Integrative Review of Family Health Nursing Support for Single-Parent Families: Evidence Gaps and Implications for a Relational Empowerment Model

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The topic is relevant to Healthcare. The manuscript’s strengths include the intention to synthesize evidence and propose a “relational empowerment” model. However, the current version has major issues regarding (i) alignment between the stated focus on single-parent families and the included evidence base, (ii) an overly narrow and potentially inadequate search strategy, (iii) PRISMA reporting quality and internal consistency, (iv) missing transparency in critical appraisal, and (v) several bibliographic and language/editing problems. These issues limit confidence that the conclusions specifically apply to single-parent families and that the model is fully evidence-grounded.

Major issues

1. Scope mismatch (single-parent families vs included studies):
   The stated aim focuses on interventions supporting single-parent families in community/primary care nursing, yet Table 1 includes multiple studies apparently addressing “families” in general (e.g., oncology, dementia, schizophrenia, bereavement, homelessness, LGBTQ adoptive families) without clear evidence they specifically involve single-parent households. This undermines the core claim of the review. Please either (a) re-run screening and include only studies clearly addressing single-parent families, or (b) revise the aim/title/conclusions to reflect a broader “families/caregivers in community health” scope.

2. Search strategy is too narrow and not fit for purpose:
   The search string (“single parent families” OR “single parent household”) AND “family nursing” is likely to miss relevant studies using terms such as lone parent, solo parent, single mother/father, one-parent family, and nursing/healthcare context terms such as community nursing, primary health care, public health nursing, family-centered care, nursing intervention, caregiver support. Please expand the strategy and report full database-specific queries, including controlled vocabulary where applicable (MeSH/CINAHL headings), ideally in a Supplement.

3. PRISMA flow diagram and reporting require substantial revision:
   The flowchart contains unclear labels/wording and questionable logic (e.g., “Excluded databases removed after Duplicate”, “Included Databases by abstract lecture”, “Elegibility References”). The numbers and exclusion steps need to be presented according to PRISMA 2020 terminology and consistently with the text. Also, exclusion criteria such as “children and pregnant woman focus” should be reconsidered and clarified, since single parenthood often involves children.

4. Critical appraisal is insufficiently described and not reported:
   The manuscript states that quality was assessed using “appropriate appraisal tools” but does not specify which tool(s) were used (e.g., JBI, CASP, MMAT) nor provide appraisal results. Please specify tools per study design, present appraisal outcomes and explain how study quality informed synthesis and conclusions.

5. Synthesis is too general and not clearly single-parent-specific:
   The four reported domains (burden, resources, relational process, empowerment) read as generic family/caregiver themes. Please explicitly indicate which findings are derived from single-parent samples and what is specific vs common across family structures. Consider adding a sub-section “Single-parent specific findings” and mapping Results/Discussion directly to the research questions.

6. Relational empowerment model needs clearer derivation from evidence:
   The proposed model would benefit from a figure/diagram and a transparent mapping from review findings to model components (e.g., a table: component → supporting evidence/citations). Without this, the model appears more conceptual than evidence-synthesized.

 Recommendation

The manuscript addresses a relevant topic, but significant methodological and reporting issues prevent reliable conclusions specific to single-parent families. The review should be revised to ensure (1) scope alignment, (2) a comprehensive search strategy, (3) PRISMA-compliant reporting, (4) transparent quality appraisal, and (5) evidence-grounded synthesis and model development.

Author Response

Author's Reply to the Review Report (Reviewer 1)

We sincerely thank the Reviewer for the careful reading of our manuscript and for the constructive and insightful comments provided. We appreciate the recognition of the relevance of the topic and of the manuscript’s intention to synthesize evidence and propose a relational empowerment model within Family Health Nursing. We acknowledge the methodological and reporting concerns raised, particularly regarding: (i) alignment between the stated focus on single-parent families and the included evidence base, (ii) scope and comprehensiveness of the search strategy, (iii) PRISMA reporting clarity and internal consistency, (iv) transparency of the critical appraisal process, and (v) bibliographic and language accuracy. In response, we have undertaken a comprehensive revision of the manuscript. Specifically, we have:

• Clarified the integrative review design and strengthened the methodological framework.
  • Explicitly addressed the scarcity of studies exclusively focused on single-parent families and justified the inclusion of conceptually transferable evidence from broader family caregiving contexts.
  • Expanded and refined the search strategy, incorporating additional synonyms and controlled vocabulary.
  • Conducted a retrospective critical appraisal of included studies using design-appropriate tools, now reported in a dedicated table.
  • Revised the PRISMA flow diagram and improved reporting transparency across all selection stages.
  • Undertaken a thorough bibliographic and language revision of the manuscript.

These revisions aim to ensure stronger alignment between the review scope, the evidence base, and the proposed relational empowerment model, thereby enhancing methodological rigor and conceptual clarity. We are grateful for the Reviewer’s guidance, which has significantly strengthened the scientific robustness and transparency of this work.

point 1: We thank the Reviewer for this important and insightful observation regarding the alignment between the stated focus on single-parent families and the evidence base included in the review. We acknowledge that the initial version of the manuscript did not sufficiently clarify the extent to which included studies specifically addressed single-parent households. As the Reviewer correctly noted, several studies included in Table 1 focused on broader family caregiving contexts (e.g., oncology, dementia, bereavement, homelessness, and diverse family structures), without always specifying single-parent family configurations. This reflects a key finding of the review itself: the significant scarcity of empirical studies explicitly targeting single-parent families within Family Health Nursing interventions, particularly in community and primary health care settings. Rather than indicating a selection inconsistency, this gap reveals an important limitation in the current evidence base. In light of this, and consistent with integrative review methodology, we have revised the manuscript to clarify that the synthesis incorporates two complementary evidence streams:

1. Studies explicitly focused on single-parent families.
2. Studies addressing broader family caregiving and vulnerability contexts with conceptual and relational transferability to single-parent family experiences.

We have taken the following corrective actions:

• Revised the aim, title, and conclusions to reflect this integrative and gap-informed scope more accurately.
  • Added explicit justification for the inclusion of transferable family evidence in the Methods section.
  • Introduced a clarifying column in Table 1 identifying whether studies are single-parent specific or conceptually transferable.
  • Strengthened the Discussion to highlight the evidence gap and its implications for Family Health Nursing research and practice. These revisions ensure greater alignment between the review scope, the available evidence, and the development of the relational empowerment model, while preserving the manuscript’s focus on advancing knowledge relevant to single-parent families. We are grateful to the Reviewer for prompting this clarification, which has strengthened the conceptual coherence and methodological transparency of the manuscript.

point 2: We acknowledge that the initial search string, as reported in the manuscript — (“single parent families” OR “single parent household”) AND “family nursing” — may have been overly restrictive and could potentially limit retrieval of relevant studies using alternative terminology.

In response to the Reviewer’s recommendation, we have undertaken a refinement and expansion of the search strategy to enhance comprehensiveness and terminological sensitivity. The revised strategy incorporates additional synonyms and related terms for single-parent family structures, including: “lone parent*”, “solo parent*”, “single mother*”, “single father*”, and “one-parent famil*”. Furthermore, we expanded the health and nursing context descriptors to include terms such as: “community nursing”, “primary health care”, “public health nursing”, “family-centered care”, “nursing intervention*”, and “caregiver support”. Where applicable, controlled vocabulary was incorporated, including MeSH terms (e.g., Single-Parent Family, Family Nursing, Primary Health Care) and CINAHL Headings to ensure database-specific sensitivity. To ensure transparency and reproducibility, the full revised search strategies for each database have now been provided in a Supplementary File. These refinements strengthen the methodological rigor of the review and enhance confidence that relevant literature was comprehensively identified within the integrative review framework. We are grateful to the Reviewer for highlighting this aspect, which has contributed to improving the search transparency and robustness of the manuscript.

Point 3

We acknowledge that the terminology and labeling used in the initial flowchart did not fully align with PRISMA 2020 standards and may have generated ambiguity. Specifically, expressions such as “Excluded databases removed after duplicate,” “Included databases by abstract lecture,” and “Elegibility references” were imprecise and have now been revised for clarity and methodological accuracy.

In response to the Reviewer’s recommendation, we have undertaken the following revisions:

• The PRISMA flow diagram has been fully redesigned in accordance with PRISMA 2020 terminology and structure.
  • All stages of the selection process (identification, screening, eligibility, inclusion) are now clearly labeled and numerically consistent with the manuscript text.
  • Reasons for exclusion at the full-text stage have been clarified and explicitly itemized.
  • Terminology has been standardized (e.g., “records screened,” “full-text articles assessed,” “studies included in synthesis”).

Regarding the exclusion criterion related to studies focused on “children and pregnant women,” we appreciate the Reviewer’s pertinent observation. We have revised this criterion to clarify that studies were excluded only when the primary focus was exclusively biomedical or maternal-child clinical care, without a Family Health Nursing or relational caregiving perspective. Studies involving children within single-parent family contexts were not excluded when aligned with the review scope. These revisions enhance the transparency, methodological rigor, and internal consistency of the review selection process. We thank the Reviewer for highlighting these reporting issues, which have contributed to improving the clarity and accuracy of the manuscript.

Point 4: We acknowledge that the initial version of the manuscript did not sufficiently detail the methodological quality assessment procedures, nor did it present appraisal outcomes. We appreciate the Reviewer’s recommendation to clarify this aspect.

In response, we have conducted a retrospective critical appraisal of all included studies, consistent with integrative review methodological guidance. Design-appropriate appraisal tools were applied as follows:

• Qualitative studies: Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research.
  • Quantitative studies: Critical Appraisal Skills Programme (CASP) checklists.
  • Mixed-methods studies: Mixed Methods Appraisal Tool (MMAT), where applicable.

The appraisal process evaluated methodological rigor, sampling adequacy, data collection procedures, analytical transparency, and coherence between study aims and findings. Appraisal outcomes are now presented in a dedicated table (Table X), summarizing study design, appraisal tool applied, and overall quality level. Importantly, consistent with integrative review methodology, studies were not excluded based on quality alone. Instead, appraisal findings were used to contextualize the strength of evidence within the synthesis and to inform the interpretation of results and development of the relational empowerment model. These additions enhance the methodological transparency and strengthen confidence in the evidence base underpinning the review conclusions. We thank the Reviewer for highlighting this issue, which has contributed to improving the rigor and clarity of the manuscript.

Point 5: Synthesis is too general and not clearly single-parent-specific

We acknowledge that, in the initial version of the manuscript, the four domains identified (burden, resources, relational processes, and empowerment) may have appeared as broadly applicable family and caregiver themes, without sufficient distinction between findings derived from single-parent samples and those originating from wider family contexts.This reflects an important empirical reality identified through the review process: the limited availability of studies explicitly focused on single-parent families within Family Health Nursing and community care interventions. Consequently, several synthesized themes emerged from evidence that was conceptually transferable rather than exclusively single-parent-specific.

In response to the Reviewer’s recommendation, we have strengthened the analytical transparency of the synthesis through the following revisions:

• We introduced a dedicated sub-section titled “Single-Parent-Specific Findings” within the Results section.
  • We explicitly distinguished findings derived from studies involving single-parent family samples from those emerging from broader caregiving or family health contexts.
  • We clarified which relational and empowerment processes appear unique or particularly intensified in single-parent family experiences.
  • We mapped the synthesized domains directly to the review research questions to enhance conceptual coherence between aims, findings, and discussion.

These revisions allow readers to more clearly identify what is empirically grounded in single-parent evidence and what is theoretically or conceptually transferable from wider Family Health Nursing literature. We appreciate the Reviewer’s recommendation, which has contributed to strengthening the analytical precision and interpretive clarity of the synthesis.

Question 6: We acknowledge that, in the initial manuscript version, the model was presented primarily within the conceptual and interpretive discussion, without sufficient visual representation or explicit mapping to the synthesized evidence. We appreciate the Reviewer’s recommendation to strengthen the transparency of its empirical grounding.

In response, we have undertaken the following revisions:

• We developed and incorporated a conceptual figure illustrating the relational empowerment model and its core components.
  • We explicitly defined each component of the model, clarifying relational processes, contextual influences, and empowerment outcomes.
  • We created a mapping table linking model components to supporting evidence derived from the review findings (component → key supporting studies/citations).
  • We revised the Results–Discussion integration to demonstrate how synthesized domains informed model construction.

These additions clarify the analytical pathway from evidence synthesis to conceptual model development, reinforcing the model’s grounding within the integrative review findings rather than solely theoretical interpretation. We are grateful for the Reviewer’s suggestion, which has strengthened the operational clarity, visual accessibility, and empirical credibility of the relational empowerment framework.

Reviewer 2 Report

Comments and Suggestions for Authors

This integrative review addresses a relevant and timely topic within community and family health nursing. Single-parent families constitute a growing and particularly vulnerable population, and the focus on Family Health Nursing and empowerment-oriented interventions is appropriate and well aligned with the scope of Healthcare.Overall, the manuscript has clear potential, but substantive revisions are required before it can be considered for publication.

Methodological rigor of the integrative review

Although the authors state that the review follows PRISMA 2020 guidelines, the manuscript does not clearly describe how the methodological quality of the included studies was assessed.It is unclear which appraisal tools ( CASP, JBI, MMAT, or equivalent) were used according to study design.The number of reviewers involved in study selection, appraisal, and data extraction is not specified, nor is the procedure for resolving disagreements.

The authors should explicitly describe the critical appraisal process, including the tools used, the number of reviewers involved, and how study quality informed (or did not inform) the synthesis.

While a PRISMA flow diagram is provided, the selection process remains somewhat generic.The exclusion criteria are broad and would benefit from clearer justification.Reasons for exclusion at the full-text stage are not sufficiently detailed.A summary of methodological characteristics of included studies is missing.

The authors should improve transparency by: Clarifying reasons for exclusion at each stage.Adding a table summarizing key methodological characteristics of the included studies (design, context, population, intervention type).

 Operationalization of the proposed relational empowerment model

The proposed relational empowerment model is conceptually interesting but remains insufficiently operationalized.The authors should:

• Provide a clear conceptual figure illustrating the relational empowerment model.
• Explicitly define its core components and how they interact.
• Clarify the added value of the model compared to existing family nursing and empowerment frameworks.

Balance between evidence synthesis and conceptual interpretation

In several sections of the Results and Discussion, empirical findings from the reviewed studies are interwoven with conceptual interpretation without clear distinction.

This may lead readers to overestimate the level of empirical support for some claims.
The authors should clearly differentiate:Findings directly supported by the reviewed studies.Conceptual interpretations or proposed theoretical extensions.

Author Response

Author's Reply to the Review Report (Reviewer 2)

We sincerely thank the Reviewer for the careful and constructive appraisal of our manuscript. We appreciate the recognition of the relevance and timeliness of the topic, as well as the alignment of the manuscript with the scope of Healthcare. We also acknowledge the Reviewer’s methodological and conceptual recommendations, which have been instrumental in strengthening the rigor, transparency, and analytical clarity of this integrative review.

In response, we have undertaken substantial revisions across the manuscript, as detailed below.

Comment: Methodological rigor of the integrative review

We appreciate the Reviewer’s observation regarding the need for greater transparency in the description of the methodological quality appraisal process.

In response, we conducted a retrospective critical appraisal of all included studies, consistent with integrative review methodological guidance. Design-appropriate appraisal tools were applied as follows:

• Qualitative studies were assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research.
  • Quantitative studies were appraised using the Critical Appraisal Skills Programme (CASP) checklists appropriate to study design.
  • Mixed-methods studies were evaluated using the Mixed Methods Appraisal Tool (MMAT), where applicable.
  • Review studies were appraised using Joanna Briggs Institute tools for evidence syntheses, and psychometric studies using the JBI Analytical Cross-Sectional Checklist.

