Dear Dr. Pamela Miloya Godia,

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KK has acted as a consultant, speaker or received grants for investigator-initiated studies for Astra Zeneca, Boehringer Ingelheim, Bayer, Novo Nordisk, Sanofi-Aventis, Servier, Lilly and Merck Sharp & Dohme, Oramed Pharmaceuticals, Pfizer, Roche, Daiichi-Sankyo, Applied Therapeutics, Embecta, Amgen, Bristol Myers Squibb and Nestle Health Science. KK is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands (ARC EM), NIHR Global Research Centre for Multiple Long-Term Conditions, NIHR Cross NIHR Collaboration for Multiple Long-Term Conditions,NIHR Leicester Biomedical Research Centre (BRC) and the British Heart Foundation (BHF) Centre of Excellence.

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Nordisk, Abbott and Takeda.

RL has received speaker honoraria, advisory board or educational grants or research funding: Novo Nordisk, Boehringer Ingelheim, AstraZeneca, Sanofi.

SC are supported by the National Institute for Health Research (NIHR) Global Health Research Group for Cardiometabolic Disease Research in Africa Partnership (CREATE).

SC, DI, are supported by the NIHR Applied Research Collaboration East Midlands (ARC EM), NIHR Global Research Centre for Multiple Long-Term Conditions.

PG, MH, RW, UE, PJ, JO, GA, JA, MC, AY, DF, AM, JC, CN, AD have declared no competing interests exists.”

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Additional Editor Comments:

The paper offers some interesting information and proposes a relevant model for chronic care of cardiometabolic diseases in low/middle income countries.

However, several detailed comments raised by the Reviewers need to be addressed in full.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: No

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: The manuscript provides a timely and relevant overview of cardiometabolic diseases (CMDs), particularly highlighting the disproportionate burden borne by low- and middle-income countries (LMICs). The authors propose an adaptation of the Chronic Care Model (CCM) as a potential response, with an emphasis on person-centred and community-orientated care.

A key strength of the study lies in its effort to triangulate multiple sources of data (from a literature review to community engagement), which are then synthesised into a proposed model. The emphasis on preserving core CCM principles while adapting the model to LMIC contexts is commendable.

To further strengthen the manuscript, it may be helpful to situate this work more clearly within the broader body of literature that has sought to revise or adapt the traditional CCM. Several recent iterations have moved toward greater collaboration and integration across sectors, and referencing these could help clarify how the proposed Collaborative Chronic Care Model (CoCCM) builds upon, or diverges from, existing efforts.

While the focus on CMDs is well-argued, it would be valuable to more explicitly demonstrate how the CoCCM offers unique utility for CMD management compared to its application for other chronic conditions. Clarifying this would enhance the specificity and relevance of the proposed model.

There appears to be some misalignment between the stated knowledge gap, namely, the lack of evidence around the implementation and scale-up of collaborative care models in LMICs, and the study’s stated aim to develop a person-centred model of care for CMD management. Clarifying how the study responds to this gap may help improve the coherence of the paper.

The framing of LMICs (and Africa in particular) could be strengthened. At times, the manuscript presents a high-income versus low-income dichotomy, which may unintentionally reinforce deficit-based narratives. It also overlooks evidence showing that cardiovascular disease (CVD) mortality has plateaued, or even increased, in some high-income countries.

A more balanced approach would be to highlight both the ongoing challenges, the local innovations and gains in CMD management seen in specific African countries such as Kenya, Ghana, and Mozambique (which the paper later references). This would offer a more nuanced and empowering perspective, rather than generalising across the entire African continent or all LMICs.

It may also be helpful to reconsider the use of the term “sub-Saharan Africa”, as it has been critiqued in scholarly literature for its lack of specificity and its problematic historical associations.

The manuscript could benefit from more explicit articulation of how the proposed CoCCM was shaped by the specific needs, characteristics, and resources of people living with CMD in the LMIC (or African) context. While the literature review and data collection are comprehensive, it is not entirely clear what was learned about the unique needs, characteristics and resources across the study settings and how these inputs were translated into design elements of the model. More detail on this process would enhance the model’s contextual relevance and practical applicability.

Finally, by focusing mainly on individual behaviour change as the key aspect of the CoCM model, the authors risk advocating for a care model that ignores how structural factors constrain or facilitate individual agency.

Reviewer #2: This manuscript presents the development of a health care model for people with multiple chronic cardiometabolic diseases (CMD/MLTC) in sub-Saharan Africa. The authors clearly articulate the study’s aim, and ethical clearance was appropriately obtained from the relevant committees in Kenya, Ghana, and Mozambique.

The development of the model was informed by a systematic review, qualitative synthesis, and a needs assessment with stakeholders. The resulting CREATE intervention comprises five key components: a self-management education (SME) programme, a training package for educators to deliver the SME, a training package to upscale health care providers and community champions in CMD, a decision making tool for a data registry, and an improved referral pathway.

Although the authors have stated that all information is included in the manuscript and the supporting information files, I could not find any access links to the supporting files. I believe that resources such as guides for the SME sessions, community linkage training materials, and shared decision-making guidelines, are of interest in the context of this manuscript. Inclusion of those resources in the supporting information files should be considered.

The manuscript is generally well-structured and linguistically sound. The following minor revisions are recommended to accept the manuscript for publication. All cited pages below refer to the manuscript page at the bottom of each page and not the pdf page.

1. To my understanding, the chronic conditions focused on by this program are T2DM, hypertension, cholesterol, and cardiovascular disease. I suggest describing in the manuscript why the model was limited to these four chronic conditions.

2. Table 3: The alignment between SME features and SME sessions in Table 3 is unclear. For example, SME feature "Focus on creating lifestyle habits that are tailored to people's routine" is in the same row as SME sessions "Recommendations of moderate vs vigorous", which seem unrelated to each other. I suggest modifying the data presentation to avoid misunderstanding. Some options: Option 1. nested table (instead of aligning features and sessions row by row, nest the features and sessions under the same objective: one row per objective, list all features in the objective in the same row in column 2, list all sessions under the objective in the same row in column 3). Option 2. bulleted concept map (diagram). Other forms may be utilized according to how the authors see fit.

3. Kindly specify who the audience for the SME program was: HCP, patients, or both. (page 16-17)

4. The six components of CREATE CoCCM in the article were 1) Self-Management support, 2) Clinical information system, 3) Delivery system design (streamlining the referral pathway), 4) Organisation of health care, 5) Decision support (which included health care provider training), and 6) Community linkages; these do not match the components in the results section of the Abstract. Consider streamlining for clarity.

5. Please check the manuscript and amend some grammatical and typographical errors, including, but not limited to:

- consistency with American or British spelling (British spelling was used for the phrase "Randomised Control Trials", whereas other parts of the manuscript uses American English).

- inaccurate use of capital letters where they are not needed e.g. "Randomised Control Trials" on page 8 and "Systolic Blood Pressure" on page 25.

- consistency with abbreviations; some terms' abbreviations have been specified but unabbreviated terms are used again in the later parts of the manuscript. For example, "Multiple long-term conditions (MLTC)" has been cited on page 8, but is inconsistently written as the unabbreviated form (pages 8, 9, 10) and abbreviated form (page 24). Similarly for "Chronic Care Model (CCM)" and "Collaborative care models".

- grammatical errors such as "traditional high calorific calories" -> "high calorific value" or "high calorie foods".

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Kenneth Yakubu

Reviewer #2: No

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Development of a collaborative chronic care model for management of cardiometabolic disease in low- and middle-income countries

PONE-D-25-22410R1

Dear Dr. Godia,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Paolo Magni

Academic Editor

PLOS One

Additional Editor Comments (optional):

The paper has been improved and all reviewers' comments have been addressed.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: (No Response)

Reviewer #2: Thank you for the opportunity to review the revised version of the manuscript. I appreciate the authors' careful and thorough responses to the comments raised in the initial review.

The following revisions, along with the revisions made in response to Reviewer #1, have substantially strengthened the manuscript:

- The rationale for focusing on the selected cardiometabolic conditions has been clarified

- The format of Table 3 has been improved

- The clarification of the SME target audience enhances reader understanding of the programme

- The alignment between the intervention components in the abstract and the main text has been addressed

- The manuscript has been edited for consistency and grammatical accuracy

I have no further substantive comments and consider the manuscript suitable for publication in its current form.

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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: Kenneth Yakubu

Reviewer #2: No

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