A qualitative examination of the experiences and perspectives of interprofessional primary health care teams in the distribution of the COVID-19 vaccination in Ontario, Canada

Rachelle Ashcroft; Catherine Donnelly; Peter Sheffield; Simon Lam; Connor Kemp; Keith Adamson; Judith Belle Brown

doi:10.1371/journal.pone.0304616

Peer Review History

Original SubmissionAugust 1, 2023
20 Nov 2023 Decision Letter - Elif Ulutaş Deniz, Editor PONE-D-23-23366A Qualitative Examination of the Facilitators and Barriers Shaping Primary Health Care Teams’ Experiences in the Distribution of the COVID-19 Vaccination in Ontario, CanadaPLOS ONE Dear Dr. Ashcroft, 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. Academic Editor: The reviewers have provided their comments and recommendations. Based on their feedback, you are encouraged to revise the manuscript, addressing and responding to each comment specifically. Please submit your revised manuscript by Jan 04 2024 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, Elif Ulutaş Deniz Academic Editor PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. Additional Editor Comments: Dear Rachelle Ashcroft, Manuscript PONE-D-23-23366 titled "A Qualitative Examination of the Facilitators and Barriers Shaping Primary Health Care Teams’ Experiences in the Distribution of the COVID-19 Vaccination in Ontario, Canada" which you submitted to PLOS ONE, has been reviewed. The reviewers suggest some major revisions to your manuscript. Therefore, I invite you to respond to the reviewer(s)' comments and revise your manuscript. Sincerely, Elif Ulutaş Deniz [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: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: 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: Yes Reviewer #2: 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 Reviewer #2: 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: Comments to the Author Congratulations on the submitted manuscript. The topic is timely and will be of interest to the readers of the journal. However, a few changes are suggested to improve the clarity of this manuscript. I have several recommendations and questions about the manuscript. Abstract A descriptive qualitative design informed this study. We conducted focus groups with a range of interprofessional healthcare providers, administrators, and staff working in PHC teams across Ontario. Eight focus groups were conducted with 39 participants representing the six health regions of the province. -Harmonize the statements: A qualitative approach was used for this study, which involved 39 participants from six health regions of the province. Eight focus groups were conducted---- Introduction -Very good explanation. Methodology Our study used a qualitative description approach, using focus groups to explore the experiences of participants. -Here need to explain how many participants were involved in this study. Data collection and data analysis took place simultaneously, with data analysis following the thematic analysis process as outlined by Braun & Clark [29]. -Explain the steps of data analysis using Braun & Clark(2006), to make it more clear for the readers. Discussion -Very good. References -Most of the citations are above 5 years. Very good. Reviewer #2: Overall, this is a well-executed study on an important topic, written up clearly and with a nice selection of meaningful excerpts. I do have one larger overarching concern and several smaller issues that are related. Major concern: 1. The research question is appropriately stated as " to identify the facilitators and challenges experienced by interprofessional PHC team" (my highlight). Understanding the experiences of key players in the healthcare system is important, but it is also important to be mindful of the limitation that study design brings with it. For example, both the analysis and the conclusions highlights the importance of a trusting relationship between PHC provider and patient to combat vaccine hesitancy. But while this may be the case (and there's other, cited literature to support the idea), this study provides virtually no data that could actually support this as a finding: we don't know if patients actually valued the relationship or if they were just being polite, if some patients would actually prefer a non-PHC setting, if the providers saw a biased sample of patients, etc. More generally, based on the study design, we simply don't stand to learn much about what PHCs are (comparatively) good at in the context of vaccinations -- all we have is their self-assessment. One way to think about this might be that observations about process are more likely to be analytically relevant then observations about outcomes. What we can (and do) learn, on the other hand, are how they operated, where they perceived challenges, how they solved problems: accordingly the sections about red tape or lack of inclusion in systemic planning are both the most interesting and the most analytically relevant sections of the paper. I'd encourage authors to - expand on those themes at the expense of some of the themes that provide less analytical leverage, especially in the discussion section of the paper - carefully weigh, phrase, and potentially omit specific policy conclusions based on the type of evidence they're based on. Minor concerns: 2. As noted above, the discussion on the lack of inclusion in systemic planning is particularly strong and fairly long. I wonder if authors' coding would allow dividing this into two more fine-grained codes to strengthen the precision of the analysis and the clarity of presentation. 3. In the discussion, the paper notes in several places variation between different PHCs (e..g. on vaccine access, handling red tape, etc.). This variation is very interesting, but does not come through much in the analysis section. I'd like to see that explored more clearly, including more on the nature/drivers of variation to the extent those can be discerned. 4. The discussion section overall is a bit long and unfocussed, going through every theme one-by-one. I'd encourage focussing this more and picking some highlights in the findings for more detailed discussion, leaving other topics out. 5. The conclusion seems a bit anticlimactic and short. Taking up one or two key issues, highlighting how the study has improved our understanding and suggesting further avenues for study would all be nice to see there. 6. Data availability: I understand that data may not be shareable given consent and REB protocol, but if it can be made available on reasonable request, it should be made available through a data repository as per PLOS's data policy. If that's not possible, or data can only be shared by permission from the REB or similar, that should be clearly stated. Data sharing by request to the author is not in line with PLOS's policy. ******** 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: Yes: DR RUSNANI AB LATIF Reviewer #2: Yes: Sebastian Karcher ******** [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. Attachments Attachment Submitted filename: Comment Reviewer A Qualitative Examination of the Facilitators and Barriers Shaping Primary Health Care.pdf https://doi.org/10.1371/journal.pone.0304616.r001
Revision 1
26 Jan 2024 Author Response Dear Dr. Deniz: We are pleased to submit revisions to our manuscript titled “A Qualitative Examination of the Facilitators and Barriers Shaping Primary Health Care Teams’ Experiences in the Distribution of the COVID-19 Vaccination in Ontario, Canada”. We appreciate the reviewer’s feedback and have revised the manuscript in a way that responds to all editor and reviewer comments. Please find below an itemized response to all reviewer and editor comments: Reviewer 1 Comment Congratulations on the submitted manuscript. The topic is timely and will be of interest to the readers of the journal. Response: Thank you! We appreciate your enthusiasm and positive feedback. We also appreciate the time you took to review our manuscript. Reviewer 1 Comment: Abstract: A descriptive qualitative design informed this study. We conducted focus groups with a range of interprofessional healthcare providers, administrators, and staff working in PHC teams across Ontario. Eight focus groups were conducted with 39 participants representing the six health regions of the province. -Harmonize the statements: A qualitative approach was used for this study, which involved 39 participants from six health regions of the province. Eight focus groups were conducted---- Response: We revised the methods section of abstract which now reads: “A qualitative approach was used for this study, which involved 39 participants from the six health regions of the province. Eight focus groups were conducted with a range of interprofessional healthcare providers, administrators, and staff working in PHC teams across Ontario. The sample reflected a diverse range of clinical, administrative, and leadership roles in PHC. Focus groups were audio-recorded and transcribed, while transcriptions were then analyzed using thematic analysis.” Reviewer 1 Comment Introduction -Very good explanation. Response: Thank you! Reviewer 1 Comment: Methodology Our study used a qualitative description approach, using focus groups to explore the experiences of participants. -Here need to explain how many participants were involved in this study. Response: The sentence now reads as: “Our study used a qualitative description approach, using focus groups to explore the experiences and perspectives of 39 participants.” Reviewer 1 Comment: Data collection and data analysis took place simultaneously, with data analysis following the thematic analysis process as outlined by Braun & Clark [29]. -Explain the steps of data analysis using Braun & Clark(2006), to make it more clear for the readers. Response: We added the following sentence early in the data analysis section: “The six steps as outlined by Braun and Clarke [29] included i) familiarization with the data, ii) generating initial codes, iii) searching for themes, iv) reviewing the themes, v) defining and naming the themes, and vi) producing a report.” The following sentence was also added to the data analysis section: “The primary and secondary data analysts familiarized themselves by reading transcripts prior to coding.” Reviewer 1 Comment: Discussion -Very good. References -Most of the citations are above 5 years. Very good. Response: Thank you! Reviewer 2 Comment Overall, this is a well-executed study on an important topic, written up clearly and with a nice selection of meaningful excerpts. Response: Thank you! We appreciate your positive feedback and the time you took to review our manuscript. Reviewer 2 Comment: The research question is appropriately stated as " to identify the facilitators and challenges experienced by interprofessional PHC team" (my highlight). Response: We revised the objective which now reads as: “The key objective informing this study was to explore the experiences and perspectives of interprofessional PHC teams in the distribution of COVID-19 vaccination across Ontario.” We believe that the revised objective is better aligned with the study aim and the results. We revised the title to: “A qualitative examination of the experiences and perspectives of interprofessional primary health care teams in the distribution of the COVID-19 vaccination in Ontario, Canada” Reviewer 2 Comment: Understanding the experiences of key players in the healthcare system is important, but it is also important to be mindful of the limitation that study design brings with it. For example, both the analysis and the conclusions highlights the importance of a trusting relationship between PHC provider and patient to combat vaccine hesitancy. But while this may be the case (and there's other, cited literature to support the idea), this study provides virtually no data that could actually support this as a finding: we don't know if patients actually valued the relationship or if they were just being polite, if some patients would actually prefer a non-PHC setting, if the providers saw a biased sample of patients, etc. More generally, based on the study design, we simply don't stand to learn much about what PHCs are (comparatively) good at in the context of vaccinations -- all we have is their self-assessment. Response: Thank you for noting this important point. The following sentences are added to the limitation section: “Although understanding the experiences of key players in the healthcare system is important, it is important to recognize that the lack of patients’ perspectives is a limitation in our study. Healthcare providers in our study overwhelmingly emphasized the importance and role of trusting relationships in the distribution of the COVID-19 vaccination yet without the perspective of patients, we cannot confirm the accuracy of healthcare providers’ perspectives given the dynamic nature of therapeutic relationships. Despite this limitation, we believe our study provides unique insights about the experiences and perceptions of interprofessional providers and PHC teams.” Reviewer 2 Comment: One way to think about this might be that observations about process are more likely to be analytically relevant then observations about outcomes. What we can (and do) learn, on the other hand, are how they operated, where they perceived challenges, how they solved problems: accordingly the sections about red tape or lack of inclusion in systemic planning are both the most interesting and the most analytically relevant sections of the paper. I'd encourage authors to expand on those themes at the expense of some of the themes that provide less analytical leverage, especially in the discussion section of the paper; carefully weigh, phrase, and potentially omit specific policy conclusions based on the type of evidence they're based on. Response: We revised the objective which now reads as: “The key objective informing this study was to explore the experiences and perspectives of interprofessional PHC teams in the distribution of COVID-19 vaccination across Ontario.” We believe that the revised objective is better aligned with the study aim and the results and addresses some of the concerns raised. Reviewer 2 Comment: As noted above, the discussion on the lack of inclusion in systemic planning is particularly strong and fairly long. I wonder if authors' coding would allow dividing this into two more fine-grained codes to strengthen the precision of the analysis and the clarity of presentation. Response: Thank you for the suggestion. After re-reviewing the results and going back into the data, we have opted not to re-code the data as we believe that the current codes and grouping reflect what we heard from the participants. Reviewer 2 Comment: In the discussion, the paper notes in several places variation between different PHCs (e..g. on vaccine access, handling red tape, etc.). This variation is very interesting, but does not come through much in the analysis section. I'd like to see that explored more clearly, including more on the nature/drivers of variation to the extent those can be discerned. Response: The following sentence is added to the discussion: “Some of these variations may be because of differences inherent in the community context, patient population, and/or organizational structures such as team composition, resourcing, and leadership [31, 32].” Reviewer 2 Comment: The discussion section overall