PONE-D-20-34174

Magnitude and associated factors to medication poor adherence among diabetic and hypertensive patients visiting public health facilities in Ethiopia during the COVID-19 pandemic

PLOS ONE

Dear Dr. Shimels,

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 note that the comments by the reviewers are quite extensive. Please make sure that you adequately address them. Some parts of the introduction and the discussion could be shortened by having them much more concise. This will allow to extend on several aspects as required by the reviewers.

Please submit your revised manuscript by Mar 07 2021 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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We look forward to receiving your revised manuscript.

Kind regards,

Hans-Peter Brunner-La Rocca, M.D.

Academic Editor

PLOS ONE

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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?

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

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

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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: No

Reviewer #2: Yes

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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: No

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors present an original reasearch article entiteled: Magnitude and associated factors to medication poor adherence among diabetic and hypertensive patients visiting public health facilities in Ethiopia during the COVID-19 pandemic.

The manuscripts reads like a first version manuscript. It needs to be rewritten with clearer senteces. A native speaker should edit the manuscript.

Abstract: the abstract is well written but quite long. Please be consise.

Introduction: THe introduction reads as a textbook with little conffection between the paragrafs.

The first paragraph starts with defining the WHO criteria for adherence. What does adherence refer to. Such a paragfar is not appealing to read further. I suggest to start with why drug adherence for hyperntension and diabetes is of interenst to study.

The paragraphs discussing the literature may be more suitable for the discussion (paragraf 3 and 4). Could be in 2 or 3 sentecences in the introduction.

Methods:

"A cross sectional study design was conducted in August 2020 among seven public health facilities (two hospitals and five health centers) to assess adherence of patients to antidiabetic and antihypertensive medications during the COVID-19

pandemic. " Was it from the start of august till the end of august? Wat was the time window for the study? Who assessed the data?

Wat is there an approval from the Medical ethical commitee?

Where only chronic patients included or also patients with hypertension and DM de novo.

"Content validity was of the tool was ensured by study team. Cronbach’s

alpha test of reliability of the scale among pretested samples showed acceptable range for both

hospitals (α=0.88) and health centers [α=0.63]. " This is describtion of the results. I suggest to transfer it to the results section.

The descrioption of the adherence is unclear for readers who are not familiar with the morskey score. Perhaps a table would be more suitable.

Results:

Please put tables at the end of the paper.

The description of the results is not conssitent. For example: AOR: 0.58; 95%C.I: 0.35-0.97 and AOR: 0.50; 95% C.I:0.27-0.89

Discussion:

Can be extended with the literature discussion from the introduction.

Please start the discussion with a short discription of the results.

The conclusion is again a summary of the results, please make it a conclusion and add a clear recommendation paragraph.

Please add in the discussion a clear strenght and limitation paragraph.

Reviewer #2: This study investigated the adherence to medication in patients with diabetes and hypertension in Ethiopia during the COVID-pandemia. Only app. ¼ of the patients were fully adherent. COVID was mentioned in app. 40% of the patients as causing some reduction in adherence. Other factors could be identified to increase or reduce adherence.

Some comments:

Introduction:

good summary. However, the authors could highlight a bit more what the added value of their work is, in addition to investigating the situation during the COVID pandemia, as compared to the papers cited in the introduction (e.g. differences in the setting as I can imaging that the populations seen in different settings differ, or why numbers of other studies may be not representative, or that the population of this study is the same as that of one of the other studies, allowing to investigate the direct impact of COVID on adherence).

Methods:

Where all patients including during the time period or was it a selected group of patients? Did all patients consent to participate in the study? Probably not, To what extend did those not included differ from those that participated in this study? It may be helpful to have a figure explaining the patient flow.

The sample size calculation is unclear. What was the aim / target for the calculation? Please be more precise. I do not understand it at present.

It would be helpful to add the questionnaire, at least as supplementary file. This makes it also easier to understand exactly how good adherence was defined.

Is it correct that participating patients did not give written informed consent? If yes, was this an exemption specifically approved by the Ethical Committee a priori?

Were all variables included in multivariable analysis or were there any selection criteria? If no selection criteria applied, the power may be not sufficient for multivariable analysis given the number of independent variables. In this case, I would recommend to first perform a univariable analysis and only include those with a e.g. P<0.1 in the multivariable analysis. At present, it is not clear why some variables are mentioned in table 2 and others not.

Results:

How was the presence of close people defined? How was co-morbidity defined? Would it not be better to name the prevalence of co-morbidities (at least for the most prevalent ones)? In addition, it would be interesting with which medication patients were treated.

Figure 1. % instead of absolute numbers would be better.

As far as I understand, an OR of <1.0 indicates less non-adherence, i.e. better adherence. I think that it is easier to understand if you only better adherence (with an OR > 1) and worse adherence (with an OR <1). This is easier to understand. This obviously also applies to the according parts of the discussion (e.g. association with better adherence instead of association with lower odds of poor adherence).

Would it not be better to use the poverty line as cut-off instead of the median within the study, particularly as this is also related to the discussion?

Please define AOR and COR in table 2.

Discussion:

It is a bit confusing that you refer that 40% are negatively affected by the pandemia regarding non-adherence, but in fact, there were 57%. This applies also to the abstract. This is confusing. In addition, you do not need to repeat results in the discussion (use e.g. the majority instead).

Please discuss your findings in the light of previous findings in your country. You only do so regarding the overall adherence. It would be interesting to hear if factors associated with better adherence were similar in other studies and what potential explanations for the differences are.

The finding and discussion of low income being associated with better adherence is interesting. What do other studies say on this and what may be the differences with your findings? This is missing. The findings related to co-morbidites etc. are in line with your findings. This needs to be mention and is separate to the discussion about impact of low income.

Have a separate paragraph regarding limitations. You also need to add that the number of included patients is limited and other important factors may have been missed because of this limitation. In addition, the selection of patients may be a limitation (not only that inclusion was limited to one month), but this is difficult to judge as nothing is reported in this regard (see above).

Minor comments:

There are quite some spelling and grammatical mistakes (e.g. incorrect use of tenses). Please check and correct.

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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.

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Reviewer #1: No

Reviewer #2: No

[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.]

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PONE-D-20-34174R1

Magnitude and associated factors of poor medication adherence among diabetic and hypertensive patients visiting public health facilities in Ethiopia during the COVID-19 pandemic

PLOS ONE

Dear Dr. Shimels,

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.

See comments by reviewer #2. These are not major issues, but you still should address them. In particular, please provide the adequate information about the power calculation and have your manuscript copy-edited by a native speaking person.

Please submit your revised manuscript by Apr 11 2021 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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Hans-Peter Brunner-La Rocca, M.D.

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: 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 #1: Yes

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 #1: Yes

Reviewer #2: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors adressed all comments adequately.

The respons en manuscript can be improved to a more neat version, but probably with the editing phase this matter can be adressed.

Reviewer #2: I would like to thank the authors for the improvement in their manuscript. Most issues are resolved sufficiently, but there are still some remaining.

Thus, the authors still fail to provide sufficient information regarding the power calculation. The authors provide references from previous studies, but they fail to exactly mention their assumptions that led to the required sample size.

The use of the English language has improved, but the manuscript still contains mistakes. As there is no copy-editing for PLOS ONE, the manuscript must be provided in good English without mistakes. I understand that this may be difficult for the authors. Therefore, they need to have the manuscript corrected by a person that is (almost) native English speaking.

Please provide the information that written informed consent was not required.

According to the instruction to authors, tables should be placed directly after the paragraph in which they are cited (the recommendation by the other reviewer was not correct).

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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 #1: No

Reviewer #2: No

[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.

Magnitude and associated factors of poor medication adherence among diabetic and hypertensive patients visiting public health facilities in Ethiopia during the COVID-19 pandemic

PONE-D-20-34174R2

Dear Dr. Shimels,

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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Kind regards,

Hans-Peter Brunner-La Rocca, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: