The Intercultural Mediator as a Bridge in Healthcare Professional–Migrant Patient Care Relationships: A Qualitative Study

Peer Reviewer 1

N

Comment

Authors’ Responses

Manuscript Part

This submission was outstanding. This is easily one of the best papers I've come across in MDPI both methodologically and of novelty. I enjoyed reading about IMs in the context of healthcare especially as I am also embarking on some public health research related to immigrants in the North American context. Great job, please see below for minor suggestions:

We thank the Reviewer for the positive assessment of the manuscript. The requested minor revisions have been addressed point by point.

General response

1

Results. Change "Male" and "Female" throughout the submission to "Man" and "Woman" as the former indicates biological sex at birth. Alternatively, you can keep it the same and instead use the word "Sex" instead of "Gender".

The terminology was revised throughout the manuscript. The labels in the participant tables were changed from Male/Female to Man/Woman, and the table heading was revised accordingly to avoid ambiguity between sex and gender identity.

Results; Tables 1 and 2

2

Table 1. When providing the range of nurses and physicians, could you please also report the median next to those values (i.e., 1-25, 2-8).
Discussion. Did you find any differences in sentiments between physicians and nurses?
Limitations. You were only able to recruit 4 physicians and thus, this would be a notable limitation to include.

We revised Table 1 by adding the median years of professional experience for nurses and physicians. We also clarified in the Discussion that no formal subgroup analysis was conducted; however, some contextual differences were observed between professional accounts. Finally, the limited number of physicians was acknowledged in the Strengths and Limitations section.

Results; Discussion; Strengths and Limitations

3

Methods, Line 211-212. You mention "data saturation" here and then later mention "thematic saturation" under Strengths and Limitations. Here, you are actually touching on 2 different concepts (see here https://pmc.ncbi.nlm.nih.gov/articles/PMC5993836/). Please rectify this and indicate which of the two were actually sought.

We revised the Methods section to use data saturation consistently. Saturation was defined as the point at which no new meaningful information, codes, or categories emerged from subsequent interviews. The wording on thematic saturation was removed and the limitation regarding assessment at the overall sample level was clarified.

Methods; Strengths and Limitations

4

Additional comments:

Methodology: The methodology was robust, where the investigators presented extensive detail on the study setting, recruitment, and analysis. The authors even went beyond to comment on trustworthiness, which is rarely completed in qualitative research. This shows the authors were well-versed in qualitative methods.

We thank the Reviewer for this observation. No substantive change was required. The methodological reporting was checked for consistency after the revisions to sampling, saturation, and analytic procedures.

Methods

5

Conclusions: Although the study has a small sample size, the investigators are careful to stay close to the Italian context. The conclusions could be tempered, although it is not a flaw in the submission - rather only a mild preference that I would have, which is why I didn't suggest it in my initial review.

The Conclusions were revised to adopt a more cautious wording and to remain closer to the Italian hospital contexts explored in this study.

Conclusions

6

References: I was pleased to see a wide variety of references being used, with particular attention on most of these references being relatively new.

Reference list retained; Malterud et al. was added for the information power approach.

References

Peer Reviewer 2

N

Comment

Authors’ Responses

Manuscript Part

This study is a qualitative descriptive research examining the experiences of healthcare professionals collaborating with intercultural mediators (IMs) in their care relationships with immigrant patients. The research focuses on current and important issues such as cultural competence in healthcare, health equity, and immigrant health. The findings show that IMs are perceived not only as individuals who translate languages, but also as professionals who facilitate the transmission of cultural meanings and strengthen the therapeutic relationship. The topic is current and valuable. However, the study appears to have significant shortcomings in terms of methodological reporting, depth of data analysis, and presentation of findings.

We thank the Reviewer for the detailed methodological comments. The Methods, Results, Discussion, and Strengths and Limitations sections were revised to improve transparency in sampling, saturation, data analysis, and presentation of findings.

General response

1

Data saturation is inadequately explained. The authors state "Data saturation was achieved," but do not specify how saturation was achieved. In which interview was saturation achieved? In how many of the last interviews was no new code generated? Was a saturation grid used? The saturation process should be detailed.

We expanded the description of the saturation process. Data collection and analysis were conducted concurrently, and saturation was assessed at the overall sample level when no new meaningful information, codes, or categories emerged from subsequent interviews. We also clarified that saturation was not assessed separately within professional subgroups.

Methods; Strengths and Limitations

2

The sample size is not justified. Two hospitals, Different clinics, different professional roles, heterogeneity is high. Sample adequacy should be explained with the information power approach or the suggestions of Malterud et al.

We added a justification of sample adequacy using the information power approach proposed by Malterud et al. The sample was considered appropriate for the exploratory and descriptive aim of the study because participants were purposively selected for their direct experience with IMs and because the interviews provided rich and relevant data. The limited physician subgroup was also acknowledged.

Methods; Strengths and Limitations; References

3

Transparency of data analysis should be explained in detail. Total number of codes number of subcategories, category creation process, sample coding matrix should be given.

We revised the Data Analysis section to describe the analytic process more explicitly. The text now clarifies the phases of open coding, category creation, and abstraction, the role of independent coding and consensus discussion, and the use of an audit trail. The final framework included three main categories and six subcategories, and a coding matrix is provided in Supplementary File 3.

Methods; Results; Suppl. File 3

4

Participant citations are insufficient. Many sub-themes are supported by only 1-2 citations. In qualitative research, more representative data should be provided for each sub-theme.

We strengthened the presentation of findings by retaining and organizing representative quotations across subcategories. Additional quotations and participant sources are also reported in Supplementary File 3 to support the link between participants’ accounts and the analytic categories.

Results; Suppl. File 3

5

All participants seem to have evaluated IMs positively. Were there any negative consequences of IM use? Were there any conflicts? Was there a trust issue? If there are negative examples, they should be clearly stated.

We revised the Results and Discussion to make the critical findings more explicit. Participants did not report direct adverse outcomes attributable to IMs, but they described relevant limitations, including limited availability, peripheral positioning within teams, role ambiguity, underuse of mediation, and difficulties related to trust and continuity.

Results; Discussion

6

There is an inconsistency in the percentage values ​​in Table 1. Nurse: 9 (69.3) Physician: 4 (30.8). The percentage totals do not match.

The percentages in Table 1 were checked and corrected so that the values for nurses and physicians are consistent with the total sample.

Results; Table 1

Peer Reviewer 3

N

Comment

Authors’ Responses

Manuscript Part

This is an interesting study describing healthcare providers’ experiences of collaborating with intercultural mediators in the Italian healthcare context. The topic is relevant and the findings may contribute to improving culturally sensitive healthcare delivery. However, several methodological issues merit further consideration. However, this study is not flawless and could be improved.

We thank the Reviewer for the careful reading of the manuscript. The methodological reporting and limitations were revised to clarify sampling, saturation, professional subgroups, clinical context, and future research directions.

General response

1

The authors report that data saturation guided the decision to stop participant recruitment. While this may have been achieved for the sample as a whole, the physician subgroup comprised only four participants. Given the distinct professional roles of physicians and nurses, as well as the different types of communication they engage in with patients, it is unclear whether sufficient depth and breadth of physician perspectives were captured. The authors should clarify whether saturation was assessed separately within professional groups or only across the overall sample.

We clarified that saturation was assessed across the overall sample and not separately within professional groups. For this reason, physician-specific insights are presented cautiously and are not treated as independent subgroup findings. This issue was also acknowledged in the limitations.

Methods; Strengths and Limitations

2

A related concern is that all physician participants were early-career professionals, with the oldest participant being only 33 years old. Mid-career and senior healthcare professionals may encounter different challenges and have different experiences when working with intercultural mediators. In contrast, the nursing subgroup appears to be more diverse in terms of age and experience. This limitation should be acknowledged and its potential implications for the findings discussed.

We added this point to the Strengths and Limitations section. The manuscript now acknowledges that the physician subgroup included only four participants and that all physicians were early-career professionals. We also noted that mid-career and senior physicians may experience collaboration with IMs differently.

Strengths and Limitations

3

It would also be helpful to provide information on the broad clinical areas in which participants worked. There is no need to identify specific subspecialties, as this could compromise participant anonymity. However, indicating whether participants worked in areas such as pediatrics, emergency medicine, surgery, internal medicine, etc. could provide useful context and allow readers to better understand the applicability of the findings.

We expanded the contextual description by reporting broad clinical areas rather than specific subspecialties, to preserve participant anonymity while improving transferability. These areas include medical, surgical, emergency, pediatric, rehabilitation, and outpatient or day-hospital contexts.

Methods; Participants

4

The authors may wish to discuss whether characteristics of intercultural mediators themselves influence their effectiveness as facilitators of healthcare communication. Factors such as age, gender, cultural background, professional training, and prior experience may shape interactions with both patients and healthcare providers.

We added a discussion of this issue in the section on future research. The manuscript now notes that IM characteristics, including cultural and linguistic background, gender, age, professional training, prior experience, and familiarity with specific clinical settings, may influence trust-building, perceived legitimacy, and collaboration with both patients and healthcare professionals.

Discussion; Future research