The appraisal process evaluated methodological rigor, sampling adequacy, data collection procedures, analytical transparency, and coherence between study aims and findings. Consistent with integrative review methodology, studies were not excluded based on quality appraisal alone; rather, appraisal outcomes were used to contextualize the strength of evidence within the synthesis.

Appraisal results are now presented in a dedicated table (Table X), summarizing study design, appraisal tool applied, and overall methodological quality level.

Regarding reviewer involvement, we acknowledge that study selection, appraisal, and data extraction were conducted by a single reviewer. This has now been explicitly stated as a methodological limitation in the manuscript.

Comment: PRISMA reporting and transparency of study selection

We thank the Reviewer for highlighting the need for improved transparency in the study selection process.

In response, the PRISMA flow diagram has been fully revised in accordance with PRISMA 2020 reporting standards. All stages of identification, screening, eligibility, and inclusion are now clearly labeled and numerically consistent with the manuscript text.

Reasons for exclusion at the full-text stage have been clarified, categorized, and explicitly itemized. Exclusion criteria have also been refined to distinguish studies focused exclusively on biomedical or institutional care contexts from those aligned with Family Health Nursing and relational caregiving perspectives.

Furthermore, we have added a summary table presenting the methodological characteristics of included studies, including study design, context, population, and intervention type, thereby enhancing transparency and interpretive clarity.

Comment: Operationalization of the relational empowerment model

We appreciate the Reviewer’s constructive observation regarding the operational clarity of the proposed relational empowerment model.

In response, several revisions were undertaken:

• A conceptual figure illustrating the relational empowerment model and its core components has been developed and incorporated.
  • Each model component has been explicitly defined, including relational processes, contextual determinants, and empowerment outcomes.
  • A mapping table was created linking model components to supporting evidence derived from the integrative synthesis (component → key supporting studies).
  • The Results and Discussion sections were revised to demonstrate the analytical pathway from evidence synthesis to model development.

These revisions enhance the operational transparency, theoretical grounding, and practical applicability of the relational empowerment framework.

Comment: Balance between evidence synthesis and conceptual interpretation

We thank the Reviewer for this insightful observation regarding the analytical distinction between empirical findings and conceptual interpretation.

In response, we revised the Results and Discussion sections to ensure clearer differentiation between:

• Findings directly supported by the reviewed studies.
  • Conceptual interpretations derived from integrative synthesis.
  • Proposed theoretical extensions informing the relational empowerment model.

To further enhance specificity, we introduced a dedicated sub-section titled “Single-Parent-Specific Findings,” explicitly distinguishing evidence derived from single-parent family samples from conceptually transferable findings originating in broader family caregiving contexts.

These revisions strengthen the analytical transparency of the synthesis and reduce the risk of overinterpretation of empirical findings.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript now demonstrates greater methodological transparency, clearer articulation of the integrative review approach, and improved theoretical positioning within Family Health Nursing. The inclusion of PRISMA 2020 guidance, expanded methodological explanation, and explicit discussion of the evidence gap significantly strengthen the work.

However, The manuscript would benefit from clarification regarding:

1. Whether appraisal was conducted independently or by a single reviewer.

How discrepancies (if applicable) were handled.

Whether any scoring or grading system was used.

How appraisal outcomes informed synthesis (beyond general contextualization).

Clarifying these elements would strengthen methodological rigor and reproducibility.

2. The integrative approach appropriately includes conceptually transferable evidence; however, the criteria used to determine transferability remain somewhat broad. It would strengthen the manuscript to:

More explicitly define how transferability was operationalized.

Indicate how many of the 29 included studies directly involved single-parent samples versus those considered transferable.

Clarify whether transferable studies were weighted differently in synthesis.

Providing greater transparency here would enhance methodological credibility.

3. The proposed relational empowerment model is an important contribution; however, its structure remains somewhat implicit. If it is presented as a “model,” readers would benefit from:

A clearer schematic representation (e.g., conceptual diagram).

Explicit description of model components and their interrelationships.

A brief explanation of how the model was derived from thematic synthesis.

Currently, it reads more as a conceptual orientation than a fully articulated model. Strengthening this section would significantly enhance the manuscript’s impact.

4. While the argument that evidence is “limited” or “scarce” is justified in relation to single-parent-specific interventions, the manuscript would benefit from more precise phrasing (e.g., specifying proportion of studies directly focused on single-parent families).

Author Response

We sincerely thank the Reviewer for the positive appraisal of the revised manuscript and for acknowledging the improvements in methodological transparency, theoretical positioning, and reporting clarity. We appreciate the constructive suggestions provided to further strengthen rigor, reproducibility, and conceptual clarity. In response, we have addressed each point as follows

1. Clarification of the Critical Appraisal Process

We appreciate the Reviewer’s request for greater methodological precision regarding the appraisal procedures.

• Study selection, appraisal, and data extraction were conducted by a single reviewer. This has now been explicitly stated in the Methods section, and acknowledged as a methodological limitation.

• As the review was conducted by a single reviewer, no discrepancy resolution procedure was applicable. This has also been clarified in the manuscript.

• No formal numerical scoring or grading system was applied. Instead, appraisal tools (JBI, CASP, MMAT) were used to assess methodological rigor across domains such as sampling adequacy, analytical coherence, and clarity of reporting. This decision is consistent with integrative review methodology, which emphasizes interpretive synthesis rather than quantitative grading of evidence.

• Appraisal outcomes informed the synthesis by contextualizing the strength of evidence underpinning each thematic domain and model component. Studies with stronger methodological rigor were used to support core analytical conclusions, while findings from studies with methodological limitations were interpreted with appropriate caution. This clarification has now been added to the Methods and Discussion sections.

These additions enhance transparency and reproducibility.

2. Operationalization of Conceptual Transferability

We thank the Reviewer for highlighting the need for clearer operationalization of transferability criteria.

In response:

• The manuscript now explicitly defines transferability as the relevance of findings to relational processes, caregiving concentration, resource mobilization, and empowerment dynamics applicable to single-parent family structures.

• We have specified that among the 29 included studies, a limited subset directly involved single-parent family samples, while the majority provided conceptually transferable evidence from broader family caregiving contexts. The exact number and proportion are now stated in the Results section.

• Transferable studies were not statistically weighted differently; however, analytical distinction was maintained. Findings derived from direct single-parent samples are clearly identified in the “Single-Parent-Specific Findings” subsection, whereas transferable findings are explicitly framed as conceptually applicable rather than empirically exclusive.

These clarifications strengthen methodological credibility and analytical transparency.

3. Further Operationalization of the Relational Empowerment Model

We appreciate the Reviewer’s recommendation to further articulate the proposed model.

To address this:

• A schematic conceptual diagram of the relational empowerment model has been included.

• The core components of the model—contextual vulnerability, caregiving concentration, nurse–family relational processes, and resource mobilization strategies—are now explicitly defined.

• Interrelationships among components are described as iterative and bidirectional, rather than linear.

• A mapping table has been added linking each model component to supporting evidence derived from the thematic synthesis.

• The manuscript now more clearly explains how the model was inductively derived from the four principal thematic domains identified in the integrative review.

These revisions reinforce the model’s analytical derivation and clarify its empirical grounding.

4. Precision in Describing the Evidence Gap

We agree that greater specificity strengthens the argument regarding evidence scarcity.

The manuscript now explicitly states the proportion of included studies that directly focused on single-parent families versus those considered conceptually transferable. The phrasing has been refined to avoid general statements of “scarcity” and instead specify the relative representation within the included evidence base.

We are grateful for the Reviewer’s thoughtful and constructive recommendations, which have significantly enhanced the methodological rigor, analytical precision, and conceptual clarity of the manuscript.