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. 2022 Aug 17;17(8):e0271914. doi: 10.1371/journal.pone.0271914

Social and behavioral factors related to blood pressure measurement: A cross-sectional study in Bhutan

Hiromi Kohori Segawa 1,2, Hironori Uematsu 1, Nidup Dorji 3, Ugyen Wangdi 3, Chencho Dorjee 3, Pemba Yangchen 4, Susumu Kunisawa 1, Ryota Sakamoto 5, Yuichi Imanaka 1,*
Editor: Marcelo Arruda Nakazone6
PMCID: PMC9385017  PMID: 35976922

Abstract

Cardiovascular disease is a leading cause of death in the Kingdom of Bhutan, and early detection of hypertension is critical for preventing cardiovascular disease. However, health-seeking behavior, including blood pressure measurement, is infrequently investigated in Bhutan. Therefore, this study investigated factors related to blood pressure measurement in Bhutan. We performed a secondary data analysis of a target population of 1,962 individuals using data from the “2014 Bhutan STEPS survey data”as a cross-sectional study. Approximately 26% of those with hypertension who were detected during the STEPS survey had never had their blood pressure measured. Previous blood pressure measurement was significantly associated with age and working status in men (self-employed [odds ratio (OR): 0.219, 95% CI: 0.133–0.361], non-working [OR: 0.114, 95% CI: 0.050–0.263], employee [OR: 1.000]). Previous blood pressure measurement was significantly associated with higher income in women (Quartile-2 [OR: 1.984, 95% CI: 1.209–3.255], Quartile-1 [OR: 2.161, 95% CI: 1.415–3.299], Quartile-4 [OR: 1.000]). A family history of hypertension (OR: 2.019, 95% CI: 1.549–2.243) increased the likelihood of having experienced a blood pressure measurement in both men and women. Multivariate logistic regression showed that people with unhealthy lifestyles (high salt intake [adjusted odds ratio (AOR): 0.247, 95% confidence interval (CI): 0.068–0.893], tobacco use [AOR: 0.538, 95% CI: 0.380–0.761]) had a decreased likelihood of previous blood pressure measurement. To promote the early detection of hypertension in Bhutan, we suggest that more attention be paid to low-income women, non-working, self-employed, and low-income men, and a reduction of barriers to blood pressure measurement. Before the STEPS survey, a substantial number of hypertensive people had never had their blood pressure measured or were unconcerned about their health. As a result, we propose that early blood pressure monitoring and treatment for people with hypertension or at higher risk of hypertension be given increased emphasis.

Introduction

According to the World Health Organization (WHO), 38 million people die from non-communicable diseases (NCDs) annually. Approximately three-quarters of these deaths (28 million) occur in low- and middle-income countries [1]. This increase in NCDs, such as cardiovascular disease, has led to an economic burden on individuals, families, and society [2].

Hypertension is one of the strongest risk factors for almost all cardiovascular diseases. The course of cardiovascular disease is indicated by asymptomatic alterations in numerous organs linked with hypertension [3]. Secondary prevention strategies such as screening, early detection, counseling, and continued follow-up of people with high blood pressure are essential to prevent cardiovascular-related diseases. There is, however, a distinction between the true prevalence of hypertension and the rates of diagnosis and treatment [4].

Similarly, in the Kingdom of Bhutan, mortality due to NCDs has increased from 53% (2008) to 69% (2016) [5, 6] and is the leading cause of mortality [6]. The government of Bhutan provides free access to basic public health services for all its citizens, and the Ministry of Health has initiated primary prevention programs such as maintaining a healthy diet, avoiding alcohol and tobacco, and exercising, all of which are essential in preventing NCDs [7–9].

However, a previous qualitative study indicated that most Bhutanese have inadequate knowledge about how to protect themselves from hypertension through daily practices, although they wish to be healthy because health is an important factor for happiness [10]. The participants were diagnosed with hypertension during previous fieldwork conducted in 2017, and some had never had their blood pressure measurement before this fieldwork and were unaware of the importance of regular blood pressure measurement [10]. Furthermore, according to the STEPS survey report, “Around 31.3% of the study population had never had their blood pressure checkup. The prevalence of raised blood pressure or hypertension (SBP≥140 and/or DBP≥90) was 35.7% (men 35.5%, women 35.9%) when those currently using medication were included.” [7].

Blood pressure measurement is vital as a first step in subsequent hypertension prevention. Therefore, the STEPS survey data can be used to determine which social backgrounds are associated with lower blood pressure measurements in Bhutan. This can also reveal which high-risk behaviors for hypertension are associated with blood pressure measurement. However, in Bhutan, these topics have received less attention, especially in terms of quantitative and representative research.

In this study, we looked into the social backgrounds of those who had less access to blood pressure measurement, as well as behavioral factors associated with less blood pressure measurement experience, in order to contribute to more hypertension prevention efforts in Bhutan.

We need to consider both aspects of " access and behaviors" and "vulnerability" when examining the prevention of severe hypertension and early detection of hypertension. We have a related manuscript, the aspect from "vulnerability". https://doi.org/10.1371/journal.pone.0256811.

Objectives

To use the STEPS survey in Bhutan to investigate

  1. The social factors that are associated with less blood pressure measurement experience.

  2. Whether high-risk behavioral factors for hypertension are associated with less blood pressure measurement experience.

Methods

Study design

This cross-sectional study was conducted using data from the “National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan– 2014” [7].

Study setting

Bhutan is located in the eastern Himalayas between India in the east, west, and south and China in the north. This region has an area of 38,394 km2. As of 2020, the Bhutanese population was estimated to be 748,931 [11]. The gross domestic product (GDP) per capita was estimated to be USD 3,411.94 in 2019 [11]. Bhutan’s national development is based on the philosophy of “gross national happiness (GNH)”, which aspires to sustainable development and happiness for all its citizens [12, 13].

Data sources

Data were derived from the “National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan– 2014”, which was conducted by WHO and the government of Bhutan from March to June 2014 [7]. The sample size was 2,912, which was considered sufficient to represent the target population (adults aged 18–69 years) in Bhutan (S1 File). To ensure the representativeness of the sample, the study applied multistage cluster sampling combined with probability measures proportionate to the size and systematic random sampling. The strata level considered was urbanicity (rural: urban = 7:3); an area block was designated as the cluster level (n = 182) and was selected from gewogs (group of villages). The Kish method was applied to select participants from each household using age and gender as variables, and the sampling framework from the “Population and Housing Census of Bhutan 2005” was employed [14]. According to the sampling plan, trained health staff recruited participants in each sampling field where the participants were living. Trained health staff collected data through face-to-face interviews. The number of valid respondents was 2,822 with a response rate of 97%. A previous report by WHO and the Ministry of Health in Bhutan provides the details of the survey procedure [7].

Definitions of variables

Objective variables

Previous blood pressure measurement was defined as 1 for "Yes" and 0 for "No" for the questionnaire item in the survey “Have you ever had your blood pressure measured by a doctor or other health worker?” (This question regarded the period before the survey, excluding blood pressure measurement that occurred during the survey).

Explanatory variables

Explanatory variables were selected and categorized mainly by following the WHO guidelines [15] and previous literature [16–30].

Gender (men, women), marital status (married or cohabiting, never married, separated or divorced or widowed), age, level of education (non-formal education, elementary education [1–10 years], high school education [11–12 years], and tertiary education [above 12 years]; a promotion test is given in the 10th and 12th years in Bhutan), working status (i.e., employed, self-employed, and non-working), residential area (urbanicity), income (Quartile-1 (Q1) (Nu. 60,001+: USD 805.8+), Quartile-2 (Q2) (Nu. 30,001–60,000: USD 403.0–805.7), Quartile-3 (Q3) (Nu. 9,001–30,000: USD 120.9–402.9), Quartile-4 (Q4) (Nu. 0–9,000: USD 0–120.8)), and survey language (Dzongkha, Tshanglakha, Lhotshamkha, English) were also recorded.

Tobacco use (never, current, or any [not only smoking but also chewing tobacco]) [15], alcohol consumption (none, light or moderate, or heavy) [15, 21], fruit and vegetables consumption (<5, 5, or >5 portions per day) [15, 19], physical activity level (≥150 min of moderate activity per week or <150 min of moderate activity per week) [15, 20], and estimated salt intake (<5 g, 5 g, or >5 g per day with a cutoff point determined according to the WHO guidelines and the Tanaka formula used for estimation: Salt intake per day(g) = (21.98 × ((spot urinary sodium/ (spot urinary creatinine × 10/0.0884)) × (((14.89 × weight [Kg]) +(16.14 × height [m]) × (2.04 × age [years])) - 2244.45)) × 0.392)/17.1) were investigated [15, 22–26]. All variables were measured using the WHO guidelines.

Hypertension was defined by the following criteria: (1) systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg measured as the mean of three measurements taken by health staff in the STEPS survey; (2) a previous diagnosis of hypertension by healthcare workers; (3) current treatment with medication for hypertension [15].

Statistical methods

Descriptive statistics were used to describe the characteristics of the study population. Univariable logistic regression was performed to evaluate the associations between objective variables and each explanatory variable. All available and selected data from the STEPS survey were considered to be related to the objective variables from previous literature. Among those variables that may be related to blood pressure measurement, we selected explanatory variables to be fed into the model using a directed acyclic graph (S2 File).

Health behavior such as blood pressure measurement is affected by various factors. In particular, we considered both individual and social environmental factors as targets for health promotion interventions. “Interpersonal” processes are known to shape human behavior and lifestyles [25, 26].

Health policy is common for all Bhutanese across the country. Some but not all of the primary prevention programs for NCDs, such as displays of posters in health facilities, had already started by 2014 at the time of the survey. The number of primary health centers (PHCs) was also increasing in rural areas due to the expansion of primary health care. We predict that the situations of diagnosis and risk perception were also diverse. Furthermore, risk perception (threat) is also known to affect human behavior [3]. We selected individual and social environmental factors that influence interpersonal decisions or close networks. Gender, marital status, age, level of education, working status, income, and survey language were among the selected characteristics. Tobacco use, alcohol consumption, fruit and vegetable consumption, physical activity level, estimated salt intake, history of hypertension, and family history of hypertension were all chosen as lifestyle-related and biological risk perception factors.

We evaluated the association between previous blood pressure measurement and the individual and social environmental factors affecting interpersonal decisions or close networks through descriptive and univariable logistic regression, the association between previous blood pressure measurement and the high-risk behavioral factors of hypertension through descriptive and multivariable logistic regression (S2 File: Directed acyclic graph for multivariable logistic regression). Through the directed acyclic graph, we defined the minimal sufficient adjustment sets for estimating the total effect of high-risk behavioral factors of hypertension on the experience of having a blood pressure measurement.

All data were analyzed using IBM Statistical Package for Social Sciences version 23 with the module for Complex Sample Analysis (IBM Corp., Armonk, NY, USA), excluding the non-weighted calculation for Table 1 (mean and standard deviation). All estimates are presented with 95% confidence intervals (CIs) after adjusting for weight following the WHO guidelines to ensure they were representative of the national population [7] and adjusted based on the adjusted F-value, which is a variant of the second-order Rao–Scott adjusted chi-square statistic given the multistage random sampling [31, 32]. Variables with a p-value <0.05 were considered significant. In the study, participants aged 18–69 years were included. Those with missing data were excluded, and pregnant women were excluded because of health behavioral and biological differences.

Table 1. Distribution of socio-demographic characteristics and life behaviors.

n Mean1) Standard deviation1) Weight adjusted2) BP measured3) Estimated4) 95% CI
Total 1962 100% 1402 67.1% ( 62.9% – 71.2% )
Gender Men 772 57.6% 486 60.8% ( 54.5% – 66.8% )
Women 1190 42.4% 916 75.8% ( 72.4% – 78.9% )
Marital status Married or cohabiting 1588 83.1% 1158 69.6% ( 64.9% – 73.8% )
Never married 155 10.4% 86 46.7% ( 37.2% – 56.4% )
Separated, divorced, or widowed 219 6.5% 158 69.1% ( 59.9% – 77.0% )
Age 40.25 12.36
18–29 years 443 28.5% 297 61.4% ( 54.7% – 67.7% )
30–39 years 571 36.6% 427 67.7% ( 61.3% – 73.6% )
40–49 years 475 17.1% 349 73.3% ( 67.9% – 78.2% )
50–59 years 306 11.4% 213 68.6% ( 61.2% – 75.2% )
60–69 years 167 6.3% 116 70.0% ( 60.3% – 78.2% )
Education 4.90 12.05
No formal education 1203 54.1% 828 63.6% ( 58.4% – 68.5% )
1–10 years 600 35.9% 453 71.2% ( 65.8% – 76.0% )
11–12 years 99 6.2% 70 63.0% ( 49.0% – 75.1% )
Above 12 years 60 3.7% 51 86.5% ( 72.6% – 94.0% )
Working status Employee 342 23.7% 278 82.7% ( 76.5% – 87.5% )
Self-employed 1081 53.3% 746 62.6% ( 58.6% – 66.4% )
Non-working 539 23.0% 378 61.7% ( 50.7% – 71.6% )
Income 924.61 3164.90
USD 0–120.8 502 25.2% 325 58.5% ( 51.3% – 65.3% )
USD 120.9–402.9 546 29.3% 360 58.2% ( 51.6% – 64.5% )
USD 120.9–402.9 412 22.7% 319 78.2% ( 71.7% – 83.5% )
USD 403.0–805.7 502 22.8% 398 77.2% ( 71.5% – 82.0% )
Survey language Dzongkha 701 33.8% 514 71.8% ( 66.6% – 76.6% )
Tshanglakha 680 30.8% 494 70.7% ( 63.3% – 77.2% )
Lhotshamkha 547 33.2% 368 58.6% ( 50.8% – 66.1% )
English 34 2.2% 26 73.4% ( 51.0% – 87.9% )
Family history of hypertension Negative 1311 64.9% 882 62.0% ( 57.0% – 66.7% )
Positive 651 35.1% 520 76.7% ( 71.9% – 80.9% )
Tobacco use Never use 1556 74.3% 1151 71.0% ( 66.6% – 75.0% )
Currently use 406 25.7% 251 56.1% ( 48.6% – 63.4% )
Alcohol consumption Never drink 990 47.7% 721 67.8% ( 62.6% – 72.6% )
Light or moderate drinker 548 30.3% 379 66.7% ( 59.1% – 73.6% )
Heavy drinker 424 21.9% 302 66.3% ( 59.2% – 72.8% )
Fruit and vegetables consumption 4.52 3.48
Above 5 portions per day 656 33.9% 485 69.3% ( 62.0% – 75.8% )
Below or 5 portions per day 1306 66.1% 917 66.0% ( 61.3% – 70.5% )
Physical activity 475.97 682.04
Above or 150 mins per week 1811 93.3% 1295 67.0% ( 62.5% – 71.2% )
Below 150 mins per week 151 6.7% 107 69.2% ( 58.9% – 77.8% )
Salt intake 14.42 12.81
Below 5 g per day 22 0.8% 18 86.1% ( 65.2% – 95.3% )
Above or 5 g per day 1940 99.2% 1384 67.0% ( 62.7% – 71.0% )
Blood pressure5) Normal 1068 58.0% 705 62.4% ( 57.0% – 67.5% )
High 894 42.0% 697 73.7% ( 68.6% – 78.3% )
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1) Non-weighted calculation

2) Complex sampling weight-adjusted %

3) Participants who answered "Yes" to the questionnaire item “Have you ever had your blood pressure measured by a doctor or other health worker?”

4) Estimated % adjusted with complex sampling: Participants with a previous blood pressure measurement/total target population

5) "High" blood pressure was defined by the following criteria: (1) systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg, measured as the mean of three measurements taken by health staff in the STEPS survey; (2) a previous diagnosis of hypertension by healthcare workers; (3) currently taking medication for hypertension.

In addition, given the gender differences and mother-child health programs, we also conducted a subgroup analysis for gender groups.

Research ethics

The study protocol was approved by the Research Ethics Board of Health, Ministry of Health of the Royal Government of Bhutan (No. REBH/Approval/2018/089) and the Ethics Committee of the Kyoto University Hospital and Graduate School of Medicine (No. R1796). The above ethics committees waived the requirement for individual informed consent because this secondary analysis used only de-identified data. We have submitted a written pledge of confidentiality to the Ministry of Health of the Royal Government of Bhutan.

Results

Our target participants included 1,962 individuals (Fig 1).

Fig 1. Target population.

Fig 1

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Table 1 shows the distribution of sociodemographic characteristics of all participants in this study. The target participants included 772 men (57.6%, standard error (SE): 1.9%, 95% CI: 53.7–61.4%) and 1,190 women (42.4%, SE: 1.9%, 95% CI: 38.6–46.3%). Most participants were married or cohabiting (83.1%, SE: 1.2%, 95% CI: 80.5–85.4%). The mean participant age was 40.25 years (non-weighted), 37.5 years (weighted) (SD: 12.4, SE: 0.407, 95% CI: 36.7–38.3). Over half of participants had no education (54.1%, SE: 2.1%, 95% CI: 50.0–58.2%) and were self-employed (53.3%, SE: 3.3%, 95% CI: 46.9–59.7%). Forty-two percent (SE: 1.7%, 95% CI: 38.7–45.4%) of all participants had hypertension, and 67.1% (SE: 2.1%, 95% CI: 62.9–71.2%) of participants had never had a blood pressure measurement. Among those with hypertension, 26.3% (crude n = 197, SE: 2.5%, 95% CI: 21.7–31.4%) had never had a blood pressure measurement before.

Table 2 shows the descriptive differences between those who had hypertension or not. In total, those who had hypertension had a higher coverage of blood pressure measurement. However, except for the category of salt intake (<5 g per day), no category had 100% coverage of blood pressure measurement before the NCD STEPS survey.

Table 2. Differences between participants with hypertension or not and the distribution of socio-demographic characteristics and life behaviors for blood pressure measurement.

Hypertension1) Normal blood pressure
n BP measured2) Estimated3) 95% CI n BP measured2) Estimated3) 95% CI
Gender Men 348 246 67.6% ( 59.9% – 74.5% ) 424 240 56.1% ( 48.3% – 63.6% )
Women 548 452 81.4% ( 77.0% – 85.1% ) 642 464 71.4% ( 66.3% – 76.0% )
Marital Status　 Married or cohabiting 735 576 74.5% ( 32.9% – 74.5% ) 115 62 43.8% ( 32.8% – 55.5% )
Never married 40 24 54.5% ( 69.1% – 79.2% ) 853 582 65.8% ( 59.6% – 71.5% )
Separated, divorced, or widowed 121 98 81.5% ( 70.5% – 89.0% ) 98 60 55.7% ( 42.0% – 68.7% )
Age 18–29 years 98 79 75.2% ( 62.2% – 84.9% ) 345 218 57.5% ( 50.4% – 64.3% )
30–39 years 238 187 68.4% ( 59.0% – 76.5% ) 333 240 67.3% ( 59.3% – 74.4% )
40–49 years 263 207 78.2% ( 71.3% – 83.7% ) 212 142 67.9% ( 59.9% – 75.0% )
50–59 years 186 141 75.7% ( 65.4% – 83.8% ) 120 72 56.7% ( 46.5% – 66.3% )
60–69 years 111 84 77.7% ( 66.7% – 85.8% ) 56 32 53.1% ( 37.4% – 68.3% )
Education No formal education 611 470 72.6% ( 65.9% – 78.5% ) 592 358 55.5% ( 48.5% – 62.2% )
1–10 years 243 194 73.9% ( 65.1% – 81.1% ) 357 259 69.5% ( 62.7% – 75.6% )
11–12 years 18 14 75.6% ( 43.3% – 92.6% ) 81 56 60.0% ( 44.2% – 74.0% )
Above 12 years 24 20 90.2% ( 73.5% – 96.8% ) 36 31 84.2% ( 63.2% – 94.3% )
Working status Employee 142 125 88.3% ( 81.0% – 93.0% ) 200 153 79.1% ( 70.5% – 85.7% )
Self-employed 524 392 68.4% ( 62.1% – 74.0% ) 557 354 57.9% ( 52.4% – 63.2% )
Non-working 230 181 73.1% ( 60.7% – 82.7% ) 309 197 54.4% ( 43.4% – 64.9% )
Income USD 0–120.8 235 167 64.2% ( 55.5% – 72.1% ) 267 158 53.6% ( 45.0% – 62.1% )
USD 120.9–402.9 262 200 68.6% ( 58.6% – 77.2% ) 284 160 50.5% ( 42.8% – 58.2% )
USD 120.9–402.9 177 150 88.9% ( 81.5% – 93.5% ) 235 169 72.2% ( 62.4% – 80.3% )
USD 403.0–805.7 222 181 78.5% ( 70.5% – 84.9% ) 280 217 76.1% ( 68.6% – 82.3% )
Survey language Dzongkha 279 224 78.0% ( 69.7% – 84.6% ) 422 290 67.5% ( 59.9% – 74.4% )
Tshanglakha 369 281 73.8% ( 65.0% – 81.0% ) 311 213 67.9% ( 58.1% – 76.3% )
Lhotshamkha 243 189 68.8% ( 58.7% – 77.4% ) 304 179 52.0% ( 43.7% – 60.1% )
English 5 4 87.5% ( 39.0% – 98.7% ) 29 22 71.3% ( 46.6% – 87.6% )
Family history of hypertension Negative 580 427 68.5% ( 61.5% – 74.7% ) 731 455 57.4% ( 51.5% – 63.0% )
Positive 316 271 83.1% ( 76.9% – 87.9% ) 335 249 71.9% ( 64.7% – 78.0% )
Tobacco use Never use 733 579 75.9% ( 70.6% – 80.5% ) 823 572 67.2% ( 61.7% – 72.3% )
Currently use 163 119 66.6% ( 55.8% – 75.9% ) 243 132 49.7% ( 40.5% – 59.0% )
Alcohol consumption Never drink 403 327 75.2% ( 68.8% – 80.7% ) 587 394 63.2% ( 56.7% – 69.2% )
Light or moderate drinker 258 190 69.9% ( 60.3% – 78.0% ) 290 189 64.3% ( 54.5% – 73.1% )
Heavy drinker 235 181 76.0% ( 68.0% – 82.4% ) 189 121 57.3% ( 46.8% – 67.3% )
Fruit and vegetables consumption Above 5 portions per day 319 245 71.2% ( 61.9% – 79.0% ) 337 240 67.8% ( 58.2% – 76.1% )
Below or 5 portions per day 577 453 75.1% ( 69.5% – 80.0% ) 729 464 59.7% ( 53.9% – 65.2% )
Physical activity Above or 150 mins per week 832 649 73.8% ( 68.3% – 78.7% ) 979 646 62.0% ( 56.5% – 67.3% )
Below 150 mins per week 64 49 72.5% ( 57.4% – 83.7% ) 87 58 67.0% ( 53.3% – 78.3% )
Salt intake Below 5 g per day 10 10 100.0% ( 100.0% – 100.0% ) 12 8 76.5% ( 46.1% – 92.5% )
Above or 5 g per day 886 688 73.5% ( 68.3% – 78.1% ) 1054 696 62.2% ( 56.8% – 67.4% )
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1) Hypertension was defined by the following criteria: (1) systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg, measured as the mean of three measurements taken by health staff in the STEPS survey; (2) a previous diagnosis of hypertension by healthcare workers; (3) currently taking medication for hypertension.

2) Participants who answered "Yes" to the questionnaire item “Have you ever had your blood pressure measured by a doctor or other health worker?”

3) Estimated % adjusted with complex sampling: Participants with a previous blood pressure measurement/total target population

Among those who had normal blood pressure, current tobacco use, heavy alcohol drinker, less fruit and vegetables consumption, and high salt intake had less coverage of blood pressure measurement. However, a shortage of physical activity had a higher coverage of blood pressure measurement.

Table 3 shows the descriptive differences between men and women.

Table 3. Gender differences in the distribution of the socio-demographic characteristics and life behaviors for blood pressure measurement.

Men Women
n BP measured1) Estimated2) 95% CI n BP measured1) Estimated2) 95% CI
Marital status Married or cohabiting 652 423 63.2% ( 56.5% – 69.4% ) 936 735 78.6% ( 74.9% – 81.8% )
Never married 80 41 45.0% ( 33.2% – 57.3% ) 75 45 50.4% ( 35.8% – 64.8% )
Separated, divorced, or widowed 40 22 58.5% ( 38.8% – 75.8% ) 179 136 73.3% ( 63.8% – 81.1% )
Age 18–29 years 142 69 48.9% ( 38.1% – 59.7% ) 301 228 74.6% ( 68.3% – 80.0% )
30–39 years 223 152 63.1% ( 53.9% – 71.4% ) 348 275 75.8% ( 70.1% – 80.7% )
40–49 years 192 130 71.0% ( 63.4% – 77.6% ) 283 219 76.3% ( 68.7% – 82.4% )
50–59 years 137 84 61.3% ( 52.1% – 69.8% ) 169 129 78.1% ( 68.4% – 85.5% )
60–69 years 78 51 66.0% ( 53.3% – 76.7% ) 89 65 76.2% ( 62.7% – 85.9% )
Education No formal education 383 214 52.1% ( 43.7% – 60.3% ) 820 614 74.4% ( 70.3% – 78.0% )
1–10 years 297 205 67.9% ( 60.5% – 74.6% ) 303 248 77.9% ( 71.1% – 83.5% )
11–12 years 50 31 55.3% ( 38.4% – 71.1% ) 49 39 80.0% ( 63.4% – 90.3% )
Above 12 years 42 36 87.2% ( 69.6% – 95.3% ) 1 15 84.0% ( 58.6% – 95.1% )
Working status Employee 246 198 83.2% ( 76.0% – 88.6% ) 96 80 79.9% ( 66.2% – 89.0% )
Self-employed 424 239 52.1% ( 46.2% – 57.9% ) 657 507 76.5% ( 72.6% – 80.0% )
Non-working 102 49 36.1% ( 22.5% – 52.5% ) 437 329 73.7% ( 66.9% – 79.6% )
Income USD 0–120.8 179 94 48.7% ( 38.5% – 59.0% ) 323 231 70.0% ( 64.1% – 75.2% )
USD 120.9–402.9 219 123 49.2% ( 39.4% – 59.0% ) 327 237 70.6% ( 64.1% – 76.4% )
USD 120.9–402.9 167 119 75.5% ( 66.6% – 82.7% ) 245 200 82.2% ( 75.1% – 87.6% )
USD 403.0–805.7 207 150 72.8% ( 63.6% – 80.3% ) 295 248 83.4% ( 78.2% – 87.6% )
Survey language Dzongkha 259 184 70.2% ( 62.4% – 76.9% ) 442 330 73.9% ( 68.7% – 78.6% )
Tshanglakha 238 152 65.0% ( 52.9% – 75.4% ) 442 342 77.2% ( 71.5% – 82.1% )
Lhotshamkha 255 135 48.2% ( 38.8% – 57.8% ) 292 233 76.1% ( 68.2% – 82.5% )
English 20 15 70.6% ( 42.0% – 88.8% ) 14 11 83.3% ( 46.5% – 96.6% )
Family history of hypertension Negative 528 307 55.0% ( 47.9% – 61.9% ) 783 575 71.8% ( 67.2% – 76.1% )
Positive 244 179 72.0% ( 64.0% – 78.8% ) 407 341 82.7% ( 77.2% – 87.1% )
Tobacco use Never use 525 347 64.4% ( 57.1% – 71.0% ) 1031 804 77.9% ( 74.2% – 81.1% )
Currently use 247 139 53.8% ( 45.0% – 62.3% ) 159 112 63.6% ( 53.5% – 72.6% )
Alcohol consumption Never drink 287 183 58.9% ( 50.0% – 67.2% ) 703 538 75.2% ( 70.8% – 79.2% )
Light or moderate drinker 278 172 63.9% ( 54.0% – 72.9% ) 270 207 73.2% ( 65.9% – 79.4% )
Heavy drinker 207 131 59.1% ( 50.3% – 67.3% ) 217 171 81.0% ( 73.1% – 87.0% )
Fruit and vegetables consumption Above 5 portions per day 270 170 63.3% ( 51.8% – 73.4% ) 386 315 79.1% ( 72.4% – 84.6% )
Below or 5 portions per day 502 316 59.4% ( 52.8% – 65.6% ) 804 601 74.3% ( 70.1% – 78.2% )
Physical activity Above or 150 mins per week 733 460 60.7% ( 54.1% – 66.9% ) 1078 835 76.2% ( 72.6% – 79.4% )
Below 150 mins per week 39 26 62.4% ( 43.0% – 78.4% ) 112 81 72.7% ( 61.6% – 81.5% )
Salt intake Below 5 g per day 10 8 81.3% ( 45.0% – 95.9% ) 12 10 90.5% ( 65.5% – 97.9% )
Above or 5 g per day 762 478 60.6% ( 54.3% – 66.6% ) 1178 906 75.6% ( 72.2% – 78.8% )
Blood pressure3) Normal 424 240 56.1% ( 48.3% – 63.6% ) 642 464 71.4% ( 66.3% – 76.0% )
High 348 246 67.6% ( 59.9% – 74.5% ) 548 452 81.4% ( 77.0% – 85.1% )
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1) Participants who answered "Yes" to the questionnaire item “Have you ever had your blood pressure measured by a doctor or other health worker?”

2) Estimated % adjusted with complex sampling: Participants with a previous blood pressure measurement/total target population

In total, women had an increased likelihood of previous blood pressure measurements than men.

Table 4 shows the univariable regression for blood pressure measurement for all participants. Women (odds ratio (OR): 2.019, 95% CI: 1.533–2.660) and those who were married or cohabiting (OR: 2.611, 95% CI: 1.731–3.937) or separated, divorced, or widowed (OR: 2.556, 95% CI: 1.439–4.540) had a significantly increased likelihood of previous blood pressure measurement. Those with an education level of 1–10 years (OR: 1.414, 95% CI: 1.104–1.811) also had an increased likelihood of previous blood pressure measurement compared with those with no formal education (OR: 1.000). Regarding working status, self-employed (OR: 0.351, 95% CI: 0.234–0.526) and non-working (OR: 0.338, 95% CI: 0.193–0.593) participants had a decreased likelihood of previous blood pressure measurement than employees (OR: 1.000). In terms of income, all participants in Quartile-4 (Nu. 60,001+: USD 805.8+ (OR: 2.404, 95% CI: 1.575–3.667)) and Quartile-3 (Nu. 30,001–60,000: USD 403.0–805.7 (OR: 2.546, 95% CI: 1.640–3.955)) had an increased likelihood of previous blood pressure measurement compared with those in the lowest income category, Quartile-1 (Nu. 0–9,000: USD 0–120.8 [OR: 1.000]). We found a significant association between Quartile-3, Quartile-4, and previous blood pressure measurement but not between Q2 (Nu. 9,001–30,000: USD 120.9–402.9) and previous blood pressure measurement.

Table 4. Univariable logistic regression of previous blood pressure measurement in the target population.

Total Men Women
OR 95% CI P-value OR 95% CI P-value OR 95% CI P-value
Gender Men Ref ( – ) 0.000 Ref ( – – – ) – Ref ( – – – ) –
Women 2.019 ( 1.533 – 2.660 ) – ( – – – ) – – ( – – – ) –
Marital Status Never married Ref ( – ) 0.000 Ref ( – ) 0.010 Ref ( – ) 0.000
Married or cohabiting 2.611 ( 1.731 – 3.937 ) 2.101 ( 1.253 – 3.524 ) 3.611 ( 1.906 – 6.842 )
Separated, divorced, or widowed 2.556 ( 1.439 – 4.540 ) 1.724 ( 0.669 – 4.441 ) 2.708 ( 1.244 – 5.896 )
Age 18–29 years Ref ( – ) 0.038 Ref ( – ) 0.004 Ref ( – ) 0.968
30–39 years 1.318 ( 0.971 – 1.789 ) 1.790 ( 1.114 – 2.875 ) 1.068 ( 0.726 – 1.57 )
40–49 years 1.726 ( 1.249 – 2.385 ) 2.559 ( 1.507 – 4.348 ) 1.094 ( 0.664 – 1.803 )
50–59 years 1.371 ( 0.909 – 2.069 ) 1.658 ( 0.958 – 2.871 ) 1.216 ( 0.683 – 2.168 )
60–69 years 1.466 ( 0.905 – 2.375 ) 2.032 ( 1.058 – 3.900 ) 1.089 ( 0.548 – 2.164 )
Education No formal education Ref ( – ) 0.008 Ref ( – ) 0.000 Ref ( – ) 0.575
1–10 years 1.414 ( 1.104 – 1.811 ) 1.951 ( 1.376 – 2.765 ) 1.218 ( 0.812 – 1.826 )
11–12 years 0.975 ( 0.534 – 1.778 ) 1.140 ( 0.539 – 2.410 ) 1.382 ( 0.577 – 3.314 )
Above12 years 3.677 ( 1.483 – 9.119 ) 6.282 ( 2.029 – 19.452 ) 1.805 ( 0.494 – 6.603 )
Working status Employee Ref ( – ) 0.000 Ref ( – ) 0.000 Ref ( – ) 0.587
Self-employed 0.351 ( 0.234 – 0.526 ) 0.219 ( 0.133 – 0.361 ) 0.820 ( 0.406 – 1.656 )
Non-working 0.338 ( 0.193 – 0.593 ) 0.114 ( 0.050 – 0.263 ) 0.707 ( 0.324 – 1.545 )
Income USD 0–120.8 Ref ( – ) 0.000 Ref ( – ) 0.000 Ref ( – ) 0.001
USD 120.9–402.9 0.989 ( 0.714 – 1.372 ) 1.021 ( 0.606 – 1.718 ) 1.033 ( 0.710 – 1.502 )
USD 120.9–402.9 2.546 ( 1.640 – 3.955 ) 3.250 ( 1.768 – 5.974 ) 1.984 ( 1.209 – 3.255 )
USD 403.0–805.7 2.404 ( 1.575 – 3.667 ) 2.816 ( 1.524 – 5.203 ) 2.161 ( 1.415 – 3.299 )
Tobacco use　 Never use Ref ( – ) 0.000 Ref ( – ) 0.035 Ref ( – ) 0.003
Currently use 0.523 ( 0.378 – 0.724 ) 0.643 ( 0.427 – 0.969 ) 0.496 ( 0.314 – 0.785 )
Alcohol consumption　 Never drink Ref ( – ) 0.925 Ref ( – ) 0.586 Ref ( – ) 0.280
Light or moderate drinker 0.953 ( 0.662 – 1.372 ) 1.239 ( 0.754 – 2.036 ) 0.897 ( 0.600 – 1.342 )
Heavy drinker 0.936 ( 0.663 – 1.322 ) 1.008 ( 0.652 – 1.556 ) 1.405 ( 0.849 – 2.326 )
Fruit and vegetables consumption　 Above 5 portions per day Ref ( – ) 0.408 Ref ( – ) 0.525 Ref ( – ) 0.222
Below or 5 portions per day 0.862 ( 0.605 – 1.228 ) 0.848 ( 0.509 – 1.413 ) 0.764 ( 0.496 – 1.178 )
Physical activity Above or 150 mins per week Ref ( – ) 0.681 Ref ( – ) 0.871 Ref ( – ) 0.488
Below 150 mins per week 1.104 ( 0.687 – 1.775 ) 1.072 ( 0.461 – 2.492 ) 0.832 ( 0.493 – 1.403 )
Salt intake Below 5 g per day Ref ( – ) 0.066 Ref ( – ) 0.218 Ref ( – ) 0.175
Above or 5 g per day 0.328 ( 0.100 – 1.079 ) 0.354 ( 0.067 – 1.859 ) 0.327 ( 0.065 – 1.651 )
Family history of hypertension Negative Ref ( – ) 0.000 Ref ( – ) 0.000 Ref ( – ) 0.004
Positive 2.019 ( 1.549 – 2.633 ) 2.107 ( 1.427 – 3.112 ) 1.87 ( 1.227 – 2.849 )
High blood pressure1) Normal Ref ( – ) 0.000 Ref ( – ) 0.011 Ref ( – ) N/A
High 1.695 ( 1.280 – 2.243 ) 1.639 ( 1.122 – 2.394 ) ( – )
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1) "High" blood pressure was defined by the following criteria: (1) systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg, measured as the mean of three measurements taken by health staff in the STEPS survey; (2) a previous diagnosis of hypertension by healthcare workers; (3) currently taking medication for hypertension.

N/A: Not able to calculate systematically

In terms of gender differences, there were significant associations between previous blood pressure measurement and age, education, income, and working status (self-employed [OR: 0.219, 95% CI: 0.133–0.361], non-working [OR: 0.114, 95% CI: 0.050–0.263], employee [OR:1.000]) among men but not among women. There was a significant association between hypertension and income level (Quartile-2 [OR: 1.984, 95% CI: 1.209–3.255], Quartile-1 [OR: 2.161, 95% CI: 1.415–3.299], Quartile-4 [OR:1]) among women.

Those with a family history of hypertension (OR: 2.019, 95% CI: 1.549–2.633) and those with hypertension (OR: 1.695, 95% CI: 1.280–2.243) also had an increased likelihood of previous blood pressure measurement.

Table 5 shows the multivariable regression analysis for blood pressure measurement and behavioral factors for all participants. Tobacco use (adjusted odds ratio (AOR): 0.538, 95% CI: 0.380–0.761) and salt intake (AOR: 0.247, 95% CI: 0.068–0.893) were associated with a decreased likelihood of previous blood pressure measurement.

Table 5. Multivariable logistic regression analysis of previous blood pressure measurement and life-related behavioral factors.

Explanatory variables AOR 95% CI P-value1)
Model-1 Tobacco use Never use ( – ) 0.001
Currently use 0.538 ( 0.380 – 0.761 )
Model-2 Alcohol consumption Never drink ( – ) 0.994
Light or moderate drinker 1.010 ( 0.728 – 1.400 )
Heavy drinker 0.989 ( 0.713 – 1.371 )
Model-3 Fruit and vegetables consumption Above 5 portions per day ( – ) 0.676
Below or 5 portions per day 0.934 ( 0.678 – 1.287 )
Model-4 Physical activity Above or 150 mins per week ( – ) 0.625
Below 150 mins per week 0.923 ( 0.670 – 1.273 )
Model-5 Salt intake Below 5 g per day ( – ) 0.033
Above or 5 g per day 0.247 ( 0.068 – 0.893 )
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Model-1 was adjusted for Age, Education, Family history of hypertension, Gender, Income, Marital status, Working status

Model-2 was adjusted for Education, Family history of hypertension, Gender, Income, Survey language, Working status

Model-3 was adjusted for Education, Family history of hypertension, Income, Marital status, Survey language, Working status

Model-4 was adjusted for Age, Education, Income, Marital status, Survey language, Working status

Model-5 was adjusted for Education, Family history of hypertension, Income, Marital status, Survey language, Working status

1) P-value: Bonferroni

Discussion

Inadequate blood pressure screening

Participants with normal blood pressure and 26.3% of those who had hypertension had never undergone blood pressure measurement before the STEPS survey. This may suggest that screening for blood pressure was inadequate. Blood pressure measurement is necessary in people with hypertension or people at high risk of hypertension. Early detection and treatment of hypertension can be effective in preventing other diseases [3, 17]. Some of the risk factors for hypertension are preventable, whereas some, such as aging or genetics, are not [9, 17].

A previous qualitative study in Bhutan indicated that there were people who had never undergone blood pressure measurement although they had high blood pressure; however, this previous qualitative study could not show that these results were representative of Bhutan more widely due to the small sample size from a small area [10]. Using a national survey with sample sizes representative of Bhutan [7], we could demonstrate the importance of early detection of hypertension. People with hypertension remain undiagnosed for multiple reasons, including behavioral reasons, lack of awareness, limited access to the health system, patient projections, or medical costs [33–35]. Medical tests should be conducted given their cost-effectiveness. If all the people with no previous blood pressure measurement had normal blood pressure, there would not be a problem. However, this is not the case, so a selective approach is needed to identify people with hypertension or people at high risk for hypertension and which simultaneously does not waste scarce resources.

Social background factors and gender differences

Married women had more experience with blood pressure measurement than men. For men, aging and working environment were significantly associated with previous blood pressure measurement. However, for women, except for income, there was no significant association between previous blood pressure measurement and working status or aging (Table 4). The socioeconomic factors associated with blood pressure measurement may differ between men and women.

In this study, we could not determine the cause of the gender differences observed in blood pressure measurement; however, existing maternal and child health programs might be the reason that women with a married or cohabiting status had an increased prevalence of previous blood pressure measurement [36, 37]. In Bhutan, maternal and child health services have improved markedly in the past two decades [37, 38]. The government of Bhutan provides free access to basic public health services for all [12]. Nonetheless, among women, those in the above-average income category had a higher coverage of previous blood pressure measurement than those in the below-average income category. This difference might be explained by the travel cost or time cost involved in going to blood pressure measurement appointments [11, 39]. The number of PHCs has increased, and access to health care has improved over the past 30 years [37–40]. An additional 87.7% of the population had access to a PHC within two hours in 2019 [41]. However, traveling for two hours on a mountain road in Bhutan may be difficult for women. Lower-income women might also experience some barriers to visiting the hospital, as previous studies in other countries have indicated, such as insufficient education, gender gap problems, and insufficient family support [42].

We should pay more attention to the low-income group because we need to reduce barriers to accessing health care and promote blood pressure measurement among this group. Previous studies in other countries have also indicated that health-seeking behavior differs by gender [42, 43]. Women have greater awareness and higher consciousness of the treatments for hypertension but simultaneously experienced more barriers to visiting the hospital than men [42–45].

In Bhutan, there are fewer paternal programs for men than there are mother and child health programs; therefore, men might have less chance of having their health screened while healthy. For men, aging is a risk factor for hypertension [46]; therefore, it may be that men tend to go to the hospital after facing health problems as they age. If so, including men in the existing maternal and child health care programs could increase their opportunities to have their blood pressure monitored, encouraging them to pay attention to their own health and the health of their wives, children, and families. Working status had a significant association with the experience of blood pressure measurement among men. Those who are employed may have more opportunities to have their health examined and greater access to other services from their companies than those who are self-employed or non-working [47]. It is possible that housemen or self-employed men must work continuously to obtain a daily income, making it impossible to leave work and seek medical attention, or they may not be able to seek medical attention without other initiatives. Those who are employed may have received some health care through their employer or colleagues. While workplace-based interventions can be effective [45–49], especially among men, methods of providing preventive health management to self-employed, non-working, and low-income people is an issue that remains to be addressed.

Health behavior and risk perception

People with a family history of hypertension or those with hypertension had more experiences with blood pressure measurement in all analyses most likely because they have an increased awareness of the health threats they might face. People with an unhealthy lifestyle may not be aware of health threats or perceived health vulnerability, and one of the characteristics of people with a healthy lifestyle may be the ability to perceive health threats, regardless of whether they have pre-existing health problems or not. People with an unhealthy lifestyle (high salt intake or tobacco use) had less experience with blood pressure measurement.

Another previous study also showed that risk perception and preventive behavior are closely related [49]. Health perception of hypertension might also be related to health behavior [27, 50].

From the point of view of prevention, it is necessary to promote more blood pressure measurements to those who are at high risk or who have modifiable risk factors. In rural Bhutan, health education and health-related meetings often involve household representatives gathering in PHCs to provide knowledge. This is an effective means of communication due to the characteristics of strong family cohesion in Bhutan [10]. Furthermore, when developing and improving prevention programs, it may be necessary not only to make healthy people healthier but also to approach those at high risk of lifestyle-related diseases effectively and selectively. This selection should occur regardless of whether people are health conscious or not, because 26.3% of subjects in the STEPS survey had never had their blood pressure monitored before.

Strengths and limitations of this study

This study was rare in that it focused on factors that are related to the experience of blood pressure measurement in Bhutan after adjusting for all possible variables and available confounders. Our study had several strengths. First, the dataset of the “National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan– 2014” was representative of the whole of Bhutan, with a 97% valid response rate and the adoption of cluster random sampling methods. Second, the questionnaire included some biomarkers to adjust for risk factors for high blood pressure. Regarding limitations, first, a wish by participants to provide socially desirable answers could have affected the results due to face-to-face interviews. Nonetheless, this was the only method available to collect data from a low literacy rate target population. Second, we cannot deny that there were unmeasurable confounders for some associations that we found in this study, although we tried to adjust for all possible confounders from previous studies.

Conclusions

To contribute to the early detection of hypertension, we investigated the rate of blood pressure measurement and associated factors in Bhutan. Participants with unhealthy lifestyles had less experience with blood pressure measurement. There was a gender gap in which social determinant factors were associated with previous blood pressure measurement. It is necessary to promote the early detection of hypertension and to pay more attention to low-income women, the self-employed, and non-working men. Levels of blood pressure screening were generally inadequate. Individuals with hypertension or those at high risk for hypertension, such as one-quarter of subjects who had never had their blood pressure monitored before and those who lacked health consciousness, should not be overlooked.

Supporting information

S1 File. Sample size, power calculation, weighting, and adjusting the cluster random sampling procedure.

(PDF)

Click here for additional data file. (293.3KB, pdf)
S2 File. Directed acyclic graph for multivariable logistic regression.

(PDF)

Click here for additional data file. (200.5KB, pdf)

Acknowledgments

We would like to thank Cambridge English Correction Service for English language editing.

We appreciate the Khesar Gyalpo University of Medical Sciences of Bhutan, the Ministry of Health, Bhutan, and all the support from the Graduate School of Medicine, Kyoto University, Japan.

We used dagitty (http://www.dagitty.net/dags.html 3.0: released 2019-01-09) to evaluate a minimal sufficient adjustment set for total effect, models 1–5 (Table 5).

Data Availability

Since the Ministry of Health, Bhutan is the authority for the data, the authors were not able to make it available with this paper. However, the original report (World Health Organization and Ministry of Health in Bhutan. National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan – 2014) is available from https://apps.who.int/iris/handle/10665/204659. Requests to access the raw data can be directed to the Research Ethics Board of Health at the Ministry of Health, Royal Government of Bhutan. Contact: P.O. Box: 726, Kawajangsa, Thimphu, Bhutan Phone No: +975-2-328095, 321842, 322602, 328091.

Funding Statement

This study was supported by K. Matsushita Foundation (http://matsushita-konosuke-zaidan.or.jp/en/) in the form of a grant (19-048) to HKS. This study was also supported by Kyoto University (https://ipcr.cseas.kyoto-u.ac.jp/), Program of Collaborative Research at the Centre for Southeast Asian Studies (IPCR-CSEAS) with funding (type 4) for YI and funding (type 7) for HKS. Kyoto University also supported this study with funding (Ishizue 2022) for YI. There are no grant numbers associate with the support from Kyoto University. This study was also supported by Japan Society for the Promotion of Science (JSPS Kakenhi) in the form of a grant (JP19H01075) to YI. The funders played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Marcelo Arruda Nakazone

21 Jul 2021

PONE-D-21-12027

Factors related to blood pressure measurement, with attention needed for unemployed men, poor women, and people’s health behaviors: A cross-sectional study in Bhutan

PLOS ONE

Dear Dr. Imanaka,

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.

==============================

ACADEMIC EDITOR: 

The manuscript is interesting but will require further reworking and a major revision.<o:p></o:p>

While they recognize the potential interest of the subject studied, the reviewers raised a number of important issues that need to be properly addressed.<o:p></o:p>

==============================

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We look forward to receiving your revised manuscript.

Kind regards,

Marcelo Arruda Nakazone, M.D., Ph.D.

Academic Editor

PLOS ONE

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Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

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- the recruitment date range (month and year)

- a description of any inclusion/exclusion criteria that were applied to participant recruitment

- a statement as to whether your sample can be considered representative of a larger population

- a description of how participants were recruited

- descriptions of where participants were recruited and where the research took place."

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Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now

 This information should be included in your cover letter; we will change the online submission form on your behalf.

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We will update your Data Availability statement on your behalf to reflect the information you provide.

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: 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 major problems is the methodology and analysis done did not fit the study objectives. The study objective is to determine the factors associated with blood pressure measurement. It is not clear in the method the operational definition of blood pressure measurement in this study. What is the main outcome in this study? Is it behaviour practice of BP measurement for the past? duration or ever checked BP?

Reviewer #2: Reviewer Comments

Kohori-Segawa et al conducted a study to determine what characteristics are associated in Bhutanese people with the experience of having a blood pressure measurement. I find the article very interesting and neatly conducting. I have a few questions regarding the design:

1) In line x you mention patients with hypertension that had not had blood pressure measured, can you specify then how was the diagnosis made? Do you have any information regarding this? You mention this again in the conclusions in which you say people with hypertension have never had blood pressure measurements in their life so I do not understand how they know their hypertension status. Is it possible that they do not remember having their blood pressure measured rather than the measurement not being performed?

2) Regarding multivariable analysis, I would like for you to specify adjustment variables rather than just listing the variable category (line 162)

3) In line 317 you mention than unemployed or self employed men are less likely to have their blood pressure measured. A possible explanation could be the need to work on a daily basis to obtain income which makes it impossible to leave and seek for medical attention. I would like to know your thoughts about this.

Finally I would suggest changing the wording in sentences mentioning previous studies.

Reviewer #3: 1-Line 184: Can't find Figure1?. Does it refer to Table1?

2- It is difficult to understand the % in last column in table 1. How these % were calculated?

3-How to identify potential confounders? What are the potential confounders' variables to be included in multivariate analysis?

4-I am not English native speaker, but I just feel that there might be a need to further improvement in English writing fashion?

5-Title: It is too long, it should be revised?

6-Income: Readers who are not from the Kingdom of Bhutan may not understand like "Nu.0–9,000; ...." Is it possible to convert into a commonly known like UDS?

7-Discussion: Authors raised about "Considering barriers......" (line 284-285) and "Contradictions in health behavior...." (line 320), these are all the factors associated with blood pressure measure. The words .... barriers, contradictions might not appropriate to be used here?

**********

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Reviewer #1: No

Reviewer #2: Yes: Mercedes Aguilar-Soto

Reviewer #3: No

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PLoS One. 2022 Aug 17;17(8):e0271914. doi: 10.1371/journal.pone.0271914.r002

Author response to Decision Letter 0

3 Sep 2021

Dear Editor and reviewers,

We really appreciate your review and feedback during these difficult times of the COVID-19 pandemic. We have improved our manuscript by responding to your comments, as detailed below:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

⇒We have addressed PLOS ONE's style requirements, including those for file naming.

2. Thank you for including your ethics statement: "The Research Ethics Boards of Health, Ministry of Health of the Royal Government of Bhutan (No. REBH/Approval/2018/089), and the Kyoto University Hospital and Graduate School of Medicine, Ethics Committee (No. R1796) approved the study protocol.".

Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research.

⇒We have added an explanation of the ethical considerations of our study, as detailed below:

→(p12, line210-215 )　The Research Ethics Boards of Health, Ministry of Health of the Royal Government of Bhutan (No. REBH/Approval/2018/089) and the Ethics Committee of the Kyoto University Hospital and Graduate School of Medicine (No. R1796) approved the study protocol. The above ethics committees waived the requirement for individual informed consent as this secondary analysis used only de-identified data. We have submitted a written pledge of confidentiality to the Ministry of Health of the Royal Government of Bhutan.

3. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

- the recruitment date range (month and year)

⇒Thank you for your comments. The survey “National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan – 2014” was conducted from March to June in 2014.　

→We added “from March to June”. (p 7, line 127)

- a description of any inclusion/exclusion criteria that were applied to participant recruitment

⇒Thank you for your comments.

In the “National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan – 2014”, age 18 to 69 years was an inclusion criterion, and missing data were excluded from the analysis. Furthermore, in this study, pregnant women were excluded from the analysis because of health behavioral and biological differences.

We have rephrased this as shown below:

→(p 11,　lines 202–204)　In the study, individuals aged 18 to 69 years were included. Those with missing data and pregnant women were excluded from the analysis because of health behavioral and biological differences.　

- a statement as to whether your sample can be considered representative of a larger population

⇒Thank you for your comments.

We have added the following phrase:　

→(p 11, line 198-197)　 “to ensure they were representative of the national population”

- a description of how participants were recruited

- descriptions of where participants were recruited and where the research took place."

⇒Thank you for your comments. We have added the following sentences:

→(p 8, lines 134–135)　“According to the sampling plan, trained health staff recruited participants in each sampling field where the participants were living.”

Further information about survey procedure can be obtained from the report “National Survey for Noncommunicable Disease Risk Factors and Mental Health Using WHO STEPS Approach in Bhutan – 2014”. We have provided supporting information quoted from the report (S1 File).

4. Please provide a sample size and power calculation in the Methods, or discuss the reasons for not performing one before study initiation.

⇒Thank you for your comments. The survey “National Survey for Noncommunicable Disease Risk Factors and Mental Health Using WHO STEPS Approach in Bhutan – 2014” already considered the sample size and power calculation. Hence, we did not mention it in this paper; however, additional information from the Method part quoted from the report (S1 file) is now provided as supporting information.

Sample size and power calculation

“The Sample size estimate of the number of households to be surveyed with 95% confidence was calculated. The prevalence of overweight and obesity was 52.8% from the last STEPS survey carried out in Thimphu which was the closest value to 50%. d = margin of error. The expected half width of the confidence interval was taken as 0.05 for this study

　N=[1.96*1.96{0.528（1-0.528）}]/0.05*0.05

Four domains were chosen based on men and women and two age groups: younger (18–39 years) and older (40–69 years), providing four age/sex estimates. Taking into account the number of domains and ensuring enough representation by either age-sex groups or urban-rural groups in men and women, and with a design effect of 1.5 to address the issue of cluster sampling, the expected sample size was as follows:

n = 382.9552 * 1.5 * 4 = 2297.7316

Assuming an expected 80% response rate, the final required sample size was 2912.

n = 2297.7316/0.8 = 2872.1646~ (rounded to 2912 for logistical ease)

5. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

⇒Thanks so much for your point out. We have addressed.

→(p26,　Line438-449)　Our research was supported by　

1) Hiromi Kohori Segawa, K. MATSUSHITA FOUNDATION, Grant Number 19-048 http://matsushita-konosuke-zaidan.or.jp/en/

2) Yuichi Imanaka, Program of Collaborative Research at the Centre for Southeast Asian Studies (IPCR-CSEAS), Kyoto University 2018 type4 https://ipcr.cseas.kyoto-u.ac.jp/

3) Hiromi Kohori Segawa, Program of Collaborative Research at the Centre for Southeast Asian Studies (IPCR-CSEAS), Kyoto University 2020 type7 https://ipcr.cseas.kyoto-u.ac.jp/

4) Yuichi Imanaka, JSPS KAKENHI Grant Number JP19H01075 from the Japan Society for the Promotion of Science https://www.jsps.go.jp/english/

The funders played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

6. Thank you for stating the following in your Competing Interests section:

“NO”

Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now

This information should be included in your cover letter; we will change the online submission form on your behalf.

⇒Thank you for your comments. We have mentioned this in our cover letter with the following information.

→The authors have declared that no competing interests exist. The funders played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

7. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

⇒Thank you for your comments. We have rephrased this information as shown below.

→(p 26,　lines 429–436)　Since the Ministry of Health, Bhutan is the authority for the data, the authors were not able to make it available in this manuscript. However, the original report (World Health Organization and Ministry of Health in Bhutan. National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan – 2014) is available at https://apps.who.int/iris/handle/10665/204659. Requests to access the raw data can be directed to the Research Ethics Board of Health, Ministry of Health, Bhutan, or the Royal Government of Bhutan.

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: No　　　　　　Reviewer #2: Yes　　Reviewer #3: Partly

________________________________________

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

Reviewer #1: No　　Reviewer #2: Yes　　Reviewer #3: I Don't Know

________________________________________

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No　　Reviewer #2: No　　Reviewer #3: Yes

________________________________________

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No　　Reviewer #2: Yes　　Reviewer #3: 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 major problems is the methodology and analysis done did not fit the study objectives. The study objective is to determine the factors associated with blood pressure measurement. It is not clear in the method the operational definition of blood pressure measurement in this study. What is the main outcome in this study? Is it behaviour practice of BP measurement for the past? duration or ever checked BP?

⇒Thank you for these important comments. We acknowledge the limitation of our explanation. We would like to make it clearer.

During the survey “National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan – 2014”, blood pressure was checked 3 times by health workers. We could identify the gap between self-reported hypertension and examination based on the survey time (including diagnosis by health staff before the survey or current medication treatment). We believe that this gap is critical because individuals who have hypertension but are unaware should start to control their blood pressure. In particular, those who answered that they had no experience with blood pressure monitoring should be given attention. Periodic blood pressure monitoring is very important. As public health workers prevent worsening hypertension, we need to pay adequate attention to those with hypertension who did not have their blood pressure monitored before the survey. Hence, we wanted to identify what factors prevented them from being aware of their hypertension status before the survey. We wanted to identify whether they had concerns about their health but were unable have their blood pressure monitored or were unaware of their risk.

In the current study, we first wanted to identify factors related to experience with blood pressure monitoring before the survey. Second, we wanted to explore what factors are related to experience with blood pressure measurement among individuals with hypertension before the survey before the survey.

To make these factors clear, we have made the following changes:

1) We have added second objective “To explore what factors are related to experience with blood pressure measurement among individuals with hypertension before the survey” (p 6,　lines 110–111 )　

2) We have added information about the time of diagnosis of hypertension (during or before the survey).

3) We have improved the explanation of the definition of hypertension used in this study.

→(p 9-10,　line 167-170 )　 Hypertension was defined by the following criteria: (1) systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg measured as the average of three measurements taken by health staff in the survey; (2) a previous diagnosis of hypertension by healthcare workers; (3) current treatment with medication for hypertension

Reviewer #2: Reviewer Comments

Kohori-Segawa et al conducted a study to determine what characteristics are associated in Bhutanese people with the experience of having a blood pressure measurement. I find the article very interesting and neatly conducting. I have a few questions regarding the design:

1) In line x you mention patients with hypertension that had not had blood pressure measured, can you specify then how was the diagnosis made? Do you have any information regarding this? You mention this again in the conclusions in which you say people with hypertension have never had blood pressure measurements in their life so I do not understand how they know their hypertension status. Is it possible that they do not remember having their blood pressure measured rather than the measurement not being performed?

⇒Thank you for your comments. We acknowledge the shortcomings in the explanation. We would like to clarify. (Your comments are similar to the comments from reviewer 1; therefore, our responses are repeated.)

During the survey “National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan – 2014”, blood pressure was checked 3 times by health workers. We could identify the gap between self-reported hypertension and examination based on the survey time (including diagnosis by health staff before the survey or current medication treatment). We believe that this gap is critical because individuals who have hypertension but are unaware should start to control their blood pressure. In particular, those who answered that they had no experience with blood pressure measurement should be given attention. Periodic blood pressure monitoring is very important. As public health workers prevent worsening hypertension, we need to pay adequate attention to those with hypertension who did not have their blood pressure measured before the survey. We wanted to identify whether they had concerns about their health but were unable have their blood pressure measured or were unaware of their risk.

To make these factors clear, we have made the following changes:

1) We have added second objective “To explore what factors are related to experience with blood pressure measurement among individuals with hypertension before the survey” (p 6,　lines 110–111 )　

2) We have added information about the time of diagnosis of hypertension (during or before the survey).

3) We have improved the explanation of the definition of hypertension used in this study.

→(p 9-10,　line 167-170 )　 Hypertension was defined by the following criteria: (1) systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg measured as the average of three measurements taken by health staff in the survey; (2) a previous diagnosis of hypertension by healthcare workers; (3) current treatment with medication for hypertension

There is a possibility that the participants might not remember having their blood pressure measured as you mentioned. Such an unconscious measurement can be counted as not measured. If the participants forgot that they had their blood pressure measured, this indicates that they were not aware of the blood pressure measurement, so it is not a problem to count it as not having been taken. The important point is finding the gap in their practices, their wishes, and their real risk.

2) Regarding multivariable analysis, I would like for you to specify adjustment variables rather than just listing the variable category (line 162)

⇒Thank you for your comments. We specified this point in the explanatory variables’ subsection (adjustment variables). To clarify, we added the explanation shown below and deleted the categories.

→(p 10,　line 177 )　 as mentioned in the explanatory variables.

3) In line 317 you mention than unemployed or self-employed men are less likely to have their blood pressure measured. A possible explanation could be the need to work on a daily basis to obtain income which makes it impossible to leave and seek for medical attention. I would like to know your thoughts about this.

⇒We acknowledge your valuable comments.

We have added the following explanation:

→(p 22–23,　lines 366–370 )　 It is possible that non-working or self-employed men must work on a daily basis to obtain income, making it impossible to leave work and seek medical attention, or they may not be able to seek medical attention without other interactions. Those who are employed may have received some health care through their employer or colleagues.

Finally I would suggest changing the wording in sentences mentioning previous studies.

⇒Thank you for your comments.　We have changed the wording about previous studies.

(p 20,　line 323 )　previous study →　A previous qualitative study

(p 20,　lines 324–325 )　this study →　this previous qualitative study

Reviewer #3:

1- Line 184: Can't find Figure1?. Does it refer to Table1?

⇒Thank you for your comments. It was Figure 1. PlosOne indicated to display the figures in different files not in the manuscript. Hence, we followed these directions.

2- It is difficult to understand the % in last column in table 1. How these % were calculated?

⇒Thank you for your comments. We calculated these data with the weight adjusted and adjusted for multistage cluster random sampling with SPSS. The total percentage is not 100 percent due to this adjustment. The last column is the point estimates after the adjustment. We did not include confidence intervals, which might have been confusing. Therefore, we have added 95% CIs and mentioned “estimates” instead of “adjusted” in Table 1. Furthermore, we have improved the footnotes in Table 1 and added S1 File.

(p 14 )　

1) Weight adjusted % (S1 File)

2) Population with blood pressure monitoring using the questionnaire item “Have you ever had your blood pressure measured by a doctor or other health worker?” Answers of “yes” were counted.

3) Estimated % adjusted with complex sampling: Population with blood pressure monitoring/Total target population (S1 File)

We have added the explanation in the supporting information (S1 File). .

3-How to identify potential confounders? What are the potential confounders' variables to be included in multivariate analysis?

⇒We acknowledge your valuable comments. Health behavior such as blood pressure measurement is known to be affected by various factors. All of these various factors are associated with each other.

Kenneth et al (1988) proposed an ecological model for health promotion that focuses attention on both individual and social environmental factors as targets for health promotion interventions. It is important that “interpersonal” processes shape human behavior [1].

Barton H et al (2006) also displayed the determinants of health and wellbeing in a human habitation map and mentioned “lifestyle” in various factors [2].

Reflecting on the Bhutanese situation, health policy is common for all Bhutanese across the country. Some but not all of the primary prevention programs for NCDs, such as displays of posters in health facilities, had already started in 2014 at the time of the survey. The number of primary health centers (PHCs) was also increasing in rural areas due to expansion of primary health care. Thus, we predicted that the situations of diagnosis and risk perception were also diverse. Furthermore, risk perception (threat) is also known to affect human behavior [3].

We selected individual and social environmental factors affecting interpersonal decisions or close networks, lifestyle-related factors, health conditions of hypertension, and family history of hypertension as biological risk perception factors.

1. McLeroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly. 1988;15(4):351-77.

2. Barton H, Grant M. A health map for the local human habitat. Journal of the Royal Society for the Promotion of Health. 2006;126(6):252-3.

3. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q. 1988;15(2):175-83.

According to the abovementioned theories, we selected the variables from “National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014”.

We selected that gender and marital status; age, level of education, working status, residential area (urbanicity), income, and survey language Tobacco use, alcohol consumption, fruits and vegetables consumption, physical activity, estimated salt intake, having hypertension, and family history of hypertension. We put all these variables we selected to our models forcefully, after we checked the interaction effect and coefficient, excluding the residential area (urbanicity) due to adjusting cluster random sampling.

We improved our explanation on the statistical methods and deleted the categories in explanatory

4-I am not English native speaker, but I just feel that there might be a need to further improvement in English writing fashion?

⇒Thank you for your comments. English is our second language. We have asked a professional English copyeditor to review and edit our manuscript to ensure that it is written in standard English.

5-Title: It is too long; it should be revised?

⇒Thank you for your comments. We have shortened our title as below.

Old Title: Factors related to blood pressure measurement, with attention needed for unemployed men, poor women, and people’s health behaviors: A cross-sectional study in Bhutan

Revised title: Social and behavioral factors related to blood pressure measurement: A cross-sectional study in Bhutan

6-Income: Readers who are not from the Kingdom of Bhutan may not understand like "Nu.0–9,000; ...." Is it possible to convert into a commonly known like UDS?

⇒We acknowledge your valuable comments. We converted from Bhutanese Ngultrum (Nu) into USD.

→(p 9,　lines 145–147 )　

1 USD = 74.4707 BTN (Accessed on 11th August 2021 https://www.xe.com/)

Nu. 0–9,000　→0–120.8 USD

Nu. 9,001–30,000　　→120.9–402.9 USD

Nu. 30,001–60,000　　→403.0–805.7 USD

Nu. 60,001+　　→805.8+ USD

7-Discussion: Authors raised about "Considering barriers......" (line 284-285) and "Contradictions in health behavior...." (line 320), these are all the factors associated with blood pressure measure. The words .... barriers, contradictions might not appropriate to be used here?

⇒Thank you for your comments. We reconsidered appropriate subtitles for the discussion. We agree with your suggestion that the barriers or contradictions should be discussed in phase but are not needed in the title. We have now changed the subtitles in the discussion.

→(p 21,　line 334)　Considering barriers to self-employed or unemployed men, and poor women →Self-employed or non-working men and low income women

→(p 23,　line 373)　Contradictions in health behavior and risk perception → Health behavior and risk perception

________________________________________

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Reviewer #1: No　Reviewer #2: Yes: Mercedes Aguilar-Soto　　Reviewer #3: No　Author：Yes

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Decision Letter 1

Marcelo Arruda Nakazone

19 Oct 2021

PONE-D-21-12027R1Social and behavioral factors related to blood pressure measurement: A cross-sectional study in BhutanPLOS ONE

Dear Dr. Imanaka,

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.

==============================

ACADEMIC EDITOR: 

The manuscript is interesting but will require minor revisions.<o:p></o:p>

While they recognize the potential interest of the subject studied, the Reviewers raised some concerns that need to be properly addressed.<o:p></o:p>

==============================

Please submit your revised manuscript by Dec 03 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Marcelo Arruda Nakazone, M.D., Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: 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 #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: I Don't Know

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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 #1: Yes

Reviewer #2: Yes

Reviewer #3: 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 #1: The author has adequately addressed all comments based form previous reviewers and the manuscript seem to be sound. However, I would like to advise the author to add the p value for the multivariate or bivariate analysis and highlight- bold the results that are significant. This can help the readers to recognized those significant factors in the table easily.

Reviewer #2: Yuichi Imanaka et al conducted a study to determine social and behavioral factors that determine having blood pressure measurements in Bhutan. They have corrected prior comments but there are some changes that are still needed.

Line 55: had a lower likelihood of undergoing blood pressure measurement

Correct wording.

I would further specify everytime you mention hypertensive patients did not have their blood pressure measured that this was after the first diagnosis measurement. (Line 65, 66)

LINE 88 : Have showed to be necessary instead of has

Again in line 94 you mention people with hypertension have not had their blood pressure measured but this is impossible. Please address this like you did previously. In line 96 you mention according to NCD survey reports, “Around 96 (31.3%) of the study population had never had their blood pressure checkup”, but this again does not make sense if they already have the diagnosis. They needed at least 2 measurements performed priorly. Perhaps you should clarify “follow-up” blood pressure in all sentences regarding new measurements.

Line 163: How was salt intake estimated? Based on a diet questionnaire?

Line 170: I do not understand why you used family history on hypertension as a definition for diagnosis. I suggest you remove this definition.

Line 176: I do not understand what you mean by this: All of the data are available and considered to be related to the dependent variable from the previous literature as mentioned in the explanatory variables.

I would suggest you specify very clearly which patients were included: only patients who had prior diagnosis of hypertension defined as known diagnosis or those who were diagnosed during the National Survey for Noncommunicable Disease Risk Factors and Mental Health.

Line 205: Again it is not clear why you made sub-analysis for people with hypertension, you need to be very careful with wording as to say that your objective is to know factors that determine the experiences of having blood pressure measurements and whether they differ for patients who had prior hypertension diagnosis and those who did not.

In the results section, if variables have a parametric distribution, it is better to state mean and standard deviation rather than standard error.

In table 1 rename variable Gender_Marital Status since it looks like you just left the statistical program output without correcting variable names.

In table two remove the parenthesis after 1 and 2 super indexes. Income variable in table 2 is not in the same format as the rest of the table.

In line 317 you still insist that patients with hypertension never underwent blood pressure measurement in their lives, but this, again, is not possible since that is the only way to diagnose hypertension is measuring blood pressure. You have explained in previous responses what you mean but you need to be very explicit about it throughout your discussion.

Check wording in line 352.

Reviewer #3: I have no idea whether data analysis was done appropriately and rigorously. However, the presentation of the results is clear and response to the research objectives.

**********

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.

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Reviewer #1: No

Reviewer #2: Yes: Mercedes Aguilar-Soto

Reviewer #3: No

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PLoS One. 2022 Aug 17;17(8):e0271914. doi: 10.1371/journal.pone.0271914.r004

Author response to Decision Letter 1

31 Mar 2022

Dear Editor and reviewers,

We really appreciate your review and feedback during these difficult times of the COVID-19 pandemic. We took long time to learn causal inference and modify. However, now we have improved our manuscript by responding to your comments, as detailed below:

Reviewer #1: The author has adequately addressed all comments-based form previous reviewers and the manuscript seem to be sound. However, I would like to advise the author to add the p value for the multivariate or bivariate analysis and highlight- bold the results that are significant. This can help the readers to recognized those significant factors in the table easily.

⇒Thank you so much for your advice. I added p-value as much as possible and made them bold for significant results. However, in complex-sampling module Ver23, we are not able to calculate p-value individually in our logistic multivariable regression model. I asked IBM company, they guided us if we want to get p-value individually we need to change all references in our data set.

Reviewer #2: Yuichi Imanaka et al conducted a study to determine social and behavioral factors that determine having blood pressure measurements in Bhutan. They have corrected prior comments but there are some changes that are still needed.

Line 55: had a lower likelihood of undergoing blood pressure measurement

Correct wording.

⇒Thank you for your comments. However, we think the wording are correct. We think that likelihood Is better than odds in this case due to complex survey module, and proofed by professional English editor. In case of “undergoing “makes confuse, we changed the word from” undergoing” to “having experience”. (Line59, 62)

I would further specify everytime you mention hypertensive patients did not have their blood pressure measured that this was after the first diagnosis measurement. (Line 65, 66)

⇒Thank you for your comments. We added “before the STEPS survey” and modified explanation. (Line 67-68, 96,104-106, 114-116, 173,289,365)

LINE 88 : Have showed to be necessary instead of has

⇒Thank you for your advice.　We have changed from “have” to “has”.(Line90)

Again in line 94 you mention people with hypertension have not had their blood pressure measured but this is impossible. Please address this like you did previously. In line 96 you mention according to NCD survey reports, “Around 96 (31.3%) of the study population had never had their blood pressure checkup”, but this again does not make sense if they already have the diagnosis. They needed at least 2 measurements performed priorly. Perhaps you should clarify “follow-up” blood pressure in all sentences regarding new measurements.

⇒Thank you for your comments. I added explanation “before the previous field work conducted in 2017”. However, we can’t modify the quoted sentences from previous government NCD survey report. We mention whom have no experience of high blood measurement before we met or before survey. During field work or the survey, we diagnosed their hypertension. (Line96)

Line 163: How was salt intake estimated? Based on a diet questionnaire?

⇒Thank you for your comments. We estimated salt intake based on spot urine. Details of the method to estimate salt intake are now included in the manuscript.

Salt intake was calculated using the Tanaka Formula (Tanaka T, Okamura T, Miura K, Kadowaki T, Ueshima H, Nakagawa H, et al. A simple method to estimate populational 24-h urinary sodium and potassium excretion using a casual urine specimen. Journal of Human Hypertension. 2002;16(2):97-103).

Salt Intake per day(g) = (21.98 * ((Spot Urinary Sodium/

(Spot Urinary Creatinine *10/0.0884)) * (((14.89* Weight (Kg))+(16.14*height(m))*(2.04*age))-2244.45))**0.392)/17.1 (Line167-169)

Line 170: I do not understand why you used family history on hypertension as a definition for diagnosis. I suggest you remove this definition.

⇒Thank you for your suggestion. We have removed it. (Line175-176)

Line 176: I do not understand what you mean by this: All of the data are available and considered to be related to the dependent variable from the previous literature as mentioned in the explanatory variables.

⇒Thank you for your comments. We have improved the sentence as below

All available and selected data from the STEPS survey are considered related to the objective variable from previous literature. Among those variables that may be related to blood pressure measurement, we selected the explanatory variables to be fed into the model using the Directed Acyclic Graph (S3 File). (Line180-183)

I would suggest you specify very clearly which patients were included: only patients who had prior diagnosis of hypertension defined as known diagnosis or those who were diagnosed during the National Survey for Noncommunicable Disease Risk Factors and Mental Health.

⇒Thank you for your suggestion. Our explanation may make you confuse. We include all aged 18 to 69 years. We didn’t exclude normal blood pressure(Figure1). We just evaluate the hypertension during NCD STEPS survey. We added the explanation of the definition about hypertension through our paper.

Line 205: Again, it is not clear why you made sub-analysis for people with hypertension, you need to be very careful with wording as to say that your objective is to know factors that determine the experiences of having blood pressure measurements and whether they differ for patients who had prior hypertension diagnosis and those who did not.

⇒Thank you for your meaningful advice.　We deeply considered and erased the subgroup analysis for multivariable regression models.”

In the results section, if variables have a parametric distribution, it is better to state mean and standard deviation rather than standard error.

⇒Thank you for your advice. We have added standard deviations in Table1. We recognize that logistic regression does not matter whether variables have a parametric distribution or not. And we adjusted the weight and cluster using SPSS complex sampling module, so it is better to use Standard Error than Standard Deviation. So, we kept standard error too. (Table1,Line,206-207,231)

In table 1 rename variable Gender_Marital Status since it looks like you just left the statistical program output without correcting variable names.

⇒Thank you for your advice. We deeply considered and changed not only names but also our models. We divided the combined variables as original. Because we can show the effects individually. (Line153-154, S3File)

In table two remove the parenthesis after 1 and 2 super indexes. Income variable in table 2 is not in the same format as the rest of the table.

⇒Thank you for your advice. We improved it.

In line 317 you still insist that patients with hypertension never underwent blood pressure measurement in their lives, but this, again, is not possible since that is the only way to diagnose hypertension is measuring blood pressure. You have explained in previous responses what you mean but you need to be very explicit about it throughout your discussion.

⇒Thank you for your meaningful advice.

We have added the explanation throughout our discussion. All descriptions include the definition of Hypertension in this paper so that reader can understand who has never had a blood pressure measurement prior to the NCD STEPS survey. Hypertension was determined during the NCD STEPS survey, and the experience of blood pressure measurement was prior to the NCD STEPS survey. (Line 67-68, 96,104-106, 114-116, 173,289,365)

From this your advice, we also learned about causal inferences in the field of epidemiology, considered that there is a clear time difference between the blood pressure measurement experience and the hypertension, and reconsidered our multivariate analysis model. The variable of hypertension should be collider in our models (S3 File).

Check wording in line 352.

⇒Thank you for advice. We have changed as below

Lower income women might also experience some barriers to visit the hospital, as previous studies in other countries have indicate. (Line324-325)

Reviewer #3: I have no idea whether data analysis was done appropriately and rigorously. However, the presentation of the results is clear and response to the research objectives.

⇒Thank you so much for your comments. Regarding the data analysis, we have done the previous revisions rigorously. However, we have reconsidered and changed models from view point of causal inference. There was no significant change in the results from the last revision.

Sincerely yours

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Decision Letter 2

Marcelo Arruda Nakazone

4 May 2022

PONE-D-21-12027R2Social and behavioral factors related to blood pressure measurement: A cross-sectional study in BhutanPLOS ONE

Dear Dr. Imanaka,

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.

==============================

ACADEMIC EDITOR:

Previous comments have been addressed. But the manuscript will require a minor revision.<o:p></o:p>

While they recognize the potential interest of the subject studied, one of the Reviewers raised additional comments that need to be properly addressed.<o:p></o:p>

==============================

Please submit your revised manuscript by Jun 18 2022 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,

Marcelo Arruda Nakazone, M.D., Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[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 #2: (No Response)

**********

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 #2: Yes

**********

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

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: No

**********

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 #2: No

**********

6. Review Comments to the Author

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

Reviewer #2: Kohori-Segawa et al conducted a study to determine what characteristics are associated in Bhutanese people with the experience of having a blood pressure measurement. The article is interesting, however I still have a few corrections that need to be revised:

1) In line 174 the final definition of hypertension is having medication for hypertension and a positive family history of hypertension. I would suggest citing where was this definition taken from or how do you justify it.

2) Line 199 repeats again in line 201.

3) In line 203 I would further clarify which variables you identified as confounders in your multivariable analyses.

4) Line 212-216 are written incorrectly.

5) Line 259 is missing reference.

6) In line 266 where you say you did not find an association between Q3 and the experience of blood pressure measurement, why are you focusing only on Q3? If it is because it is the only one with a statistical association you should write it like that. And why are highest income quartiles categorized as Q1? Usually Q1 is the lowest quartile.

7) Line 292 is repetitive using diseases twice.

8) Line 306 background should be written as one word.

9) Line 306 this subtitle does not accurately reflect what you explain in the paragraph.

10) In line 324 you mention other barriers but not explain further which ones.

11) Line 338 should say “have more opportunities on having their health examined” rather than the actual wording.

12) In line 347 I would further explain your hypotheses on this association or move line 352 next to this paragraph.

13) Line 350 is repetitive, I would suggest: Those with a family history of hypertension or those with hypertension had more experiences with blood pressure measurement in all analyses probably because they have an increased awareness of the health threats they might face.

Finally, there are still several grammar mistakes that I would suggest you proofread.

**********

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 #2: Yes: Mercedes Aguilar-Soto

[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.

PLoS One. 2022 Aug 17;17(8):e0271914. doi: 10.1371/journal.pone.0271914.r006

Author response to Decision Letter 2

20 May 2022

We appreciate your review and feedback.

We have addressed all of the reviewers’ comments as below

1) In line 174 the final definition of hypertension is having medication for hypertension and a positive family history of hypertension. I would suggest citing where was this definition taken from or how do you justify it.

⇒Thank you for your suggestion. We realized that the definition was mistakenly written as “and a positive family history of hypertension”. Therefore, we removed it.

2) Line 199 repeats again in line 201.

⇒Thank you for your confirmation. Starting words were the same as “we evaluated…”. Actually, there is not repetition in the contents. We changed the sentence to better the understanding.

Line 199: We evaluated the association between the experiences of having blood pressure measurements and individual and social environmental factors affecting interpersonal decisions or close networks through descriptive and univariable logistic regression, the association between the experiences of having blood pressure measurements and high-risk behaviors of hypertension factors through descriptive and multivariable logistic regression.

3) In line 203 I would further clarify which variables you identified as confounders in your multivariable analyses.

⇒Thank you for your advice. We added the explanation as below.

Line203-206: Through Directed Acyclic Graph, we defined minimal sufficient adjustment sets for estimating the total effect of high-risk behaviors of hypertension factors on the experiences of having blood pressure measurements.

4) Line 212-216 are written incorrectly.

⇒Thank you reviewer. We modified the sentence as below.

Line214: In the study, participants aged 18 to 69 years were included. Variables with missing data and pregnant women were excluded from the analysis because of health behavioral and biological differences.

5) Line 259 is missing reference.

⇒Thank you reviewer for this notification.

Actually, the reference here relates to reference of Odds calculated (i.e. no formal education). We changed from (Ref) to (OR:1).

6) In line 266 where you say you did not find an association between Q3 and the experience of blood pressure measurement, why are you focusing only on Q3? If it is because it is the only one with a statistical association you should write it like that. And why are highest income quartiles categorized as Q1? Usually Q1 is the lowest quartile.

⇒Thank you reviewer for this critical comment and the valuable suggestion. We modified the sentence as below.

Line263: In terms of income, all participants in the Q4 (Nu. 60,001+: 805.8+ USD (OR:2.404, 95% CI:1.575 –3.667)) and Q3 category (Nu 30,001–60,000: 403.0–805.7 USD (OR:2.546, 95% CI: 1.640–3.955)) had an increased likelihood of having experienced blood pressure measurement compared with those in the lowest income category Q1 (Nu 0–9,000: 0–120.8 USD[OR:1]). We could find the significant association between Q1, Q3, Q4 and the experience of blood pressure measurement, but we could not find a significant association between Q2 (Nu 9,001–30,000: 120.9–402.9 USD) and the experience of blood pressure measurement.

7) Line 292 is repetitive using diseases twice.

⇒ “cardiovascular diseases” is removed from the sentence

Line 294: Early detection and treatment of hypertension can be effective in preventing other diseases [3,17]

8) Line 306 background should be written as one word.

⇒Thank you. “Back ground” is changed to single word “background” as suggested

9) Line 306 this subtitle does not accurately reflect what you explain in the paragraph.

⇒Thank you for this critique. We modified from “Social background factors and gender difference: Self-employed, non-working or low-income men, and low-income women” to “Social background factors and gender differences”.

10) In line 324 you mention other barriers but not explain further which ones.

We added the explanation as below.

Line326-328: Lower income women might also experience some barriers to visiting the hospital, as previous studies in other countries have indicated, such as insufficient education, gender problems, insufficient family supports, etc. [42].

11) Line 338 should say “have more opportunities on having their health examined” rather than the actual wording.

⇒Thank you reviewer for your suggestion. We modified the sentence as below.

Line341: Those who are employed may have more opportunities on having their health examined and other services from their companies than those who are self-employed or non-working [47].

12) In line 347 I would further explain your hypotheses on this association or move line 352 next to this paragraph.

⇒We moved the sentences as suggested.

13) Line 350 is repetitive, I would suggest: Those with a family history of hypertension or those with hypertension had more experiences with blood pressure measurement in all analyses probably because they have an increased awareness of the health threats they might face.

⇒Thank you reviewer for your suggestion. Much appreciated. We improved the sentences as below.

Line350-356: Those with a family history of hypertension or those with hypertension had more experiences with blood pressure measurement in all analyses probably because they have an increased awareness of the health threats they might face. People with unhealthy lifestyle may not be aware of health threats or perceived health vulnerability, and one of the characteristics of people with healthy lifestyle may be the ability to perceive health threats, regardless of whether they have pre-existing health problems or not. People with unhealthy lifestyle (high salt intake or tobacco use) had less experience with blood pressure measurement.

Finally, there are still several grammar mistakes that I would suggest you proofread.

We agree and therefore, we proofread again.

Sincerely yours

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (21KB, docx)

Decision Letter 3

Marcelo Arruda Nakazone

6 Jun 2022

PONE-D-21-12027R3Social and behavioral factors related to blood pressure measurement: A cross-sectional study in BhutanPLOS ONE

Dear Dr. Imanaka,

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.

Previous comments have been addressed. However, the manuscript will require a minor revision.

Reviewer #2 still raised some points that require the authors attention before publication.

In this context, I strongly recommend an English speaker proofreading since grammar mistakes remain persistent through the review process.

Please submit your revised manuscript by Jul 21 2022 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:

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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Marcelo Arruda Nakazone, M.D., Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #2: 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 #2: Yes

**********

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

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: No

**********

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 #2: No

**********

6. Review Comments to the Author

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

Reviewer #2: In the abstract: Cardiovascular disease is a leading cause of death in the Kingdom of Bhutan, and the early detection of hypertension is critical for preventing it.

Again in the abstract clarify that “26% of the participants with hypertension never underwent blood pressure measurements” after their diagnosis since it is imposible to diagnose hypertension without a blood measurement, or whether this patients were identified during the STEPS survey.

Line 59 says “having experienced with blood pressure measurement.” Check grammar.

Check grammar in lines 80-81, 215-216, 242, 243, 245, 253, 278, 300, 336.

Line 238 would be better this way: Among those with hypertension, 26.3% (crude n=197, SE: 2.5%, 95% CI :21.7–31.4%) had never had blood pressure measurement before.

In line 268 you say Q1 was also significantly associated with the experience of blood pressure measurment, however Q1 was the reference so I do not understand this line.

I highly recommend an English speaker proofreading since grammar mistakes have been present through revisions.

**********

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 #2: Yes: Mercedes Aguilar-Soto

**********

[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.

PLoS One. 2022 Aug 17;17(8):e0271914. doi: 10.1371/journal.pone.0271914.r008

Author response to Decision Letter 3

20 Jun 2022

We really appreciate your review and feedback.

Reviewer #2: In the abstract: Cardiovascular disease is a leading cause of death in the Kingdom of Bhutan, and the early detection of hypertension is critical for preventing it.

Again in the abstract clarify that “26% of the participants with hypertension never underwent blood pressure measurements” after their diagnosis since it is imposible to diagnose hypertension without a blood measurement, or whether this patients were identified during the STEPS survey.

⇒Thank you for your comment. We asked the English proofreader and had improved the sentence as follows.　

Line53:“Approximately 26% of those with hypertension who were detected during the STEPS survey had never had their blood pressure measured.”

Line 59 says “having experienced with blood pressure measurement.” Check grammar.

⇒Thank you for your comment. We asked the English proofreader and had improved the sentence as follows.　

Line60: “A family history of hypertension (OR: 2.019, 95% CI: 1.549–2.243) increased the likelihood of having experienced a blood pressure measurement in both men and women. “

Check grammar in lines 80-81, 215-216, 242, 243, 245, 253, 278, 300, 336.

⇒Thank you for your comments.　

We have hired a professional English proofreader and improved some sentences.

The improved points were highlighted in green with you mentioning them, highlighted in yellow was without you mentioning them.

Line 238 would be better this way: Among those with hypertension, 26.3% (crude n=197, SE: 2.5%, 95% CI :21.7–31.4%) had never had blood pressure measurement before.

⇒Thank you for your advice. We had improved as follows.

Line257: “Among those with hypertension, 26.3% (crude n=197, SE: 2.5%, 95% CI :21.7–31.4%) had never had a blood pressure measurement before.

In line 268 you say Q1 was also significantly associated with the experience of blood pressure measurment, however Q1 was the reference so I do not understand this line.

We could find the significant association between Q3, Q4 and the experience of blood pressure measurement, but we could not find a significant association between Q2 (Nu 9,001–30,000: 120.9–402.9 USD) and the experience of blood pressure measurement.

⇒Thank you for your advice. We asked the English proofreader and had improved the sentence as follows.

Line 285: “In terms of income, all participants in Quartile-4 (Nu. 60,001+: USD 805.8+ (OR: 2.404, 95% CI: 1.575 –3.667)) and Quartile-3 (Nu. 30,001–60,000: USD 403.0–805.7 (OR: 2.546, 95% CI: 1.640–3.955)) had an increased likelihood of previous blood pressure measurement compared with those in the lowest income category, Quartile-1 (Nu. 0–9,000: USD 0–120.8 [OR: 1.000]). We found a significant association between Quartile-3, Quartile-4, and previous blood pressure measurement but not between Q2 (Nu. 9,001–30,000: USD 120.9–402.9) and previous blood pressure measurement.”

I highly recommend an English speaker proofreading since grammar mistakes have been present through revisions.

⇒Thank you for your advice. We asked the English speaker professional proofreader and had improved the whole sentence.

Attachment

Submitted filename: 20220620Response to Reviewers.docx

Click here for additional data file. (17.1KB, docx)

Decision Letter 4

Marcelo Arruda Nakazone

11 Jul 2022

Social and behavioral factors related to blood pressure measurement: A cross-sectional study in Bhutan

PONE-D-21-12027R4

Dear Dr. Imanaka,

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

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

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Marcelo Arruda Nakazone, M.D., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #2: 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 #2: Yes

**********

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

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: 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 #2: 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 #2: Imanaka et al conducted a study in Buthan in order to determine health behaviour attitudes and social factors that are associated with patients getting blood pressure measurements.

After several prior revissions all comments have been adressed, methodology has been explained better and grammar has been profread.

**********

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 #2: Yes: Mercedes Aguilar-Soto

**********

Acceptance letter

Marcelo Arruda Nakazone

8 Aug 2022

PONE-D-21-12027R4

Social and behavioral factors related to blood pressure measurement: A cross-sectional study in Bhutan

Dear Dr. Imanaka:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Marcelo Arruda Nakazone

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 File. Sample size, power calculation, weighting, and adjusting the cluster random sampling procedure.

    (PDF)

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    S2 File. Directed acyclic graph for multivariable logistic regression.

    (PDF)

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    Attachment

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    Data Availability Statement

    Since the Ministry of Health, Bhutan is the authority for the data, the authors were not able to make it available with this paper. However, the original report (World Health Organization and Ministry of Health in Bhutan. National Survey for Noncommunicable Disease Risk Factors and Mental Health using WHO STEPS Approach in Bhutan – 2014) is available from https://apps.who.int/iris/handle/10665/204659. Requests to access the raw data can be directed to the Research Ethics Board of Health at the Ministry of Health, Royal Government of Bhutan. Contact: P.O. Box: 726, Kawajangsa, Thimphu, Bhutan Phone No: +975-2-328095, 321842, 322602, 328091.

    Articles from PLoS ONE are provided here courtesy of PLOS

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