Use of Social Determinants of Health Screening among Primary Health Care Nurses of Developed Countries: An Integrative Review
Round 1
Reviewer 1 Report
I enjoyed reading your paper. The following are feedback and comments for your consideration:
Originality: As the authors mentioned, there is a lack of consensus about the concerns regarding implementing social determinants of health screening in the primary care practice, such as which screening tools to use, who are responsible for conducting screening, when and how to perform screening, etc. This paper can help further our understanding of this important topic by synthesizing what is known and identifying what remains unknown, which will inform future practice and research. Therefore, although this paper is not entirely original, it is helpful for closing gaps in the knowledge base, which justifies the consideration for publication.
Relationship to Literature: The paper generally demonstrated a sufficient understanding of the relevant literature through citing and discussing an appropriate range of literature sources that examined existing study findings and their theoretical underpinnings. This manuscript overall has been developed based on a solid literature review, and its findings have been discussed in the context of literature.
Methodology: The methods on which this manuscript was built were overall appropriate and thoroughly described.
Results and conclusions: The results were overall presented clearly and appropriately.
Implications: Implications for practice and future research on this topic have been clearly discussed.
Quality of Communication: The manuscript was generally well written. But it could use further proofreading and editing as there were some issues in spelling, grammar, punctuation, sentence structures, and reference citations.
Author Response
Thank you for your feedback. I appreciate the time you have taken to review the manuscript and provide comments to improve the manuscript. Please see below responses to your comments.
Kind regards
Reviewer 1:
Originality: As the authors mentioned, there is a lack of consensus about the concerns regarding implementing social determinants of health screening in the primary care practice, such as which screening tools to use, who are responsible for conducting screening, when and how to perform screening, etc. This paper can help further our understanding of this important topic by synthesizing what is known and identifying what remains unknown, which will inform future practice and research. Therefore, although this paper is not entirely original, it is helpful for closing gaps in the knowledge base, which justifies the consideration for publication. No change required.
Relationship to Literature: The paper generally demonstrated a sufficient understanding of the relevant literature through citing and discussing an appropriate range of literature sources that examined existing study findings and their theoretical underpinnings. This manuscript overall has been developed based on a solid literature review, and its findings have been discussed in the context of literature. No change required.
Methodology: The methods on which this manuscript was built were overall appropriate and thoroughly described. No change required.
Results and conclusions: The results were overall presented clearly and appropriately. No change required.
Implications: Implications for practice and future research on this topic have been clearly discussed. No change required.
Quality of Communications: The manuscript was generally well written. But it could use further proofreading and editing as there were some issues in spelling, grammar, punctuation, sentence structures, and reference citations.
Response 1: Thank you for your comments. The manuscript has been proofread and edited changes tracked in Version 1.1.
Reviewer 2 Report
Many thanks for the opportunity to review this article on Primary health care nurses’ of developed countries’ use of social determinants of health screening through an integrative systematic review. This article is well organized. I suggest removing aims and objectives from M&M to Introduction. The rest of them seem to be fine to me. All the best.
Author Response
Thank you for your feedback. I appreciate the time you have taken to review the manuscript and provide comments to improve the manuscript. Please see below responses to your comment.
Reviewer 2:
Point 1: Many thanks for the opportunity to review this article on Primary health care nurses’ of developed countries’ use of social determinants of health screening through an integrative systematic review. This article is well organized. I suggest removing aims and objectives from M&M to Introduction. The rest of them seem to be fine to me. All the best.
Response Point 1: Thank you for your comments. The aims and objectives have been moved to the introduction. This change has been tracked in Version 1.1
Reviewer 3 Report
The article aims to bridge a gap in the literature by examining the screening Nurses are undertaking, the perspectives of PHNs and the methods they use to identify adverse Social Determinants of Health in developed countries. The article is generally well written with valid methods used for the meta-analysis. However, the following comments could be useful:
1. I feel the topic should be adjusted to read "Use of Social determinants of health screening Among primary health care nurses of developed countries: an integrative systematic review"
2. Authors did no explain why specific attention was given to developed countries.
3. Figure 1 was not provided or missing
4. Authors should proofread their work thoroughly for grammar
Author Response
Thank you for your feedback. I appreciate the time you have taken to review the manuscript and provide comments to improve the manuscript. Please see below responses to your comments.
Reviewer 3:
Point 1: I feel the topic should be adjusted to read "Use of Social determinants of health screening Among primary health care nurses of developed countries: an integrative systematic review"
Response Point 1: Thank you for comments. The title has been changed accordingly and tracked in Version 1.1. The word ‘systematic’ has been removed from the title in response to Reviewer 5’s suggestion.
Point 2: Authors did not explain why specific attention was given to developed countries.
Response 2: Developed nations were chosen as their health systems are comparative to the Australian context. The manuscript has not been revised as this is already in the manuscript (Version 1.1 lines 154-156).
Point 3: Figure 1 was not provided or missing
Response 3: Figure 1 was present in the manuscript. I am not sure why you (and other reviewers) were not able to see it. Nonetheless, I will follow up with the editor and I have uploaded Figure 1 to the portal for your review.
Point 4. Authors should proofread their work thoroughly for grammar
Response 4: Thank you for your comments. The manuscript has been proofread and edited changes tracked in Version 1.1.
Reviewer 4 Report
Dear authors,
Congratulations for the extensive work you have performed and for the topic of interest, which I consider of the most relevance nowadays in organizations, regardless the sector of activity.
Kindly check my humble suggestions/comments in the attached file. I hope it can help you to improve the quality of your work.
Comments for author File: 
Comments.pdf
Author Response
Thank you for your feedback. I appreciate the time you have taken to review the manuscript and provide comments to improve the manuscript. Please see below responses to your comments.
Reviewer 4:
Point 1: Consider to replace your keywords by MeSH terms. For example, use “Social Determinants of Health” instead of “social determinants”.
Response 1: Thank you for your comments. Keywords have been amended in Version 1.1 to include MeSH terms ‘health screening’. ‘nurses’ and ‘social determinants of health’.
Point 2: Aim of your study: Along the manuscript you identify your aim. Make sure they all match. Lines 11-13: Identify objective and subjective measures primary healthcare nurses use to screen for social determinants of health; how and when primary health care nurses perform social determinants of health screening; and implications for advancing nursing practice. Line 47: Evaluate and synthesise research that has investigated SDH screening by PHNs, and to identify how and when PHNs are performing SDH screening. Line 247: Identify how and when PHNs perform SDH screening. Lines 373-375: Identify how and when PHNs perform SDH screening by systemically identifying the objective and subjective measures PHNs use; when these measures are utilised; and to identify the implications for advancing nursing practice (373-375)
Response 2: The manuscript (Version 1.1) has been amended to reflect consistent aims of “to evaluate and synthesise research that has investigated SDH screening by primary healthcare nurses; how and when primary health care nurses perform SDH screening; and implications for advancing nursing practice”.
Point 3: Materials and Methods: Your review question is “how and when are PHNs in developed nations performing SDH screening?”. Make sure the review question matches with the objective of your study. You state that the research question was developed according to PICO methodology. PICO means Population/Problem/Patient (not only Patient as you write in line 99), Intervention, Comparison and Outcomes. How do you identify PICO in your review question? PHNs are your population, perfoming SDH screening is your intervention, but what is your outcome and your comparisons? The formulation of your review question looks like a PCC question (Population/Problem, Concept and Context), which is a scoping review. Review carefully this issue.
Response 3: The PICO methodology was used to identify the research question, however on reflection, the research question is as you suggest, a PCC question. The manuscript Version 1.1 has been updated accordingly.
Point 4: Explain the reason why the search was performed between 2010 and 2020.
Response 5: Manuscript Version 1.1 has been amended with the following:
Social determinant of health screening is gaining interest in health research, yet is a relatively novel intervention for healthcare workers (3), thus the search was limited to 10 years prior to the date of search commencement.
Point 5: Figure 1 is not available in the manuscript, not given in the supplementary files.
Response 5: Figure 1 was present in the manuscript. I am not sure why you (and other reviewers) were not able to see it. Nonetheless, I will follow up with the editor and have uploaded Figure 1 to the portal for your review.
Point 6: Supplementary Table 3 also not available and not possible to access it through www.mdpi.com/xxx/s1.
Response 6: Supplementary Table 3 has been uploaded to the portal for your review.
Point 7: Correct “data abstraction” to “data extraction”.
Response 7: This typing error has been corrected.
Point 8: Discussion: Line 430, correct “Rajah and et al.” to “Rajah et al.”.
Response 8: This typing error has been corrected.
Point 9: In order to answer the objective of identify the implications for advancing nursing practice, I recommend to present practical measures. From your findings, which practical recommendations would your give to effectively improve SDH screening in PHNs practice? Suggesting organisational and health systems support or SDH screening advocacy is vague. Which strategies could be implemented? In-services trainings? Consider it in the performance appraisal of PHNs?
Response 9: The manuscript has been amended to include more practical measures based on the findings. Version 1.1 has been updated with the following:
Suggesting environments that enable PHNs to implement SDH screening into clinical practice, such as incentives from funding bodies or effective workflows, emphasis on therapeutic relationships and flexible screening practices are more important than the method used.
Point 10: Once you chose developed nations according to WESP as their health systems are comparative to the Australian context, I suggest, from your findings, to discuss whether or not there are differences in performing SDH screening between Australia and the other countries (was that the comparison you were looking for in your PICO question? If so, it must be improved and your findings must be presented in this regard).
