Older people’s challenges and expectations of healthcare in Ghana: A qualitative study

Confidence Alorse Atakro; Abigail Atakro; Janet Sintim Aboagye; Alice Aluwah Blay; Stella Boatemaa Addo; Dorcas Frempomaa Agyare; Peter Adatara; Kwaku Gyimah Amoa-Gyarteng; Awube Menlah; Isabella Garti; George Sedinam Boni; Osei Kwaku Berchie; Isaac Kwadwo Ansong

doi:10.1371/journal.pone.0245451

Peer Review History

Original SubmissionOctober 10, 2019
28 Jan 2020 Decision Letter - Andrew Soundy, Editor PONE-D-19-28368 Older people's challenges and expectations of nursing care in Ghana: A qualitative Study. PLOS ONE Dear Prof Atakro, 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. See comments below. We would appreciate receiving your revised manuscript by Mar 13 2020 11:59PM. When you are 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. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols 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). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Andrew Soundy Academic Editor PLOS ONE Journal Requirements: 1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 3. Please include additional information regarding the aemi-structured interview guide used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a guide as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Also, pretesting of this guide was referred to in the text but further details concerning the nature of number of participants is required. Furthermore, please expand on the recruitment of participants to this study and any inclusion/exclusion criteria employed. Additional Editor Comments: Abstract No need for prevalence figures in background information Introduction Make sure you justify why qualitative descriptive approaches are so valuable Methods You need to consider a framework which will support your write up e.g., COREQ or SRSQ – you need this to make sure you address each requirement of these – again it is not about a correct answer but that your method make sense in terms of the results you give e.g., sample size considerations? when I started to look at this type of approach this article talks about content analysis and frameworks https://journals.sagepub.com/doi/full/10.1177/1937586715614171 Study design You will need to give a better reference for your qualitative descriptive design e.g., a paper which gives key steps that are expected to be taken e.g., a specific paper which mentions some options could be. A general text book which is not specific to the design wouldn’t be appropriate. Reconsider this and within this consider your paradigmatic stance and methodological stance You need to justify your selected interview guide – did you do a cognitive interview before? Was it piloted – did you use literature to work out questions? Why so few questions? Not looking for a correct answer but your choices need justification You will need to include a full audit trail without this it will be hard to follow how you got the results that you have obtained - without this the paper will be rejected at the next point. Does your data analysis approach fit with the descriptive design you mention above? Please justify your choices Results I would like to see themes at the minor level from an audit trail [Note: HTML markup is below. Please do not edit.] Reviewers' comments: [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 to be viewed.] 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 us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0245451.r001
Revision 1
12 Mar 2020 Author Response Comment 1:When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Response 1: Plos one requirements were followed in the submission of manuscript Comment 2: We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. Response 2: Cover letter was modified to reflect data availability. An audit trail has now been provided that shows data collection at every stage and could show some challenges and expectations described by older people. Minimal data collected has also been provided to enable replication of this study. The number of the ethical committee provided for request of full data set. Comment 3:Please include additional information regarding the semi-structured interview guide used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a guide as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Also, pretesting of this guide was referred to in the text but further details concerning the nature of number of participants is required. Furthermore, please expand on the recruitment of participants to this study and any inclusion/exclusion criteria employed. Response 3: A copy of interview guide provided. all participant could speak English and did not need any translation for researchers. Additional information on the pretest such as the number pf people pre-tested has now been added. Comment 4:Abstract No need for prevalence figures in background information Response 4: The prevalence has now been removed as suggested. comment 5: Introduction Make sure you justify why qualitative descriptive approaches are so valuable Response 5:Justification of the qualitative study in introduction has now been included and highlighted. Comment 6: . Methods You need to consider a framework which will support your write up e.g., COREQ or SRSQ – you need this to make sure you address each requirement of these – again it is not about a correct answer but that your method make sense in terms of the results you give e.g., sample size