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Hypertension Knowledge and Treatment Initiation BMJ Open: first published as 10.1136/bmjopen-2020-040252 on 20 January 2021. Downloaded from PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. ARTICLE DETAILS TITLE (PROVISIONAL) Hypertension knowledge and treatment initiation, adherence, and discontinuation among adults in Chennai, India: a cross-sectional study AUTHORS Sudharsanan, Nikkil; Ali, Mohammed; McConnell, Margaret VERSION 1 – REVIEW REVIEWER Mayowa Owolabi University of Ibadan, Nigeria REVIEW RETURNED 27-Jun-2020 GENERAL COMMENTS This cross-sectional design was able to identify some behavioral /belief factors associated with BP control in India. Due to the study design, predictors of clearly defined outcomes could not be established. This limitation could be emphasized by the authors. It is also not clear why factors such as cost, availability, affordability, social/family support and frequency of doses were not explored. REVIEWER Sophie Galson Duke, USA http://bmjopen.bmj.com/ REVIEW RETURNED 15-Jul-2020 GENERAL COMMENTS This paper describes the gaps in care for hypertensive patients in Chennai, India. While this is a timely and very important topic, there are major flaws in methods utilized that likely resulted in a biased sample and questionable BP readings. The authors also have not fully researched the qualitative literature on HTN in LMICS or taken advantage of universal guidelines to obtain BP on October 1, 2021 by guest. Protected copyright. measurements in research studies or validated tools to determine knowledge, attitudes and practices regarding hypertension care. Title – the care “continuum” is still unclear to me and was not fully explored in this paper Intro – Line9 -sounds like you plan to describe the care in all of India Methods How were patients selected – randomly?, cluster design? How did you investigate reasons- in-depth interviews/ focus groups? Results 1 BMJ Open: first published as 10.1136/bmjopen-2020-040252 on 20 January 2021. Downloaded from It is unclear why you have separated all the data by gender as this does not seem to be a primary focus of your paper. Conclusion Contradicts what was just said in last line of the results Strength - how is your data population-based since this is not a true a random sample? Intro Page 4 Line 17- do you mean as the county ages or the population ages? Page 4, Line 33- there have been many papers looking at gaps in HTN care in LMICs – see citations at end of review Page 4, line 47, what are BP endpoints? What theory in particular leads to these explanation? This section is vague and needs to be more specific. It is not clear how these theories were used to create your hypothesis Page 5, line 8 – remove extra period Page 5, line 6- again, there have been multiple papers looking at gaps in HTN care in LMICs. Be more specific about exactly what gaps in the literature this paper is addressing. Page 5, line 10 – the “care continuum” is never fully described in this paper. It is unclear where patients are diagnosed, where they get care, how they follow-up ect… Methods Need more info about Chennai – setting section? This is important to see if your sample is actually representative of the population. Sampling – there are many weaknesses in your methods which need to be addressed and/or commented on in the limitations (in http://bmjopen.bmj.com/ addition to the ones already mentioned). Were your sampling methods based on any previously described techniques? How did you decide which respondent to use if there were multiple in the household? How did you choose a starting point in the ward? Did you go back if to the house if no one was home? How did you attempt to enroll an equal number of men and women? 1/3 of participants refused participation –do you have data about this group at all? Gender or age? Were the survey teams locals? Also on October 1, 2021 by guest. Protected copyright. when was this survey conducted and by whom? Measurements Two BP measurements separated by 1 min and then using only the 2nd value does not make sense with any international or Indian guidelines for obtaining BP measurements ? Also, taking BP 2 mins into visit does not negate white coat hypertension. I am concerned about the accuracy of this measurement. In regards to the beliefs about medicine questionnaire developed in 1999 – was it validated in the population? There are more recent questionnaire tools that have been validated- why was one of these not used? Explanatory variables What was the piloting process? Were the cards pictures? Has this card technique been used before or validated? The reference 2 BMJ Open: first published as 10.1136/bmjopen-2020-040252 on 20 January 2021. Downloaded from provided (24) does not give an explanation about why this technique was chosen. What language was this done in? Results Based on the multiple CI reported that cross zero many of the “findings” reported are likely due to chance alone. Page 14, line 36: This CI crosses 0 so this is not a “strong association”. Page 15, line 17: 6% difference w/ CI that crosses zero is likely due to chance It is unclear why you have separated all the data by gender as this does not seem to be a primary focus of your paper. If want to explore further this article might be of interest Stroope S. Seclusion, decision-making power, and gender disparities in adult health: Examining hypertension in India. Soc Sci Res. 2015;53:288-299. doi:10.1016/j.ssresearch.2015.05.013 Discussion Page 16, line 17-24 – how do your results suggest that addressing knowledge and exploring reason for BP control will causally “improve the effectiveness of efforts to control BP?” Page 16, line 33 – were they really hypertensive or were the just nervous about having strangers in their house? As above - taking BP 1 min into visit does not negate white coat hypertension. Page 16, 42 –not clear that how this study about TB can be applied to HTN Page 17, line 40 – well written/explained paragraph Limitations – see methods section Page 19, line 26 – would not use the term population-based as this was not a representative sample and would say this is one of the first studies in India rather than LMICs – please expand your http://bmjopen.bmj.com/ literature search. Here are some examples of papers addressing gaps in HTN care in LMICs ( this was from a very brief lit search for Africa alone!) Chang H, Hawley NL, Kalyesubula R, et al. Challenges to hypertension and diabetes management in rural Uganda: a qualitative study with patients, village health team members, and health care professionals. Int J Equity Health. 2019;18(1):38. doi:10.1186/s12939-019-0934-1 on October 1, 2021 by guest. Protected copyright. Yan LD, Chirwa C, Chi BH, et al. Hypertension management in rural primary care facilities in Zambia: a mixed methods study. BMC Health Serv Res. 2017;17(1):111. doi:10.1186/s12913-017- 2063-0 Odusola AO, Stronks K, Hendriks ME, et al. Enablers and barriers for implementing high-quality hypertension care in a rural primary care setting in Nigeria: perspectives of primary care staff and health insurance managers. Glob Health Action. 2016;9:29041. doi:10.3402/gha.v9.29041 Odusola AO, Hendriks M, Schultsz C, et al. Perceptions of inhibitors and facilitators for adhering to hypertension treatment among insured patients in rural Nigeria: a qualitative study. BMC Health Serv Res. 2014;14:624. doi:10.1186/s12913-014-0624-z Zack RM, Irema K, Kazonda P, et al. Determinants of high blood pressure and barriers to diagnosis and treatment in Dar es Salaam, Tanzania. J Hypertens. 2016;34(12):2353-2364. doi:10.1097/HJH.0000000000001117 3 BMJ Open: first published as 10.1136/bmjopen-2020-040252 on 20 January 2021. Downloaded from Lulebo AM, Mapatano MA, Kayembe PK, Mafuta EM, Mutombo PB, Coppieters Y. Assessment of hypertension management in primary health care settings in Kinshasa, Democratic Republic of Congo. BMC Health Serv Res. 2015;15:573. doi:10.1186/s12913- 015-1236-y Rachlis B, Naanyu V, Wachira J, et al. Identifying common barriers and facilitators to linkage and retention in chronic disease care in western Kenya. BMC Public Health. 2016;16:741. doi:10.1186/s12889-016-3462-6 Ofili MI, Ncama BP, Sartorius B. Hypertension in rural communities in Delta State, Nigeria: Prevalence, risk factors and barriers to health care. Afr J Prim Health Care Fam Med. 2015;7(1):875. doi:10.4102/phcfm.v7i1.875 Parker A, Nagar B, Thomas G, Badri M, Ntusi NBA. Health practitioners’ state of knowledge and challenges to effective management of hypertension at primary level. Cardiovasc J Afr. 2011;22(4):186-190. doi:10.5830/CVJA-2010-066 REVIEWER Lori Ann Spies Baylor University USA REVIEW RETURNED 03-Aug-2020 GENERAL COMMENTS Abstract - The hypertension care continuum is not clearly defined and aspects of prevention are omitted in the abstract and in the study. The authors state "We describe the hypertension care continuum among adults diagnosed with hypertension and investigate reasons for gaps at each continuum step" is a strong plan but it is not clearly executed in the manuscript. 1 & 3 Clearly stated objectives and prespecified hypotheses missing 9 & 10 -The research questions and objectives are not clearly defined. The reference to multiple theories makes it unclear what components are being considered is being considered.
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