General practitioners’ everyday clinical decision-making on psychosocial problems of children and youth in the Netherlands

Lennard T. van Venrooij; Pieter C. Barnhoorn; Anne Marie Barnhoorn-Bos; Robert R. J. M. Vermeiren; Matty R. Crone

doi:10.1371/journal.pone.0278314

Peer Review History

Original SubmissionApril 10, 2022
27 Aug 2022 Decision Letter - Hugh Cowley, Editor PONE-D-22-10593General practitioners’ everyday clinical decision-making on psychosocial problems of children and youth in the NetherlandsPLOS ONE Dear Dr. van Venrooij, 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 note that we have only been able to secure a single reviewer to assess your manuscript. We are issuing a decision on your manuscript at this point to prevent further delays in the evaluation of your manuscript. Please be aware that the editor who handles your revised manuscript might find it necessary to invite additional reviewers to assess this work once the revised manuscript is submitted. However, we will aim to proceed on the basis of this single review if possible. The reviewer has raised some significant concerns regarding the reporting of this study. When revising your manuscript, please ensure you address each of the comments fully; the requested methodological detail has a bearing on whether the conclusions of this study can be reasonably found to add to the body of knowledge in this field. Please submit your revised manuscript by Oct 09 2022 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). 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Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide [Note: HTML markup is below. Please do not edit.] 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: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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: No ****** 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 ****** 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: Only very little is reported from the qualitative study, since most findings are presented as percentages, which is inappropriate given the non-representative character of both samples (see remarks below). I would assume that IF e.g. divergent types of CDM could be found, this would be of more relevance to the average reader, especially since the qualitative study did not seem to have informed the quantitative arm of the study substantially (both studies were conducted in the same timeframe). Sampling technique: All GP´s were recruited from a regional academic research Network – this might have lead to selection effects (or all all GPs in the region members of this network)? I did not fully understand the criteria for GPs who were approached for the quantitatve study: all remaining GPs not expressing their interest in research? Plus GPs not responding to the qualittive study? It seems that GPs could indicate their interest in both studies, but there was no overlap between both study groups – was this by purpose or not? Furthermore, if the qualitative study part included one participant max. per district, this would mean that the sample initially has been restricted to n=14 – or did the number and distribution happened by chance? If further inclusion/exclusion criteria like e.g. restricting the number of perticipants for the qualitative study based on the GP´s district, this should be made clear and should be justified. The sample obtained showed a long history of working as GPs; it might be of interest to see the range of years they have been working in the field. One would expect that GP´s with an average history of 18 years of practive usually have more routine in their CDM, and this might in part explain their hight self-rated competence. Inclusion criteria (“GPs reporting seeing psychosocial problems among children and youth a minimum of three times per two weeks”) and finding in table 1 (max monthly psychosocial problems in children (35%) in the qualitative study and 50% in the quantitative study do not match. Participants . Are the inclusion criteria defined as ALL criteria need to be fulfilled or at least one of the criteria has to be fulfilled? ****** 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: 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.0278314.r001
Revision 1
18 Oct 2022 Author Response Point-by-point response to comments given by the reviewer * Only very little is reported from the qualitative study, since most findings are presented as percentages, which is inappropriate given the non-representative character of both samples (see remarks below). Pages 13-19. The authors have now used words to describe the findings, instead of percentages (e.g. ‘some’, ‘many’, ‘a few’). Additionally, we have made a distinction between the qualitative and quantitative results by separating the two arms more clearly in the text (using indents). It was our intention to compare the quantitative with the qualitative data and to explore whether both substudies would show similar results. * I would assume that IF e.g. divergent types of CDM could be found, this would be of more relevance to the average reader, especially since the qualitative study did not seem to have informed the quantitative arm of the study substantially (both studies were conducted in the same timeframe). Page 21. We used a convergent mixed-method design, as our first aim was to explore what kind of decision-making processes could be distinguished. By combining and comparing the perspectives from qualitative and quantitative data, we aimed to triangulate the