PONE-D-20-34499

Prevalence of post-traumatic stress disorder on health professionals in the era of COVID-19 pandemic, Northwest Ethiopia, 2020: multi-centred cross-sectional study.

PLOS ONE

Dear Dr. Alemayehu,

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.

Two experts in the field handled your manuscript, and we are appreciative of their time and contributions. Although interest was found in your study, several major concerns arose that require your attention. Please address ALL of the reviewers' comments in your revised manuscript and detail your revisions in a response-to-reviewers document. 

Please submit your revised manuscript by Mar 27 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

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2. Please include in your Methods section (or in Supplementary Information files) the participating hospitals/institutions.

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5.Thank you for submitting the above manuscript to PLOS ONE. During our internal evaluation of the manuscript, we found significant text overlap between your submission and the following previously published works, some of which you are an author.

https://www.healthcarefinancenews.com/news/healthcare-workers-treating-covid-19-show-more-negative-mental-health-effects

https://www.researchsquare.com/article/rs-23828/v1

https://pubmed.ncbi.nlm.nih.gov/30343247/

https://www.newkerala.com/news/2020/60792.htm

https://www.statnews.com/2020/04/03/the-covid-19-crisis-too-few-are-talking-about-health-care-workers-mental-health/

https://www.mdpi.com/2071-1050/12/9/3834/html

http://www.ephysician.ir/2017/5212.pdf

https://link.springer.com/article/10.1186/s12992-020-00621-z?code=c5fb9c70-dc49-4d3d-8d9c-ae8d56f4a3d9&error=cookies_not_supported

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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: Partly

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

Reviewer #1: Yes

Reviewer #2: No

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

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

Reviewer #1: No

Reviewer #2: No

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

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

Reviewer #1: No

Reviewer #2: No

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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: This manuscript intended to reveal the prevalence and predictors of PTSD in health professionals, which addressed an important question. However, the current version suffered from several problems.

1. In introduction, predictors of PTSD under COVID-19 should be addressed with latest literature.

2. More information was expected about the participants: e.g., educational level, department.

3. 423 was calculated as sufficient sample size. However, only 396 participants were included finally, which was insufficient. How is the process of recruitment of participants? Why not more people were invited initially?

4. The instrument Oslo needs more information, such as validity, sample question, et al.

5. In regression, I wonder why not all variables were included in the analysis such as age, gender, and profession? Maybe these variables predicted PTSD significantly.

6. Very limited predictors were analyzed in the current survey, in which other potentially important factors were not discussed, such as coping style, emotional status. Authors should list this in limitations at least.

7. Overall, authors should pay more attention on the writing, including space, capitalization, punctuation, et al.

Reviewer #2: Thank you for the opportunity to review this paper. It highlights the prevalence of PTSD among health care workers responding to the COVID-19 pandemic in Amhara, Ethiopia, and also points out risk factors (e.g., access to PPE, social support, medical problems) associated with PTSD. This is a useful addition to the growing literature on COVID-19. In order to get the message across effectively, I recommend heavily proofreading with an eye for English sentence structure and grammar. In addition, I have some comments about the analysis:

Major comments on analysis:

1. What variables were in the multivariate logistic regression? Were demographic characteristics included? Things that affect the exposure and also affect PTSD should be included. I think it would be important to control for age, sex, marital status, profession, and perhaps some others, if possible. Whether to include all of the risk factors of interest in a single model should also be carefully considered. For example, perhaps social support should not be included in the assessment of marital status, as it may be a mediator of the effect of marital status on PTSD. Regardless, please indicate details about the variables in the model in both the text and a footnote to Table 3.

2. “Social support = strong” only has 11 people with PTSD. This makes it a poor reference group and perhaps its use leads to the very large confidence intervals for the social support estimates. I recommend combining the “moderate” and “strong” categories, and making this the reference group.

3. Please report either in the Methods section, or as the first comment in the Results section (not later) how many people were invited to participate and how many actually participated. In addition, please state whether people who chose not to participate were different than people who did participate in terms of key demographic characteristics.

Minor comments:

4. The abstract should clearly state that the aims of the paper were to assess the prevalence of PTSD in this population and to assess the association of certain risk factors with PTSD in this population.

5. I would be interested to see more discussion of the “perceived stigma” findings. What types of stigma have health care workers in the Amhara region faced as a result of COVID-19 (or generally)?

