Undiagnosed hypertension and associated factors among older adults in Gedeo zone, southern Ethiopia: A mixed methods approach

Tsion Mulat Tebeje; Mihret Fikreyesus; Temesgen Leka Lerango; Daniel Sisay

doi:10.1371/journal.pone.0322610

Peer Review History

Original SubmissionJuly 16, 2024
16 Jul 2024 Author Response https://doi.org/10.1371/journal.pone.0322610.r001
5 Sep 2024 Decision Letter - Amanuel Yoseph, Editor PONE-D-24-27240The hidden burden of hypertension-undiagnosed hypertension and associated factors among elderly individuals in Gedeo zone: A mixed methods approachPLOS ONE Dear Dr. Tebeje, 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 Oct 20 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. 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Additional Editor Comments: I critically reviewed your article entitled “The hidden burden of hypertension-undiagnosed hypertension and associated factors among elderly individuals in Gedeo zone: A mixed methods approach” which has the potential to add to the existing body of scientific knowledge, particularly in developing countries. However, there are some limitations in your article that need addressing before publication. 1. There are several grammatical and typological errors that authors need to carefully review. 2. Authors should extensively format manuscripts based on PLOS ONE journal style, including file naming. Avoid unnecessary italicizing and capitalization throughout the manuscript. 3. Make sure that your reference contains all the necessary details and PLOS ONE style. Decision: Major revision [Note: HTML markup is below. Please do not edit.] 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 Reviewer #3: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 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 Reviewer #3: Yes ****** 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: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 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: Thank you the authors working on the so called silent killer of undiagnosed hypertension.This is a prospective study so that what was the difficulty of getting consent from each indiviadual or what does it mean for publication consent is not applicable?....exclusion criteria?,operational definition? some editting of language/expert involvement is better to be involved Reviewer #2: The study is good for the body of knowledge and abstract and introduction was written in a clear , concise and intelligible manner. • The title should be modified to be clear . what is your background to say elderly 50 years or above? there is other age classification for elderly population . Does the the district (3) selected for the study is representative for the Gedeo zone (13)? . Data management and analysis should be concise, clear and precise Eg. VIF and multicollinearity. . For qualitative study what types of analysis method used? what does it mean thematic content analysis, it vague and not clear, please specify it. it creates mislead to qualitative result interpretation. in addition the qualitative result interpretation should be consistent/matched with analysis method. . what the qualitative study result support? please put the qualitative result in appropriate place . Please check the study for grammar and plagiarized content? .Majority (63.4%) of the study participants were age between 50 to 59 years, this classified as middle age adult. does it can say elder? . what is the sample size for second objective? . undiagnosed HTN is new so it is possible to say prevalence of undiagnosed HTN? Why did you merge overweight and obesity? The degree of being obese and being overweight is different and could have different impacts. • Study period: replace the phrase “between March 19 and May 20, 2023” with “from March 19 to May 20, 2023” • Regarding measurement of the dependent variable, two measurements were taken 5 minutes apart. I don’t think 5 minutes are enough to diagnose a patient with hypertension. Whenever possible, the diagnosis should not be made on a single office visit. • Before measuring the blood pressure, have you addressed the protocols to measure blood pressure? For example, how do you assesses the participants to avoid smoking, caffeine and exercise for 30 min; empty bladder; remain seated and relaxed for 3–5 min? Nothing is written in this case as it could have impact on the result. Additionally, was the room Quiet with comfortable temperature? • Regular physical activity was defined as Moderate intensity aerobic exercise (walking, jogging, cycling, yoga, or swimming) for 30 minutes on 5–7 days per week but in your case it is “Engaging in physical activity for 20–30 minutes, three days a week, is considered regular physical exercise” Reviewer #3: Although the manuscript is good, I have several criticisms. thus you'll attempt to review and edit in light of the feedback. I made to attach all comments in PDF format. concept, data analysis, and following the rules when writing the manuscript are some of those. ****** 6. 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 Reviewer #2: No Reviewer #3: Yes: Wasihun Kindalem Work ******** [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-24-27240_reviewer.pdf Attachment Submitted filename: Comment.pdf https://doi.org/10.1371/journal.pone.0322610.r002
Revision 1
28 Oct 2024 Author Response Subject: Responses to comments Dear Editor, Thank you for taking the time to consider our manuscript titled “Undiagnosed hypertension and associated factors among older adults in Gedeo zone, southern Ethiopia: A mixed methods approach” for the Plos One Journal original research article. We appreciate the time and effort you and the reviewers have dedicated to providing valuable feedback on our manuscript. We have considered the comments and concerns and made every effort to address them. We agree with all the comments and have incorporated the corresponding revisions into the revised manuscript. All revised texts are track-changed to point out the changes we made. We believe that our manuscript has been significantly improved as a result of these revisions. We would like to thank you once again for your consideration of our work and for inviting us to submit the revised manuscript. We look forward to hearing from you. Our detailed, point-by-point responses to the comments are given below. Best regards, Tsion Mulat Tebeje School of Public Health, Dilla University, Dilla, Ethiopia. Email: yemarina12@gmail.com / Tsionmulat@du.edu.et (corresponding author) Response to journal’s requirements 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Response: We prepared the manuscript according to the journal's requirements and double-checked its compliance before submitting our revised manuscript. 2. Thank you for stating the following financial disclosure: “This research was supported by a Health Professionals Education Partnership Initiative (HEPI) grant (grant number: R25TW011214) obtained from the US National Institutes of Health, Fogarty International Center.” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. Response: Thank you for asking about the role of the funder. We have included the role of funder statement in the cover letter. 3. Thank you for stating the following in the Acknowledgments Section of your manuscript: “We would like to acknowledge the HEPI initiative for providing funds to conduct this study.” We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: “This research was supported by a Health Professionals Education Partnership Initiative (HEPI) grant (grant number: R25TW011214) obtained from the US National Institutes of Health, Fogarty International Center.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. Response: We removed any funding-related text from the revised manuscript. We included the funding statement and role of funder statement in the cover letter. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Response: Thank you. We included a caption of the supplementary files at the end of the revised manuscript. Edits requested on the submission 1. Thank you for uploading your study's underlying data set in the Supporting Information file "dataset.xlsx". We noticed that this file may contain potentially identifying participant information. Before we proceed, we kindly ask that you please ensure that the data shared are in accordance with participant consent and all applicable local laws. If any data shared is not in accordance with participant consent, please remove these data and re-upload a fully anonymized data set. Please also note that spreadsheet columns with identifying information must be removed and not hidden as all hidden columns will appear in the published file. Response: Thank you for the suggestion. The shared dataset does not contain any potentially identifying participant information such as names, addresses, images, or other unique identifiers. The dataset is fully anonymized. Additionally, the dataset aligns with participants’ consent agreements. Additional Editor Comments: I critically reviewed your article entitled “The hidden burden of hypertension-undiagnosed hypertension and associated factors among elderly individuals in Gedeo zone: A mixed methods approach” which has the potential to add to the existing body of scientific knowledge, particularly in developing countries. However, there are some limitations in your article that need addressing before publication. Response: Dear editor, Thank you for giving us your valuable time and for sharing your valuable input. 1. There are several grammatical and typological errors that authors need to carefully review. Response: Thank you. The revised manuscript has been meticulously edited and proofread to rectify quality issues, such as misspellings, grammatical errors, and unclear sentences. 2. Authors should extensively format manuscripts based on PLOS ONE journal style, including file naming. Avoid unnecessary italicizing and capitalization throughout the manuscript. Response: Thank you for your suggestion. We prepared the revised manuscript according to the PLOS ONE requirements 3. Make sure that your reference contains all the necessary details and PLOS ONE style. Response: Thank you for your suggestion. We have made sure the references fulfill the PLOS ONE guideline in the revised manuscript. Response to reviewer’s comments Comments from Reviewer 1 1. Thank you the authors working on the so called silent killer of undiagnosed hypertension. Response: Thank you for giving us your valuable time to review our paper and for your comments and suggestions, which we got as valuable input to improve the manuscript. 2. This is a prospective study so that what was the difficulty of getting consent from each indiviadual or what does it mean for publication consent is not applicable?.... Response: Thank you. We did not face any difficulty obtaining consent, we got written consent from our participants as we explained in the ethical consideration section. We mentioned publication consent is not applicable because there was no personal identifier data or imaging that required publication consent. 3. exclusion criteria?,operational definition? Response: Thank you for pointing this out. The inclusion and exclusion criteria were incorporated in the population section of the methods. Highlighted in Page 6, Line 113-116. We already included operational definition as “measurements” Page 8-10, Line 146-185. 4. some editting of language/expert involvement is better to be involved Response: Thank you. We have edited the revised manuscript to rectify misspellings, grammatical errors, and unclear sentences. Comments from Reviewer 2 1. The study is good for the body of knowledge and abstract and introduction was written in a clear , concise and intelligible manner. Response: Thank you for giving us your valuable time to review our paper and for your comments and suggestions, which we got as valuable input to improve the manuscript. 2. The title should be modified to be clear Response: Thank you for the suggestion. We modified the title to “Undiagnosed hypertension and associated factors among older adults in Gedeo zone, southern Ethiopia: A mixed methods approach”. 3. what is your background to say elderly 50 years or above? there is other age classification for elderly population Response: Thank you for the insightful inquiry. Including hypertension, chronic diseases are more common among older adults (adults aged 50 and above). As proved by previous studies, the incidence of hypertension and other chronic illnesses increases as individuals age. Additionally, many studies in Africa used the age of 50 and above to define older adults. We have clearly explained the rationale for using these populations in the introduction section of the revised manuscript, page 5, lines 83-90. This study aims to measure undiagnosed hypertension among older adults who have been overlooked in previous studies. To ensure consistency, the term "elderly population" in the title was modified to "older adults". 4. Does the the district (3) selected for the study is representative for the Gedeo zone (13)? Response: Thank you. As per the information we obtained from Gedeo zone administration, all the mentioned districts and town administrations belong to the Gedeo zone, which makes them representative of the zone. 5. Data management and analysis should be concise, clear and precise Eg. VIF and multicollinearity. Response: Thank you. We rewrote the multicollinearity and VIF more clearly in the revised manuscript. Page 11-12, Lines 226-229. 6. For qualitative study what types of analysis method used? what does it mean thematic content analysis, it vague and not clear, please specify it. it creates mislead to qualitative result interpretation. in addition the qualitative result interpretation should be consistent/matched with analysis method. Response: Thank you for the insightful inquiry. We would like to clarify that we employed thematic analysis for our qualitative study. The reference to thematic content analysis was made in error, and we have since corrected it to accurately reflect our use of thematic analysis. Regarding the consistency of our results with the method of analysis, we have revisited our interpretations and cross-verified them against our thematic analysis results. Each interpretation has been linked to specific themes in the revised manuscript, ensuring that the conclusions are grounded in the evidence presented. 7. what the qualitative study result support? please put the qualitative result in appropriate place Response: Thank you for the suggestion. The results of qualitative analysis were placed after the quantitative result, page 18-21, Lines 308-362. 8. Please check the study for grammar and plagiarized content? Response: Thank you. We have edited the revised manuscript to rectify misspellings, grammatical errors, and unclear sentences. 9. Majority (63.4%) of the study participants were age between 50 to 59 years, this classified as middle age adult. does it can say elder? Response: Thank you for the insightful inquiry. Adults aged 50 and above are indeed not elderly rather they are adults who are relatively older (older adults). As we responded to question number 3, we explained why 50+ adults are our population, in the introduction section of the revised manuscript, page 5, lines 83-90. 10. What is the sample size for second objective? Response: Thank you for your question. We have included the sample size calculation for both objectives in supplementary file 1 of the revised manuscript. We found that the sample size calculated for the second objective was lower, so we used the larger sample size from the first objective. 11. undiagnosed HTN is new so it is possible to say prevalence of undiagnosed HTN? Response: Thank you for the insightful inquiry. We collect the data cross-sectionally, where the dependent and independent variables were collected simultaneously. Therefore, we could not determine whether the undiagnosed HTN was new or not. In order to calculate the incidence we were supposed to follow a group of people who were initially free from the undiagnosed HTN. 12. Why did you merge overweight and obesity? The degree of being obese and being overweight is different and could have different impacts. Response: Thank you for the insightful inquiry. We merged being obese and overweight for the health and statistical context. In the health research context, both overweight and obesity are linked to increased risk of diseases, more specifically chronic diseases, though the degree of risk varies. This provides valuable insights for effective decision-making. Regarding the statistical perspective, merging variables leads to meeting the chi-square test criteria and improved statistical power to make comparisons. 13. Study period: replace the phrase “between March 19 and May 20, 2023” with “from March 19 to May 20, 2023” Response: Thank you for the insightful suggestion. As per your suggestion, we modified the study period to ‘from March 19 to May 20, 2023’ in the abstract and methods section of the revised manuscript. 14. Regarding measurement of the dependent variable, two measurements were taken 5 minutes apart. I don’t think 5 minutes are enough to diagnose a patient with hypertension. Whenever possible, the diagnosis should not be made on a single office visit. Response: Thank you for the insightful inquiry. We made the diagnosis in a single office visit to save time and avoid missing participants during follow-up visits to measure blood pressure. The repeated measurements were separated by 5 minutes. For proper measurement of blood pressure in an office in a sitting position, repeated measurements can be separated by 1-2 min (10.1161/HYP.0000000000000087). Therefore, a 5-minute interval was quite enough. 15. Before measuring the blood pressure, have you addressed the protocols to measure blood pressure? For example, how do you assesses the participants to avoid smoking, caffeine and exercise for 30 min; empty bladder; remain seated and relaxed for 3–5 min? Nothing is written in this case as it could have impact on the result. Additionally, was the room Quiet with comfortable temperature? Response: Thank you for pointing this out. We completely agree with you. We addressed all protocols to measure blood pressure before taking the blood pressure measurement. We waited for 30 minutes, after making sure that the participants were refrained from smoking cigarettes, drinking alcohol, or taking caffeine before their BP measurement was taken. This by default made them eligible for BP measurement as we confirmed they had not taken anything within 30 minutes. The participants were also told to empty their bladder and avoid drinking water shortly before the measurement. After they entered the measurement room, the participants sat in a chair with feet flat on the floor and back supported for 3 minutes before taking the first BP reading. The second measurements were taken 5 minutes later. We included this procedure in the revised manuscript. Page 8, lines 147-154 16. Regular physical activity was defined as Moderate intensity aerobic exercise (walking, jogging, cycling, yoga, or swimming) for 30 minutes on 5–7 days per week but in your case it is “Engaging in physical activity for 20–30 minutes, three days a week, is considered regular physical exercise” Response: Thank you for the insightful inquiry. We measured physical activity according to the International Physical Activity Questionnaire (IPAQ), which is a widely used tool designed to assess physical activity levels in various populations globally. As per the IPAQ, a minimum of at least three activities in a week for 20-30 minutes per day is needed to be considered as a physical activity. Comments from Reviewer 3 Although the manuscript is good, I have several criticisms. thus you'll attempt to review and edit in light of the feedback. I made to attach all comments in PDF format. concept, data analysis, and following the rules when writing the manuscript are some of those. Response: Thank you for giving us your valuable time to review our paper and for your comments and suggestions, which we got as valuable input to improve the manuscript. 1. From the title line 1, there is a reputation for “hypertension-undiagnosed hypertension”, please rewrite again to get more credit or approval? Response: Thank you for the suggestion. We modified the title to “Undiagnosed hypertension and associated Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0322610.r003
29 Nov 2024 Decision Letter - Amanuel Yoseph, Editor PONE-D-24-27240R1Undiagnosed hypertension and associated factors among older adults in Gedeo zone, southern Ethiopia: A mixed methods approachPLOS ONE Dear Dr. Tebeje, 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 Jan 13 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, Amanuel Yoseph, MPH 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 #2: (No Response) Reviewer #3: All comments have been addressed ******** 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: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes Reviewer #3: Yes ****** 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 Reviewer #3: 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 #2: 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 #2: Thank you very much to get the opportunity to review this important public health problem. The authors are fully addressed the comment I raised previously. but I have some suggestions to improve quality and scientific back ground of the manuscript. 1.What adds this study from qualitative finding? 2.In discussion parts the qualitative study have not support the quantitative finding simply put in separate manner and compares with other similar study only. what is the reason to add qualitative study to this research? I don.t see its relevance as it stands. 3. the objective is the same for both quantitative and qualitative, but it seems like different in your write up. it needs arrangement. for example you should explained the quantitative study, then followed by qualitative finding to make the finding strong. 4. non of the participants knew the scientific back ground of the HTN. It needs modification. 5.the qualitative analysis in some sentences seems like to summative content analysis. it needs some modification. 7.quantitative and qualitative study lack integrity at discussion parts of the manuscript. it needs align together. Reviewer #3: (No Response) ****** 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 #2: Yes: Asmamaw Deguale Worku Reviewer #3: Yes: wasihun kindalem worku ******** [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. https://doi.org/10.1371/journal.pone.0322610.r004
Revision 2
13 Jan 2025 Author Response Subject: Responses to comments (revision 2) Dear Editor, Thank you for taking the time to consider our manuscript titled “Undiagnosed hypertension and associated factors among older adults in Gedeo zone, southern Ethiopia: A mixed methods approach” for the Plos One Journal original research article. We appreciate the time and effort you and the reviewers have dedicated to providing valuable feedback on our manuscript. We have considered the comments and concerns and made every effort to address them. We agree with all the comments and have incorporated the corresponding revisions into the revised manuscript. All revised texts are track-changed to point out the changes we made. We believe that our manuscript has been significantly improved as a result of these revisions. We would like to thank you once again for your consideration of our work and for inviting us to submit the revised manuscript. We look forward to hearing from you. Our detailed, point-by-point responses to the comments are given below. Best regards, Tsion Mulat Tebeje School of Public Health, Dilla University, Dilla, Ethiopia. Email: yemarina12@gmail.com / Tsionmulat@du.edu.et (corresponding author) Journal Requirements 1. 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. Response: We have reviewed our list of references and changed some references. We have removed and replaced the retracted articles with relevant and current references. All changes made to the reference list have been highlighted in the revised manuscript using track change. Response to reviewers Reviewer 2 General comment: Thank you very much to get the opportunity to review this important public health problem. The authors are fully addressed the comment I raised previously. but I have some suggestions to improve quality and scientific back ground of the manuscript. Response: Thank you for your kind words and for reviewing our manuscript which benefited from your comments and suggestions. Comment 1: What adds this study from qualitative finding? Response 1: The qualitative study aimed to assess participants' knowledge and attitudes towards hypertension. Participants' knowledge is one aspect measured in the quantitative portion of this research. Consequently, the qualitative findings provided further insight into their understanding of hypertension, including its definition, signs and symptoms, self-management strategies, and preventive measures. This approach revealed additional concepts regarding knowledge about hypertension that are not addressed in the quantitative questions. Comment 2: In discussion parts the qualitative study have not support the quantitative finding simply put in separate manner and compares with other similar study only. what is the reason to add qualitative study to this research? I don.t see its relevance as it stands. Response 2: Thank you. As we mentioned above the qualitative study is meant to assess participants' knowledge and attitudes towards hypertension. We aligned the qualitative and quantitative study in the discussion section. Comment 3: the objective is the same for both quantitative and qualitative, but it seems like different in your write up. it needs arrangement. for example you should explained the quantitative study, then followed by qualitative finding to make the finding strong. Response 3: Thank you for your insightful suggestion. In the results section, we started with quantitative results, followed by qualitative findings. Comment 4: non of the participants knew the scientific back ground of the HTN. It needs modification. Response 4: Thank you. We have changed it to “few of them knew the scientific definition of HTN” and we made the changes with track change to spot the changes. Comment 5: The qualitative analysis in some sentences seems like to summative content analysis. it needs some modification. Response 5: Thank you. As per your suggestion, we have modified the parts that may seem summative content analysis. Page, lines Comment 6: quantitative and qualitative study lack integrity at discussion parts of the manuscript. it needs align together. Response 6: Thank you for pointing this out. In the discussion section, we integrated the qualitative findings with the quantitative findings. Attachments Attachment Submitted filename: Response_to_reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0322610.r005
26 Mar 2025 Decision Letter - Daniele Romanello, Editor Undiagnosed hypertension and associated factors among older adults in Gedeo zone, southern Ethiopia: A mixed methods approach PONE-D-24-27240R2 Dear Dr. Author, 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. 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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 Reviewer #3: All comments have been addressed ******** 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: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? 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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 #2: Yes: Asmamaw Deguale Worku Reviewer #3: No ******** https://doi.org/10.1371/journal.pone.0322610.r006
Formally Accepted
Acceptance Letter - Daniele Romanello, Editor PONE-D-24-27240R2 PLOS ONE Dear Dr. Tebeje, 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. Daniele Romanello Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0322610.r007

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