PONE-D-22-35306Trends in self-reported cost barriers to dental care in Ontario.PLOS ONE

Dear Dr. Mona Abdelrehim,

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.

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PLOS ONE

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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: Partly

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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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

Reviewer #3: 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: Overall;

The manuscript can be very useful for policy makers in Canada, but the news value is limited for readers outside of Canada. Therefore, acceptation of this manuscript may only be useful for Canadian readers. Maybe it is better to submit this manuscript to a Canadian dental journal. Furthermore, the manuscript is quite lengthy and sometimes written more in prose style than in scientific style. Please change the style throughout the manuscript.

Introduction;

- Are dental costs not covered by insurance for underaged people in Canada (i.e. <18 years)? If so why would you include underaged people to the study?

Methods;

- How did you formulate the questions? Did you use standardized/validated questionnaires or did you just formulated questions?

- Why did you choose for a Poisson Regression? The outcome is binary. Why did you not choose a logistic regression?

- In both the methods and results section you mention p-values and significance for comparing unadjusted ratio's. How did you calculate those p-values? I cannot find the test you used for this.

- How did you check for not violating the assumptions that have to be met for a Poisson Regression?

Results;

- I do not see absolute numbers anywhere? Please report them to be able to interpret the data better.

- You made a lot of figures that could be captured in one table altogether. Please consider combining the figures in one table.

- Consider mentioning only the most important results in text and to further cite your tables instead of writing everything in text.

Discussion;

- How about residusal confounding in your results? Despite adjusting for a lot of variables, the found associations can still be explained by non-adjuted confounding variables.

Reviewer #2: 1- A good job was done. But I think the article is too long (50 pages of text in addition to 23 Figures) and boring for readers.

2- Considering that many similar articles related to the current topic have been published by the same authors (especially by Carlos Quiñonez which written bellow), it is better to remove the published results of their previous articles and only focus on the trends of cost barriers to avoiding dental treatment.

o Thompson B, Cooney P, Lawrence H, Ravaghi V, Quiñonez C. Cost as a barrier to accessing dental care: findings from a Canadian population‐based study. Journal of public health dentistry. 2014 Aug;74(3):210-8.

o Thompson B, Cooney P, Lawrence H, Ravaghi V, Quiñonez C. The potential oral health impact of cost barriers to dental care: findings from a Canadian population-based study. BMC Oral Health. 2014 Dec;14:1-0.

o Ramraj C, Sadeghi L, Lawrence HP, Dempster L, Quinonez C. Is accessing dental care becoming more difficult? Evidence from Canada's middle-income population. PloS one. 2013 Feb 20;8(2): e57377.

o Ravaghi V, Quiñonez C, Allison PJ. The magnitude of oral health inequalities in Canada: findings of the Canadian health measures survey. Community dentistry and oral epidemiology. 2013 Dec;41(6):490-8.

o Locker D, Maggirias J, Quiñonez C. Income, dental insurance coverage, and financial barriers to dental care among Canadian adults. Journal of public health dentistry. 2011 Sep;71(4):327-34.

o Sadeghi L, Manson H, Quiñonez CR. Report on access to dental care and oral health inequalities in Ontario. Public Health Ontario; 2013.

3- The objectives in the abstract section are related to previously published articles by the same authors. The purpose of the present manuscript should be written based on the title (trends and their attributable factors).

4- The Anderson model of health care utilization in the present study is the same as the Anderson model of health care utilization, which was published in their previous article:

Thompson B, Cooney P, Lawrence H, Ravaghi V, Quiñonez C. Cost as a barrier to accessing dental care: findings from a Canadian population‐based study. Journal of public health dentistry. 2014 Aug;74(3):210-8.

5- The Figures' captions don't have been numbered.

Reviewer #3: Comments to the Author

Overview comments

The methodology used is sound and logically explained, the results are reported relatively clearly and the authors provide reasonable interpretation in the discussion, offering acceptable conclusions based on the findings. However, I feel the paper needs small revisions before it will be ready for publication. Therefore, I recommend the authors consider the following points:

1) Although, the discussion has pulled all the information together in one place and the content of each paragraph is clear and it feels as if most of the arguments are well supported; but In relation to education level and cost barrier, the result showed opposite direction. It seems in this case education as a predisposing factor is somehow not properly linked to the enabling factors. Therefore, we can not only look for one reason to explain the opposite direction, rather multiple potential reasons could be the involved as a source of such finding.

The question is asking about the highest household education, how about if mother is holding the higher education and not working? What if he/she despite having a higher education cannot find a job or have a precarious employment which affects the family’s income and insurance type? Therefore, aside from the explanation provided in the second paragraph of page 35, there is a possibility for other reasons that each one could be applicable to some of the study participants. I would recommend the authors considering different possibilities and provide more explanation in the discussion section in order to strengthen this section.

2) The importance of trend analysis of national data is highly valuable in many ways. Among others, these studies can be helpful in identification and prioritization of candidate predictors, recognition of magnitude of the problem, and help with better allocation of resources to cover the unmet needs of the population. After working with multiple cycles of two large dataset (CCHS & CHMS), authors are in the best position to provide some “suggestions” for improvement of the type and structure of questions used in those surveys. These suggestions can help to generate consistent data, increase the quality, simplify the future trend investigations and provide more reliable findings.

Good luck

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PONE-D-22-35306R1Trends in self-reported cost barriers to dental care in Ontario.PLOS ONE

Dear Dr. Mona Abdelrehim,

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 21 June, 2023. 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,

Hadi Ghasemi

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.

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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 #4: (No Response)

Reviewer #5: All comments have been addressed

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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 #4: Yes

Reviewer #5: Yes

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

Reviewer #4: Yes

Reviewer #5: 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 #4: Yes

Reviewer #5: 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 #4: Yes

Reviewer #5: 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 #4: This is an interesting study about Ontario's cost barriers to dental care.

The study is well-conducted, and the authors addressed most of the reviewer's comments. However, The manuscript and data are still too limited to one Province in Canada. This reviewer suggests that the authors include in the introduction additional information about the affordability and dental health published previously in other Canadian Provinces and some other countries such as Australia, the UK, etc.

Also, the discussion should include some available data from other Canadian Provinces, territories, and countries.

Reviewer #5: Very good paper. The authors addressed all comments from other reviewers of the previous version.

I agree with authors, the findings are useful to global readers, the issue of affordability of dental care is a major issue in other countries with universal health coverage that does not cover dentistry or offer limited coverage to dental care. It is also a major issue in countries with no universal coverage like USA.

I have two comments. In Tables 3 and 4, what is the point of the empty row for the reference group? either insert ‘1’ in this row (given you are using PR) or delete the row and write next to variable name (reference group XX).

There are other explanations of the lack of, or reversed education inequality in avoiding dental care that the authors may consider. The categorisation of education (high school or less vs >high school) is not the best categorisation that reflects greater opportunities for having better jobs. It is also possible that immigration status could explain the reversed, or lack of association. Immigrants could have higher education, but not necessarily successful in securing good jobs.

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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.

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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 #4: No

Reviewer #5: No

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[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.

Trends in self-reported cost barriers to dental care in Ontario.

PONE-D-22-35306R2

Dear Dr. Mona Abdelrehim,

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,

Hadi Ghasemi

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 #4: All comments have been addressed

Reviewer #5: All comments have been addressed

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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 #4: Yes

Reviewer #5: Yes

**********

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

Reviewer #4: Yes

Reviewer #5: 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 #4: Yes

Reviewer #5: 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 #4: Yes

Reviewer #5: 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 #4: The authors have adequately responded to all raised questions! The manucript can be accepted for publication.

Thanks

Reviewer #5: The authors have addressed all comments and amended the manuscript accordingly. I recommend accepting the manuscript as it stands

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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 #4: No

Reviewer #5: No

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