Psychological distress among health service providers during COVID-19 pandemic in Nepal

Khagendra Kafle; Dhan Bahadur Shrestha; Abinash Baniya; Sandesh Lamichhane; Manoj Shahi; Bipana Gurung; Partiksha Tandan; Amrita Ghimire; Pravash Budhathoki

doi:10.1371/journal.pone.0246784

Peer Review History

Original SubmissionOctober 31, 2020
14 Dec 2020 Decision Letter - Simone Savastano, Editor PONE-D-20-34279 Psychological Distress among Health Service Providers during COVID-19 Pandemic in Nepal PLOS ONE Dear Dr. Dhan Bahadur Shrestha 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. Albeit nice and potentially interesting this study has some important limitations as highlighted by the two reviewers. I hope Authors could be able to handle them in order to improve the quality of the manuscript and the clarity of the message they want to give. Please submit your revised manuscript by Jan 28 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Simone Savastano Academic Editor PLOS ONE Additional Editor Comments Albeit nice and potentially interesting this study has some important limitations as highlighted by the two reviewers. I hope Authors could be able to handle them in order to improve the quality of the manuscript and the clarity of the message they want to give. Journal requirements: When submitting your revision, we need you to address these additional requirements. 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 2.The text in Figure 1 is hard to read. Please increase the size of the font. [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: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ****** 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: Yes Reviewer #2: 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: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The study raises several major comments and concerns. 1. The measurements of the prevalence of peritraumatic distress related to COVID-19 may be influenced by the timing of the assessment with respect to the temporal evolution of the pandemic. Specifically, the study was conducted in October 2020, i.e., several months after the first outbreak. There is no mention of the potential changes and/or temporal evolution of psychological distress over time and how it could have been influenced the main findings. Do coping mechanisms develop over time or does the burden increase as the pandemic progresses? 2. Another critical issue is that the setting of the study is unclear, i.e., “hospitals”, “higher centers”, “health posts” are generic denominations. It is obvious that COVID-19-related psychological distress is clearly influenced by the fact that healthcare workers have to deal (or not) to patients with COVID-19. Was the study specifically focusing on workers who had to care for this patient group or not? Importantly, the severity of COVID-19 is highly variable (from asymptomatic cases to those in need of ICU admission). Thus, it is conceivable that people who have to care to ICU cases are more scared and distressed than those working in a general ward where patients with less severe disease are admitted. 3. How is it possible to claim that the pandemic has heightened the psychological distress amongst health care service providers? While this is quite expected, the use of CPDI is focused on COVID-19-related distress and broader implications (i.e., “the psychological distress”) are unwarranted and not grounded in the study results. 4. The CPDI was developed in China; was it validated in the Nepalese population? Are psychometric properties of the Nepalese version satisfactory? 5. Most participants were very young. Does working experience mitigate the psychological distress elicited by COVID-19? Minor points 1. Avoid mentioning statistical software in the “Abstract” section. 2. “ Gender” is a psychosocial construct; consider “sex” instead. Please also replace “female” and “male” with “women” and “men”, respectively. Reviewer #2: The study is well written and it focuses on an important aspect of the pandemic which has affected entire health care systems. However, there are several issues that have to be clarified. First of all, the vast majority of the population is less than 30 years old and this may not represent the overall population within the health care system. Second, the institute categories are not well specified especially when considering that the specific conditions in which employees work can affect their psychological distress regardless of the pandemic. Moreover, it's not clear whether all the participants worked directly with COVID-19 patients or not or how this distress level compares to pre-pandemic surveys of healthcare workers. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Benedetta Vanini Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0246784.r001
Revision 1
29 Dec 2020 Author Response Joerg Heber, Editor in Chief, PLOS ONE Dear Dr. Heber, Thank you for your interest in our manuscript: PONE-D-20-34279, Psychological Distress among Health Service Providers during COVID-19 Pandemic in Nepal. We are grateful to the editors for allowing us to revise our manuscript. We responded to the reviewer’s comments and concerns, and believe our manuscript is clearer and of greater quality as a result. Below we repeat each of the comments from the referees in bold italics followed by our responses in plain text with yellow highlights. Journal requirements: When submitting your revision, we need you to address these additional requirements. 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 Reply: We have amended in manuscript text. 2. The text in Figure 1 is hard to read. Please increase the size of the font. Reply: We have amended in manuscript text. 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: Partly Reviewer #2: Yes ________________________________________ 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ________________________________________ 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: Yes Reviewer #2: 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: Yes Reviewer #2: Yes ________________________________________ 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The study raises several major comments and concerns. 1. The measurements of the prevalence of peritraumatic distress related to COVID-19 may be influenced by the timing of the assessment with respect to the temporal evolution of the pandemic. Specifically, the study was conducted in October 2020, i.e., several months after the first outbreak. There is no mention of the potential changes and/or temporal evolution of psychological distress over time and how it could have been influenced the main findings. Do coping mechanisms develop over time or does the burden increase as the pandemic progresses? Reply: Distress severity is contrasted in discussion section. In similar survey in Nepalese residents using CDPI in early phase of pandemic showed distress in only 11%. While present survey showed significantly higher number of participants having distress, could be being this survey was only among health professional who has risk of contracting the infection and next may be due to evolution of pandemic. 2. Another critical issue is that the setting of the study is unclear, i.e., “hospitals”, “higher centers”, “health posts” are generic denominations. It is obvious that COVID-19-related psychological distress is clearly influenced by the fact that healthcare workers have to deal (or not) to patients with COVID-19. Was the study specifically focusing on workers who had to care for this patient group or not? Importantly, the severity of COVID-19 is highly variable (from asymptomatic cases to those in need of ICU admission). Thus, it is conceivable that people who have to care to ICU cases are more scared and distressed than those working in a general ward where patients with less severe disease are admitted. Reply: This is detailed in methods sections in revision. Available data about institution and type of job is presented in table 1 of result section. 3. How is it possible to claim that the pandemic has heightened the psychological distress amongst health care service providers? While this is quite expected, the use of CPDI is focused on COVID-19-related distress and broader implications (i.e., “the psychological distress”) are unwarranted and not grounded in the study results. Reply: Result of similar study regarding psychological distress in Nepalese community is contrasted in discussion. In prior study, may be due to early phase of pandemic distress level was relatively low in Nepal comparing with other countries, which were already in mid-later phase of pandemic. In present study, we found significantly higher proportion of health professionals with distress suggesting towards its relation with development of pandemic. 4. The CPDI was developed in China; was it validated in the Nepalese population? Are psychometric properties of the Nepalese version satisfactory? Reply: CPDI is widely under use due to its COVID-19 specific nature. In several studies carried out in Nepal and other countries are using it due to its specific nature. In our case we checked internal consistency of 24 CPDI variables using Cronbach's α. Its internal reliability was found to be 0.905 indicating high internal consistency of the scale. 5. Most participants were very young. Does working experience mitigate the psychological distress elicited by COVID-19? Reply: We have explained in limitation section in discussion. Minor points 1. Avoid mentioning statistical software in the “Abstract” section. Reply: We have amended in manuscript text. 2. “Gender” is a psychosocial construct; consider “sex” instead. Please also replace “female” and “male” with “women” and “men”, respectively. Reply: We have amended in manuscript text. Reviewer #2: The study is well written and it focuses on an important aspect of the pandemic which has affected entire health care systems. However, there are several issues that have to be clarified. First of all, the vast majority of the population is less than 30 years old and this may not represent the overall population within the health care system. Second, the institute categories are not well specified especially when considering that the specific conditions in which employees work can affect their psychological distress regardless of the pandemic. Moreover, it's not clear whether all the participants worked directly with COVID-19 patients or not or how this distress level compares to pre-pandemic surveys of healthcare workers. Reply: Amended, These issues discussed in method section and limitation section. ________________________________________ Thank you for your consideration. We look forward to hearing from you. Sincerely, Dhan Bahadur Shrestha Mangalbare Hospital, Morang, Nepal Attachments Attachment Submitted filename: Rebuttal letter.docx https://doi.org/10.1371/journal.pone.0246784.r002
27 Jan 2021 Decision Letter - Simone Savastano, Editor Psychological Distress among Health Service Providers during COVID-19 Pandemic in Nepal PONE-D-20-34279R1 Dear Dr. Dhan Bahadur Shrestha 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, Simone Savastano 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 #1: All comments have been addressed 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 #1: (No Response) Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 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 ****** 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: (No Response) Reviewer #2: All the comments have been addressed except the comparison of the distress level with pre-pandemic surveys of healthcare workers. However, this could be an option for a future study in order to strenghten the results founded in this paper. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** benedetta vanini Reviewer #2: No https://doi.org/10.1371/journal.pone.0246784.r003
Formally Accepted
29 Jan 2021 Acceptance Letter - Simone Savastano, Editor PONE-D-20-34279R1 Psychological distress among health service providers during COVID-19 pandemic in nepal Dear Dr. Shrestha: 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 Dr. Simone Savastano Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0246784.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .