Title: Using Implementation Science Frameworks to Translate and Adapt a Pregnancy App for
an Emerging Latino Community
Version: 3 Date: 25 May 2022
Reviewer:  Karolina Kuberksa
Reviewer's report:
Thank you for the opportunity to review this manuscript - I read it with pleasure.
This is a very good paper qualitatively describing a structured approach to carrying out a much-
needed access to health improvement initiative.
The aims of the paper are clear and suited to the methods described.  However, I'm not sure if
the title of the paper is accurate - it seemed like the qualitative study was a part of the three-
step process, and that what the paper describes is both the qualitative approach to information
gathering AND the app adaptation process. Perhaps a solution is to give up the part of the title
after the colon, e.g. Adapting a Pregnancy App to Address Disparities in Healthcare Access
Among an Emerging Latino Community Using Qualitative Study and Implementation Science
Frameworks.
Below, you will find multiple minor comments – I do not expect all of them to be taken on
board but perhaps it’s useful to see how someone from outside of the US healthcare system read
your manuscript.
I would like to praise the authors for accurate navigation of phrasing around language skills of
the intended users of the app. However, in line 50, you mention "non-English speakers" only –
but later on you explain that poor access to healthcare characterises also those whose fluency is
poor or simply insufficient to their needs - perhaps it would be worth being a bit more precise
at the beginning of the paper as well.
On one occasion, you use the phrase "Hispanic or Latino" but then you only use the word
"Latino" even though the app whose development you're describing targets Spanish speakers
rather than all immigrants from Latin America. Perhaps a sentence on how you’re using the
word “Latino” in your paper would help to clarify this issue.
In line 105-6, it says “Spanish version”, would you consider “Spanish-language version”?
Line 109, the word “app” is capitalised – I’m not sure why.
Line 126-7 – I’m wondering if the effect of the patient-provider relationship you have in mind is
positive or negative? From the sentence it perhaps seems like it’s positive but maybe it’s worth
making it clear?
Line 135 – “mHealth apps” – is the plural intentional because you mean generic mobile health
apps? If so, would you consider spelling it out as mHealth may look like a brand name to those
less familiar with the healthcare provision landscape.
Line 147-9 – you give an example of an open-ended question but the question in the bracket
is a yes/no question – perhaps it’d be better to choose a different example or, indeed, rephrase
the question into e.g. “can you tell us about your worries about…” In that same section, I
would perhaps have liked to learnt what the questions were covering (something more specific
than “themes identified”), a brief recapitulation of the topics covered in the semi-structured
interviews would be helpful to the reader.
Sometimes you put the examples of questions in quotation marks (e.g. line 167, sometimes you
don’t – e.g. line 148ff) – I’m sure you’d like to make it consistent.
Line 186-7, demographics. I was wondering if this group is in any way representative of ethnic
background of Latino immigrants in the US? My guess would be no, but perhaps it’s worth
clarifying.
Line 191 (but also elsewhere) – I’m finding “language appropriateness” ambiguous – I’m not
sure if that means Spanish or simplifying/slowing down English. If you are referring to fluency,
perhaps using a more accurate wording would work better?
This is a point about the structuring of the results, there’s phrasing that, while absolutely
unambiguous, is a little odd. E.g. you write: “In the Language domain, some emphasised
language appropriateness….” What you frame as “language domain” is a part of your analysis,
what “some emphasised…” describes is what participants said. But these domains were imposed
after, so when the participants were mentioning things, they did not know the domains their
remarks will end up in. I understand you may feel it’s a petty comment but I think it would
be much clearer if you simply used subheadings with domains names and reported on what
participants said that you ended up categorising under any given domain.
Talking about domain names, is “language” better than “communication” given how you
describe it in lines 191-195.
Line 233 – it should be “an mHealth”, not “a mHealth” – could I double-check with you if the
word “app” is missing between “mHealth” and “implementation”. I’d like to encourage you to
revise this sentence – I’m sure there’s a way of making it a bit clearer.
Line 239 – Is it “MyHeathy Pregnancy Prototype” or “MyHealthy Pregnancy App prototype”?
Lines 253-260 – it’s not clear how pregnant women find their way to the pregnancy app – is one
specific one recommended? How is it different for Latino pregnant individuals?
Lines 269-271 – how is the app addressing the issue of people not being able to ask follow up
questions – or rather – can the app address this problem at all?
Lines 284-290 – I would love to see a few examples of this translation process.
I'd like to encourage you to have another go at the conclusion and think about how your study
could be applicable in other contexts, what else it could be useful for, in what way using
this process can translate into improving outcomes for Spanish-speaking communities in other
healthcare contexts? In a nutshell,  I'd like to see how it fits into broader debates.
I know it seems like I’ve listed a ton of things to improve but I really think this is an excellent
paper and an excellent project in service of a worthy cause. It is almost ironic that you have to
write about it in English, isn’t it?