PONE-D-24-07197Prevalence and risk factors of diabetes among adult populations of Hawassa town, Ethiopia: A community based cross-sectional study  Dear Dr. Belete,

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. could you please correct and amend the given comments as possible?

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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: Yes

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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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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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: 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: Comments to the Author

In this study, Belete et al. did the study focusing on Prevalence and risk factors of diabetes among adult populations of Hawassa town, Ethiopia: A community based cross-sectional study.

The main goal of the study was to fill the gaps in existing research on the prevalence of diabetes and its predictors. The findings of this research could improve the methods used to prevent and manage diabetes. Furthermore, the lack of data from African countries highlights the importance of the data presented by Belete et al., as it contributes valuable information to the current literature. As a result, I have several suggestions that the authors may consider to improve the quality of the manuscript.

Title page

Please! Remove the prefix: prof, from HL Sithole

It is my belief that the primary author possesses two addresses, therefore it is imperative that both are included on the title page in the following manner:

Getu Kassa Belete1, 2*, HL Sithole2

1World Health organization (WHO), Sidama, Ethiopia

2College of Health Studies at the University of South Africa (UNISA)

*Corresponding Author

E-mail: getish98@gmail.com

Abstract part

CI, AOR, DM: Please! Describe fully prior to abbreviating the words

Being illiterate: it is better, if you say “unable to read and write” than saying “illiterate”

Keywords: please! Remove the second keywords “Key words: Magnitude, diabetes, non-communicable, risk factors”

Please! Use similar writing manner when writing: medium cycle (AOR: 2.79; 95% CI: 1.02, 7.63), having ever chewed khat (AOR: 6.50; 95% CI: 4.07, 10.39)

Conclusion part: authors should focus on modifiable risk factors: such as lifestyle changing (dietary habit, declining options of overweight and obesity) and behavioural changes. Because risk factors in your study were almost modifiable risks except gender.

Introduction Part

The authors would benefit from including the diabetes trends observed in previous studies conducted in the Sidama region.

Q1) Before mentioning the objective of their study, it is crucial to emphasize the significant gaps that the authors identified in previous research, which motivated them to address these gaps in their own study.

Materials and methods

Study setting part

The study was conducted in Hawassa town, Ethiopia. Modify it to: “The study was conducted in Hawassa town, Sidama regional state, Southern Ethiopia”

Inclusion and exclusion part

Kindly provide clarification on the cases of previously diagnosed and known diabetes, as there is no information regarding them in the inclusion/exclusion section.

Sample size determination part

Q2) Why did the authors choose to rely solely on the prevalence rate when determining the sample size, given that their objective was to determine both prevalence and risk factors? Why didn't the authors attempt to determine the sample size using risk factors? It is advisable to calculate the sample size using both the prevalence rate and risk factors, and then select the larger sample size as the final sample size by comparing the sample sizes calculated using both methods.

Study variables part

Q3)Why the economic/monthly income status of the study subjects was not considered as an independent factor?

Q4) Why the study did not take into account independent factors like comorbid health conditions, hypertension, or the use of medications for comorbid health problems among the study subjects?

Definitions part

Body Mass Index (BMI): A standard cut-offs limit calculated using the formula Kg/m2 to assess

an individual’s fat.

Please! Correct it to: “Body Mass Index (BMI): A standard cut-offs limit calculated using the formula Kg/m2 to assess an individual’s fat

Data collection part

A standard glucometer (Auto-cad) used for fasting blood test following overnight fasting prior to testing.

Q5) is it auto code or auto-cad?

“The data collection period was from September, 2023 to November, 2023”.

Please! Remove this redundant sentence because once it was mentioned in the study period part.

Q6) How was the accuracy of the glucometer instrument checked at first and at regular intervals during data collection?

Q7) The management of data quality remains unclear as there is no information provided on how it was addressed?

Q8) What actions did you or your study team take for the newly diagnosed DM subjects? It is important to address this aspect as there is no information provided about these subjects in your data collection or ethical issue sections

Results part

Prevalence of diabetes

Q9) Out of the total prevalence rate of 14.4%, what is the number of newly diagnosed cases of DM and how many are cases of previously diagnosed and known DM?

Q10) what is the prevalence rate of prediabetes in your study?

*It is preferable to provide an explanation regarding the “Behavioural and biological risk factors of diabetes and tis table” prior to discussing the prevalence of diabetes.

*please! Put footnote for all abbreviated words below table (table3: COR, AOR, CI)

Discussion part

*Slightly higher than a study done in Hawassa zuria woredas (12.2%) [17]. Not slightly higher but comparable because your study confidence interval included the rate. The rreference 17 reveals the prevalence of DM in Hawasaa zuria is not 12.2% but 12.4%. Please check and correct it.

*Also, the highest prevalence of diabetes (19.7%) and (18.4%) were reported in the age category between 50-59 years and 30-39 years, respectively. Please! Use the word higher but not highest

Q11) what is possible reason for this increment? Please! Mention it.

*In this particular research, the prevalence of diabetes was higher in Males than females,

20.7% versus 10.0% respectively. The finding is higher than the study done in Korea (males,

10.7% and females, 8.4%) [19] and Ethiopia (males, 9.1% and females, 8.4%) [20].

What are your possible reasons for the variations? Please describe it. Please! Use similar discussion manner in all discussion parts.

Reviewer #2: I thank the editor for his/her invitation and the authors for their efforts to come up with this interesting scientific report. I suggest and inquire the authors to make their report more robust and readable.

“…risk factors…” in the title should be replaced by ‘associated factor’.

The authors included the population between ages 20 to 69? What were your rationale behind the inclusion this particular population.

The authors stressed description of type-2 diabetes in the introduction section. Was their study only assessed the prevalence of type-2 diabetes?

The introduction section did not show your depth of knowledge about the risk factors of diabetes, your second specific objective.

The study setting is not detail. The number of sub-cities and the estimated number of house-holds would be included.

The authors’ excluded pregnant women, physical disabilities, terminally sick and individual with mental illness. Why did you exclude all physical disabled and mentally ill individuals? It seems like discrimination. You don’t think people with physical disability and mental problems develop diabetes in their lives? Also, known diabetic women could get pregnant and still might be excluded from this study.

How did you manage when you got more than one eligible individuals (aged 20 to 69) in the selected house-holds?

Under “variables” subheading, it would better to say ‘prevalence of diabetes’

Term definitions would be cited.

“Currently tobacco smoking” this would be time bounded. What if an individual had been smoked until the last month prior to your survey?

The authors measured the BMI of the participants but they did not detail the measurement instrument and procedures as well as the instrument’s calibres. How did you manage waste disposal throughout the study period?

Authors did not mention the data quality control measures they were applied. Did you check the tool’s validity? How did you ensure whether the subjects fasted over night? At what time in the morning you tested their blood sugar? If you executed it before the subject’s breakfast, you could not test the blood sugar of that all participants within two months. This issue needs explanation.

The authors stated that they obtained a written informed consent from the study subjects. So how did they obtained the consent from 173 uneducated (they said “illiterate” that is also uncomfortable name) participants?

It would be better if table 3 was not congested. To do so, the p-values of the bivariable analysis could be omitted or included in the text narration. The NA variables in this table also would not be included. If they did not show association in the bivariable analysis why did you included them in this table?

The authors did not discuss all their findings.

The authors would state the shortcomings of their study.

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Reviewer #1: Yes:  Agete Tadewos Hirigo

Reviewer #2: No

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PONE-D-24-07197R1Prevalence and risk factors of diabetes among adult populations of Hawassa town, Ethiopia: A community based cross-sectional studyPLOS ONE

Dear Dr. Belete,

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 Feb 06 2025 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,

Mengistu Hailemariam Zenebe, PhD

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.

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

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: Manuscript Number: PONE-D-24-07197R1 "Prevalence and risk factors of diabetes among adult populations of Hawassa town, Ethiopia: A community based cross-sectional study"

Dear authors,

Thank you for your prompt response and for making significant revisions to your manuscript. I appreciate the effort you have put into improving the work so far. After reviewing the latest version, I have added a few additional comments and suggestions that I believe will further enhance the quality of the manuscript. These revisions are intended to help clarify certain aspects and make your findings more insightful for the readers. Once these changes are incorporated, I believe the manuscript will be well-suited for publication.

C1.Title: Please! Correct it to “Prevalence and associated factors of diabetes among adult populations of Hawassa town, southern Ethiopia. A community based cross-sectional study”

Abstract part

C2. Background

Therefore, the aim of this study was to investigate the magnitude and preventable risk factors of diabetes among adult populations in Hawassa town, Ethiopia

But in your included non-modifiable risks like sex please modify it to “Therefore, the aim of this study was to investigate the magnitude and risk factors of diabetes among adult populations in Hawassa town, southern Ethiopia” “Preventable risk factors” Please! Correct it to “modifiable risk factors” because modifiable risk factors" is generally the better term to use when discussing factors that can be changed or controlled to reduce the risk of disease or adverse outcomes.

C3.A community based cross-sectional study was conducted from September, 2023 to November, 2023 among adult populations” avoid redundant words “Hawassa town, Ethiopia” because the words described in the abstract introduction section.

C4. Methods If you are interested, you can use this "An interviewer-administered questionnaire was used to collect data. Additionally, participants were also instructed to fast overnight, after which the standard fasting blood sugar test was conducted. A binary logistic regression model was fitted to identify independent predictors of diabetes."

C5. Conclusion If you are comfortable, you can use this “This study identified a high prevalence of diabetes among adults in Hawassa, driven by various risk factors. This presents an opportunity to mitigate diabetes risk through public health measures, including avoiding khat chewing, promoting healthy diets, managing overweight and obesity, implementing community-based screening, enhancing health literacy, and integrating health information into daily life.”

Introduction part

C6: Also, the magnitude of khat chewing in Hossana, Ethiopia reported at 58%, of those khat chewers, 75.2% and 24.7% were men and women, respectively [19]. It would be more informative if the authors presented data on the prevalence of diabetes/prediabetes and examined the association between khat chewing and the increased prevalence of these conditions. The above statement only addresses the magnitude of khat chewing without linking it to blood sugar levels or diabetes risk. You can use the following 2 or 3 literatures from the following 3 links ".

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC7024885/pdf/dmso-13-307.pdf

2. file:///C:/Users/admin/Downloads/Prevalence_and_associated_risk_factors_of_pre-diab.pdf

3. https://www.dovepress.com/article/download/71642

C7. Introduction part last sentence: please! Modify it to “A previous study conducted in Hawassa town was facility-based and mainly focused on individuals seeking medical care. In contrast, this study was aimed to determine the prevalence of diabetes and risk factors among adults through a community-based survey in Hawassa town, southern Ethiopia”

Materials and methods part

Study setting

C8. There are also 81,523 households in the town

Study design and period

C9. You mentioned only the study design but not period and please! Correct it to “A community based cross-sectional study design was employed from September, 2023 to November, 2023 in Hawassa town, southern Ethiopia.”

Definition of terms part

C10. Pls! Correct it to “Body Mass Index (BMI): A standard cut-offs limit calculated using the formula Kg/m2 to assess an individual’s body mass and classified as underweight (<18.5kg/m²), normal weight (18.5–24.9kg/m²), overweight (25–29.9kg/m²), and obesity (≥30kg/m²). Reference: A healthy lifestyle - WHO recommendations. https://www.who.int/europe/news-room/fact-sheets/item/a-healthy-lifestyle---who-recommendations

C11. Diabetes: Pls! correct it to “It is defined as a fasting blood glucose level of ≥126 mg/dL (or ≥7.0 mmol/L), a self-reported diagnosis of diabetes, or the use of oral or injectable hypoglycemic agents."

C12. Fasting blood test: please! Correct it to “Fasting blood glucose test”

C13. Please! Minimize Ethical consideration as much as possible.

Discusion part

("Please refine the Discussion section to make it more insightful.") Use the below paragraph as a sample

C14. "The finding is consistent with previous community-based studies conducted in southern Ethiopia, such as the 14.7% prevalence in the ostracized Menja community [25] and 12.4% in the Hawassa Zuria Woreda [29]." In contrast, the finding is higher than those of previous studies conducted in other countries, such as Botswana (9.3%), Zanzibar (4.4%), and Thailand (9.9%) [21, 22, 31]."

Conclusion part:

If you are interested use this “In conclusion, this study identified a noticeable prevalence of diabetes and its association with modifiable risk factors among the adult population of Hawassa town. The evidence-based risk factors associated with diabetes highlight the need for urgent public health interventions, particularly community-level screening programs aimed at early detection and prevention.in addition, the findings emphasize the importance of addressing behavioral practices, such as khat chewing, and promoting lifestyle modifications, including dietary changes and the reduction of overweight and obesity. Regular health check-ups and follow-up care for individuals with diabetes are also crucial. Moreover, risk communication strategies for diabetes should be integrated into public health campaigns to raise awareness. Lastly, these findings could serve as a baseline for future studies focused on operational study related to diabetes management and prevention.”

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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:  Agete Tadewos Hirigo

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Prevalence and associated  factors of diabetes among adult populations of Hawassa town, southern Ethiopia: A community based cross-sectional study

PONE-D-24-07197R2

Dear Dr. Belete,

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,

Mengistu Hailemariam Zenebe, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: