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PONE-D-20-29419

Visual aids in clinical practice: experiences, perceptions and needs of patients and healthcare professionals

PLOS ONE

Dear Dr. Hafner,

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 all points raised during the review process.

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Barbara Schouten

Academic Editor

PLOS ONE

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CGR 75659

Edmond J. Safra Foundation.

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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: No

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

Reviewer #1: N/A

Reviewer #2: N/A

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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: No

Reviewer #2: No

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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: Many papers have been published about visual aids. This manuscript adds relevant additional knowledge to current insights based on qualitative interviews. The research question is well embedded in literature, the methodology fits, the results are described clearly. My main issue is that I would expect some more citations to illustrate the findings, as some paragraphs don’t use any citation at all. I have the following minor issues as suggestions for further improvement.

Methods:

• When was the study performed?

• Focusgroup: what number of participants was your aim? What were criteria for purposive selection (e.g. gender, age, health literacy, experience)?

• With respect to the criteria for purposive selection: did you find any indication how the results were influenced by these criteria? Did you look for conflicting evidence?

• The definition of VAs is somehow problematic, as you did leave this to the focus group (and later you give direction to the discussion by giving examples). Hence it is not clear what kind of VAs this research addresses.

o In general, I believe this is not problematic in the context of this paper. As the results show, different types of VA were named during the FGs.

o Please discuss this (also with respect to more modern/complex interventions that include visual material, such as instruction video’s, animations, instruction games).

o Did you notice any differences in benefits and limitations with respect to the type of VAs?

• Please include the interview guide in the manuscript (not as supplement).

Results

• The use of citation seems unbalances (no citation in the first paragraphs, appropriate citations in the second part)

• I believe line ‘117 Professions of healthcare participants’ can be skipped.

• Paragraph Identification.

o Please support your findings in this paragraph with appropriate citations.

• Paragraph context

o I believe Table 2 might be skipped as the information is well covered within the text.

o Illustrate the first part ‘context’ with citations

o Should the text below the Table be part of the Title of Table 3 ‘Purposes and roles of visual tools with cited examples (not exhaustive) and their advantages and constraints of use.’?

o Line 214, page 12. What is the active rol (as this is not clear)? Please give an example: The active role of the patient while using “visual tools” is essential but it should also be the case in the process of creation of VA.

• I believe the paragraphs Summary of results and Strengths and limitation should be part of the discussion

Discussion:

• Some more limitations might be discussed, such as the interview guide, the very broad scope of the topic (ranging from pictograms to games).

• Discusion please include the following aspects in your discusion

o How do the cultural background and patient characteristics such as age, gender and disease characteristics influence the need for VA, and what cultural aspects are most relevant in this context?

o Co creation: very interesting topic. Is this meant in the context of development of VA, or might this also apply to the use of VA during every single consultation?

o How should be accounted for diversity in health literacy in the use and development of VAs?

Remark:

• Statement concerning data availability: it seems that the underlying data (complete transcriptions, analysis and audio-taped focusgroup interviews) are not available. I do not believe this is needed for this paper. However I believe the statement that “all data underlying the findings described fully available, without restriction, and from the time of publication” is not true.

Reviewer #2: Overall impression

The authors describe a study consisting of focus groups with patients and healthcare professionals on the use of visual aids in ambulatory medical practice. Their aim is to understand how visual aids are used and to identify benefits and practical constraints. The authors conclude that there is a need for visual aids in medical practice, that patients are concerned about replacing the conversation with visual aids and that practitioners are looking for support with access to high quality materials. It is a topic worth exploring, with a commonly-used methodology and great to see a multidisciplinary researcher team. However, there are major weaknesses in the paper with regards to presenting the data (i.e., only for some part of the Results are data presented in a way that shows they follow from the interview; other sections read more like the authors' interpretations) and logic (i.e., conclusions are drawn that do not seem to follow from the presented data and that are not in line with the presented research questions). In addition, the practice implications to create a database with visual elements does not seem to follow from the study findings.

Introduction

1. The introduction should ideally begin with an explanation of the problem that will be addressed in the study, along the lines of “In the medical (…) adapted to patients”, lines 47-49

2. 41-42: The definition of visual aids appears to be incomplete. The description seems to cover ‘visual’ without focussing on the role of ‘aid’

3. The examples in lines 42-43 are incomplete and not very informative. There are several mentions of ‘.etc’ in the first few pages (lines 38, 42, 52) where it would be more appropriate to present a fuller context.

4. 52: the ‘therefore’ does not follow logically from the sentence before. The authors may want to consider adding something like “It is therefore difficult to draw evidence-based conclusions on what can be considered good practice…”

Methods

5. The described methods generally sound appropriate, but are not tailored to the question on insight into current use of visual aids, for which you would preferably have a wider cross-section. The described method would be better suited to address the question on stakeholders’ perceptions on helpful ways(/barriers) to use visual aids instead.

6. In addition to this, the focus group guide (supplementary file) does not appear to address practical constraints, which is one of the indicated research questions.

7. Line 99-100: Please expand on why the separation of patients and HCPs seemed important or how it helped facilitate discussion, e.g. did they feel more comfortable to share their stories?

8. Line 109: Please provide the intercoder reliability for the double-coded section.

Results

9. Major issue - This section does not meet standards for qualitative reporting. It is generally unclear what was discussed in the interviews and what is interpretation by the authors (e.g. line 214-215: “The active role … creation of VA”). It is also unclear whether findings were mentioned once by a single stakeholder or whether there was group consensus – it would be helpful to add numbers or general indicators (“the group agreed that..”). Quotes should be added, like in section 178-202. The summary of results (283-291) indicates the potential of interesting findings from the interview data, but this is not adequately presented in the results section.

10. It is great to see the diversity of healthcare professionals included. I am missing the characteristics/demographics of the patient participants. Characteristics such as being a chronic vs new patient, age, literacy levels and cultural background can have great impact on preferences for the use and look of visual aids.

11. 125: what do the authors mean with “complete elaborate VA”?

12. 129-135: this is more a methodological consideration re the researchers’ use of language in the interviews than a result to report.

13. 142+145: the authors make a distinction between ‘visual support’ and ‘visual tool’. However, the language used for this distinction is not very intuitive. If I understand the difference right, I would suggest using ‘stand-alone visual aids’ vs ‘interactive visual aids’. This is in line with what the authors state in line 206 that ‘the main common characteristic of visual tool is their context of use’.

14. 164: The authors list ‘some examples of visual support’ in table 2. This list needs to be extensive, as the aim of the work is to understand how visual aids are being used.

15. 166, Table 2 – also, 174, Table 3: Were the roles of the visuals and advantages and constraints of use discussed in the interviews, or are these the authors’ interpretations?

16. 166, Table 2: The body of the text talks about the importance of ‘tone’ and ‘frightening pictogram’. The table does not mention emotional effects as a consideration for use.

17. 174, Table 3: The authors may want to think about a more specific term for ‘Communication’ as a purpose, as explanation and situation setting are also forms of communication.

18. 185: Could the authors clarify what they mean with ‘typically visual information’?

19. 230: Could the authors clarify what they mean with “we have not been able to identify a system of how VA are read by patients”

20. 238: Who offered this solution of co-construction?

21. 248: Did the patients and healthcare professionals mention it was a good idea to learn a common reference system or do the authors make this claim based on literature?

22. 258: Who suggested to create a digital database? Seems like a pretty big leap from a conversation about the use of visual aids, and most patients not having much experience with it as the authors describe, to them suggesting the development of a digital database.

23. 265-266: “We have senses… been explicitly stated”. This is not data but the authors’ interpretation.

24. 295-296: Could the authors please elaborate on how their experience has helped to mitigate bias in the research

25. 298: If the authors were interested to explore stakeholders’ perceptions on potential uses of visual aids, the statement regarding generalisation might be true to some extent. But findings on how visual aids are being used in a single location are not necessarily generalisable to different healthcare context. The authors should be more realistic and specific about the extent to which their findings are generalisable.

Discussion

26. Although there appear to be some interesting findings, this section is confused as well. It presents some data that is not apparent in the results section, e.g. lines 332-33: “several healthcare professionals… for translation purposes” and lines 343-345: “the healthcare professionals… context of the patient.”

27. 307: While I see how the classification of visual aids in practice can be helpful for the research team, I am not convinced that this is a priority finding in the context of use of visual aids and barriers and facilitators in practice. Perhaps the authors can restructure the discussion to place more emphasis on discussing the research questions.

28. 302-303: These sentences seem to contradict each other: “they do not… by their graphic characteristics” vs “…emphasize the importance of aesthetics”, which is shaped by the graphic characteristics.

Conclusion

29. 356: The conclusion does not answer the research question of how visual aids are used in ambulatory practice and identifying practical constraints. Instead, the conclusions mainly focus on integrating visual aids in clinical practice, although it does seem to address the question on benefits of visual aids in practice.

30. 363-364: I am unsure what this conclusion is based on.

Practice implication

31. 366-368: This might be a helpful project, but does not follow from the described work and could have been proposed regardless of the specific study findings.

Others

32. Spelling/grammar could be improved in places, e.g. leave out ‘have’ in several instances (lines 34, 104, 113…)

33. I would suggest to make the title a more specific: single-site and ambulatory care

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Reviewer #1: Yes: Sander D. Borgsteede

Reviewer #2: No

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PONE-D-20-29419R1

Visual aids in clinical practice: experiences, perceptions and needs of patients and healthcare professionals

PLOS ONE

Dear Dr. Hafner,

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 Jul 30 2021 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: http://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,

Barbara Schouten

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.

Additional Editor Comments (if provided):

One reviewer has now commented on the revised draft of your manuscript. As you well see, he has some remaining comments to further improve upon your manuscript. In particular, the point raised about whether or not ethical clearance has been obtained to perform your study should be clarified.

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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: (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: Partly

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

Reviewer #1: N/A

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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

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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

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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: Some minor remarks (line numbers from version with track changes):

Definition of VA (introduction): you seem to focus on non-moving images, also illustrated by your examples. Please add this to your definition.

Methods: include in the manuscript when the interviews were performed.

Approach: purposive selection: please include your criteria for selection of HP as well (including motivation). You should mention some key characteristics of these professionals (experience, gender) as well, and mention if the were distributed well over the focus groups

Ethics (p6, line 102-103): it is not clear if the proposal was submitted to the Research Ethics Council or not. The authors state: 'full submission was not required'. Does this mean that there was a procedure that the Counsil approved a brief version of the protocol? Or was the protocol not submitted nor judged in any respect at all?

Minor detail (p7, line 123) authors state that seperation of patients SEEMED important. It looks like this WAS CONSIDERED by the authors, and not based on a result of this study.

Results (p 17, line 287, semantic point): main characteristic of interactive VA was their context of use. I doubt if you can call this a characteristic, if this is part of your definition. It is valuable to read how HP and professionals interact with VA, but this is not be both an essential element of the definition and a characteristic.

P20, line 370: please include a citation for 'pateints fear time of interaction with HP may be suppressed' as this seems an important point that comes back in the summary of results.

In my opinion, the abstract does not cover your main findings. You might consider to include the concepts of stand alone and interactive VA, and the purpose of VAs in the abstract.

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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: Sander D. Borgsteede

[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.

Visual aids in clinical practice: experiences, perceptions and needs of patients and healthcare professionals

PONE-D-20-29419R2

Dear Dr. Hafner,

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.

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Kind regards,

Barbara Schouten

Academic Editor

PLOS ONE