Cultural Adaptations of Evidence-Based Interventions in Dementia Care: A Critical Review of Literature

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for a very interesting and important paper. I have some comments for improvement: 

1: I would very much like to see a "sharper" problematization and rationale of why structure cultural adaptations are important. I believe all the text is there, it's just a matter of re-organisation of it to get the message through better. For example, the text on page 2, lines 50-62 can preferably be better merged. Also, the last paragraph where you describe the strategy you applied in the review should be part of the Methods section as it states the procedure. 

2.2. Last paragraph in the Introduction should be integrated here. You may consider renaming the heading to  Framework and Study appraisal and let Data extraction come under a separate heading. 

3.1. I would suggest to split this section since it includes different types of information about the adaptations. It is more than an overview. 

3.2. Please compare text with Table 1. I see there is a redundancy and I suggest you shorten the text and check if the table allows for addition of some details. 

Table 1 (the first one): The heading needs revision. It is not Overview of Adaptations, it is details about the studies included, including details about the intervention, not adaptation.

3.3.1. Some text would be better suited in the discussion, e.g. lines 200ff.

Table 1 on page 9 should maybe be Table 2? Please check the format and adapt to mdpi-instructions. Please also check the headings. Is Language appropriate? Translation strategy? What do you mean by Person? The descriptions in the column is diverse. Reconsider all columns and text. It is too long and not clear throughout.

4. The discussion raises important issues, however, throughout there is a lack of discussion against additional references despite they are available. I would suggest revising the discussion to add more to the scientific knowledge base. 

5. The first paragraph is not Conclusion, it is more of a problematization and rationale for conducting this type of studies. I suggest deleting this paragraph and to elaborate on the Conclusion. What is the message you would like to send to the reader? 

 

 

 

Author Response

Comment 1: I would very much like to see a "sharper" problematization and rationale of why structure cultural adaptations are important. I believe all the text is there, it's just a matter of re-organisation of it to get the message through better. For example, the text on page 2, lines 50-62 can preferably be better merged. Also, the last paragraph where you describe the strategy you applied in the review should be part of the Methods section as it states the procedure. 

Response 1: 1. We have made the rationale for the review clear by adding a “problem statement” in both the abstract and introduction. 

Comment 2: 2.2. Last paragraph in the Introduction should be integrated here. You may consider renaming the heading to  Framework and Study appraisal and let Data extraction come under a separate heading.

Response 2: Thank you for this suggestion, we have added the last section of the paragraph to this section and have now created a separate header for data extraction. 

Comment 3: 3.1. I would suggest to split this section since it includes different types of information about the adaptations. It is more than an overview. 

Response 3: We have now split the section into two; overview and context & population. 

Comment 4: 3.2. Please compare text with Table 1. I see there is a redundancy and I suggest you shorten the text and check if the table allows for addition of some details. 

Response 4: Thank you for pointing out the redundancy in the texts. We have now revised the text (now 3.3) accordingly. 

Comment 5: Table 1 (the first one): The heading needs revision. It is not Overview of Adaptations, it is details about the studies included, including details about the intervention, not adaptation.
Response 5: We have updated the title of the table to “Characteristics of Included Studies”. 

Comment 6: 3.3.1. Some text would be better suited in the discussion, e.g. lines 200ff.

Response 6: We have removed the sentence “This approach was particularly evident in adaptations of the iSupport caregiver program, where authors often conducted preliminary adaptations before inviting stakeholders to review and suggest changes” as it belongs to the discussion as you suggested. 

Comment 7: Table 1 on page 9 should maybe be Table 2? Please check the format and adapt to mdpi-instructions. Please also check the headings. Is Language appropriate? Translation strategy? What do you mean by Person? The descriptions in the column is diverse. Reconsider all columns and text. It is too long and not clear throughout.

Response 7: Thank you for this comment, we have now comprehensively formatted and revised the table. The revised Table 2 is consistent with MDPI guidelines and is easier to comprehend. 

Comment 8: 4. The discussion raises important issues, however, throughout there is a lack of discussion against additional references despite they are available. I would suggest revising the discussion to add more to the scientific knowledge base. 

Response 8: Thank you for the suggestion, we have added more literature to the discussion

Comment 9: 5. The first paragraph is not Conclusion, it is more of a problematization and rationale for conducting this type of studies. I suggest deleting this paragraph and to elaborate on the Conclusion. What is the message you would like to send to the reader? 

Response 9: We have now revised the first paragraph of the conclusion based on your recommendation. 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is based on the premise that ‘cultural adaptation of evidence-based interventions is important for improving their acceptability, relevance, and effectiveness across diverse populations, especially in dementia care where sociocultural contexts strongly influence helpseeking and caregiing practices.’ This statement highlights the relevance of the topic to the field of knowledge, aligning with the journal’s scope and likely to be of interest to its readers.

Its review nature does not compromise its originality, especially considering that the research findings contribute to addressing certain scientific gaps. The systematization of the results also distinguishes it from other published works of a similar profile.

Although clear and presented in a well-structured manner, the manuscript lacks an explicit statement of the main research question and the general and/or specific objectives of the study, which could be more clearly highlighted in both the abstract and the introduction. Additionally, the keywords repeat terms from the title, which limits the paper’s indexing potential.

Section 1 (Introduction) contextualizes the topic and presents some theoretical and conceptual postulates, while there is room for further elaboration on those considered central. This concise introductory text is supported by relatively recent references—approximately 80% from the last decade and 60% from the past five years.

Beginning with the search strategy (Subsection 2.1), based on the identification of relevant studies, conducted across four data-bases—PubMed, PsycINFO, CINAHL, and Scopus —Section 2 (Materials and Methods) explains the search terms and the temporal scope starting from 2018, as well as the inclusion and exclusion criteria, which are systematized in the supplementary material. This concise description of methodological procedures, which could benefit from further elaboration and the inclusion of relevant references, also presents information on study appraisal and data extraction, guided by the Integrated Strategy for the Cultural Adaptation of Evidence-Based Interventions. Overall, this section could be detailed to make the manuscript more scientifically sound and to facilitate the reproducibility of the results.

With extensive engagement with previous references, Section 3 (Results) clarifies in Subsection 3.1 (Overview of the Adaptations Included in the Review) that, out of 23 publications, the study examined how 19 cultural adaptations of dementia-related interventions were conducted. ‘Six focused on behavioral and psychological symptoms of dementia, one was a dyad intervention for both people with dementia and caregivers, and the rest targeted informal caregivers exclusively.’ In Subsection 3.2  (Frameworks/theories guiding cultural adaptation processes), the authors state that ‘a total of ten distinct theoretical frameworks guided the cultural adaptations across the 19 studies are included.’ In both parts, nearly all newly cited references are dated from 2020 onward (approximately 90%).

Subsection 3.3 (Evaluating Cultural Adaptation Processes Through the Lens of Sidani’s Framework) comprises content related to assessing the ethno-cultural community beliefs, examining the interventions fit with the community’s beliefs, adapting interventions, and modifications made to the original interventions and fidelity check. This part of the text includes summary tables providing an overview of the adaptations included in the review, and modifications to the original interventions. The authors explain that ‘most studies followed consistent, iterative processes involving stakeholder engagement through focus group, pilot testing, and refinement. However, communities were not involved in the initial selection of interventions, a critical gap in ensuring cultural relevance. Furthermore, although many studies preserved core components, post-adaptation fidelity checks were not conducted in some of the studies.’ In this final stage of presenting the results, few new sources are included—all from the last decade, with nearly 67% published within the past five years.

With extensive debate of the results, Section 4 (Discussion) also introduces few new references—around 75% from the last decade, with approximately 50% from the past five years. Within this section, important findings and challenges are clarified, alongside the limitations of the review.

Despite its concise content, Section 5 (Conclusions) is consistent with the evidence and arguments presented, outlining contributions of the study ‘offering a structured synthesis of current practices and identifying key opportunities to strengthen future adaptation efforts.’ In this context, the authors recommend that ‘adaptations should prioritize stakeholder involvement in intervention selection and implement fidelity assessments to ensure both cultural fit and intervention integrity.’

The recency of the references is one of the manuscript’s strengths—approximately 75% are from the last decade and over 90% from the past five years. As expected for a systematic review, these sources are also relevant to the topic studied.

Finally, the tables are considered appropriate and essential; however, it is noted that there are issues with their numbering. Two subsections are labeled as 3.3.2, which leads to Inaccuracies in subsequent sections.

Comments on the Quality of English Language

The text needs small spelling and grammatical adjustments, as well as minor typing corrections.

Author Response

Comment 1: The manuscript is based on the premise that ‘cultural adaptation of evidence-based interventions is important for improving their acceptability, relevance, and effectiveness across diverse populations, especially in dementia care where sociocultural contexts strongly influence helpseeking and caregiing practices.’ This statement highlights the relevance of the topic to the field of knowledge, aligning with the journal’s scope and likely to be of interest to its readers.

Response 1: Thank you. 

Comment 2: Its review nature does not compromise its originality, especially considering that the research findings contribute to addressing certain scientific gaps. The systematization of the results also distinguishes it from other published works of a similar profile.

Response 2: Thank you. 

Comment 3: Although clear and presented in a well-structured manner, the manuscript lacks an explicit statement of the main research question and the general and/or specific objectives of the study, which could be more clearly highlighted in both the abstract and the introduction. Additionally, the keywords repeat terms from the title, which limits the paper’s indexing potential.

Response 3: We have made the rationale for the review clear by adding a “problem statement” in both the abstract and introduction. We have explicitly stated the review question as well as the specific objectives.

Comment 4: Section 1 (Introduction) contextualizes the topic and presents some theoretical and conceptual postulates, while there is room for further elaboration on those considered central. This concise introductory text is supported by relatively recent references—approximately 80% from the last decade and 60% from the past five years.

Response 4: Thank you, we have revised the background to provide more context for the study. 

Comment 5: Beginning with the search strategy (Subsection 2.1), based on the identification of relevant studies, conducted across four data-bases—PubMed, PsycINFO, CINAHL, and Scopus —Section 2 (Materials and Methods) explains the search terms and the temporal scope starting from 2018, as well as the inclusion and exclusion criteria, which are systematized in the supplementary material. This concise description of methodological procedures, which could benefit from further elaboration and the inclusion of relevant references, also presents information on study appraisal and data extraction, guided by the Integrated Strategy for the Cultural Adaptation of Evidence-Based Interventions. Overall, this section could be detailed to make the manuscript more scientifically sound and to facilitate the reproducibility of the results.

Response 5: Thank you for your kind comment, we have added more information to improve replicability. For instance, in lines 124-125, we added the date we completed our search. We created separate header for data extraction (see line 147). 

Comment 6: With extensive engagement with previous references, Section 3 (Results) clarifies in Subsection 3.1 (Overview of the Adaptations Included in the Review) that, out of 23 publications, the study examined how 19 cultural adaptations of dementia-related interventions were conducted. ‘Six focused on behavioral and psychological symptoms of dementia, one was a dyad intervention for both people with dementia and caregivers, and the rest targeted informal caregivers exclusively.’ In Subsection 3.2  (Frameworks/theories guiding cultural adaptation processes), the authors state that ‘a total of ten distinct theoretical frameworks guided the cultural adaptations across the 19 studies are included.’ In both parts, nearly all newly cited references are dated from 2020 onward (approximately 90%).

Response 6: Thank you. 

Comment 7: Subsection 3.3 (Evaluating Cultural Adaptation Processes Through the Lens of Sidani’s Framework) comprises content related to assessing the ethno-cultural community beliefs, examining the interventions fit with the community’s beliefs, adapting interventions, and modifications made to the original interventions and fidelity check. This part of the text includes summary tables providing an overview of the adaptations included in the review, and modifications to the original interventions. The authors explain that ‘most studies followed consistent, iterative processes involving stakeholder engagement through focus group, pilot testing, and refinement. However, communities were not involved in the initial selection of interventions, a critical gap in ensuring cultural relevance. 

Response 7: Thank you. 

Comment 8: Furthermore, although many studies preserved core components, post-adaptation fidelity checks were not conducted in some of the studies.’ In this final stage of presenting the results, few new sources are included—all from the last decade, with nearly 67% published within the past five years.

Response 8: Thank you. 

Comment 9: With extensive debate of the results, Section 4 (Discussion) also introduces few new references—around 75% from the last decade, with approximately 50% from the past five years. Within this section, important findings and challenges are clarified, alongside the limitations of the review. 

Response 9: Thank you. 

Comment 10: Despite its concise content, Section 5 (Conclusions) is consistent with the evidence and arguments presented, outlining contributions of the study ‘offering a structured synthesis of current practices and identifying key opportunities to strengthen future adaptation efforts.’ In this context, the authors recommend that ‘adaptations should prioritize stakeholder involvement in intervention selection and implement fidelity assessments to ensure both cultural fit and intervention integrity.

Response 10: Thank you. 

Comment 11: The recency of the references is one of the manuscript’s strengths—approximately 75% are from the last decade and over 90% from the past five years. As expected for a systematic review, these sources are also relevant to the topic studied

Response 11: Thank you. 

Comment 12: Finally, the tables are considered appropriate and essential; however, it is noted that there are issues with their numbering. Two subsections are labeled as 3.3.2, which leads to Inaccuracies in subsequent sections

Response 11: Great catch! We have now updated the numbering of the section, thank you. 

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

As previously mentioned, the guiding premise of the research highlights the relevance of the topic to the field of knowledge, aligning with the journal’s scope and is likely to be of interest to its readers. In turn, its review-based nature does not compromise its originality, with findings that contribute to addressing specific scientific gaps, as well as other aspects that distinguish it from previously published works of a similar profile.

The restructuring of the abstract addresses the main observations and the significant improvement in the keywords improves the indexing alternatives for the article.

The current version of the manuscript incorporates an explicit statement of the main research question and the specific objectives of the study, particularly in Section 1 (Introduction), which was expanded based on prior feedback and includes a revised background to provide more context for the research.

In Section 2 (Materials and Methods), the addition of new information was detailed to make the manuscript more scientifically sound and to improve the replicability of the procedures. These improvements enabled a better understanding of the content in Section 3 (Results), including item subdivisions and additions to enhance contextual clarity.

However, adjustments are needed in Table 2 (Modifications to the original interventions) regarding language translation specifications. In the cases of Álvares Pereira et al. (2022) and Teles et al. (2021), the former is labeled simply as ‘Portuguese’, while the latter specifies ‘European-Portuguese’. For Dahlan et al. (2023), the term ‘Malaysia’ is used instead of the correct ‘Malay’. For Monteiro et al. (2023), the label ‘Brazilian’ is inaccurate, as this is not a recognized language; it should be replaced with ‘Brazilian-Portuguese’.

The extensive debate of the results in Section 4 (Discussion) was enriched with several analytical passages. Nevertheless, Section 5 (Conclusions) remains quite concise, despite maintaining consistency with the evidence and arguments presented, and successfully outlining the study’s contributions and recommendations.

The current references continue to be one of the manuscript’s strengths, and other minor editorial issues pointed out in the preceding text have been resolved.

Comments on the Quality of English Language

The text still requires small spelling and grammatical adjustments, as well as minor typing corrections.

Author Response

Comment 1: As previously mentioned, the guiding premise of the research highlights the relevance of the topic to the field of knowledge, aligning with the journal’s scope and is likely to be of interest to its readers. In turn, its review-based nature does not compromise its originality, with findings that contribute to addressing specific scientific gaps, as well as other aspects that distinguish it from previously published works of a similar profile.

Response 1: Thank you. 

Comment 2: The restructuring of the abstract addresses the main observations and the significant improvement in the keywords improves the indexing alternatives for the article.

Response 2: Thank you. 

Comment 3: The current version of the manuscript incorporates an explicit statement of the main research question and the specific objectives of the study, particularly in Section 1 (Introduction), which was expanded based on prior feedback and includes a revised background to provide more context for the research.

Response 3: Thank you. 

Comment 4: In Section 2 (Materials and Methods), the addition of new information was detailed to make the manuscript more scientifically sound and to improve the replicability of the procedures. These improvements enabled a better understanding of the content in Section 3 (Results), including item subdivisions and additions to enhance contextual clarity.

Response 4: Thank you. 

Comment 5: However, adjustments are needed in Table 2 (Modifications to the original interventions) regarding language translation specifications. In the cases of Álvares Pereira et al. (2022) and Teles et al. (2021), the former is labeled simply as ‘Portuguese’, while the latter specifies ‘European-Portuguese’. For Dahlan et al. (2023), the term ‘Malaysia’ is used instead of the correct ‘Malay’. For Monteiro et al. (2023), the label ‘Brazilian’ is inaccurate, as this is not a recognized language; it should be replaced with ‘Brazilian-Portuguese’.

Response 5: We have revised the table following your suggestions, thank you. 

Comment 6: The extensive debate of the results in Section 4 (Discussion) was enriched with several analytical passages. Nevertheless, Section 5 (Conclusions) remains quite concise, despite maintaining consistency with the evidence and arguments presented, and successfully outlining the study’s contributions and recommendations.

Response 6: Thank you for this observation. While we aimed to keep conclusion concise to avoid duplication of points covered in the Discussion, we have expanded the section slightly by adding a broader statement on the implications of cultural adaptation for advancing equity in health research and global uptake of interventions.

Comment 7: The current references continue to be one of the manuscript’s strengths, and other minor editorial issues pointed out in the preceding text have been resolved.

Response 7: Thank you.