Understanding the diagnostic delays and pathways for diabetes in eastern Uganda: A qualitative study

Francis Xavier Kasujja; Fred Nuwaha; Meena Daivadanam; Juliet Kiguli; Samuel Etajak; Roy William Mayega

doi:10.1371/journal.pone.0250421

Peer Review History

Original SubmissionDecember 10, 2020
26 Jan 2021 Decision Letter - Claudia Marotta, Editor PONE-D-20-38847 Understanding the diagnostic delays and pathways for diabetes in eastern Uganda: A qualitative study PLOS ONE Dear Dr. Kasujja Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by 15 Febraury. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: 1) Good detail of characteristics of participants, could use more info about vulnerable populations, comorbidities, socioeconomic status and social support 2) Good detail on the interviewing process - where were they conducted? Was the transcript read back to the interviewee? 3) excellent reflexivity section - though this could have included some information about the author’s relationship with the participants 4) good description of sampling 5) The quotes were well used and documented with participant identifiers 6) line 308 this might be a transcription error in the quote, or if not, add in the meaning in brackets ‘I didn’t (know) what it was’ 7) line 426 delete ‘at the’ Reviewer #2: I read with great interest the paper. non comunicable diseases are important topic in low setting. I appreciate both the idea research and the context of stdy Some suggestions 1. Introduction: add data on globala burden of diabetes. Add information on tb and diabetes. In fact Uganda, has high incidence of Tb and TB MDR. DIabetes represent a risk factor for tb and for worste outcome. Tuberculosis and diabetes are a topical example of an association between communicable and non-communicable diseases. These diseases are mutually linked, increasing each other's complications, making diagnosis and management more difficult and worsening disease course and outcomes. Furthermore, each disease is a risk factor for the occurrence and exacerbation of the other. (see and cite Prevalence of diabetes mellitus in newly diagnosed pulmonary tuberculosis in Beira, Mozambique. Afr Health Sci. 2017 Sep;17(3):773-779. doi: 10.4314/ahs.v17i3.20 and Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital. Antibiotics (Basel). 2020 Aug 7;9(8):489. doi: 10.3390/antibiotics9080489) 2. Methods and result are clear 3. Discussion: the development of a systematic approach to treat non-communicable diseases, particularly diabetes, in low-income countries is urgent and necessary. (cite Diabetes in active tuberculosis in low-income countries: to test or to take care? Lancet Glob Health. 2019 Jun;7(6):e707. doi: 10.1016/S2214-109X(19)30173-1) ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Ahmed Al-Naher Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0250421.r001
Revision 1
19 Mar 2021 Author Response Reviewer #1: 1) Good detail of characteristics of participants, could use more info about vulnerable populations, comorbidities, socioeconomic status and social support Thank you very much for your feedback on participant characteristics. Regarding the issue of vulnerable populations, none of the participants in this study can be classified as vulnerable. All were adult, of sound mind, and their participation was not coerced. According to the Uganda National Council of Science and Technology (National Guidelines for Research involving Human Subjects) and the ICH Good Clinical Practice (ICH GCP Guideline E6), vulnerable individuals and groups are those with limited capacity or freedom to consent or decline consent and those whose participation motivated by undue expectation of benefits or threats of retaliation from senior members of a hierarchy. None of these criteria apply to our study participants. Four of the patients participating in this study had been diagnosed with hypertension. We have updated table 1 with this information. Regarding other chronic diseases, none of the participating patients had been diagnosed with heart disease. Similarly, none had been diagnosed with HIV probably because HIV and its co-morbidities are managed at the HIV clinic which is a different clinic within the out-patient department. For socioeconomic status, we have added a row to table 1 with the occupations of the patients participating in the study as a surrogate for socioeconomic status is supported by the findings of Fujishiro, Xu and Gong (2010) (Fujishiro K, Xu J, Gong F. What does "occupation" represent as an indicator of socioeconomic status?: exploring occupational prestige and health. Soc Sci Med. 2010 Dec;71(12):2100-7. doi: 10.1016/j.socscimed.2010.09.026. Epub 2010 Oct 30. PMID: 21041009.) highlighting the utility of occupational prestige, a marker of social standing that is associated with self-rated health. We have also added a row to table 1 for the patients’ sources of social support during the diagnostic pathway. 2) Good detail on the interviewing process - where were they conducted? Was the transcript read back to the interviewee? - The interviews were conducted at Iganga Hospital. This is mentioned in line 85 of the tracked changes version of the manuscript under the study setting sub-section. - The transcripts were not read back to participants as we had to translate them first before transcription which we did several days after data collection. 3) excellent reflexivity section - though this could have included some information about the author’s relationship with the participants Thank you for the observation regarding the need to include some information about the author’s relationship with study participants. We have added a statement on line 150-152 to explain that the author was not involved in the provision of clinical services to the patients and neither was he involved in the supervision of the healthcare workers who participated in the study. 4) good description of sampling This is noted; thank you very much. 5) The quotes were well used and documented with participant identifiers Thank you very much. 6) line 308 this might be a transcription error in the quote, or if not, add in the meaning in brackets ‘I didn’t (know) what it was’ The omission of “know” on line 308 was indeed a transcription error. I have added this word in the revised manuscript. This change is now on line 311 of the tracked changes version of the revised manuscript. 7) line 426 delete ‘at the’ Thanks for catching that typo. I have deleted that phrase as seen on line 433 of the tracked changes version of the manuscript. Reviewer #2: 1) I read with great interest the paper. non communicable diseases are important topic in low setting. I appreciate both the idea research and the context of study. Thank you very much for your kind words. 2) Introduction: add data on global burden of diabetes. Add information on tb and diabetes. In fact Uganda, has high incidence of Tb and TB MDR. Diabetes represent a risk factor for tb and for worst outcome. Tuberculosis and diabetes are a topical example of an association between communicable and non-communicable diseases. These diseases are mutually linked, increasing each other's complications, making diagnosis and management more difficult and worsening disease course and outcomes. Furthermore, each disease is a risk factor for the occurrence and exacerbation of the other. (see and cite Prevalence of diabetes mellitus in newly diagnosed pulmonary tuberculosis in Beira, Mozambique. Afr Health Sci. 2017 Sep;17(3):773-779. doi: 10.4314/ahs.v17i3.20 and Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital. Antibiotics (Basel). 2020 Aug 7;9(8):489. doi: 10.3390/antibiotics9080489) Thank you very much for highlighting a very topical issue regarding TB and diabetes interactions. I have added this information to the manuscript, citing Pizzol et al. (2017) (Pizzol D, Di Gennaro F, Chhaganlal KD, Fabrizio C, Monno L, Putoto G, Saracino A. Prevalence of diabetes mellitus in newly diagnosed pulmonary tuberculosis in Beira, Mozambique. Afr Health Sci. 2017 Sep;17(3):773-779. doi: 10.4314/ahs.v17i3.20. PMID: 29085405; PMCID: PMC5656213.) and Di Gennaro (2020) (Di Gennaro F, Vittozzi P, Gualano G, Musso M, Mosti S, Mencarini P, et al. Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital. 2020;9(8)) as advised. These changes are on lines 63-66 of the tracked changes version of the revised manuscript. Methods and result are clear This is noted with thanks. Discussion: the development of a systematic approach to treat non-communicable diseases, particularly diabetes, in low-income countries is urgent and necessary. (cite Diabetes in active tuberculosis in low-income countries: to test or to take care? Lancet Glob Health. 2019 Jun;7(6):e707. doi: 10.1016/S2214-109X(19)30173-1) We have added this point to the discussion and cited accordingly on lines 420-423 of the tracked changes version of the revised manuscript. https://doi.org/10.1371/journal.pone.0250421.r002
7 Apr 2021 Decision Letter - Limakatso Lebina, Editor Understanding the diagnostic delays and pathways for diabetes in eastern Uganda: A qualitative study PONE-D-20-38847R1 Dear Dr.Kasujja, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Limakatso Lebina, MBChB Academic Editor PLOS ONE Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: All previous comments have been addressed to a satisfactory standard. The paper should add to the body of knowledge on this topic. Reviewer #2: Authors improved their paper that now can be accept. The paper is well written and the research idea and the setting very relevant ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Ahmed Al-Naher Reviewer #2: No https://doi.org/10.1371/journal.pone.0250421.r003
Formally Accepted
12 Apr 2021 Acceptance Letter - Limakatso Lebina, Editor PONE-D-20-38847R1 Understanding the diagnostic delays and pathways for diabetes in eastern Uganda: A qualitative study Dear Dr. Kasujja: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Limakatso Lebina Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0250421.r004

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