PONE-D-22-12568Magnitude of  Chronic diabetes complication and its associated factors among adults with type 2 diabetes in Tigray region, northern EthiopiaPLOS ONE

Dear Dr. Berhe,

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.

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We look forward to receiving your revised manuscript.

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Manal S. Fawzy, Ph.D., M.D.

Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

Based on the reviewers' feedback and the editorial assessment, several concerns should be addressed by the authors.

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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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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

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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: No

Reviewer #2: No

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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 article can be made simpler for the scientific community with some modifications and clarifications as below.

Minor comments

1. Consistently use either “Tigray” or “Tigrai” in the title, author affiliation, study area, and elsewhere.

2. Change “north Ethiopia / northern Ethiopia” to “Northern Ethiopia” throughout the manuscript

3. Instead of saying "an institutional-based study," say “a multi-center cross-sectional study." since the study was conducted in ten public general hospitals.

4. It is better to say 54% rather than 54.0%, and 27% rather than 27.0%.

5. Throughout the manuscript, apply comma for numbers with more than two digits, like instead of saying 60 000–100 000 people, better to say 60,000-100,000 people.

6. Remove double full stops throughout the manuscript

7. Since it is an international journal, better to change the income status that you mentioned in Ethiopian birr (ETB) to US dollar using the exchange rate at the date of data collection.

8. I recommend you to avoid writing formulas for sample size calculations, it would be better to make it in sentence format the approach you applied for calculating the sample size than writing detailed mathematical equations.

9. Remove the Hosmer-Lemeshow goodness-of-fit test result you mentioned in the method section and put it at the result section (particularly at the multivariable regression table), At the method section you have to mention what you have did not what you found.

10. Add your response rate in the result section, as your study is a cross-sectional study

11. I appreciate writing of the findings of the measure of effect (AOR with its 95% CI), make it consistent in the result section of the manuscript (you mentioned [AOR (95% CI) = 0.48(0.26-0.90), P=0.023]), re-write it as you have rightly described in the abstract section.

12. Avoid P-value if used 95% CI instead of writing like ([AOR (95% CI) = 0.48(0.26-0.90), P=0.023]), remove the P-value and re-write it as (AOR=0.48; 95% CI 0.26,0.9), and remove the hyphen (-), rather use comma for writing the 95% CI.

13. Check the reference section, the majority of the citations are appropriate, but there are some references citrated in appropriately, check them again using software’s or manually

14. Make sure whether your questionnaire has three or four parts, there are inconsistencies in their parts mentioned in the data collection tool and measurement part.

Major comments

1. Rationale of the study: You mentioned that the previous studies had a critical methodological limitation, which hindered the scientific community to make any conclusion or judgment? How do you know whether the sample size was small, if appropriately calculated even 10 sample size can be enough? There are more than ten similar articles published elsewhere in the country, including in the region, what was the added value of your study? I would suggest you to re-write it again, considering convincible scientific argument.

2. Did you assess the risk factors? What you assessed was factors associated with chronic diabetic complications, do you think that we can interchangeably use risk factors and factors associated? Can we assess risk factors using simple, classical cross-sectional study design? I recommend you to consistently use the term factors associated, not risk factors in your manuscript.

3. Sample size calculation: It is appreciable that you have used 3% margin of error to maximize the sample size, and your response rate was 94.6%, but after adding 10% non-response rate, the final sample size should be 1,178 not 1,061.

4. Rewrite incomplete sentences, as there are many incomplete sentences, check the spelling and grammar issues, please check again the whole manuscript for spelling and grammar issues (use of present or past tense), I am not comfortable with the write-up.

Reviewer #2: PLOS ONE

PONE-D-22-12568

Research Article

Magnitude of Chronic diabetes complication and its associated factors among adults

with type 2 diabetes in Tigray region, northern Ethiopia

By: kalayou kidanu Berhe,

Mekelle University College of Health Sciences

Mekelle, Tigray ETHIOPIA

Dr Hussein Ismail, Reviewer report to PLOS one December 2022

1. There is a lot of English language errors that need to be corrected, I believe the manuscript needs a professional proofreading before publications. A lot of errors are identified as in the title Chronic (is written with capital letter and it should not).

2. Moreover, there are a lot of abbreviation errors, that need to be corrected, e.g., in the abstract Bsc nurses, OHA, …etc. The manuscript has a lot of abbreviation errors as well, e.g., IDF in the abstract.

3. Title: Magnitude of Chronic diabetes complication and its associated factors among adults

with type 2 diabetes in Tigray region, northern Ethiopia.

The authors stated that they studied 10 general hospitals out of 13 hospitals, and they did not included any referral or primary care centers. So, the selection is based on general hospitals only, there fore it should be mentioned in the title.

My suggestion for the title:

Magnitude of chronic diabetes complication and its associated factors among diabetic patients attending

the general hospitals in Tigray region, northern Ethiopia.

4. METHODS

4.1. Why did not the author include all the 13 general hospitals? I was surprised of taking 10 hospitals and leaving 3 hospitals. Please explain.

4.2. Sampling:

The methods of sampling were explained efficiently. Although, the author in included p=0.535, (p=proportion of chronic diabetes complications) please include the refence you used that stated the complications proportion as 0.535. Sampling is a step the author did before the research; I am surprised that this proportion used in the sampling was 0.535 is the same as the magnitude of diabetes complications which was the main finding of this study. Please explain.

4.3. Regarding the operational definitions, the definition of hypertension the author used was BP> 140/90, I checked the reference used and it was outdated. Reference number 30.

30. Muxfeldt ES NAdR, Salles GF, Bloch KV. Demographic and clinical characteristics of hypertensive patients in the internal medicine outpatient clinic of a university hospital in Rio de Janeiro. Sao Paulo Med J Child Adolesc Behav. 2004;122:87-93.

My suggestion: please update all the operational definitions according to the updated guidelines or manuscript. Regarding hypertension, you may use the American heart association guidelines 2017 or the European Society of cardiology (ESC) guideline 2018. I recommend the ESC because it agrees with the level of 140/90 that you chose.

Moreover, according to guidelines: No caffeine, no smoking, no eating for at least 2 h before measurement. The author stated BP was measured after30 minutes after hot drink as coffee. Please, explain and what is the refence you used?

5. RESULTS

5.1. The author stated in the results

• (….. in which 29.4%, 34.0%, 47.1% and 52.4% participants had chroic diabets complication respectively.)

• in which 42.7%, 10.0% and 13.0% had chronic diabetes complication

respectively.

• had DBP of > 90.00 mmHg in which 6.0%, 32.2% , 19.7% and 6.6%

participants had at least one chronic diabetes complication respectively.

Suggestion:

• Please specify each complication associated with these numbers.

• Please apply this notion along the whole paper.

5.2. Tables: The authors need to put all the abbreviations in the footnote related to each table. Some abbreviations are missing in the footnotes.

6. DISCUSSION

The discussion is well written.

7. CONCLUSION

It highlights the main findings and supported by the study results.

8. Reference

The authors included a lot of outdated refences. As the refences included:

• Reference 10: 1996

• Reference 22: 1965

Suggestion: updating the refences accordingly.

Regarding recent refences: Only one reference (number 35) was published 2020.

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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: Zenawi Hagos Gufue, Adigrat University, Ethiopia

Reviewer #2: Yes: Hussein M. Ismail, MD Cardiology

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PONE-D-22-12568R1Magnitude of chronic diabetes complications and its associated factors among diabetic patients attending the general hospitals in Tigray region, Northern EthiopiaPLOS ONE

Dear Dr. Berhe,

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 Jun 30 2023 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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Manal S. Fawzy, Ph.D., M.D.

Academic Editor

PLOS ONE

Journal Requirements:

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.

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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 #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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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 #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

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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 #2: Yes

Reviewer #3: Yes

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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 #2: No

Reviewer #3: Yes

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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 #2: First, the manuscript looks much better than the first version, thanks for the authors.

Although, I do not think it is ready for publication.

The most important is to revise the enligh language again, and the author should submit an offcial proofreading certifcate for the manuscript, if the Editorial Board advise on this regard, it will be very helpful. As I still see lot of English and Grammer mistakes, and the writing way is not quite professional.

1. The abstarct/conclusion:

Conclusion: In this study, the magnitude of chronic diabetes complication was higher because more than half

of the study participants had at least one complication.

I donot understand this statement, the magitude is high than...what?

Also, revise the conculsion

2. The exclusion and inclusion criteria:

The author put bothe the criteria togther, which is confusing. Please specifiy what are the inclusion criteria? and what are the eclusion criteria?

3. Diagnosis of chronic diabetes complication:

3.1. I suggest using this statment in stead of yours

Coronary artery disease (CAD): The diagnosis criteria for CAD were either a patient with typical anginal pai or equivalent

symptoms and an abnormal resting ECG or an asymptomatic patient with abnormal stress test, either by

ECG or echo or a nuclear perfusion imaging test .

3.2. Peripheral vascuar disease:

The peripheral vascular disease defintion, it is advised to limit the ABI to less than 0.9 only, and delete more than 1.3

3.3. Neuropathy

loss of sensitivity is mis nomer, replace with hyposthesia or anasthesia in lower and upper limbs

spelling: limp ---> limb.

4. Tables:

4.1. Yes column: yes is wrongly written. Plz, correct.

4.2: The abbreveiations shoud be consistent: if you use SBP for systolic blood pressure, you have to use DBP for diastolic blood pressue, plz be consistent along the whole manuscript

Reviewer #3: I thank the authors to conduct this interesting study at the local setting.

All comments have addressed. No further comment required.

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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 #2: Yes: Hussein M Ismail

Reviewer #3: Yes: Mohammed Abdu Seid

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Magnitude of chronic diabetes complications and its associated factors among diabetic patients attending the general hospitals in Tigray region, Northern Ethiopia

PONE-D-22-12568R2

Dear Dr. Berhe,

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.

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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,

Manal S. Fawzy, Ph.D., M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors have adequately addressed the concerns raised by the reviewers. Thank you

Reviewers' comments: