PONE-D-23-17539Dependent older adults’ care barriers: brazilian primary health care managers’ perspectivePLOS ONE

Dear Dr. Gonçalves,

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.

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We look forward to receiving your revised manuscript.

Kind regards,

Marília Jesus Batista de Brito Mota, Post-doc

Academic Editor

PLOS ONE

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Additional Editor Comments :

The manuscript is very relevant considering the aging rates observed around the world. The study provides data to guide public policies and needs to be revised in some aspects described by reviewer 1.

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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

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

Reviewer #1: 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

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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

**********

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: Current and relevant topic in view of the socio-sanitary impacts of the demographic transition. The text analyzes important issues for the formulation of public policies, as well as the organization of care practices for the elderly, especially for the elderly, that is, those over 80 years of age.

The article is theoretically and methodologically structured, with clear arguments and relevant dialogues with national and international publications on the subject.

Despite these considerations on the merits of the article, I highlight some aspects that deserve necessary revisions for publication:

I. Introduction

1. The Brazilian Institute of Geography and Statistics (IBGE) published the 2022 Demographic Census. I suggest updating the demographic data presented in the article.

2. The results presented are part of a larger research, as the authors mention (lines 126-131). However, the choice of the objective of this article with other aspects found is not sufficiently clarified. It inappropriate to say “the entire collection of this knowledge is registered in a thematic issue of the Ciência & Saúde Coletiva jornal” (lines 160-161). There are in this publication, for example, other articles that do not deal with the same theme.

3. Programa Acompanhante de Idosos (PAI) of the Municipal Secretary of Health of São Paulo is the correct name. It’s necessary to change (line 82) “São Paulo has the Acompanhamento ao Idoso (“Elderly Monitoring”)...”.

II. Methods

1. Presents theoretical foundation, description of procedures and ethical aspects of the research. However, It’s appropriate to rephrase the paragraph (lines 138-143) “... all of them (including Araranguá) share that they are hubs for gathering the demand of SUS users since they have all the equipment and resources for primary, secondary, tertiary, and ultra-specialized care” The reference (22) is insufficient to characterize the health care network. Publications in reference (23) have more adequate paragraphs about it.

2. 16 study participants in the 8 cities. It’s necessary to describe this distribution, as also the responsibilities inherent in managing care for dependent older adults.

3. It’s advisable to specify the software used in the research (line 172).

III. Results

It’s appropriate to clarify acronyms and citation some excerpts from the interviews – “PAIF”, “Mais Médicos”, “PNAB”.

Note: also in other parts of the article, such as “PHC”, “SUS”.

IV. Discussion

In general, this part of the text is well founded with current publications, supported by research in the Brazilian reality, as well as international experiences, enabling comparative analyzes and possible contributions to the Brazilian context.

However, It’s necessary to review some aspects:

1. The dimension “barriers caused by problems in family care for the dependent older adults” has not been sufficiently analysed.

2. There are participants who have been worked in Belo Horizonte. However They didn’t talk about ”Greater Care”. Fact that deserves discussion.

3. The argument in lines 386-394 doesn’t establish a dialogue necessary with lack of knowledge of the subjects of the policy.

4. Including in the Introduction the paragraph (lines 402-409) is more adequate.

5. It’s necessary discuss more appropriately with the results the argument “It is a consensus among the authors that a health hospital-and-medical professional-centered system alone will have to be modified” (lines 450-451).

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Reviewer #1: No

**********

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PONE-D-23-17539R1Dependent older adults’ care barriers: brazilian primary health care managers’ perspectivePLOS ONE

Dear Dr. Gonçalves,

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,

Marília Jesus Batista de Brito Mota, Post-doc

Academic Editor

PLOS ONE

Additional Editor Comments:

"Dependent older adults’ care barriers: brazilian primary health care managers’ perspective"

The authors have answered the points in the first review. The manuscript brings a very relevant issue about the barriers for atend dependent older adults in Primary Health Care. The problem of the manuscript is that the results is focused in national context and would be more appropriated national publication. Many importante points were evaluated for the new reviewers in this fase of the editorial process in order to improve the manuscript to be eligible for publication. After the changes the can submit again the manuscript.

Reviewer 1

Introduction:

1- It is bureaucratic and, at times, generic. It needs to be very clear about what is meant by "dependent adult". It needs to explain to the foreign reader in a synthetic way how PHC is organized in Brazil and how it is articulated in the elderly care network, etc. Make it clearer what it is, including SUS!!!

2- References are missing in paragraphs 4, 6, 7, 8, 9 and many others.

3- “In Brazil, PHC’s attributions are promoting health, preventing diseases, and providing care7”. In this sentence, you need to be careful, since it cannot be just in Brazil, as they are attributes of (non-selective) APS internationally.

4- In the sentence “Structuring an Elderly Care Network regulated by Primary Care requires close communication between the Unified Health System (SUS) and the Unified Social Assistance System (SUAS), as recommended in other countries”, a reference is needed at the end of the sentence and, Also, justify why? It was confusing and also does not make it clear to the non-Brazilian reader what SUS and SUAS mean.

5- In general, the introduction paragraphs are not articulated and are only descriptive, lacking some criticality in the writing and approach. The problem is not well discussed in the introduction. According to the research question, discuss PHC and its relationship with elderly care in Brazil and around the world. The question is not thematized in the introduction, which raises relevant questions, although disjointed and without debate appropriate to the problem presented. The barriers were not discussed in the text or were poorly explained in the description.

Materials and methods:

6- There are many references missing in the paragraphs to strengthen the argument.

7- Where and how was it used in hermeneutic-dialectic analysis? There is nothing to demonstrate its use. In what aspects did HD help in understanding the results and their discussion?

8- Is HD possible without data triangulation? Why does this research, the result of a larger and richer research as a whole, boil down to treating the perception of managers without triangulating it with other data, including sociodemographic data?

9- Why and how were the cities chosen? Why is one of them not a state capital and what is the implication of this in the analyses?

10- Why 4 managers in Araranguá and fewer in the others?

11- I suggest a map with the location of these municipalities in the country for better visualization.

12- Also, a table is needed with data from these municipalities: population, PHC coverage, other services, number of elderly people, epidemiological data, etc.

13- The authors state that the choice was made for convenience, but what is appropriate in qualitative research is an intentional choice!!! (could you justify it better?).

14- Regarding the interviews, you need to provide details with COREQ and not just indicate what you used, as important details are missing (Who carried them out? See Quoreq and try to bring up aspects that clarify the conditions of data production). The average interview time was 30 minutes? (Only? What depth is possible in such short interviews?). Explain in the method how you arrived at the categories/topics.

Results:

15- The fragments are interesting and rich. However, there are two general problems: the description of the results is VERY synthetic and does not explore the wealth of information. In this sense, the description is limited to repeating the managers' arguments as if the statements contained a truth in themselves;

16- As a result, the text contains many fragments (empirical results), but does not explore them and, consequently, leaves it up to the reader to interpret the results. In my understanding, this choice impoverished many of the data found and compromised the entire article, making it fragile and without sufficient argumentative strength.

17- There would be a need to rewrite all the results, even if the chosen topics were maintained, but described with more attention and more criticality (the description does NOT mean repetition of arguments, but elaboration of text that synthesizes the ideas contained explicitly or implicitly in the managers' fragments).

18- Are the categories/topics common for all elected municipalities? Is there no diversity among managers? Wouldn't this be an aspect worth considering?

Discussion:

19- I feel that the discussion does not fulfill the promise of hermeneutic-dialectic analysis. Or I would need to demonstrate the strength of dialectics in writing. The text is quite descriptive and, to some extent, repeats the results without sufficient criticality, historicity or dialectics.

20- In the way they judge families, there would be a need to consider the different family contexts across the country (demographic and socioeconomic data added to inferences that consider national complexity in different regions of the country).

21- Are there no differences between regions and cities? How can a “poor” Brazilian family take care of a dependent elderly person? How do different family arrangements manage to care for the elderly? As it stands, there is a homogeneity in the way of thinking about such families' responsibilities and viability.

22- Managers point out in a bureaucratic way, but the analysis needs to counter argue the findings.

It is not understandable because methodologically different cities/regions of the country were used and this diversity does not appear in the results or in the discussion. It needs to be justified or at least revised. I think this impoverished and compromised the quality and originality of the article, as everything became generic.

The discussion with the literature is bureaucratic and prescriptive without any argumentative force that goes beyond the description and compilation of national and international findings. I think there is a need for rewriting and new arguments to make the text rich and capable of providing aspects that contribute to research on elderly care.

Finally, the discussion does NOT answer the research question sufficiently, as APS practically disappears from the analyses. I think that the authors would need to review the entire analytical approach.

Final considerations: insufficient and generic. It needs to answer the research question supported by the results. But bring perspectives of intervention in politics in a less generic way.

Reviewer 2

The text discuss a very relevant issue in Brazilian reality and has an interesting focus to present the perceptions of the managers of health services towards barriers in care for older adults.

The text is confusing sometimes due to the use of prepositions that may not be the most appropriate, literal translation of expressions or idioms that may not have the same meaning in English, and other aspects that require the support of a professional reviewer that may have access to the text written in the Portuguese for the correct alterations.

As for the structure of the text, in the results section we advise the authors to check how the statements presented may reinforce or build upon what has been presented and will be presented in the discussion section. At one point the authors suggest a comparison between Brazil's health system and other countries, but forget to explain that Brazilian's federalism, consisted of 3 federative beings, is not easily comparable due to its particularities. This makes the implementation of primary health a particular challenge in Brazil. There is a lack of connection of primary care for dependent older adults and the Brazilian family health strategy, this could be an important aspect of the implementation of services.

In discussion, the authors present a figure related to older adults who are responsible for families (line 400), but present an outdated figure, the same author has much recent work on the subject, even including the effect of the Covid-19 outbreak on families and the income of older populations. Lines 419-421 repeat the figures in the introduction, which are not from the "Censo" but from another household research, make sure you cite the updated values that increase 60+ participation in our society. Content between lines 441-443 were not very clear, and need careful review. Line 477 cites a study by Brazilian authors that is not presented in the reference list. The last paragraphs before conclusions cite Japanese examples and possible adaptations but does not suggest how to adapt and which services could be formulated for dependent older adults.

There could be a paragraph where some of the limitations of the study are presented (Why 4 participants in a middle-size city and just 1 in most of the largest cities? How can this short list of professionals limit or influence the results? How was the interview carried and what were some of the possible limitations in the interview script? and other things that they may consider relevant).

We hope our suggestion can improve and better connect what has been presented throughout the article with the relevant debate of the subject.

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

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 #2: All comments have been addressed

Reviewer #3: (No Response)

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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 #2: Partly

Reviewer #3: Partly

**********

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

Reviewer #2: N/A

Reviewer #3: 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 #2: No

Reviewer #3: Yes

**********

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 #2: Yes

Reviewer #3: 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 #2: Introduction: It is bureaucratic and, at times, generic. It needs to be very clear about what is meant by "dependent adult". It needs to explain to the foreign reader in a synthetic way how PHC is organized in Brazil and how it is articulated in the elderly care network, etc. Make it clearer what it is, including SUS!!! References are missing in paragraphs 4, 6, 7, 8, 9 and many others. “In Brazil, PHC’s attributions are promoting health, preventing diseases, and providing care7”. In this sentence, you need to be careful, since it cannot be just in Brazil, as they are attributes of (non-selective) APS internationally. In the sentence “Structuring an Elderly Care Network regulated by Primary Care requires close communication between the Unified Health System (SUS) and the Unified Social Assistance System (SUAS), as recommended in other countries”, a reference is needed at the end of the sentence and, Also, justify why? It was confusing and also does not make it clear to the non-Brazilian reader what SUS and SUAS mean. In general, the introduction paragraphs are not articulated and are only descriptive, lacking some criticality in the writing and approach. The problem is not well discussed in the introduction. According to the research question, discuss PHC and its relationship with elderly care in Brazil and around the world. The question is not thematized in the introduction, which raises relevant questions, although disjointed and without debate appropriate to the problem presented. The barriers were not discussed in the text or were poorly explained in the description.

Materials and methods: There are many references missing in the paragraphs to strengthen the argument. Where and how was it used in hermeneutic-dialectic analysis? There is nothing to demonstrate its use. In what aspects did HD help in understanding the results and their discussion? Is HD possible without data triangulation? Why does this research, the result of a larger and richer research as a whole, boil down to treating the perception of managers without triangulating it with other data, including sociodemographic data? Why and how were the cities chosen? Why is one of them not a state capital and what is the implication of this in the analyses? Why 4 managers in Araranguá and fewer in the others? I suggest a map with the location of these municipalities in the country for better visualization. Also, a table is needed with data from these municipalities: population, PHC coverage, other services, number of elderly people, epidemiological data, etc. The authors state that the choice was made for convenience, but what is appropriate in qualitative research is an intentional choice!!! (could you justify it better?). Regarding the interviews, you need to provide details with COREQ and not just indicate what you used, as important details are missing (Who carried them out? See Quoreq and try to bring up aspects that clarify the conditions of data production). The average interview time was 30 minutes? (Only? What depth is possible in such short interviews?). Explain in the method how you arrived at the categories/topics.

Results: The fragments are interesting and rich. However, there are two general problems: the description of the results is VERY synthetic and does not explore the wealth of information. In this sense, the description is limited to repeating the managers' arguments as if the statements contained a truth in themselves; 2) As a result, the text contains many fragments (empirical results), but does not explore them and, consequently, leaves it up to the reader to interpret the results. In my understanding, this choice impoverished many of the data found and compromised the entire article, making it fragile and without sufficient argumentative strength. There would be a need to rewrite all the results, even if the chosen topics were maintained, but described with more attention and more criticality (the description does NOT mean repetition of arguments, but elaboration of text that synthesizes the ideas contained explicitly or implicitly in the managers' fragments). Are the categories/topics common for all elected municipalities? Is there no diversity among managers? Wouldn't this be an aspect worth considering?

Discussion: I feel that the discussion does not fulfill the promise of hermeneutic-dialectic analysis. Or I would need to demonstrate the strength of dialectics in writing. The text is quite descriptive and, to some extent, repeats the results without sufficient criticality, historicity or dialectics. In the way they judge families, there would be a need to consider the different family contexts across the country (demographic and socioeconomic data added to inferences that consider national complexity in different regions of the country). Are there no differences between regions and cities? How can a “poor” Brazilian family take care of a dependent elderly person? How do different family arrangements manage to care for the elderly? As it stands, there is a homogeneity in the way of thinking about such families' responsibilities and viability. Managers point out in a bureaucratic way, but the analysis needs to counter argue the findings.

It is not understandable because methodologically different cities/regions of the country were used and this diversity does not appear in the results or in the discussion. It needs to be justified or at least revised. I think this impoverished and compromised the quality and originality of the article, as everything became generic.

The discussion with the literature is bureaucratic and prescriptive without any argumentative force that goes beyond the description and compilation of national and international findings. I think there is a need for rewriting and new arguments to make the text rich and capable of providing aspects that contribute to research on elderly care.

Finally, the discussion does NOT answer the research question sufficiently, as APS practically disappears from the analyses. I think that the authors would need to review the entire analytical approach.

Final considerations: insufficient and generic. It needs to answer the research question supported by the results. But bring perspectives of intervention in politics in a less generic way.

Reviewer #3: The text discuss a very relevant issue in Brazilian reality and has an interesting focus to present the perceptions of the managers of health services towards barriers in care for older adults.

The text is confusing sometimes due to the use of prepositions that may not be the most appropriate, literal translation of expressions or idioms that may not have the same meaning in English, and other aspects that require the support of a professional reviewer that may have access to the text written in the Portuguese for the correct alterations.

As for the structure of the text, in the results section we advise the authors to check how the statements presented may reinforce or build upon what has been presented and will be presented in the discussion section. At one point the authors suggest a comparison between Brazil's health system and other countries, but forget to explain that Brazilian's federalism, consisted of 3 federative beings, is not easily comparable due to its particularities. This makes the implementation of primary health a particular challenge in Brazil. There is a lack of connection of primary care for dependent older adults and the Brazilian family health strategy, this could be an important aspect of the implementation of services.

In discussion, the authors present a figure related to older adults who are responsible for families (line 400), but present an outdated figure, the same author has much recent work on the subject, even including the effect of the Covid-19 outbreak on families and the income of older populations. Lines 419-421 repeat the figures in the introduction, which are not from the "Censo" but from another household research, make sure you cite the updated values that increase 60+ participation in our society. Content between lines 441-443 were not very clear, and need careful review. Line 477 cites a study by Brazilian authors that is not presented in the reference list. The last paragraphs before conclusions cite Japanese examples and possible adaptations but does not suggest how to adapt and which services could be formulated for dependent older adults.

There could be a paragraph where some of the limitations of the study are presented (Why 4 participants in a middle-size city and just 1 in most of the largest cities? How can this short list of professionals limit or influence the results? How was the interview carried and what were some of the possible limitations in the interview script? and other things that they may consider relevant).

We hope our suggestion can improve and better connect what has been presented throughout the article with the relevant debate of the subject.

**********

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 #2: No

Reviewer #3: No

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Barriers to care for dependent older adults: Brazilian Primary Health Care managers’ perspective

PONE-D-23-17539R2

Dear Dr. Gonçalves,

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,

Marília Jesus Batista de Brito Mota, Post-doc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

I would like to explain in advance and apologize for the delay in the editorial process. This was due to the difficulty in finding reviewers for this manuscript, but we were able to complete the process satisfactorily.

The reviewers of this manuscript found that the authors had made all the recommended changes. The decision is therefore to accept the manuscript for publication.

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 #3: 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 #3: Yes

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

Reviewer #1: N/A

Reviewer #3: N/A

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Reviewer #1: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

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Reviewer #1: (No Response)

Reviewer #3: The authors have taken reviews into consideration and improved the manuscript. From my perspective the text discuss a relevant issue and bring views from different locations. Maybe more contradictions in terms of PHC promotion, care and access could have been presented, however the text achieves the objective aimed.

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Reviewer #1: No

Reviewer #3: No

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