PONE-D-24-18421Hypertension and Medication Adherence: An Institution-based Study at Hypertension and Research Center, RangpurPLOS ONE

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

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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?

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Reviewer #1: No

Reviewer #2: No

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Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Title: Hypertension and Medication Adherence: An Institution-based Study at Hypertension and Research Centre, Rangpur

The authors came with a good research area that investigates the prevalence of medication adherence and associated factors among patients with hypertension who received follow-up care at the Hypertension and Research Centre in Rangpur, Bangladesh.

However, despite it has a potential, the manuscript is not sufficient for publication in its current form and it needs a careful revision.

Minor comments

- The word/phrase “hypertension/hypertensive patients” is not a good usage of language because it focuses on labelling of patients. Despite you may find it in a lot of literature, but it has a negative and discriminative sense of language and not advised to use. “Patients with hypertension” is generally preferred in scientific writing. It focuses on the condition rather than labelling the patient. Please you need to change it in all sections of the manuscript.

- The MMAS-8 likely requires permission to use, right? "Have you obtained permission to use the MMAS-8 in your study? It's important to ensure you have the necessary permissions before publishing your findings. The authors need to ensure this. Other ways you are making yourselves and others busy with nothing.

- The journal requires a manuscript fully available without restriction, but you put restriction to your data availability. Please refer the Data availability policy of the journal.

Major comments

Title

#1.... The title as it stands is ambiguous, and it needs to be clarify with your interest to investigate. Determining the prevalence of medication adherence and its associated factors in patients with hypertension is the aim of the study you are going to investigate, right? So, please could you make it clear in this context?

Abstract

#1… Is Pearson’s chi-square test used to explore factors associated with medication adherence?

#2… bivariate and multivariable logistic regression analyses: is it bivariable or bivariate?

#3…It would be good if you could include statistical analysis software and your declarations used for this particular study.

#4…Result or results

#5… “Duration of hypertension diagnosis (AOR: 0.32; 95% CI: 0.11-0.95 for hypertension diagnosed <10 years back and AOR: 0.28; 95% CI: 0.09-0.84 for >10 years)”

I didn’t find the point on these results, or if there is something not clearly presented, please could you clarify it? You mentioned both < 10 and > 10 years duration of hypertension diagnosis as a factor for medication adherence. What is the counterpart reference here? I mean, patients living < 10 and >10 years with hypertension had poor/good medication adherence than what?

#6… Better to use “AOR =” instead of “AOR:”

#7…Your conclusion is not aligned with your main outcome variable. Your main outcome variable is prevalence of medication adherence, right? If so, your conclusion should inform readers what does the outcome implies. These things mentioned here might be used for your justification and recommendation about the outcome.

Introduction

#1… organized and written well, but some evidences are mentioned without a citation, please you need to cite and acknowledge appropriate literature for it.

#2… there is a redundancy of the word hypertension or the hypertension in the first paragraph, better to re-write without redundant it.

#3… Make sure of using updated evidence, while you are mentioning the WHO and other international organizations’ reports and evidence. For instance, the WHO published an update on 16 March 2023. https://www.who.int/news-room/fact-sheets/detail/hypertension#:~:text=Approximately%201%20in%205%20adults,33%25%20between%202010%20and%202030.

Methods

#1… “..Adult participants registered...”… What does registered means? Did they receive antihypertensive medications? If so, why we couldn’t mention them …adult participants who received antihypertensive medications?”

#2… Why you chose six months? Is there any implication or rationale? Why not three months?

#3... You said participants were included based on the inclusion criteria. You should better to clarify these inclusion criteria more than this. You need to clarify our confusion in the abstract section above here.

4#... What is 5th? You did not inform us how you did the sample size calculation, and you just wrote only “the sampling interval-K”. Please move this section including sampling technique you used after the sample size calculation because you are going to calculate k after determined the sample size.

#5…Why you would like to use a larger sample size of 325, while you found a sample size of ~292 is enough for this stud?

#6… You used a thorough literature review to organize the questionnaire for this study. You need to cite and acknowledge these literature used for developing your questionnaire.

#7. Pearson’s chi-square test here in the method section is presented appropriately unlike in the abstract.

#8… bivariate, the same as state in the abstract

#9…better to incorporate your declaration of statistical significant p-value here.

Results

#1…When I just observed the number of respondents [352] in the table 1, I was surprised to observe a 100% response rate. This is rare in many studies. I wander if you could include this with some methods used to achieve a 100% response rate. Your experience may be valuable to other researchers.

#2… Table 1 and its description: you described using texts almost all of the variables in the table 1. Please put only some texts to describe tables, other ways it looks duplication or no need of tables.

#3... The same is true for Table 2 and its description texts. I think the need of table is to present variables in short, so focus on the main variable you would like to describe using texts and leave others in the table with reference [table citation] for the readers.

#4… Again you mentioned all variable using texts to figure 1, and then you are presenting as a figure again. Please avoid the figure and present only using texts or if you want to keep both mentioned the text like this: “Forgetfulness (20.29%) followed by a busy work schedule (7.71%) were the most common cause of poor medication adherence as reported by the respondents [Figure 1]”

Table 3

#5… I found here the problem you made in the abstract that confused the readers of your manuscript.

In the variable, “how many years ago were you first diagnosed as hypertensive (in years)” you used this category: < 5 years, < 10 years, and ≥ 10 years… but you just presented < 10 and > 10 in the abstract.

This category should be re-write because it is a bit confusing. You need categorize this as follows and please clarify the abstract section in this method. <5, 5-10, and ≥ 10 years.

In addition, please be careful where to place the boundaries in your case. For instance, is 5 included in the lower or in the middle?

Better to use this variable... “How many years ago were you first diagnosed as hypertensive (in years)…concisely and clearly like... “Duration of hypertension diagnosis or Duration since diagnosed for hypertension or Duration since first diagnosed as hypertensive”

#6…Better to incorporate the outcome variable (medication adherence) with frequency of good adherence and poor adherence for all independent variables. Then every reader easily understand particularly the odds ration from respective variables.

#7... Here also you didn’t want to mention about a p-value you were going to declare a statistical significant association. Even, you didn’t inform us in the statistical analysis section of the method. So how readers know about it whether it is < 0.05 or something different …?

Discussion

#1...Just you only mentioned that the overall prevalence of good adherence is higher than poor adherence and this is in line with some studies in Bangladesh [], Ethiopia [], and Malaysia [].

I don’t think this is enough. Is the proportion of good adherence being more than 50% by itself enough to say patients with hypertension had good medication adherence level? Of course, in your study, only around 54% had good medication adherence. You need to present in detail and compare with other evidence. Because you are talking about the prevalence, I expect you need to present and interpret your finding in terms of three points: In line [you mentioned], lower and, and higher findings as compared with your finding.

In general, the discussion should be organized by presenting the summarized findings in the first paragraph. Then discuss each finding of the study in terms of possible explanations for the disparity and consistence, your possible scientific suggestions, and its implications accordingly.

Limitation

The second limitation is somewhat unclear. Does it mean they were going to or unable to respond/participate because of their fear to their future treatment? Please could you clarify it more? In addition, please your limitation should be specific to your particular study.

Conclusion

No need of much talk here, and better to move some points to your discussion section. You should conclude here about your main outcome variables and their interpretation as I mentioned in the abstract section.

Reviewer #2: Thank you for the opportunity to review “Hypertension and Medication Adherence: An Institution-based Study at Hypertension and Research Center, Rangpur”

The manuscript is of interest to the reader. I commend the authors for nice work. The manuscript reads well. But the following points need to be addressed by authors.

Introduction

The introduction needs to be succinct and focused to hypertension and medication adherence.

NCDs is used for first time in the introduction… please mention in bracket before start using acronym.

What unique contribution this study would make if there were many studies on medication adherence in hypertension patients in Bangladesh. The authors need to assert the relevance of their study in the introduction.

Method

In the method and result section. The authors used two confusing categories of duration of hypertension diagnosis. Less than 10 years and less than 5 years are not mutually exclusive. Make sure you rewrite to ensure mutual exclusivity. This should be 5-10 year and <5 years. Otherwise, authors need to justify it for readers.

Despite the authors' claim of a larger sample size in the methods section, the sample size appears to be small, as evidenced by the very wide confidence intervals. The assertion of a large sample size in the methods section needs to be revised.

The authors stated that they included every variable in the regression. Including all uncorrelated variables in this small sample can lead to overfitting of the model. However, the actual number of included variables is not quite large. The authors better reflect what they actually did. It is good to be modest with their descriptions. Otherwise, a clear description of variable selection technique and inclusion criteria to the regression model need to be described.

The authors need to ensure they have obtained permission to use the MMAS-8 tool, as Morisky et al. typically require permission or payment for its use.

Result

Distribution of Medication Adherence and Table 2. I think simply expressing as chi squared test could be enough.

Table 3 and associated result description. The Hypertension duration categories need to be mutually exclusive.

Discussion

The authors' discussion is very shallow and should be made more relevant to their setting. The discussion section and conclusion are not seamlessly connected. The discussion's claim that good adherence is higher than poor adherence should not be the focus of the study. The fact that 45.17% of the sample exhibited poor adherence is significant and needs to be thoroughly discussed.

Limitation

“Firstly, due to the cross-sectional nature of the study, we could not establish any causal association with poor medication adherence among the participants.” It is a known generic limitation of cross-sectional studies. The authors better describe limitation only relevant to their specific study and setting.

Conclusion

“In conclusion, medication adherence is a critical aspect of hypertensive patient

management. Improving adherence could significantly enhance blood pressure control and reduce the risk of cardiovascular complications.” This is irrelevant. The authors should only conclude based on their result and specific to their setting/Bangladesh.

Minor points

Spellings errors and punctuation need to be addressed throughout.

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Reviewer #1: No

Reviewer #2: No

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<p>Prevalence and Determinants of Medication Adherence among Hypertensive Patients: An Institution-Based Cross-Sectional Study

PONE-D-24-18421R1

Dear Dr. Sharif,

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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Dr Buna Bhandari

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 #2: 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: (No Response)

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

Reviewer #2: (No Response)

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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

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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 Response)

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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: (No Response)

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Reviewer #2: No

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