PONE-D-24-08489Developing and validating a HEalthCare NAvigation Competency (HECNAC) Scale for refugees in the United StatesPLOS ONE

Dear Dr. Yeo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

This study appears to be a good addition to the current literature. It addresses health care needs and understanding among refugees from an ethnic population for which little information is currently available. There are some areas in the manuscript needing improvement. In particular, key details such as target population and research approach are sketchy in the background. That section needs more refinement. In addition, the methods and results section are overlapping; methods details should be all appear in that section and moved from the findings. Further clarifications and language edits are also needed throughout the manuscript. All comments from both reviewers should be addressed carefully in the revision.

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We look forward to receiving your revised manuscript.

Kind regards,

Magdalena Szaflarski, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to invite me reviewing this paper titled” Developing and validating a HEalthCare NAvigation Competency (HECNAC) Scale for refugees in the United States”. It is a very interesting topic and the HECNAC scale might have an important role in supporting with healthcare navigation and tailored interventions as well as improve accessibility in refugees’ populations in US, and perhaps can be adapted in many other Western countries for other migrants’ population. Please see the detailed comments in the attached file.

Reviewer #2: Thank you for this very interesting study - the results will be very useful and immediately applicable in the field. There are some areas in the text that aren't well-communicated, but with some clarification this will be a very strong study.

I've included here a mixture of minor and major comments:

1. Line 38, page 12: Think you mean, Therefore? Subsequently is awkward here

2. Figure 1 - 2 things: would say 1st round and 2nd round... also clarify whether 2nd set of 39 is same or different

3. Page 15, Line 110 - numerous variations "of the" Delphi would flow better

4. Page 16, Line 115 - What is the geographic distribution of your group? healthcare challenges in the US have regional characteristics as well as universal ones. Also the refugee populations are different and thus the systems they are used to vary widely and staff have to know those groups, so across the country would have different experiences. would be good to comment on this (I see that you report this later on but would be good to discuss in the discussion)

5. Page 16, Line 123 - The sentence starting with Niederberger and Spranger is confusing... meaning on average the number of experts is low to medium double digit? Saying 'the Delphi studies' sounds like you are referring to specific ones... is that what you mean? If so, which ones?

6. In the same paragraph as the sentence above a minor note, but if you use the name for one study, would do it for all (or do it for none) unless Niederberger and Spranger are well-known as originators of the method or some other founding role.

7. Page 17, Line 151 - but only 14 accepted? The others refused?

8. Section on translation - you need to introduce the focus on Afghan refugees MUCH earlier that this is the language of focus and WHY

9. Page 18, Line 176 cognitive interviews with whom? how were they identified?

10. Page 19, Line 179 this needs to come at the beginning of the section

11. Page 19, Line 183 and transcribed? what did you do with the recordings?

12. The methods and results seem mixed together.... a lot of the detail I felt was missing in methods appears here in results. If you want to organize it that way, then I would keep the methods much more high level and use the results to provide the detail. OR put all of this detail in the methods and really focus the results on describing what came out of the whole process vs. the process. I'd definitely suggest modeling your set up on other Delphi papers... how do they approach this?

13. Page 19, Line 195 Some of these really seem more like roles rather than identities.

14. Table 1 - spacing in 'Group' is off; Race/ethnicity: Why group the others if you have given specificity for the one person who is Middle Eastern, there is no reason for an 'other' category unless they refused

15. Page 21, Line 232 This (note about table 5) needs more context... did this come from the Delphi discussions?? the table below felt like a surprise despite this... the suggestions are excellent, they just need more lead in; Table 5: This needs prep in the results... it kind of comes out of nowhere here in the flow.

16. page 23, Line 255 yes re: the limitation of focusing on Afghans - and this needs much better intro early in the paper

17. same page, line 260 as you have elsewhere I'd say refugees and immigrants

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Reviewer #1: Yes: Wendan Shi

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Reviwers comments.docx

PONE-D-24-08489R1Developing and validating a HEalthCare NAvigation Competency (HECNAC) Scale for refugees in the United StatesPLOS ONE

Dear Dr. Yeo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The revised manuscript reads much better and clarifies previous questions/comments about the study. However, minor further revisions are still recommended. Specifically, the context of focusing on Dari speaking Afghans needs much earlier introduction as a key contextual factor, and the study the limitations need more refinement. Please see Comments from Reviewer 2 for further details.

Please submit your revised manuscript by Dec 13 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Magdalena Szaflarski, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for addressing those comments and the revised manuscript looks great. No further comments. Thank you.

Reviewer #2: I appreciate the edits the authors have made to the manuscript. It reads much more clearly now and will be a valuable contribution. I appreciate the context added regarding the influx of Afghan refugees since 2019 as well as the explanation of the outreach in the lead investigator's circle. That said, I still think the context of focusing on Dari speaking Afghans needs much earlier introduction - e.g. in the intro - as a contextual factor, not to minimize the value of the scale developed here nor the importance of this group - likely an understudied group!, but rather because the scale definitively DOES need testing in other refugee groups to ensure the assumptions hold up. On that point, the limitations need to be strengthened, too.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Wendan Shi

Reviewer #2: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Developing and validating a HEalthCare NAvigation Competency (HECNAC) Scale for refugees in the United States

PONE-D-24-08489R2

Dear Dr. Yeo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Magdalena Szaflarski, PhD

Academic Editor

PLOS ONE

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