PONE-D-20-24599

The Community Burden of Hypertension and Treatment Patterns: An In-depth age predictor analysis: The Rural Community Risk of Non-Communicable Disease Study - (Nyive Phase I)

PLOS ONE

Dear Dr. Osei-Yeboah,

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.

I found this paper to be a potentially valuable addition to the literature.  Similar to the comments from the other reviewers, I believe that if you provide additional context for some of your statements, the paper will become more clear and understandable for readers who aren't familiar with the region you are studying in Ghana.  

Within the comments provided by the other reviewers, please ensure that you incorporate all the major or mandatory comments I've highlighted in parentheses.   We believe that once you incorporate these suggestions, the paper will be significantly improved and suitable for publication.  

Please submit your revised manuscript by Oct 29 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Sonak D. Pastakia

Academic Editor

PLOS ONE

Additional Editor Comments:

The authors describe an interesting study describing their teams efforts to describe of hypertension amongst rural community members. My comments mirror the comments of the reviewers and would request that you address these comments to provide additional clarity on the issues they mention.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

4. Please amend your list of authors on the manuscript to ensure that each author is linked to an affiliation. Authors’ affiliations should reflect the institution where the work was done (if authors moved subsequently, you can also list the new affiliation stating “current affiliation:….” as necessary).

5. Please include a copy of Table 6 which you refer to in your text (line 234).

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: I Don't Know

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: Recommendation | The Community Burden of Hypertension and Treatment Patterns: An In-depth age

predictor analysis: The Rural Community Risk of Non-Communicable Disease Study -

(Nyive Phase I)

The manuscript talks about a health condition that is certainly of interest to healthcare and may contribute to literature. Hence, understanding risk factors to hypertension such as age and the effect of the condition on a community in addition to the "treatment patterns" available may help to improve care for hypertensive patients. 

This manuscript shows strengths in its introduction and clear lay out of the table of results. Authors random selection of participants is an additional strength.

Under discussion, it seems the authors are suggesting that the time period within which the study was done could be one of the factors contributing to the variation in the burden of hypertension. Not sure if I missed it but authors should consider indicating months/year data was collected to help readers connect to the above implication. Furthermore, the manuscript could benefit from an elaborate discussion on bridging the numbers from the results with the aims. What gap in literature will this fill?  (mandatory)

Under methods, authors should consider disclosing the number of all the participants contacted and those who opted out of the study. Did all eligible participants contacted by investigators consent to participate in the study? Kindly indicate the response rate and if the recorded number is small, consider indicating that as a limitation of the study. (mandatory if possible)

Authors should also consider describing the parts of the WHO STEPwise approach used since the study does not report on all the three steps. For example, There are other variables worth mentioning such as diet, smoking and exercise that affect hypertension but were not reported as part of the data collected. Did the questionnaire include all the variables in the WHO STEPwise approach? Consider stating this as potential limitation.  (optional)

Again, it is indicated in the manuscript that there were objective and subjective measures of hypertension by definition. The subjective report could also be a potential limitation.

"Rural hypertension" may not be a term that is widely known. Therefore, it will be appropriate to define what the term mean in the study at first mention. That is, please define "rural hypertension".  (Please make this more clear)

Other consideration:

Title: Consider revising the title, for instance, "Community Burden of Hypertension and Treatment Patterns - The Rural Community Risk of Non-Communicable Disease Study (Nyive Phase I): An In-depth age predictor analysis"

Abstract:

* Under methods; Sentence 2: Suggestion, "WHO STEPS Instrument... OR ..."The WHO STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) instrument...." as stated on the WHO website instead of "The WHO STEPS wise approach for non-communicable diseases risk (NCD) instrument..." (minor)

Introduction:

* Review of literature seems fair although authors could consider information from more recent literature. Generally the review includes literature from Ghana and Sub-Saharan Africa. Almost half of the reference is 10 or more years. I suggest adding current literature such as: (major)

Methods:

*Line 33 & 34; revise the wording for the WHO instrument used as suggested under "Abstract" above.

* Line 100; Consider revising, "...is was the tool used to the collect data and ..."

* Line 115; Consider revising, "...Committee (JNC VII) on Prevention, Detection,..." NOT line 116 "...(JNC VII) criteria for blood pressure..."

*If data was collected before JNC VIII became available, then authors can ignore this recommendation. If not, JNC VIII guidelines have been available since December 2013. Consider adding a reason why JNC VII was preferred as reference for this study instead of the recent JNC VIII guidelines.

Results/Findings:

*Line 157, 162, 163 and 165; Consider revising, "... ever...". Are you trying to state "never"?

Discussion:

*Line 241; Consider revising, "...ever..."

*Line 243, Suggest, ".This rate of hypertension was...." and Line 244 to 245, "...with previously diagnosed hypertension."

*Line 296, Optimal BP control may differ based on individual patient condition and BP goal. Consider adding more information to clarify this assertion from the referenced literature.

Thank you for the opportunity to review this manuscript.

Reviewer #2: This paper is a significant contribution to the under-studied field of hypertension (HTN) control in Ghana. Although I recommend some significant revisions for clarity and context, I think it is an important analysis that merits publication. My comments by section follow below.

Introduction

There are a few typos and style issues to address - for instance the word "indicates" in line 53, and the use of "Africa" in line 55 when I presume "sub-Saharan Africa" would be more accurate. More broadly, however - the section could incorporate some additional context (space permitting) to make the paper's contribution clearer and stronger. For instance, the section makes reference to the Community Based Health Planning and Services (CHPS) program without citing or explaining it - consider detailing how this program works via, say, Phillips 2006 or other references. Similarly, the paper does not reference recent efforts to incorporate HTN care into CHPS, such as per Ogedegbe, 2018 and the TASSH study, or Haykin, 2020. There is also some limited data on HTN in Ghana in rural areas worth noting (e.g. Gomez-Olive, 2017). Detailing further what we currently know about attempts to measure and address the rural HTN burden in Ghana would make it easier for the reader to see why this new paper is noteworthy. (mandatory)

Methods

The study area section might benefit from a map, so persons unfamiliar with Ghana's geography can appreciate where the site is. Further explaining the features of the LLIN dataset would also help orient the reader, as would some more details on exactly how the current work builds on the Rural Community Risk of Non-Communicable Disease Study. (mandatory)

It is laudable that the study ensured that blood pressure was measured only after 3-5 minutes' rest, in a seated position, and documented this fact. Ideally, BP should be measured at arm's level, and the subject told not to eat or hold their urine prior to the BP check. Was this done? (mandatory)

The definitions of HTN use JNC 7 criteria rather than the 2017 ACC/AHA criteria. If possible, I would prefer the analysis be done using these cutoffs (if only as a sensitivity analysis), as they better reflect an updated understanding of the risk of elevated BP between 120 and 139 mm Hg systolic.  (optional)

Results

These are generally clear and straightforward, with a few typos (e.g., divorce vs divorced in table 1, and "having been" diagnosed with HTN in lines 163-164). I would suggest however rewording the paragraph in lines 162-171 for readability - I found it hard to follow what relative fraction of patients were using orthodox versus herbal medications versus both, as a proportion of all persons on treatment. These results are shown in table 2 but remain a bit confusing to me: for instance, how the bottom 3 rows (adding up to 73 persons) overlap with those treated in the last 2 weeks (63 persons) - were the other 10 persons off medicine for the last two weeks? I'd suggest making clearer the denominators (e.g., the 73 persons on treatment) relative to the numerators and percentages (e.g., 10, 46, and 17 persons on herbal versus orthodox versus both treatments).  (optional)

I'd also be keen to see if age, education level, and occupation (if not marital status) corresponds with tendency to take herbal versus non-herbal (orthodox) medication - the results are displayed only as a function of gender. Can this analysis also be added?  (optional)

Lastly - the finding that >35 and >39 are important age thresholds for HTN in men and women respectively is notable. However I was unable to follow the discriminating power calculation, and this does not seem to be discussed in the methods section. Can you kindly clarify?  (please clarify)

Discussion

This section is generally well-written, though I would be interested to hear more about the findings regarding herbal medication use (especially if we have more data as above on predictors of same). Are there other findings on this question besides Liwa and Smart's papers (references 36-38 - one is listed twice?) How much do these findings focus on Ghana and/or rural areas in particular? (optional)

I would be happy to review a revised version.

**********

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: No

Reviewer #2: Yes: David J. Heller MD MPH

[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.

Community Burden of Hypertension and Treatment Patterns: An In-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - (Nyive Phase I)

PONE-D-20-24599R1

Dear Dr. Osei-Yeboah,

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,

Sonak D. Pastakia

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

This version is considerable improvement from the last version. I would correct a couple of the editorial typos mentioned by the reviewers prior to publication.

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: (No Response)

Reviewer #2: (No Response)

**********

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: Thanks again for the opportunity to review this manuscript and for considering reviewers suggestions.

Overall, great improvement in clarity, detail and cohesiveness. I recognize the attempt to connect the findings in this study to previous study, however, Doumas et al., 2013 does not seem to fit the statement made (page 24, line 334-337). The need for cardio-protection for premenopausal women on certain therapies may be beneficial but the point on how that can help explain early on-set of hypertension in men is not clear? Please clarify or elaborate so that readers understand how the statement supports the claim.

Reviewer #2: I am satisfied by the thoughtful revisions provided by the authors. These include adding key context to the introduction section; a helpful map of the target area; and clarifying how blood pressure was checked.

I am fine with using the JNC-7 guidelines given these are still used by the Ghana Health Service. I also found the clarifications helpful (in the table and the text) regarding orthodox versus herbal medication.

I propose the paper be accepted essentially as-is, but I propose some minor edits beforehand:

1. Ideally please add a reference in/around line 152 indicating that JNC7 remains the hypertension guideline of choice for the Ghana Health Service;

2. Please indicate in line 205 that the numbers for the three categories of medications used (orthodox, herbal, or both) add up to 53.28% (the total who are on medication)

3. Please proof the paper once more for typos that spell check might have missed (e.g., thumb instead of tomb, line 188).

4. Lastly, forgive any methodological ignorance on my part, but I don’t quite understand what is meant (at a practical level) by the critical at risk age of 35 for men and 29 for women. Can the authors add a line explaining expressly what this means for the clinician?

I have no further comments and thank the reviewers for their edits.

**********

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: Akua A. Appiah-Num, PharmD, MS

Reviewer #2: No