6. Is the IES-R validated for use in this population (e.g., Northwestern Ethiopia or Ethiopia in general)?

7. A “limitations” section should be added.

8. Be consistent with labeling the pandemic as “COVID-19” versus “Corona” or other labels.

9. The underlying data do not appear to be in the manuscript, as stated.

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Reviewer #1: Yes: Qin Dai

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.]

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PONE-D-20-34499R1

Prevalence of post-traumatic stress disorder on health professionals in the era of COVID-19 pandemic, Northwest Ethiopia, 2020: multi-centred cross-sectional study

PLOS ONE

Dear Dr. Alemayehu,

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 reviewers have remaining comments that must be addressed. In addition, the authors need to contact a professional copyeditor to proof the manuscript before resubmission.

Please submit your revised manuscript by Jun 26 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,

Frank T. Spradley

Academic Editor

PLOS ONE

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: (No Response)

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

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: No

Reviewer #2: No

**********

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

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

Reviewer #1: No

Reviewer #2: No

**********

6. Review Comments to the Author

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

Reviewer #1: The manuscript intended to reveal the prevalence of PTSD in health care professionals in Ethiopia during COVID-19 pandemic. The topic is interesting and deserves to explore. However, the writing of this version suffered from several major shortcomings.

1. The English need to be improved by native speaker.

2. The relationship between IES and PTSD need more exploration in introduction.

3. The significance of this investigation to the current pandemic need to be clearly addressed in the introduction.

4. How to health care professionals? This point need to be addressed in introduction or methods.

5. In introduction, latest literature referring to the PTSD in health care professionals especially during the current pandemic should be systematically reviewed.

6. 423 participants are insufficient for the sample size, which indicated that the current sample size is in a low power of effect size. Any statistic methods carried out to improve the effect size? Or any other methods could be carried out to solve the problem?

7. The format of Figure and Table need to be attended, especially the capitalization and the accuracy of English (severe instead of sever)

8. Model information about the regression should be given in the results.

Reviewer #2: Thank you for the opportunity to review the revised version of this manuscript. It is greatly improved. After the authors clarified the multivariate regression methods, I have do have some remaining concerns about that set of analyses.

Major comments:

1. I am interested in seeing the bivariate results in addition to the multivariate results. These should all be displayed. I suggest one table with bivariate results, and another table with results of the multivariate analysis. Even the “non-significant” results should be shown, along with 95% CI. This would allow the reader to assess the size and precision of each association.

2. In the multivariate analysis, I think that it is more important to choose variables to add in the multivariable model based on conceptual reasons/based on existing literature, rather than p<0.05 in the bivariate analyses. P>0.05 might be driven by small sample size or other statistical reasons. I think it would be particularly important to include age and gender in the multivariable model, since they are strongly associated with PTSD and many of the other factors in the model.

3. When interpreting results of the multivariable model, add “when controlling for the other variables in the model.” For example, “The odds of developing post-traumatic stress disorder among health care providers were 2.27 times higher among those participants who had not standardized PPE supply as compared with those who had standardized PPE supply, *controlling for the other variables in the model* (AOR=2.27,95CI;1.29,3.98).” Similarly, in the discussion, it should be made clear that the results described are from the multivariate (adjusted) models.

4. The following phrase on page 6 should be revise for clarity: “Factors associated with post-traumatic stress disorder were selected during the bivariate analysis with p<0.05 for further analysis in the multivariable logistic regression analysis. In the multivariable logistic regression analysis, variables with p<0.05 at 95% CI with adjusted OR were considered statistically significant.”

5. I suspect that marital status is not significantly associated with PTSD in the multivariate model because social support is a mediator of this relationship (i.e., being unmarried leads to poor social support, which then leads to PTSD), and social support is controlled for. This does not have to be mentioned in the discussion, but could be.

Minor comments:

1. On page 3, several previous studies of the prevalence of PTSD are mentioned. Were these all among health care workers? Nurses, specifically? Please specify.

2. Is South Gondar 666 *kilometers* from Addis Ababa? Miles? Please specify.

3. In describing the sample size calculations, does P refer to prevalence? Also, I think that specifying Z=1.96, 95% CI, and alpha=0.05 is repetitive. I think just specifying a standard normal distribution and alpha=0.05 would be enough.

4. The sentence about the number of participants from each hospital could be rewritten as, “Health professionals were from Debretabor (N=325), Andabet (N=62), Estie (N=55)..." for clarity.

5. Please specify that 396 participants, not 396 questionnaires, were included.

6. It is noted that, “All health professionals working in South Gondar Zone hospitals were included, and those participants who were on annual leave and severely ill were excluded.” This is confusing following the statement that there were 396 participants included. Perhaps this comment should be moved to the beginning of the paragraph, if it is referring to initial eligibility criteria?

7. When describing the tools used to measure PTSD, social support, etc. the authors seems to discuss each tool, and then describe them all again in the same order. Can this section be restructured to have a single section on each tool?

8. In “data processing and analysis” please change “descriptive, bivariate, and multivariate logistic regression” to “descriptive statistics, and bivariate and multivariate logistic regression” (i.e., the word “statistics” is missing.)

9. Page 9: State that the *prevalence*, not magnitude, of PTSD was 55.1%. Magnitude can be confused with severity.

10. Unless specified otherwise by editors, limitations may be better off before the conclusions.

11. I suggest removing the detail about the number of participants invited from the abstract (and only leave the number that actually were included), as it is distracting from the primary message of the abstract. There is sufficient detail in the main manuscript.

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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

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.

PONE-D-20-34499R2

Prevalence of post-traumatic stress disorder on health professionals in the era of COVID-19 pandemic, Northwest Ethiopia, 2020: multi-centred cross-sectional study

PLOS ONE

Dear Dr. Alemayehu,

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 Aug 20 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,

Frank T. Spradley

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.

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: (No Response)

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

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: No

Reviewer #2: No

**********

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

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

Reviewer #1: No

Reviewer #2: No

**********

6. Review Comments to the Author

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

Reviewer #1: Authors have done a good job in revision. I have only one suggestions: The language of this manuscript still needs improve, please improve the language substantially.

Reviewer #2: Thank you for the opportunity to review a revised version of this manuscript. It is improved from the previous version. Thanks to the authors for adding the bivariate results. Although I list several comments below, they are minor in nature. I would also like to note that copy-editing is necessary.

1. First sentence is confusing. I don’t think SARS should be mentioned, as it takes the focus away from COVID-19.

2. In the first paragraph, “the election” is referenced. Which election?

3. Information about IES-R was added to the introduction in this version. In my opinion, that should be saved for the methods section.

4. Fix the last sentence of the introduction: “magnitude and associated factors” is confusing. Maybe “prevalence of PTSD, as well as risk factors for PTSD.”

5. I want to clarify point 2 in my previous review (“In the multivariate analysis, I think that it is more important to choose variables to add in the multivariable model based on conceptual reasons/based on existing literature, rather than p<0.05. P<0.05 might be driven by small sample size or other statistical reasons”). I think p<0.05 alone that this is not a good reason to choose variables for the multivariate model. The decision should also be based on existing literature. Perhaps you can say, “the bivariate results may have been subject to confounding. Therefore, we conducted a multivariate analysis containing all variables associated with PTSD. Variables for the multivariate model were selected based on a combination of known risk factors for PTSD from existing literature, and variables significantly associated with PTSD in the bivariate analyses.” Also, remove “not too large” from this section.

6. In Table 4, there should be a footnote stating that the results shown are adjusted for all of the other variables listed. I would also suggest adding, “when controlling for other variables in the model” to paragraph 2 in the Discussion. I think this information is important for interpreting the results from the multivariate (adjusted) model.

7. Thank you for your revision in response to point 7 on my last review (“When describing the tools used to measure PTSD, social support, etc. the authors seems to discuss each tool, and then describe them all again in the same order. Can this section be restructured to have a single section on each tool?”). I appreciate that you have “data sources and measurement” and then “operational definitions.” It would still be my preference for easier reading to have each tool described once (measurement and operational definition together). As previously noted, some of this information is currently in the introduction, as well.

Wording comments:

8. Page 9: Instead of “found to be significant,” should be “found to be significantly associated with PTSD.”

9. On page 12, “magnitude” should be replaced with “prevalence.”

10. On page 12, “corona outbreak” should be replaced with “COVID-19 pandemic.”

11. On page 13, I am not sure what is meant by “conversely, being a physician affected PTSD positively.” Do you mean “being a physician made PTSD less likely”?

12. Replace “likely hood” with “likelihood” throughout.

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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: Qin Dai

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.

Prevalence of post-traumatic stress disorder on health professionals in the era of COVID-19 pandemic, Northwest Ethiopia, 2020: multi-centred cross-sectional study

PONE-D-20-34499R3

Dear Dr. Alemayehu,

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Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE