Perspectives of Non-Hospitalised Patients with COVID-19 Self-Isolating for 10 Days at Home: A Qualitative Study in Primary Care in Greece

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Thank you for making the necessary amendments to your article. 

I recommend acceptance of the manuscript

Non

Author Response

We would like to thank you for your involvement in the review prosess of the article and for your recommendation of its acceptance by the COVID journal.

Reviewer 2 Report (New Reviewer)

I have reviewed the article "Perspectives of non-hospitalised patients with COVID-19 self-isolating for 10 days at home: a qualitative study in primary care in Greece" and have several concerns regarding its methodology, analysis, and conclusions.

Firstly, the study's sample size is small and not representative of the broader population. The study only included patients who were young to middle-aged and capable of self-monitoring their mild COVID-19 symptoms. This limits the generalizability of the study's findings to other populations, such as older adults or those with communication difficulties. Secondly, the study's methodology is not clearly described. The authors state that they used a "grounded theory approach," but it is unclear how this approach was applied in the study. The authors also do not provide a clear description of their data analysis process, which makes it difficult to assess the rigor of their findings. Thirdly, the study's conclusions are not well-supported by the data. The authors suggest that primary care physicians have a key role in supporting patients with mild COVID-19 in self-isolation, but this conclusion is not well-supported by the data. The study only provides a limited perspective on patients' experiences during self-isolation and does not provide a comprehensive understanding of the role of primary care physicians in supporting these patients. Summarising, the study has some strengths, such as its use of qualitative methodology and in-depth analysis of patients' perspectives, its limitations and weaknesses significantly undermine the validity and generalizability of its findings. I recommend that the authors revise the study to address these concerns before considering it for publication. Here are some constructive suggestions for the authors:

1. The authors need to provide a clear description of their methodology, including how they applied the grounded theory approach and their data analysis process. This will help readers understand the rigor of their findings.

2. The authors need to expand their sample size to include a more diverse population, such as older adults or those with communication difficulties. This will increase the generalizability of their findings.

3. The authors need to provide more support for their conclusions, particularly regarding the role of primary care physicians in supporting patients with mild COVID-19. They should consider conducting follow-up studies to explore this topic further.

4. The authors need to address the limitations of their study, such as the limited representation of certain perspectives and the ever-changing nature of the pandemic. They should acknowledge these limitations and suggest areas for future research.

5. The authors should improve the clarity and organization of their writing. They should ensure that their findings are presented in a logical and coherent manner, and that their conclusions are supported by the data.

By addressing these suggestions, the authors can improve the quality and rigor of their study and make it more acceptable for publication.

Author Response

Response to Reviewer 2 Comments

Point 1: Firstly, the study's sample size is small and not representative of the broader population. The study only included patients who were young to middle-aged and capable of self-monitoring their mild COVID-19 symptoms. This limits the generalizability of the study's findings to other populations, such as older adults or those with communication difficulties. The authors need to expand their sample size to include a more diverse population, such as older adults or those with communication difficulties. This will increase the generalizability of their findings.

Response 1: Thank you for your comment.

The sample size is not used in qualitative research in the same way as in quantitative research. We know from the theory (Shari L. Dworkin, “Sample Size Policy for Qualitative Studies Using In-Depth Interviews” Arch Sex Behav (2012) 41:1319–1320) that in qualitative research the samples’ extent is determined by the saturation of the results and that usually a sample size of minimum 25-30 interviews is considered sufficient for studies drawing on grounded theory and in-depth interviews. In the present study, a larger number of interviews (37) were conducted until no new codes emerged in the last three transcripts, indicating saturation (line 156).

Regarding the diversity of the sample, it is stated in the limitations (lines 403-408) that the study population consisted of patients who were mostly young to middle-aged, and capable of self-monitoring of their mild COVID-19 disease and that people who are older and those with communication difficulties, such as cognitive impairment/dementia, severe mental illness or learning disabilities, would have needed additional support, even with very mild forms of the disease. Including these other populations was beyond the scope of this project. We do not expect the findings of a qualitative study to be generalizable or applicable to other populations other than those with similar characteristics to the study population. However, these findings are still important and clinically relevant because they refer to a very large group of patients with COVID-19 who are managed in the community. 

Point 2: The authors state that they used a "grounded theory approach," but it is unclear how this approach was applied in the study. The authors also do not provide a clear description of their data analysis process, which makes it difficult to assess the rigor of their findings. The authors need to provide a clear description of their methodology, including how they applied the grounded theory approach and their data analysis process. This will help readers understand the rigor of their findings. 

Response 2: Thank you for the comment.

In lines 103-106 we cited the literature [17] that supports the approach of analysis when using the “grounded theory approach”, a process of developing analytic codes and categories, which is based on collected data rather than pre-existing hypotheses. In lines 152-154 we explain how the "grounded theory approach," was applied in the study, through an inductive (bottom-up) analysis, which helped us to collect data and to formulate conclusions from them. Open coding and then axial and selective coding were performed. (lines 156-157).

 At your suggestion we have added more information in the section “Data analysis”, so the text has taken the following form: 

In grounded theory approach the process of developing analytic codes and categories is based on collected data rather than pre-existing hypotheses. An inductive (bottom-up) approach was used in order to formulate conclusions from the data. The transcripts were consecutively coded manually while interviews were underway, and recruitment ended when no new codes emerged in the last three transcripts, indicating saturation. Open coding and then axial and selective coding were performed. The process of open coding involved the segmentation of data into smaller units of words or phrases, which were then categorized under conceptual headings, known as codes. During coding, the process of identifying similarities and differences was carried out through a continuous comparison of the data with newly emerging information. Coding was conducted by two female GP researchers (AC, SD), experienced in transcript coding and qualitative studies. A coding framework was developed, agreed upon, applied to all transcripts, and refined iteratively (Figure 1). Our coding process involved a close examination of the participants' emerging feelings (e.g., fear), participants' processes (e.g., how they acted in response to problems) and opinions (e.g., expectations).  During axial coding, we tried to identify possible connections between codes (e.g., managing work responsibilities during isolation) and subsequently generated sub-themes. During the phase of selective coding, the core themes were identified, which encompassed the sub-themes in terms of their explanatory significance. Ultimately, a comprehensive thematic summary was generated.  

Key emergent themes and sub-themes, and their meaning were identified [18] through inductive thematic analysis. Differences in coding or thematic analysis were discussed with the analysis team until a consensus was reached. Selected illustrative quotes are presented in the results. 

Point 3: The authors suggest that primary care physicians have a key role in supporting patients with mild COVID-19 in self-isolation, but this conclusion is not well-supported by the data. The study only provides a limited perspective on patients' experiences during self-isolation and does not provide a comprehensive understanding of the role of primary care physicians in supporting these patients. The authors need to provide more support for their conclusions, particularly regarding the role of primary care physicians in supporting patients with mild COVID-19. They should consider conducting follow-up studies to explore this topic further.

Response 3: Thank you for your comment.

In line 294 it is noted that GPs and Internists exclusively practising in Primary Health Care. Primary care physicians’ key role in supporting patients with mild COVID-19 in self-isolation is demonstrated both by the provision of patient’s telephone monitoring and psychological support, as well as by their emergence as the only source of valid information (P 18, P 29, P 7).

‘As soon as I got the test results, I called my Internist who gave me a list of medication and we communicated daily. [...] The doctor was always by my side. She helped me a lot, she did not let my morale deteriorate. [...] She gave me courage.’ (P18)

‘They must check very closely their symptoms and consult their doctor, and no one else but him, because I believe there is over-information in terms of the media and the best source of information is the doctor who already knows patients. […] What happens around us is real and we should not believe anyone posting online...’ (P29)

‘My area’s Health Centre was very helpful. I could not ever dream of such behaviour! Such great service and interest!’ (P7)  

The present study highlighted patients' unmet needs and their views on the role that PHC physicians played in supporting them during the period of isolation. From these results arise clinical implications, which are presented in lines 409-420.

Point 4: The authors need to address the limitations of their study, such as the limited representation of certain perspectives and the ever-changing nature of the pandemic. They should acknowledge these limitations and suggest areas for future research.

Response 4: Thank you for your comment.

We understand the pandemic evolved dynamically and some things may have changed since the study was conducted. We have listed that as a limitation (lines 400-403): “In addition, the ever-changing environment of the pandemic promotes the emergence and even resolution of new and older patients’ problems respectively, whose entirety is impossible to be recorded during the limited time of the study.”

We have already listed the possibility that some different perspectives might not have been captured as a limitation (lines 398-400). The remaining suggested limitations, as well as the suggested areas for future research, are presented in lines 398-408.

Point 5: The authors should improve the clarity and organization of their writing. They should ensure that their findings are presented in a logical and coherent manner, and that their conclusions are supported by the data.

Response 5: Thank you for your comment.

We have tried to present study’s findings in a logical and coherent manner and conclusions supported by the data.

Round 2

Reviewer 2 Report (New Reviewer)

Some sections are very short (Section 4, Section 9). More lengthy discussion of results and conclusions should be provided. The organization of the manuscript can be improved by joining several sections together as subsections.

Author Response

Response to Reviewer 2 Comments

Point 1: Some sections are very short (Section 4, Section 9). More lengthy discussion of results and conclusions should be provided. The organization of the manuscript can be improved by joining several sections together as subsections.

Response 1: Thank you for your comment.

Sections 5 (main findings) and 6 (interpretation) are part of section 4 (discussion) and should not be numbered separately, but as subsections of the discussion section. In line 344 we added the sentence “In this section we list the main findings of the study and their interpretation.” to clarify it.

At your suggestion, we have also provided a lengthier conclusions’ section, which now has the following format:

COVID-19 in combination with home isolation affects patients' mental health, promoting fear for personal or even other people's health, and feelings of helplessness, as patients are forced to self-monitor their disease, or alienation, as they are forced to self-isolate from their family and social environment. These findings indicate that Primary Health Care should promptly respond to patients' needs, starting on the first day of self-isolation, by using all its health professionals, to achieve a holistic approach.

A key observation of this study is the occurrence of various difficulties, due to self-isolation, in the presence of a variety of individuals’ health needs, arising from the disease. The combination of illness and isolation multiplies the psychological burden of patients, indicating the need for provision of psychological support. 

Over-information on the complications of the disease promotes fear. As targeted information from the authorities and the scientific community define perception about illness and social behaviour, attention should be paid to provision of personalized information and guidance through Primary Health Care Physicians.

Finally, the fact that in our country the practical needs of patients were served by the social environment indicates that the state needs to strengthen characteristics that society displayed during the pandemic period, such as solidarity, in order to increase social cohesion.

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

The manuscript entitled “Experiences of non-hospitalised patients with COVID-19 self-isolating at home: a qualitative study in primary care in Greece” presents research to identify the psychosocial impact of self-isolating. 

–      “telephone interviews” – If the survey was by telephone interviews the written consent (signed) was not possible to obtain. How it was handles?  Please clarify it…

–      Lines 56-58 – “Given the widespread vaccination program in the developed countries, most people with COVID-19 have a disease that requires no hospitalization and are managed in the community [11].’ – please add the data and % of vaccination in this period

–      Lines 73-74 -  “that requires no hospitalisation.” – it seem, that it is not a big problem for patients (no threat to life; only 10 days in isolation) – the justification for this study is needed.

–      In introduction Authors presented the information associated with Covid-19 pandemic mainly in Greece. This section should be briefly presented – what do we know and what is the background for this study. Some detailed information about other studies are necessary. The good background should present the history of problem, the current knowledge and scientific "gap", and then authors should present how their study could fill this gap to justify the study.

–      More detailed information about recruitment procedure should be presented.

–      Socio-demographic data should be presented.

–      Samples size should be calculated.

–      In title authors should add “10 days of self-isolation” to be precise.

–      Some of this qualitative study concerns universal problems: I'm not just talking about COVID. When someone lives alone for years, once we get sick and stay at home, the only problem we face is nutrition. – How authors deals with this bias.

–      Authors should conduct deeper analyses the data.

–      In the presented form, the manuscript adds nothing new to science

Reviewer 2 Report

Experiences of non-hospitalised patients with COVID-19 self

isolating at home: a qualitative study in primary care in Greece

Thank you for giving me the opportunity to review this paper. This is an interesting study that examines an important topic.  The study is well written, and the writing is coherent and well-organized. Nevertheless, the results section is incomplete. Therefore, I recommend accepting the paper after the following changes have been made:

Title

·         I suggest replacing the term 'Experiences' with 'perspective' or 'view' to make the research more accurate.

Abstract

·         Please rewrite the research conclusions such that they summarize the research findings and rely directly on them.

Introduction

·                The literature review is good. Nevertheless, the authors should sharpen the rationale and after that clearly indicate the objective of the review.

 Methods

·         The authors need to indicate what type of qualitative research they conducted and why: phenomenological? narrative? ethnographic? Data analysis is unclear.

Result

·         The data in Table 3 is unnecessary and can either be written in text or attached to Table 2.

·         In presenting the findings, we recommend reducing the direct quotations from the participants and providing more in-depth interpretation and discussion of emotional depth.

·         In their analysis, the authors identified four main themes. In my opinion, some of these themes overlap and could be merged. It is difficult to distinguish when a new theme starts and when there is a reference to a sub-theme. Alternatively, the authors need to emphasize what sets them apart. It seems that the analysis requires an additional step from shared categories to themes.

DISCUSSION

·         There is not enough discussion of the findings related to the theme.

·         The discussion should also include Clinical Implications section.

Comments for author File: Comments.pdf