considerations? when I started to look at this type of approach this article talks about content analysis and frameworks https://journals.sagepub.com/doi/full/10.1177/1937586715614171 Response 6: The COREQ framework has now been used in reporting work. The framework of COREQ was used in reporting all sections of the study. Comment 7: Study design You will need to give a better reference for your qualitative descriptive design e.g., a paper which gives key steps that are expected to be taken e.g., a specific paper which mentions some options could be. A general text book which is not specific to the design wouldn’t be appropriate. Reconsider this and within this consider your paradigmatic stance and methodological stance Response 7: This suggestion has been complied with and highlighted. Comment 8: You need to justify your selected interview guide – did you do a cognitive interview before? Was it piloted – did you use literature to work out questions? Why so few questions? Not looking for a correct answer but your choices need justification. Response 8: Justification now provided for the interview guide and highlighted. Questions were developed based on literature review. A pilot was done with 10 older people and ambiguous questions were modified. Comment 9:You will need to include a full audit trail without this it will be hard to follow how you got the results that you have obtained - without this the paper will be rejected at the next point. Response 9: The audit trail of this study has now been provided. Comment 10: Does your data analysis approach fit with the descriptive design you mention above? Please justify your choices. Response 10: This suggestion has been complied with and highlighted. Comment 11: . Results I would like to see themes at the minor level from an audit trail Response 11: Audit trail now provided. Attachments Attachment Submitted filename: RESPONSE TO REVIEW COMMENTS.docx https://doi.org/10.1371/journal.pone.0245451.r002
7 May 2020 Decision Letter - Andrew Soundy, Editor PONE-D-19-28368R1 Older people's challenges and expectations of nursing care in Ghana: A qualitative Study. PLOS ONE Dear Dr Atakro, 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. Please see comments from the reviewers and address. We would appreciate receiving your revised manuscript by 6 June 2020. When you are 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. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols 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). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Andrew Soundy Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] 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: (No Response) Reviewer #2: (No Response) ******** 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: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: (No Response) ****** 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: (No Response) ****** 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: (No Response) ****** 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: 1. Study setting Page 5 under settings: lines 2 -5, the authors stated that Ghana has 10 regions and listed the 10 regions. Now Ghana has 16 Regions. I recommend that the 16 regions should be used since the work is yet to be published. When stating the regions, for instance Ashanti Region, the R for the region should be an upper case. For example, Volta Region, Ashanti Region etc. 2. Data collection Page 6, line 2, I suggest that the authors use researchers instead of investigators. 3. Page 6, line 4: the authors stated that the interview guide was tested on 10 elderly persons; were these 10 elderly persons selected from the 3 research settings or other settings? Please state it. 4. Pages 6 and 7 seem to have repetitions: • lines 3-6, the authors stated that “The interview guide was developed based on literature and pre-tested on 10 elderly persons in order to identify and modify ambiguous questions. Semi-structured interviews (Appendix 1) were conducted in English since all participants could speak English.” • Last sentence on page 6 and first sentence on page 7 seems to be saying the same thing; “Interview guide was pretested on ten older people to identify ambiguous questions. Interviews were conducted in English”. The authors should please work on the repetition. 5. Rigour Page 7 line 1 should be “a pretest of semi-structured interview guide was …” the guide was omitted. 6. Ethical considerations Page 8, the last sentence: the authors stated that “Researchers made sure that this study did not cause any physical or psychological harm to any participant”. Please state how these were ensured. 7. Demographic characteristics of participants Page 8, the authors should be consistent with the use of the percentages. Some are in words and others are in figures. Please reconcile. 8. Discussions • Page 17: instead of using ‘elderly persons in this study’ authors should rather use participants. This should be effected throughout the manuscript. • Page 19, line 20: The authors should use client instead of patient since not all aged sent to the aged homes for care are sick. 9. Strengths of the study Page 20 line 4: throughout the manuscript, I did not see any recommendation for medical officers to be trained in Gerontology as stated here by the authors. Please delete the medical officers if it has not earlier been stated. 10. There are few grammatical errors. I suggest the authors employ the services of a language editor Reviewer #2: (No Response) ****** 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: No Reviewer #2: No [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 to be viewed.] 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 us at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: PONE-D-19-28368_reviewer.pdf Attachment Submitted filename: older people paper.docx https://doi.org/10.1371/journal.pone.0245451.r003
Revision 2
19 May 2020 Author Response Response to reviewer 1 comment 1:Study setting Page 5 under settings: lines 2 -5, the authors stated that Ghana has 10 regions and listed the 10 regions. Now Ghana has 16 Regions. I recommend that the 16 regions should be used since the work is yet to be published. When stating the regions, for instance Ashanti Region, the R for the region should be an upper case. For example, Volta Region, Ashanti Region etc. Response 1: These recommended corrections have been adhered to and highlighted in manuscript. Comment 2: Data collection Page 6, line 2, I suggest that the authors use researchers instead of investigators. Response 2: This suggestion had been adhered to and highlighted. Comment 3: Page 6, line 4: the authors stated that the interview guide was tested on 10 elderly persons; were these 10 elderly persons selected from the 3 research settings or other settings? Please state it. Response 3:The pretest was conducted in another region (Central region). This is now stated in manuscript as suggested. Comment 4:Pages 6 and 7 seem to have repetitions: • lines 3-6, the authors stated that “The interview guide was developed based on literature and pre-tested on 10 elderly persons in order to identify and modify ambiguous questions. Semi-structured interviews (Appendix 1) were conducted in English since all participants could speak English.” • Last sentence on page 6 and first sentence on page 7 seems to be saying the same thing; “Interview guide was pretested on ten older people to identify ambiguous questions. Interviews were conducted in English”. The authors should please work on the repetition. Response 4: Repetitions were removed throughout manuscript. Comment 5:Rigour Page 7 line 1 should be “a pretest of semi-structured interview guide was …” the guide was omitted. Response 5:This recommended correction has been adhered to and highlighted. Comment 6: Ethical considerations Page 8, the last sentence: the authors stated that “Researchers made sure that this study did not cause any physical or psychological harm to any participant”. Please state how these were ensured. Response 6: This has now been corrected. Researchers avoided questions that could cause any form of psychological trauma. Comment 7: Demographic characteristics of participants Page 8, the authors should be consistent with the use of the percentages. Some are in words and others are in figures. Please reconcile. Response 7: This recommended suggestion has been implemented. Comment 8: Discussions • Page 17: instead of using ‘elderly persons in this study’ authors should rather use participants. This should be effected throughout the manuscript. • Page 19, line 20: The authors should use client instead of patient since not all aged sent to the aged homes for care are sick. Response 8: This change has been done as recommended. Comment 9: Strengths of the study Page 20 line 4: throughout the manuscript, I did not see any recommendation for medical officers to be trained in Gerontology as stated here by the authors. Please delete the medical officers if it has not earlier been stated. Response 9: This correction has been done. Comment 10: There are few grammatical errors. I suggest the authors employ the services of a language editor. Response 10: The help of an editor was sought to make necessary grammatical corrections within manuscript. Response to reviewer 3: Comment 1: Title: I suggest that the word “nursing care” in the title be replaced with “healthcare” as findings from the study were not exclusively nursing care issues, Response 1: This suggestion has been adhered to. Comment 2: Abstract The abstract was well structured and well written, but minor revisions required. See main document. Response 2: Minor correction made in abstract. Comment 3: Background The background was well written to set the stage for the study. Very minor revisions required. Response 3: Minor correction made in background. Comment 4: Methods This section although it read well, there were few repetitions. Some revisions required. Response 4: Repetitions now removed as recommended. Comment 5: The descriptions of the elderly demographic characteristic did not play any role in the study as it would have been interesting elaborating on that. For example, it was reported that 33% of the older people who were presumed to have been retired were still in active employment. The detail of this was missing. Also, how it impacted their health and medical cost was also left hanging. Furthermore, majority of the older people were females. It would have been interesting to explore and report on the motivation for health seeking behaviour among the two gender and whether marital status and number of children played a role in their healthcare needs and hospital attendance. Response 5: This suggestion has been complied with and highlighted within work. However, differences in heath seeking behaviors between females and males was not explored in this study. Comment 6: The descriptions of the codes (variables) in the themes well not detailed enough. Moreso, most of the themes described were basic healthcare delivery or system challenges and not exclusive nursing care issues. There were some overlaps, for example, the themes financial burden and a cry for cost subsidisation read pretty much the same and could be collapsed as one theme. I believe repetitions and discrepancies will be minimised if further descriptions are given to all the codes/variables. The lengthy quotations should be reduced. Response 6: The recommendation has been complied with. Overlapping themes have now been condensed to avoid repetitions. There is also now more concentration on health workers rather than just nurses. Lengthy quotations reduced as recommended. Comment 7: The discussion needs a major revision. The discussion as it is shows a substantial difference of what is discussed and what was reported in the findings. For example, the chunk proportion of information on nursing education in gerontology and licencing examination in that field has no relation to the findings. The study did not look at the courses nurses read in training and therefore has no business discussing that. There is no consistency in the discussion as some of the information given was out of context. The study did not look at health service organisation and implications on the care of the elderly, yet, the discussions covers it. I suggest that the discussion section should be rewritten and attention paid to the findings of the study. Response 7: The discussion has been rewritten as recommended. Discussions now organised to be in line with findings as recommended in order to stay away from extensive discussions that did not border on findings specifically. Comment 8: Referencing The recommended referencing style and format must be adhered to. Response 8: Referencing format adhered to as recommended. Attachments Attachment Submitted filename: Responses to reviewers17thmay20.docx https://doi.org/10.1371/journal.pone.0245451.r004
10 Jul 2020 Decision Letter - Rosemary Frey, Editor PONE-D-19-28368R2 Older people’s challenges and expectations of healthcare in Ghana: A qualitative study PLOS ONE Dear MS ATAKRO, 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. ============================== Please make the minor changes to wording requested by Reviewer 2. ============================== Please submit your revised manuscript by 10 August 2020. 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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Rosemary Frey Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] 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: All comments have been addressed ******** 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: N/A 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: No Reviewer #2: (No Response) ****** 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: (No Response) Reviewer #2: Title: Fits the content Abstract The abstract is well structured and well written. Background The background was well written to set the stage for the study. Methods This section reads well. Findings The findings section was well structured for easy read, however, few observations made and outlined as follows: 1. Under theme 1, the use of verbs such as thoughts, wish, and felt are difficult to measure. Hence, it they must be written as reported expressions. For example, … some participants shared their thoughts that...Others said that they wished…. 2. Under theme 2, similar observations were made for example…in line 2 sentence 2 the word felt was used. 3. Under theme 3, the second sentence should begin with the word “Although” instead of though. 4. Under the fourth theme, subtheme 1, the check-ups should read check-up visits from health workers, not by health workers. Discussion The discussion reads much better. Limitation Well written ****** 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: No Reviewer #2: Yes:** LILLIAN AKORFA OHENE [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. https://doi.org/10.1371/journal.pone.0245451.r005
Revision 3
10 Jul 2020 Author Response Comment 1: Under theme 1, the use of verbs such as thoughts, wish, and felt are difficult to measure. Hence, it they must be written as reported expressions. For example, … some participants shared their thoughts that...Others said that they wished…. Response 1: The recommended change has been complied with and highlighted within manuscript. Comment 2: Under theme 2, similar observations were made for example…in line 2 sentence 2 the word felt was used. Response 2: The recommended change has been complied with and highlighted within manuscript. Comment 3: Under theme 3, the second sentence should begin with the word “Although” instead of though. Response 3: The recommended change has been complied with and highlighted within manuscript. Comment 4: Under the fourth theme, subtheme 1, the check-ups should read check-up visits from health workers, not by health workers. Response 4: The recommended change has been complied with and highlighted. Attachments Attachment Submitted filename: RESPONSE TO REVIEWERS.docx https://doi.org/10.1371/journal.pone.0245451.r006
13 Nov 2020 Decision Letter - Rosemary Frey, Editor PONE-D-19-28368R3 Older people’s challenges and expectations of healthcare in Ghana: A qualitative study PLOS ONE Dear Dr. Atakro, 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. ============================== Please address the issues raised by reviewers three and four. ============================== Please submit your revised manuscript by 13 December 2020. 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. 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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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Rosemary Frey Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] 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 #2: (No Response) Reviewer #3: (No Response) Reviewer #4: All comments have been addressed ******** 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 #2: (No Response) Reviewer #3: No Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: (No Response) Reviewer #3: N/A Reviewer #4: 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 #2: (No Response) Reviewer #3: No Reviewer #4: Yes ****** 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 #2: (No Response) Reviewer #3: No Reviewer #4: 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 #2: (No Response) Reviewer #3: This study of perceptions of health care among a population of elderly patients addresses an important subject. However, I am concerned that the study lacks a basic hypothesis which leads to a-theoretical purposive sampling and difficulty in interpreting results. It is unclear if saturation was achieved and if so by what criteria; rather, the approach seems to have been to select a qualitative sample size ahead of the study. The paper also does not frame the study in any larger conversations about care for aging populations or quality of care more broadly. Though local by nature, qualitative research is made valuable to various readers through this final process of synthesizing and making connections. Reviewer #4: Thank you for giving me to review your manuscript. This manuscript is interesting and scientifically meaningful for exploring healthcare challenges and expectations of elderly persons in developing countries facing aging societies in the future. Regarding the contents, I have several suggestions. 1. In the abstract, the authors stated, "Elderly persons across the globe are increasingly becoming marginalised and isolated." This research focuses on developing countries, so the author should focus this sentence on the issues in developing countries. 2. In the introduction, the authors delineate the condition of healthcare among older people broadly. The background section should include developed countries' conditions and the differences from LMICs that the authors deal with in this research for international readers. 3. In the introduction, again, several grammatical mistakes such as the many challenges, very little empirical, and so on. The authors should check wording seriously in the whole manuscript. 4. In the sample section of the method, there is no definition of older persons. There is various definition regarding older people/patients. The authors should show the definition with a reference. 5. In the method section's measurement, the authors clearly described the rigor of the method. To improve the rigor, the authors can include the researchers' reflectivity, such as researchers' backgrounds. 6. This research was based on content analysis, which may not be based on grounded theory. So, a theoretical foundation cannot be achieved based on the authors' methodology. A description of the situation may not be needed. 7. The result section should include a table of the background of the participants. 8. In the limitation section of the discussion, the authors delineate the generalizability of this study. Qualitative research should be assessed regarding credibility, transferability, dependability, and confirmability. This study has a high level of truthfulness. These four criteria should be evaluated through the manuscript. ****** 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 #2: No Reviewer #3: No Reviewer #4: No [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. https://doi.org/10.1371/journal.pone.0245451.r007
Revision 4
15 Nov 2020 Author Response Response to reviewer 3. Comment 1:This study of perceptions of health care among a population of elderly patients addresses an important subject. However, I am concerned that the study lacks a basic hypothesis which leads to a-theoretical purposive sampling and difficulty in interpreting results. Response 1: The authors did not formulate a hypothesis in the study. The study used a content analysis approach to explore challenges and expectations of older people in Ghanaian health system and reported this using COREQ criteria for reporting qualitative research (cited in study). The study did not utilise a grounded theory approach and therefore did not use a theoretical sampling technique. These methods were further clarified by the 4th reviewer as she/he states “This research was based on content analysis, which may not be based on grounded theory. So, a theoretical foundation cannot be achieved based on the authors' methodology”. Comment 2: It is unclear if saturation was achieved and if so by what criteria; rather, the approach seems to have been to select a qualitative sample size ahead of the study. Response 2: This has now been clarified in the data collection section as follows: Five participants were initially interviewed in each region. Additional five persons were interviewed in each region as saturation was not determined with the initial interviews. Saturation was determined after interviewing the 30th participant. Comment 3: The paper also does not frame the study