Cultural Determinants of Chronic Disease Management: A Cross-Comparative Medical Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

General comments:                 

Line 11: Define “cultural factors” here. 

The process for doing a literature search in abstract is not described. Please also concisely outline the main findings. 

The paper should be qualified with more supporting evidence (only 29 references were used). 

The introduction is very fragmented and does not provide a clear rationale for the current review. Avoid using subheading, numbering, and bullet points. A clear description of the evidence gap that this review is filling is required at the last paragraph. 

The lack of methodology used in the selection of the papers given in the review is a crucial problem. Does the paper represent the body of existing literature on the subject, or was the selection of papers made at random? As a result, both the criteria used to assess the evidence from the published research and a technique for choosing the studies to include in the review are required. A few papers were reviewed, although it's unclear how these articles were selected for the review. 

Line 104-294: This review reads to me slightly like a list of studies with little synthesis of the information. Narrative synthesis needs to be much longer and well developed with many more discussion. 

It is highly recommended to incorporate tables summarizing all studies. 

Eliminate redundancies and unnecessary repetitions throughout paper. 

Give explicit information about the review's limitations, including the types of challenges and how they affected the studies. 

Don't make too general claims; instead, make detailed recommendations for further studies. Consider the findings' ramifications and how they might affect further research.

Author Response

We thank the reviewer for their comprehensive and constructive feedback. In response, we have substantially revised the manuscript to improve conceptual clarity, methodological rigor, and narrative synthesis. We now explicitly define cultural factors at first mention, revise the Abstract to describe the literature search process and concisely state the main findings, and expand the reference base to strengthen evidentiary support. The Introduction has been reorganized into a cohesive narrative with removal of unnecessary subheadings and the addition of a clearly articulated evidence gap that motivates the review. A dedicated Methods section now details the literature search strategy, inclusion and exclusion criteria, and qualitative narrative synthesis approach, clarifying that study selection was systematic and representative rather than random. Section 3 has been substantially expanded with integrative cross-case synthesis to move beyond descriptive listing, and redundancies have been eliminated throughout. We have also added an explicit Limitations section addressing methodological, structural, and feasibility constraints, and refined recommendations to be more specific and grounded in the reviewed evidence, with attention to implications for future research rather than general claims.

Reviewer 2 Report

Comments and Suggestions for Authors

The text is interesting. It raises an important issue regarding the validity of considering cultural traditions in the treatment process, as well as the economic situation of the patient and the community to which they belong.

Examples are provided of the negative consequences of patients' failure to respect physicians' recommendations due to cultural tradition, family pressure on the patient, and expectations of respect for tradition and religion. Examples are also provided of positive solutions to moral dilemmas experienced by patients from selected cultural backgrounds, based on combining cultural messages (including the way life is organized in the community to which the patient belongs) with physicians' recommendations drawn from specialized scientific knowledge.

I did not identify the sources of these examples – whether they are actual cases or proposals created to better illustrate the idea presented in the paper. If these are authentic examples, the question arises of the patient and their physician (doctor, therapist, etc.) consenting to the use of the paper, although the descriptions do not include personal data, only a description of the ailment/illness/biochemical test results, etc., gender, age, cultural background, and region of the world. Proposals for incorporating the legacy of cultural traditions into the diagnostic and therapeutic process are undoubtedly important for increasing the effectiveness of treatment and improving the well-being of the patient and their family.

Some of the indications and suggestions contained in the text, while important, are prospective in nature, currently wishful thinking, or idealistic. In a few cultures, pharmacogenomic testing is expected to be culturally embedded. Furthermore, in many environments/countries, it is quite expensive. The author notes the need for changes in insurance systems in various regions of the world, both those with low levels of economic development and those with affluent but unequal income distribution. Training and employing bilingual/multilingual specialists (diagnosticians, clinicians, therapists, ethnographers, anthropologists, etc.) in the healthcare system, and their integration with local authorities, herbalists, healers (and others involved in folk medicine), would greatly enhance the effectiveness of treatment and the acceptance of physician recommendations. The text also explores the idea of ​​justifying the education of individuals from local communities and their return to their "roots." The text provides a rationale for viewing culture as a clinical risk factor that modifies the genesis of symptoms, the course of disease, and its treatment. These indications are also consistent with the concept of personalized medicine, which respects cultural conditions.

I suggest you consider the title.

Author Response

We thank the reviewer for this thoughtful and important comment. To address concerns regarding the nature and ethical status of the examples presented, we have explicitly clarified in Section 3 that all case examples are composite clinical vignettes synthesized from recurring patterns reported in the peer-reviewed literature, rather than descriptions of real or identifiable patients. No protected health information or clinician-specific data are included, and therefore institutional review board approval or individual consent was not required.

To further strengthen transparency, we have anchored the illustrative cases more explicitly to existing studies, emphasizing that the clinical and cultural dynamics described are supported by published qualitative and epidemiologic research rather than anecdotal observation.

We also appreciate the reviewer’s observation regarding the feasibility of certain proposed interventions. In response, we have expanded the Limitations section to explicitly acknowledge that recommendations such as widespread pharmacogenomic testing, multidisciplinary multilingual care teams, and structural insurance reform are context-dependent and currently constrained by cost, infrastructure, and health system capacity in many regions. These proposals are therefore presented as directional and aspirational, aligned with emerging trends in precision and personalized medicine, rather than as universally implementable standards of care.

We believe these revisions clarify the intent, ethical grounding, and practical scope of the manuscript while preserving its central argument that culture functions as a clinically meaningful modifier of chronic disease outcomes.

 

Reviewer 3 Report

Comments and Suggestions for Authors

This is to thank you on presenting this manuscript on the role of cultural beliefs and practices in chronic disease management. The subject matter is pertinent and it could be of value to clinicians and educators. But significant revisions on transparency, structure, and evidentiary rigor would make the manuscript much stronger. Make the type of article clear and enhance transparency of methods. Specifically, please indicate whether this is a narrative review, scoping review, or systematic review. Included in a brief methods subsection is a description of: databases searched, search terms, time window, inclusion/exclusion criteria and the selection and synthesis of studies. Readers require an open method even in the case of a narrative review in order to minimize the perception of selectivity. Individualize the organization and eliminate structural redundancy. The case-based content is represented in more than a single location and reads like duplicated/overlapping segments. When combining and condensing the case material into one coherent unit with a definite purpose (e.g., “Illustrative Clinical Vignettes), please do not repeat the same framing twice. For example, one can consider a more narrow flow: (a) core concepts/frameworks, (b) culturally informed clinical implications, (c) vignettes, (d) practical recommendations.Assign claims and key statements to strength of evidence. Certain statements are made formulations that are absolute (e.g., “essential/not optional). Kindly change to a more scientific tone with suitable hedging unless backed up by substantial evidence. Whenever feasible, specify the grade/type of backing of significant assertions (e.g. systematic reviews, cohort studies, qualitative syntheses) and do not extrapolate without justification by the literature that backed the claim. Clean and upgrade reference base. Substitute any non-scholarly or ambiguous sources with peer-reviewed primary research, high-quality reviews or authoritative guidelines. Make sure that the fundamental frameworks and the most significant clinical statements are supported by the modern and high-quality sources. Enhance usefulness in practice, using a synthesis table. Include a mapping table: cultural domain/belief information into mechanism/pathway (e.g., adherence, diet, health-seeking behavior) information into clinical risk/impact information into recommended clinician response information into supporting references. This will go a long way in enhancing readability and utility to the reader. Language and style edits Careful editing pass in English is advised so as to enhance the clarity, minimize redundant points, and standardize terms and headings.

Comments on the Quality of English Language The overall comprehensibility of the manuscript is rather good, yet the English is not professionally edited and should be considered in order to become more clear, academic, and consistent. Key issues include: The phrase that is too absolute/advocacy-style (e.g., not optional, essential), which must be translated to a more objective scientific form except in a case that is well-evidenced. Some repetitions and wordiness in other parts; trimming down of sentences would enhance the reading and curb redundancy. The use of inconsistent terminology and headings (e.g., duplicating on two sections under the same title, case); standardising the section titles and transition would be better. Minimal grammatical and punctuation errors such as some awkward construction and irregular capitalization. Before publication, it is better to recommend a specific language edit that is aimed at conciseness, use of hedging when needed, and consistent terminology.

Author Response

We thank the reviewer for their thoughtful and constructive feedback. In response, we have clarified the article type by explicitly identifying the manuscript as a narrative review and substantially enhanced methodological transparency through the addition of a dedicated Methods subsection detailing databases searched, search terms, time window, inclusion and exclusion criteria, and the narrative synthesis approach. The manuscript has been structurally reorganized to eliminate redundancy, with all case-based material consolidated into a single, clearly framed section (“Illustrative Clinical Vignettes and Cross-Cultural Case Synthesis”) and a streamlined flow from core frameworks to clinical implications and recommendations. Absolute language has been revised to a more scientific, evidence-calibrated tone, and major claims are now explicitly aligned with the strength and type of supporting evidence. The reference base has been cleaned and strengthened using peer-reviewed primary studies, high-quality reviews, and authoritative guidelines. To enhance practical utility, we have added a synthesis table mapping cultural determinants to clinical mechanisms, associated risks, recommended clinician responses, and supporting evidence. Finally, the manuscript has undergone careful language and style revision to improve clarity, reduce redundancy, and standardize terminology and headings.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript has significantly improved by these revisions. Some points remained.

1. Avoid using subheadings in the introduction.
2. Avoid using numbering and bullet points throughout the manuscript.
3. Well-designed sections are included, although the information is not as well synthesized (Line 179-340; Line 353-399; Line 440-533).
4. Add a reference column to Table 1.

Author Response

1. Avoid using subheadings in the introduction.
   1. Thank you for this comment, I have lessened the amount of total subheadings in the introduction. However, given the length and complexity of this paper, the use of subheadings helps organize key concepts, improves clarity, and guides the reader through the structure of the argument. Rather than detracting from the introduction, the subheadings serve to enhance readability and ensure that the purpose, scope, and framework of the paper are clearly communicated.
2. Avoid using numbering and bullet points throughout the manuscript.
   1. Thank you for this comment. We have gone back and removed several numbered and bulleted lists throughout the manuscript. However, we believe that removing additional lists would reduce clarity and make the paper more difficult to read, particularly given the length and complexity of the content.
3. Well-designed sections are included, although the information is not as well synthesized (Line 179-340; Line 353-399; Line 440-533).
   1. Thank you for this comment. We have revised Section 2 to strengthen synthesis between biomedical pathophysiology and sociocultural determinants, explicitly integrating biological mechanisms with culturally patterned behaviors, beliefs, and structural factors. Rather than presenting these elements in parallel, the revised text clarifies how culture functions as an active modifier of disease expression, progression, and clinical outcomes across conditions.
4. Add a reference column to Table 1.
   1. Thank you for this comment

Reviewer 3 Report

Comments and Suggestions for Authors

Overall assessment

The theme addressed in the manuscript is clinically important: the influence of cultural determinants on the presentation, adherence, and outcomes of chronic diseases in different populations. The strengths include the cross-disease, clinically oriented framing and the effort to conceptualize the concepts into practical recommendations.

Nevertheless, the paper still requires better conceptual definition, more obvious evidence-review procedures, and evidence-connection to prevent overwritings and overallization.

Comments of high priority (major)

Explain the type of review and enhance transparency. You refer to a systematic narrative strategy where there are databases, date span, eligibility, and a screening process. Such a degree of organization puts a strain of reproducibility. Add: Examples of complete search queries (one per disease domain at least), Date of last search, Basic counts (records retrieved, screened, full text assessed, included), A short outline of evidence included by type of study (e.g., cohort, qualitative, trials, guidelines). Operationalize the concept of culture strictly and isolate it to other factors. The manuscript occasionally amalgamates cultural determinants (beliefs, norms, stigma, family roles, traditional practices) and: Structural determinants (access, cost, barriers of health system, discrimination), Genetic variation based on biological or ancestry (pharmacogenomics). Give a brief conceptual description or boxed definition that defines the difference between these domains and has an explanation of how each of them affects clinical outcomes. Less deterministic/generalizing language. Other statements are causal or mechanistic between groups. Taking into account the heterogeneity between people and settings, employ more probabilistic language and clearly indicate the within-group variability. Included in it is a short paragraph on how to prevent stereotyping and how to personalize care (e.g., finding out what the patient has to say by eliciting his explanatory model and preferences). Enhance Table 1 (traceability of evidence) Table 1 could be helpful, although the descriptions of the supporting evidence are generic in many cases, not traceable. Improve by: In connecting each row with certain key sources, or Including an evidence-level scheme (e.g., guideline, trial, cohort, qualitative) with their mapping of every claim. In the absence of this, the table would pass across as an expert opinion and not evidence synthesis. Case vignettes should be better grounded and demarcated. You are quite right in saying that vignettes are composite and non-identifiable. Still, each vignette should: Make a distinction between evidence-based and illustrative, Connect the suggested clinical response with the existing clinical principles or guide, Do not make the implication that a whole cultural group acts in a certain manner. Quality of references and verification. There is an inconsistent use of older or non-primary sources and some citations seem non-standard or challenging to confirm. Enhance with a focus on peer-reviewed primary research, high-quality reviews, and official clinical recommendations on any important statement, and make sure that all sources are verifiable and formatted accordingly.


Minor comments (quick fixes)

Correct spelling mistakes/bad typing and discrepancies in capitalization. Make sure that the terminology of the population labels is the same and fits the journal audience. Adding brief, disease-specific, Key clinical takeaways boxes would enhance readability and clinical use.

Comments on the Quality of English Language

English quality is good to very good overall: clear, professional, and readable. The main issues are minor copy-editing points (punctuation, occasional awkward phrasing, consistency in capitalization/formatting) and overly strong wording in a few claims. A light professional copy-edit is recommended.

Author Response

Thank you for the thoughtful and detailed review. We appreciate the care taken to strengthen both the methodological rigor and conceptual clarity of the manuscript. We have addressed each major point raised and summarize the revisions below.

First, we clarified the nature of the review and enhanced transparency. The Methods section now explicitly characterizes the review as a structured narrative synthesis and includes examples of complete search queries (at least one per disease domain), the date of the last search, and basic counts of records retrieved, screened, assessed in full text, and included. We also added a concise outline of the types of evidence incorporated (e.g., cohort studies, qualitative studies, trials, guidelines).

Second, we operationalized the concept of culture more strictly and disentangled it from structural determinants and biological/genetic factors. A boxed conceptual definition now distinguishes cultural determinants (beliefs, norms, stigma, family roles, traditional practices), structural determinants (access, cost, health system barriers, discrimination), and biological or ancestry-related variation (e.g., pharmacogenomics), with a brief explanation of how each domain can independently and interactively influence clinical outcomes.

Third, we revised the language throughout the manuscript to reduce determinism and generalization. Statements that could be interpreted as causal or mechanistic at the group level have been reframed using probabilistic language, with explicit acknowledgment of within-group heterogeneity and contextual variation. We also added a short paragraph explicitly addressing the prevention of stereotyping and emphasizing personalization of care, including eliciting patients’ explanatory models, preferences, and values.

Fourth, Table 1 has been enhanced to improve traceability of evidence. Each row is now linked to key supporting sources, and an evidence-level designation (e.g., guideline, trial, cohort, qualitative) has been added to clarify the strength and nature of the underlying evidence. This revision ensures that the table functions as an evidence synthesis rather than expert opinion.

Fifth, the case vignettes have been more clearly demarcated as composite and illustrative. Each vignette now explicitly distinguishes between evidence-based elements and illustrative context, connects the proposed clinical response to established clinical principles or guidelines, and avoids implying that behaviors are representative of an entire cultural group.

Finally, we conducted a comprehensive review of the references. Older or non-primary sources were replaced where possible with peer-reviewed primary research, high-quality systematic reviews, and official clinical recommendations. All citations have been verified for accuracy and standardized formatting.

In response to the minor comments, we corrected typographical and capitalization errors, standardized population terminology to align with the journal’s audience, and added brief, disease-specific “Key Clinical Takeaways” boxes to improve readability and clinical utility.