-->PONE-D-25-54593-->-->‘Us and them’: a realist interview study exploring how and why health system factors influence dentists’ participation in state funded, contracted primary dental care for low-income populations in Ireland -->-->PLOS One

Dear Dr. Leavy,

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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The manuscript has been evaluated by three reviewers, and their comments are available below.

The reviewers have raised a number of concerns that need attention. In particular, they request additional information on methodological aspects of the study, further details on reflexivity, and improvements to the Discussion section.-->-->Could you please revise the manuscript to carefully address the concerns raised?-->

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Research funded by the Health Research Board SPHeRE 2018-1

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The authors wish to thank the following members of the Project Advisory Group (PAG): Professor Paul Batchelor, Dr Sarah Barry, Dr Will Rymer, Dr. Katherine Carr, Mr Michael Dolan, Miss Sophie Mulcahy Symmons. This Research is funded by the Irish Health Research Board (HRB) under the SPHeRE Programme 2018-1

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Research funded by the Health Research Board SPHeRE 2018-1

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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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #3: No

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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

Reviewer #3: 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: This is a brilliant piece of scholarship filling a gap in the global literature. This study examines the health system factors that are likely structurally causative to dentist non-participation in public programs, and therefore provides a roadmap of political/structural/policy approaches that could remediate the situation and improve access to dental care both in Ireland and around the globe. It is well written, empirically sound, and based in the literature. No substantive critiques - excellent article.

Reviewer #2: First, I would like to congratulate the authors on a well-developed and methodologically sound study addressing an important and policy-relevant issue. The use of realist interviews to examine health system influences on GDP engagement in state-funded care is both appropriate and timely. The manuscript demonstrates strong conceptual grounding, adherence to realist principles, and clear policy relevance within the Irish reform context.

The study clearly addresses a significant knowledge gap and builds meaningfully upon the authors’ prior realist review.

That said, I offer the following suggestions to strengthen clarity, methodological transparency, and theoretical contribution.

1. Introduction and Rationale

There is some redundancy between the “Study rationale” section in the Introduction and the subsequent “Rationale” subsection within the Methods. The justification for a realist approach appears twice — first conceptually in the Introduction and then methodologically in the Methods.

It may improve narrative flow to more clearly differentiate these sections:

The Introduction should justify why the study is needed (policy and empirical gap).

The Methods should justify why a realist approach is appropriate and how it was operationalised.

Streamlining this would reduce repetition and strengthen structural coherence.

2. Sampling and Theoretical Sufficiency

The inclusion of diverse stakeholders is a notable strength. However, clarification is needed regarding:

Why only six frontline GDPs were included.

Whether this number was determined by theoretical sufficiency.

How “theoretical sufficiency” was operationalised in the context of realist interviews.

It would be helpful if the authors could elaborate on:

How they determined that sufficient variation had been achieved,

Whether new mechanisms ceased to emerge,

And how sufficiency was judged within the iterative realist interview process.

3. Reflexivity

Given the theory-driven nature of realist interviews, reflexivity is particularly important. The manuscript would benefit from clarification regarding:

How the interviewer’s prior knowledge and involvement in the earlier realist review may have influenced the interview process.

Whether reflexive journaling or other strategies were used to monitor interpretive influence.

4. CMOC Development and Refinement

Further methodological transparency would strengthen the realist contribution. Specifically:

Were CMOCs refined iteratively across interviews?

Were conflicting or competing CMOCs retained and explored?

How were the 13 individual CMOCs consolidated into five higher-level CMOCs?

Providing a brief explanation of this consolidation process would enhance analytic clarity.

5. Results – Differentiation of Context, Mechanism, and Outcome

The Results are rich and policy-relevant, and the five consolidated CMOCs form a coherent explanatory account.

To further strengthen the realist contribution, the manuscript would benefit from clearer and more consistent differentiation between:

Contexts, Mechanisms (reasoning/resources), and Outcomes.

Several constructs (e.g., trust, demotivation, fragmentation) appear to function in multiple roles across CMOCs. Clarifying how these were categorised would improve conceptual precision.

Additionally, some potentially contentious claims (e.g., references to cultural opportunism or perceptions of accusatory tone) would be strengthened by clarifying:

Whether these views were widely shared or contested across stakeholder groups, and

How disconfirming or divergent cases informed programme theory refinement.

6. Discussion

The Discussion is coherent and appropriately situates the findings within Irish oral health reform and the broader international literature.

However, the opening section reiterates the programme theory in language closely aligned to the Results. Tightening this section would reduce repetition and allow clearer emphasis on the novel theoretical refinements beyond the earlier realist review.

The comparative discussion with England is insightful but would benefit from explicit caveats regarding cross-system comparability (differences in contract design, basket of care, oversight mechanisms).

The “Us and them” implications section is compelling and well articulated. It could be further strengthened by translating each consolidated CMOC into more explicit, actionable system levers (e.g., contract design and remuneration reform, standardisation of prior approval governance, risk-based and peer-led QA approaches, reinstatement of consultative structures). Making explicit how these levers would disrupt negative mechanisms and activate countervailing mechanisms would enhance practical utility.

A small number of phrases read as evaluative. Framing these more explicitly as perceptions operating within a low-trust context would maintain analytic neutrality while preserving the strength of the findings.

7. Conclusion

The conclusion succinctly summarises the key findings; however, it largely reiterates the identified CMOCs rather than distilling the central explanatory insight of the programme theory.

Consider tightening this section to foreground the core causal pathway — namely how political marginalisation, governance design, and communication practices interact to produce autonomy threat, mistrust, and disengagement within a mixed public–private market.

Framing mechanisms not solely as “sentiments” but as professional reasoning responses to structural conditions would further reinforce the realist explanatory contribution. The conclusion could also more explicitly identify key modifiable system levers suggested by the findings (e.g., relational governance, supportive contract administration, consultative structures), strengthening its policy relevance.

Reviewer #3: This is a well-written and thoughtfully conducted study addressing an important topic, and the manuscript demonstrates considerable effort in applying a realist approach utilising the teaching-learning cycle, WHO health systems building blocks and program theory frameworks. To further strengthen the paper, greater transparency regarding the analytic process would be helpful with an audit table. In addition, please consider including the full interview guide as a supplementary file to support transparency regarding the realist interviewing process. Finally, tables referenced in the manuscript and/or supplementary materials were not located; these should be provided or clearly indicated to ensure completeness of reporting.

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Reviewer #1: No

Reviewer #2: Yes: Vineetha Karuveettil

Reviewer #3: No

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‘Us and them’: a realist interview study exploring how and why health system factors influence dentists’ participation in state funded, contracted primary dental care for low-income populations in Ireland

PONE-D-25-54593R1

Dear Dr. Paul Leavy,

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,

Maria Giulia Nosotti, Master's Degree

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 #2: 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 #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: 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 #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 #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. 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: The authors have adequately addressed all the comments and suggestions raised during the review process. The revised manuscript reflects the necessary modifications and improvements in clarity, methodology, and presentation of results. The responses provided by the authors are satisfactory and demonstrate careful consideration of the reviewers’ concerns. Overall, the updated manuscript is well-structured, scientifically sound, and suitable for publication in its present form.

Reviewer #3: I feel the authors have addressed all questions adequately. However I did not see the interview guide or the tables that have been referenced in the manuscript.

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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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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: Yes: Vineetha Karuveettil

Reviewer #3: No

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