Response 10: There was no intention to compare SDH screening tool use in Australia with other developed nations, therefore this has not been included in the findings.
Author Response File: 
Author Response.docx
Reviewer 5 Report
Title does not read well. wonder if it should start with 'use of social ...' or 'from' instead of 'of'. Just have integrative review and remove 'systematic. After reading the article this is more then an integrative review, more like a scoping review. Good rigour.
Line 23 - good recommendation but how needs to be included
line 37 - should be new sentence from 'they act'
line 43 - start sentence with 'instead' to link points
line 44 - or were not identified maybe instead of 'and not identified'
be nice to know why nurses are not doing the screening as well. Should there be a sentence in here about that fact that this is in relation to developed countries.
Background more clearly needs to identify the gap in the literature to justify this paper. A bit confusing about whether this is about developing or developed as you mainly discussed developing. Explain this more. Also need to explain the link to nurses and their role.
no prisma
In results, change the wording up so that it reads better. For instance, saying one study could be another study or chage the sentence around
refer to table 2 in text. Describe what is in the tables
line 261 maybe add an example here f the factors
3.2.1 do not feel what is written here fits the theme. May have fitted the sub themes but these were not there. Work needs inking more. Need to provide an overview of what the theme is.
3.2.2 same comment
said sub themes would be identified in italics - cannot see this
3.2.3 good start, need to link the first two paragraphs though
you mentioned in the first theme that some nurses used body langauge to do screening - wondered if that belongs here
line 346 does not fit with rest of this section - completely different topic
line 359 sentence does not fit with rest of paragrapgh. Next sentence needs a link
last paragraph in this section does not seem to fit with theme
needs some critique
name the strengths as strengths
put recommendation in conclusion
very comprehensiev paper
Author Response
Thank you for your feedback. I appreciate the time you have taken to review the manuscript and provide comments to improve the manuscript. Please see below responses to your comments.
Reviewer 5:
Point 1: Title does not read well. wonder if it should start with 'use of social ...' or 'from' instead of 'of'. Just have integrative review and remove 'systematic. After reading the article this is more then an integrative review, more like a scoping review. Good rigour.
Response 1: Thank you for your comments. The tile has been amended to ‘Use of social determinant of health screening among primary health care nurses of developed countries: an integrative review.’ Reference to ‘systematic integrative review’ or ‘systematic review’ has been changed in the manuscript to ‘integrative review’
Point 2: Line 23 - good recommendation but how needs to be included
Response 2: Recommendations have been included in the abstract, as outlined below:
Recommendations are made for valuing therapeutic relationships, social determinant of health screening education, and promotion of SDH screening by health systems and professional bodies. Overall, further research examining the best SDH screening method for PHN use is required.
Point 3: line 37 - should be new sentence from 'they act'
Response 3: Manuscript Version 1.1 has been amended to reflect this change.
Point 4: line 43 - start sentence with 'instead' to link points
Response 4: Manuscript Version 1.1 has been amended to reflect this change.
Point 5: line 44 - or were not identified maybe instead of 'and not identified'
Response 5: Manuscript Version 1.1 has been amended to reflect this change.
Point 6: be nice to know why nurses are not doing the screening as well. Should there be a sentence in here about that fact that this is in relation to developed countries.
Response 6: Manuscript Version 1.1 has been amended to include the following:
Primary health care nurses may have performed screening in this latter group, however there was insufficient reporting, potentially reflecting lack of consensus around implementation of SDH screening(5).
Point 7: Background more clearly needs to identify the gap in the literature to justify this paper. A bit confusing about whether this is about developing or developed as you mainly discussed developing. Explain this more. Also need to explain the link to nurses and their role.
Response 7:
Manuscript V1.1 has been amended to:
- A paragraph has been added to the manuscript to identify the gap:
The literature shows a variety of health care professionals undertake SDH screening, from medical providers, clerical staff, volunteers, nursing clinicians, medical assistants, medical interns, and students [6, 15, 16]. While healthcare workers and clinicians support SDH screening and recognise the benefits for holistic care [13, 14, 17], clinicians are not routinely screening clients [17, 18]. Common barriers reported include discomfort and lack of time, knowledge, and confidence [17, 18]. PHNs are well placed to address SDH and nurse leaders advocate for greater attention to SDH in baccalaureate programs and nurse practice [19, 20]. Yet, it is not clear if PHNs are screening clients for SDH [6].
- Remove confusion around developing or developed nations by changing the language to ‘low-income’ and ‘high-income’ nations.
Point 8: no prisma
Response 8: Figure 1 PRISMA was present in the manuscript and I am not sure why you (and other reviewers) were not able to see it. Nonetheless, I will follow up with the editor and have uploaded Figure 1 to the portal for your review.
Point 9: In results, change the wording up so that it reads better. For instance, saying one study could be another study or change the sentence around
Response 9: Manuscript Version 1.1 has been amended to reflect this change.
Point 10: refer to table 2 in text. Describe what is in the tables
Response 10: Manuscript Version 1.1 has been amended to include the following:
Table two outlines the codes, sub-themes and themes identified from the reviewed studies.
Point 11: line 261 maybe add an example here of the factors
Response 11: Manuscript version 1.1 has been amended to include the following:
…such as incentives from funding bodies or professional organisations, protected time and workflows to promote SDH screening and flexibility when implementing SDH screening workflows.
Point 12: 3.2.1 do not feel what is written here fits the theme. May have fitted the sub themes but these were not there. Work needs inking more. Need to provide an overview of what the theme is.
Response 12: Manuscript version 1.1 has been amended to include the following overview of theme 3.2.1. Additionally, the sub-themes have been italicised.
There are diverse enablers and barriers to SDH screening at the individual, organizational and health system level, which highlight the need for organisational and health system support to enable PHNs to perform SDH screening.
Point 13: 3.2.2 same comment
Response 13: Manuscript version 1.1 has been amended to include the following overview of theme 3.2.2.. Additionally, the sub-themes have been italicised.
Attitudes and perceptions PHNs have towards SDH screening often results in a reluctance to incorporate SDH screening into clinical practice.
Point 14: said sub themes would be identified in italics - cannot see this
Response 14: I apologise for this error, the sub-themes have been italicised.
Point 15: 3.2.3 good start, need to link the first two paragraphs though
Response 15: Manuscript version 1.1 has been amended to better link these two paragraphs.
Point 16: you mentioned in the first theme that some nurses used body language to do screening - wondered if that belongs here
Response 16: PHNs using body language to perform screening is in theme 3.2.3 – The importance of interpersonal relationships for SDH screening.
Point 17: line 346 does not fit with rest of this section - completely different topic
Response 17: On reflection, the content in line 246 does not fit with this theme and has been moved to theme 3.2.1 (Organisational and health system supports are required to enable PHNs) and consequently rephrased to the following:
Monsen et al.[31] compared standardised nursing terminology use in diverse electronic health record systems (primary care clinics, hospitals, and public health), and found nurse clinicians are more likely to use standardised terminologies when documenting SDH than non-clinical staff. Monsen and colleagues suggest SDH standardised nursing terminology can assist PHNs to document, communicate with other health professionals and understand the SDH needs of people in their care[31].
Point 18: line 359 sentence does not fit with rest of paragrapgh. Next sentence needs a link
Response 18: A new paragraph has been started at line 359 and expanded to give relevance to the theme, as outlined below:
Two studies(32,39) utilised community-based participatory approaches to build relationships with community members. Amiri and Zhao(39) worked with community members to advocate for community environmental pollutants with legislators, senators, and government departments. In this study, community members were provided with workshops about communicating with legislators, key stakeholders and reducing lead level exposure in drinking water (39). Another study(32) built community skills through a community-based health literacy intervention.
Point 19: last paragraph in this section does not seem to fit with theme, needs some critique
Response 19: On reflection, this section does not belong in this theme and is better suited to the 2nd theme: PHNs are often reluctant to perform SDH screening. The content has been revised and moved to this section, as outlined below:
Godecker et al.(30) suggest client attitudes and perceptions of PHNs may result in non-disclosure of adverse SDH, perceiving PHNs to be less likely to experience hardships. Godecker et al.(30) compared PHN and community health worker SDH screening interviews and found community health workers identified different SDH risk. Community health workers identified more subjective responses, such as concerns or worries(30).
Point 20: name the strengths as strengths
Response 20: Thank you, a sentence (below) has been to the manuscript to identify the strengths:
There are many strengths to this study.
Point 21: put recommendation in conclusion
Response 20: The conclusion has been amended to include recommendations as outlined below:
The SDH screening practices of PHNs are poorly defined and understood. Evidence suggests that PHNs do not routinely use standardised SDH screening tools or other objective methods such as interviews and questionnaires. Results suggest subjective measures should be used carefully and in tandem with objective measures, however further research examining the best SDH screening method for PHN use is required. To enable PHNs to ask clients about their SDH needs valuing therapeutic relationships and investment in skill development, such as training, time and resources is required. Nursing education and training can improve knowledge and confidence in performing SDH screening, however, must be matched with evidence of actual behaviour change. Health systems and professional bodies can promote SDH screening through incentives or funding requirements. There is great potential for PHNs to become SDH screening advocates and expand their practice to bridge health disparities and build healthier communities.
Point 22: very comprehensive paper
Response 21: Thank you.
