PONE-D-23-28342Interventions to improve primary healthcare in rural settings: A scoping reviewPLOS ONE

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Additional Editor Comments:

Thank you for submitting this interesting manuscript. In general, we believe this treatment is too superficial. We understand that more in-depth treatment will be given to topics in subsequent papers but this paper should not merely be an appetizer. Readers should learn something from your effort. Try to give at least some high-level content analysis in the body of the article and more depth about the gaps and areas for further research. Please also respond to each comment from the reviewers.

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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: General comments

This is a scoping review of the literature on interventions to improve primary health care in rural settings. The review covers 1996-2022 and is wide-ranging. The authors do not limit their review to either high income countries (HICs) or low- and middle-income countries (LMICs), but include both. The review covers a variety of health conditions, outcomes (access; quality; efficiency) and study types. They excluded purely descriptive articles.

The authors made the decision to include articles from both HICs and LMICs. This, of course, means that the contexts vary widely in terms of the epidemiology of disease and the strength and organization of the health system. This makes for a more ambitious and difficult undertaking in terms of drawing conclusions.

Specific comments

Introduction

• The authors don’t clearly and explicitly state the definition or framework they are using for Primary Care or Primary Health Care. They seem to be screening articles mainly by level of care and excluding specialist or hospital-delivered care. But are they using any kind of characteristics of primary care, like the classic 4 C’s (first contact, coordination, comprehensiveness, and continuity). If the common feature of included articles is only that they are at the most basic level of care (i.e., “first contact”), but not necessarily that the care is coordinated or comprehensive, for instance, then are all included articles truly about “PHC” or “PC” or would they more accurately be described as about “basic health care” or “non-specialist care.” I take as an illustrative example of what I mean by this distinction one of the interventions listed in Appendix 3 on Clinical Outcomes. From what is listed in the table, it is not clear if this was a “vertically delivered” intervention that was not integrated into other health care. Perhaps it was integrated into a coordinated, comprehensive, and continuous system of care. But I don’t feel that there is enough information given for the reader to confirm that is the case.

* Shakya, 2016, Nepal

* Uncontrolled before/after

* The primary purpose of this study was to assess the knowledge of cervical cancer among women in rural Nepal and explore the feasibility and impact of a community-based awareness program on cervical cancer. Code: Patient Education/Navigation

* Community-based educational meetings on cervical cancer and its prevention were conducted among women’s groups in rural Nepal.

* Questionnaires with open-ended and closed-ended questions were administered through a face-to-face interview. All interviews were performed by the primary investigator and a doctor trained in interviewing. The questionnaire consisted of sociodemographic information (age, education level, and income source), personal information (age at marriage, number of live births, number of marriages), and questions on knowledge and attitudes related to cervical cancer to determine the outcome measures of interest. The messages that were emphasized during the education session were: (1) cervical cancer is preventable, (2) risk factors, signs, symptoms, and asymptomatic nature of early cervical cancer, and (3) the importance of undergoing gynaecological examination and cervical screening. The participants were asked whether they would participate in an upcoming cost-free cervical cancer screening program two weeks after the educational meeting.

Methods

• The authors followed a systematic and standard process for this Scoping Review, following the standard process originally outlined by Arksey and O'Malley in 2005 and the PRISMA-ScR checklist for presentation.

• The authors searched the following databases: PubMed, CINAHL, Cochrane Library, Embase, but did not attempt to include grey literature in their review. Can they give a reason for this?

• The authors present their search terms for an illustrative database (MEDLINE). I’m curious: It does not seem that the authors included any term on cost or cost-effectiveness although this is one of the sub-outcomes under Efficiency outcomes that they list in Table 3.

• In the PRISMA diagram the authors ought to list the reasons for exclusion (and how frequently the reason was used to exclude an article).

Results

• I am bit confused by the categorization of some issues as “outcomes” and others as strategies.” For instance, on Page 6, “recruitment of family physicians” and “retention of family physicians” are listed as sub-outcomes under Access, rather than as strategies or interventions that are meant to improve outcomes like availability.

• Related to the last point, I’m not sure how or why the authors decided to sub-divide the outcome of efficiency. A fairly well-known sub-division of this concept is the following: availability, accessibility, accommodation, affordability, acceptability (Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981 Feb;19(2):127-40. doi: 10.1097/00005650-198102000-00001).

Reviewer #2: This is a very interesting topic and article that offers an overview of quantity, type, and topics within the rural primary care literature…but I am left feeling like I didn’t learn as much as I wanted. As mentioned in limitations, identifying the interventions and their findings (what actually worked?) will come in other papers, but it’s a very lengthy article to have such limited substance. Perhaps the narrative description of the papers could be shortened (it’s mostly already in the table) and presented in other ways (bar charts or other tools), with more space allotted for background, discussion, and some analysis of content around which interventions had an impact on primary care access or outcomes. I recognize this would add a lot of work, but otherwise I feel the paper's a bit too superficial.

Some specific comments:

Introduction - it's quite brief, and should be expanded upon in 2 areas in my opinion. 1) rural/remote context, e.g., the authors don’t mention vast geography, lack of public transit, data about distribution of HCP or specialists in rural Canada (or elsewhere), or why Indigenous peoples have unique issues accessing health care (with citation/support that's currently missing). 2) Could explain health system issues and how primary care is situated within the system - primary care physicians’ work settings, role, and part of multidisciplinary teams (or not).

Line 169 - stated there was an increase in number of publications per year, yet it looks like these peaked around 2017 and then went back to almost pre-peak volume - is this consistent with all publications during this time (e.g., due to the pandemic)? Either way, it’s worth noting as it’s not a steady increase as you suggest.

Line 196 - not sure why "chronic disease diabetes" is stated rather than simply diabetes?

Line 207 - "before-after studies (n=42), randomized controlled trials (n=32)." needs and between rather than comma

Line 224 - "prospective cohort studies (n=15), cohort studies (n=14), retrospective cohort studies (n=11)" - it's unclear to me what a cohort study is that is neither prospective or retrospective.

Line 353 - "rurality is associated with a 2-5 year deficit in life expectancy (2,5,392,393) which does not compare to the effect of widely studied diseases such as diabetes, heart disease and stroke.(394) However, the far greater prevalence suggests that ..." Consider rewording this to increase clarity.

Reference #1 - United Nations D of E and SA Population Division,. (edit for format)

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Reviewer #1: Yes: Jim Ricca

Reviewer #2: No

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PONE-D-23-28342R1Interventions to improve primary healthcare in rural settings: A scoping reviewPLOS ONE

Dear Dr. Aubrey-Bassler,

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 Jun 01 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Jennifer Yourkavitch

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thank you for the revisions. Please address the remaining few comments from the reviewer.

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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: (No Response)

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

Reviewer #1: N/A

Reviewer #2: (No Response)

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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: (No Response)

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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: (No Response)

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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 your thoughtful responses to my comments and to those of the other review adn the editor. I find the manuscript clearer now. I especially like the clear focus on pointed out issues for further in-depth review. I find the discussion more in-depth and the findings in each sub-section of the results better summarized.

I only add that I think that one of my previous comments was not completely addressed. I am speaking of my first comment:

• The authors don’t clearly and explicitly state the definition or framework they are using for Primary Care or Primary Health Care. They seem to be screening articles mainly by level of care and excluding specialist or hospital-delivered care. But are they using any kind of characteristics of primary care, like the classic 4 C’s (first contact, coordination, comprehensiveness, and continuity). If the common feature of included articles is only that they are at the most basic level of care (i.e., “first contact”), but not necessarily that the care is coordinated or comprehensive, for instance, then are all included articles truly about “PHC” or “PC” or would they more accurately be described as about “basic health care” or “non-specialist care.”

I appreciate that you added a sentence in the limiatations. But I actually don't find a clear delineation/definiation of Primary Care/Primary Health Care to be a limitation. I think that having (and stating) a definition makes clear the scope of the Scoping Review. I think that a statement of hte definition you are using belongs in the Introduction. I think that some of what you wrote in your response to me should go there - Namely, that you are using the Canadian FOundation for Healthcare Improvement's definition and that this adheres to the common PC principles of First Contact, Comprehensiveness, Continuity, an Coordinated. But that you also "loosened" your criteria (I would be explict about HOW exactly you loosened the criteria......I think that this concern is most relevant when I see in the manuscript various entries for articles about mental health. Were these done in a setting that in which the services were deliverd by mental health specialists or were they integreated into a comprehensive primary care service delivery setting or system? I bring up mental health as an example, but I also have a question in my mind when I see the entires for cancer screening. I have seen such programs carried out as part of "community outreach" by tertiary care hospitals. I don't know if you encourntered any examples in the articles you reviewed. If so, did you exclude them or include them? I thnk you should make state such considerations and your decisions about them clearly in the introduction.

Other than this one remianing comment, I am quite satisfied with your responses and the improvements in the manuscript.

Reviewer #2: Detailed additions that address earlier concerns.

Typo on line 599: the increase in the yearly number of rural primary care must be...

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Reviewer #1: Yes: Jim Ricca

Reviewer #2: No

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Interventions to improve primary healthcare in rural settings: A scoping review

PONE-D-23-28342R2

Dear Dr. Aubrey-Bassler,

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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Kind regards,

Jennifer Yourkavitch

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: 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

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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: Thank you for addressing the one remaining comment that I had. I feel that all my comments have been addressed.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Jim Ricca

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