PONE-D-23-38644Investigating Patient Adherence to Medications for Hypertension, Hyperlipidemia, and Diabetes: A Study on Expired Medication Recycling at Community Pharmacies Using the Chinese Version of a Two-Part Medication Nonadherence ScalePLOS ONE

Dear Dr. Lin,

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Academic Editor

PLOS ONE

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Additional Editor Comments:

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 please consider the following in addition to reviewers' comments: <ul> <li>

The introduction is too long, require summarization. There are many statements require citation

• Method is poorly described, re-write and organize it : research design, inclusion criteria  should be clearly.
• The results:  re-write the results , the you need to highlight the main findings and the table said the rest.
• Discussion too many requirements are required see the reviewers comments.

Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

For Lab, Study and Registered Report Protocols: These article types are not expected to include results but may include pilot data. 

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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: No

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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: Yes

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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: Reviewer # Comment

General comment:

The research topic is interested that addresses the main public health burden that is increasing overtime. However, the sample size is not justified and seems to be too small, so it lacks generalizability. As the authors stated in the limitation part, it is a pilot study, so the phrase “pilot study” better to be included in the title. Lack of generalizability better to be stated under limitation section. Authors are advised to check for grammatical errors and coherence issues.

Specific comments

Abstract

1. Separate what is presented in result and method sections.

2. Data analysis method used, cutoff point for interpretation in method section

3. Write main finding in result section

4. Conclusion should be based on main findings

Introduction

5. Make sure you follow the journal guideline for in text citation.

6. The introduction is too long is there any way to make it precise without losing the main ideas? Check in text citation that some statements not cited.

Method

7. Better to include background information about study setting.

8. Sample size is not justified (too small)

Discussion

9. Is subheading under discussion recommended in the journal guideline?

Reviewer #2: Title: Investigating Patient Adherence to Medications for Hypertension, Hyperlipidemia, and Diabetes: A Study on Expired Medication Recycling at Community Pharmacies Using the Chinese Version of a Two-Part Medication Nonadherence Scale

Abstract:

• Title: the title is not in line with the contents of the article. The title should be revised to reflect the objectives of the study

• ‘’This study conducted surveys among individuals collecting medications for the three highs and those returning expired medicines at a central Taiwan pharmacy chain’’: From this statement the inclusion criteria where patients who visited the community pharmacy for their medicines and those who returned expired medicines. This should be clearly stated in the method section of the manuscript.

Introduction

• Consider breaking down some lengthy sentences for better readability and understanding. For instance, the second paragraph contains several statistics and causes of death. Consider presenting this information in a more concise and structured manner.

• When introducing acronyms like TPMNS, provide a brief explanation the first time they are mentioned.

• Some information is repeated or presented in a slightly different manner. Ensure consistency and eliminate redundancy to maintain a clear and focused narrative.

• If available, include the most recent statistics and data relevant to the context of your study. This ensures that the information is current and aligns with the latest developments.

• Emphasize the significance of your study earlier in the introduction. Clearly state the gap in knowledge or the problem your research aims to address.

• Although adherence is briefly defined, consider providing a clearer and more concise definition of medication nonadherence at the beginning of the introduction.

Method

• The research design should be clearly stated. Questionnaire based approach is not a research design but rather a data collection approach. Information provided under the subheading ‘’Research design and implementation period’’ focuses more on data collection. Kindly revise this section and provide the appropriate information under this section.

• The inclusion criteria should be clearly stated.

• The section on the intervention is very misplaced in the manuscript. Why was the intervention conducted, what was the purpose of conducting the intervention. The objective of the study was to use a tool to assess adherence and then determine factors associated with adherence. So why did the authors conduct an intervention to improve the adherence level of the participants in the study. Are the results presented based on the intervention, if so, is it based on this the baseline data or the end of study data. The authors need to clarify this section.

• The methodology is poorly described. The authors should clearly describe the process of sampling, calculation of sample size, development, and validation of questionnaire, data collection and these should be in line with the objectives of the study.

• Clarify how data from the "NHI MediCloud system" were extracted and linked to individual participants. Ensure that the process of obtaining consent from participants for accessing their data is clearly outlined.

• Explain in more detail the rationale behind choosing the Medication Possession Ratio (MPR) as the indicator for medication adherence. Additionally, provide a brief explanation of VMPR and how it was calculated in this study.

• Provide more information on the specifics of data processing, especially in terms of dealing with missing or incomplete data. Describe any statistical techniques used to address confounding variables or biases.

• While Cronbach’s alpha is mentioned for assessing internal consistency reliability, provide a brief explanation of why this measure was chosen. Additionally, elaborate on the cutoff point used to categorize participants into adherence and nonadherence groups.

• Clearly outline the factors that were considered in the analysis of medication adherence. Provide a rationale for why these specific factors were chosen and discuss any potential limitations in the scope of factors considered.

• Clearly outline the methodology and rationale behind classifying participants into normal and abnormal groups for indicators related to the three highs. Discuss any limitations or considerations in using this classification approach.

• Expand on how the level of medication adherence was compared between different medications. Specify the criteria or metrics used for this comparison and discuss the implications of any observed differences.

• Validation of the C-TPMNS: If not already conducted, perform a validation study of the C-TPMNS against objective measures of medication adherence (e.g., pharmacy refill records, electronic monitoring devices) to confirm its reliability and validity in this population.

• Control for Confounding Variables: Utilize multivariable regression models to control for potential confounding variables that could affect the relationship between the identified factors and MN. This approach would strengthen the causal inferences drawn from the study.

Results

• Specify the exact cutoff points used for dichotomizing adherence scores. Clarify whether multiple cutoff points were considered and provide a rationale for the chosen threshold.

• There results section should provide a brief description of the results and the tables should be referred to. The following information should be provided in a table. ‘’Following the guidelines outlined by the Health Promotion Administration, participants were classified into normal and abnormal groups for each indicator related to the three highs, based on testing results obtained within the past 6 months. An individual was placed in the abnormal group if their HbA1c, glucose ante cibum (AC), glucose post cibum (PC), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, LDL-C, low-density lipoprotein (LDL) cholesterol, or triglyceride levels were ≥6.5% (62.5% of total participants) ≥126mg/dl (32.5%), ≥200mg/dl (33.3%), ≥140mmHg (47.1%), ≥90mmHg (10.2%), ≥160mg/dl (46.9%), ≥100mg/dl (30.6%), and ≥150mg/dl (36.7%), respectively’’

• The results section should have less writing and the information. Consider incorporating visual aids, such as tables or figures, to enhance the presentation of complex data, especially when comparing adherence rates or displaying ROC curves.

• Information provided under subheading 3.2 is too lengthy. Authors should modify this section and provide at least two subheadings.

• Table 1: percentages should be stated for the Females

Discussion

• Information provided under subheading 4.1 is not appropriate. Challenges encountered whiles recruiting participants should be placed under limitations of the study. The subheading 4.1 should be modified to reflect the information provided.

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• Provide more context or possible explanations for the odds ratios presented in relation to diseases like depression and kidney disease. Discuss the clinical significance of these findings and any potential implications for future interventions.

• Elaborate on the concept of regimen complexity and why it was considered as a potential factor influencing medication adherence. Discuss the implications of the observed trend in nonadherence odds ratios for patients taking more than five medicines.

• While Cronbach's alpha and the Area under the ROC Curve are mentioned, briefly explain the significance of these measures in assessing reliability and validity. Additionally, discuss any limitations or potential sources of bias in the validation process.

• While Table 4 mentions that the majority of participants reported rarely or never encountering situations leading to nonadherence, provide more specific information on the reported reasons for medication adherence. This could offer valuable insights into potential intervention targets.

• Expand on the discussion of the unique cultural, social, and healthcare system factors that may influence medication adherence in Taiwan. Provide specific examples or case studies that illustrate how these factors can impact patient behaviour and healthcare delivery.

• Emphasize the importance of a patient-centered approach to medication management and how it can address the specific challenges identified in the study. Discuss potential strategies for healthcare providers to tailor interventions based on patient preferences.

• Provide more details on the types of technology-based interventions that could be effective in improving medication adherence. Discuss the feasibility of implementing such interventions within the Taiwanese healthcare system

Conclusion

• Summarize the key findings of the study in the conclusion section to reinforce the main takeaways for the reader. This can help emphasize the practical implications of the research.

• Strengthen the emphasis on the collaborative role of healthcare providers, including physicians and nurses, in addition to pharmacists, in supporting patients with chronic diseases

• Provide specific recommendations or strategies that pharmacists can implement to improve medication compliance. For example, mention the importance of personalized medication management plans, regular follow-up, and effective communication with patients.

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Reviewer #1: No

Reviewer #2: Yes: Afia Frimpomaa Asare Marfo

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Investigating Medication Adherence among Taiwanese Patient with Hypertension, Hyperlipidemia, and Diabetes: A Pilot Study Using the Chinese Version of a Two-Part Medication Nonadherence Scale and the NHI MediCloud system

PONE-D-23-38644R1

Dear Dr. Ming-Hung Lin,

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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Kind regards,

Fadwa Alhalaiqa

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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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 #1: Yes

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

Reviewer #1: 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 #1: 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 #1: 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 #1: Dear author you have addressed comments raised.

However, still there are some concerns such as in text citation should be in close bracket []. In reference bibliography, if there are more than six authors, list the first six authors et al.,

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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 #1: Yes: Taklo Simeneh Yazie

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