Prevalence and risk factors of hypertension among clients seeking care at Selected Healthcare Facilities in Kenya

Jasmit Shah; Soraiya Manji; Cynthia Smith; Jamila Nambafu; Anthony Ochola; Linda Barasa; Faraj Amir; Husni Abdalla; Simeon Jowi; Caroline Mithi; Rajiv Patel; Sayed K. Ali

doi:10.1371/journal.pone.0334255

Peer Review History

Original SubmissionFebruary 21, 2025
7 Aug 2025 Decision Letter - Sandra Kushitor, Editor Dear Dr. Shah, 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 Sep 21 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. 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'. 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Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 3. We note that there is identifying data in the Supporting Information file <Hypertension Data.xls>. Due to the inclusion of these potentially identifying data, we have removed this file from your file inventory. Prior to sharing human research participant data, authors should consult with an ethics committee to ensure data are shared in accordance with participant consent and all applicable local laws. Data sharing should never compromise participant privacy. It is therefore not appropriate to publicly share personally identifiable data on human research participants. 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[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? Reviewer #1: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: Overall, the manuscript is well-written. The aim of the study is clearly described. The methods are aligned with the study aim. The results are reported and discussed satisfactorily. Introduction • Paragraphs 2 and 3 are a repetition of the same point. Could be combined in one paragraph or summarised. Methods • Clearly described. Methods are aligned with the study aim. Results • The planned sample size was 328 but 1444 participants were recruited. What was the rationale for increasing the sample size 4 times. • Significant findings (hypertension was associated with obesity and age) were not stated in the Results section. Please provide narrative describing the data in the tables. • The abbreviation FV is not widely used. Consider writing in full. Conclusion • The conclusions answer the research question. References • Please format the references according to the journal guidelines and include DOIs. ****** 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: Keshena Naidoo ******** [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: Hypertension - 20th Feb 2025.docx https://doi.org/10.1371/journal.pone.0334255.r001
Revision 1
12 Aug 2025 Author Response Response to Comments Overall Editor Comments Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Response: We have revised the manuscript to the journals style requirements. We have incorporated from both the templates. 2. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response: We have included the captions. 3. We note that there is identifying data in the Supporting Information file <Hypertension Data.xls>. Due to the inclusion of these potentially identifying data, we have removed this file from your file inventory. Prior to sharing human research participant data, authors should consult with an ethics committee to ensure data are shared in accordance with participant consent and all applicable local laws. Data sharing should never compromise participant privacy. It is therefore not appropriate to publicly share personally identifiable data on human research participants. Please remove or anonymize all personal information, ensure that the data shared are in accordance with participant consent, and re-upload a fully anonymized data set. Please note that spreadsheet columns with personal information must be removed and not hidden as all hidden columns will appear in the published file. Response: We have revised and ensured the data file is completely anonymous. 4. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Response: We appreciate the reviewer’s comments as they have helped us to strengthen our manuscript. Reviewer #1: Introduction 1. Paragraphs 2 and 3 are a repetition of the same point. Could be combined in one paragraph or summarised. Response: We have revised the introduction for better flow. Methods 2. Clearly described. Methods are aligned with the study aim. Response: Thank you for the comment. Results 3. The planned sample size was 328 but 1444 participants were recruited. What was the rationale for increasing the sample size 4 times. Response: Based on an assumption of 24.5% and an attrition rate of 15%, the minimum sample size calculated was 328 participants. Since we were recruiting from three types of facilities (private, public and faith-based), the minimum sample required was 984 participants. We have revised this in the methods section. 4. Significant findings (hypertension was associated with obesity and age) were not stated in the Results section. Please provide narrative describing the data in the tables. Response: This has been revised in the results section 5. The abbreviation FV is not widely used. Consider writing in full. Response: We have revised and written it in full. Conclusion 6. The conclusions answer the research question. Response: Thank you for the comment. References 7. Please format the references according to the journal guidelines and include DOIs. Response: We have revised the references accordingly. If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site Response: Furthermore, the reviewer had suggested few changes and comments to the manuscript. Below are the comments and our responses. 1. The title is misleading. The sample are not people living with HPT, but clients attending the OPD. Change to “Prevalence and risk factors of hypertension among clients seeking care at selected facilities in Kenya” Response: We have revised the Title. Abstract Comments: 2. Abstract: Include a section about how the data was analysed. Response: We have included a summary of the analysis in the Methods of the abstract. 3. Is goal blood pressure determined by the clients or medical doctors? Are you referring to hypertension control as directed by the WHO. Response: We have included in the abstract the use of guidelines defined by the Joint National Committee. 4. This statement is misleading. The facility is faith-based not all the clients are pastors. Kindly rewrite for clarity. Response: We have clarified the sentence. Introduction Comments: 5. The switch from global, to regional and national level evidence from the literature is inconsistent. You have Kenya in the previous sections, Nigeria in this section and from line 89 you have global evidence. Use the funnel Response: We have reworked the entire Introduction to flow it better. 6. I disagree with this assertion; there are countless studies on hypertension in SSA. Look at the RODAM project and EDULINK project Response: We have omitted the sentence. Methods Comments: 7. Long confusing sentence. Group them by location first; for example Nairobi. And only indicate the number that are private, public or faith-based. Response: We have revised and grouped them based on the type of healthcare facility. 8. Include references for the behavioral risk factors. Response: We have included the references. 9. Kindly describe how BMI was measured in the methods. BMI is a lifestyle or behavioural risk but not demographic characteristics Response: We have described in the methods and put BMI with the other behavioral characteristics. 10. Start sentence with words. Response: This has been revised. 11. Restructure the Results for Table 3. Response: We have revised the results. 12. This statement is incorrect. Past history is hyp diagnosis. Response: We have revised the sentences for better clarity. Discussion 13. Kindly present your logistic regression before the discussion. Although you have presented the discussion in sections; it is best to present a key section where you summarise your results before providing the interpretation Response: We have not done logistic regression for these analyses. We have excluded it from the methods. This was an oversight. We have tried to rework on the discussion for better structure. References: 14. Most of the references are incomplete. Add the url link for the reports. For example, how can we access ref 4. Responses: We have tried to incorporate and correct the references. 15. What is the heading for this table Response: We have included the headings. 16. Why do the sample size vary across variables. This is very confusing. Keep only the same sample size throughout the study. Response: Since participation in the survey was voluntary, some questions were left unanswered, resulting in missing responses for certain variables. To ensure transparency, we have reported the sample size (n) for each variable, allowing readers to see where data are missing. 17. This difference between 52 and 49 is quite small. This association will not be retained in a regression model. Kindly provide evidence of this in a regression model Response: The observed difference is not between 51.5% and 48.5%, but rather between 51.5% of participants with elevated blood pressure who were from rural areas and 39.3% of participants without elevated blood pressure who were from rural areas. This represents a 12.2 percentage point difference. Attachments Attachment Submitted filename: Hypertension PLOS ONE - Response Feedback 11th Aug.docx https://doi.org/10.1371/journal.pone.0334255.r002
12 Sep 2025 Decision Letter - Sandra Kushitor, Editor Dear Dr. Shah, 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 27 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. 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 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, Sandra Boatemaa Kushitor, Ph.D. Academic Editor PLOS ONE Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 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. Additional Editor Comments: Dear Authors, Kindly revise the manuscript based on the comments in the attached file. In the response to reviewer's file do only indicate "this correction has been made", copy and paste the revision. Your document should be such that decisions can be made based on it. Kind regards, [Note: HTML markup is below. Please do not edit.] [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: Hypertension - Clean 11th Aug.docx https://doi.org/10.1371/journal.pone.0334255.r003
Revision 2
15 Sep 2025 Author Response We have revised all the edits and suggestions given by the reviewer as a track changed document. Below are our responses to specific comments and suggestions made specifically on the document. Kindly revise the manuscript based on the comments in the attached file. In the response to reviewer's file do only indicate "this correction has been made", copy and paste the revision. Your document should be such that decisions can be made based on it. 1. Revision from patients to clients Response. This correction has been made. 2. Kindly consider how this is phrased. In rural areas, faith-based facilities are the dominant care providers. If you flip this around, htn is increasing in rural areas, which is what your findings indicate. This was not the case in the past and it would be great if you could highlight that Response: We have rephrased and added “ In rural areas, faith-based facilities are the dominant care providers” 3. Hospital? Response: The statement is correct. For each hospital, we have provided the location (city or town) where it is situated, for example, Aga Khan University Hospital, Nairobi. 4. Did you consider those with previous diagnosis? Response: We considered both with and without previous diagnosis. We have revised in the statement where it was highlighted. 5. Kindly present the logistic regression results. Response: We have added the Odds Ratio (OR) in Table 3 and revised the results section accordingly. 6. The data does not support this conclusion: only 72 participants were diagnosed by the study who had no previous diagnosis Response: From the 1444 clients, 425 (29.4%) met the criteria for hypertension at clinic visit. Among the 425 clients that met the criteria for hypertension, 219 (51.5%) had a prior diagnosis of hypertension whereas 206 (48.5%) did not have a prior diagnosis. We have included the numbers in the paragraph, and this reflects in the table. 7. Another motivation could also be that these facilities provide relatively inexpensive services Response: The correction has been made and have added this in the discussion. 8. Kindly indicate whether these are not the only hospitals in the counties. These centres may have their own pull factors, such as short waiting times compared to crowded public hospitals. Going to seek care at any facility is not a risk factor of hypertension Response: We agree that the site of care is not a risk factor for hypertension. Our intention was to highlight the role of faith-based hospitals as major providers of care in rural Kenya, which may explain why the largest proportion of participants were recruited from these facilities. We have revised the text to clarify that these hospitals are not the only health facilities in their counties. 9. This was not part of your results Response: We agree that the statement about prehypertension in primary school children was not part of our study results but was included as supporting evidence from previous literature. To avoid confusion, we have revised the text to clearly separate our findings from published data as this is presented in future considerations. 10. Which government unit should be doing this? Is blood pressure assessment part of regular OPD services? If yes, that’s facility level screening. Now find out how community level screening can be done and suggest that Response: We have corrected and revised the paragraph. Attachments Attachment Submitted filename: Hypertension PLOS ONE - Response Feedback 15th Sept.docx https://doi.org/10.1371/journal.pone.0334255.r004
24 Sep 2025 Decision Letter - Sandra Kushitor, Editor Prevalence and Risk Factors of Hypertension Among Clients Seeking Care at Selected Healthcare Facilities in Kenya PONE-D-25-09467R2 Dear Dr. Shah, 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. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . 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, Sandra Boatemaa Kushitor, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0334255.r005
Formally Accepted
Acceptance Letter - Sandra Kushitor, Editor PONE-D-25-09467R2 PLOS ONE Dear Dr. Shah, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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. Sandra Boatemaa Kushitor Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0334255.r006

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