son capaces de controlar mejor los síntomas de ansiedad y estrés, disminuyendo el riesgo de PGD que los que tenían menor apoyo social. Thus, in the meta-analysis by Yuan et al [30], the prevalence of PGD was 20.9% (95% CI: 13.8-30.3%), while PGD symptoms were 75.0% (95% CI: 14.9- 98.1%). Subgroup analyses highlighted the proportion of mothers in the study samples as a statistically significant heterogeneity factor. Specifically, a significantly higher prevalence of PGD was observed in studies with a percentage of mothers >60% than in those with a percentage of mothers ≤60% (30.9% vs. 14.0%, p= 0.001). This result highlights the importance of clinical follow-up of these mothers because of their increased vulnerability.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Editor and Reviewer,

Thank you for the opportunity to review the article "Nursing Interventions in Primary Care for the Management of Maladaptive Grief and Maladaptive Grief Risk: A Scoping Review," which aims to synthesize the evidence available about the interventions carried out by Primary Health Care nurses, by means of an individual approach to reduce maladaptive grief or maladaptive grief risk.

I commend the authors for the revisions made to the article which have improved its quality. However, I suggest the following additional revisions:

• Explain in the methodology why the cut-off year of 2009 was chosen.
• The creation of Table 2 is considered unnecessary; besides the table being overly complex, as it is a scoping review, it is not necessary to perform an evaluation of the methodological quality.
• In the limitations, add linguistic bias and the fact that it only covers studies from 2009 onwards.

Good work.

Author Response

Dear Editor and Reviewer,
Thank you for the opportunity to review the article "Nursing Interventions in Primary Care for the Management of Maladaptive Grief and Maladaptive Grief Risk: A Scoping Review," which aims to synthesize the evidence available about the interventions carried out by Primary Health Care nurses, by means of an individual approach to reduce maladaptive grief or maladaptive grief risk.
I commend the authors for the revisions made to the article which have improved its quality. However, I suggest the following additional revisions:
We thank reviewer 3 for his comments and suggestions for improvement on our manuscript.
 • Explain in the methodology why the cut-off year of 2009 was chosen.
  This aspect was briefly mentioned in the introduction. However, it has been mentioned in the methodology (search strategies statement) and later thoroughly justified in the discussion (first paragraph), to highlight that in 2009, a review by Nagraj and Barclay (reference number 9) focused on interventions to address PGD in the context of PHC was conducted. Additionally, we have added the citation number ([9]) in the introduction (and discussion) next to the authors' names to highlight this reference.
• The creation of Table 2 is considered unnecessary; besides the table being overly complex, as it is a scoping review, it is not necessary to perform an evaluation of the methodological quality.
  Table 1 has been removed from the manuscript text and added as a supplementary file. Additionally, the remaining tables have been renumbered in the text. In Table 2 (now

Table 1), a final column has been added to include information on the critical appraisal of the studies included in the review.
Additionally, all table numbers in the manuscript have been renumered.
 • In the limitations, add linguistic bias and the fact that it only covers studies from 2009 onwards.
 We have added a sentence to address the limitations suggested by the reviewer 3 regarding the study inclusion dates and language bias.
Limitations due to the methodological time filter should be noted, as only studies published after 2009 were included. Additionally, there is a linguistic bias since only studies published in English, Spanish, and Portuguese were considered. This bias could be significant, given that many studies have been published in the context of Asia.
Additionally, a paragraph has been added to emphasize the need for future research into a greater number of contexts regarding differences between rural and urban environments, as well as population subgroups by age and gender:
In the future, it will be essential to conduct a more in-depth investigation into the differences in PGD between rural and urban settings across a wider range of international contexts. Additionally, further research is needed to explore how different subgroups, such as gender or age, respond to interventions designed to improve grief.

- Good work.
Thank you very much for the comments and suggestions for improvement, which have enhanced the manuscript as a whole.

Author Response File: Author Response.pdf