in any larger conversations about care for aging populations or quality of care more broadly. Though local by nature, qualitative research is made valuable to various readers through this final process of synthesizing and making connections. Response 3: The difference in the quality of healthcare received by older people in developed and developing countries has now been stated in abstract to set the tone for the details in differences in background and discussion. The first section of the background is discussed in line with global dynamics in ageing. This has now been given a broader perspective by comparing health systems for the aged in developing countries to developed countries. The difference in care is mostly due to social and economic disadvantages in African countries (this point made and highlighted). The discussion section has also now suggested some evidence-informed global practices that could be adapted in Ghana to improve the health of older Ghanaians. These changes are highlighted in the study. Response to reviewer 4. Comment 1: In the abstract, the authors stated, "Elderly persons across the globe are increasingly becoming marginalised and isolated." This research focuses on developing countries, so the author should focus this sentence on the issues in developing countries. Response 1: This suggestion has been made and highlighted in manuscript (abstract). Comment 2: In the introduction, the authors delineate the condition of healthcare among older people broadly. The background section should include developed countries' conditions and the differences from LMICs that the authors deal with in this research for international readers. Response 2: This suggestion has now been included. Aged care systems such as residential and community care in developed countries are now compared with developing and middle-income countries. The changes have been highlighted in the background of the study. Comment 3: In the introduction, again, several grammatical mistakes such as the many challenges, very little empirical, and so on. The authors should check wording seriously in the whole manuscript. Response 3: grammatical errors were corrected throughout the manuscript with the assistance of a professional editor. Comment 4: In the sample section of the method, there is no definition of older persons. There is various definition regarding older people/patients. The authors should show the definition with a reference. Response 4: The United Nations definition of older persons, that is persons who are 60years or over, has now been included and highlighted. Comment 5: In the method section's measurement, the authors clearly described the rigor of the method. To improve the rigor, the authors can include the researchers' reflectivity, such as researchers' backgrounds. Response 5: This suggestion has now been included and highlighted. The background of the authors as qualitative researchers further helped in ensuring qualitative rigor in the study. Comment 6: The result section should include a table of the background of the participants. Response 6: A table has now been included and highlighted. Comment 7: In the limitation section of the discussion, the authors delineate the generalizability of this study. Qualitative research should be assessed regarding credibility, transferability, dependability, and confirmability. This study has a high level of truthfulness. These four criteria should be evaluated through the manuscript. Response 7: These suggested corrections have now been done and highlighted. Attachments Attachment Submitted filename: Response to reviewers15thNov20.docx https://doi.org/10.1371/journal.pone.0245451.r008
2 Jan 2021 Decision Letter - Rosemary Frey, Editor Older people’s challenges and expectations of healthcare in Ghana: A qualitative study PONE-D-19-28368R4 Dear Ms. ATAKRO, 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. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Rosemary Frey Academic Editor PLOS ONE Additional Editor Comments (optional): 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 #2: All comments have been addressed Reviewer #4: All comments have been addressed ******** 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 #2: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: N/A Reviewer #4: 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 #2: Yes Reviewer #4: Yes ****** 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 #2: Yes Reviewer #4: 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 #2: Title: Fits the content Abstract The abstract is well structured and well written. Background The background was well written to set the stage for the study. Methods This section reads well. Findings The findings section was well structured for easy read. Discussion The discussion reads much better. Limitation Well written Reviewer #4: The manuscript has been considerably improved. I think that this paper is suited for inclusion in our journal. ****** 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 #2: No Reviewer #4: Yes:** Ryuichi Ohta https://doi.org/10.1371/journal.pone.0245451.r009
Formally Accepted
7 Jan 2021 Acceptance Letter - Rosemary Frey, Editor PONE-D-19-28368R4 Older people’s challenges and expectations of healthcare in Ghana: A qualitative study Dear Dr. Atakro: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Rosemary Frey Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0245451.r010

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