findings. Additionally, the qualitative findings explained to some extent the mechanisms behind the decision-making processes that were found in both study arms. The study provided some indication for different types of GPs regarding their CDM, but the sample was not sufficiently large to be able to distinguish divergent types of CDM. However, it will be an interesting next step to assess whether different profiles of GPs can be distinguished, as has also been described by Roberts et al 2014, who described the three role archetypes GPs can fulfill while identifying mental health problems in children and youths: ‘fixers’, ‘future planners’ and ‘collaborators’. We elaborated on this point in the Discussion. * Sampling technique: All GP´s were recruited from a regional academic research Network – this might have lead to selection effects (or all all GPs in the region members of this network)? Page 21. We agree the recruitment from the regional academic research network might have led to inclusion of GPs who were particularly interested in youth care. This may have influenced our results. Therefore, we have added this point to the Discussion. * I did not fully understand the criteria for GPs who were approached for the quantitatve study: all remaining GPs not expressing their interest in research? Plus GPs not responding to the qualittive study? It seems that GPs could indicate their interest in both studies, but there was no overlap between both study groups – was this by purpose or not? Pages 8 & 11. All GPs who were registered in the research network were invited to participate in both the quantitative and qualitative substudy. Unpurposely, all GPs who participated in the qualitative substudy did not fill-out the questionnaire of the quantitative substudy. Both substudies were conducted at roughly the same time. We have processed our response in the text. * Furthermore, if the qualitative study part included one participant max. per district, this would mean that the sample initially has been restricted to n=14 – or did the number and distribution happened by chance? If further inclusion/exclusion criteria like e.g. restricting the number of participants for the qualitative study based on the GP´s district, this should be made clear and should be justified. Page 8. Since there are 14 districts in Holland Rijnland, the sample initially has been restricted to n=14. If two or more GPs from a particular district indicated their wish to participate in the qualitative substudy, the GP who responded first was included. We clarified our response in the text describing our sampling criteria. * The sample obtained showed a long history of working as GPs; it might be of interest to see the range of years they have been working in the field. One would expect that GP´s with an average history of 18 years of practive usually have more routine in their CDM, and this might in part explain their hight self-rated competence. Pages 11, 20 and Table 1. We have reported the range of years GPs have been working in the field and the range of years they have been working in their current general practice. We did not found that GPs who worked more years in the field had a higher self-rated competence. However, we found that more experienced GPs tend to give more priority to somatic instead of psychosocial problems. * Inclusion criteria (“GPs reporting seeing psychosocial problems among children and youth a minimum of three times per two weeks”) and finding in table 1 (max monthly psychosocial problems in children (35%) in the qualitative study and 50% in the quantitative study do not match. Page 9. We agree this inclusion criteria and these findings cause some confusion. In both substudies, we aimed to include GPs who see psychosocial problems among children and youths a minimum of three times per two weeks. However, during the recruitment phase, there were quite some GPs who reported seeing psychosocial problems about once to three times a month. Therefore, we have adjusted the sampling criteria. *Participants . Are the inclusion criteria defined as ALL criteria need to be fulfilled or at least one of the criteria has to be fulfilled? Pages 8 & 9. The authors confirm that all sampling criteria needed to be fulfilled. As mentioned above, the criterion of seeing psychosocial problems among children and youths a minimum of three times per two weeks was found to be too strict, although it was our aim to include GPs who see these problems in a sufficient frequency. https://doi.org/10.1371/journal.pone.0278314.r002
6 Nov 2022 Decision Letter - Margaret Williams, Editor PONE-D-22-10593R1General practitioners’ everyday clinical decision-making on psychosocial problems of children and youth in the NetherlandsPLOS ONE Dear Dr. Lennard van Venrooij 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. ============================== REVIEWERS COMMENTS: Only very little is reported from the qualitative study, since most findings are presented as percentages, which is inappropriate given the non-representative character of both samples (see remarks below). I would assume that IF e.g. divergent types of CDM could be found, this would be of more relevance to the average reader, especially since the qualitative study did not seem to have informed the quantitative arm of the study substantially (both studies were conducted in the same timeframe). Sampling technique: All GP´s were recruited from a regional academic research Network – this might have lead to selection effects (or all all GPs in the region members of this network)? I did not fully understand the criteria for GPs who were approached for the quantitatve study: all remaining GPs not expressing their interest in research? Plus GPs not responding to the qualittive study? It seems that GPs could indicate their interest in both studies, but there was no overlap between both study groups – was this by purpose or not? Furthermore, if the qualitative study part included one participant max. per district, this would mean that the sample initially has been restricted to n=14 – or did the number and distribution happened by chance? If further inclusion/exclusion criteria like e.g. restricting the number of perticipants for the qualitative study based on the GP´s district, this should be made clear and should be justified. The sample obtained showed a long history of working as GPs; it might be of interest to see the range of years they have been working in the field. One would expect that GP´s with an average history of 18 years of practive usually have more routine in their CDM, and this might in part explain their hight self-rated competence. Inclusion criteria (“GPs reporting seeing psychosocial problems among children and youth a minimum of three times per two weeks”) and finding in table 1 (max monthly psychosocial problems in children (35%) in the qualitative study and 50% in the quantitative study do not match. Participants . Are the inclusion criteria defined as ALL criteria need to be fulfilled or at least one of the criteria has to be fulfilled? ============================== Please submit your revised manuscript by 30 November 2022. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Margaret Williams, Ph.D Academic Editor PLOS ONE Additional Editor Comments (if provided): Only very little is reported from the qualitative study, since most findings are presented as percentages, which is inappropriate given the non-representative character of both samples (see remarks below). I would assume that IF e.g. divergent types of CDM could be found, this would be of more relevance to the average reader, especially since the qualitative study did not seem to have informed the quantitative arm of the study substantially (both studies were conducted in the same timeframe). Sampling technique: All GP´s were recruited from a regional academic research Network – this might have lead to selection effects (or all all GPs in the region members of this network)? I did not fully understand the criteria for GPs who were approached for the quantitative study: all remaining GPs not expressing their interest in research? Plus GPs not responding to the qualitative study? It seems that GPs could indicate their interest in both studies, but there was no overlap between both study groups – was this by purpose or not? Furthermore, if the qualitative study part included one participant max. per district, this would mean that the sample initially has been restricted to n=14 – or did the number and distribution happened by chance? If further inclusion/exclusion criteria like e.g. restricting the number of participants for the qualitative study based on the GP´s district, this should be made clear and should be justified. The sample obtained showed a long history of working as GPs; it might be of interest to see the range of years they have been working in the field. One would expect that GP´s with an average history of 18 years of practice usually have more routine in their CDM, and this might in part explain their hight self-rated competence. Inclusion criteria (“GPs reporting seeing psychosocial problems among children and youth a minimum of three times per two weeks”) and finding in table 1 (max monthly psychosocial problems in children (35%) in the qualitative study and 50% in the quantitative study do not match. Participants . Are the inclusion criteria defined as ALL criteria need to be fulfilled or at least one of the criteria has to be fulfilled? [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.] 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.0278314.r003
Revision 2
13 Nov 2022 Author Response * Only very little is reported from the qualitative study, since most findings are presented as percentages, which is inappropriate given the non-representative character of both samples (see remarks below). Pages 7, 9, 11-19 & 21. We have now used words to describe the findings, instead of percentages (e.g. ‘some’, ‘many’, ‘a few’). Additionally, we have made a distinction between the qualitative and quantitative results by separating the two arms more clearly in the text (using indents). It was our intention to compare the quantitative with the qualitative data and to explore whether both substudies would show similar results. In total, 14 GPs were interviewed. Next, 15 GPs completed the questionnaire. Five GPs started, but did not filled it out completely. This latter group did not differ greatly from the group that filled out the whole questionnaire regarding sociodemographic characteristics or frequency of seeing children and youths with psychosocial problems. In total, we had either qualitative or quantitative clinical decision-making information of 29 GPs, using the same vignettes in both substudies. * I would assume that IF e.g. divergent types of CDM could be found, this would be of more relevance to the average reader, especially since the qualitative study did not seem to have informed the quantitative arm of the study substantially (both studies were conducted in the same timeframe). Page 21. We used a convergent mixed-method design, as our first aim was to explore what kind of decision-making processes could be distinguished. By combining and comparing the perspectives from qualitative and quantitative data, we aimed to triangulate the findings. Additionally, the qualitative findings explained to some extent the mechanisms behind the decision-making processes that were found in both study arms. The study provided some indication for different types of GPs regarding their CDM, but the sample was not sufficiently large to be able to distinguish divergent types of CDM. However, it will be an interesting next step to assess whether different profiles of GPs can be distinguished, as has also been described by Roberts et al 2014, who described the three role archetypes GPs can fulfill while identifying mental health problems in children and youths: ‘fixers’, ‘future planners’ and ‘collaborators’. We elaborated on this point in the Discussion. * Sampling technique: All GP´s were recruited from a regional academic research Network – this might have lead to selection effects (or all all GPs in the region members of this network)? Page 21. We agree the recruitment from the regional academic research network might have led to inclusion of GPs who were particularly interested in youth care. This may have influenced our results. Therefore, we have added this point to the Discussion. * I did not fully understand the criteria for GPs who were approached for the quantitatve study: all remaining GPs not expressing their interest in research? Plus GPs not responding to the qualittive study? It seems that GPs could indicate their interest in both studies, but there was no overlap between both study groups – was this by purpose or not? Pages 8 & 11. All GPs who were registered in the research network were invited to participate in both the quantitative and qualitative substudy. Unpurposely, all GPs who participated in the qualitative substudy did not fill-out the questionnaire of the quantitative substudy. Both substudies were conducted at roughly the same time. We have processed our response in the text. * Furthermore, if the qualitative study part included one participant max. per district, this would mean that the sample initially has been restricted to n=14 – or did the number and distribution happened by chance? If further inclusion/exclusion criteria like e.g. restricting the number of participants for the qualitative study based on the GP´s district, this should be made clear and should be justified. Page 8. Since there are 14 districts in Holland Rijnland, the sample initially has been restricted to n=14. If two or more GPs from a particular district indicated their wish to participate in the qualitative substudy, the GP who responded first was included. We clarified our response in the text describing our sampling criteria. * The sample obtained showed a long history of working as GPs; it might be of interest to see the range of years they have been working in the field. One would expect that GP´s with an average history of 18 years of practive usually have more routine in their CDM, and this might in part explain their hight self-rated competence. Pages 11, 20 and Table 1. We have reported the range of years GPs have been working in the field and the range of years they have been working in their current general practice. We did not found that GPs who worked more years in the field had a higher self-rated competence. However, we found that more experienced GPs tend to give more priority to somatic instead of psychosocial problems. * Inclusion criteria (“GPs reporting seeing psychosocial problems among children and youth a minimum of three times per two weeks”) and finding in table 1 (max monthly psychosocial problems in children (35%) in the qualitative study and 50% in the quantitative study do not match. Page 9. We agree this inclusion criteria and these findings cause some confusion. In both substudies, we aimed to include GPs who see psychosocial problems among children and youths a minimum of three times per two weeks. However, during the recruitment phase, there were quite some GPs who reported seeing psychosocial problems about once to three times a month. Therefore, we have adjusted the sampling criteria. *Participants . Are the inclusion criteria defined as ALL criteria need to be fulfilled or at least one of the criteria has to be fulfilled? Pages 8 & 9. The authors confirm that all sampling criteria needed to be fulfilled. As mentioned above, the criterion of seeing psychosocial problems among children and youths a minimum of three times per two weeks was found to be too strict, although it was our aim to include GPs who see these problems in a sufficient frequency. https://doi.org/10.1371/journal.pone.0278314.r004
15 Nov 2022 Decision Letter - Margaret Williams, Editor General practitioners’ everyday clinical decision-making on psychosocial problems of children and youth in the Netherlands PONE-D-22-10593R2 Dear Dr. van Venrooij 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, Margaret Williams, Ph.D Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0278314.r005
Formally Accepted
16 Dec 2022 Acceptance Letter - Margaret Williams, Editor PONE-D-22-10593R2 General practitioners’ everyday clinical decision-making on psychosocial problems of children and youth in the Netherlands Dear Dr. van Venrooij: 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 Professor Margaret Williams Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0278314.r006

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