‘If relevant, yes; if not, no’: General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory

Maria Roura; Joseph W. LeMaster; Ailish Hannigan; Anna Papyan; Sharon McCarthy; Diane Nurse; Nazmy Villarroel; Anne MacFarlane

doi:10.1371/journal.pone.0251192

Peer Review History

Original SubmissionJune 11, 2020
24 Feb 2021 Decision Letter - Barbara Schouten, Editor PONE-D-20-17815 ‘If relevant, yes; if not, no’: General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory PLOS ONE Dear Dr. MacFarlane, 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 submit your revised manuscript by March 23th . 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. 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Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 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 ****** 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 ****** 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: Overall, this is a well-written, clear and well-argued article that merits publication. I had very few comments, namely: - In the introduction, following paragraph 2: are the Irish Travellers’ normally considered a different ‘racial’ group in Ireland or is it more likely that they are a different ethnic group? It strikes me that they would probably still be considered Caucasian in research? (Just to clarify: in my experience, people tend to refer the term ‘race’ to the large continental groups – Caucasian, African, Asian etc – and the term ethnicity to other differences within those very large groups); - This is a very minor comment, but there were a few misplaced commas and a missing full stop on pg 11. Otherwise I didn’t notice any missing punctuation or typos; - Pg 11 3rd paragraph: it would be good if you could add a couple of sentence about a) whether participants were familiar with the HSE guidance and proposed categories and b) whether they knew of the potential benefits and challenges relating to the collection of ethnicity data. I imagine that was a precursor to the FGDs but it would be good if you could clarify this. Providing such information is particularly important because the quotes in the article reveal that people may not have fully understood the reason for asking questions about ethnicity (see also my comment on Table 5) and because of the sensitivity of the questions during the interviews; - What is the difference between ‘IDIs with GPs’ and ‘informal meetings with GPs’? - The proposed alternative questions if Table 5 are quite interesting, because at least to me they suggest that the participants may not have understood what the HSE questions are trying to get at. The reframed questions seem to be directly either about the service experience (e.g. do you prefer a male or female gynaecologist; do you need an interpreter) or about things that more directly link to health (what foods do you eat; is there something in your travel history that could explain your symptoms) – but obviously, that is not what the HSE questions are trying to get at. If you decide to keep Table 5 and the immediately preceding paragraph, then I think that you do need to comment on this in the main text of the article, and offer a bit of a reflection about what this means for your overall results? Is this a limitation to your study perhaps? Reviewer #2: A study that is useful in Primary Care beyond the Irish context. Could have been even better if paired with a systematic review of reasons (see Sofaer and Strech) as for example used by Moscrop et al to look at socio-economic (asking and coding) questions in the consultation. Whilst the number of GPs participating was low for this kind of study, the reasons for this make sense. ****** 6. 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:** Jantina De Vries 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.] 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.0251192.r001
Revision 1
19 Apr 2021 Author Response PONE-D-20-17815 ‘If relevant, yes; if not, no’: General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory PLOS ONE Response to reviewers April 2 2021 Reviewer #1: Overall, this is a well-written, clear and well-argued article that merits publication. RESPONSE: Thank you for this positive feedback. - Reviewer #1: In the introduction, following paragraph 2: are the Irish Travellers’ normally considered a different ‘racial’ group in Ireland or is it more likely that they are a different ethnic group? It strikes me that they would probably still be considered Caucasian in research? (Just to clarify: in my experience, people tend to refer the term ‘race’ to the large continental groups – Caucasian, African, Asian etc – and the term ethnicity to other differences within those very large groups); RESPONSE: In the Irish context, Irish Travellers are defined as a minority ethnic group – see reference 10. - Reviewer #1: This is a very minor comment, but there were a few misplaced commas and a missing full stop on pg 11. Otherwise I didn’t notice any missing punctuation or typos; RESPONSE: We have edited some commas and added the missing full stop on page 11. Reviewer #1: Pg 11 3rd paragraph: it would be good if you could add a couple of sentence about a) whether participants were familiar with the HSE guidance and proposed categories and b) whether they knew of the potential benefits and challenges relating to the collection of ethnicity data. I imagine that was a precursor to the FGDs but it would be good if you could clarify this. Providing such information is particularly important because the quotes in the article reveal that people may not have fully understood the reason for asking questions about ethnicity (see also my comment on Table 5) and because of the sensitivity of the questions during the interviews; RESPONSE: At the beginning of the focus groups, we explained to participants that the HSE was interested in ethnicity data collection as an equality monitoring measure to examine health outcomes and inform service adaptations in Ireland. We showed participants the ethnic identifier (see Figure 1). The focus groups were designed to elicit their views about the potential benefits and challenges. This information has been added to the paper, page 11. Reviewer #1: - What is the difference between ‘IDIs with GPs’ and ‘informal meetings with GPs’? RESPONSE: The semi-structured interviews (and focus groups) were based on a topic guide designed to gather in-depth information about the practice setting and to explore sense-making and engagement (See SFile 4). These were audio-recorded. The informal interviews were short meetings with GPs about the research and its progress. These were recorded as researcher debriefing notes. Reviewer #1: The proposed alternative questions if Table 5 are quite interesting, because at least to me they suggest that the participants may not have understood what the HSE questions are trying to get at. The reframed questions seem to be directly either about the service experience (e.g. do you prefer a male or female gynaecologist; do you need an interpreter) or about things that more directly link to health (what foods do you eat; is there something in your travel history that could explain your symptoms) – but obviously, that is not what the HSE questions are trying to get at. If you decide to keep Table 5 and the immediately preceding paragraph, then I think that you do need to comment on this in the main text of the article, and offer a bit of a reflection about what this means for your overall results? Is this a limitation to your study perhaps? RESPONSE: The alternative questions were proposed by participants because they thought that they were better questions to ask if the HSE was interested in adapting health services to meet their needs. It is not a limitation of the study because this is precisely the kind of data we were interested in: whether and how participants made sense of the idea of an ethnic identifier and the actual questions used to collect ethnicity data. This is why we say under Implications for policy and practice that our findings could be used to appraise and update HSE resources (information leaflets and training materials) to strengthen further the link between the ethnic identifier questions and health service improvement. We have edited that material to make this point clearer – see page 27. Reviewer #2: A study that is useful in Primary Care beyond the Irish context. Could have been even better if paired with a systematic review of reasons (see Sofaer and Strech) as for example used by Moscrop et al to look at socio-economic (asking and coding) questions in the consultation. Whilst the number of GPs participating was low for this kind of study, the reasons for this make sense RESPONSE: Thank you for positive comments about the study and GP participation. Thank you for the two references and we acknowledge the merits of a systematic review of reasons. Our grant, however, prioritised resources for an in-depth NPT informed analysis of three cases. As per page 6, and in line with your comment here about the usefulness of our study beyond the Irish context, these are a vehicle to learn about the collection of ethnicity data in primary care in Ireland and can be used to draw broader lessons that can be transferred to other general practice and primary care settings (conceptual generalizability). Attachments Attachment Submitted filename: Response April 2021.docx https://doi.org/10.1371/journal.pone.0251192.r002
22 Apr 2021 Decision Letter - Barbara Schouten, Editor ‘If relevant, yes; if not, no’: General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory. PONE-D-20-17815R1 Dear Prof. MacFarlane, 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, Barbara Schouten Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0251192.r003
Formally Accepted
3 May 2021 Acceptance Letter - Barbara Schouten, Editor PONE-D-20-17815R1 ‘If relevant, yes; if not, no’: General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory. Dear Dr. MacFarlane: 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. Barbara Schouten Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0251192.r004

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