PONE-D-21-33341

Caregiver perceptions and experiences of Paediatric Emergency Department attendance during the COVID-19 Pandemic: a mixed-methods study

PLOS ONE

Dear Dr. Maggie,

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Additional Editor Comments:

1. Abstract: please remove the "discussion" section from the Abstract

2.This is a mixed method study design, however, it reads like a multiple method study as there is no integration of the quantitative and the qualitative study findings (quantitative and qualitative results were analysed and reported separately in this manuscript). Integration is the key difference between mixed-method and multiple method study design, so please carefully address this issue in your revised manuscript.

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Reviewers' comments:

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 #2: Partly

Reviewer #3: Partly

Reviewer #4: Yes

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

Reviewer #2: Yes

Reviewer #3: N/A

Reviewer #4: Yes

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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 #2: No

Reviewer #3: Yes

Reviewer #4: 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 #2: Yes

Reviewer #3: Yes

Reviewer #4: 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: Thank you for the opportunity to review this manuscript. The paper outlines a mixed-methods study which sought to examine the impact of health-seeking behaviour of parents accessing care in the paediatric emergency department during the pandemic. Beyond a few key concerns, which I will outline below, I think the study is well designed and conducted, however, it fails to outline how the research builds on existing evidence on this topic and whether there are any implications for research, policy, or practice going forward.

Introduction

When identifying gaps in the literature, the authors state “as the pandemic continues there is a need to understand whether the same patterns of behaviour are being seen in emergency care, particularly whether young children are experiencing unintended consequences due to delayed presentation”. However, it is unclear how the present design and results identifies unintended consequences so I would suggest re-wording this as it may be misleading for the reader.

Methods

Study Design and study population:

The authors state that the mixed methods approach was selected because it “allowed for corroboration, triangulation, exploration of complementary and diverging points as well as expansion of ideas”. However, it is not clear from the results how this was carried out as it appears that the quantitative and qualitative data were analysed separately. It could be that I’m interpreting this incorrectly but in that case, this section needs to be re-worded.

Were all attendees to the ED during the timeframe described asked to participate? If not, how were they selected and was there a risk of any bias? What was the response rate?

Data Collection:

More information of the design of the survey is needed. Was it piloted ahead of the study? Any information on validity?

The authors mention that triage scores and outcomes were noted. Were these extracted from medical notes? If so, this needs to be stated as a source of data.

Were any sample size calculations carried out?

Results

I think Table 1 in S4 should be a table in the main text rather than a supporting file.

Historical figures: What was the source of the data described in this section? Are these figures publically available or were they extracted from a hospital database for the study? They form the basis of a key conclusion in the study so I think it’s important to include a section in Methods to outline the data source.

Page 12: Please use the ρ coefficient to denote the results of Spearman’s rho instead of “calculated correlation co-efficient”

Discussion

Page 13, line 629: “appear outweighed” This phrasing is difficult to understand.

One element that I feel is missing from the research is information on the socioeconomic profile of the parents (education, job status, income etc.) as this is well known to influence health seeking. I think this is an important limitation and needs to be recognised or fleshed out in the discussion. Maybe information about the location of or population the hospital serves?

This research took place in November 2020 when the pandemic had been ongoing for 9 months and people had had time to adjust to living in a pandemic, restrictions, mask wearing etc. Is it possible that this may have had an impact on the results?

Are there any recommendations for policy or planning arising from the research? This would be particularly valuable with regards to future planning for public health emergencies.

Supplementary file 4:

Table 1: It’s not clear why you would expect there to be a difference between those who completed the questionnaire only, interview only or both. I think this should be collapsed into one column and this table brought into the main text.

Table 2: As mentioned previously, the source of this historical data needs to be included in the methods

Table 3: As with table 1, it’s not clear why you would expect there to be a difference between the two groups. As a result, I don’t think Table 3 is needed at all and would recommend removing.

Reviewer #2: Thank you so much for the opportunity to review the paper Caregiver perceptions and experiences of Paediatric Emergency Department attendance during the COVID-19 Pandemic: a mixed-methods study. This qualitative paper covers an important topic in public health literature, as it focuses in decision-making of parents to attend paediatric emergency care during the current COVID-19 pandemic. I applaud the authors for conducting this research during this challenging time and I think the results are important and relevant. Unfortunately, for this paper to be accepted for publication, several major changes need to be made, which I will outline per section below.

1. To start, a general comment of editing. This paper needs to be proofread, as there are several grammatical errors in the paper. Please attend to this.

2. The abstract reads well, but the conclusion is vague (also in the paper). Please clarify what the take-home message is of the paper and what we can learn from the your findings. What should policy-makers, health workers or parents do differently?

3. The introduction is well-written, but some of the studies mentioned in the background do not show a significant delay in seeking care for children. This does not reinforce your objectives of doing this study. Is there anything else in the examples you can highlight that are of interest to your study? This links to my concerns about the overall objectives of the study, as the background does not stress the concerns at length, and therefore, you need to reinforce your argument with using other examples. For instance, what were the qualitative outcomes in reference 26? And how are these different or similar to your work?

4. The methods are well-described, but I was wondering why data collection was only conducted during office hours and during the week? Maybe parents coming in the weekend or evening might have delayed attending the emergency room for different reasons or waited longer? I am also curious to read more about the questions asked in the interview, you only mention information provision as a topic, which seems limited. I would also like to read which emerging themes derived during the data analysis process. I would also add the specifics of the participants and the length of the interviews to the methods, instead of the findings. Also, the interviews were really short, was this time sufficient for the researchers? And why, or why not?

5. The findings are relevant, but I wonder if you can shorten theme 1. This speaks about the general experiences of COVID-19 and has some interesting quotes, but they are not related to the main topic. I would emphasize the findings of Theme 2 more, as they link well to your research questions and are well described. The theme also gives a gives a good impression of the confusion and fear of parents and their decision-making process of seeing a health care provider for their children and trying to keep other family members safe. We can learn a lot about that. In Theme 3, I was expecting to read more about parents’ interactions with health workers, such as being judged for coming in or feeling inadequate as parents, but they are not described in the theme. Only the waiting times were discussed in the theme, which seems limited.

6. The discussion of the findings is limited, which might be attributed to the novelty of the study, but I would have liked to see a comparison of your findings with studies conducted in other countries. There is literature around delayed decision-making for getting immunisations for children for instance, which has been studied in several countries. I also have several remaining questions that seem relevant, including; how were other paediatric departments in government clinics attended in other countries, or parts of the UK? And what can we learn from your findings? If we get into a similar situation, like COVID-19, how can paediatric communication be improved? Or what should be teach young parents about attending care during a national crisis. How can you convince parents that they are not ‘overburdening the NHS’ and reassure them that their own health and that of their children is most important?

Overall, I think this study is relevant and results should be published, but several improvements need to me made to strengthen the aim, objectives and outcomes of the paper.

Reviewer #3: The authors have written on a relevant topic.

The following are my few comments:

Abstract

Methods: More information should be provided here, eg: method of selection of participants (sampling technique), method of data analysis/ analysis carried out

Result: Quantitative result appears too scanty here, add a little more details eg demographic characteristics.

Main Body

Methods: Line 127, Kindly provide the name of the study design used in this study, perhaps read up types of study design and identify where this falls under. What was written is more of a description of what was done.

Results of quantitative survey should also be presented in tables.

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PONE-D-21-33341R1Caregiver perceptions and experiences of paediatric emergency department attendance during the COVID-19 pandemic: a mixed-methods studyPLOS ONE

Dear Dr. -Nyang'wa,

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 Sep 04 2022 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,

Alison Wang

Academic Editor

PLOS ONE

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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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #3: All comments have been addressed

Reviewer #4: 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 #3: Yes

Reviewer #4: Yes

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

Reviewer #3: Yes

Reviewer #4: Yes

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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 #3: Yes

Reviewer #4: 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 #3: Yes

Reviewer #4: 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 #3: Overall comment:

I think this paper has drastically improved and I am happy with the changes made in the updated version. I am happy for this paper to be accepted, although I have made some additional suggestions below. Once these are considered, I think this paper will make an excellent contribution to body of knowledge focusing on the impact of the COVID-19 pandemic in the global North.

Comments:

1. Abstract: in the methods, you speak about data triangulation, but in the mixed methods study, you only used 2 different methods; survey and interviews. How was the data triangulated? And more importantly, how was the data analysed and synthesized?

2. Line 67: use a different word to start the sentence. Despite this – does not link well to the previous paragraph, unless you say: ‘despite hospitals remaining open throughout the various lockdowns, the was a decreased …..’

3. Line 102: ‘was driven by fear and knowledge’ – can you be more specific here? What kind of knowledge are we speaking about…. Or a lack of knowledge maybe? This seems relevant to the study.

4. Line 161: consider rewriting: ‘that they were too worried about and wanted to focus on their child.’ Just change into; feeling too worried about their child.

5. Line 188: I understand that the data cannot be disclosed, but how was the ‘historical data’ used? To see if the child had been attending the ER before COVID, or to understand illness and symptoms?

6. Line 205: what themes derived out of the analysis? And how was reflexivity and positionality of the project staff being explored and negotiated within the team? I would like to read more about this, as it is an important aspect of data analysis.

7. Line 298: I think it would be great to have a quote that illustrates the ‘new normal’.

8. Line 309: Similar to comment above. A quote from ID12 or ID20 speaking about the differences in illness symptoms between flu and COVID could strengthen this paper

9. Line 350: A quote about the confusion of the rules would be a benefit to this paper

10. Line 376: A last sentence can be added here that explains that the interviewees had been living with the pandemic for 6 months at the time of the interview, so had a chance to adapt to the ‘new normal’.

11. Line 395: I would like to read a few quotes here too, especially about the ‘parents’ instinct or ‘gut feeling’.

12. Line 739 – 741: this sentence does not flow well, and I am not sure what the authors are trying to say. Please rewrite/simplify

Reviewer #4: (No Response)

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Reviewer #3: No

Reviewer #4: No

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Caregiver perceptions and experiences of paediatric emergency department attendance during the COVID-19 pandemic: a mixed-methods study

PONE-D-21-33341R2

Dear Dr. Maggie Nyirenda,

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,

Alison Wang

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: