The First Telementoring Programme in Latvia: A Qualitative Study of the “ECHO School of Psychiatry” for General Practitioners

Round 1

Reviewer 1 Report (New Reviewer)

Comments and Suggestions for Authors

I have reviewed the manuscript titled ‘The First Telementoring Programme in Latvia: A Qualitative Study of the “ECHO School of Psychiatry” for General Practitioners’. In this study, the authors investigate general practitioners’ experiences of a psychiatry telementoring programme using qualitative semi-structured interviews to examine its perceived impact on clinical practice and professional development.

1. The manuscript would benefit from clearer conceptualisation of psychiatric constructs discussed within the programme (e.g., depressive, neurotic, and somatoform disorders), explicitly aligning them with DSM-5 diagnostic criteria and clarifying how general practitioners were expected to operationalise these constructs in clinical decision-making.

2. The qualitative methodology is generally appropriate; however, the use of voluntary response sampling with only 13 participants raises concerns about selection bias and limited representativeness. The authors should more critically discuss how this may have influenced the overwhelmingly positive findings and consider strategies to mitigate this bias in future research.

3. The description of data saturation is brief and somewhat formulaic; greater methodological transparency is needed regarding how saturation was operationalised, particularly given the short interview duration (mean 14 minutes), which may limit thematic depth.

4. The study relies heavily on self-reported perceived improvements in clinical practice (e.g., increased confidence, antidepressant prescribing, use of PHQ-9/GAD-7) without objective measures. The authors should explicitly acknowledge this limitation and avoid implying causal impact on patient outcomes.

5. The literature review is adequate but should be strengthened with more recent studies (last 2–3 years) on ECHO interventions in mental health and primary care, particularly those evaluating clinical or patient-level outcomes and implementation challenges in European contexts.

6. The findings related to screening tools (PHQ-9, GAD-7) would benefit from clearer discussion of their diagnostic versus screening role, including limitations, and how their use aligns with DSM-5 diagnostic processes rather than serving as proxies for diagnosis.

7. Although reflexivity is mentioned, the dual role of the interviewer as programme coordinator introduces a significant risk of social desirability bias. This issue should be more critically examined, and its potential impact on data interpretation more explicitly addressed.

8. The manuscript would benefit from clearer and more structured “Limitations” and “Future Research Directions” sections, including recommendations for mixed-methods or longitudinal designs, incorporation of objective clinical outcomes, and consideration of anonymised data sharing (e.g., coded qualitative data excerpts) to enhance transparency and reproducibility where ethically feasible .

Author Response

Thank you very much for taking time to review this manuscript. Please find the detailed responses below and the corresponding revisions marked in red in the re-submitted files.

Comments 1: The manuscript would benefit from clearer conceptualisation of psychiatric constructs discussed
within the programme (e.g., depressive, neurotic, and somatoform disorders), explicitly aligning them with
DSM-5 diagnostic criteria and clarifying how general practitioners were expected to operationalise these
constructs in clinical decision-making.
Response 1: Thank you for this valuable comment. We acknowledge the importance of clearly conceptualising
the psychiatric constructs addressed within the programme and their relevance for clinical practice. In response,
we have revised the Methods section to clarify that the selected diagnostic groups were based on the ICD-10
classification system, which is used in Latvian clinical practice. These categories were chosen to reflect mental
health conditions commonly assessed and initially managed by general practitioners in primary care settings.
As DSM-5 is not used in routine clinical practice in Latvia, we chose not to align the programme content with
DSM-5 criteria, to ensure that the description reflects real-world clinical practice and maintains contextual
relevance.
Added text in the manuscript: “These diagnostic categories were based on the ICD-10 (International
Classification of Diseases, 10th Revision) classification system used in Latvia and were selected to reflect
mental health conditions and symptom presentations that are commonly assessed and initially managed by
general practitioners in primary care.” (Materials and Methods, page 3, lines 122-125)

 

Comments 2: The qualitative methodology is generally appropriate; however, the use of voluntary response
sampling with only 13 participants raises concerns about selection bias and limited representativeness. The
authors should more critically discuss how this may have influenced the overwhelmingly positive findings and
consider strategies to mitigate this bias in future research.
Response 2: Thank you for this comment. We acknowledge that the use of voluntary response sampling may
have influenced the predominance of positive findings and may have limited the representation of less engaged
or dissatisfied participants. We have discussed these issues throughout the limitations section in the Discussion,
including the potential overrepresentation of more motivated participants, the underrepresentation of
dissatisfied participants, the possible influence of the interviewer-participant relationship and potential social
desirability bias. We have also incorporated the reviewer’s suggestion regarding future research by adding a
methodological consideration that purposive sampling strategies, including the recruitment of less engaged
participants, could help to reduce self-selection bias in future studies. Finally, we revised the Conclusions
section to emphasise cautious interpretation of the findings, noting that the voluntary nature of participation
may influence the reported positive perceptions and may not fully reflect the views of all eligible participants.
Added text in the manuscript:
1. “Methodologically, future studies could implement purposive sampling strategies, including less
engaged participants and non-completers to reduce potential self-selection bias.” (Discussion, page
15, lines 631-633)
2. “Although the programme was perceived positively, these perceptions should be interpreted with
caution, as they may be influenced by the voluntary nature of participation and social desirability bias,
and may not capture the perspectives of all eligible participants.” (Conclusions, page 15, lines 641-
644)

 

Comments 3: The description of data saturation is brief and somewhat formulaic; greater methodological
transparency is needed regarding how saturation was operationalised, particularly given the short interview
duration (mean 14 minutes), which may limit thematic depth.
Response 3: Thank you for this comment. We acknowledge the reviewer’s concern regarding the need for
greater methodological transparency in the description of data saturation, particularly in the context of relatively
short interviews. This has been acknowledged as a methodological limitation of this study and is discussed in
detail in the Limitations section of the Discussion, including the potential impact of time constraints on the
richness of data and thematic saturation. As detailed in the Methods section, data saturation was achieved
iteratively, with no new codes emerging after the 11th interview and confirmed by two additional interviews.
We have revised the Data Collection subsection in Methods to explicitly acknowledge the relatively brief
interview duration as a potential limitation on the depth and richness of the data, as well as on the exploration
of more complex themes. We also explicitly acknowledge in both the Methods and Discussion sections that the
relatively short duration of the interviews may have limited the depth and richness of the data and the
exploration of more complex themes. This consideration is now incorporated into the interpretation of the
findings.
Added text in the manuscript: “Nonetheless, the relatively brief duration of the interviews may have limited the
depth and richness of the data and the capacity to explore more complex themes; accordingly, the findings
should be interpreted with due caution.” (2.4. Data Collection, page 5, lines 180-183)

 

Comments 4: The study relies heavily on self-reported perceived improvements in clinical practice (e.g.,
increased confidence, antidepressant prescribing, use of PHQ-9/GAD-7) without objective measures. The
authors should explicitly acknowledge this limitation and avoid implying causal impact on patient outcomes.
Response 4: Thank you for pointing this out. We acknowledge that the study is based on participants’ selfreported perceptions and does not include objective measures of clinical practice or patient outcomes. In
response, we have strengthened the Discussion section to explicitly acknowledge this as a methodological
limitation, noting that the findings reflect perceived changes in practice rather than objectively verified
outcomes This aspect is also acknowledged in the Results (3.3. subsection) to emphasise that the presented
accounts reflect self-reported experiences rather than objectively verified changes in patient care. We have
clarified that the self-reported nature of the data does not allow for causal interferences regarding patient care
and management.
Added text in the manuscript:
1. “It is important to mention that these accounts reflect participants’ self-reported experiences rather
than objectively measured changes in patient care.” (Results, 3.3. subsection, page 9, lines 329-331)
2. “Furthermore, the findings are based on participants’ own perceptions of the programme and its
impact on their practice, which does not reflect objective changes in patient care and management.”
(Discussion, page 14, lines 611-613)

Comments 5: The literature review is adequate but should be strengthened with more recent studies (last 2–3
years) on ECHO interventions in mental health and primary care, particularly those evaluating clinical or
patient-level outcomes and implementation challenges in European contexts.
Response 5: Thank you for this comment. We agree it is important to provide an up-to-date and comprehensive
overview of the literature on ECHO programmes. In response, we reviewed the manuscript to ensure that it
reflects up-to-date evidence, including studies published within the last 2–3 years. The current version already
includes recent European research on ECHO programme implementation and outcomes (e.g., Bessell et al.,
2023; Winkler et al., 2025, Kyanko et al., 2022; Papachristopoulos et al., 2023). In addition, foundational
literature on ECHO model (e.g., Arora et al., 2007) and relevant studies on the context of mental health in
Latvia (e.g., Rancans et al., 2020) are also included to provide background for the study. We believe that this
combination of recent and foundational sources provides an adequate and balanced context for the study.

 

Comments 6: The findings related to screening tools (PHQ-9, GAD-7) would benefit from clearer discussion
of their diagnostic versus screening role, including limitations, and how their use aligns with DSM-5 diagnostic
processes rather than serving as proxies for diagnosis.
Response 6: Thank you for this suggestion. We acknowledge the importance of clearly distinguishing the role
of screening instruments from diagnostic tools in clinical practice. In response, we have revised the Discussion
section to clarify that instruments such as PHQ-9 and GAD-7 are intended to support the identification and
assessment of symptoms, but do not replace formal diagnosis according to established diagnostic frameworks
(in this context, ICD-10, which is used in Latvian clinical practice). This clarification emphasises that the
observed increases in the use of screening instruments reflect participants’ self-reported practice changes and
do not imply objective diagnostic outcomes or causal effects on patient care.
Added text in the manuscript: “It should be noted that screening instruments can support clinical assessment
but do not replace formal diagnosis according to ICD-10 criteria.” (Discussion, page 12, lines 507-508)

 

Comments 7: Although reflexivity is mentioned, the dual role of the interviewer as programme coordinator
introduces a significant risk of social desirability bias. This issue should be more critically examined, and its
potential impact on data interpretation more explicitly addressed.
Response 7: Thank you for this useful suggestion. We acknowledge that the dual role of the interviewer may
introduce social desirability bias. In response, we strengthened the Discussion section to more explicitly address
this issue, including its potential contribution to the predominantly positive tone of participants’ accounts and
its implications for data interpretation. Reflexivity strategies to support critical evaluation and minimise
confirmation bias were also described in the Methods section. Additionally, we added a sentence emphasising
that this potential source of bias should be considered when interpreting the findings.
Added text in the manuscript:
1. “However, these findings should be interpreted with caution, as they reflect self-reported experiences
from a small, voluntary sample and may be influenced by social desirability bias, which is
acknowledged as a study limitation.” (Discussion, page 12, lines 487-489)
2. “This potential bias should be considered when interpreting the predominantly positive findings.”
(Discussion, page 14, lines 584-585)
3. “Although the programme was perceived positively, these perceptions should be interpreted with
caution, as they may be influenced by the voluntary nature of participation and social desirability bias,
and may not capture the perspectives of all eligible participants.” (Conclusions, page 15, lines 641-
644)

 

Comments 8: The manuscript would benefit from clearer and more structured “Limitations” and “Future
Research Directions” sections, including recommendations for mixed-methods or longitudinal designs,
incorporation of objective clinical outcomes, and consideration of anonymised data sharing (e.g., coded
qualitative data excerpts) to enhance transparency and reproducibility where ethically feasible.
Response 8: Thank you for this valuable comment. We agree that a clearer structure of the Limitations and
Future Research Directions strengthens the manuscript. In response, we revised the Limitations section to
improve its organisation and clarity, presenting the key methodological considerations in a more structured
sequence, including sampling strategy, sample characteristics, interviewer–participant relationship, interview
duration, and implications for transferability of the findings. We also expanded the Future Research Directions
to include methodological recommendations, such as the use of mixed-methods and longitudinal designs,
incorporation of objective clinical and patient-level outcomes, and strategies to triangulate subjective and
objective data. In addition, we acknowledge the importance of transparency and data sharing in qualitative
research and note that, where ethically feasible, future studies could consider approaches to sharing anonymised
qualitative data (e.g., coded excerpts), while ensuring participant confidentiality.
Added text in the manuscript: “Future research could employ longitudinal or mixed-methods designs and
integrate objective clinical outcomes, which would provide more comprehensive assessment of the programme’s
impact. Combining subjective and measurable data would enable robust triangulation and offer stronger
evidence regarding the sustainability and practical impact of practice changes resulting from participation.”
(Discussion, page 15, lines 624-628)

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

This manuscript addresses a relevant and timely topic and presents an exploratory qualitative evaluation of the first ECHO psychiatry telementoring programme in Latvia. The paper is generally well structured, and the topic is clearly relevant to primary care mental health and continuing medical education. However, in its current form, the manuscript requires major revision, mainly because some of the claims in the Abstract, Discussion, and Conclusions go beyond what can be supported by the qualitative data collected from a small, self-selected sample.

My main comments are as follows:

The conclusions are currently stronger than the evidence allows.

The study is based on 13 voluntary interviewees out of 108 eligible participants, and the authors themselves acknowledge that reasons for non-participation were not systematically collected and that less satisfied perspectives may therefore be underrepresented (lines 146–152, 542–547).

Despite this, the manuscript sometimes moves beyond reporting participants’ perceptions and implies broader effects on competencies, capacity, and care delivery. For example, the Abstract states that the study contributes by “highlighting mechanisms through which ECHO programmes may support mental healthcare competencies and capacity building in underserved settings” (lines 33–35). The Introduction similarly refers to “support sustainable workforce capacity” (lines 105–106), and the Conclusions refer to “contributing to management capacity within primary care” and “support sustainable workforce development” (lines 610). These claims should be substantially softened and consistently reframed as participant-reported perceptions, not demonstrated programme outcomes.

The sampling strategy and likely positive-response bias need to be integrated more strongly into the interpretation of the findings.

The use of voluntary response sampling is clearly reported (lines 138–152), but its implications are not fully carried through the manuscript. In particular, many of the findings are highly positive, and the authors later note that the predominantly positive tone may reflect voluntary participation and social desirability effects (lines 576–583). This is an important limitation and should shape the interpretation more clearly throughout the Discussion and Conclusions.

The role of the interviewer creates an important risk of social desirability bias that should be handled more explicitly.

The interviewer was involved in programme coordination (lines 160–163), and the manuscript later acknowledges that participants may have perceived this as affiliation with programme management and that this may have influenced willingness to provide critical feedback (lines 567–573). This is an important issue in qualitative research and should be discussed even more explicitly in relation to recruitment, interviewing, and interpretation.

The interviews appear relatively brief for the level of interpretation offered.

The average interview duration was 14 minutes, with a range of 9–21 minutes (line 166). The manuscript also claims that saturation was reached after 11 interviews (lines 171–173). Given the brevity of many interviews, the saturation claim should be presented more cautiously, and the paper should avoid broad interpretive claims that would usually require deeper qualitative material.

The methods are reasonably described, but several elements require fuller reporting.

The topic guide was refined iteratively after initial interviews (lines 156–158), but it is not clear how the guide changed or whether this affected comparability across interviews. Also, while the coding process is outlined, the manuscript would benefit from greater analytic transparency. A supplementary table showing example codes, and linked quotations would strengthen credibility.

The Results section is clear overall, but some wording still overstates what was observed.

The quotations are useful and the themes are logically organised. However, some claims are stronger than the evidence shown. For example, the paper reports self-reported patient improvement after antidepressant prescribing (lines 319–322) and more frequent use of PHQ-9/GAD-7 (lines 323–332). These are interesting findings, but they remain subjective participant reports and should not be presented as verified changes in care or outcomes.

There are places in the Discussion where interpretation should be more cautious.

One example is the statement that “The doctors did not report any barriers to participation” (lines 469–470). Since the interviewed sample consisted of volunteers who had participated in the programme and also agreed to be interviewed, this should not be interpreted as evidence that barriers were absent in the broader programme population. The manuscript partially qualifies this claim, but the wording remains too strong.

Similarly, the Discussion states that participants perceived the programme as “strengthening capacity and supporting the delivery of mental health care” (line 494). Again, this should be framed more cautiously and consistently as self-reported perceptions from a limited sample.

The tables are useful, but they could be more informative.

Table 1 and Table 2 are clear and relevant, and Table 3 provides a good overview of themes and subthemes. However, Table 3 could be improved by including brief descriptions or one illustrative quotation per theme/subtheme, which would increase transparency and make the analytic structure easier to evaluate.

The English is generally understandable but should be revised for clarity and precision.

There are several sentences that read awkwardly or imprecisely. For example, “The findings suggest that the ECHO model may provide useful framework with the potential to address the certain aspects of these challenges” (lines 515–516) would benefit from language editing. Likewise, “based on participants reflected experiences” in the Conclusions (line 610) is not idiomatic.

The references appear broadly relevant, but the balance between recent and older references could be strengthened.

The reference list includes relevant international and local studies, but some cited sources are relatively old, including foundational ECHO papers and older Latvian qualitative work (e.g., references from 2007, 2016, 2017, 2019, 2020). This is understandable for foundational literature and national background, but the manuscript would benefit from ensuring the most recent qualitative and implementation literature on ECHO is fully represented.

Author Response

Thank you very much for taking time to review this manuscript. Please find the detailed responses below and the corresponding revisions marked in red in the re-submitted files.

Comments 1: The conclusions are currently stronger than the evidence allows.
The study is based on 13 voluntary interviewees out of 108 eligible participants, and the authors themselves
acknowledge that reasons for non-participation were not systematically collected and that less satisfied
perspectives may therefore be underrepresented (lines 146–152, 542–547).
Despite this, the manuscript sometimes moves beyond reporting participants’ perceptions and implies broader
effects on competencies, capacity, and care delivery. For example, the Abstract states that the study contributes
by “highlighting mechanisms through which ECHO programmes may support mental healthcare competencies
and capacity building in underserved settings” (lines 33–35). The Introduction similarly refers to “support
sustainable workforce capacity” (lines 105–106), and the Conclusions refer to “contributing to management
capacity within primary care” and “support sustainable workforce development” (lines 610). These claims
should be substantially softened and consistently reframed as participant-reported perceptions, not
demonstrated programme outcomes.
Response 1: Thank you for pointing this out. We acknowledge the concern that some formulations in the
manuscript may have implied broader system-level effects beyond what can be supported by the qualitative
design and the nature of the data. Therefore, the manuscript has been revised to ensure that all statements reflect
only participant-reported perceptions. All statements referring to programme impact have been moderated to
reflect participants’ reported perceptions and experiences, rather than demonstrated effects on competencies,
capacity, or care delivery. Specifically, the Abstract has been simplified to report only the observed findings,
the final paragraph of the Introduction has been revised to avoid forward-looking system-level claims, and the
Conclusions section has been rewritten to focus exclusively on participant-reported perceptions. Furthermore,
we have revised the Discussion section to use more measured language and to ensure that interpretations remain
grounded in participants’ perspectives and the qualitative nature of the data.
Added text in the manuscript:
1. “This study provides insights into strengths and areas for improvement of the “ECHO School of
Psychiatry” as perceived by general practitioners. It also acknowledges cur-rent challenges in primary
care, such as limited access to specialists and professional isolation.” (Abstract, Conclusions, page 1,
lines 31-34)
2. “These insights are essential for guiding further development and optimisation of the programme,
offering an understanding of how participants experienced the programme and its perceived relevance
for their clinical practice.” (Introduction, page 3, lines 104-106)
3. “They also acknowledge ongoing challenges in primary care and the need for further educational
support, with the ECHO model being perceived by participants as a potential tool for sharing
knowledge and learning, particularly in rural and underserved settings. Although the programme was
perceived positively, these perceptions should be interpreted with caution, as they may be influenced
by the voluntary nature of participation and social desirability bias, and may not capture the
perspectives of all eligible participants.” (Conclusions, page 15, lines 639-644)

Comments 2: The sampling strategy and likely positive-response bias need to be integrated more strongly into
the interpretation of the findings.
The use of voluntary response sampling is clearly reported (lines 138–152), but its implications are not fully
carried through the manuscript. In particular, many of the findings are highly positive, and the authors later
note that the predominantly positive tone may reflect voluntary participation and social desirability effects
(lines 576–583). This is an important limitation and should shape the interpretation more clearly throughout
the Discussion and Conclusions.
Response 2: Thank you for this valuable comment. We acknowledge that the implications of voluntary response
sampling and potential positive-response bias should be more explicitly integrated into the interpretation of the
findings. In response, we have revised the Discussion section to clarify that participants’ reflections represent
reported experiences and may reflect motivation to participate rather than objective impacts on engagement
and practice changes. The language throughout the Discussion and Conclusions sections was moderated to
ensure that interpretations remain grounded in participants’ reported experiences, avoiding broader claims.
Finally, we added an explicit statement in the Conclusions section highlighting that the positive perceptions
reported in this study should be interpreted with caution, as they may not fully represent the views of all eligible
participants. These revisions ensure that the manuscript clearly reflects the limitations related to sampling and
potential bias, as suggested.
Added text in the manuscript:
1. “These reflections represent participants’ reported experiences and need to be interpreted more
cautiously, as they may indicate their motivation to participate rather than actual impacts on
engagement and practice adjustments.” (Discussion, page 11, lines 461-464)
2. “However, these findings should be interpreted with caution, as they reflect self-reported experiences
from a small, voluntary sample and may be influenced by social desirability bias, which is
acknowledged as a study limitation.” (Discussion, page 12, lines 487-489)
3. “Although the programme was perceived positively, these perceptions should be interpreted with
caution, as they may be influenced by the voluntary nature of participation and social desirability bias,
and may not capture the perspectives of all eligible participants.” (Conclusions, page 15, lines 641-
644)

 

Comments 3: The role of the interviewer creates an important risk of social desirability bias that should be
handled more explicitly.
The interviewer was involved in programme coordination (lines 160–163), and the manuscript later
acknowledges that participants may have perceived this as affiliation with programme management and that
this may have influenced willingness to provide critical feedback (lines 567–573). This is an important issue in
qualitative research and should be discussed even more explicitly in relation to recruitment, interviewing, and
interpretation.
Response 3: Thank you for this useful suggestion. We acknowledge that the dual role of the interviewer may
introduce social desirability bias. In response, we strengthened the Discussion section to more explicitly address
this issue, including its potential contribution to the predominantly positive tone of participants’ accounts and
its implications for data interpretation. Reflexivity strategies to support critical evaluation and minimise
confirmation bias were also described in the Methods section. Additionally, we added a sentence emphasising
that this potential source of bias should be considered when interpreting the findings.
Added text in the manuscript:
1. “However, these findings should be interpreted with caution, as they reflect self-reported experiences
from a small, voluntary sample and may be influenced by social desirability bias, which is
acknowledged as a study limitation.” (Discussion, page 12, lines 487-489)
2. “This potential bias should be considered when interpreting the predominantly positive findings.”
(Discussion, page 14, lines 584-585)
3. “Although the programme was perceived positively, these perceptions should be interpreted with
caution, as they may be influenced by the voluntary nature of participation and social desirability bias,
and may not capture the perspectives of all eligible participants.” (Conclusions, page 15, lines 641-
644)

 

Comments 4: The interviews appear relatively brief for the level of interpretation offered.
The average interview duration was 14 minutes, with a range of 9–21 minutes (line 166). The manuscript also
claims that saturation was reached after 11 interviews (lines 171–173). Given the brevity of many interviews,
the saturation claim should be presented more cautiously, and the paper should avoid broad interpretive claims
that would usually require deeper qualitative material.
Response 4: Thank you for pointing this out. We acknowledge that the relatively short duration of the interviews
requires a more cautious presentation of both data saturation and the scope of interpretation.
In response, we revised the Data Collection subsection in the Methods section to provide a more cautious and
transparent description of data saturation, clarifying how it was assessed and acknowledging that the brevity of
interviews may have limited the depth of the data. We also explicitly recognise in the manuscript that the
relatively short duration of the interviews may have constrained the exploration of more complex themes.
In addition, we revised the Discussion and Conclusions sections throughout to ensure that interpretations
remain appropriately aligned with the depth of the dataset, using more measured language and avoiding broader
conceptual or system-level claims beyond what the data can support.
Added text in the manuscript: “Nonetheless, the relatively brief duration of the interviews may have limited the
depth and richness of the data and the capacity to explore more complex themes; accordingly, the findings
should be interpreted with due caution.” (2.4. Data Collection, page 5, lines 180-183)

 

Comments 5: The methods are reasonably described, but several elements require fuller reporting.
The topic guide was refined iteratively after initial interviews (lines 156–158), but it is not clear how the guide
changed or whether this affected comparability across interviews. Also, while the coding process is outlined,
the manuscript would benefit from greater analytic transparency. A supplementary table showing example
codes, and linked quotations would strengthen credibility.
Response 5: Thank you for this comment. We agree that the iterative refinement process of the interview topic
guide requires additional reporting. In response, we have revised the Methods section (2.3. Interview Topic
Guide subsection) to provide more detail on this process, including the information that initial interviews
informed the addition of follow-up prompts to support participants in recalling specific aspects of the
programme when necessary and serving only as a supplementary guidance, preserving comparability across
interviews. We also acknowledge the value of including a supplementary table with example codes and linked
quotations to enhance analytic transparency. However, we chose not to include such a table, as the manuscript
already provides detailed description of the coding process and integrates illustrative quotations throughout the
Results section to support the themes and interpretations. We believe that these elements together provide
sufficient transparency regarding the analytic process.
Added text in the manuscript: “The topic guide was refined through an iterative process, with initial interviews
in-forming the addition of follow-up prompts to support participants in recalling specific programme aspects
when needed, which helped sharpen the focus of subsequent interviews on relevant areas identified in the initial
discussions. These prompts served only as a guidance, preserving comparability across interviews.” (Materials
and Methods, 2.3. subsection, page 4, lines 159-162)

 

Comments 6: The Results section is clear overall, but some wording still overstates what was observed.
The quotations are useful and the themes are logically organised. However, some claims are stronger than the
evidence shown. For example, the paper reports self-reported patient improvement after antidepressant
prescribing (lines 319–322) and more frequent use of PHQ-9/GAD-7 (lines 323–332). These are interesting
findings, but they remain subjective participant reports and should not be presented as verified changes in care
or outcomes.
Response 6: Thank you for pointing this out. We acknowledge that the study is based on participants’ selfreported perceptions and does not include objective measures of clinical practice or patient outcomes. In
response, we have strengthened the Discussion section to explicitly acknowledge this as a methodological
limitation, noting that the findings reflect perceived changes in practice rather than objectively verified
outcomes This aspect is also acknowledged in the Results (3.3. subsection) to emphasise that the presented
accounts reflect self-reported experiences rather than objectively verified changes in patient care. We have
clarified that the self-reported nature of the data does not allow for causal interferences regarding patient care
and management.
Added text in the manuscript:
1. “It is important to mention that these accounts reflect participants’ self-reported experiences rather
than objectively measured changes in patient care.” (Results, 3.3. subsection, page 9, lines 329-331)
2. “Furthermore, the findings are based on participants’ own perceptions of the programme and its
impact on their practice, which does not reflect objective changes in patient care and management.”
(Discussion, page 14, lines 611-613)

 

Comments 7: There are places in the Discussion where interpretation should be more cautious.
One example is the statement that “The doctors did not report any barriers to participation” (lines 469–470).
Since the interviewed sample consisted of volunteers who had participated in the programme and also agreed
to be interviewed, this should not be interpreted as evidence that barriers were absent in the broader programme
population. The manuscript partially qualifies this claim, but the wording remains too strong.
Similarly, the Discussion states that participants perceived the programme as “strengthening capacity and
supporting the delivery of mental health care” (line 494). Again, this should be framed more cautiously and
consistently as self-reported perceptions from a limited sample.
Response 7: Thank you for pointing this out. We acknowledge that certain statements in the Discussion section
required more cautious interpretation in light of the study sample and design. In response, we have revised the
Discussion section to ensure that statements are more carefully framed, particularly in places where the wording
may have overstated the findings. The Discussion section has been revised throughout to use more measured
language and to ensure that all interpretations remain grounded in participants’ perspectives, without extending
to broader system-level implications and remain consistent with the qualitative nature of the data.

 

Comments 8: The tables are useful, but they could be more informative.
Table 1 and Table 2 are clear and relevant, and Table 3 provides a good overview of themes and subthemes.
However, Table 3 could be improved by including brief descriptions or one illustrative quotation per
theme/subtheme, which would increase transparency and make the analytic structure easier to evaluate.
Response 8: Thank you for this comment. We acknowledge that including brief descriptions or illustrative
quotations within Table 3 could enhance transparency. However, we chose to retain the current structure of the
table as a concise overview of themes and subthemes, while presenting detailed descriptions and illustrative
quotations within the Results section. This approach allows for a more contextualised and interpretive
presentation of the data, without overloading the table and reducing its readability. We therefore believe that
the combination of a structured thematic overview (Table 3) and supporting quotations in the main text provides
sufficient transparency of the analytic process.

 

Comments 9: The English is generally understandable but should be revised for clarity and precision.
There are several sentences that read awkwardly or imprecisely. For example, “The findings suggest that the
ECHO model may provide useful framework with the potential to address the certain aspects of these
challenges” (lines 515–516) would benefit from language editing. Likewise, “based on participants reflected
experiences” in the Conclusions (line 610) is not idiomatic.
Response 9: Thank you for pointing this out. We agree that several sentences in the manuscript could benefit
from more precise language. In response, we have carefully reviewed the manuscript and revised the English
throughout to enhance clarity. Specifically, the examples noted in this comment were addressed. We believe
these improvements have enhanced the overall readability and precision of the manuscript.
Added text in the manuscript: “Based on participants’ reflections, the findings suggest that the ECHO model
may pro-vide a useful framework to address certain aspects of these challenges.” (Discussion, page 13, lines
538-540)

 

Comments 10: The references appear broadly relevant, but the balance between recent and older references
could be strengthened.
The reference list includes relevant international and local studies, but some cited sources are relatively old,
including foundational ECHO papers and older Latvian qualitative work (e.g., references from 2007, 2016,
2017, 2019, 2020). This is understandable for foundational literature and national background, but the
manuscript would benefit from ensuring the most recent qualitative and implementation literature on ECHO is
fully represented.
Response 10: Thank you for this comment. We agree it is important to provide an up-to-date and comprehensive
overview of the literature on ECHO programmes. In response, we reviewed the manuscript to ensure that it
reflects up-to-date evidence, including studies published within the last 2–3 years. The current version already
includes recent European research on ECHO programme implementation and outcomes (e.g., Bessell et al.,
2023; Winkler et al., 2025, Kyanko et al., 2022; Papachristopoulos et al., 2023). In addition, foundational
literature on ECHO model (e.g., Arora et al., 2007) and relevant studies on the context of mental health in
Latvia (e.g., Rancans et al., 2020) are also included to provide background for the study. We believe that this
combination of recent and foundational sources provides an adequate and balanced context for the study.

Round 2

Reviewer 1 Report (New Reviewer)

Comments and Suggestions for Authors

The authors have completely addressed all my comments, and I have no further concerns. Therefore, I recommend accepting the paper.

Author Response

Thank you for your constructive comments throughout the review process. We appreciate your time and feedback. 

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

The revised manuscript is substantially improved. The authors have clearly made a serious effort to respond to the previous review. In particular, the paper now does a better job of framing the findings as participants’ perceptions, rather than as demonstrated programme effects. The Abstract conclusion is more cautious, the Introduction has been moderated, the limitations section is more explicit and much stronger, and the Results now acknowledge that reported changes in practice are self-reported rather than objectively verified. The manuscript is also more transparent regarding the iterative refinement of the interview guide, the interviewer’s role, the risk of social desirability bias, and the limited interview duration. These are meaningful improvements.

That said, two issues remain and should still be revised:

1. The Introduction still includes one sentence that feels too effectiveness-oriented

The revised Introduction is improved overall, but the sentence “To evaluate the effectiveness and impact of this first ECHO telementoring programme in Latvia, a systematic research process has been initiated” (lines 92–93) still suggests a broader evaluative claim than this specific qualitative study can support. Since this manuscript reports an exploratory qualitative component focused on participant perceptions, the wording here should be adjusted accordingly.

2. Methods are improved, but analytic transparency could still be strengthened

The clarification of the interview guide refinement is helpful, and the analytic description is more robust than before. The manuscript now explains the iterative prompts, audit trail, collaborative theme development, and reflexive notes. This is a clear improvement.

However, I still think the paper would benefit from one additional layer of analytic transparency. Even if the authors do not wish to include a full coding appendix, a brief supplementary table with one example code linked to one subtheme and one theme, plus an illustrative quotation, would make the analysis easier to evaluate. I no longer consider this essential for publication, but it would strengthen the paper.

Comments on the Quality of English Language

The manuscript is readable and generally clear, but there are still a few places where the phrasing could be tightened for precision and idiomatic English. For instance, some discussion sentences remain somewhat dense or repetitive, especially where the text alternates between “participants perceived,” “the findings suggest,” and “this may indicate.” A final round of careful language editing would improve flow and precision.

Author Response

Thank you very much for taking time to review this manuscript. Please find the detailed responses below and the corresponding revisions marked in red in the re-submitted files.

 

Comments 1: The Introduction still includes one sentence that feels too effectiveness-oriented.

The revised Introduction is improved overall, but the sentence “To evaluate the effectiveness and impact of this first ECHO telementoring programme in Latvia, a systematic research process has been initiated” (lines 92–93) still suggests a broader evaluative claim than this specific qualitative study can support. Since this manuscript reports an exploratory qualitative component focused on participant perceptions, the wording here should be adjusted accordingly.

Response 1: Thank you for pointing this out. We agree that the initial wording could be interpreted as suggesting that this study evaluates the effectiveness and impact of the programme. Therefore, we have revised the sentence to clarify that it refers to a broader, ongoing research process employing multiple methods, within which this study specifically focuses on exploring participants’ experiences and perceptions and provides qualitative insights of them (Introduction, page 3, lines 94-95).

Added text in the manuscript: “This study focuses on exploring participants’ experiences and perceptions of the programme using a qualitative approach.”

 

Comments 2: Methods are improved, but analytic transparency could still be strengthened

The clarification of the interview guide refinement is helpful, and the analytic description is more robust than before. The manuscript now explains the iterative prompts, audit trail, collaborative theme development, and reflexive notes. This is a clear improvement.

However, I still think the paper would benefit from one additional layer of analytic transparency. Even if the authors do not wish to include a full coding appendix, a brief supplementary table with one example code linked to one subtheme and one theme, plus an illustrative quotation, would make the analysis easier to evaluate. I no longer consider this essential for publication, but it would strengthen the paper.

Response 2: Thank you for this comment. We acknowledge the value of including a supplementary table linking codes, subthemes, and themes to enhance analytic transparency. However, we consider that the manuscript already provides sufficient transparency through the description of the analytic process, the integration of illustrative quotations throughout the Results section, and the presentation of interconnections between subthemes and themes. We believe that the current presentation allows readers to adequately evaluate the analysis.

 

Comments 3: The manuscript is readable and generally clear, but there are still a few places where the phrasing could be tightened for precision and idiomatic English. For instance, some discussion sentences remain somewhat dense or repetitive, especially where the text alternates between “participants perceived,” “the findings suggest,” and “this may indicate.” A final round of careful language editing would improve flow and precision.

Response 3: Thank you for pointing this out. We appreciate the suggestion to further improve language precision and flow. In response, we have carefully reviewed the manuscript and revised the phrasing throughout, aiming to reduce repetition and text density in addition to improving clarity. These revisions aim to enhance readability, conciseness.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. Summary and key contribution

This qualitative study explores GP experiences of Latvia’s first psychiatry ECHO telementoring program. Methods include remote semi-structured interviews (May–Sept 2025), thematic analysis (Braun & Clarke), NVivo, and the authors report 4 themes (value/structure, impact on practice, limitations in professional isolation/collaboration, and improvement suggestions). The key contribution is providing early implementation insights in a setting with documented constraints in specialist access and rural service gaps.

1. Methodology/analysis/conclusions: main weaknesses that must be fixed

• The authors used voluntary response sampling, and the sample appears to be women only (acknowledged). This risks over-representing motivated participants and under-capturing dissatisfaction, barriers, and drop-out reasons. You can address this by: (i) describing programme enrolment numbers and participation profile (if already available administratively), (ii) clarifying who declined and why (if known), and (iii) strengthening a transferability statement (what contexts your findings can/cannot generalise to).
• The authors state reflexivity notes and team discussion, but you also note no transcript return/member checking and no repeat interviews. The manuscript should explicitly describe credibility strategies (triangulation, audit trail, peer debrief, negative case search). Even if you did not do member checking, authors can describe how coding disagreements were resolved and how theme boundaries were decided.
• “Saturation” needs operational detail. You define saturation and state it occurred after 11 interviews with 2 more confirmatory interviews. Authors should provide evidence in text: e.g., “after interview 11, no new codes were added, subsequent interviews only elaborated existing categories,” and link that to the codebook development and final code counts.
• The Results/Discussion section risks reading like a theme list rather than an analytic story.You report 33 codes, 14 subthemes, 4 themes (Table 3). The write-up should: (i) include more interpretive linking between themes, (ii) contrast positive vs critical accounts, and (iii) highlight “what surprised you” or “what didn’t work,” especially since one main theme is limited effect on isolation/collaboration.

Author Response

Thank you very much for taking time to review this manuscript. Please find the detailed responses below and the corresponding revisions marked in red in the re-submitted files.

Comments 1: The authors used voluntary response sampling, and the sample appears to be women only (acknowledged). This risks over-representing motivated participants and under-capturing dissatisfaction, barriers, and drop-out reasons. You can address this by: (i) describing programme enrolment numbers and participation profile (if already available administratively), (ii) clarifying who declined and why (if known), and (iii) strengthening a transferability statement (what contexts your findings can/cannot generalise to).

Response 1: Thank you for pointing this out. In response to this suggestion, we have made several clarifications in the revised manuscript. First, in the Methods (Participants) section (lines 147-152), we now report the total number of eligible general practitioners enrolled in the programme and the number who agreed to participate in the interviews. We have added a clarification that all eligible participants, including those who did not complete the programme, were invited to participate. This provides clearer context regarding the participation profile. Second, we clarify that information on reasons for declining participation were not systematically collected; this limitation is now acknowledged in the Discussion (lines 542-547). Third, we have expanded the limitations section (lines 590-592) to discuss potential self-selection bias related to voluntary response sampling and to clarify the transferability of the findings, noting that they may be applicable to similar voluntary continuing medical education preprogrammes. The relevant additions are indicated below:

1. “Of the 108 eligible general practitioners enrolled in the programme, including those who discontinued participation before completion, 13 were interested and agreed to participate in the interviews: four participants from the first group, five from the second, and four from the third. Information on reasons for non-participation was not systematically collected; therefore, the perspectives of general practitioners who chose not to participate, including those who may have had less satisfactory experiences, may not be represented.” (Methods, 2.2. Participants, the last paragraph, lines 147-152).
2. “The use of a voluntary sampling method may have resulted in the overrepresentation of more motivated and engaged participants, while the perspectives of potentially dissatisfied general practitioners may be underrepresented. Additionally, information on reasons for non-participation was not systematically collected, and therefore barriers to engagement experienced by those who did not participate may not have been fully captured.” (Discussion section, page 13, lines 542-547)
3. “The findings may be most transferable to similar voluntary continuing medical education programmes, particularly telementoring interventions in comparable healthcare systems and professional contexts.” (Discussion, page 14, lines 590-592)

Comments 2: The authors state reflexivity notes and team discussion, but you also note no transcript return/member checking and no repeat interviews. The manuscript should explicitly describe credibility strategies (triangulation, audit trail, peer debrief, negative case search). Even if you did not do member checking, authors can describe how coding disagreements were resolved and how theme boundaries were decided.

Response 2: Thank you for the valuable advice. We agree that it is important to clearly describe strategies used to enhance credibility of  qualitative analysis. In response to this comment, we have expanded the Data Analysis section (pages 5-6, lines 191-205) to provide additional information on procedures used to enhance the rigour of the analysis. These include iterative coding, regular team discussions, consensus-based resolution of coding disagreements, maintenance of an audit trail, and documentation of reflective considerations regarding researchers’ positionality.

The relevant addition in the text:

“To enhance credibility and rigour of the analysis, coding and theme development were conducted iteratively, with the research team members holding discussions to review coding decisions and refine theme boundaries. Coding disagreements were dis-cussed until consensus was reached. An audit trail was maintained to document coding decisions, code revisions, and theme development. Given that members of the research team were involved in the implementation of the programme, particular attention was paid to reflexivity. The potential impact of the interviewer-participant relationship was identified and its possible influence on social acceptance bias was assessed. The research team actively reviewed the data to ensure that the themes accurately reflected participants’ accounts and that no relevant perspectives were overlooked. Reflective notes covered not only coding decisions, but also documented researchers’ positionality and its potential impact on data interpretation, supporting critical evaluation and minimisation of confirmation bias. The research team reviewed the data iteratively to ensure that themes accurately reflected participants’ accounts and that divergent or less frequent perspectives were not overlooked.”

 

Comments 3: “Saturation” needs operational detail. You define saturation and state it occurred after 11 interviews with 2 more confirmatory interviews. Authors should provide evidence in text: e.g., “after interview 11, no new codes were added, subsequent interviews only elaborated existing categories,” and link that to the codebook development and final code counts.

Response 3: Thank you for pointing this out. We agree that the process for assessing data saturation should be described more explicitly. In response, the Data Collection section (page 5, lines 174-176) has been revised to clarify how saturation was determined during the analytic process. We now report that no new codes were identified after the 11^th interview and that two additional confirmatory interviews were conducted to ensure the stability of the codebook and thematic structure, resulting in a final sample of 13 interviews.

Added text: “In this study, data saturation was observed after the 11th interview, when no new codes were identified. Two additional confirmatory interviews were conducted, which con-firmed the stability of the codebook and themes, bringing the total number of interviews to 13.”

 

Comments 4: The Results/Discussion section risks reading like a theme list rather than an analytic story. You report 33 codes, 14 subthemes, 4 themes (Table 3). The write-up should: (i) include more interpretive linking between themes, (ii) contrast positive vs critical accounts, and (iii) highlight “what surprised you” or “what didn’t work,” especially since one main theme is limited effect on isolation/collaboration.

Response 4: Thank you for this valuable recommendation. We agree that qualitative findings should be presented as an integrated analytic narrative rather than a simple list of themes. In response, we have revised the Results section to emphasise the interpretive connections between themes and to provide a more integrated analytic account. Specifically, some descriptive passages were condensed, and interpretative linking text was added to clarify connections between themes, particularly the relationship between the perceived educational value of the programme and its influence on clinical practice. In addition, we more clearly highlight contrasts between participants’ positive reported experiences and critical perspectives, especially concerning the programme’s limited effect on professional isolation and peer interaction. Finally, the Discussion section has been expanded to reflect on these contrasting findings and to situate them within the broader context of the Latvian healthcare system and cultural factors shaping professional communication and engagement. These revisions aim to provide a more reflective interpretation of the findings.

Reviewer 2 Report

Comments and Suggestions for Authors

Overall

Against the backdrop of Latvia's lack of mental health care resources, regional disparities, and increasing reliance on general practitioners (GPs), the introduction of the ECHO model (telementoring) is consistent with both healthcare policy and on-site needs.

The ECHO model itself is globally established (with numerous cited references), and this study merely "reaffirms" its effectiveness.

Rather than simply dismissing it as "Latvia's first case study," more attention should be paid to contextual factors, such as how the ECHO model worked and what did not work in Latvia's unique context (e.g., the former Soviet Union's healthcare system, the extreme physician shortage, and cultural background).

Short Interview Duration (Critical)
`The average interview duration was 14 minutes (range: 921 minutes).`
In qualitative research (especially those aiming for a phenomenological approach or detailed description of experiences), an average of 14 minutes is extremely short. Semi-structured interviews typically require approximately 30-60 minutes. Interviews between 9 and 21 minutes may only provide superficial impressions ("good" or "helpful") and may not provide deep insight or allow for the interpretation of complex social phenomena (the goal stated in the introduction). This should be described more strongly as a methodological limitation. While it may be justified by citing participants' busy schedules, researchers should acknowledge the possibility that the data may not be comprehensive enough.

When interpreting the results, it would be more honest to avoid strong terms like "comprehensive" or "deep understanding" and instead stick to terms like "initial insights" or "perceived utility."

While 13 participants is acceptable for qualitative research, short interviews may not be due to a lack of information, suggesting that new codes have stopped emerging (saturation) but rather that only superficial information has been obtained. Double-check that the quotes presented in the `Results` section are specific and contextual. If the quotes are too short or general, the reliability of the analysis will be undermined.

It says that the interviewer (MB) was a "researcher involved in coordination."
To the participants (GPs), the interviewer was "someone on the program's management side." As such, they may have felt that "criticizing the program would be disadvantageous or rude," and thus may have been biased toward overly positive opinions.
Please clearly state this possible bias due to the "interviewer-participant relationship" in the "Limitations" section of the discussion. While the interviewer claims to have no teaching role, being on the program's management side, bias cannot be completely eliminated.

All participants were female (100% female). While 93.5% of the program was female, there were zero male perspectives. Also, the interviews were voluntary. People who were "satisfied with the program" tended to respond to interviews. This does not capture the voices of dissatisfied dropouts or passive participants. When asserting "success" in the conclusion, you should revise the statement to reflect a qualified success, such as "among female GPs who were willing to respond."

Evaluation of the "ECHO School of Psychiatry"...
While being specific is fine, adding "A Qualitative Study of General Practitioners' Perspectives in Latvia" in the subtitle to clearly indicate that this is a qualitative study will help set readers' expectations appropriately. Writing "evaluation" risks leading readers to expect quantitative outcomes, so it's safer to use "perspectives" or "experiences."

Abstract (Methods):
`...transcribed verbatim, and the resulting transcripts were analyzed thematically...`
Adding "using an inductive approach" here would clarify the direction of the analysis.

You're writing the ECHO model as if it were a "magic solution." In addition to highlighting the benefits of the ECHO model, please clearly state the research gap: "While effective globally, the adaptation of the ECHO model to the specific post-Soviet healthcare context of Latvia remains unexplored." This is the core of the originality of this study.

4. Results

The quotes provided are somewhat "goody-goody" ("This format was perfect!", "I felt completely comfortable").
These appear to be the result of "social desirability bias."
If you have data, you should include at least one quote that expresses uncertainty or conflict.
For example, "At first, I was afraid to turn on the camera, but I gradually got used to it" or "I was so busy I panicked because I couldn't find time to watch the recording." Including negative or neutral elements will increase the credibility of positive results.

This comment was edited using artificial intelligence. In accordance with the journal's policy on artificial intelligence tools in peer review, they are not used for editorial assessment of submissions, and submissions are not uploaded to any AI-based features by the assigning editor, in line with the Committee on Publication Ethics (COPE) position statement on the use of AI and AI-assisted technologies in manuscript preparation and peer review.

Author Response

Thank you very much for taking time to review this manuscript. Please find the detailed responses below and the corresponding revisions marked in red in the re-submitted files.

Comments 1: Rather than simply dismissing it as "Latvia's first case study," more attention should be paid to contextual factors, such as how the ECHO model worked and what did not work in Latvia's unique context (e.g., the former Soviet Union's healthcare system, the extreme physician shortage, and cultural background).

Response 1: Thank you for pointing this out. We agree that the findings should be interpreted in relation to Latvia’s specific healthcare and cultural context, rather than being framed primarily through the novelty of the programme as the first ECHO model initiative in the country. In response, we have expanded the Discussion section (page 13, lines 521-531) to provide contextual interpretation of how the ECHO model functioned and faced limitations in Latvia. We now specifically address physician shortages, limited access to specialist mental healthcare, and cultural norms affecting professional communication and engagement. These additions clarify why certain aspects of the programme, such as accessibility and structured expert support, were perceived as valuable, while peer interaction and reduction of professional isolation remained more limited.

Added text in the manuscript: “These results should be interpreted in the context of Latvia’s cultural and healthcare system characteristics. The healthcare system is relatively centralized, with most specialists concentrated in major cities, contributing to a shortage of physicians in regional areas. While this shortage may increase perceived value of continuing educational programmes and encourage participation in such initiatives, several contextual factors may limit engagement. These include the unfamiliar structure of the telementoring format, cultural norms such as adherence to traditional professional hierarchies and cautious attitudes towards new collaborative models, as well as varying levels of technological access and proficiency, which together may reduce active participation in discussions and limit engagement in such programmes overall.”

 

Comments 2: Short Interview Duration (Critical) – `The average interview duration was 14 minutes (range: 921 minutes).` In qualitative research (especially those aiming for a phenomenological approach or detailed description of experiences), an average of 14 minutes is extremely short. Semi-structured interviews typically require approximately 30-60 minutes. Interviews between 9 and 21 minutes may only provide superficial impressions ("good" or "helpful") and may not provide deep insight or allow for the interpretation of complex social phenomena (the goal stated in the introduction). This should be described more strongly as a methodological limitation. While it may be justified by citing participants' busy schedules, researchers should acknowledge the possibility that the data may not be comprehensive enough.

Response 2: Thank you for this valuable comment. We agree that the relatively short duration of some interviews represents a methodological limitation. In response, we have expanded the Discussion section (pages 13-14, lines 553-566) to acknowledge this issue and its potential impact on the depth and richness of the data. We now note that participants’ limited time availability may have constrained the exploration of more nuanced experiences and perspectives. At the same time, the interviews still generated a substantial number of codes and themes, suggesting that participants were able to provide meaningful reflections despite the relatively brief format. These points are now explicitly discussed in the revised manuscript.

Added text in the manuscript: “Additionally, the relatively short duration of the interviews (an average of 14 minutes) represents a further methodological limitation of this study. Although semi-structured interviews were designed to explore participants’ experiences using a focused topic guide, time constraints may have limited the depth of the data collected and the ability to explore more complex themes. This may have reduced the opportunity to capture more nuanced perspectives and complex aspects of participants’ experiences. The relatively short duration of the interviews was likely influenced by participants’ busy clinical schedules and limited availability; however, it is important to acknowledge that this may have constrained the completeness, depth, and overall scope of the findings. Consequently, relatively short interviews could limit the richness of the data obtained and the extent to which full thematic saturation was achieved, despite the fact that consistent patterns in participants’ accounts were identified through thematic analysis. This should be considered when interpreting the findings, as additional or more in-depth interviews could have yielded further nuances and perspectives.”

 

Comments 3: When interpreting the results, it would be more honest to avoid strong terms like "comprehensive" or "deep understanding" and instead stick to terms like "initial insights" or "perceived utility."

Response 3: Thank you for pointing this out. We agree that some formulations in the initial version of the manuscript were stronger than appropriate for a qualitative study of this scale. In response, we have revised the manuscript throughout to use more measured language and to ensure that interpretations remain grounded in participants’ perspectives and the qualitative nature of the data. Specifically, we have replaced overly strong or evaluative expressions with more cautious wording across the Introduction, Results, Discussion, and Conclusions sections. These changes aim to present the findings as context-specific insights into perceived value, limitations, and potential areas for further development.

 

Comments 4: While 13 participants is acceptable for qualitative research, short interviews may not be due to a lack of information, suggesting that new codes have stopped emerging (saturation) but rather that only superficial information has been obtained. Double-check that the quotes presented in the `Results` section are specific and contextual. If the quotes are too short or general, the reliability of the analysis will be undermined.

Response 4: Thank you for pointing this out. We have carefully reviewed the quotations included in the manuscript and revised the Results section to prioritise quotes that provide clearer illustration of participants’ experiences and the analytic interpretation of the themes. General or repetitive quotations were reduced, retaining those that are contextually grounded and provide more specific insight. In addition, we have added clarifying text in the Results section to emphasise the interpretive role of the selected quotations (page 6, lines 212-214). Finally, as recommended, the Discussion section  now explicitly acknowledges that the relatively short duration of the interviews may have limited the depth of the data and may have contributed to a more concise range of reported experiences (pages 13-14, lines 553-566).

Added text in the manuscript: “Illustrative quotes were selected to reflect the main themes and to provide contextual insight into the participants’ experiences, supporting the interpretation of the results.” (Results, page 6, lines 212-214)

 

Comments 5: It says that the interviewer (MB) was a "researcher involved in coordination." To the participants (GPs), the interviewer was "someone on the program's management side." As such, they may have felt that "criticizing the program would be disadvantageous or rude," and thus may have been biased toward overly positive opinions. Please clearly state this possible bias due to the "interviewer-participant relationship" in the "Limitations" section of the discussion. While the interviewer claims to have no teaching role, being on the program's management side, bias cannot be completely eliminated.

Response 5: Thank you for this important comment. We agree that the interviewer–participant relationship may have introduced the potential for social desirability bias, as the interviewer (MB) was involved in the programme’s coordination. In response, we have expanded the Limitations section in the Discussion (page 14, lines 570-574) to acknowledge that participants may have perceived the interviewer as linked to the programme’s organisational side, which could have affected how openly they expressed critical accounts. Although the interviewer did not hold any teaching or evaluative role within the programme, this association may still have influenced participants’ responses. This potential source of bias is now discussed as a limitation of the study.

Added text in the manuscript: “Another potential limitation relates to the involvement of M.B. in conducting the interviews due to prior contact with the participants. Although M.B. was not involved in teaching or evaluating the participants and had no hierarchical role within the pro-gramme, she was involved in programme coordination, which could be acknowledged by the participants as affiliation with the programme’s management. This represents a possible bias due to the interviewer-participant relationship, which might have influenced participants’ willingness to provide more critical feedback and may have contributed to social desirability bias that cannot be fully excluded. To support reflexivity and enhance analytic rigour, all stages of thematic analysis were conducted collaboratively within the research team.” (page 14, lines 570-574)

 

Comments 6: All participants were female (100% female). While 93.5% of the program was female, there were zero male perspectives. Also, the interviews were voluntary. People who were "satisfied with the program" tended to respond to interviews. This does not capture the voices of dissatisfied dropouts or passive participants. When asserting "success" in the conclusion, you should revise the statement to reflect a qualified success, such as "among female GPs who were willing to respond."

Response 6: Thank you for pointing this out. We agree that the composition of the interview sample and the voluntary nature of participation should be clearly acknowledged when interpreting the findings. In response, we have clarified several points in the Methods section regarding the composition and voluntary nature of the interview sample, noting that all participants were female (page 4, lines 147-152). This reflects the gender distribution within the programme itself, where the vast majority of participants were women. Additionally, we have expanded the Limitations section to acknowledge that participation in the interviews was voluntary, potentially resulting in the underrepresentation of the perspectives of less engaged participants or those who chose not to participate (page 13, lines 543-552). Finally, we have revised the Conclusions section to ensure that the interpretation of the findings remains appropriately cautious and clearly reflects that the findings represent the perceptions of participating general practitioners within this study.

Added text in the manuscript:

1. “Of the 108 eligible general practitioners enrolled in the programme, including those who discontinued participation before completion, 13 were interested and agreed to participate in the interviews: four participants from the first group, five from the second, and four from the third. Information on reasons for non-participation was not systematically collected; therefore, the perspectives of general practitioners who chose not to participate, including those who may have had less satisfactory experiences, may not be represented.” (Methods section, page 4, lines 147-152).
2. “This qualitative study has several limitations. The use of a voluntary sampling method may have resulted in the overrepresentation of more motivated and engaged participants, while the perspectives of potentially dissatisfied general practitioners may be underrepresented. Additionally, information on reasons for non-participation was not systematically collected, and therefore barriers to engagement experienced by those who did not participate may not have been fully captured. Furthermore, the study sample consisted of only women general practitioners, reflecting both the gender distribution typical of the general practitioner population in Lat-via [43] and the demographic profile of programme participants. This should be considered when interpreting the findings and may limit transferability to more gender-diverse contexts.” (Discussion section, page 13, lines 543-552)

 

Comments 7: Evaluation of the "ECHO School of Psychiatry"... While being specific is fine, adding "A Qualitative Study of General Practitioners' Perspectives in Latvia" in the subtitle to clearly indicate that this is a qualitative study will help set readers' expectations appropriately. Writing "evaluation" risks leading readers to expect quantitative outcomes, so it's safer to use "perspectives" or "experiences."

Response 7: Thank you for this helpful comment. We agree that it is important to make clear that this manuscript presents a qualitative study focused on participants’ perspectives and experiences rather than a quantitative evaluation of the programme. In response, we revised the wording throughout the manuscript, particularly in the Discussion section, to clarify that the findings reflect the perspectives of the participating general practitioners. Regarding the manuscript title, we carefully considered your suggestion. However, we chose to retain the current title, because it already explicitly identifies the manuscript as “A Qualitative Study” and specifies both the programme and the target professional group. We believe that the current title provides appropriate and concise indication of the manuscript’s focus.

 

Comments 8: Abstract (Methods): `...transcribed verbatim, and the resulting transcripts were analyzed thematically...` Adding "using an inductive approach" here would clarify the direction of the analysis.

Response 8: Thank you for this comment. We completely agree that specifying the analytic approach in the Methods section of the Abstract improves clarity. Accordingly, we have revised the Methods section (page 1, line 24) to indicate this detail.

Added text in the manuscript: “Individual semi-structured interviews were conducted remotely between May and September 2025, audio-recorded, transcribed verbatim, and the resulting transcripts were analysed thematically using an inductive approach, supported by NVivo software.” (Abstract, Methods, page 1, line 24)

 

Comments 9: You're writing the ECHO model as if it were a "magic solution." In addition to highlighting the benefits of the ECHO model, please clearly state the research gap: "While effective globally, the adaptation of the ECHO model to the specific post-Soviet healthcare context of Latvia remains unexplored." This is the core of the originality of this study.

Response 9: Thank you for pointing this out. We agree that the manuscript should more clearly define the research gap and avoid portraying the ECHO model in overly general or uniformly positive terms. In response, we revised the Introduction section to highlight that, while the ECHO model has demonstrated value in various international contexts, its adaptation to the specific healthcare and cultural context of Latvia has not previously been explored (page 2, lines 88-91). We also adjusted the surrounding wording to ensure that the ECHO model is presented as a context-dependent and potentially useful approach rather than as a universally effective solution.

Added text in the manuscript: “Despite the evidence of the effective implementation of ECHO model globally, its adaptation and applicability within the specific healthcare system context in Latvia remains unexplored.” (Introduction, page 2, lines 88-91)

 

Comments 10: The quotes provided are somewhat "goody-goody" ("This format was perfect!", "I felt completely comfortable"). These appear to be the result of "social desirability bias." If you have data, you should include at least one quote that expresses uncertainty or conflict. For example, "At first, I was afraid to turn on the camera, but I gradually got used to it" or "I was so busy I panicked because I couldn't find time to watch the recording." Including negative or neutral elements will increase the credibility of positive results.

Response 10: Thank you for this helpful comment. We agree that including a range of participant perspectives, including more neutral or critical reflections, enhances the credibility of qualitative findings. In response, we reviewed the quotations in included in the Results section and incorporated additional excerpts reflecting more mixed or cautious experiences of the programme (page 7, lines 245-257). These additions help illustrate that, alongside predominantly positive accounts, participants also highlighted certain challenges related to participation. In addition, we expanded the Limitations section in the Discussion to acknowledge the potential impact of social desirability bias and the influence of voluntary participation on the overall tone of the reported experiences (page 13, lines 543-547 and page 14, lines 577-584).

Added text in the manuscript:

1. “While most participants valued the structured thematic scope and additional materials provided, one participant expressed dissatisfaction with the excessive focus on guidelines and classifications, highlighting their insufficient alignment with the realities of clinical practice and the decision-making processes within it. “Classifications and guidelines do not really help me. In practice, they often do not work because I personally do not have the time to engage deeply with them. How do endless classifications help you in your daily work? They do not… It is just theory. But what should you actually do in real life – which diagnosis should you chose, which medication should you prescribe?” (Participant 7)” (Results, page 7, lines 245-257)
2. “This qualitative study has several limitations. The use of a voluntary sampling method may have resulted in the overrepresentation of more motivated and engaged participants, while the perspectives of potentially dissatisfied general practitioners may be underrepresented. Additionally, information on reasons for non-participation was not systematically collected, and therefore barriers to engagement experienced by those who did not participate may not have been fully captured.” (Discussion, page 13, lines 543-547)
3. “The predominantly positive tone of participants’ accounts therefore requires more cautious interpretation. Although it may reflect genuine experiences, it cannot be fully disentangled from the voluntary nature of participation, the participants' perception of the interviewer's affiliation with the programme, or potential social desirability effects. Efforts were made to identify and discuss any data that might alter the emerging themes, ensuring that alternative perspectives were considered. Despite collaborative analysis and reflective measures, complete analytic independence could not be assumed in the insider context of this research.” (Discussion, page 14, lines 577-584)

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for the opportunity to read your manuscript. I genuinely appreciate the effort behind launching and evaluating the first ECHO-based psychiatry telementoring programme in Latvia. The topic is timely, contextually important, and clearly meaningful for your healthcare system. That said, while the paper is good and promising, I believe there are several major issues that prevent it from being publishable.

* Apologies in advance if I use bulleted points rather than more elaborated thoughts.

1. The study risks being perceived as program promotion rather than independent evaluation

I am concerned about the closeness between the research team and the intervention. The programme was developed and delivered by the Department of Psychiatry and Narcology at your institution, and all authors are affiliated with it. One author conducted interviews and was involved in coordination of the programme.

Even though you acknowledge reflexivity and the absence of a hierarchical role, I believe the risk of positive bias is still substantial. The overwhelmingly positive tone of the findings reinforces this concern. There is very limited critical reflection from participants, and very little negative data.

In qualitative research, especially when evaluating one’s own intervention, I would expect:

• Stronger reflexive positioning

• Clearer discussion of power dynamics

• Evidence of searching for disconfirming cases

• Explicit strategies to mitigate social desirability bias

At the moment, I do not see sufficient safeguards to ensure analytic independence. This weakens the credibility of the findings.

2. The sample is small, homogeneous, and likely biased You interviewed 13 participants out of 108 eligible doctors. That is roughly 12 percent of the pool. All were women. All were volunteers. All completed the programme.

This creates multiple layers of selection bias:

• Only those who finished the programme

• Only those willing to volunteer

• Likely those most positively inclined

You state that saturation was reached after 11 interviews. I am not convinced. The interviews were short, averaging 14 minutes. For a qualitative study claiming depth of experiential insight, that duration is quite limited. I would expect richer and more nuanced data to justify claims of saturation.

At present, the dataset appears narrow. The conclusions about impact and transformation feel stronger than the data can realistically support.

3. You frame the study as exploring “perceived impact,” which is appropriate. However, in the Discussion and Conclusions, the language shifts toward implying real system level effectiveness and capacity strengthening.

For example, you argue that the ECHO model:

• Strengthens capacity

• Supports delivery of mental health care

• Enhances competencies

• Enables timely patient management

But the evidence presented is entirely self-reported perception from a small, positively selected group. There are no behavioural measures, no objective practice data, no patient outcomes, and no triangulation.

I believe the manuscript overreaches. At minimum, you need to:

• Strictly contain your claims to perceived changes

• Avoid suggesting demonstrated effectiveness

• Avoid system level generalisations

Otherwise, the conclusions are not epistemologically aligned with the design.

4. 

You state that you used Braun and Clarke’s thematic analysis with an inductive approach. However, the results read largely as structured summaries of positive feedback.

I see:

• 33 codes

• 14 subthemes

• 4 themes

But I do not see:

• Clear analytic depth

• Conceptual development

• Tension or contradiction

• Theoretical integration beyond superficial linking to ECHO literature

For example, the theme on professional isolation is potentially rich. It could open up discussion about cultural communication norms, digital participation behaviour, hierarchy, or psychological safety. Instead, it remains descriptive.

I believe the analysis would need stronger interpretive work. Right now, it feels closer to a program evaluation report than a qualitative research contribution.

5. The interviews are too short to support the depth of conclusions. An average of 14 minutes per interview is extremely brief for qualitative inquiry into professional experience and practice change. This raises two concerns:

• Depth of data

• Depth of analysis

I struggle to see how complex themes such as professional identity, boundary clarification, and community of practice can be robustly explored in interviews of 9 to 21 minutes.

If this is the dataset you have, I would recommend narrowing the scope of claims substantially. As it stands, the conceptual framing is more ambitious than the data volume allows.

6. Lack of negative cases and critical voices

Nearly all presented quotes are positive. Even limitations are framed gently. This creates a credibility issue.

In qualitative research, especially in intervention evaluation, I expect to see:

• Dissenting views

• Ambivalence

• Frustration

• Critical feedback beyond logistical improvements

If those perspectives were absent, that itself deserves deeper analytic reflection. Why were they absent? Is it sampling? Interviewer relationship? Cultural norms?

Without this, the study feels unbalanced.

-

I want to emphasise that I see clear value in your work. Launching and evaluating the first ECHO psychiatry initiative in Latvia is important and commendable. The topic is relevant, and the dataset, though small, is not without merit.

However, for publication in a rigorous journal, the manuscript requires substantial strengthening in:

• Reflexivity and independence

• Analytical depth

• Alignment between claims and data

• Critical engagement with bias and limitations

• Containment of effectiveness claims

If you significantly recalibrate the claims, deepen the analysis, and more transparently confront methodological constraints, I believe the paper could become a solid qualitative contribution.

I hope these comments are received in the constructive spirit intended. I genuinely think the project is meaningful. It just needs more methodological and analytical rigour before it is ready for publication.

Author Response

Thank you very much for taking time to review this manuscript. Please find the detailed responses below and the corresponding revisions marked in red in the re-submitted files.

Comments 1: 1. The study risks being perceived as program promotion rather than independent evaluation

I am concerned about the closeness between the research team and the intervention. The programme was developed and delivered by the Department of Psychiatry and Narcology at your institution, and all authors are affiliated with it. One author conducted interviews and was involved in coordination of the programme.

Even though you acknowledge reflexivity and the absence of a hierarchical role, I believe the risk of positive bias is still substantial. The overwhelmingly positive tone of the findings reinforces this concern. There is very limited critical reflection from participants, and very little negative data.

In qualitative research, especially when evaluating one’s own intervention, I would expect:

• Stronger reflexive positioning
• Clearer discussion of power dynamics
• Evidence of searching for disconfirming cases
• Explicit strategies to mitigate social desirability bias

At the moment, I do not see sufficient safeguards to ensure analytic independence. This weakens the credibility of the findings.

Response 1: Thank you for this thoughtful comment. We acknowledge the importance of reflexivity and transparency, particularly when researchers are closely connected to the programme being studied. In response to this concern, we have strengthened the description of reflexive and analytic procedures in the Data Analysis subsection of the Methods to provide a clearer information on how potential influences related to the interviewer-participant relationship and social desirability bias were considered during the analytic process (pages 5-6, lines 191-205). In addition, we clarified that coding and theme development were reviewed collaboratively by the research team, with discussions aimed at exploring alternative interpretations and ensuring that themes remained grounded in participants’ accounts rather than assumptions about the programme. The Discussion section has also been revised to acknowledge that the predominantly positive tone of participants’ accounts may partly reflect the voluntary nature of participation and the interviewer–participant relationship (Discussion section, page 13, lines 543-547 and page 14, lines 570-574, lines 577-584). This potential source of bias is now discussed more explicitly as a study limitation. Overall, these revisions aim to strengthen the transparency of the analytic process and clarify the strategies used to support the credibility of findings in the context of a programme developed within the same institutional setting.

Added text in the manuscript:

1. “To enhance credibility and rigour of the analysis, coding and theme development were conducted iteratively, with the research team members holding discussions to re-view coding decisions and refine theme boundaries. Coding disagreements were dis-cussed until consensus was reached. An audit trail was maintained to document coding decisions, code revisions, and theme development. Given that members of the research team were involved in the implementation of the programme, particular attention was paid to reflexivity. The potential impact of the interviewer-participant relationship was identified and its possible influence on social acceptance bias was assessed. The research team actively reviewed the data to ensure that the themes accurately reflected participants’ accounts and that no relevant perspectives were overlooked. Reflective notes covered not only coding decisions, but also documented researchers’ positionality and its potential impact on data interpretation, supporting critical evaluation and minimisation of confirmation bias. The research team reviewed the data iteratively to ensure that themes accurately reflected participants’ accounts and that divergent or less frequent perspectives were not overlooked.” (Methods section, Data Analysis subsection, pages 5-6, lines 191-205)
2. “This qualitative study has several limitations. The use of a voluntary sampling method may have resulted in the overrepresentation of more motivated and engaged participants, while the perspectives of potentially dissatisfied general practitioners may be underrepresented. Additionally, information on reasons for non-participation was not systematically collected, and therefore barriers to engagement experienced by those who did not participate may not have been fully captured.” (Discussion, page 13, lines 543-547)
3. “Another potential limitation relates to the involvement of M.B. in conducting the interviews due to prior contact with the participants. Although M.B. was not involved in teaching or evaluating the participants and had no hierarchical role within the pro-gramme, she was involved in programme coordination, which could be acknowledged by the participants as affiliation with the programme’s management. This represents a possible bias due to the interviewer-participant relationship, which might have influenced participants’ willingness to provide more critical feedback and may have contributed to social desirability bias that cannot be fully excluded. To support reflexivity and enhance analytic rigour, all stages of thematic analysis were conducted collaboratively within the research team.” (page 14, lines 570-574)
4. “The predominantly positive tone of participants’ accounts therefore requires more cautious interpretation. Although it may reflect genuine experiences, it cannot be fully disentangled from the voluntary nature of participation, the participants' perception of the interviewer's affiliation with the programme, or potential social desirability effects. Efforts were made to identify and discuss any data that might alter the emerging themes, ensuring that alternative perspectives were considered. Despite collaborative analysis and reflective measures, complete analytic independence could not be assumed in the insider context of this research.” (Discussion, page 14, lines 577-584)

 

Comments 2: 2. The sample is small, homogeneous, and likely biased. You interviewed 13 participants out of 108 eligible doctors. That is roughly 12 percent of the pool. All were women. All were volunteers. All completed the programme.

This creates multiple layers of selection bias:

• Only those who finished the programme
• Only those willing to volunteer
• Likely those most positively inclined

Response 2: Thank you for this important comment. We acknowledge that the characteristics of the interview sample may introduce multiple layers of potential selection bias. As participation in the interviews was voluntary and limited to programme completers, the perspectives of less engaged participants or those who chose not to participate may be underrepresented. In response, we have expanded the Methods section to describe the participant recruitment and clarify the proportion of eligible participants who participated in the interviews (Methods section, page 4, lines 147-152). We have also strengthened the Limitations section in the Discussion to explicitly acknowledge the potential influence of voluntary participation, the absence of perspectives from non-completers’, and the resulting implications for the transferability of the findings (Discussion, page 13, lines 543-552, page 14, lines 590-592).

Added text in the manuscript:

1. “Of the 108 eligible general practitioners enrolled in the programme, including those who discontinued participation before completion, 13 were interested and agreed to participate in the interviews: four participants from the first group, five from the second, and four from the third. Information on reasons for non-participation was not systematically collected; therefore, the perspectives of general practitioners who chose not to participate, including those who may have had less satisfactory experiences, may not be represented.” (Methods section, page 4, lines 147-152).
2. “This qualitative study has several limitations. The use of a voluntary sampling method may have resulted in the overrepresentation of more motivated and engaged participants, while the perspectives of potentially dissatisfied general practitioners may be underrepresented. Additionally, information on reasons for non-participation was not systematically collected, and therefore barriers to engagement experienced by those who did not participate may not have been fully captured. Furthermore, the study sample consisted of only women general practitioners, reflecting both the gender distribution typical of the general practitioner population in Latvia [43] and the demographic profile of programme participants. This should be considered when interpreting the findings and may limit transferability to more gender-diverse contexts.” (Discussion, page 13, lines 543-552)
3. “The findings may be most transferable to similar voluntary continuing medical education programmes, particularly telementoring interventions in comparable healthcare systems and professional contexts.” (Discussion, page 14, lines 590-592)

 

Comments 3: You state that saturation was reached after 11 interviews. I am not convinced. The interviews were short, averaging 14 minutes. For a qualitative study claiming depth of experiential insight, that duration is quite limited. I would expect richer and more nuanced data to justify claims of saturation.

At present, the dataset appears narrow. The conclusions about impact and transformation feel stronger than the data can realistically support.

Response 3: Thank you for pointing this out. We acknowledge this concern that relatively short interviews may have limited the depth of the data collected and posed challenges for interpreting data saturation. In response, the Data Collection section in Methods has been revised to provide more detailed information on how saturation was assessed, including the observation that no new codes emerged after the 11^th interview and that two additional confirmatory interviews were conducted to verify the stability of the coding framework (page 5, lines 174-176). In addition, we expanded the Discussion section to explicitly acknowledge the short interview duration as a methodological limitation and to emphasise that time constraints may have limited the depth and richness of participants accounts (pages 13-14, lines 553-566). Finally, we have adjusted the interpretation of the findings to ensure that the conclusions remain closely aligned with the scope and nature of the qualitative data collected.

Added text in the manuscript:

1. “In this study, data saturation was observed after the 11th interview, when no new codes were identified. Two additional confirmatory interviews were conducted, which con-firmed the stability of the codebook and themes, bringing the total number of interviews to 13.” (Methods section, Data Collection subsection, page 5, lines 174-176)
2. “Additionally, the relatively short duration of the interviews (an average of 14 minutes) represents a further methodological limitation of this study. Although semi-structured interviews were designed to explore participants’ experiences using a focused topic guide, time constraints may have limited the depth of the data collected and the ability to explore more complex themes. This may have reduced the opportunity to capture more nuanced perspectives and complex aspects of participants’ experiences. The relatively short duration of the interviews was likely influenced by participants’ busy clinical schedules and limited availability; however, it is important to acknowledge that this may have constrained the completeness, depth, and overall scope of the findings. Consequently, relatively short interviews could limit the richness of the data obtained and the extent to which full thematic saturation was achieved, despite the fact that consistent patterns in participants’ accounts were identified through thematic analysis. This should be considered when interpreting the findings, as additional or more in-depth interviews could have yielded further nuances and perspectives.” (Discussion, pages 13-14, lines 553-566)

 

Comments 4: 3. You frame the study as exploring “perceived impact,” which is appropriate. However, in the Discussion and Conclusions, the language shifts toward implying real system level effectiveness and capacity strengthening.

For example, you argue that the ECHO model:

• Strengthens capacity
• Supports delivery of mental health care
• Enhances competencies
• Enables timely patient management

But the evidence presented is entirely self-reported perception from a small, positively selected group. There are no behavioural measures, no objective practice data, no patient outcomes, and no triangulation.

I believe the manuscript overreaches. At minimum, you need to:

• Strictly contain your claims to perceived changes
• Avoid suggesting demonstrated effectiveness
• Avoid system level generalisations

Otherwise, the conclusions are not epistemologically aligned with the design.

Response 4: Thank you for this comment. We acknowledge that some statements and formulations in the original manuscript might be interpreted as implying system-level effectiveness beyond the scope of the qualitative design of the study. In response, we carefully revised the Discussion and Conclusions sections to ensure that interpretations remain strictly aligned with the nature of the data. Any statements suggesting demonstrated effectiveness or system-level impact have been moderated to reflect participants’ reported experiences and perceptions of the programme. Specifically, references to programme impact are now framed in terms of perceived changes in participants’ confidence, decision-making, and clinical practices, rather than as demonstrated improvements in service delivery or system-level capacity. These revisions aim to strengthen the epistemological alignment between the qualitative study design and the interpretation of the findings.

 

Location of the revisions:

1. Discussion section – revised wording to moderate claims regarding programme impact.
2. Conclusions section – revised to reflect perceived impact rather than system-level effects.

 

Comments 5: 4. You state that you used Braun and Clarke’s thematic analysis with an inductive approach. However, the results read largely as structured summaries of positive feedback.

I see:

1. 33 codes
2. 14 subthemes
3. 4 themes

But I do not see:

• Clear analytic depth
• Conceptual development
• Tension or contradiction
• Theoretical integration beyond superficial linking to ECHO literature

For example, the theme on professional isolation is potentially rich. It could open up discussion about cultural communication norms, digital participation behaviour, hierarchy, or psychological safety. Instead, it remains descriptive.

I believe the analysis would need stronger interpretive work. Right now, it feels closer to a program evaluation report than a qualitative research contribution.

Response 5: Thank you for this constructive and thoughtful comment. We acknowledge the reviewer’s suggestion to strengthen the interpretive depth of the analysis and move beyond descriptive summaries of themes. In response, the Results section was revised to enhance the analytic narrative by condensing purely descriptive passages and adding interpretive links between themes to better illustrate how different aspects of participants’ experiences relate to each other. We also included quotations and interpretations that reflect more critical or ambivalent perspectives in order to better represent variation in the data (Results, page 7, lines 245-257). The Discussion section was expanded to provide more contextual interpretation of the findings, considering factors such as professional communication culture, workload pressures, and features of the Latvian healthcare system that may influence participant engagement and experiences of professional isolation (Discussion, page 13, lines 521-531). These revisions aim to strengthen the interpretive dimension of the analysis and offer a more nuanced understanding of the findings within the specific programme context.

Added text in the manuscript:

1. “While most participants valued the structured thematic scope and additional materials provided, one participant expressed dissatisfaction with the excessive focus on guidelines and classifications, highlighting their insufficient alignment with the realities of clinical practice and the decision-making processes within it. “Classifications and guidelines do not really help me. In practice, they often do not work because I personally do not have the time to engage deeply with them. How do endless classifications help you in your daily work? They do not… It is just theory. But what should you actually do in real life – which diagnosis should you chose, which medication should you prescribe?” (Participant 7)” (Results, page 7, lines 245-257)
2. “These results should be interpreted in the context of Latvia’s cultural and healthcare system characteristics. The healthcare system is relatively centralized, with most specialists concentrated in major cities, contributing to a shortage of physicians in regional areas. While this shortage may increase perceived value of continuing educational programmes and encourage participation in such initiatives, several contextual factors may limit engagement. These include the unfamiliar structure of the telementoring format, cultural norms such as adherence to traditional professional hierarchies and cautious attitudes towards new collaborative models, as well as varying levels of technological access and proficiency, which together may reduce active participation in discussions and limit engagement in such programmes overall. (Discussion, page 13, lines 521-531)

 

Comments 6: 5. The interviews are too short to support the depth of conclusions. An average of 14 minutes per interview is extremely brief for qualitative inquiry into professional experience and practice change. This raises two concerns:

• Depth of data
• Depth of analysis

I struggle to see how complex themes such as professional identity, boundary clarification, and community of practice can be robustly explored in interviews of 9 to 21 minutes.

If this is the dataset you have, I would recommend narrowing the scope of claims substantially. As it stands, the conceptual framing is more ambitious than the data volume allows.

Response 6: Thank you for pointing this out. We acknowledge the reviewer’s concern that the relatively short duration of the interviews may have limited the depth of the data and constrained the exploration of complex experiential themes. In response, we undertook several revisions to ensure that the interpretation of the findings remains appropriately aligned with the scope of the dataset. First, the quotations in the Results section were carefully reviewed, with priority given to excerpts that provide clearer contextual support for the identified themes. Second, the Discussion section was expanded to explicitly acknowledge the relatively short duration of the interviews as a methodological limitation and to note that time constraints may have limited the depth and richness of participants’ accounts (Discussion, pages 13-14, lines 553-566). Finally, language throughout the Results, Discussion, and Conclusions sections was moderated to ensure that interpretations remain focused on participants’ reported experiences and perceived changes, avoiding broader conceptual or system-level claims beyond what the data can support.

Added text in the manuscript:

1. “Additionally, the relatively short duration of the interviews (an average of 14 minutes) represents a further methodological limitation of this study. Although semi-structured interviews were designed to explore participants’ experiences using a focused topic guide, time constraints may have limited the depth of the data collected and the ability to explore more complex themes. This may have reduced the opportunity to capture more nuanced perspectives and complex aspects of participants’ experiences. The relatively short duration of the interviews was likely influenced by participants’ busy clinical schedules and limited availability; however, it is important to acknowledge that this may have constrained the completeness, depth, and overall scope of the findings. Consequently, relatively short interviews could limit the richness of the data obtained and the extent to which full thematic saturation was achieved, despite the fact that consistent patterns in participants’ accounts were identified through thematic analysis. This should be considered when interpreting the findings, as additional or more in-depth interviews could have yielded further nuances and perspectives.” (Discussion, pages 13-14, lines 553-566)

 

Comments 7: 6. Lack of negative cases and critical voices

Nearly all presented quotes are positive. Even limitations are framed gently. This creates a credibility issue.

In qualitative research, especially in intervention evaluation, I expect to see:

• Dissenting views
• Ambivalence
• Frustration
• Critical feedback beyond logistical improvements

If those perspectives were absent, that itself deserves deeper analytic reflection. Why were they absent? Is it sampling? Interviewer relationship? Cultural norms?

Without this, the study feels unbalanced.

Response 7: Thank you for this helpful comment. We agree that including a range of participant perspectives, including more neutral or critical reflections, enhances the credibility of qualitative findings. In response, we reviewed the quotations in included in the Results section and incorporated additional excerpts reflecting more mixed or cautious experiences of the programme (page 7, lines 245-257). These additions help illustrate that, alongside predominantly positive accounts, participants also highlighted certain challenges related to participation. In addition, we expanded the Limitations section in the Discussion to acknowledge the potential impact of social desirability bias and the influence of voluntary participation on the overall tone of the reported experiences (page 13, lines 543-547 and page 14, lines 577-584).

Added text in the manuscript:

1. “While most participants valued the structured thematic scope and additional materials provided, one participant expressed dissatisfaction with the excessive focus on guidelines and classifications, highlighting their insufficient alignment with the realities of clinical practice and the decision-making processes within it. “Classifications and guidelines do not really help me. In practice, they often do not work because I personally do not have the time to engage deeply with them. How do endless classifications help you in your daily work? They do not… It is just theory. But what should you actually do in real life – which diagnosis should you chose, which medication should you prescribe?” (Participant 7)” (Results, page 7, lines 245-257)
2. “This qualitative study has several limitations. The use of a voluntary sampling method may have resulted in the overrepresentation of more motivated and engaged participants, while the perspectives of potentially dissatisfied general practitioners may be underrepresented. Additionally, information on reasons for non-participation was not systematically collected, and therefore barriers to engagement experienced by those who did not participate may not have been fully captured.” (Discussion, page 13, lines 543-547)
3. “The predominantly positive tone of participants’ accounts therefore requires more cautious interpretation. Although it may reflect genuine experiences, it cannot be fully disentangled from the voluntary nature of participation, the participants' perception of the interviewer's affiliation with the programme, or potential social desirability effects. Efforts were made to identify and discuss any data that might alter the emerging themes, ensuring that alternative perspectives were considered. Despite collaborative analysis and reflective measures, complete analytic independence could not be assumed in the insider context of this research.” (Discussion, page 14, lines 577-584)

Reviewer 4 Report

Comments and Suggestions for Authors

The topic is of interest, and the methods are generally acceptable. However, the writing style of the manuscript should be improved considering the following comments:

 

1. All abbreviations should be written in full the first time they are used, even in the title.

2. The background section of the Abstract should be summarized.

3. The main inclusion criteria should be added to the Abstract.

4. Keywords should be selected from MeSH (Medical Subject Headings).

5. A brief description of the medical education model in Latvia and the status of psychiatry education within it should be added to the Introduction.

6. It should be clearly stated in the Abstract and throughout the manuscript that all participants are female.

7. The ECHO school should be described in more detail in the Methods section.

8. The age and, if possible, the years of employment of each participant should be added after each example sentence.

9. The Results section should be summarized. Some examples are excessive, and certain explanations should be removed or integrated.

10. In the Discussion section, the current findings should be compared with those of previous studies, mentioning the countries where the studies were conducted. In addition, suggestions for future research should be included.

 

Author Response

Thank you very much for taking time to review this manuscript. Please find the detailed responses below and the corresponding revisions marked in red in the re-submitted files.

Comments 1: All abbreviations should be written in full the first time they are used, even in the title.

Response 1: Thank you for this suggestion. We carefully considered this point. However, we chose to retain “ECHO” in the title, as it is a part of the official name of the programme and is widely used in the literature in abbreviated form, including in article titles. Spelling out the full term in the title would substantially reduce its clarity and readability. To ensure clarity for readers, the full term (Extension for Community Healthcare Outcomes) has been provided at its first mention in the abstract (Abstract, Background/Objectives, page 1, lines 15-16). All other abbreviations are also provided in full when first introduced in the manuscript.

 

Comments 2: The background section of the Abstract should be summarized.

Response 2: We appreciate this comment. We have carefully reviewed the Background/Objectives section of the Abstract to assess whether further summarisation would improve clarity. However, we found that the current wording already presents the essential context and study aim concisely. Removing additional elements would risk losing important contextual information on the rationale for the study. Therefore, the text has been retained in its current form.

 

Comments 3: The main inclusion criteria should be added to the Abstract.

Response 3: Thank you for pointing this out. We agree with this comment. Therefore, we have revised the Abstract to specify the main inclusion criteria, clarifying that participants were general practitioners who engaged in the programme during a defined time period (Abstract, Methods, page 1, lines 19-20).

Added text in the manuscript: “Methods: Thirteen women general practitioners who had participated in the programme between October 2023 and February 2025 were recruited using voluntary response sam-pling, via email invitations from programme coordinators.”

 

Comments 4: Keywords should be selected from MeSH (Medical Subject Headings).

Response 4: Thank you for pointing this out. We have revised the Keywords to include standardised MeSH terms (primary health care, psychiatry, continuing education, general practitioners) to ensure consistency. In addition, we retained keywords “telementoring” and “ECHO project”, which are not MeSH terms but are essential to accurately reflect the study focus.

 

Comments 5: A brief description of the medical education model in Latvia and the status of psychiatry education within it should be added to the Introduction.

Response 5: We appreciate this suggestion. To address it, we have added a brief overview of the medical education model in Latvia in the Introduction to provide more specific context for the study (page 2, lines 47-51).

Added text in the manuscript: “In Latvia, medical education comprises six years of undergraduate training followed by four to five years of specialised residency. Although this educational model provides foundational knowledge, it may have limited ability to develop specific skills in the man-agement of mental disorders in routine primary care practice.” (Introduction, page 2, lines 47-51)

 

Comments 6: It should be clearly stated in the Abstract and throughout the manuscript that all participants are female.

Response 6: Thank you for pointing this out. We agree that the composition of the interview sample should be clearly acknowledged. In response, the Abstract has been revised to clearly state this fact (Abstract, Methods, page 1, line 19). Additionally, we have clarified several points in the Methods section regarding the composition and voluntary nature of the interview sample, noting that all participants were female (page 4, lines 147-152). This reflects the gender distribution within the programme itself, where the vast majority of participants were women. Furthermore, the Discussion has been updated to address the study sample’s gender homogeneity, which should be considered when interpreting the findings and may limit transferability to more gender-diverse professional contexts (Discussion, page 13, lines 548-552 and page 14, lines 590-592).

Added text in the manuscript:

1. “Of the 108 eligible general practitioners enrolled in the programme, including those who discontinued participation before completion, 13 were interested and agreed to participate in the interviews: four participants from the first group, five from the second, and four from the third. Information on reasons for non-participation was not systematically collected; therefore, the perspectives of general practitioners who chose not to participate, including those who may have had less satisfactory experiences, may not be represented.” (Methods section, page 4, lines 147-152).
2. “Furthermore, the study sample consisted of only women general practitioners, reflecting both the gender distribution typical of the general practitioner population in Latvia [43] and the demographic profile of programme participants. This should be considered when interpreting the findings and may limit transferability to more gender-diverse contexts.” (Discussion section, page 13, lines 548-552).
3. “The findings may be most transferable to similar voluntary continuing medical education programmes, particularly telementoring interventions in comparable healthcare systems and professional contexts.” (Discussion section, page 14, lines 590-592).

 

Comments 7: The ECHO school should be described in more detail in the Methods section.

Response 7: Thank you for this helpful recommendation. In response, we expanded the Methods section to provide a more detailed description of the “ECHO School of Psychiatry” (page 3, lines 115-125). The revised text now outlines the programme’s format, duration, session structure, objectives, thematic content, and participant numbers. These additions provide a clearer overview of the intervention and its implementation context.

Added text in the manuscript: “The “ECHO School of Psychiatry” operates as a telementoring programme comprising eight online seminars attended by groups of 25-50 general practitioners from various regions of Latvia. The programme aims to enhance general practitioners’ knowledge and strengthen their clinical confidence in managing mental disorders. Seminars are designed to promote active interaction among participants as well as between participants and psychiatrists, focusing on the analysis of real challenges encountered in practice. Each session includes a didactic lecture and case-based discussions, offering participants the opportunity to present and analyse their own challenging clinical cases. Each of the eight sessions focuses on a specific diagnostic group or aspect of mental healthcare relevant to primary care (Table 1). The programme also provides access to session recordings, presentations, and supplementary educational materials to support learning beyond the programme. To date, three training groups have been conducted, with 108 general practitioners enrolled in the programme and 93 having completed it.” (Methods section, page 3, lines 115-125).

 

Comments 8: The age and, if possible, the years of employment of each participant should be added after each example sentence.

Response 8: Thank you for this suggestion. We used participant numbers as the only identifiers in the quotations because information on age and professional experience was not systematically collected for all interviewees. In addition, given the small and relatively homogeneous sample, including such details could increase the risk of indirect identification and compromise confidentiality. We therefore retained anonymised participant numbers only, while aiming to provide sufficient contextual information to support understanding of the findings.

 

Comments 9: The Results section should be summarized. Some examples are excessive, and certain explanations should be removed or integrated.

Response 9: Thank you for this valuable recommendation. We have revised the Results section to improve the analytic narrative by summarising some descriptions and connecting the interpretation across several themes to better illustrate their interconnections. General or repetitive quotations were reduced, retaining those that are contextually grounded and provide more specific insight, and interpretative linking text was added to clarify connections between themes, particularly the relationship between the perceived educational value of the programme and its influence on clinical practice. In addition, we have added clarifying text in the Results section to emphasise the interpretive role of the selected quotations (page 6, lines 212-214).

Added text in the manuscript: “Illustrative quotes were selected to reflect the main themes and to provide contextual insight into the participants’ experiences, supporting the interpretation of the results.” (Results, page 6, lines 212-214)

 

Comments 10: In the Discussion section, the current findings should be compared with those of previous studies, mentioning the countries where the studies were conducted. In addition, suggestions for future research should be included.

Response 10: Thank you for pointing this out. In response, we have revised the Discussion section to provide more detailed comparison of findings with those of previous studies, highlighting context-specific factors of Latvian healthcare system. Additionally, we have included potential directions for future research in the Discussion section (page 14, lines 594-599).

Added text in the manuscript: “A potential direction for future research could include exploration of patient-level outcomes linked to general practitioners’ engagement in the ECHO programme. Further studies might investigate the long-term effects of participation on clinical practice and the sustainability of reported changes. Additionally, the adaptation of the ECHO model to other medical professionals could be examined, with subsequent evaluation of its perceived effectiveness across diverse clinical contexts within the Latvian healthcare system.” (Discussion, page 14, lines 594-599).