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. 2024 Apr 18;19(4):e0297165. doi: 10.1371/journal.pone.0297165

Role and knowledge of nurses in the management of non-communicable diseases in Africa: A scoping review

Jean Toniolo 1,2,3,*, Edgard Brice Ngoungou 1,2,4, Pierre-Marie Preux 1, Pascale Beloni 1,3
Editor: Ermel Johnson5
PMCID: PMC11025970  PMID: 38635822

Abstract

Background

31.4 million people in low- and middle-income countries die from chronic diseases annually, particularly in Africa. To address this, strategies such as task-shifting from doctors to nurses have been proposed and have been endorsed by the World Health Organization as a potential solution; however, no comprehensive review exists describing the extent of nurse-led chronic disease management in Africa.

Aims

This study aimed to provide a thorough description of the current roles of nurses in managing chronic diseases in Africa, identify their levels of knowledge, the challenges, and gaps they encounter in this endeavor.

Methods

We performed a scoping review following the key points of the Cochrane Handbook, and two researchers independently realized each step. Searches were conducted using five databases: MEDLINE, PyscINFO, CINAHL, Web of Science, and Embase, between October 2021 and April 2023. A descriptive analysis of the included studies was conducted, and the quality of the studies was assessed using the Downs and Black Scale.

Results

Our scoping review included 111 studies from 20 African countries, with South Africa, Nigeria, and Ghana being the most represented. Findings from the included studies revealed varying levels of knowledge. Nurses were found to be actively involved in managing common chronic diseases from diagnosis to treatment. Facilitating factors included comprehensive training, close supervision by physicians, utilization of decision trees, and mentorship. However, several barriers were identified, such as a shortage of nurses, lack of essential materials, and inadequate initial training.

Conclusion

There is significant potential for nurses to enhance the screening, diagnosis, and treatment of chronic diseases in Africa. Achieving this requires a combination of rigorous training and effective supervision, supported by robust policies. To address varying levels of knowledge, tailored training programs should be devised. Further research is warranted to establish the effectiveness of nurse-led interventions on population health outcomes.

Introduction

Africa is currently facing a double challenge linked to epidemiological transition [1, 2]. This transition involves the emergence of chronic diseases in an environment where infectious diseases continue to prevail [2]. Contributing factors include changes in health habits, such as tobacco and alcohol use, as well as economic development and urbanization. As the prevalence of chronic diseases increases, they significantly impact health outcomes and the healthcare system [1, 2].

Chronic diseases, also known as non-communicable diseases (NCDs), are characterized by their non-transmissible occurrence and duration, lasting for three months or more [3]. The World Health Organization (WHO) defines non-communicable diseases as diseases that do not spread from person to person and typically have a long disease duration with slow progression [4]. The main types of NCDs include cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes, with neurological disorders and mental health issues often included in this category. Annually, chronic diseases account for the death of 41 million people worldwide, representing approximately 71% of global deaths, with three-quarters of these deaths (31.4 million) occurring in low- and middle-income countries, notably in Africa [5, 6].

Efficient management of these pathologies with modifiable risk factors necessitates access to care and prevention measures to mitigate their impact on the healthcare system. However, a key challenge faced by African health systems is the shortage of healthcare personnel, with limited resources and an overwhelming workload [7]. For instance, there are only 0.29 doctors and 1.88 nurses per 1000 people in the region [8, 9].

In line with the goal of universal health coverage by 2030, the WHO acknowledges that nurses could be a viable solution to help manage chronic diseases [10–12]. Implementing task-shifting strategies from physicians to nurses is safe and effective in chronic disease management [13, 14]. Task shifting is defined as the transfer of tasks from doctors to nurses [13]. However, the role of nurses in chronic disease management is not limited to this. Chronic disease management activities in primary care include tasks such as taking vital signs, education on healthy diets, lifestyle advice, chronic disease education, and chronic disease clinics [15]. In northern countries, nurses provide NCDs care in a variety of settings, independently and collaboratively, with clinical, managerial, and accountability responsibilities [15, 16]. Furthermore, various strategies have already been tested in the African context to manage infectious diseases, such as task-shifting from doctors to nurses. This approach proved successful in HIV management, where nurses’ role enhanced antiretroviral therapy access, and improved patient retention, knowledge, and comfort [13, 17].

Nurses already contribute to managing chronic diseases in Africa, even though it is pertinent to emphasize that there are no systematic country-specific definitions for nursing care in the management of chronic diseases in Africa [18]. Indeed not all countries have policies in place to regulate the nursing profession and nursing care [18]. To define nursing and standardize nursing education and training programs, the West African Health Organization proposed a specific curriculum in 2014 to guide the nursing profession with ten core competencies [19]. These competencies encompass the analysis of functions related to nursing and obstetrical practices; the handling of clinical situations by referring to the physiology and diseases of the human body; intervention in community health; application of methods and techniques of nursing and obstetrics; application of research processes; management of nursing and obstetrical care; promotion, prevention, and rehabilitative care for the "mother and child; administration of nursing care; management of medico-surgical pathologies; and provision of culturally acceptable and high-quality care during pregnancy, childbirth, and delivery, with the ability to manage specific emergency situations to maximize the health of women and their newborns [19]. To note, the program allocated only 20 hours of coursework, specifically for chronic diseases raising questions on nurse knowledge and involvement in chronic disease management. To our knowledge, no comprehensive review has described their roles and knowledge in this context. Consequently, there is a pressing need to clearly outline the role of nurses in chronic disease management and their level of knowledge in Africa. This would facilitate the design of national strategies for nurse-led chronic disease management.

Our review question was: What were the nurses’ roles and knowledge in managing NCDs in Africa?

We aimed to provide a thorough description of the current roles of nurses in managing NCDs in Africa and identify their levels of knowledge, challenges, and gaps they encounter.

Methods

We conducted a scoping review [20] following the key points outlined in the Cochrane Handbook [21] from October 01, 2021, to February 10, 2022, with an update conducted before publication, extending until April 30, 2023. This study and its protocol were registered in the PROSPERO database (CRD42021267403). This study was reported following the Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [22].

Search strategy

To identify relevant articles for review, five databases were searched: MEDLINE, Web of Science, Embase, CINALH, and PyscINFO [23].

The search strategy used a combination of subject headings and keywords of the main topics of the review: nursing, noncommunicable diseases, and Africa. Additionally, a ‘‘title and abstract” search was performed for MEDLINE. The search strategy was adapted to suit the specificities of each database for the others. The search strategy used for each database are available in S1 Table.

Inclusion and exclusion criteria

Based on the review question, the inclusion criteria were defined using the PICOS framework. For the “population” item, all studies focusing on nurses’ NCDs management, nurses’ knowledge of NCDs, or adult patients receiving nursing intervention for NCDs management in Africa were included. Regarding the “intervention” item, studies describing all nurse-led activities regarding chronic diseases [i.e., tasks done by nurses to manage chronic disease, including those that are habitually performed by physicians [13]) or nurses’ chronic diseases knowledge evaluation were included. The "comparison" item was not defined because our review did not focus solely on interventional studies. The “Outcomes” items were defined as the efficacy of nursing interventions, nurses’ level of knowledge regarding NCDs, and gaps and challenges linked to nurses’ NCDs management. For the "study design" item, we included all study designs relevant to our topic. No language or publication date exclusion criteria were applied. Studies that did not specify specific outcomes for nurses were excluded. Studies were also excluded if they were incomplete study protocols or ongoing studies, editorials, conference proceedings, or if they were published in non-peer-reviewed journals.

Selection and data collection processes

Rayyan QRCI tool was used to export all identified articles and remove duplicates.

The study selection process was conducted independently by two researchers who were unaware to each other’s decisions in the two phases. Initially, studies were identified by reading the titles and abstracts, and eligible articles were then fully read. If disagreements arose, a third researcher was consulted.

Data extraction and data synthesis

Data extraction was systematically performed using an Excel spreadsheet that included information such as the first author’s name, publication year, journal, country where the study was conducted, main objective, study design, disease, intervention/nursing care of interest, sample characteristics, results regarding the intervention/impact of nursing care, facilitators, barriers, and study limitations identified by the authors. A descriptive synthesis was employed, and no meta-analysis was performed. Subgroup analyses were carried out based on disease type and study location.

Quality assessment

The bias and quality of each study were evaluated. Quantitative studies were evaluated using the Downs and Black scale[24]. Qualitative studies, were evaluated using the specific EQUATOR guidelines [25].

Ethical approval was not required for this study.

Results

The PRISMA flowchart summarizing the selection process is shown in Fig 1. Following the removal of duplicates, we screened a total of 3,464 articles. Of these, 3,009 were excluded as their titles and abstracts did not align with our specified criteria. Among the remaining 455 articles, a thorough review was conducted, leading to the identification of 111 articles that met our inclusion criteria and were subsequently included into this scoping review.

Fig 1. PRISMA flowchart.

Fig 1

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From: http://www.prisma-statement.org/.

Description of the selected studies

S2 Table describes the characteristics of each study. Among the 111 studies, 42 had a cross-sectional design, 19 were qualitative, 12 were prospective interventional non-randomized, 10 were retrospective data analysis, eight were randomized (controlled, cluster, or pilot), eight were quasi-experimental, five were descriptive, four were cohort studies, and three were mixed-method. Publication years ranged from 1985 to 2023. The results of the studies concerned 6,031 nurses and 182,791 patients from 20 African countries. The repartition of the studies in Africa is shown in Fig 2. South Africa was the country with the most important number of studies related to our review (n = 28), followed by Nigeria (n = 16), and Ghana (n = 12). The studies included in our review were mainly conducted in English-speaking African countries.

Fig 2. Distribution of included studies regarding the number of publications and language.

Fig 2

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Map credit: https://commons.wikimedia.org/wiki/File:BlankMap-Africa.svg#filelinks.

Quality assessment and limitations of the included studies

Overall, we found low-quality scores among the quantitative included studies. The median score for the Downs and Black scale was 14 (IQR: 11–17). The minimum score was 10, the maximum score was 28. Internal validity was the most concerned subscale for low scores with power calculation. Most of the studies did not calculate the sample size. The detailed Downs and Black scores for each study included in our review are presented in S3 Table. Qualitative studies met almost all quality standards of qualitative research regarding appropriate EQUATOR guidelines.

S2 Table shows the main limitations of the included studies. They were mainly related to small sample sizes and qualitative, non-randomized, or non-interventional studies.

Results of the included studies

The studies included in our review were 32.4% focusing on cancer (n = 36), 18% on cardiovascular diseases (n = 20), 17.1% on metabolic diseases (n = 19), 12.6% on mental illness (n = 14), 11.7% on chronic diseases globally (n = 13), 6.3% focusing on neurological diseases (n = 7), and 0.9% on chronic respiratory disease and chronic kidney diseases. S2 Table describes the results of each study.

Role and knowledge of nursing among chronic diseases

Among the 36 studies which focused on cancer, 12 were on breast cancer [26–36], 22 on cervical cancer [37–57], one on cancer generally [58] and one on oral cancer [59]. Studies on cervical cancer were focused on nurse-led screening and treatment of human papillomavirus. Screening strategies using nurses were effective, with good agreement with medical doctors. Nurses’ level of knowledge varied geographically and in a timely manner among cervical and breast cancer patients, ranging from low- to high-level knowledge. Nurse-led breast cancer screening was also implemented in a lower proportion than cervical cancer screening; however, after training, good examination skills were also identified [34], and a study focused on echography led by nurses with promising results [31].

Cardiovascular diseases were the second major topic of the included studies. There were 17 on high blood pressure [60–75], two on cardiovascular diseases globally [76, 77], and one on heart failure [78]. Nurses’ knowledge of high blood pressure varied importantly, ranging from poor to good knowledge after specific training. Nurses obtained a statistically significant improvement in blood pressure; they independently screened and managed blood pressure after training, following decision trees in rural and urban areas. Echocardiography was used to screen for heart failure in a study on nurse-led heart failure screening [78].

Diabetes exclusively represented metabolic diseases [79–97]. Nurses had varying levels of knowledge about diabetes and its complications ranging from poor associated with the misconception that diabetes was a contagious disease as an example [80] to good knowledge associated with improved diabetes management [83, 84, 86, 91]. In most of the studies, nurses were trained in diagnosis and monitoring including prescribing treatments and augmentation for diabetes. Decision trees and algorithms were used for this purpose.

Thirteen studies focused on managing or knowing chronic diseases globally, or among multiple chronic diseases [85, 98–109]. Nurses’ roles were similar to those described above: they managed chronic diseases, followed training with algorithms or decision trees, and supervision. They obtained positive outcomes for high blood pressure, diabetes, asthma, diabetes, sickle cell, and adherence [98, 99, 102, 104, 105, 108, 109].

Regarding mental illness, seven studies focused on mental illness globally [110–116], six on depression [117–122], and one on schizophrenia [123]. Globally, there was a gap in nurses’ mental health knowledge. They improved their knowledge with training and were able to perform psychological interventions, screening, and initiation of treatment improving the mental health status and satisfaction of patients.

Studies on neurological diseases included epilepsy (n = 4) [124–127], and post-stroke dysphagia (n = 3) [128–130]. Studies on post-stroke dysphagia were focused on nurses’ attitudes and knowledge. They found a low level of knowledge regarding the topic including diagnosis, evaluation, and treatment. Regarding epilepsy, these were interventional studies, where nurses could, after training, effectively manage epilepsy (diagnosis, treatment, and follow-up).

The two topics that were least covered were respiratory and chronic kidney diseases. A study focused on nurse-led management of asthma [131] was associated with an improvement in asthma condition in patients. One study focused on nurses’ level of knowledge of chronic kidney disease which remained moderate [132].

Challenges and gaps to nurse-led chronic diseases management

S2 Table shows the details of the challenges and gaps identified in our review. To summarize, the main challenges identified in our review to nurse-led chronic disease management were linked to the initial nurses’ knowledge gap regarding chronic diseases. The different curricula of the nurses did not include sufficient basic knowledge in each of our categories of chronic diseases. Other barriers were linked to the cost of care, shortage of nurses, lack of materials, and lack of transportation for patients.

Facilitators were also identified as key components of a well-done nurses’ task-shifting strategy. The first important facilitator was training; moreover, regular training, supervision by physicians, and mentorship were the key points associated with the effective implementation of nurse-led strategies. The training should include both theoretical and practical sessions, in which training varied widely between studies, from one session for half a day to multiple and repeated sessions. Moreover, the use of decision trees or algorithms was associated with positive patient outcomes. Using an already existent system, such as HIV clinics was also a favorable strategy to implement chronic diseases care.

Discussion

To the best of our knowledge, this scoping review represents a pioneering effort conducted in Africa to comprehensively delineate the roles and knowledge of nurses in managing NCDs. The findings of our review indicate that nurses possess varying levels of knowledge; however post-training, they demonstrate the capability to enhance the detection, treatment, and overall management of most chronic diseases. Effective task-shifting programs are achieved through essential components such as comprehensive training, ongoing supervision, and the use of decision trees, ensuring the quality of nurse-led interventions. While our review covered the major categories of chronic diseases, it is crucial to note that several subjects, such as Chronic Obstructive Pulmonary Disease and Alzheimer’s disease, received limited or no investigation in Africa.

The varying levels of knowledge among nurses about different chronic diseases, ranging from low to high, reflect the gaps in their initial training and curricula. This was also found in international literature for diabetes [133] as examples. Not all nursing diplomas in Africa are at the Bachelor’s level. Harmonizing the quality of higher education in nursing, as initiated by the African Union [134], is essential to improve the quality of care [135]. Increasing the level of training to the Bachelor’s level and incorporating chronic disease management into the curriculum can be instrumental in enhancing nurses’ capacity to manage NCDs effectively [10, 134].

Despite the variability in knowledge, our review demonstrated improved patient outcomes resulting from nursing interventions for chronic diseases. This observation aligns with existing evidence from task-shifting strategies implemented in the context of infectious diseases in Africa [17]. Numerous studies have already shown the effectiveness of nurses’ task-shifting strategies [14], such as managing cardiovascular diseases [136], detecting cancer [137], and providing mental health support [138, 139]. These strategies are encouraged by the WHO to enhance NCDs management [7, 10].

The challenges and gaps identified in our review were consistent with the literature on implementation science. Adequate training, well-designed strategies, supervision, funding, leadership, and sufficient resources are the key facilitators of successful implementation [140, 141]. Addressing these factors can lead to improved chronic disease management outcomes in the African healthcare systems.

The different task-shifting strategies identified in our review have prompted us to consider the potential of expanding nurses’ roles in Africa. The roles described in the studies closely align with those of advanced practice nursing notably regarding their clinical skills [142–144]. Implementing advanced practice nursing in addition to training nurses in task-shifting strategies could be an effective or complementary solution. Although the implementation of advanced practice nursing has begun in some African countries such as South Africa and Kenya, it remains limited [145]. Scaling up the implementation of advanced practice nursing across African countries could significantly improve chronic disease management [146] and population outcomes [143].

This study has important implications for public health. First, we emphasize the potential of task shifting to nurses to enhance healthcare access, particularly in regions with healthcare professional shortages. We also highlight the effectiveness of nurse-led chronic disease management, which supports the argument for efficient healthcare models, particularly in resource-constrained settings, where cost-effectiveness is paramount. Our research also indicates that nurse-led care can have a positive impact on patient satisfaction and outcomes, advocating for a shift towards patient-centered care models. This transformation is critical for improving management of chronic diseases. Nurse-led care also enhances continuity, ensuring that patients receive sustained support, education, and follow-up. This is of utmost importance in the effective management of chronic conditions and prevention of complications. Furthermore, our study highlighted the multifaceted role of nurses, extending beyond individual patient care to community health promotion. Nurses’ involvement in addressing the risk factors for chronic diseases at the community level is crucial. Moreover, our research suggests potential avenues for the development of training programs and educational initiatives designed to equip nurses with the skills and knowledge necessary for effective chronic disease management. Furthermore, our study calls for policymakers in each country to formally define, recognize, and support nurses’ roles in chronic disease management. This recognition could lead to the establishment of improved regulatory frameworks and increased resources for nurse-led care. Finally, our research contributes to data-driven decision-making within healthcare systems, enabling administrators to make informed choices regarding resource allocation.

Limitations

The results of our review must be interpreted with caution because of the relatively low quality of the included studies, particularly concerning their external validity and heterogeneity. Despite encountering studies with low scores in the Downs and Black assessment, we deliberately chose to include all the identified studies in our analysis. This decision stems from the nature of scoping reviews as a form of evidence synthesis that seeks to systematically identify and map the breadth of available evidence on a specific topic. Unlike other review types, the rigorous assessment of methodological quality is not an absolute prerequisite for scoping reviews. However, in our commitment to enhancing the quality and credibility of our research, we undertook the assessment to evaluate the methodological robustness of the included studies. This assessment was carried out to elevate the overall rigor of our study and to provide readers with a discerning evaluation of the studies’ evidentiary foundation. By undertaking this assessment, our intention was to ensure a high level of transparency, integrity, and meticulousness throughout our review process. More robust studies with randomized controlled designs are needed to ascertain the effectiveness of nurse-led interventions compared to usual care. Additionally, most of the included studies were conducted in English-speaking African countries, possibly influenced by the historical link between these countries and North America, where nurses have had an expanded role and have developed university nursing curricula and research partnerships [147].

Conclusions

We provide a comprehensive overview of nurses’ knowledge and role in managing NCDs using a robust scoping review methodology, making it the first in Africa. Our findings serve as a guide for future research and offer recommendations for developing nursing programs in Africa.

Nurses can play a crucial role in addressing the shortage of doctors and the treatment gap in managing chronic diseases. However, nurses require robust training, ongoing supervision, supportive environments, and strong policies to fulfill this potential. Further research with a robust study design is necessary to conclusively assess the effectiveness of these strategies. African countries employing task-shifting strategies should consider the implementation of advanced practice nursing, as evidenced by successful examples such as the management of diabetes in South Africa.

Supporting information

S1 Table. Search strategy for each database included in the review.

(DOCX)

pone.0297165.s001.docx (15.6KB, docx)
S2 Table. Description of the included studies.

Studies were classified according to disease type and in chronological order.

(DOCX)

pone.0297165.s002.docx (115.2KB, docx)
S3 Table. Downs and Black assessment for included studies.

(DOCX)

pone.0297165.s003.docx (211.9KB, docx)
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.

(DOCX)

pone.0297165.s004.docx (84.4KB, docx)

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Delfina Fernandes Hlashwayo

11 Jul 2023

PONE-D-23-15682Role and knowledge of nurses in the management of non-communicable diseases in Africa: a scoping reviewPLOS ONE

Dear Dr. Toniolo,

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.

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  1. Conduct thorough English proofreading to ensure that the manuscript adheres to proper grammar, style, and language usage.

  2. Improve the clarity and alignment of the abstract with the objectives of the study.

  3. Enhance the introduction by addressing any inconsistencies and providing a clearer explanation of the role of nurses in the context of the study.

  4. Reconsider the inclusion of studies with low quality in your review. Evaluate their impact on the overall credibility and reliability of the findings. If included, we encourage you to provide a rationale for their inclusion or consider excluding them from the study.

In addition to these key points, please consider the following suggestions:

  1. Please ensure to reference each supplementary file appropriately within the manuscript.

  2. To avoid redundancy, it would be advisable to keep the search terms in the supplementary file.

  3. Ensure that the information provided in Supplementary Table 2 is complete.

  4. Please verify the accuracy and completeness of your reference list, including all relevant references, such as Higgins et al., 2019, and ensure consistent citation format throughout the manuscript as per the guidelines provided by the journal.

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We look forward to receiving your revised manuscript.

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Delfina Fernandes Hlashwayo, M.Sc.

Academic Editor

PLOS ONE

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Reviewer #1: Yes

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: N/A

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: 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: The authors clearly were careful in choosing this topic. The paper definitely provides a solution to a widely asked question on the role of nurses and other health care providers apart from physicians / medical doctors and medical specialists in the diagnosis and management of non-communicable diseases in Africa where they are fast increasing in prevalence due to various life changing landscapes.

However, the authors need to correctly write some of their sentences for them to have a clear meaning to the readers.

Also, the conclusion of the study which clearly stated what role can the nurses assume in these circumstances need to be supported by other strong findings which were not sated in this particular paper. Such issues as what training and for how long needs to be researched and explained in detail for researchers to come to their stated conclusion.

Reviewer #2: I appreciate the opportunity to review the article Role and Knowledge of Nurses in the Management of non-communicable diseases in Africa: a scoping review.

This, without a doubt, is of interest for the development of nursing in the world, as well as it shows us a broad panorama of Nursing in Africa.

However, this document needs to be addressed in many aspects. I believe that if the researchers carry out an in-depth review of the document, as well as pay attention to all the comments, it can improve and be publishable in such a prestigious journal.

I comment on general points in case the researchers wish to attend to them and revise them.

In relation to the summary: specifically the method, this is more than explaining what the researchers did, it must explain the design and search strategy, as well as the sources of information.

The conclusion of the summary does not correspond to the stated objectives, it does not describe the levels of knowledge they have and how they manage non-communicable diseases.

They show nurses as a solution to the lack of doctors, but not to the lack of nurses itself.

Background: page 6 line 125. Place an acronym, after the words: non-communicable disease (NCD).

Page 6 lines 139-143: it mentions twice that task-shifting is used, the paragraph is repeated and it does not mention what they are, only that it worked for HIV management.

At the same time, it does not justify that the lack of doctors is responded to by nurses taking on more activities if there is also a lack of personnel. They are not compensated and there is no mention of interdisciplinary work.

Method: page 7, lines 158 to 163. It shows two types of appointments, it must be unified or in any case, for example. “According to Higgins(quote) in case you want to show the author's name.

Page 7 lines 168 -169. Much use is made of the first-person text, the passive voice is recommended in scientific articles.

On the other hand, in this same section, it is observed that it is improper to show the degrees of the researchers or what they did when this is shown in the contributions of the researcher.

Line 171-173. They could only mention the main topics of the review and mention the attached table in which it is specifically elaborated.

The search equations are removed from the method section and left as supplementary material.

Page 10 method section.: The inclusion and exclusion criteria could be reduced to population and intervention, including in the last part of the objectives that were sought, such as level of knowledge.

It does not include the years that are taken into account

Page 11. Line 251 is peer review, not double blinding

On pages 12 and 13 lines 295-299, I don't know if these results could make a table and point it out or if this comes in table 2, mention it.

Page 13, line 303, You could mention the chronic diseases found or not communicable and later describe them.

Page 15, Did the training last some time, was it given to all the nurses or specifically to a single group?

Also, was the level of knowledge prior to the training assessed in any way? or how to prove that it worked?

Page 16, line 394: use passive voice.

Page 18 line 435 is missing an S.

Page 19 lines 453 to 459: Perhaps advanced practiced nurses because of the knowledge they have, but non-specialized nurses could not be a solution.

I recognize the supplementary material 2 summary table of the 111 articles is too extensive and has something that worries me a little. The document speaks in general about the knowledge that Nursing has, but in these articles, the population is doctors, nurses, and patients. Wouldn't it be exclusive to have different types of targeted populations? It seems that there was no systematization, but if this point is clarified, we will gladly continue.

In supplemental material number 3. I consider that there are very low scores. Because those articles were not removed as they have poor methodological quality.

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Reviewer #1: No

Reviewer #2: No

**********

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Attachment

Submitted filename: Recommendation for the Reviewed Journal.docx

pone.0297165.s005.docx (13.7KB, docx)
PLoS One. 2024 Apr 18;19(4):e0297165. doi: 10.1371/journal.pone.0297165.r002

Author response to Decision Letter 0

23 Aug 2023

Dear Delfina Fernandes Hlashwayo,

We would like to express our gratitude to you and the esteemed reviewers for dedicating valuable time and providing insightful feedback on our manuscript PONE-D-23-15682 entitled “Role and knowledge of nurses in the management of non-communicable diseases in Africa: a scoping review”.

Your constructive comments have undoubtedly enhanced the quality and rigor of our research, and we are honored by the opportunity to address these concerns and suggestions.

In this response letter, we have diligently addressed below each reviewer's comments, providing detailed explanations of the revisions we have made to the manuscript. The changes were highlighted in the manuscript.

Editor comments :

1. Conduct thorough English proofreading to ensure that the manuscript adheres to proper grammar, style, and language usage.

We performed a complete proofreading of the paper.

2. Improve the clarity and alignment of the abstract with the objectives of the study.

The abstract was modified in alignment with the objectives of the study: p3-4 L60-86.

3. Enhance the introduction by addressing any inconsistencies and providing a clearer explanation of the role of nurses in the context of the study.

We rewrite and completed the introduction : p4-6.

4. Reconsider the inclusion of studies with low quality in your review. Evaluate their impact on the overall credibility and reliability of the findings. If included, we encourage you to provide a rationale for their inclusion or consider excluding them from the study.

We added a paragraph in the Method section (L193-195) and the Limitations section (L359-369). It is important to note that the low-quality scores obtained by qualitative studies were due to the use of the Downs and Black scale, which was initially constructed for quantitative studies, this scale was employed as part of our concerted endeavor to standardize our evaluative approach. To enhance clarity, we removed the assessment of qualitive studies by the Downs and Black scale. We ensured the quality of qualitative studies using appropriate EQUATOR guidelines.

Furthermore, it is essential to clarify the nature of scoping reviews. Scoping reviews are a type of evidence synthesis that aims “to systematically identify and map the breadth of evidence available on a particular topic, field, concept, or issue, often irrespective of the source (i.e., primary research, reviews, non-empirical evidence) within or across specific contexts. Scoping reviews can clarify key concepts and definitions in the literature and identify key characteristics or factors related to a concept, including those related to methodological research”(Munn, 2022, JBI evidence synthesis). Moreover, regarding the assessment of the methodological quality of included studies, it is not a strict requirement for scoping reviews. However, we performed this assessment to elevate the quality of our research work and to provide a critical appraisal for readers regarding the level of evidence of the studies' findings. By conducting this assessment, we aimed to ensure transparency and rigor in our review process. Taken together, these arguments make it possible to maintain all the studies included in our review.

In addition to these key points, please consider the following suggestions:

1. Please ensure to reference each supplementary file appropriately within the manuscript.

It was done.

2. To avoid redundancy, it would be advisable to keep the search terms in the supplementary file.

It was done.

3. Ensure that the information provided in Supplementary Table 2 is complete.

The information provided in supplementary table 2 is complete.

4. Please verify the accuracy and completeness of your reference list, including all relevant references, such as Higgins et al., 2019, and ensure consistent citation format throughout the manuscript as per the guidelines provided by the journal.

We adjusted the reference list and verified citation format throughout the manuscript.

5. We kindly request you to remove any unnecessary components of the main manuscript file, such as the Funding Statement, Declaration of Interests, Authorship Contribution, and Twitter handles. These can be included in the online submission system.

It was done.

Journal requirements:

1. Please ensure that your manuscript meets PLOS ONE's style requirements

We modified the manuscript.

2. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety.

S1 and S2 tables are available with the manuscript, they provide essential information that allows for the replication of the study findings.

3. Please include a separate caption for each figure in your manuscript.

It was done.

4. We note that Figure 2 in your submission contain [map/satellite] images which may be copyrighted.

We have modified Fig 2 using a non-copyrighted map from the public domain source: https://commons.wikimedia.org/wiki/File:BlankMap-Africa.svg#filelinks.

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly.

It was done: p26

Reviewer #1:

“The authors clearly were careful in choosing this topic. The paper definitely provides a solution to a widely asked question on the role of nurses and other health care providers apart from physicians / medical doctors and medical specialists in the diagnosis and management of non-communicable diseases in Africa where they are fast increasing in prevalence due to various life changing landscapes.”

Thank you for your positive comments.

“However, the authors need to correctly write some of their sentences for them to have a clear meaning to the readers.”

We performed a complete proofreading of the paper.

“Also, the conclusion of the study which clearly stated what role can the nurses assume in these circumstances need to be supported by other strong findings which were not sated in this particular paper. Such issues as what training and for how long needs to be researched and explained in detail for researchers to come to their stated conclusion.”

We modified the conclusion section (P16 L374-385) and precise in the results sections for training (P13 L297-298).

Reviewer #2:

“I appreciate the opportunity to review the article Role and Knowledge of Nurses in the Management of non-communicable diseases in Africa: a scoping review.

This, without a doubt, is of interest for the development of nursing in the world, as well as it shows us a broad panorama of Nursing in Africa.

However, this document needs to be addressed in many aspects. I believe that if the researchers carry out an in-depth review of the document, as well as pay attention to all the comments, it can improve and be publishable in such a prestigious journal.

I comment on general points in case the researchers wish to attend to them and revise them.”

Thank you for your positive comments.

“In relation to the summary: specifically the method, this is more than explaining what the researchers did, it must explain the design and search strategy, as well as the sources of information.

The conclusion of the summary does not correspond to the stated objectives, it does not describe the levels of knowledge they have and how they manage non-communicable diseases.

They show nurses as a solution to the lack of doctors, but not to the lack of nurses itself.”

We modified the abstract according to these suggestions: P3-4 L60-86.

“Background: page 6 line 125. Place an acronym, after the words: non-communicable disease (NCD).”

It was done and the acronym was used throughout the manuscript.

“Page 6 lines 139-143: it mentions twice that task-shifting is used, the paragraph is repeated and it does not mention what they are, only that it worked for HIV management.

At the same time, it does not justify that the lack of doctors is responded to by nurses taking on more activities if there is also a lack of personnel. They are not compensated and there is no mention of interdisciplinary work.”

We modified this paragraph, we clearly describe the role of nurses for HIV and explained the role of nurses for chronic disease management as well as the fact that they work independently or collaboratively. (P5-6 L119-128)

“Method: page 7, lines 158 to 163. It shows two types of appointments, it must be unified or in any case, for example. “According to Higgins(quote) in case you want to show the author's name.”

It was modified.

“Page 7 lines 168 -169. Much use is made of the first-person text, the passive voice is recommended in scientific articles.”

We modified the method section using passive voice. (P6-9)

“On the other hand, in this same section, it is observed that it is improper to show the degrees of the researchers or what they did when this is shown in the contributions of the researcher.”

We withdrew the sentence.

“Line 171-173. They could only mention the main topics of the review and mention the attached table in which it is specifically elaborated.

The search equations are removed from the method section and left as supplementary material.”

It was done.

“Page 10 method section.: The inclusion and exclusion criteria could be reduced to population and intervention, including in the last part of the objectives that were sought, such as level of knowledge.”

We have modified this paragraph, but still using the PICOS method, which provides greater clarity from our point of view. (P7-8 L 161-175).

“It does not include the years that are taken into account.”

It was noted that “No language or publication date exclusion criteria were applied” (P8 L 173).

“Page 11. Line 251 is peer review, not double blinding”

Each investigator was unaware to the other's decisions regarding the inclusion of articles and throughout the other steps of the literature review, We modified the sentence. (P8 L179-180).

“On pages 12 and 13 lines 295-299, I don't know if these results could make a table and point it out or if this comes in table 2, mention it.”

Results are available in S2 Table, we mentioned it: P10 L227.

“Page 13, line 303, You could mention the chronic diseases found or not communicable and later describe them.”

We modified the paragraph but as the study focused on the different diseases we prefer immediately mentioned them. (P10 L231)

“Page 15, Did the training last some time, was it given to all the nurses or specifically to a single group? Also, was the level of knowledge prior to the training assessed in any way? or how to prove that it worked?”

It is difficult to summarize the content of all the training programs for all the studies in a few lines, so we have modified the paragraph and added some clarifications, as for the other studies, the study design and content of the training programs are available in the S2 Table. (P13 L 293 – 301)

“Page 16, line 394: use passive voice.”

It was done. (P14 L327)

“Page 18 line 435 is missing an S.”

It was modified.

“Page 19 lines 453 to 459: Perhaps advanced practiced nurses because of the knowledge they have, but non-specialized nurses could not be a solution.”

I agree with you but advanced practice nursing is not the only solution to address the healthcare challenges. Registered nurses, with appropriate training and support, can indeed play a crucial role in task-shifting strategies. By expanding the scope of practice for registered nurses and providing them with additional training in specific areas, they can effectively take on tasks traditionally performed by advanced practice nurses or physicians. Task-shifting to nurses is a viable and effective approach in various healthcare settings, especially in regions with limited healthcare resources, such as many parts of Africa.

We modified the conclusion. (P16 L374-386)

“I recognize the supplementary material 2 summary table of the 111 articles is too extensive and has something that worries me a little. The document speaks in general about the knowledge that Nursing has, but in these articles, the population is doctors, nurses, and patients. Wouldn't it be exclusive to have different types of targeted populations? It seems that there was no systematization, but if this point is clarified, we will gladly continue.”

We specified this point in the method (P7-8 L172-176). As described in the method, we included all studies that specifically examined nurses' involvement in chronic disease management or assessed nurses' knowledge related to chronic diseases. We excluded studies that did not provide explicit outcomes related to nurses to maintain a focused and relevant analysis. However, it is important to note that the studies we considered could involve not only nurses but also patients or doctors. As part of our comprehensive approach, we have reported the complete composition of the study population.

“In supplemental material number 3. I consider that there are very low scores. Because those articles were not removed as they have poor methodological quality.”

As explained above, very low scores were linked to qualitative design. We added a paragraph in the Method section (L193-195) and the Limitations section (L359-369). It is important to note that the low-quality scores obtained by qualitative studies were due to the use of the Downs and Black scale, which was initially constructed for quantitative studies. Despite receiving low scores, these qualitative studies were of good quality and adhered to the standards for qualitative research. This scale was employed as part of our concerted endeavor to standardize our evaluative approach. To enhance clarity, we removed the assessment of qualitive studies by the Downs and Black scale. We ensured the quality of qualitative studies using appropriate EQUATOR guidelines.

We believe that the revisions we have implemented significantly improve the overall clarity and impact of our work. The revised manuscript now aligns more closely with the high standards set by PLOS One, and we are confident that it will contribute meaningfully to the scientific community.

Once again, we express our gratitude for the guidance provided by the reviewers and yourself. We are committed to ensuring the highest quality of our research and welcome any further suggestions for improvement.

Please find attached the revised version of the manuscript.

Thank you for your continued support, and we eagerly await your decision on our revised submission.

Sincerely

Attachment

Submitted filename: Response to Reviewers.docx

pone.0297165.s006.docx (25.2KB, docx)

Decision Letter 1

Delfina Fernandes Hlashwayo

10 Oct 2023

PONE-D-23-15682R1Role and knowledge of nurses in the management of non-communicable diseases in Africa: a scoping reviewPLOS ONE

Dear Dr. Toniolo,

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.

In addition to the comments made by the two reviewers, please address the following points in the revised version of the manuscript:

General comments:

  1. Please review the writing in the entire manuscript to ensure there are no grammatical errors, typos, or any other issues.

  2. Please review the abbreviation: NCDs stand for non-communicable diseases, while 'NCD' is used for the singular term.

Methods:

  1. Line 146: Consider capitalizing "PROSPERO" for consistency.

  2. Line 157: In the context of systematic reviews and database searches, the term "equation" is not commonly used. Instead, the more appropriate term is "search strategy."

  3. Lines 204-205: Please review the sentence construction for improved clarity.

Results:

  1. Line 225: Replace "6,3%" with "6.3%" for standard numeric representation.

  2. Line 304: Consider using "overall" instead of "globally" for better precision.

  3. Reevaluate the placement of the quality assessment in the results section; it might be more suitable to position it elsewhere rather than at the end.

Discussion: Please expand on the implications of your results for public health.

Conclusions:

  1. Consider beginning without the phrase 'despite these limitations'.

  2. Lines 383-384: Instead of "will guide," consider "serves as a guide for future research."

  3. It is not customary to include citations in the conclusions section.

Figures and Supplementary files:

  1. Fig 2: Please rephrase the caption for better clarity. Consider using a term other than "repartition" for improved adequacy.

  2. S2 Table: Consider repeating header rows for enhanced clarity.

Please submit your revised manuscript by Nov 24 2023 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,

Delfina Fernandes Hlashwayo, M.Sc.

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 #3: All comments have been addressed

Reviewer #4: 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 #3: Partly

Reviewer #4: Yes

**********

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

Reviewer #3: N/A

Reviewer #4: 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 #3: No

Reviewer #4: 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 #3: Yes

Reviewer #4: 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 #3: This manuscript provides a comprehensive overview to help guide the management of NCDs in Africa. There are a few recommendations. In the introduction section, the authors should articulate the nursing roles for the management of NCDs as defined by nursing organizations within the country. This will enable a thorough discussion of this information with the study's findings. Additionally, it would be advantageous to provide a clear description of the levels of evidence present in the included studies.

Reviewer #4: Reviwer’s comments

The authors have chosen a very interesting topic. The world is faced with a growing number of chronic diseases.

• In line 123, the sentence seems incomplete , I suggest that the authors complete the sentence

• In line 135 – well done to the authors -the review question is relevant in achieving the aim and objectives of the study.

• In terms of the results section, I suggest that the authors should start by describing the types of the studies reviewed, then present the reviewed results . the contents in line 210-219 may have been presented before the roles and knowledge of the nurses.

• It should have been of importance if the findings from the review were presented in themes , the reader of the manuscripts should know the types of roles and the knowledge found in the review.

• In line 282-300, the authors presented the barriers and facilitators ,where as in the aims of the study the authors talked about challenges and gaps. This creates a confusion. It feels like it is a two in one study. I suggest the authors be consistent with the words used.

• Line 315-324, the paragraph does not have reference, the starting of the paragraph starts with “To our knowledge …” which may show assumption , I believe there has been more reviews , this review may be adding to the available or bringing in new knowledge. I suggest that the authors look into paragraph.

• The study reviewed 111 studies, however in line 343-247,only two studies were included in relation to the barriers and facilitators.

**********

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 #3: No

Reviewer #4: 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.

Attachment

Submitted filename: Reviwer comments Plos One.docx

pone.0297165.s007.docx (13.6KB, docx)
PLoS One. 2024 Apr 18;19(4):e0297165. doi: 10.1371/journal.pone.0297165.r004

Author response to Decision Letter 1

16 Oct 2023

Dear Delfina Fernandes Hlashwayo,

We would like to express our gratitude to you and the esteemed reviewers for dedicating valuable time and providing insightful feedback on our manuscript PONE-D-23-15682R1 entitled “Role and knowledge of nurses in the management of non-communicable diseases in Africa: a scoping review”.

Your constructive comments have undoubtedly enhanced the quality and rigor of our research, and we are honored by the opportunity to address these concerns and suggestions.

In this response letter, we have diligently addressed below each reviewer's comments, providing detailed explanations of the revisions we have made to the manuscript. The changes were highlighted in the manuscript.

Editor comments :

General comments:

1. Please review the writing in the entire manuscript to ensure there are no grammatical errors, typos, or any other issues.

It was done.

2. Please review the abbreviation: NCDs stand for non-communicable diseases, while 'NCD' is used for the singular term.

It was done.

Methods:

1. Line 146: Consider capitalizing "PROSPERO" for consistency.

It was done.

2. Line 157: In the context of systematic reviews and database searches, the term "equation" is not commonly used. Instead, the more appropriate term is "search strategy."

We have modified it.

3. Lines 204-205: Please review the sentence construction for improved clarity.

We modified this sentence: “Following the removal of duplicates, we screened a total of 3,464 articles. Of these, 3,009 were excluded as their titles and abstracts did not align with our specified criteria. Among the remaining 455 articles, a thorough review was conducted, leading to the identification of 111 articles that met our inclusion criteria and were subsequently included into this scoping review.”

Results:

1. Line 225: Replace "6,3%" with "6.3%" for standard numeric representation.

It was done.

2. Line 304: Consider using "overall" instead of "globally" for better precision.

We modified it.

3. Reevaluate the placement of the quality assessment in the results section; it might be more suitable to position it elsewhere rather than at the end.

We modified the order of the result section.

4. Discussion: Please expand on the implications of your results for public health.

We added a paragraph at the end of the discussion: “This study has important implications for public health. First, we emphasize the potential of task shifting to nurses to enhance healthcare access, particularly in regions with healthcare professional shortages. We also highlight the effectiveness of nurse-led chronic disease management, which supports the argument for efficient healthcare models, particularly in resource-constrained settings, where cost-effectiveness is paramount. Our research also indicates that nurse-led care can have a positive impact on patient satisfaction and outcomes, advocating for a shift towards patient-centered care models. This transformation is critical for improving management of chronic diseases. Nurse-led care also enhances continuity, ensuring that patients receive sustained support, education, and follow-up. This is of utmost importance in the effective management of chronic conditions and prevention of complications. Furthermore, our study highlighted the multifaceted role of nurses, extending beyond individual patient care to community health promotion. Nurses' involvement in addressing the risk factors for chronic diseases at the community level is crucial. Moreover, our research suggests potential avenues for the development of training programs and educational initiatives designed to equip nurses with the skills and knowledge necessary for effective chronic disease management. Furthermore, our study calls for policymakers in each country to formally define, recognize, and support nurses' roles in chronic disease management. This recognition could lead to the establishment of improved regulatory frameworks and increased resources for nurse-led care. Finally, our research contributes to data-driven decision-making within healthcare systems, enabling administrators to make informed choices regarding resource allocation.”

Conclusions:

1. Consider beginning without the phrase 'despite these limitations'.

It was done.

2. Lines 383-384: Instead of "will guide," consider "serves as a guide for future research."

We modified it.

3. It is not customary to include citations in the conclusions section.

We modified it.

Figures and Supplementary files:

1. Fig 2: Please rephrase the caption for better clarity. Consider using a term other than "repartition" for improved adequacy.

We modified this term by “distribution”.

2. S2 Table: Consider repeating header rows for enhanced clarity.

We modified it.

Reviewer #2:

The authors have chosen a very interesting topic. The world is faced with a growing number of chronic diseases.

Thank you for your positive comment.

• In line 123, the sentence seems incomplete, I suggest that the authors complete the sentence

We modified this sentence.

• In line 135 – well done to the authors -the review question is relevant in achieving the aim and objectives of the study.

Thank you for your positive comment.

• In terms of the results section, I suggest that the authors should start by describing the types of the studies reviewed, then present the reviewed results. The contents in line 210-219 may have been presented before the roles and knowledge of the nurses.

We modified the order in the results section.

• It should have been of importance if the findings from the review were presented in themes, the reader of the manuscript should know the types of roles and the knowledge found in the review.

Themes have been synthesized in the Discussion section, and we posit that pathology-specific synthesis is of paramount importance. This approach enhances the practicality and clarity of the results obtained from our research, particularly when considering the various pathologies addressed. This methodology enables the identification of interventions specific to each pathology in response to encountered issues, thus simplifying the process for the stakeholders. For instance, it is more straightforward to pinpoint mental health-related interventions in response to particular challenges than to seek general therapeutic education practices applicable across all contexts. Consequently, we have maintained the structure of the results section to reflect this comprehensive approach.

• In line 282-300, the authors presented the barriers and facilitators, whereas in the aims of the study the authors talked about challenges and gaps. This creates a confusion. It feels like it is a two in one study. I suggest the authors be consistent with the words used.

We modified the terms and standardize them.

• Line 315-324, the paragraph does not have reference, the starting of the paragraph starts with “To our knowledge …” which may show assumption, I believe there has been more reviews, this review may be adding to the available or bringing in new knowledge. I suggest that the authors look into paragraph.

We have revised the paragraph to present a more nuanced perspective, although we did not find any additional reviews on this specific topic. This section does not include references, as it serves as a synthesis of our research findings.

• The study reviewed 111 studies, however in line 343-247, only two studies were included in relation to the barriers and facilitators.

The two studies cited are not included in the review. These studies are used here to discuss the challenges and gaps identified in our review.

Reviewer #3:

This manuscript provides a comprehensive overview to help guide the management of NCDs in Africa. There are a few recommendations.

Thank you for your positive comment.

In the introduction section, the authors should articulate the nursing roles for the management of NCDs as defined by nursing organizations within the country. This will enable a thorough discussion of this information with the study's findings.

It is difficult to use country-specific definitions of nursing care. Indeed, there is not necessarily an authority regulating the nursing profession in every country, and because this is a global description, we wanted to use a universal international definition of nursing care.

Additionally, it would be advantageous to provide a clear description of the levels of evidence present in the included studies.

The quality scores of the included studies can be found in Table S3. It's important to note that, as a scoping review, the evaluation of study quality and level of evidence was undertaken to enhance the overall quality of our research and to offer readers a critical appraisal of the studies' findings. This assessment was carried out with the objective of ensuring transparency and rigor in our review process, although it is not considered a methodological mandatory requirement.

We believe that the revisions we have implemented significantly improve the overall clarity and impact of our work. The revised manuscript now aligns more closely with the high standards set by PLOS One, and we are confident that it will contribute meaningfully to the scientific community.

Once again, we express our gratitude for the guidance provided by the reviewers and yourself. We are committed to ensuring the highest quality of our research and welcome any further suggestions for improvement.

Please find attached the revised version of the manuscript.

Thank you for your continued support, and we eagerly await your decision on our revised submission.

Sincerely yours.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0297165.s008.docx (27KB, docx)

Decision Letter 2

Ermel Johnson

5 Dec 2023

PONE-D-23-15682R2Role and knowledge of nurses in the management of non-communicable diseases in Africa: a scoping reviewPLOS ONE

Dear Dr. Toniolo,

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 19 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.

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,

Ermel Johnson, MD, MPH, PhDc

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 #3: All comments have been addressed

Reviewer #4: 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 #3: Partly

Reviewer #4: Yes

**********

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

Reviewer #3: N/A

Reviewer #4: N/A

**********

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 #3: Yes

Reviewer #4: 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 #3: Yes

Reviewer #4: 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 #3: In the introduction section, the authors should articulate the nursing roles for the management of NCDs as defined by nursing organizations within the region. This will be consistent with the manuscript title and facilitates a comprehensive discussion of this information with the study's findings.

Reviewer #4: Thank you for addressing all the comments. The manuscript can be accepted for publication. The publication will assist other researchers on integrated management of communicable and non communicable diseases.

**********

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Reviewer #3: No

Reviewer #4: No

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PLoS One. 2024 Apr 18;19(4):e0297165. doi: 10.1371/journal.pone.0297165.r006

Author response to Decision Letter 2

6 Dec 2023

Dear Ermel Johnson,

We would like to express our gratitude to you and the esteemed reviewers for dedicating valuable time and providing insightful feedback on our manuscript PONE-D-23-15682R1 entitled “Role and knowledge of nurses in the management of non-communicable diseases in Africa: a scoping review”.

Your constructive comments have undoubtedly enhanced the quality and rigor of our research, and we are honored by the opportunity to address these concerns and suggestions.

In this response letter, we have diligently addressed below each reviewer's comments, providing detailed explanations of the revisions we have made to the manuscript. The changes were highlighted in the manuscript.

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.

It was done. We added two references linked to the reviewers comments.

Reviewer #3:

1. In the introduction section, the authors should articulate the nursing roles for the management of NCDs as defined by nursing organizations within the region. This will be consistent with the manuscript title and facilitates a comprehensive discussion of this information with the study's findings.

We added a paragraph in the introduction, L130-145.

Reviewer #4:

1. Thank you for addressing all the comments. The manuscript can be accepted for publication. The publication will assist other researchers on integrated management of communicable and non communicable diseases.

Thank you very much.

We believe that the revisions we have implemented significantly improve the overall clarity and impact of our work. The revised manuscript now aligns more closely with the high standards set by PLOS One, and we are confident that it will contribute meaningfully to the scientific community.

Once again, we express our gratitude for the guidance provided by the reviewers and yourself. We are committed to ensuring the highest quality of our research and welcome any further suggestions for improvement.

Please find attached the revised version of the manuscript.

Thank you for your continued support, and we eagerly await your decision on our revised submission.

Sincerely yours.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0297165.s009.docx (22.5KB, docx)

Decision Letter 3

Ermel Johnson

2 Jan 2024

Role and knowledge of nurses in the management of non-communicable diseases in Africa: a scoping review

PONE-D-23-15682R3

Dear Dr. Toniolo,

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,

Ermel Johnson, MD, MPH, PhDc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Ermel Johnson

24 Mar 2024

PONE-D-23-15682R3

PLOS ONE

Dear Dr. Toniolo,

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,

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Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ermel Johnson

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Search strategy for each database included in the review.

    (DOCX)

    pone.0297165.s001.docx (15.6KB, docx)
    S2 Table. Description of the included studies.

    Studies were classified according to disease type and in chronological order.

    (DOCX)

    pone.0297165.s002.docx (115.2KB, docx)
    S3 Table. Downs and Black assessment for included studies.

    (DOCX)

    pone.0297165.s003.docx (211.9KB, docx)
    S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.

    (DOCX)

    pone.0297165.s004.docx (84.4KB, docx)
    Attachment

    Submitted filename: Recommendation for the Reviewed Journal.docx

    pone.0297165.s005.docx (13.7KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0297165.s006.docx (25.2KB, docx)
    Attachment

    Submitted filename: Reviwer comments Plos One.docx

    pone.0297165.s007.docx (13.6KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0297165.s008.docx (27KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0297165.s009.docx (22.5KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its Supporting Information files.

    Articles from PLOS ONE are provided here courtesy of PLOS

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