Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana

Patience A. Afulani; Akua O. Gyamerah; Jerry J. Nutor; Amos Laar; Raymond A. Aborigo; Hawa Malechi; Mona Sterling; John K. Awoonor-Williams

doi:10.1371/journal.pone.0250294

Peer Review History

Original SubmissionSeptember 10, 2020
8 Jan 2021 Decision Letter - Vincenzo Lionetti, Editor PONE-D-20-28591 Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana PLOS ONE Dear Dr. Gyamerah, 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. ============================== all issues raised by reviewers are required. ============================== Please submit your revised manuscript by Feb 21 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, Vincenzo Lionetti, M.D., PhD Academic Editor PLOS ONE 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. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information [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: Yes Reviewer #2: No ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: No ****** 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: Covid-19 is the most salient topic of the year, from a health, social, and scientific point of view. The authors detailed the psychological (and psychopathological) impact of the pandemic on the most affected category in terms of mental well-being. The statistical analysis carried out appears meticulous and well explained. The number of variables investigated is large and overall sufficient to realistically describe the distress condition of the HCWs. Through the survey, the authors characterize study participants with demographic, professional, cognitive, and emotional specifications. The constructs of stress and burnout, assessed by validated scales, undoubtedly reflect the difficulties faced by the HCWs, and the association with the insufficient perceived preparedness stimulates reflection about potential and necessary improvements in Ghana – and global – health system. Main concerns: I suggest adding or clarifying some information about sampling and data selection methods. 1.Since respondents have the option to skip some questions, you should specify if and how many subjects were excluded from the analysis (i.e. has a cut-off been set? Have the stress and burnout questionnaires been included only if complete?) 2.It is unclear whether the two samples (n = 414 and n = 409 for stress and burnout, respectively) overlap or if they are distinct groups (i.e did each subject answer to both questionnaires or only one of them, either burnout or stress?) In the last line of paragraph 2.2. you wrote that "Additional study methods can be found elsewhere (41)", but in the cited article I found an identical description. In this regard, given the mention and the similarities, it would be appropriate to elucidate the possible relationship between the two manuscripts. Minor comments: I noticed that several times you mentioned online news sites (e.g. Reuters, GhanaWeb, CNN, Deutsche Well, ScienceDaily). I recommend, if and when possible, replacing them with references from scientific journals. I found some typing errors in the list of references (ref. N ° 17, n ° 35). I recommend checking it out. Reviewer #2: Evaluations: Title 1. Does the title give clear idea about the article? No I think it is better as “Is inadequate preparedness for, response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana?” Also, please write full words in the short title. (HCW) Abstract 2. Does the abstract that concisely describes the content and scope of the project and identifies the project’s objective, its methodology and its findings, conclusions, or intended results? Yes Introduction 3. Does the introduction give clear idea about the article? YES Please write references in same fashions. Example, (line 3rd of introduction, ----people as of August 10th, 2020 (1). And line 5th of introduction ……World Health Organization (WHO)(2). Make Times New Roman style “perceived preparedness” Methods 4. Did methodology part is clear? NO -I haven’t seen the importance of narrating “2.1. Context…….” under methods. -You were collecting the data through social media. Your sampling seem non probability because participants those only your friends. - I am afraid of the quality of data. -Well, if sociodemographic of participants included 5. It is well if sub-headed methodology part as: study setting and period, study design, and so on. 6. Did you conduct a pretest? If yes, how and where? If no, why? 7. What language/s used for data collection? 8. You have no inclusion and exclusion criteria. Please give more clarification for this. 9. What do you think about voluntary participation in your study? Results 10. You categorized professional type to Doctor, Nurse related and Other. First, what are others? Please specify. Second, it is not recommended to use for more than 5% for others. But yours is 17.6% 11. How you classify years of experiences and age of participants? 12. You classify marital status in to married and single. What others? (This is what I said quality of data) 13. Revise the references as the journal guideline 14. Tables titles are not written in the standard form. ****** 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: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0250294.r001
Revision 1
12 Jan 2021 Author Response Dear Dr. Lionetti, Thank you for the opportunity to revise and resubmit our manuscript. We have given careful consideration to all the issues raised by the reviewers and revised our manuscript accordingly. Below is a point-by-point clarification and explanation of revisions made in response to the reviewers. Sincerely, Manuscript authors Response to comments Journal comments 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Response: We have revised the manuscript to meet PLOS ONE’s style requirements and name files according to the journal’s guidelines. We have also added the following sections: “contributors”, “data availability”, “Funding”, and competing interests after the conclusions section, on page 20. 2. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Response: We have renamed our Supporting Information files to reflect the journal’s guidelines, added a Supporting Information section after the references, on page 26, and revised in-text citations of the supporting information accordingly. Reviewer #1: Covid-19 is the most salient topic of the year, from a health, social, and scientific point of view. The authors detailed the psychological (and psychopathological) impact of the pandemic on the most affected category in terms of mental well-being. The statistical analysis carried out appears meticulous and well explained. The number of variables investigated is large and overall sufficient to realistically describe the distress condition of the HCWs. Through the survey, the authors characterize study participants with demographic, professional, cognitive, and emotional specifications. The constructs of stress and burnout, assessed by validated scales, undoubtedly reflect the difficulties faced by the HCWs, and the association with the insufficient perceived preparedness stimulates reflection about potential and necessary improvements in Ghana – and global – health system. Response: Thank you Main concerns: I suggest adding or clarifying some information about sampling and data selection methods. 1.Since respondents have the option to skip some questions, you should specify if and how many subjects were excluded from the analysis (i.e. has a cut-off been set? Have the stress and burnout questionnaires been included only if complete?) Response: Yes, we only used data from respondents who completed all of the stress and burnout questions. 646 people started the survey (i.e answered the first question), but many did not complete the survey. For the present study, we excluded data from 232 and 237 people from the stress and burnout analytic samples. Many of the respondents we excluded answered only the first few questions in the survey and the stress and burnout questions were among the final set of questions. Thus, given that stress and burnout were the key outcomes in this paper, we did not think it was appropriate to impute for the missing data. We however compared the characteristics of those excluded (since the demographic questions were the initial questions and many just answered those) to those included. We have added Appendix 3 to our revised manuscript, which shows that the analytic sample and excluded people were not substantially different. We have described this in the methods section on page 10 and in the sensitivity analysis on page 15. 2.It is unclear whether the two samples (n = 414 and n = 409 for stress and burnout, respectively) overlap or if they are distinct groups (i.e did each subject answer to both questionnaires or only one of them, either burnout or stress?) Response: These two samples overlap. The difference is due to a few more missing observations on the burnout items. We have clarified this in the methods section on page 10. -In the last line of paragraph 2.2. you wrote that "Additional study methods can be found elsewhere (41)", but in the cited article I found an identical description. In this regard, given the mention and the similarities, it would be appropriate to elucidate the possible relationship between the two manuscripts. Response: The first study manuscript we referenced examines factors associated with perceived preparedness of healthcare workers. We referenced it for its description of the psychometric analyses used to validate the perceived preparedness scale. In our submitted manuscript on burnout and stress, perceived preparedness is a key predictor, however we did not go into details in our methods section on the psychometric analyses/validation methods. Thus, we referenced the first manuscript for those methods. We have clarified this in the revised manuscript. Minor comments: -I noticed that several times you mentioned online news sites (e.g. Reuters, GhanaWeb, CNN, Deutsche Well, ScienceDaily). I recommend, if and when possible, replacing them with references from scientific journals. Response: We have searched for articles in scientific journals for these references, however, we unfortunately did not find any for the Reuters, GhanaWeb, and CNN references, all of which discuss Ghanaian healthcare worker strike threats, cases, and related deaths from COVID-19. Unfortunately, these developments were reported in news articles and not in scientific reports. We have however replaced the Deutsche Welle reference with a scientific journal article (Ref # 27) and removed the Science Daily reference since it discusses a scientific study that is already referenced in our manuscript (Ref # 50). -I found some typing errors in the list of references (ref. N ° 17, n ° 35). I recommend checking it out. Response: Thank you for flagging these. We have corrected the typing errors. Thank you for your insightful comments which have strengthened our manuscript. Reviewer #2: Title 1. Does the title give clear idea about the article? No I think it is better as “Is inadequate preparedness for, response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana?” Response: Thank you for the suggestion. Given that titles in the form of a question are generally not advised for scientific papers that report findings, we would prefer not to frame the title in the form of a question. We chose our title based on the suggestion to use titles that are concise statements of study findings to draw the attention of readers. However, we defer to the Journal editors on whether the suggested title would be preferred for the manuscript. -Also, please write full words in the short title. (HCW) Response: We have done this. Abstract 2. Does the abstract that concisely describes the content and scope of the project and identifies the project’s objective, its methodology and its findings, conclusions, or intended results? Yes Response: Thank you Introduction 3. Does the introduction give clear idea about the article? YES Response: Thank you -Please write references in same fashions. Example, (line 3rd of introduction, ----people as of August 10th, 2020 (1). And line 5th of introduction ……World Health Organization (WHO)(2). Response: We have checked the in-text references and they are consistent. The mention of “WHO” is not a reference, but rather an abbreviation for World Health Organization. We have restructured the sentence to make this clear. Make Times New Roman style “perceived preparedness” Response: We have checked to confirm that all formatting is in Times New Roman style font. Methods 4. Did methodology part is clear? NO -I haven’t seen the importance of narrating “2.1. Context…….” under methods. Response: We thought it would be appropriate to describe the context for people who might not be familiar with it to situate the study. We think this is important, but can delete it if you feel strongly about not describing the context. -You were collecting the data through social media. Your sampling seem non probability because participants those only your friends. Response: We acknowledge that this was a non-probability sample as described in our method. Probability sampling was not feasible given the situation at the time of the study due to the COVID-19 pandemic, but we thought it was important to conduct this study to provide data to inform policy discussions on the country’s COVID-19 response. It is however inaccurate to say participants are only our friends. As noted in the methods, we disseminated survey links to Facebook and WhatsApp pages of different professional groups, graduation year groups, and regional groups of HCWs, as well as to leaders of professional organizations and Ghana Health Service directors to share with members of their groups. This approach was used to ensure that we reached a diverse sample of health workers outside of our networks. The sampling method is described in our Methods section, and we discuss the limitations of a non-probability sample in our Discussion section on page 18. - I am afraid of the quality of data. Response: Per other subsequent comments, this concern appears to be related to recoding of variables. We recoded some variables to avoid very small categories for the regression analysis. We did not think it was important to go into these details. But given your concern, we have added notes to the tables, highlighting composition of recoded categories. -Well, if sociodemographic of participants included Response: Sociodemographic characteristics of respondents are shown on table 1. We have modified the table title to reflect this. 5. It is well if sub-headed methodology part as: study setting and period, study design, and so on. Response: We have added the suggested heading(s). 6. Did you conduct a pretest? If yes, how and where? If no, why? Response: Yes, we pretested the survey with HCWs in Ghana before the actual study. We have added this to the methods on page 8. 7. What language/s used for data collection? Response: English: We have added this 8. You have no inclusion and exclusion criteria. Please give more clarification for this. Response: The inclusion criteria were identifying as a HCW based in Ghana, which by default meant exclusion criteria was not identifying as a HCW, and not based in Ghana. We have noted the eligibility criteria in the methods to clarify this on page 8. 9. What do you think about voluntary participation in your study? Response: As noted in our limitations, voluntary participation is a limitation as volunteers may respond differently from non-volunteers. But as mandated by ethical guidelines from the Institutional Review Board, participation in any study should be voluntary and so this does not invalidate the findings. Results 10. You categorized professional type to Doctor, Nurse related and Other. First, what are others? Please specify. Second, it is not recommended to use for more than 5% for others. But yours is 17.6% Response: We acknowledge this concern. As noted in text, the other professionals, included medical laboratory professionals, disease control officers, nutritionists and other allied health care workers. We have also added this as footnotes in the tables. We grouped these together, because the number of people in these sub-groups was small compared to doctors and nurses and separating them out resulted in very small categories. 11. How you classify years of experiences and age of participants? Response: The classification was based both on the distribution of the data and to obtain conceptually meaningful categories. We however note in the text that “The average age of respondents was 34.2 years (SD=6.0), with 8.2 years of professional experience (SD=5.6).” 12. You classify marital status in to married and single. What others? (This is what I said quality of data) Response: There were too few respondents in the other groups, so these were recoded into the two categories. The married category includes 10 people (2%) who were previously married (widowed, separated, or divorced). We have added this as footnotes in the table. 13. Revise the references as the journal guideline Response: The Journal’s reference guideline is Vancouver, which we used to format our references. We have reviewed the references and verified that they meet the Vancouver guidelines. 14. Tables titles are not written in the standard form. Response: We have edited the Table titles to fit a more standard form. Thank you for your insightful comments to strengthen the paper. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0250294.r002
28 Mar 2021 Decision Letter - Vincenzo Lionetti, Editor PONE-D-20-28591R1 Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana PLOS ONE Dear Dr. Gyamerah, 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: Issue related to discussion is required. ============================== Please submit your revised manuscript by May 12 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. 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, Vincenzo Lionetti, M.D., PhD 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. Additional Editor Comments (if provided): The authors have improved the manuscript, but in light of revised version it is important that authors highlight potential comorbidities that affect the enrolled patients (i.e.: cardiovascular disease, obesity). Indeed, recent preclinical study demonstrated that psychosocial stress exerts bigger detrimental effect in the presence of overweight/obesity. Moreover, cardiac function is also impaired following exposure to psychosocial stress since significant oxidative stress occurs in both brain and heart (please see EBioMedicine. 2019 Sep;47:384-401). Since COVID19 induce severe inflammatory response and impair cardiovascular function, authors should discuss their data in light of abovementioned study. [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 #1: 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 ****** 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 ****** 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: I was pleased to receive and review for the second time the article entitled "Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana", regarding psychopathological impact of the pandemic on the most affected category in terms of mental well-being. The authors have exhaustively clarified my doubts, responding privately to my comments or adding specific requests in the text. In particular: information regarding sampling methods, exclusion / inclusion criteria for participants, composition of questionnaires, number and characteristics of drop outs, "overlapping" of the samples for stress and burnout, relationship with the previous paper, references from news sites . I believe that the information added corresponds to my requests and is sufficient to strengthen the manuscript. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No [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.0250294.r003
Revision 2
30 Mar 2021 Author Response Dear Dr. Lionetti, Thank you for the opportunity to revise and resubmit our manuscript. We have given consideration to the citation suggestion you made and have revised our manuscript accordingly. Below is a clarification and explanation of the revision made in response to the review. Sincerely, Manuscript authors Response to comments Additional Editor Comments (if provided): The authors have improved the manuscript, but in light of revised version it is important that authors highlight potential comorbidities that affect the enrolled patients (i.e.: cardiovascular disease, obesity). Indeed, recent preclinical study demonstrated that psychosocial stress exerts bigger detrimental effect in the presence of overweight/obesity. Moreover, cardiac function is also impaired following exposure to psychosocial stress since significant oxidative stress occurs in both brain and heart (please see EBioMedicine. 2019 Sep;47:384-401). Since COVID19 induce severe inflammatory response and impair cardiovascular function, authors should discuss their data in light of abovementioned study. Response: We acknowledge this concern. But our study did not enroll patients. Rather it enrolled healthcare workers to examine how their preparedness to respond to COVID-19 is associated with their stress and burnout using psychosocial measures. We have carefully reviewed the paper referenced (EBioMedicine. 2019 Sep;47:384-401) and it does not appear directly relevant to our paper given its focus on biological mechanisms and effects of psychosocial stress on obese mice. Thus, citing the suggested paper would appear out of context in our paper, which focuses on how preparedness level of healthcare workers is associated with psychosocial measures of burnout and stress, not the effects of stress and burnout. We have, however, acknowledged in the limitations section that exploring the effects of stress and burnout experienced by healthcare workers and the associated biological mechanisms was beyond the scope of our paper and that future research may be needed to examine these mechanisms. Reviewer 1 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 Response: Thank you 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 Response: Thank you 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Response: Thank you 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 Response: Thank you 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 Response: Thank you 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: I was pleased to receive and review for the second time the article entitled "Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana", regarding psychopathological impact of the pandemic on the most affected category in terms of mental well-being. The authors have exhaustively clarified my doubts, responding privately to my comments or adding specific requests in the text. In particular: information regarding sampling methods, exclusion / inclusion criteria for participants, composition of questionnaires, number and characteristics of drop outs, "overlapping" of the samples for stress and burnout, relationship with the previous paper, references from news sites . I believe that the information added corresponds to my requests and is sufficient to strengthen the manuscript. Response: Thank you. 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Attachments Attachment Submitted filename: Second revision_response to reviewers.docx https://doi.org/10.1371/journal.pone.0250294.r004
5 Apr 2021 Decision Letter - Vincenzo Lionetti, Editor Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana PONE-D-20-28591R2 Dear Dr. Gyamerah, 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, Vincenzo Lionetti, M.D., PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0250294.r005
Formally Accepted
8 Apr 2021 Acceptance Letter - Vincenzo Lionetti, Editor PONE-D-20-28591R2 Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana Dear Dr. Gyamerah: 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 Prof. Vincenzo Lionetti Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0250294.r006

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