PONE-D-23-25256Priority healthcare needs amongst people experiencing homelessness in Dublin, Ireland: a qualitative evaluation of community expert experiences and opinionsPLOS ONE

Dear Dr. Ingram,

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Yes

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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: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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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: Thank you for this opportunity to read and review this paper, which reports on an analysis of qualitative interviews conducted with experts working with homeless people in Dublin.

The paper is well set-up with a clear and informative account of the public health challenge of homelessness globally, and in Ireland particularly. Design and methods are laid out in transparent fashion, including with reference to the larger ethnographic study from which this paper arises. I note that a future paper, drawing on observational data, will follow in due course and I can see how the two manuscripts will sit will together. I am also entirely persuaded of the value of qualitative research in studies of this type, and I appreciate the attention to the approach taken to the management and analysis of data. I also like how information is included on the length of interviews, and the characteristics of the 19 interviewees.

However:

For me, the paper is unusually structured, and in this regard there is room for revision. As an aside, there needs to be some relabelling of figures, as Fig 2 is used in the text to refer both to the map of services and to the summary of themes. The reporting of findings begins in a conventional way on page 6 (using the authors' running footer manuscript page numbers), with two thematic headings ('State of homelessness...' and 'Healthcare usage...'). The next thematic heading, 'Priority healthcare needs', appears with an underlining which for me implies it has a thematically different status compared with the first two themes. This is not entirely clear, though. The 'Priority...' themes and sub-themes, with sample data extracts, are then displayed in a table, with recommendations alongside. This strikes me as an unusual way of presenting what might more usually be a rich, thematic, qualitative analysis. I also think that, at this point in the paper, it is far too early to be adding recommendations. I am also then somewhat thrown by the textual summary of these same tabulated themes, without data extracts, from page 15 onwards.

Overall, then, I think a more conventional presentation of thematic findings followed by a considered set of recommendations arising from these would work better and would also make for a more succinct read without the need to cross-refer the content of Table 3 and the textual summary beneath. An option here would be, I think, to avoid the use of Table 3 altogether.

I hope these comments prove useful.

Reviewer #2: Priority healthcare needs amongst people experiencing homelessness in Dublin,

Ireland: a qualitative evaluation of community expert experiences and opinions

This well written article describes a qualitative approach to needs assessment for the unhoused population in Dublin, Ireland. The article provides a strong rationale for the study, description of methods, analysis and incorporation of the literature into the discussion. I suggest the following to improve

1. Background: Since the article is centered on the concept of equity, I would appreciate a better understanding of equity issues in the drivers of the unhoused or in the provision of services that need to be addressed. For example, the authors state that substance use is the main cause of homelessness, but do not mention the structural and societal factors that contribute to substance use. Better defining what equity means in this context would be helpful.

2. Methods: While I agree that qualitative approaches are essential for understanding the needs of marginalised persons, I would recommend reframing the use of qualitative methods as something novel in needs assessments. Rather, most needs assessments are considered inadequate without the incorporation of community voices and perspectives on needs through qualitative engagement. There is considerable literature on how to do needs assessments that makes this clear. It would be interesting, for example, to include a review of the literature on how perspectives of the unhoused are incorporated into needs assessments, including reaching out to service providers.

3. Data Collection: The authors refer to the ethnographic study of the unhoused as part of the larger study and how this influenced the development of questions. This is very interesting, but if it is going to be included more information on how these two activities informed each other is important. Did the interview questions evolve over time as researchers gained more perspective on housing issues? Additionally, there is some confusion about the identification of interviewees since the data collection section describes being informed by the observations, while the recruitment refers to using a directory of service providers.

4. Results: The results reflect a comprehensive analysis and thematic coding framework. However, Table 3 needs to be revised. The length is a bit overwhelming. More importantly, the quotations included for some of the subthemes don’t really describe the name of the subthemes. The first sub theme for example, includes a quote that describes the need for a change in mindset but doesn’t mention health equity, thus it appears that the coders are making an interpretive leap. I would say the same for the theme strategic planning. It seems that the code is named more for the solution rather than the description of the issue. Since this is the results table, it is important to learn the perspectives of the service providers and where the commonality across different types of providers, perhaps. In a related issue, the recommendation column and references to it belong in the discussion section. The recommendations are a response to the data and reflect the authors’ interpretation of practice and policy approaches to improve health equity for the unhoused. I would include a separate table, or perhaps just discuss recommendations in the discussion section. Since the paper is addressing very complex issues, this would also demonstrate how solutions work together to solve problems, rather than addressing one issue at a time.

5. The discussion section is very informative and relates well to the literature on the subject. I would recommend a review of the article to ensure active voice in the methods and analysis description. The authors do a nice job describing each person’s role, but I always appreciate understanding who the authors are in relationship to the population and the study.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-23-25256R1Priority healthcare needs amongst people experiencing homelessness in Dublin, Ireland: a qualitative evaluation of community expert experiences and opinionsPLOS ONE

Dear Dr. Ingram,

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 Nov 23 2023 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: 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,

Adetayo Olorunlana, Ph.D.

Academic Editor

PLOS ONE

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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 #1: (No Response)

Reviewer #2: 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 #1: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: 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

Reviewer #2: 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

Reviewer #2: 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: Thank you for taking the time to respond to the reviewer comments, and for summarising the changes you have made to your manuscript. My main observation related to the use of a table to summarise parts of your findings, and the overlap between the information here and the sections following in the original manuscript. For me, the paper is more clearly structured now, with main findings presented (by choice, without the use of extensive supporting data extracts) in the body of the article and with recommendations subsumed within the discussion section.

My final thought is, though: would it be an idea to introduce the thematic structure after table 2 (which helpfully summarises the participants), as opposed to heading directly into the section titled, 'State of homelessness...'? This would serve to introduce the overarching framework under which the analysis is progressed. It might also help to explain that you have elected to not exemplify your analysis with data extracts, but make references along the way to the participants whose data underpin the discursive claims you make. At present, although the meaning is inferred there is no statement explaining what you mean by including phrases like 'Hospital3' in your findings.

I hope these final observations are helpful.

Reviewer #2: The authors revisions have substantially improved the manuscript and I appreciate the enhanced definition of equity in conducting the assessment of the unhoused, as well as the removal of the recommendations in the results section. I agree that the discussion is comprehensive and well written. I am still confused by the headings "state of homelessness and addiction in Dublin" and "health care usage and outcomes" as distinct from "priority health care needs" with a thematic analysis, I would expect all three to be a theme, or not to have a heading listed that way. Please decide present these three topics as themes discussed in the interviews. If health care priorities has subthemes and the others don't that is fine. I think breaking it down into sub sub themes is excessive, as mentioned previously, I would use the heading under the sub theme 2 "accelerate action in addressing health inequalities" and describe the different points that emerged under that heading and take out all the subthemes. I would remove the parentheses (policy) and (level: health services). They are not included under every theme and they are not adding much and make the results too busy when I really just want to read about what people said in the interviews. My overall comment from the first review is not to over parse the data. The summaries are very descriptive, they fit well under the above theme, and do not need to be further broken down for the reader I think it is enough that the authors discussed the use of the framework in the analysis and if they want to return to it in the discussion that is appropriate. The size of the font in the headings also seems inconsistent with journal style, but I am sure that will be finalized in the editing process.

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Reviewer #1: No

Reviewer #2: No

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Priority healthcare needs amongst people experiencing homelessness in Dublin, Ireland: a qualitative evaluation of community expert experiences and opinions

PONE-D-23-25256R2

Dear Dr. Ingram,

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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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,

Adetayo Olorunlana, Ph.D.

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 #1: All comments have been addressed

Reviewer #2: 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 #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: 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

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for this final round of revisions, which relate to the introduction to the thematic presentation of findings.

Reviewer #2: I really appreciate the extensive background on the structural antecedents of homelessness and the changes to the presentation of the data. This is now a much more powerful paper.

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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 #1: No

Reviewer #2: Yes: Maia Ingram

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