A national audit of facilities, human and material resources for the comprehensive management of diabetes in Ghana-A 2023 update

Ernest Yorke; Josephine Akpalu; Gwendolyn de-Graft Johnson; Yacoba Atiase; Margaret Reynolds; Ruth Laryea; John Tetteh; Alfred E. Yawson; Albert G. B. Amoah

doi:10.1371/journal.pone.0303624

Peer Review History

Original SubmissionOctober 11, 2023
24 Oct 2023 Decision Letter - Sandra Boatemaa Kushitor, Editor PONE-D-23-31002A national audit of facilities, human and material resources for the comprehensive management of diabetes in Ghana-A 2023 updatePLOS ONE Dear Dr. Yorke, 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. The authors should strengthen the background, methods and discussion of the findings. I have made extensive comments in the attached pdf. Please submit your revised manuscript by Dec 08 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. 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We will update your Data Availability statement to reflect the information you provide in your cover letter. Additional Editor Comments: Dear Author, Thank you very much for submitting this important work to PLOS One. In my review of the submission, I noticed that the manuscript does not speak to the global burden of diabetes prevalence and care. The methods of the manuscript need to be strengthened. You must add a section on study variables and explain with references why the variables you assessed were selected. Kindly revise the submission so that I will invite reviewers for the peer review process to begin. [Note: HTML markup is below. Please do not edit.] [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. Attachments Attachment Submitted filename: PONE-D-23-31002_Editor.pdf https://doi.org/10.1371/journal.pone.0303624.r001
Revision 1
26 Nov 2023 Author Response Responses to Reviewers 1. Comment: The authors must add a section on the prevalence of T2D in Ghana. This suggestion has been effected. The new sentences now read as: Global prevalence of diabetes among adults aged 20-79 years in 2021 was estimated by the International Diabetes Federation (IDF) to be 537 million, which is predicted to rise to 783 million by 2045, with the largest increases expected in sub-Saharan African countries [1]. Estimated figures by IDF for Ghana were 329,200 in 2021, representing about 2% of the adult population [1]. However, community-based studies suggest a much higher prevalence than stated [2]. The rising incidence and prevalence of especially type 2 diabetes are due to sedentary lifestyles, obesity, and poor dietary habits [3]. This would bring with it both microvascular (neuropathy, retinopathy and nephropathy) and macrovascular (stroke, myocardial infarction and peripheral vascular disease) complications [1, 3]. The expected increases in diabetes-related morbidity and mortality require corresponding improvements in human and material resources. [page 3] 2. Comment:Provide reference for the statement “The incidence and prevalence of especially type 2 diabetes are increasing due to sedentary lifestyles, obesity, and poor dietary habits This suggestion has been effected. The new sentences now read as: The rising incidence and prevalence of especially type 2 diabetes are due to sedentary lifestyles, obesity, and poor dietary habits [3]. [page 3] 3. Comment:Kindly situate this work within a global conversation on diabetes burden This suggestion has been effected. The new sentences now read as: Global prevalence of diabetes among adults aged 20-79 years in 2021 was estimated by the International Diabetes Federation (IDF) to be 537 million, which is predicted to rise to 783 million by 2045, with the largest increases expected in sub-Saharan African countries [1]. Estimated figures by IDF for Ghana were 329,200 in 2021, representing about 2% of the adult population [1]. However, community-based studies suggest a much higher prevalence than stated [2]. The rising incidence and prevalence of especially type 2 diabetes are due to sedentary lifestyles, obesity, and poor dietary habits [3]. This would bring with it both microvascular (neuropathy, retinopathy and nephropathy) and macrovascular (stroke, myocardial infarction and peripheral vascular disease) complications [1, 3]. The expected increases in diabetes-related morbidity and mortality require corresponding improvements in human and material resources. [page3] 4. Comment: include refs https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194677 The suggested reference has been added as reference no. 6 [page3] Comment: Even community interventions are also low: https://pubmed.ncbi.nlm.nih.gov/36398761/ The suggested reference has been added as reference no. 7 [page 4] 5. Comment:The rationale is very weak; to pick from one study conducted in the 1990s. Please read these: https://journals.sagepub.com/doi/10.1177/13558196221111708#:~:text=Diabetes%20clinics%20for%20outpatients%20are,health%20insurance%20scheme%2C%20the%20NHIS. These reference and inferences have been incorporated as part of the rationale under the introduction as references 10 [page 4] 6 Comment: Take note of this reference: https://www.medrxiv.org/content/10.1101/2023.04.19.23288806v1.full The suggested reference and inference have been added as reference no. 12 [page 5] 7. Comment: Is T2D treatment approach not provided in the standard treatment guidelines 2017. Whilst it is true that some aspects of the Standard Treatment Guidelines, it is not comprehensive enough. The amended sentence now reads: “Whilst Standard Treatment Guidelines for Ghana has portions on the management of diabetes, it is not comprehensive and is also restricted for use at the primary and secondary levels. A truly national and comprehensive guidelines for the management of diabetes dedicated to all levels of care was unavailable at the time of this survey.” [page 5] 8. Comment: Add the last 2 paragraphs of the ‘Introduction’ This suggestion has been effected to now read: “An assessment of the current state of diabetes care was urgently needed to identify the gaps and possible solutions for improvement. A system which is robust in terms of personnel, physical facilities, diabetes care equipment, adequate and affordable medicines and laboratory services, financing and governmental support is needed to address current and future challenges. This study or needs assessment sought to update the human and material resources as well as identify the gaps and unmet needs for comprehensive diabetes care in Ghana since the last update some 25 years ago.” [page 5] 9. Comment: Were the team trained. please include how long and the content of the training Yes, the team was trained. The now included statement reads: “They were trained over 3-day period in community/facility entry protocols, selection of responsible respondents, questionnaire administration, data capture and entry.” [Page 6] 10. Comment: add the questionnaire as a supplementary file This has been added as a supporting file 11. Comment:Add a space: The suggestion on line 202 has been effected in the sentence: “Only 85 (69.7%) out of the 122 surveyed facilities had a dedicated centre…….” [page 8] 12 Comment: in your methods include a section on study variables. Write about the kinds of professionals needed for diabetes and provide refs. and indicate that you asked about these in your study A subsection on study variables now reads: “Study variables: Information obtained centered on their current state of diabetes care in terms of facilities and resources as well as existing gaps in managing diabetes. Specific areas assessed included personnel, multidisciplinary teams (trained diabetes doctors/specialists, diabetes educators and nurses, ophthalmic nurses, psychologists, ophthalmologists, foot care specialists/podiatrists dieticians and foot or vascular surgeons) [16], access to medications, access to laboratory services, financing, screening services, management of diabetes complications, and availability/use of diabetes guidelines or protocols as well as support groups.”[pages 6,7] 13. Comment: please introduce all these variables in the methods section This has been effected in comment no. 12 above [pages 6,7] 14 Comment: A cross tabulation between these variables and the type of facility will be appropriate This suggestion has been effected in tables 2,3 and 4 [Pages 9,10,13] 15. Comment: be consistent with spacing (results) This suggested has been complied with throughout the results section 16. Comment: use upper case Please design your tables well. and professionally using excel. The tables have been redesigned . They are clearer in the clean document 17. Comment: why dont the facilities have the required eduipment. the authors should reflect on this question and revise their discussion accordingly These possible reasons have been carefully adduced in the discussion section [pages 14-17] Comment: The authors repeat most of the results in the discussion, the focus should be on the why This section has been incorporated in the discussion section [Pages 14-17] 18 Comment: add the study limitations add the section on the implication of the findings 2 subsections, study limitations and implications of study findings have now been added. Another sentence has also been added to the conclusion [page 18] Attachments Attachment Submitted filename: Responses to Reviewers.docx https://doi.org/10.1371/journal.pone.0303624.r002
3 Apr 2024 Decision Letter - Sandra Boatemaa Kushitor, Editor PONE-D-23-31002R1A national audit of facilities, human and material resources for the comprehensive management of diabetes in Ghana-A 2023 updatePLOS ONE Dear Dr. Yorke, 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. In particular, edit the discussion so that it is not a repetition of the results. Let the section focus on the reasons (why) that explain your findings. Please submit your revised manuscript by May 18 2024 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, Sandra Boatemaa Kushitor, Ph.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. Additional Editor Comments: Dear Dr Yorke, Well done revising this manuscript. Kindly address the minor comments raised by the reviewers and me in the manuscript. Most importantly, strengthen the discussion and delete the repetition of the results in that section. Dedicate the discussion to explaining the results. Kind regards, [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. 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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 ****** 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 ****** 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: This study or needs assessment, aimed at updating the human and material resources, identifying the gaps and unmet needs for comprehensive diabetes care in Ghana is well written. However, there are few questions I have for the authors to answers and comments they have to consider 1. Kindly explained train diabetes doctors, are they diabetologist or medical doctors that have been trained to treat patients with diabetes? How many diabetologist do you have in Ghana? 2. Diabetes educators, what qualifications do they have? (Well trained educators or health care workers trained to educate patients with diabetes) 3. Few typographical errors? Authors should kindly read through the manuscript to correct all grammatical and typographical errors 4. Does the national treatment guideline give comprehensive approach in treating diabetes? What is the target health care workers to use national treatment guideline? ****** 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: 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. Attachments Attachment Submitted filename: PLOS ONE.docx Attachment Submitted filename: Manuscript.docx https://doi.org/10.1371/journal.pone.0303624.r003
Revision 2
11 Apr 2024 Author Response Responses to Reviewers 1. Comment: The discussion repeats a lot of the findings presented in the results. Kindly edit. Present a one paragraph on key findings without stats(if possible) and dedicate the majority of the discussion to explaining the results Response: Thanks for the suggestion. This suggestion has been effected. References to the detailed results have been edited out or reduced dramatically in the discussion. These have been done as tack changes. (pages 15-18) 2. Comment: Kindly explained train diabetes doctors, are they diabetologist or medical doctors that have been trained to treat patients with diabetes? How many diabetologist do you have in Ghana? Response: Thanks for the comment. Trained diabetes doctors are doctors who have basic medical qualification and have acquired additional training in diabetes care such as short courses and certificates. They are lumped with diabetologists in this study, who are doctors and have acquired additional specialist qualification in diabetes care or endocrinology. Such diabetologists may be internal medicine physicians, endocrinologist, or family physicians. The number of diabetologists including endocrinologists are approximately 20. Trained diabetes doctors/diabetologists provide specialised diabetes care to patients. 3. Comment: Diabetes educators, what qualifications do they have? (Well trained educators or health care workers trained to educate patients with diabetes) Response: Thanks for the comment. The term ‘diabetes educators’ as used in this study loosely refers to health care workers who are certified diabetes educators or have received some form of training to provide diabetes education (without certification). This was done considering the limited number of certified diabetes educators in Ghana. 4. Comment: Few typographical errors? Authors should kindly read through the manuscript to correct all grammatical and typographical errors Response: Thanks for the comment. Grammatical and typographical errors have been corrected throughout the manuscript and highlighted a track changes. 5. Comment: Does the national treatment guideline give comprehensive approach in treating diabetes? What is the target health care workers to use national treatment guideline? Response: Thanks for the comment. The Standard Treatment Guidelines (STGs) does not give comprehensive approach in treating diabetes. It covers treatment approaches for a wide range of diseases. Although, the ministry of health suggests that the STGs could be used at all levels of care, in practice, it is used mostly at the primary and secondary levels of care (health centres, district, and regional hospitals). This has been highlighted in the discussion section on page 17. Tertiary level practitioners will mostly rely on other guidelines from bodies such as the American Diabetes Association. (page 17-18) 6. Comment : Can you add one possible recommendation at facility level (Abstract conculsion) Response: Thanks for the comment. The new conclusion of the Abstract reads: “An urgent multisectoral collaboration, including prioritisation of resources at the facility level, to promote and achieve acceptable comprehensive diabetes care is required.” Page 3 7. Comment: Please indicate that diabetes is structured to start at the health centers. CHPS have not been designed to treat NCDs according to their protocols Response:Thanks for the comment. The suggestion has been incorporated. The new sentence reads: “Notwithstanding that CHPS compounds are not designated to treat diabetes, many of the other facilities do not have specialised centres for diabetes care. Most diabetes patients are therefore treated as part of the general clinic and hospital care.” Page 4 Attachments Attachment Submitted filename: Responses to Reviewers.docx https://doi.org/10.1371/journal.pone.0303624.r004
30 Apr 2024 Decision Letter - Sandra Boatemaa Kushitor, Editor A national audit of facilities, human and material resources for the comprehensive management of diabetes in Ghana-A 2023 update PONE-D-23-31002R2 Dear Dr. Yorke, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Sandra Boatemaa Kushitor, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0303624.r005
Formally Accepted
7 May 2024 Acceptance Letter - Sandra Boatemaa Kushitor, Editor PONE-D-23-31002R2 PLOS ONE Dear Dr. Yorke, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Sandra Boatemaa Kushitor Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0303624.r006

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