Knowledge and awareness-based survey of COVID-19 within the eye care profession in Nepal: Misinformation is hiding the truth

Sandip Das Sanyam; Sanjay Kumar Sah; Pankaj Chaudhary; Matthew J. Burton; Jeremy J. Hoffman

doi:10.1371/journal.pone.0254761

Peer Review History

Original SubmissionSeptember 18, 2020
5 Mar 2021 Decision Letter - Marianne Clemence, Editor PONE-D-20-29438 Knowledge and awareness-based survey of COVID-19 1withinthe eye care professionin Nepal:2misinformation is hiding the truth. PLOS ONE Dear Dr. Sanyam, 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. The manuscript has been evaluated by three reviewers, and their comments are available below. The reviewers have raised a number of concerns that need attention. They request additional information on methodological aspects of the study (such as the inclusion of information on the sample size and patient population), revisions to the statistical analyses, and they request additional attention to the interpretation of the study's results in the context of the current literature. Could you please revise the manuscript to carefully address the concerns raised? Please submit your revised manuscript by Apr 15 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). 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Review report Manuscript Number: PONE-D-20-29438 Manuscript Title: Knowledge and awareness-based survey of COVID-19 1within the eye care profession in Nepal:2 misinformation is hiding the truth. 1. The paper is about a contemporary issue in public health, it is clearly written, and the topic is of high importance. The abstract is clear. Title is ambiguous. 2. The introduction should give background to the choice of study participants for the study, should demonstrate gap in knowledge, justification for the study and show relevance of the research to policy and practice. Why eye care practitioners? Why is the study relevant? Will it help to better control the emergency? All these did not appear clearly in the introduction. 3. The method: Authors should state who commissioned the study. What IRB granted approval, approval date and number (see line 88). It is important to state how the sample size for the study was determined, how instrument for data collection was checked for validity and reliability. 4. The choice of analytical approach is too basic. There is no explanation of the independent and dependent variables. There is need to conduct inferential statistics, compute mean scores, standard deviations and ratios to better explain the knowledge and awareness scores obtained. 5. It is always better to avoid starting a sentence with a figure. See lines 124,128,136. 6. The References are recent and relevant, but some are incomplete. Authors may want to update their references with related publications on the subject matter. 7. Recommendation for further study appeared in the conclusion, it may be better situated in the discussion section. Reviewer #2: 1. Financial disclosure and competing interests should be edited according the journal’s instructions. 2. IRB’s full name and committee number should be mentioned. 3. Authors should include whether the inform consent was given orally or in a written form. 4. Authors should consider emphasizing the specific importance of PPE and supplementary measures (e.g. clear plastic boards placed on the slit lamp) utilization in the eye clinic. 5. Authors should update their data and cite contemporary studies regarding ocular transmission of SARA-CoV-2 and ocular manifestations. They should try and compare it to what was known in the time the questionnaires were filled and try to explain, in their opinion, if the participants would answer differently in light of the current data. 6. If available, it would be helpful to know additional background data of the participants (e.g. size of clinic, number of patients seen in a certain amount of time, etc.). 7. Authors should mention and regard the fact that the majority of participants were quite of a homogenous group and of relatively young age. They should elaborate on it in their discussion. 8. In continuum to the previous comment, authors should try and explain their results in light of the cultural and occupational background of the participants. Reviewer #3: accepted with no comments. the manuscript is well written. The manuscript describe a technically sound piece of scientific research with data that supports the conclusions. the manuscript discussed an important issue and it seems quite interesting that most of the participants are not aware enough about this pandemic. ****** 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. 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Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0254761.r001
Revision 1
31 Mar 2021 Author Response Reviewer #1: 1. The paper is about a contemporary issue in public health, it is clearly written, and the topic is of high importance. The abstract is clear. Title is ambiguous. Thank you very much for reviewing our manuscript and for providing valuable feedback. Thank you for appreciating the importance of this topic. Regarding the title, we have amended the title on the online system so that there is no confusion. 2. The introduction should give background to the choice of study participants for the study, should demonstrate gap in knowledge, justification for the study and show relevance of the research to policy and practice. Why eye care practitioners? Why is the study relevant? Will it help to better control the emergency? All these did not appear clearly in the introduction. Thank you for this comment. On a pilot online questionnaire of the same questions among 10 participants before beginning the study, the knowledge and awareness seemed poor. We therefore felt there was a need to conduct a larger, more thorough study to check if the perception was the same or different across the entire nation. Eye care practitioners are at close contact with patients and there is a high risk of transmitting COVID-19 virus through aerosols between patients and eye care personnel. Dr Li, an ophthalmologist from Wuhan who unfortunately died from COVID-19 early during the pandemic, had said COVID-19 needs to be taken seriously by eye care workers in order to protect themselves. References to this have now been added to the introduction. If gaps in knowledge were found, then these could be addressed through targeted education / training which helps reduce the risk to healthcare workers and their patients and promote good infection control practices. The introduction has now been updated to reflect these points and now reads as follows: During this period, there have been many rumors and misinformation on COVID-19 emerging, which might mislead ophthalmic personnel. Dr Li Wenliang from Wuhan, who died from COVID-19, was an ophthalmologist who warned about the contagious nature of this virus and had asked eye care practitioners worldwide to take safety precautions, given the close proximity eye care practitioners are in with their patients. The aerosols generated from diseased patients attending for eye examinations have a higher tendency to infect eye care personnel if the appropriate protection is lacking. A pilot study of ours using the same study tool revealed poor knowledge and awareness within the eye care practitioners at our institution. The aim of this study was to review the knowledge and awareness of COVID-19 amongst eye care personnel in Nepal. If gaps in knowledge were found, then this could be addressed through targeted education and training, which will help reduce the risk to healthcare workers and promote good infection control practices. 3. The method: Authors should state who commissioned the study. What IRB granted approval, approval date and number (see line 88). It is important to state how the sample size for the study was determined, how instrument for data collection was checked for validity and reliability. Thank you for these comments. As noted in the response to the Editor, we have updated the ethics statement within the methods section to include the details of the ERB, approval date and number. Please see the response above which includes the updated ethics statement. Regarding the sample size, we have added the following text to the manuscript to address the logic behind how this was determined. This section now reads as follows: The survey was sent to 600 of these clinicians working in Nepal. Participation was anonymous and voluntary. Representatives from a random selection of 12 of the 18 secondary or tertiary eye hospitals and clinics across the spectrum of health facilities within Nepal were contacted and asked to select 50 individuals randomly at their institution and contacts who were involved in eye care practice during COVID-19, who were then invited to take the survey after their agreement. This random sample of 600 ophthalmic clinicians (approximately 40% of eye care professionals within Nepal) was calculated to be representative of the staff involved in eye care, whilst being practical enough to implement, making use of established networks between eye care providers. Regarding the validity, online forms could only be completed by those directly invited and values were entered directly by the individual. This has been clarified within the text and this section now reads as follows: In order to ensure validity, online forms could only be completed by those directly invited and values were entered directly by the individual. 4. The choice of analytical approach is too basic. There is no explanation of the independent and dependent variables. There is need to conduct inferential statistics, compute mean scores, standard deviations and ratios to better explain the knowledge and awareness scores obtained. Thank you for this observation. This study was performed as a survey of the views of ophthalmic professionals, and the results reported in the knowledge section represent the percentage of question that our sample correctly answered. Therefore, reporting the results in this way, it is not possible to do any further statistical analysis. We have, however, clarified the mean results of all participants, and given the standard deviation for these results. We have only reported on the mean overall results for the Knowledge component of the questionnaire. We have not reported the mean correct results for the Awareness section, as for these questions there is no correct response. Regarding the comment about independent and dependent variables, in this survey we are not establishing cause and effect; as such we do not have any dependent or independent variables to define. We have updated the results section of the text with the following, to include standard deviations as suggested: The calculated mean knowledge performance score was 69.65% (SD ± 22.81), falling into the “satisfactory” category. 5. It is always better to avoid starting a sentence with a figure. See lines 124,128,136. This has been corrected, thank you for alerting us to this. 6. The References are recent and relevant, but some are incomplete. Authors may want to update their references with related publications on the subject matter. This has been updated now, thank you. 7. Recommendation for further study appeared in the conclusion, it may be better situated in the discussion section. Shifted the recommendation section within the discussion, thank you. Reviewer #2: 1. Financial disclosure and competing interests should be edited according to the journal’s instructions. We have edited as per PLOS ONE requirements, thank you. 2. IRB’s full name and committee number should be mentioned. We have now mentioned this within the method section, thank you. 3. Authors should include whether the inform consent was given orally or in a written form. Clarified the same in the method section of the manuscript, thank you. 4. Authors should consider emphasizing the specific importance of PPE and supplementary measures (e.g. clear plastic boards placed on the slit lamp) utilization in the eye clinic. We have revealed the importance of breath shields and other PPE for eye care practitioner in the discussion section, thank you. 5. Authors should update their data and cite contemporary studies regarding ocular transmission of SARA-CoV-2 and ocular manifestations. They should try and compare it to what was known in the time the questionnaires were filled and try to explain, in their opinion, if the participants would answer differently in light of the current data. Thank you for this comment. We have updated this in the discussion section. 6. If available, it would be helpful to know additional background data of the participants (e.g. size of clinic, number of patients seen in a certain amount of time, etc.). Thank you for this suggestion. We have added this to the results section. The following sentence has been added: These eye health personnel were from a diverse range of health facilities, from small single-practitioner clinics to stand-alone tertiary referral eye hospitals. 7. Authors should mention and regard the fact that the majority of participants were quite of a homogenous group and of relatively young age. They should elaborate on it in their discussion. Thank you for raising this point. This is now explained within the discussion and currently reads as: Within Nepal, the majority of eye health personnel fall within the 25-35 age bracket. Although the proportion of males and females within the eye health workforce nationally is unknown, a recent study from the Eastern Region of Nepal reported that approximately 55% of general health practitioners were female. [20] Within our study, the age range of our respondents was as expected, although with 55% of respondents being male, women may be slightly under-represented within this sample if the gender distribution for the eye health workforce is similar to that of general health practitioners; male participants may have been, for example, more willing to complete the online survey for cultural reasons. 8. In continuum to the previous comment, authors should try and explain their results in light of the cultural and occupational background of the participants. Thank you for this comment. We have addressed this within our response to point No. 7 above. Reviewer #3: accepted with no comments. the manuscript is well written. The manuscript describe a technically sound piece of scientific research with data that supports the conclusions. the manuscript discussed an important issue and it seems quite interesting that most of the participants are not aware enough about this pandemic. Thank you for your review. ________________________________________ 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 Reviewer #3: 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. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0254761.r002
9 May 2021 Decision Letter - Bernadine Nsa Ekpenyong, Editor PONE-D-20-29438R1 Knowledge and awareness-based survey of COVID-19 within the eye care profession in Nepal: misinformation is hiding the truth PLOS ONE Dear Dr. Sanyam, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jun 23 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, Bernadine Nsa Ekpenyong, 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 not addressed the analysis section of the review comments. both reviewer 1 and 2 expressed the need for the authors to do further analysis to express demographic, social and occupational differences in knowledge score. the authors response on this is not acceptable. it is also not clear whether the instrument for data collection was adapted, or how it was developed. if the later is the case, how issues around reliability and validity of instrument was addressed. [Note: HTML markup is below. Please do not edit.] [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.0254761.r003
Revision 2
21 Jun 2021 Author Response Journal Comments: 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. Reference list is now updated, and URLs are checked, thank you. Additional Editor Comments (if provided): The authors have not addressed the analysis section of the review comments. both reviewer 1 and 2 expressed the need for the authors to do further analysis to express demographic, social and occupational differences in knowledge score. the authors response on this is not acceptable. Thank you for this comment. We have now run further analysis on the knowledge results in terms of the background demographics (gender, age group and occupation). Fisher’s exact analysis does not show any significant difference for these demographic variables and the knowledge score obtained. We have therefore added the following sentence to the results section: We found no evidence to suggest an association between demographic variables (specifically age, gender and occupation) and answering the knowledge questions correctly (data not shown). We have also added the following to the methods section to describe the statistical testing performed: Fisher’s exact testing was performed to look for significant associations between categorical variables. it is also not clear whether the instrument for data collection was adapted, or how it was developed. If the latter is the case, how issues around reliability and validity of instrument was addressed. Thank you for highlighting this. We have added the following now to the methods section to describe how the questionnaire was developed: We used qualitative methods to generate the questions on knowledge and awareness. This has been shown to enrich the quality of questionnaire items and to improve the content validity of the questionnaire. Questions developed in this way derives item generation from the population of interest, rather than that of the researchers. Focus group discussion took place between eye care professionals, statisticians, and microbiologists, facilitated by the investigators. Note: Please be informed that we have also added one more author cum supervisor to the manuscript. Attachments Attachment Submitted filename: Response to Reviewers R2.docx https://doi.org/10.1371/journal.pone.0254761.r004
5 Jul 2021 Decision Letter - Bernadine Nsa Ekpenyong, Editor Knowledge and awareness-based survey of COVID-19 within the eye care profession in Nepal: misinformation is hiding the truth PONE-D-20-29438R2 Dear Dr. Sanyam Sandip Das 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, Bernadine Nsa Ekpenyong, PhD Guest Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0254761.r005
Formally Accepted
13 Jul 2021 Acceptance Letter - Bernadine Nsa Ekpenyong, Editor PONE-D-20-29438R2 Knowledge and awareness-based survey of COVID-19 within the eye care profession in Nepal: misinformation is hiding the truth Dear Dr. Sanyam: 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. Bernadine Nsa Ekpenyong Guest Editor PLOS ONE https://doi.org/10.1371/journal.pone.0254761.r006

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