PONE-D-24-06002Exploring the pharmacist’s role in supporting newcomer international students and their families with the transition to the Canadian healthcare system including medication use: Protocol for a qualitative studyPLOS ONE

Dear Dr. Aboelzahab,

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.

I enjoyed reading your paper. The paper tries to explores the challenges faced by international students in Canada. However, the protocol can be equally important to other countries who are receiving international students. Therefore, I request you to add more relevant information in background, methodology and discussion section so that the protocol can be of wider use for international scientific communities. I also eco with reviewer's comments, please edit your paper as per the reviewer's comments. 

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Kind regards,

Kanchan Thapa, MPH, MPhil

Academic Editor

PLOS ONE

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2. Thank you for stating in your Funding Statement:

“This work is supported by Leslie Dan Faculty of Pharmacy, University of Toronto, and the Network for Improving Health Systems (NIHS) Trainee Award, University of Toronto”

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“This work is supported by Leslie Dan Faculty of Pharmacy, University of Toronto, and the Network for Improving Health Systems (NIHS) Trainee Award, University of Toronto.”

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“This work is supported by Leslie Dan Faculty of Pharmacy, University of Toronto, and the Network for Improving Health Systems (NIHS) Trainee Award, University of Toronto”

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Additional Editor Comments (if provided):

Dear Authors,

I enjoyed reading your paper. The paper tries to explores the challenges faced by international students in Canada. However, the protocol can be equally important to other countries who are receiving international students. Therefore, I request you to add more relevant information in background, methodology and discussion section.

At this stage, I have following comments:-

Background should contain some of the information about global trends of students migration, how they face health care challenges, they provide an overview of Canada. Why it is important to have access to health care services, due to lack of which how is the situation in global, in regional and in Canada?

Aims and objectives can be stated as a paragraph in the last portion of introduction section.

Participants:-

Are the participants recruited from two institutions are generalizable about the situation of Canada?

Authors contribution section- please state as per the plos one format. Ensure all the authors mention the required criteria for authorship.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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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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

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This protocol is for a qualitative study that will explore the role that pharmacists could play in helping international students and their families during their transition from the healthcare services of their country of origin to the Canadian one. The following points will help strengthen the manuscript.

1. Lines 56-111: How do new rules for international students in Canada affect this protocol/study?

2. Lines 113-117: How is aim #1 different from aim #s 2 & 3? Please discuss.

3. Lines 123-125: Please provide a definition of “in-depth interviews”. Aren’t the interviews in a qualitative study already aim to explore ‘in-depth’ experiences of responders? What does the addition of “in-depth” mean here?

4. Lines 125-136: Thanks for providing references and explanations for “exploratory descriptive qualitative approach”. The qualitative approach is usually used to ‘explore’ and ‘describe’ phenomenon where there is little information available. Perhaps, authors should define what they mean by a “qualitative study” first for readership to understand the following sections about “exploratory” and “descriptive”. Further, as authors indicate, the “descriptive … will go beyond simple observation and data recording…”. However, authors do not provide what are the qualifications of the state that will be achieved “beyond…”. Please discuss.

5. Lines 198-211: Could authors please discuss the types of guarantees (in terms of the privacy and confidentiality of interview data) that are provided by Microsoft Teams.

6. Lines 208-210: Please discuss if authors have concerns about how comparable the interview responses will be when camera is on as opposed to when camera is off.

7. Lines 213-231: Who will conduct the interviews? Later, it is reported that there will be at least one interviewer (line 365). Please discuss if there will be other interviewers.

8. Lines 213-231: Will there be debriefing after interviews? Authors do discuss revising the guide later but that seems to be only tied to the data analysis. Please specify.

9. Lines 233-243: Will the interview guide be pilot tested?

10. Lines 234-237: “Semi-structured” interviews? Please tie back to “in-depth” interviews.

11. Lines 245-272: How will authors ensure that their results are credible?

12. Lines 245-255: Who will do the coding and other data analyses and how? There seems to be one interviewer (line365). Does that mean there will be one coder? Please describe the process clearly.

13. Lines 264-272: “COREQ”? Thanks for providing a reference but please ensure that the acronym is written out the first time it is mentioned.

14. Lines 288-294: Will there be any services available for those international students who become emotional during interviews?

15. Line 298: Again, “explorative descriptive qualitative study”?

16. Lines 323-327: Could authors explore which countries (of that total 200) are represented by U of T international students rather than reporting this as a limitation?

17. Lines 323-324: Please refrain from discussions that resemble (or make the reader think of) generalizability and give the impression that this protocol is for a quantitative study.

18. Lines 324-327: Again, which countries are those? Further, even if U of T had international students from all of those 200 countries, which characteristics of a qualitative study provide the researcher with the tools that will make the generalizability of their findings possible? Please discuss.

Reviewer #2: Dear Author,

I enjoyed the manuscript and found it informative.

After going through the manuscript and reviewing it, I found that there are some changes that need to be addressed to enhance the overall quality of the manuscript. Please find my comments on the attached file.

Reviewer #3: This is an excellent and novel protocol that holds promise in shedding light on an important and under-researched topic in Canada. The methods are clearly described, and the rationale for the study is also clear. I have only three main comments for consideration.

First, though the motivation for your study is about the issues facing newcomers in terms of access to care and inequities in health outcomes, the focus on international students may limit the ability to generate insights into the challenges facing newcomers more broadly, especially those in more structurally disadvantaged positions. Indeed, international students may be among the more privileged and may have advantages often described as the healthy immigrant effect, whereby levels of health on average for this population are better than for average Canadians, or newcomers more broadly. Could the authors elaborate on the importance of this particular subgroup of the newcomers population and how insights gained from this study could still be informative in terms of the broader issues presented in the introduction?

Second, it would help to clarify the recruitment a bit more, as it strikes me that the use of a pharmacy to recruit international students may select only those who already have some prior knowledge of existing care options available to them and who are able to access it vs those who are less aware of on campus services and supports and therefore may be facing greater barriers to care that are worth uncovering in the study. It would be great if the authors could comment on this potential limitation, or correct my misunderstanding.

Third, I understand that the motivation for this study is to examine the potential role of pharmacists in assisting navigation and transition to Canada's health systems for newcomers, but is there also room to uncover opportunities for other health providers, and perhaps gain insights into the opportunities to improve access or quality of care for this population by other care providers, such as primary care physicians, nurses, walk-in clinics, mental health services, etc? The broader implications of your study could be considered in the Discussion section, since the open-ended nature of the questions asked in the interview guide may yield new insights into these other aspects of health system.

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Reviewer #1: No

Reviewer #2: Yes: Rita Adhikari

Reviewer #3: Yes: Sara Allin

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Submitted filename: Manuscript File_Aboelzahab et al.docx...docx

Exploring the pharmacist’s role in supporting newcomer international students and their families with the transition to the Canadian healthcare system including medication use: Protocol for a qualitative study

PONE-D-24-06002R1

Dear Dr. Aboelzahab,

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.

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Kind regards,

Kanchan Thapa, MPH, MPhil

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors,

Regarding your sample size, approximately 15-20 or approximately 20. I understand that it's a qualitative study, and you've stated that you'll collect data up to saturation. However, I've noticed two different ways of presenting your sample. Therefore, I suggest maintaining consistency when presenting your sample size.

Its a nice piece of works which can guide other research and health care services linked with migration of international students in many developed countries including Canada. 

Reviewers' comments: