PONE-D-24-29698Decentralising diabetes care from tertiary hospital to primary health care units in Tigray, Ethiopia: A pilot studyPLOS ONE

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This study is funded by Mekelle University for material procurement and personal costs related to data collection and follow-up. The fund was received Dr Merhawit Atsibeha Abera from Mekelle University recurrent budget in 2019 with the reference number of ERC 1756/2020. The funder website is https://www.mu.edu.et/

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Reviewer #1: Partly

Reviewer #2: Partly

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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:  Dear Authors,

I want to commend you on the excellent work you’ve done. Your research has the potential to significantly impact diabetes mellitus (DM) care in Tigray, which is both timely and necessary. However, I have several concerns regarding the manuscript that I believe need to be addressed to strengthen your work further.

I hope these suggestions will be helpful as you revise the manuscript. I look forward to seeing the final version and am confident that, with these adjustments, your work will be even more impactful.

Thank you once again for your contributions.

Title: Diabetes service decentralize to Primary health care unit; A pilot study

Short title

Healthcare unit, not health case unit.

Abstract

Introduction

“Ethiopia has 2.57 million adults with diabetes (5.2 % of adult population) and 4.9 million adults with prediabetes. This is estimated to be the largest diabetes population in Sub-Saharan Africa. 76% do not even know that they have diabetes.” Please put references for both statements.

“Studies have shown that decentralized diabetes care has effect of diabetes morbidity and mortality and has good long term and short-term outcome. In addition, there was no significant difference in conducting necessary diabetes test, risk factors assessments and service delivery cares among referral and primary care health facilities (4-6).”

This is not clear. Which studies? Which countries or settings? Please rewrite this section.

Study setting

- It is not clear about the patients the authors moved from Ayder to Hagereselam. The authors did not explain, for example, if the patients moved from Ayder are diabetic patients who are residents of Hagereselam and its vicinity.

- Please mention Hagereselam’s elevation, demographics etc.

- Please describe the steps you followed to discuss with patients to transfer them from Ayder to Hagereselam. How many patients have you contacted to get 67 willing patients? How many patients from Hagereselam’s vicinity had follow up in Ayder? How many agreed to be moved to Hagereselam? How did you address their concerns? Unless you explain these things, we cannot know if the patients were moved voluntarily or coerced.

Results

- In the study setting you mentioned that newly diagnosed patients from Hagereselam and veteran patients from Ayder Hospital were the study population. You implied that for this purpose, healthcare professionals were trained to diagnose new diabetic patients. However, in the results section, you mentioned that only those transferred from Ayder were followed. Please clarify this.

- It is not clear how you involve patients from Ayder for comparison. You have not mentioned in your methods section about patients selected in Ayder for comparison. However, in your results section, you mentioned that you compared your 3 months lab results with randomly selected patients. This needs an explanation in your methods section. Who is this patient population you are comparing with your study population? Are you talking about the same patients you are using for pilot, or you used the same patients’ prior records? If the case is the later, it is not right as you are neglecting temporal effects.

Discussion

- You are implying that patients are satisfied. How did you assess their satisfaction levels? What model have you used to measure it?

Limitations

- Why did the authors decide to cut short/abort the study? It would have made sense to continue it to get a good picture even after the Cessation of Hostilities agreement. As they have clearly stated, the study does not show the whole picture. For example, though not very clearly stated, they mainly relied on veteran patients from Ayder to conclude. Based on this study’s findings, we cannot conclude that new patients are safe to be treated at the primary healthcare units.

Reviewer #2:  The study explores the decentralization of diabetes care in Ethiopia, which is an under-researched area in the context of sub-Saharan Africa. However, similar studies have been conducted in other low- and middle-income countries (LMICs), such as Rwanda, Malawi, and the Philippines, as cited in the manuscript. The context-specific pilot study in Tigray, Ethiopia, adds a localized perspective, addressing challenges like hospital overcrowding and accessibility in rural areas. This is a valuable contribution to Ethiopian healthcare policy discussions. There is no novelty in the study. The concept of decentralizing diabetes care is not groundbreaking, and the study primarily replicates approaches tested in other LMICs. The study would benefit from emphasizing unique findings or challenges specific to Ethiopia’s healthcare system.

The manuscript lacks an in-depth exploration of the systemic barriers and facilitators to decentralization, such as infrastructure, cultural perceptions, or financial constraints. The study does not sufficiently discuss the scalability or sustainability of its findings. For example, how would decentralization fare with larger patient cohorts or in different Ethiopian regions? Small sample size (67 patients in each group) limits the generalizability of findings.

Convenience sampling may introduce bias, as patients willing to transfer may differ systematically from those who remain in tertiary care. The study duration (one year) is not capture long-term trends or complications.

The discussion underemphasizes the challenges faced during implementation, such as resource limitations or patient adherence issues. The comparison with other studies lacks critical depth. For instance, what systemic differences make decentralization more or less effective in Ethiopia compared to other countries? The impact of training on healthcare provider performance is not evaluated quantitatively.

Furthermore, the manuscript does not address how decentralization could impact healthcare equity. For example, are rural areas with limited resources at risk of unequal care quality? The manuscript makes a useful contribution to the understanding of decentralized diabetes care in Ethiopia, but its novelty is limited by the replication of methods tested in other LMICs. The small sample size, lack of long-term data, and underexplored systemic challenges weaken the overall impact. Refining the discussion, emphasizing Ethiopia-specific insights, and addressing methodological limitations will significantly enhance the manuscript’s value.

Reviewer #3:  1. In introduction, paragraph no. 3, line no 3, it has been written as "76% do not even know that they have diabetes", it is suggested not to start the sentence with numerical value.

2. There are no references in the fourth paragraph of introduction.

3. In data collection tool: what type of questionnaire was used (structured, semi-structured...), what were the major contents of data collection tools (written but not clear)?

4. Result: (Needs to be re-written)

- "Behavioural and comorbidity characteristics section:, it is suggested to make the description and figure uniform.

- "Clinical symptoms and measurements" section: description has been provided, however, there is no table (Table no. 3 has been mentioned to refer for the result though)

- No figure for comparison related data (only description provided)

5. In consent to participate, it is suggested to replace the word 'clients' with participants. It is better if sentences would be added on anonymity, risk if any.

Confusion:

- Are the both intervention group and comparison group same?? I mean both patients group? May be I have misunderstood.

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Reviewer #1: Yes:  Hale Teka

Reviewer #2: Yes:  Junaid Ahmad

Reviewer #3: No

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Diabetes service decentralization to primary healthcare unit in Tigray, Ethiopia: A pilot study

PONE-D-24-29698R1

Dear Mr. Tesfahunegn,

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.

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Additional Editor Comments (optional):

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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 #1: 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 #1: Yes

Reviewer #3: Yes

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

Reviewer #1: 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 #1: 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 #1: Yes

Reviewer #3: 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: The authors have addressed my questions satisfactorily. I don't have any more questions.

Thank you!

Reviewer #3: (No Response)

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Reviewer #1: Yes:  Hale Teka, MD

Reviewer #3: No

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