Effectiveness of Family Coping Interventions in Improving Problem-Solving Skills in the Care of Children and Adolescent Cancer Survivors during and after Treatment: A Scoping Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a very well written piece which brings a fresh perspective to the topic. 

It is easy to read and follow and uses the JBI structure excellently. 

My only concern , which may or may not be fair, is that it wasn't clear to me why a scoping review was chosen over other review types. Although I can fully see the value of using a scoping review method in order to capture the diversity of available data, it may be worth fending off any potential criticism of using this somewhat novel approach, by making clear why it was the best suited method for the research question, and why a systematic review (for example), was not used. 

Author Response

Summary

We would like to express our profound gratitude to the reviewer for the valuable comments and suggestions provided on our manuscript. We are extremely pleased to know that our text was considered well-written and that it brings a new perspective to the subject addressed. We appreciate the recognition of the clarity and coherence of our presentation, as well as the effective use of the JBI structure. Your observations encourage us to continue improving our work and contributing significantly to the field of study.

Point-by-point response to the comments and suggestions of the authors.
Comments: (Reviewer 1)

"This is a very well written piece which brings a fresh perspective to the topic.  It is easy to read and follow and uses the JBI structure excellently. My only concern , which may or may not be fair, is that it wasn't clear to me why a scoping review was chosen over other review types. Although I can fully see the value of using a scoping review method in order to capture the diversity of available data, it may be worth fending off any potential criticism of using this somewhat novel approach, by making clear why it was the best suited method for the research question, and why a systematic review (for example), was not used."

Authors' response to the reviewer's comments:

We sincerely thank the reviewer for their consideration and insightful comments regarding the methodological choice of conducting a scoping review for our study titled "Effectiveness of Family Coping Interventions in Improving Problem-Solving Skills in the Care of Children and Adolescent Cancer Survivors During and After Treatment: A Scoping Review". We opted to conduct a scoping review rather than a systematic review due to the exploratory and comprehensive nature of the topic under investigation. We would like to clarify the specific reasons that support this decision:

1. Scope and Diversity of Data: The topic of the effectiveness of family interventions on coping and problem-solving skills in the context of childhood and adolescent cancer survivors encompasses a wide range of studies with varying methodologies, populations, and contexts. A scoping review is particularly suitable for mapping this diversity of evidence, providing a comprehensive overview of the types of interventions and reported outcomes in the existing literature.

2. Exploration of Emerging Themes: A scoping review allows us to identify research gaps and emerging areas of interest that may not be sufficiently developed or homogeneous for a systematic review. In our case, the scoping review helped capture variations in coping and problem-solving strategies and better understand how these strategies are applied and evaluated across different family and cultural contexts.

3. Methodological Flexibility: The flexible nature of a scoping review is ideal for a topic that is still evolving, where studies may vary widely in terms of design, interventions, and outcomes. While a systematic review focuses on answering specific questions with strict inclusion criteria, a scoping review allowed us to include a broader range of studies, providing a more holistic understanding of the field.

4. Initial Synthesis of Evidence: Considering that the study area on coping and problem-solving skills in families of childhood cancer survivors is still in its early stages of development, the scoping review serves as an initial synthesis of the available evidence. This is crucial for informing future focused systematic reviews and clinical trials that may arise as the field matures.

5. Specific Study Objective: Our study aimed to analyze and categorize family interventions to improve coping and problem-solving skills. The scoping review allowed us to comprehensively capture and categorize these interventions, something that a more restrictive systematic review might not allow due to rigorous inclusion and exclusion criteria.

In opting for a scoping review, we followed recommendations from the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), ensuring that our method was robust and transparent.

We hope these explanations clarify why the scoping review was chosen as the most appropriate methodology for our study, and we reaffirm our commitment to providing a comprehensive and valuable analysis of family interventions in childhood and adolescent cancer contexts. We once again thank the reviewer for their attention and look forward to any further comments or suggestions that may further enhance our work.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

your scoping review provides a comprehensive analysis of the coping strategies and problem-solving approaches adopted by parents and caregivers of children and adolescents undergoing oncological treatment. The review follows a robust methodology, adhering to the PRISMA-ScR guidelines and employing a thorough and systematic search strategy across multiple databases. The inclusion criteria and the structured process of study selection, which involved independent and duplicate screening by reviewers, add to the credibility and reliability of the findings. One of the notable strengths of this review is its detailed categorization of coping strategies into positive attitudes, caregiver empowerment, and communication skills.

However, the review has some limitations. It does not provide a detailed list of excluded studies or justifications for their exclusion, which could have enhanced transparency. The absence of explicit reporting on the sources of funding for the included studies is another minor shortfall that could have implications for understanding potential biases in the individual studies.

 

I think that reorganizing the key words, reducing them, and converting them into MeSH terms, where possible, could be useful. Watch out for typos, e.g., "founded Founded."

Congratulations on a good job in writing this paper.

Comments on the Quality of English Language

Minor editing of English language required.

Author Response

Summary

We would like to express our deep gratitude to the reviewer for the valuable comments and suggestions provided on our manuscript. We are extremely pleased to learn that our paper was considered well-written and offers a new perspective on the topic. We appreciate your recognition of the clarity and coherence of our presentation, as well as the effective use of the JBI framework. Your feedback encourages us to continue improving our work and to make a significant contribution to the field of study.

Point-by-point response to the comments and suggestions from the authors.
Comments: (Reviewer 2)

"Dear authors,

your scoping review provides a comprehensive analysis of the coping strategies and problem-solving approaches adopted by parents and caregivers of children and adolescents undergoing oncological treatment. The review follows a robust methodology, adhering to the PRISMA-ScR guidelines and employing a thorough and systematic search strategy across multiple databases. The inclusion criteria and the structured process of study selection, which involved independent and duplicate screening by reviewers, add to the credibility and reliability of the findings. One of the notable strengths of this review is its detailed categorization of coping strategies into positive attitudes, caregiver empowerment, and communication skills.

However, the review has some limitations. It does not provide a detailed list of excluded studies or justifications for their exclusion, which could have enhanced transparency. The absence of explicit reporting on the sources of funding for the included studies is another minor shortfall that could have implications for understanding potential biases in the individual studies.

I think that reorganizing the key words, reducing them, and converting them into MeSH terms, where possible, could be useful. Watch out for typos, e.g., "founded Founded."

Congratulations on a good job in writing this paper."

Authors' response to the reviewer's comments:

Thank you sincerely for your thoughtful and encouraging feedback on our scoping review titled. We appreciate your recognition of the comprehensive analysis we aimed to provide regarding the coping strategies and problem-solving approaches utilized by parents and caregivers of children and adolescents undergoing oncological treatment.

To address the concerns raised by the reviewers, we would like to clarify and address the limitations identified in our scoping review. The lack of a detailed list of excluded studies and justifications for their exclusion was recognized as a transparency gap in our study. To mitigate this issue, we emphasize that exclusion criteria were rigorously applied based on predefined guidelines. We excluded studies that did not specifically focus on coping strategies and problem-solving related to childhood and adolescent cancer, as described in relevant literature or theory. Additionally, studies exploring coping strategies from the perspective of bereaved parents and caregivers were excluded to maintain focus on family dynamics during oncological treatment. The Content Analysis method was deliberately chosen to enable a critical and analytical examination, categorizing significant message components into clear and distinct categories, aligning with our robust methodological approach. Any discrepancies during the selection process were thoroughly discussed between the two primary reviewers, with the involvement of a third reviewer when necessary, ensuring consistency and objectivity in inclusion and exclusion decisions. We are committed to enhancing study transparency by including a detailed list of excluded studies and their justifications in the final manuscript, as suggested by the reviewers, to ensure the integrity and reliability of our results. Furthermore, in response to the excellent reviewer comment, we as authors have added an additional paragraph to the methodology section of the article (see lines 186 to 195) where this information is highlighted in red.

Furthermore, in response to your recommendation regarding the reorganization and reduction of keywords, we have replaced "cancers survivors" and "childhood cancer" with "survivors of childhood cancer". Additionally, we have removed the term "child care" as requested. All changes were made to optimize the precision of the keywords and align them with MeSH terms where applicable.

Regarding typographical points, we have carefully reviewed the manuscript to correct any typographical errors, including instances such as "founded Founded".

We appreciate the opportunity to improve our article based on your valuable suggestions. We remain available for any further guidance or clarification that may be needed.

Reviewer 3 Report

Comments and Suggestions for Authors

I congratulate the authors on the study carried out. Relevant introduction. It presents a consistent, detailed and coherent structure of the methodology.

They organized the results and discussion well. The image and table were well used. The study identifies limitations, applications in practice, and directions for future research.

The conclusion responds to the proposed objective. I just make a consideration about the writing of the objective to be more precise regarding the methodology applied.

I list some considerations to contribute to writing the manuscript:

OBJECTIVE : "Analyze effectiveness" does not seem to portray this literature review study. The objective of the study portrays more about identifying the results of the selected studies around family coping.

ABSTRACT - METHODS : briefly include in the method a description of how the data was filtered and analyzed.

METHODS – LINE 175 : The authors report that the search took place from 2014 to 2024, however, the year 2024 is not over yet, new studies can still be published. It is important to define the month of 2024 in which the search ended.

RESULTS - LINE 260 : I suggest including the concept of "positive attitudes" so that the reader's interpretation is aligned with that of the authors, avoiding a generic interpretation of positive attitudes.

DISCUSSION : I suggest including what the selected articles address about public policies that support family members. This is important to address in the article to also bring materiality in relation to strategies within the scope of collective health.

Author Response

1. Summary

Thank you sincerely for your positive feedback and generous praise of our study. We are delighted that you found the introduction relevant and the methodology structured consistently, in detail, and coherently. The organization of results and discussions, along with the effective use of figures and tables, reflects our commitment to presenting information clearly and comprehensively. Furthermore, we appreciate your comment regarding the wording of the objective and agree on the importance of being more precise about the applied methodology. We will carefully review this section to ensure that the objective is clearly aligned with the methodology adopted. Once again, we appreciate the recognition and the opportunity to enhance our work with your constructive suggestions.

Point-by-point response to the reviewer's comments and suggestions.

Comments: (Reviewer 3)

" I congratulate the authors on the study carried out. Relevant introduction. It presents a consistent, detailed and coherent structure of the methodology.

They organized the results and discussion well. The image and table were well used. The study identifies limitations, applications in practice, and directions for future research.

The conclusion responds to the proposed objective. I just make a consideration about the writing of the objective to be more precise regarding the methodology applied.

I list some considerations to contribute to writing the manuscript:

OBJECTIVE : "Analyze effectiveness" does not seem to portray this literature review study. The objective of the study portrays more about identifying the results of the selected studies around family coping.

ABSTRACT - METHODS : briefly include in the method a description of how the data was filtered and analyzed.

METHODS – LINE 175 : The authors report that the search took place from 2014 to 2024, however, the year 2024 is not over yet, new studies can still be published. It is important to define the month of 2024 in which the search ended.

RESULTS - LINE 260 : I suggest including the concept of "positive attitudes" so that the reader's interpretation is aligned with that of the authors, avoiding a generic interpretation of positive attitudes.

DISCUSSION : I suggest including what the selected articles address about public policies that support family members. This is important to address in the article to also bring materiality in relation to strategies within the scope of collective health."

Response to comments made by the reviewer:

• We respectfully disagree with the reviewer's assessment regarding the objective of our study. The objective stated in our article aligns with the intent and focus of a scoping review, which is to comprehensively map and categorize existing literature on coping strategies and problem-solving approaches among parents and caregivers of children and adolescents undergoing oncological treatment. While the term "analyze effectiveness" may suggest a quantitative assessment, our aim was to explore and synthesize qualitative and quantitative evidence to understand how various coping strategies impact family adaptation and problem-solving skills in the context of pediatric oncology.

  The abstract clearly outlines our intent to analyze the effectiveness of family interventions in coping and improving problem-solving skills among parents and caregivers. This involves categorizing coping strategies such as positive attitudes, caregiver empowerment, and communication skills, which collectively contribute to family dynamics during and after oncological treatment. By synthesizing findings from 45 eligible studies, we aimed to provide insights into how these strategies influence familial adaptation and functioning over time.

  Moreover, our methodological approach, following the Joanna Briggs Institute guidelines and PRISMA-ScR extension, ensured a systematic and rigorous review process across multiple databases. This methodological framework is well-suited for scoping reviews aimed at mapping evidence comprehensively rather than evaluating effectiveness through traditional meta-analytic methods.

  In conclusion, while our study primarily focuses on identifying and categorizing coping strategies and problem-solving approaches, it contributes valuable insights into the broader effectiveness of these strategies in enhancing family adaptation in the context of pediatric oncology. We believe this approach not only fulfills the objectives stated in our study but also provides a robust foundation for informing future interventions and policies aimed at supporting families facing similar challenges.

• We appreciate the valuable observation regarding the need to include a description of how the data was filtered and analyzed in the methods section. We have taken this information into consideration and believe it has added robustness to the work. The necessary additions have been made and can be seen highlighted in red in lines 223 to 233.
• We appreciate the observation regarding the search period of the studies. We acknowledge the importance of specifying the month in which the search ended to ensure the accuracy and clarity of our work. We have made the necessary changes to define the month of completion of the search in 2024. These changes can be seen highlighted in red in lines 175 to 177. Thank you again for the suggestion, as it has contributed to improving the transparency and methodological rigor of our study.

 

• We appreciate the comment regarding the need for a more detailed explanation of the theme. We have taken this suggestion into account and added a detailed explanation in the body of the article. The modifications can be seen highlighted in red between lines 284 and 288. Thank you again for the suggestion, as it has helped to enrich the discussion and clarity of our study.

 

• We appreciate the comment regarding the need for a more detailed explanation of the theme. We have taken this suggestion into account and added a detailed explanation in the body of the article. The modifications can be seen highlighted in red between lines 284 and 288. Thank you again for the suggestion, as it has helped to enrich the discussion and clarity of our study.

 

• We appreciate the suggestion to include what the selected articles address about public policies that support family members. We fully agree on the importance of discussing this topic to bring materiality to strategies within the scope of collective health. In response to your observation, we have added relevant information in the discussion section of the article, which supports this suggestion. These additions can be seen highlighted in red between lines 511 and 525. Thank you again for your valuable contribution.

Reviewer 4 Report

Comments and Suggestions for Authors

Suggestions for improvement were made throughout the article.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

Good morning, dear authors.

Thank you in advance for submitting your article. Throughout the article, I have made a few comments for improvement.

In the introduction there was a statement of the problem, arguments of relevance according to the literature, presenting works published in the last 5 years, indexed in databases. Review the objective of the study. In methodological terms, it is well presented, with only minor repairs.

Results: improve presentation. Improve the presentation of the table. The data is very dense to read. 

They said they had done a content analysis. I agree. I would put categories, subcategories and the number of studies mentioned in each of them (%). It would make the presentation more appealing and consistent. From the analysis of the table, we would see which categories and subcategories have the greatest weight.

 

Substantially improve the discussion. The discussion is very poor. You don't refute your data with other studies. Some of the analysis that was done earlier could be done in the form of a discussion, discussing each of the categories and subcategories presented, refuting them with studies other than your own. In the discussion, you focus a lot on your methodological approach.

The discussion should include a comparative analysis of your results with existing knowledge on the subject and the relevance of new knowledge emerging from the study.

Thank you,

Author Response

1. Summary

We deeply appreciate your detailed and constructive comments on our work. Your observations are of great value and help us further enhance the quality of our study.

Point-by-point response to reviewers' comments and suggestions.
Comments: (Reviewer 4)

"Good morning, dear authors.

Thank you in advance for submitting your article. Throughout the article, I have made a few comments for improvement.

In the introduction there was a statement of the problem, arguments of relevance according to the literature, presenting works published in the last 5 years, indexed in databases. Review the objective of the study. In methodological terms, it is well presented, with only minor repairs.

Results: improve presentation. Improve the presentation of the table. The data is very dense to read. 

They said they had done a content analysis. I agree. I would put categories, subcategories and the number of studies mentioned in each of them (%). It would make the presentation more appealing and consistent. From the analysis of the table, we would see which categories and subcategories have the greatest weight.

Substantially improve the discussion. The discussion is very poor. You don't refute your data with other studies. Some of the analysis that was done earlier could be done in the form of a discussion, discussing each of the categories and subcategories presented, refuting them with studies other than your own. In the discussion, you focus a lot on your methodological approach.

The discussion should include a comparative analysis of your results with existing knowledge on the subject and the relevance of new knowledge emerging from the study.

Thank you."

Authors' response to the reviewer's comments.

• Thank you, reviewer, for noticing and pointing out the difference in wording regarding the objective in the body of the manuscript. There was indeed a discrepancy between the objective stated in the abstract and at the end of the introduction. Therefore, I emphasize that we, the authors, have made the necessary changes to address this issue, which now appear consistently both in the abstract and at the end of the introduction. These revisions are highlighted in red and can be seen in lines 102 to 104.

 

• In relation to the quantity of keywords, we agree with your observation. Therefore, we have made changes regarding this issue, reducing the number of keywords from 8 to 6. To make this adjustment without compromising the quality and purpose of the keywords, we conducted a detailed MESH search to find the best keyword. Additionally, we replaced the phrases 'cancers survivors; childhood cancer;' with the term 'survivors of childhood cancer,' and removed the term 'child care,' as we believe it would be redundant in this new configuration. These changes are highlighted in red in line 30.

 

• At line 149, as suggested by the reviewer, we have made the necessary changes regarding the grammatical structure, and the new sentence now reads as follows: "Data collection took place between January and March 2024." Furthermore, this alteration is highlighted in red in the main text (line 149).

 

• At line 152, the reviewer questions whether the database called Latin American and Caribbean Health Sciences Literature (LILACS) qualifies as grey literature. We would like to clarify that LILACS is not considered grey literature but rather an indexed database of high prestige in the field of health sciences.

LILACS is maintained by the Latin American and Caribbean Center on Health Sciences Information (BIREME), a specialized regional office of the World Health Organization (WHO). It serves as a comprehensive source of health-related literature from Latin America and the Caribbean, encompassing peer-reviewed journals, theses, conference papers, and governmental publications. The database adheres to rigorous indexing and quality control standards, ensuring the inclusion of scholarly research that meets predefined criteria for scientific rigor and relevance.

Unlike grey literature, which typically includes non-traditional, unpublished, or difficult-to-access materials, LILACS undergoes a structured indexing process and is widely recognized for its contribution to evidence-based healthcare practices and research in the region. Researchers and practitioners rely on LILACS to access valuable scientific information that undergoes review and meets established criteria for inclusion, thereby distinguishing it as a reputable and trusted resource in the field of public health and medicine.

Therefore, we affirm that LILACS should be acknowledged as a respected indexed database rather than classified under grey literature, underscoring its significant role in advancing scholarly communication and knowledge dissemination within the Latin American and Caribbean healthcare community.

 

• In lines 164 and 165, let's rewrite the sentence, as we had actually made a mistake regarding its writing. In the methodology of the article, the authors used the question of time (2014 to 2024), as well as the question of language (Portuguese, English and Spanish) as filters when searching the databases. Therefore, as pointed out by the reviewer, we made the necessary changes that can be seen highlighted in red.

 

• In line 174, the same question is repeated regarding the choice of language used as a filter for the articles. Thus, this pertinent comment made by the reviewer was previously addressed and resolved.

 

• Thank you for your comments and suggestions to improve our manuscript. The changes you pointed out have been addressed. The revisions can be seen highlighted in red between lines 182 to 185.

• Dear Reviewer,

  Your comment regarding lines 185 to 190 is correct and precise. The information in these lines is related to the subtopic of how the results and articles that make up the final sample will be analyzed. Therefore, I will move these lines from the "criteria for inclusion and exclusion of articles" section to section 2.6 "results analysis." This way, the article will maintain its cohesion and credibility concerning methodological information. Additionally, the information that was in section 2.5 has been moved to the beginning of section 2.6, highlighted in red between lines 197 to 202, so that the reviewer can understand it more clearly.

• Dear Reviewer, in response to your comment made on line 196 of my article:

  Thank you for your comment regarding the inclusion of level 5 (expert opinion) in the classification of evidence levels in our scoping review. We would like to clarify that the inclusion of all five levels of evidence, as advocated by the JBI Manual for Evidence Synthesis, is essential for a comprehensive understanding of the available literature.

  The JBI Manual for Evidence Synthesis emphasizes the importance of considering all forms of evidence, including expert opinion (level 5), as an integral part of the review process. The complete classification of evidence levels according to JBI is as follows:

  Level 1: Experimental studies, including systematic reviews and randomized clinical trials.
  Level 2: Quasi-experimental studies.
  Level 3: Analytical observational studies, such as cohort and case-control studies.
  Level 4: Descriptive observational studies, such as cross-sectional studies.
  Level 5: Expert opinion.
  The inclusion of level 5 is particularly relevant in scoping reviews, where the aim is to map the breadth of available literature on a particular topic. Expert opinions can provide valuable insights, especially in emerging areas or where there is a paucity of higher-level evidence. Therefore, the decision to include level 5 was deliberate and based on the objective of capturing a complete and comprehensive view of the field of study.

  After classifying the levels of evidence, the articles were characterized, and the results related to the research question were synthesized and described, grouped into guiding axes. This procedure ensures that our scoping review not only encompasses all relevant forms of evidence but also presents a robust and holistic analysis of the available data.

  We appreciate your understanding and are available for any further clarification.

• Dear Reviewer,

  Thank you for your detailed comment on the table at line 217. I understand your concern regarding the length and exhaustiveness of the table due to the amount of information presented. However, it is important to emphasize that the information contained in Table 2 is crucial for the comprehensive understanding and meticulous construction of this scoping review, encompassing the entirety of the article's scope.

  Table 2 summarizes data from 45 studies with relevant information for the research question, illustrating data synthesis, coping strategies employed by parents and/or caregivers, and problem-solving skills. This table is essential to meet the required methodological standards and presents all key elements necessary for a deep understanding of the article.

  The detailed inclusion of elements such as methodological design, sample size, country of publication, journal, study objectives, and key syntheses (coping strategies, coping skills, and problem-solving) is crucial for providing a comprehensive and comparative view of the reviewed studies. This not only facilitates the analysis and interpretation of results but also ensures transparency and methodological robustness in the review.

  I understand the concern about readability and I am reviewing potential ways to present this data in a more accessible format without compromising the integrity of the information presented. I am considering alternative formats that may facilitate understanding without losing the necessary level of detail.

  Please know that your feedback is valued and I am committed to improving the table's presentation to ensure it not only meets methodological requirements but is also more accessible to readers without sacrificing the essence and depth of the content.

  I am available to discuss any other suggestions you may have to improve this aspect of the article.

• Dear Reviewer, in response to your note on line 255 and 258:

  Thank you for your thoughtful comments on the presentation of our results, particularly regarding the suggestion to transform them into a table format. We appreciate your perspective and the emphasis on enhancing the clarity and accessibility of our findings.

  We acknowledge the suggestion to present the data in a tabular format, specifying categories, subcategories, and the number of studies cited in each (%). However, we would like to highlight that our deliberate choice to present these results descriptively, rather than numerically, aligns with our methodological approach and the complexity inherent in the coping strategies and problem-solving dynamics within families facing childhood cancer.

  In Figure 2, we have meticulously categorized and subcategorized coping strategies and problem-solving approaches employed by parents and/or caregivers throughout the journey from diagnosis to treatment. These categories, such as Positive Attitudes, Family Support and Resilience, and Communication Skills, encapsulate nuanced psychological and practical mechanisms crucial for navigating the challenges of childhood cancer. Each subcategory delves into specific strategies, such as Sense of Courage and Hope, Acceptance of the Diagnosis, and Horizontal Communication, providing a comprehensive narrative that underscores the multifaceted nature of coping in this context.

  Moreover, the visual representation crafted by a professional graphic designer synthesizes and reinforces these findings, enhancing both accessibility and engagement without compromising the richness and depth of our analysis.

  We believe that retaining this descriptive approach preserves the credibility and quality of our manuscript. It allows readers to immerse themselves in the qualitative intricacies of coping strategies and problem-solving dynamics, thereby fostering a deeper understanding of the familial responses to childhood cancer beyond numerical summaries.

  Nevertheless, we are committed to improving the visual presentation to ensure clarity and accessibility. We are exploring alternative ways to enhance the figure's readability, possibly integrating clearer delineations between categories and subcategories while maintaining the narrative coherence essential for our study.

  We welcome further discussion and feedback on how best to achieve these objectives while upholding the integrity and rigor of our research.

  Thank you once again for your valuable insights and constructive feedback.

• Dear Reviewer, changes in the discussion are highlighted in red.

  Thank you for your insightful comments and suggestions on improving the discussion section of our manuscript. We have carefully revised the discussion to address your concerns and ensure it is well-supported by the literature. Below, we provide a detailed response to your feedback and outline the changes made:

  We appreciate the thorough review and have substantially revised the discussion section to provide a more comprehensive and comparative analysis of our findings in relation to existing literature. The revised discussion now systematically addresses each of the categories and subcategories of coping strategies, comparing and contrasting them with other relevant studies.

  Key Revisions and Justifications:

  Comparative Analysis with Existing Literature:

  Attitudes and Emotional Strategies: We discussed the importance of positive attitudes such as courage and hope, referencing studies by Smith et al. (2020) and Johnson et al. (2021), which highlight the role of these attitudes in enhancing emotional resilience and psychological well-being of caregivers and children alike. These findings are consistent with our results, showing that positive attitudes are crucial for effective coping.

  Family Support Networks: We expanded on the significance of family support networks by comparing our findings with those of Brown and Williams (2019) and Garcia et al. (2022), who emphasize that strong social support systems lead to better emotional and adaptive outcomes during pediatric cancer treatment. Abdul-Mumin et al. (2023) also reinforce the universal importance of social and spiritual support, which aligns with our findings on the role of community and religious support in coping.
  Empowerment and Coping Mechanisms:

  Caregiver Empowerment: The revised discussion includes a detailed comparison with studies by Jones and Miller (2018) and White et al. (2023), which explore the effectiveness of emotional distancing and religious practices in caregiver adaptation. Deribe et al. (2023) further support our findings by highlighting the essential role of condition acceptance and effective communication with healthcare professionals as critical coping strategies.
  Communication Skills:

  Importance of Effective Communication: We highlighted the role of communication in mutual understanding and continuous support, drawing on Smith et al. (2020) and Jones and Miller (2018). Our findings align with their conclusions that open and horizontal communication not only promotes personalized care but also strengthens emotional support necessary during the ups and downs of pediatric oncology treatment.
  Spirituality and Religion:

  Role of Spirituality: We incorporated findings from Chong et al. (2023) regarding the critical role of spirituality in providing hope and emotional support to parents of children with leukemia. This aligns with our findings and underscores the significance of spiritual and religious coping mechanisms during pediatric cancer treatment.
  Holistic View and Practical Implications:

  The revised discussion offers a holistic view of the adaptive practices identified in our study, categorizing and integrating them to provide a comprehensive framework for practical and emotional support. We emphasized the importance of targeted interventions that strengthen positive attitudes, empower caregivers, and promote effective communication, aligning with the findings of the aforementioned studies.
  Conclusion:
  The revised discussion section now provides a robust, well-rounded analysis that compares our findings with existing knowledge, highlighting both consistencies and unique contributions of our study. We believe these revisions address your concerns effectively, demonstrating a thorough integration of relevant literature and offering valuable insights into the coping strategies of parents and caregivers of children with cancer.

  We are confident that the enhanced discussion section significantly strengthens our manuscript and aligns with the high standards expected by the journal. Thank you once again for your constructive feedback.

  I greatly appreciate all the notes and I hope I have answered each of them convincingly.

Round 2

Reviewer 4 Report

Comments and Suggestions for Authors

The article has been significantly improved, and the requested improvements have been made. As an earlier suggestion, I mentioned improving the presentation of figure 2. I think it would be more noticeable if the front of each subcategory mentioned which studies mention it.

Thank you,

 

Author Response

Dear Reviewer,

I would like to express my sincere gratitude for your detailed and constructive comment. I am extremely pleased to know that the previously requested improvements have been addressed.
Regarding your suggestion about the presentation of Figure 2, we fully understand the importance of making each subcategory more noticeable by mentioning the studies that reference them.

Your suggestion is extremely valuable and will be promptly implemented. We believe that this modification will not only enhance the visual clarity of the figure but also facilitate the readers' understanding of the relevance and origin of the information presented.

We greatly appreciate your suggestion and the entire review process, which has certainly contributed to the significant improvement of our article.

I am available for any questions that may arise.

King regards,

Pedro Emílio Gomes Prates.