Essential medicines and technology for hypertension in primary healthcare facilities in Ebonyi State, Nigeria

Azuka Stephen Adeke; Chukwuma David Umeokonkwo; Muhammad Shakir Balogun; Augustine Nonso Odili

doi:10.1371/journal.pone.0263394

Peer Review History

Original SubmissionJune 13, 2021
18 Nov 2021 Decision Letter - Susan Horton, Editor PONE-D-21-19423Essential medicines and technology for hypertension in primary healthcare facilities in Ebonyi State, NigeriaPLOS ONE Dear Dr. Adeke, 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 take into consideration the constructive comments from both referees. Please submit your revised manuscript by Jan 02 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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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: No ****** 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: This is a relatively simple, but important and well written, paper detailing the state of primary care in a state of Nigeria with respect to availability of equipment and medication. The results are grave indeed and should be considered unacceptable in contemporary times. I think it is of interest to readers and illustrates the tremendous gaps still present in economically developing nations. I was pleased to see that funding is being directed towards alleviating the problem. Can the authors comment further on the potential for technology to assist with improvement in control and supply/distribution? Is it feasible to bring medications to patients via a mobile unit? Do patients own smartphones, like they do in many lower income areas of the world? Can BP monitoring and coaching be done via a simple digital health platform such that best practice can be automated, helping community health workers to deliver care (because the physician/nurse shortage is not easily solved). Reviewer #2: Thank you - I enjoyed reading this paper which I believe is important given the growing rates of hypertension and CVD across Africa - now overtaking infectious diseases as the biggest killer in sub-Saharan Africa. My comments are only minor with potential references as suggestions only based on work i have published with others across Africa and Nigeria on NCDs, etc. These include: A) Introduction a) Illness can have catastrophic consequences for the income of families in Nigeria - Aregbeshola BS, Khan SM. Out-of-Pocket Payments, Catastrophic Health Expenditure and Poverty Among Households in Nigeria 2010. International journal of health policy and management. 2018;7(9):798-80 b) However a concern is that prescribing physicians do not always know the costs of the medicines they prescribe (in Fadare JO, Enwere OO, Adeoti AO, Desalu OO, Godman B. Knowledge and Attitude of Physicians Towards the Cost of Commonly Prescribed Medicines: A Case Study in Three Nigerian Healthcare Facilities. Value in health regional issues. 2020;22:68-74) and there can be concerns with the quality of generic medicines in Nigeria adding to the problem of affordability (in Fadare JO, Adeoti AO, Desalu OO, Enwere OO, Makusidi AM, Ogunleye O, et al. The prescribing of generic medicines in Nigeria: knowledge, perceptions and attitudes of physicians. Expert review of pharmacoeconomics & outcomes research. 2016;16:639-50) c) There are also concerns with the management of diabetes (with hypertension a key issue) in patients in Nigeria including usage of long-acting insulin analogues (in Godman B, Basu D, Pillay Y et al. Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future. Hospital practice. 2020;48(2):51-67; Godman B, Basu D, Pillay Y, Mwita JC et al. Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future. Frontiers in pharmacology. 2020;11(108) and Haque M, Islam S, Abubakar AR, Sani IH et al. Utilization and expenditure on long-acting insulin analogs among selected middle-income countries with high patient co-payment levels: findings and implications for the future. J Appl Pharm Sci. 2021;11(07):172–182). I mention diabetes as in table 2 you discuss lipid tests, weight/ height examinations and glucose levels. B) Methodology a) why when measuring hypertension did you include in Table 2 measures such as blood glucose levels, height and weight measurements as well as lipid levels - need an explanation for this b) Focus group discussion - how was the questionnaire developed - was this based on previous literature, etc.? c) How long do patients have to wait to see a HCW in a typical PHC - I say this because waiting times can be long which leads to patients self-purchasing their medicines from pharmacies if they can d) Is any counselling given to patients during their visits regarding lifestyle changes/ adherence to medicines prescribed, etc.? C) Discussion a) I would not include Brazil as they do have universal health care - so studies undertaken to assess availability to seek to ensure this. Interestingly updates on ref 15 include (if interested): Garcia MM, Barbosa MM et al. Indicator of access to medicines in relation to the multiple dimensions of access. Journal of comparative effectiveness research. 2019;8:1027-41; Barbosa MM, Moreira TA et al. Access to medicines in the Brazilian Unified Health System's primary health care: assessment of a public policy. Journal of comparative effectiveness research. 2021;10:869-79 and Barbosa MM, Nascimento RC et al. Strategies to improve the availability of medicines in primary health care in Brazil: findings and implications. Journal of comparative effectiveness research. 2021;10:243-53 b) ref 16 is old - there have been more recent studies including e.g. Babar Z, Ramzan S et al. The Availability, Pricing, and Affordability of Essential Diabetes Medicines in 17 Low-, Middle-, and High-Income Countries. Frontiers in pharmacology. 2019;10(1375); Mukundiyukuri JP, Irakiza JJ, Nyirahabimana N et al. Availability, Costs and Stock-Outs of Essential NCD Drugs in Three Rural Rwandan Districts. Ann Glob Health. 2020;86:123 and Chow CK, Ramasundarahettige C, Hu W, AlHabib KF, Avezum A, Jr., Cheng X, et al. Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study. The lancet Diabetes & endocrinology. 2018;6(10):798-808 to name just a few c) Similar comments to above - why mention diabetes when the paper is about hypertension - suggest broadening the title to talk about NCDs with a special emphasis on hypertension d) i would like to see comments on the ways forward to achieve the goals in the recent Nigerian Plan for NCDs and how these results can be used to provide guidance to the authorities, etc. ****** 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: Raj Padwal, University of Alberta, Edmonton, Canada Reviewer #2: Yes:** Brian Godman [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. 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Revision 1
16 Jan 2022 Author Response Academic editor 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 Thank you for your comments. The journal’s style requirements have been checked and adjusted made on the manuscript. We note that Figure 1 in your submission contain [map/satellite] images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/ plosone/s/ licenses-and-copyright. We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:….. Thank you for the information. We have removed the figure from the manuscript. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. We have reviewed the reference list and corrected noted errors while adding new references as suggested by Reviewer #2. Reviewer #1 This is a relatively simple, but important and well written, paper detailing the state of primary care in a state of Nigeria with respect to availability of equipment and medication. The results are grave indeed and should be considered unacceptable in contemporary times. I think it is of interest to readers and illustrates the tremendous gaps still present in economically developing nations. Thank you for your comments. I was pleased to see that funding is being directed towards alleviating the problem. Can the authors comment further on the potential for technology to assist with improvement in control and supply/distribution? Is it feasible to bring medications to patients via a mobile unit? Do patients own smartphones, like they do in many lower income areas of the world? Can BP monitoring and coaching be done via a simple digital health platform such that best practice can be automated, helping community health workers to deliver care (because the physician/nurse shortage is not easily solved). Thank you for the vital questions/suggestions raised. We are convinced of the potential role of technology to improve control of hypertension. These comments have been addressed in the discussion section and reads as…..“Also, technology may be used to improve hypertension control at primary healthcare level through channels like tele-monitoring where medical doctors can guide CHEWs on management of hypertension. A pilot study based on a pharmacy-based hypertension care model was conducted in Lagos with the use of mHealth to increase access and quality of hypertension care through task-shifting from medical doctors to pharmacists [23]. The study was shown to be a feasible care model which improved patient accessibility, attention, adherence, information provision, and BP control with the assistance of cardiologists to safeguard the quality of care provided by the pharmacists. Still in relation to technology for hypertension control, text messaging may be used to remind patients of their clinic visits and drug pick-ups, in settings where there is availability of anti-hypertensive medications.” Reviewer #2 Thank you - I enjoyed reading this paper which I believe is important given the growing rates of hypertension and CVD across Africa - now overtaking infectious diseases as the biggest killer in sub-Saharan Africa. My comments are only minor with potential references as suggestions only based on work i have published with others across Africa and Nigeria on NCDs, etc. Thank you for your comments and suggestions. The suggestions have been incorporated to further enrich the work. Introduction Illness can have catastrophic consequences for the income of families in Nigeria - Aregbeshola BS, Khan SM. Out-of-Pocket Payments, Catastrophic Health Expenditure and Poverty Among Households in Nigeria 2010. International journal of health policy and management. 2018;7(9):798-80 Thank you again for this suggested citation. The authors have read through the work however, it is our considered opinion that work is not within the scope of our study. However a concern is that prescribing physicians do not always know the costs of the medicines they prescribe (in Fadare JO, Enwere OO, Adeoti AO, Desalu OO, Godman B. Knowledge and Attitude of Physicians Towards the Cost of Commonly Prescribed Medicines: A Case Study in Three Nigerian Healthcare Facilities. Value in health regional issues. 2020;22:68-74) and there can be concerns with the quality of generic medicines in Nigeria adding to the problem of affordability (in Fadare JO, Adeoti AO, Desalu OO, Enwere OO, Makusidi AM, Ogunleye O, et al. The prescribing of generic medicines in Nigeria: knowledge, perceptions and attitudes of physicians. Expert review of pharmacoeconomics & outcomes research. 2016;16:639-50) The authors note that these are very important references in the Nigerian context. However, we do not want to expand the introduction with information on cost and quality of medicines. There are also concerns with the management of diabetes (with hypertension a key issue) in patients in Nigeria including usage of long-acting insulin analogues (in Godman B, Basu D, Pillay Y et al. Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future. Hospital practice. 2020;48(2):51-67; Godman B, Basu D, Pillay Y, Mwita JC et al. Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future. Frontiers in pharmacology. 2020;11(108) and Haque M, Islam S, Abubakar AR, Sani IH et al. Utilization and expenditure on long-acting insulin analogs among selected middle-income countries with high patient co-payment levels: findings and implications for the future. J Appl Pharm Sci. 2021;11(07):172–182). I mention diabetes as in table 2 you discuss lipid tests, weight/ height examinations and glucose levels. The authors appreciate the references suggested on diabetes. However, we kindly prefer to focus on hypertension for the introduction. Methodology why when measuring hypertension did you include in Table 2 measures such as blood glucose levels, height and weight measurements as well as lipid levels - need an explanation for this We assessed availability of other testing tools due to their importance as screening tools for other NCDs. The following statement has been added to the “data management” subsection of the methodology as explanation: “Availability of test kit for urinalysis, lipid profile testing, glucometer, weighing scale, and measuring tapes was assessed due to their importance as screening tools for other common NCDs and their risk factors.” Focus group discussion - how was the questionnaire developed - was this based on previous literature, etc.? The guide used for focus group discussion was developed by authors from their work experience. How long do patients have to wait to see a HCW in a typical PHC - I say this because waiting times can be long which leads to patients self-purchasing their medicines from pharmacies if they can PHCs in the study area do not usually have many patients so the clients do not experience long waiting time to see a HCW except on special days for vaccination and antenatal care. Long waiting time in the study area is commonly experience in secondary and tertiary hospitals. Is any counselling given to patients during their visits regarding lifestyle changes/ adherence to medicines prescribed, etc.? Counselling is given to patients. However, there may be need for more training on counselling for CHEWs to improve their delivery. Discussion I would not include Brazil as they do have universal health care - so studies undertaken to assess availability to seek to ensure this. Interestingly updates on ref 15 include (if interested): Garcia MM, Barbosa MM et al. Indicator of access to medicines in relation to the multiple dimensions of access. Journal of comparative effectiveness research. 2019;8:1027-41; Barbosa MM, Moreira TA et al. Access to medicines in the Brazilian Unified Health System's primary health care: assessment of a public policy. Journal of comparative effectiveness research. 2021;10:869-79 and Barbosa MM, Nascimento RC et al. Strategies to improve the availability of medicines in primary health care in Brazil: findings and implications. Journal of comparative effectiveness research. 2021;10:243-53 Thank you for the wonderful references suggested. Ref 15 from Brazil has been removed since they now offer universal healthcare. We also decided not to discuss about Brazil, and hence did not use any of the suggested references. ref 16 is old - there have been more recent studies including e.g. Babar Z, Ramzan S et al. The Availability, Pricing, and Affordability of Essential Diabetes Medicines in 17 Low-, Middle-, and High-Income Countries. Frontiers in pharmacology. 2019;10(1375); Mukundiyukuri JP, Irakiza JJ, Nyirahabimana N et al. Availability, Costs and Stock-Outs of Essential NCD Drugs in Three Rural Rwandan Districts. Ann Glob Health. 2020;86:123 and Chow CK, Ramasundarahettige C, Hu W, AlHabib KF, Avezum A, Jr., Cheng X, et al. Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study. The lancet Diabetes & endocrinology. 2018;6(10):798-808 to name just a few Ref 16 has been removed and replaced in the discussion section. The replacement now reads as “An assessment of availability of essential NCD drugs in primary healthcare facilities in some Rwandan districts noted low availability of essential medicines for cardiovascular diseases management [13].” Similar comments to above - why mention diabetes when the paper is about hypertension - suggest broadening the title to talk about NCDs with a special emphasis on hypertension Thank you for your observation. Although the paper is about hypertension, diabetes is a common and related disease that may increase the risk of hypertension. We therefore assessed its technology as a possible screening tool in the primary healthcare facilities. i would like to see comments on the ways forward to achieve the goals in the recent Nigerian Plan for NCDs and how these results can be used to provide guidance to the authorities, etc. Some key priority actions and activities from the Nigerian Plan for NCDs have been added under the discussion section. Attachments Attachment Submitted filename: Response to Reviewers..docx https://doi.org/10.1371/journal.pone.0263394.r002
19 Jan 2022 Decision Letter - Susan Horton, Editor Essential medicines and technology for hypertension in primary healthcare facilities in Ebonyi State, Nigeria PONE-D-21-19423R1 Dear Dr. Adeke, 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, Susan Horton Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0263394.r003
Formally Accepted
25 Jan 2022 Acceptance Letter - Susan Horton, Editor PONE-D-21-19423R1 Essential medicines and technology for hypertension in primary healthcare facilities in Ebonyi State, Nigeria Dear Dr. Adeke: 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. Susan Horton Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0263394.r004

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