is a bit long and unfocussed, going through every theme one-by-one. I'd encourage focussing this more and picking some highlights in the findings for more detailed discussion, leaving other topics out. Response: The discussion section has been substantively edited for length and focus. Reviewer 2 Comment: The conclusion seems a bit anticlimactic and short. Taking up one or two key issues, highlighting how the study has improved our understanding and suggesting further avenues for study would all be nice to see there. Response: The conclusion has been revised and now reads: “PHC teams were instrumental in supporting COVID-19 vaccinations in Ontario. Because of the longstanding experience in delivering vaccinations and diverse expertise, PHC teams were able to quickly mobilize and draw on the collective strengths of a breadth of professions. PHC teams need to be included in the planning and strategizing of future vaccination endeavors to optimize their capacity.” Reviewer 2 Comment: Data availability: I understand that data may not be shareable given consent and REB protocol, but if it can be made available on reasonable request, it should be made available through a data repository as per PLOS's data policy. If that's not possible, or data can only be shared by permission from the REB or similar, that should be clearly stated. Data sharing by request to the author is not in line with PLOS's policy. Response: We are unable to publicly share our data set because although we have removed identifiable information from transcripts, we cannot remove all information that could potentially be used to identify participants. Responses to questions contain information describing Family Health Team communities, practice settings, and providers’ personal roles and responsibilities, some of whom live in small rural communities where such information could be used to identify individuals. Our REB requires that we not share identifiable information because of the potential for identifying participants. Editor Comment Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Response: The manuscript was revised throughout to meet the PLOS ONE’s style requirements including headings, references, and title page. Editor Comment: We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. Response: We are unable to publicly share our data set because although we have removed identifiable information from transcripts, we cannot remove all information that could potentially be used to identify participants. Responses to questions contain information describing Family Health Team communities, practice settings, and providers’ personal roles and responsibilities, some of whom live in small rural communities where such information could be used to identify individuals. Editor Comment: Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. Response: The ethics statement is located in the Methods section. https://doi.org/10.1371/journal.pone.0304616.r002
7 Feb 2024 Decision Letter - Elif Ulutaş Deniz, Editor PONE-D-23-23366R1A qualitative examination of the experiences and perspectives of interprofessional primary health care teams in the distribution of the COVID-19 vaccination in Ontario, CanadaPLOS ONE Dear Dr. Ashcroft, 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 Mar 23 2024 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, Elif Ulutaş Deniz Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] [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.0304616.r003
Revision 2
8 Feb 2024 Author Response Dr. Elif Ulutaş Deniz Academic Editor PLOS One January 02, 2024 Dear Dr. Deniz: We are pleased to submit revisions to our manuscript titled “A Qualitative Examination of the Facilitators and Barriers Shaping Primary Health Care Teams’ Experiences in the Distribution of the COVID-19 Vaccination in Ontario, Canada”. We appreciate the reviewer’s feedback and have revised the manuscript in a way that responds to all editor and reviewer comments. Please find below an itemized response to all reviewer and editor comments: Reviewer 1 Comment: Congratulations on the submitted manuscript. The topic is timely and will be of interest to the readers of the journal. Response: Thank you! We appreciate your enthusiasm and positive feedback. We also appreciate the time you took to review our manuscript. Reviewer 1 Comment: Abstract: A descriptive qualitative design informed this study. We conducted focus groups with a range of interprofessional healthcare providers, administrators, and staff working in PHC teams across Ontario. Eight focus groups were conducted with 39 participants representing the six health regions of the province. Harmonize the statements: A qualitative approach was used for this study, which involved 39 participants from six health regions of the province. Eight focus groups were conducted---- Response: We revised the methods section of abstract which now reads: Reviewer 1 Comment: “A qualitative approach was used for this study, which involved 39 participants from the six health regions of the province. Eight focus groups were conducted with a range of interprofessional healthcare providers, administrators, and staff working in PHC teams across Ontario. The sample reflected a diverse range of clinical, administrative, and leadership roles in PHC. Focus groups were audio-recorded and transcribed, while transcriptions were then analyzed using thematic analysis.” Introduction: Very good explanation. Response: Thank you! Reviewer 1: Methodology: Our study used a qualitative description approach, using focus groups to explore the experiences of participants. -Here need to explain how many participants were involved in this study. Response: The sentence now reads as: “Our study used a qualitative description approach, using focus groups to explore the experiences and perspectives of 39 participants.” Reviewer 1 Comment: Data collection and data analysis took place simultaneously, with data analysis following the thematic analysis process as outlined by Braun & Clark [29]. -Explain the steps of data analysis using Braun & Clark(2006), to make it more clear for the readers. Response: We added the following sentence early in the data analysis section: “The six steps as outlined by Braun and Clarke [29] included i) familiarization with the data, ii) generating initial codes, iii) searching for themes, iv) reviewing the themes, v) defining and naming the themes, and vi) producing a report.” The following sentence was also added to the data analysis section: “The primary and secondary data analysts familiarized themselves by reading transcripts prior to coding.” Reviewer 1 Comment: Discussion -Very good. References -Most of the citations are above 5 years. Very good. Response: Thank you! Reviewer 2 Comment: Overall, this is a well-executed study on an important topic, written up clearly and with a nice selection of meaningful excerpts. Response: Thank you! We appreciate your positive feedback and the time you took to review our manuscript. Reviewer 2 Comment: The research question is appropriately stated as " to identify the facilitators and challenges experienced by interprofessional PHC team" (my highlight). Response: We revised the objective which now reads as: “The key objective informing this study was to explore the experiences and perspectives of interprofessional PHC teams in the distribution of COVID-19 vaccination across Ontario.” We believe that the revised objective is better aligned with the study aim and the results. We revised the title to: “A qualitative examination of the experiences and perspectives of interprofessional primary health care teams in the distribution of the COVID-19 vaccination in Ontario, Canada” Reviewer 2 Comment: Understanding the experiences of key players in the healthcare system is important, but it is also important to be mindful of the limitation that study design brings with it. For example, both the analysis and the conclusions highlights the importance of a trusting relationship between PHC provider and patient to combat vaccine hesitancy. But while this may be the case (and there's other, cited literature to support the idea), this study provides virtually no data that could actually support this as a finding: we don't know if patients actually valued the relationship or if they were just being polite, if some patients would actually prefer a non-PHC setting, if the providers saw a biased sample of patients, etc. More generally, based on the study design, we simply don't stand to learn much about what PHCs are (comparatively) good at in the context of vaccinations -- all we have is their self-assessment. Response: Thank you for noting this important point. The following sentences are added to the limitation section: “Although understanding the experiences of key players in the healthcare system is important, it is important to recognize that the lack of patients’ perspectives is a limitation in our study. Healthcare providers in our study overwhelmingly emphasized the importance and role of trusting relationships in the distribution of the COVID-19 vaccination yet without the perspective of patients, we cannot confirm the accuracy of healthcare providers’ perspectives given the dynamic nature of therapeutic relationships. Despite this limitation, we believe our study provides unique insights about the experiences and perceptions of interprofessional providers and PHC teams.” Reviewer 2 Comment: One way to think about this might be that observations about process are more likely to be analytically relevant then observations about outcomes. What we can (and do) learn, on the other hand, are how they operated, where they perceived challenges, how they solved problems: accordingly the sections about red tape or lack of inclusion in systemic planning are both the most interesting and the most analytically relevant sections of the paper. I'd encourage authors to expand on those themes at the expense of some of the themes that provide less analytical leverage, especially in the discussion section of the paper; carefully weigh, phrase, and potentially omit specific policy conclusions based on the type of evidence they're based on. Response: We revised the objective which now reads as: “The key objective informing this study was to explore the experiences and perspectives of interprofessional PHC teams in the distribution of COVID-19 vaccination across Ontario.” We believe that the revised objective is better aligned with the study aim and the results and addresses some of the concerns raised. Reviewer 2 Comment: As noted above, the discussion on the lack of inclusion in systemic planning is particularly strong and fairly long. I wonder if authors' coding would allow dividing this into two more fine-grained codes to strengthen the precision of the analysis and the clarity of presentation. Response: Thank you for the suggestion. After re-reviewing the results and going back into the data we have opted not to re-code the data as we believe that the current codes and grouping reflect what we heard from the participants. Reviewer 2 Comment: In the discussion, the paper notes in several places variation between different PHCs (e..g. on vaccine access, handling red tape, etc.). This variation is very interesting, but does not come through much in the analysis section. I'd like to see that explored more clearly, including more on the nature/drivers of variation to the extent those can be discerned. Response: The following sentence is added to the discussion: “Some of these variations may be because of differences inherent in the community context, patient population, and/or organizational structures such as team composition, resourcing, and leadership [31, 32].” Reviewer 2 Comment: The discussion section overall is a bit long and unfocussed, going through every theme one-by-one. I'd encourage focussing this more and picking some highlights in the findings for more detailed discussion, leaving other topics out. Response: The discussion section has been substantively edited for length and focus. Reviewer 2 Comment: The conclusion seems a bit anticlimactic and short. Taking up one or two key issues, highlighting how the study has improved our understanding and suggesting further avenues for study would all be nice to see there. Response: The conclusion has been revised and now reads: “PHC teams were instrumental in supporting COVID-19 vaccinations in Ontario. Because of the longstanding experience in delivering vaccinations and diverse expertise, PHC teams were able to quickly mobilize and draw on the collective strengths of a breadth of professions. PHC teams need to be included in the planning and strategizing of future vaccination endeavors to optimize their capacity.” Reviewer 2 Comment: Data availability: I understand that data may not be shareable given consent and REB protocol, but if it can be made available on reasonable request, it should be made available through a data repository as per PLOS's data policy. If that's not possible, or data can only be shared by permission from the REB or similar, that should be clearly stated. Data sharing by request to the author is not in line with PLOS's policy. Response: We are unable to publicly share our data set because although we have removed identifiable information from transcripts, we cannot remove all information that could potentially be used to identify participants. Responses to questions contain information describing Family Health Team communities, practice settings, and providers’ personal roles and responsibilities, some of whom live in small rural communities where such information could be used to identify individuals. Our REB requires that we not share identifiable information because of the potential for identifying participants. https://doi.org/10.1371/journal.pone.0304616.r004
15 May 2024 Decision Letter - Elif Ulutaş Deniz, Editor A qualitative examination of the experiences and perspectives of interprofessional primary health care teams in the distribution of the COVID-19 vaccination in Ontario, Canada PONE-D-23-23366R2 Dear Dr. Ashcroft, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Elif Ulutaş Deniz 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 ******** 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: Yes 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: No ****** 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: Dear Authors Congratulations on your manuscript, I have checked the reviewer’s comment, and all the amendments were implemented in response to the reviewers' recommendations and commendations. Reviewer #2: Thank you for a much more nuanced discussion section, also reflected in the changed title. Since some fairly strong statements that suggest generalizability remain in the manuscript, I'd suggest listing some additional limitations related to sample size and recruitment in the limitation section, but will leave this to the authors. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: DR RUSNANI AB LATIF Reviewer #2: Yes: Sebastian Karcher ******** https://doi.org/10.1371/journal.pone.0304616.r005
Formally Accepted
20 May 2024 Acceptance Letter - Elif Ulutaş Deniz, Editor PONE-D-23-23366R2 PLOS ONE Dear Dr. Ashcroft, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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 Dr. Elif Ulutaş Deniz Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0304616.r006

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