PONE-D-23-36328Implementation barriers and facilitators for referral from the hospital to community-based lifestyle interventions from the perspective of lifestyle professionals: a qualitative study.PLOS ONE

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 [This research is part of the LOFIT-project which is funded by The Netherlands Organization for Health Research and Development (ZonMw), grant agreement no. 555003208. Also, the national knowledge and innovation network “Centre Of Expertise for Prevention in Care and Welfare” of the Inholland University of Applied Sciences (Hogeschool Inholland) funded this research.].  

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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: 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?

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: Comments to author

Overall comment:

The topic is new and of interest to the audience. The barriers and facilitators to the service have been covered comprehensively. In addition, evidence-based strategies have been provided. I generally recommend the paper for publication considering the given comments/suggestions. Also, the paper needs to be revised for some typo errors.

1. The study presents the results of original research.

Yes

2. Results reported have not been published elsewhere.

Yes

3. Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail.

Need additional information, as suggested.

4. Conclusions are presented in an appropriate fashion and are supported by the data.

No

5. The article is presented in an intelligible fashion and is written in standard English.

Yes, but there are some typos.

6. The research meets all applicable standards for the ethics of experimentation and research integrity.

Yes

7. The article adheres to appropriate reporting guidelines and community standards for data availability.

Yes

Abstract

Under the method section, avoid using abbreviations or provide the full name (CFIR, ERIC) for those unfamiliar with them.

Introduction

Line 87: consider providing some additional information about the I-change model. It would be helpful for the readers to understand what this model is about.

Line 90: you mentioned that lifestyle coaching in the community is less costly. To whom? To the patients or the healthcare system. If it is less costly for the healthcare system, do you need to hire LFO staff? How many? Do you need to implement a certain referral system? Do you need a clinic to meet with the patients? Is it not costly to implement such a service considering all the mentioned resources?

Is there any published cost-effectiveness analysis to support your statement? Please provide further explanation. Also, it would be helpful to know when the service was implemented in the Netherlands. Especially since most of your participants, 61%, had a working experience of less than 5 years.

Line 99: you mentioned that the lifestyle broker has motivational interviewing skills. What is their qualification? E.g., a dietician or other medical specialty? Are there any required experiences?

The procedure of the referral process is not very clear, how and where they discuss the patients needs? Do the patients need to get an appointment by themselves, or do they get referred by their physician to LFO?

Also, it is not clear where and how the patient will receive the CBLI intervention? At their homes, or particular community or primary care clinics? How would the CBLI communicate with the LFO? Do they provide any written progress notes/letters/emails to the LFO?

Please provide additional information for international readers unfamiliar with this service, as their understanding of the nature of the service will help them understand the subsequent sections.

Line 110: who are the stakeholders in this context? The patients, staff of the LFO, and CBLI? Any others? What about the service leaders or implementers? Did you consider interviewing them? If not, do you think this is one of the limitations? You did interview all the stakeholders. Is that a limitation?

Method

Line 114: “we performed semi-structured interviews with various CBLI”. I am confused with using the abbreviation CBLI, which refers to community-based lifestyle interventions, not personnel. I think it is better to use another abbreviation or term, e.g., community-based healthcare providers, and change it throughout the manuscript.

Line 115-117: “Our aim was to explore views, needs and preferences regarding implementation and collaboration with an LFO in these two medical centers”. I prefer to mention your aim once in the introduction. This is a repetition, and you did not mention your participants here.

Line 118-119: Why was the study exempted from the review by the ethical committee? you can add the statement from your supplementary file 5 here, “The research does not fall within the scope of the Medical Research Involving Human Subjects Act (WMO). The reason is that the research does not have a medical-scientific question”. And remove the file S5.

Line 121: the provided Figure 1 is not of high quality, I could not read what is written in it. Please provide a higher-quality figure.

Line 158-159: I do not understand what the BLCN stands for. Also, does GLI stand for Combined Lifestyle Intervention? Or is it CLI? Is it a typo error?

Line 168: what is the necessity of doing a video call interview? Why not a phone call? Isn’t easier?

Line 181: could be? Or some sections were skipped!

Line 186: you introduce the service to the participants; this means that not all of them were familiar with the service. Should you clarify this in your inclusion criteria? E.g., participants were deemed eligible to participate whether they had previous knowledge of the service or not.

Line 202: Were the interviews in English? Or in Dutch, so did you have to translate them? If yes, what was the method of translation of the transcripts? If you did not translate the transcripts, does the used software support the Dutch language?

Line 224: you mentioned that translations were made at the end, does this mean all the previous steps were in Dutch?

Results

Line 241: it would also be helpful to know how many were already familiar with the referral service. They might have more insight into the barriers and facilitators if they witness the early implementation of the service, in which case they can explore barriers/facilitators at the early stage of the implementation and after running the service for several years.

The participant's knowledge of the service was in mind as I read through the quotations.

Line 414: Is the communication between 1ry and 2ry care always via email? Is there any paper referral? I think you need to better explain the service in the introduction, so when the reader comes to this section, he/she will already have enough understanding of the procedure.

You did not mention when you reached the saturation, and what types of saturation was considered in this study? What about triangulation, credibility, and transferability of the data.

Elaborate more on why you choose interview vs. focus group. Did you reach the data saturation? For some professions, you only interviewed 1, like a dietician; how did you reach saturation about the perspectives of this professional? Could consider this in the limitation of the study?

Discussion

Line 582: is the abbreviation correct? Integral Health care Agreement (IZA)?

Line 588: maybe you can discuss the triangulation here “A strength of this study is the input from various lifestyle professionals”

Line 596-597: “The interviews were performed in order to develop the LFO”. It would be better to move this to the introduction. Because the information provided in the introduction gives the reader the impression that the service is already available but partially implemented. This need to be clarified in the introduction and your aim.

Line 598: Did none of the participants have any experience with the service?

Line 599: I appreciate that you used evidence-based tools to develop your strategies and map them with the CFIR framework, but I was expecting to read some examples from previous studies showing that these strategies did work in practice. You did not mention anything about the improvement strategies in the discussion section.

What are the practical implications or recommendations for practice? You may need to write a few lines about it.

Conclusion

The conclusion is not firm and needs some work. You need to discuss the implications for practice and some future work to strengthen your conclusion.

Reviewer #2: Many thanks for the opportunity to review this work. The authors have reported the qualitative study well and made use of implementation science which is good. However, there are a few concerns. It is not clear that the LFO does not exist and that this piece of work is to inform the design and development and implementation of this. The reference to the CFIR is very vague and almost tokenistic. The labelling of the themes are more topic titles rather than descriptions of the themes. The proposition of matching ERIC to the CFIR categorised barriers is not robust. Authors should reconsider what this study has really investigated and demonstrated. This will help to not over-state the findings and implications.

More detailed comments are provided below:

In the abstract results, this is not clear: 'determine qualifications professionals'. Please revise.

In the introduction:'as patients are more motivated for a

82 lifestyle change when experiencing a health event.' Do the authors have any evidence to support this?

The authors make reference to the I-Change model but give no explanation of it and its significance. I would recommend providing a brief outline or removing the mention of this.

The LFO appears to be a novel concept. Is this just being implemented in the researchers' area or is this a national model. It would be good to provide a little bit of information about where this model is being provided and how successful this is if evidence exists.

Please fix the first line in the table where it states 'total = 23242'

It seems the themes might be better labelled:

'LFO knowledge about financial status and/or health eligibility of the patient'

'LFO knowledge about the cultural and linguistic needs of the patient'

'LFO knowledge about the structure and availability of CBLI services'

'LFO knowledge about the quality of CBLI services'

'Agreed referral process and content'

'Secure and equitable communication platform'

'Personal relationships between the LFO and CBLI to facilitate collaboration'

Develop support tools: how should the barrier about keeping up to date with appropriate services available be overcome?

Would a manual about the use of the communication tool be the best option? Would it not be better to find a system-wide digital solution to facilitate easy communication?

Build networks: this is really vague. I recommend the authors reconsider what the network could look like, how this might be established and sustained.

Facilitate learning collaboratives: these strategies appear to present a significant workload for the LFO. Can the authors potentially consider other options that might be more feasible and attractive?

Please can the authors clarify this sentence:' In order to realize this, representatives of the care sport connectors could be included

527 in the development and implementation team before implementation. '

The key concern with the ERIC strategies is that they are proposed by the research team. Not all seem to be very practical or feasible. It is not clear if the research team have sufficient knowledge and expertise to add credibility to recommending these strategies. Because of this, the recommendations have little value.

Discussion: I would argue that the limited number of referral options for low income patients and for non-Dutch speaking people and those living in rural areas and quality of referral options are not barriers for the implementation of a hospital based LFO. These are simply limitations of the current CBLI offer...

What do the authors mean here: '. Matching strategies were developed and for the

larger part implemented. '?

How do the authors know that these were the most important strategies: ' Most important strategies concerned identifying limited referral

options and professionals with a quality hallmark and strategies to streamline the actual

referral and the process of collaboration between basic services, primary and secondary

care'

What is the relevance of this in the context of this study: ' Digital health can facilitate and improve health care in various applications, such as

diagnostic tools, in order to make disease management and communication health care

processes more patient-centered [44, 45].'

The reader becomes aware: 'The interviews were performed in order to develop the LFO.' In the last section of the discussion! This should be made clearer at the beginning, when rationalising the need for the study.

I do not agree with this strength: ' A major strength of this study is that we systematically matched

600 evidence-based implementation strategies to the found barriers of the CBLI.' Given how these strategies were selected, I am unconvinced that these are the most practical, feasible and cost effective recommendations to implement the LFO.

Given this paper is about developing an intervention to be provided at the intersection between primary and secondary care, the discussion should be considering wider literature about other interventions that have been developed and tested at this juncture, e.g. care coordinators, disharge planners. disease-specific interventions if appropriate.

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Reviewer #1: No

Reviewer #2: No

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Implementation barriers and facilitators for referral from the hospital to community-based lifestyle interventions from the perspective of lifestyle professionals: a qualitative study.

PONE-D-23-36328R1

Dear Dr. Leonie Mariëlle te Loo,

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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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

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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

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

Reviewer #1: Yes

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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: Thanks for addressing all the comments and enhancing the paper. It is a good paper with a new, exciting concept.

My only comment is that I think the manuscript needs to be revised regarding punctuation (some full stops were missing in some paragraphs). No comments on the scientific information.

Best of luck

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

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