Psychological distress among healthcare providers during COVID-19 in Asia: Systematic review and meta-analysis

Siew Mooi Ching; Kar Yean Ng; Kai Wei Lee; Anne Yee; Poh Ying Lim; Hisham Ranita; Navin Kumar Devaraj; Pei Boon Ooi; Ai Theng Cheong

doi:10.1371/journal.pone.0257983

Peer Review History

Original SubmissionJuly 1, 2021
19 Aug 2021 Decision Letter - Ali Rostami, Editor PONE-D-21-21203 Psychological Distress Among Healthcare Providers During COVID-19 In Asia: Systematic Review and Meta-Analysis PLOS ONE Dear Dr. Cheong 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 Oct 03 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The topic is interesting and contains useful information for readers, although the following comments will help reinforce this manuscript. 1- - In the abstract, name, the used databases. 2- - Please in introduction, highlighted which factors affect the psychological distress of HCW based on quantitative and especially qualitative studies conducted in vulnerable countries in Asia? 3- - exactly mention who do you mean by HCW? 4- Please do a search on the Web of Sciences database. 5- Please specify the inclusion and exclusion criteria clearly. 6- Did you do a manual search (based on Google Scholar citation or check the references of each article) 7- Please improve the quality of Forest plots (All Figures). 8- Please discuss the causes of high heterogeneity in this study (in discussion section). 9- Please explain the reason for publication bias in this study (in discussion section). ****** 6. 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Revision 1
8 Sep 2021 Author Response Cheong Ai Theng Associate Professor Department of Family Medicine, Faculty of Medicine and Health Science, Selangor, Malaysia Date: 6 September 2021 Academic Editor: Prof. Dr. Khatijah Lim Abdullah PLOS ONE Dear Editor RESUBMISSION OF MANUSCRIPT TO PLOS ONE (PONE-D-21-21203.R1) I’m enclosing herewith a revised manuscript entitled “Psychological Distress Among Healthcare Providers During COVID-19 In Asia: Systematic Review and Meta-Analysis” for publication in PLOS ONE. All authors have read and approved the revised manuscript. Changes are made in blue-coloured text. Comments and suggestions from reviewers have been addressed clearly point by point following this covering letter. Thank you for your kind attention. Sincerely, Cheong Ai Theng… Cheong Ai Theng, Ph D Corresponding Author Department of Family Medicine, Faculty of Medicine and Health Science, 43400 Serdang UPM, Selangor Malaysia Tel: +6 (03) 9769 2538 Email: cheaitheng@upm.edu.my Thank you for the pertinent comments and we have made the changes accordingly. Comment 1. In the abstract, name, the used databases. Answer: Thank you for your comment, we have made the amendment to read as “COVID-19 pandemic is having a devastating effect on the mental health and wellbeing of healthcare providers (HCPs) globally. This review aimed at determining the prevalence of depression, anxiety, stress, fear, burnout and resilience and its associated factors among HCPs in Asia during the COVID-19 pandemic. We performed literature search using 4 databases from Medline, Cinahl, PubMed and Scopus up to March 15, 2021 and selected cross-sectional studies.” Comment 2. Please in introduction, highlighted which factors affect the psychological distress of HCW based on quantitative and especially qualitative studies conducted in vulnerable countries in Asia? Answer: We have highlighted the factors that affect the psychological distress of HCW in the Introduction section, under third paragraph to read as “In performing their duties of arresting the spread of COVID-19, the HCP are risking their lives due to a higher risk of virus exposure, high workload demand, irregular or long working hours and increased psychological distress such as depression, anxiety, stress, occupation burnout, fear, low resilience as well as fatigue[1]. In addition, the HCP were barred from taking holiday and separated from their loved ones up to weeks or even months. Wearing the full personal protective equipment or gear (PPE) that is very uncomfortable for long hours continuously every day while managing patients diagnosed with COVID-19 is extremely exhausting, not to mention that this has become a routine task in their daily work. Literature reported that factors associated with personal-, work-, and patient-related burnout among HCPs were those had direct involvement in COVID-19 management, underlying medical illness, and receiving inadequate psychological support in the workplace [6]. Those with higher points in coping score were significantly associated with reduction in anxiety and depression score [7]. Other significant factors associated with psychological distress inluding but not limited to thought of resignation and reluctant to work, fear of infecting family member, frequent change in infection prevention and control protocol or guideline, and poor social support [8]. All of the aforementioned factors had been determined as factors that are leaving negative impacts on the healthcare workers in Asian countries psychologically[8-10]. In performing their duties of arresting the spread of COVID-19, the HCP are risking their lives due to a higher risk of virus exposure, high workload demand, irregular or long working hours and increased psychological distress such as depression, anxiety, stress, occupation burnout, fear, low resilience as well as fatigue[1]. In addition, the HCP were barred from taking holiday and separated from their loved ones up to weeks or even months. Wearing the full personal protective equipment or gear (PPE) that is very uncomfortable for long hours continuously every day while managing patients diagnosed with COVID-19 is extremely exhausting, not to mention that this has become a routine task in their daily work. Literature reported that factors associated with personal-, work-, and patient-related burnout among HCPs were those had direct involvement in COVID-19 management, underlying medical illness, and receiving inadequate psychological support in the workplace [6]. Those with higher points in coping score were significantly associated with reduction in anxiety and depression score [7]. Other significant factors associated with psychological distress inluding but not limited to thought of resignation and reluctant to work, fear of infecting family member, frequent change in infection prevention and control protocol or guideline, and poor social support [8]. All of the aforementioned factors had been determined as factors that are leaving negative impacts on the healthcare workers in Asian countries psychologically[8-10].” Comment 3. exactly mention who do you mean by HCW? Answer: We have added this statement under PICO to read as The participants should be HCPs (doctors, dentists, nurses, nurse assistants, midwives, medical assistants, pharmacists, and other allied healthcare workers). Comment 4. Please do a search on the Web of Sciences database. Answer: We are sorry to inform that our institute does not have legitimate website in assessing Web of Science. Furthermore, four database were adequate to capture all the relevant studies. Comment 5. Please specify the inclusion and exclusion criteria clearly. Answer: We have revised the inclusion and exclusion criteria in the Methodology section, 4th paragraph to read as Selection criteria The inclusion criteria for this systematic review were as follow: a) The study design was cross-sectional with a minimum sample size of 100 b) The study stated the prevalence of depression, anxiety, stress, burnout, fear and resilience among HCPs during COVID-19 pandemic c) The study evaluated depression, anxiety, stress, burnout, fear and resilience based on validated instrument tools or scales d) The study involved HCPs (doctors, dentists, nurses, nurse assistants, midwives, medical assistants, pharmacists, and other allied healthcare workers) from Asian countries e) The studies must be published in English peer-reviewed journal. Studies with the following criteria were excluded: a) Perspective, opinion, review articles, case reports, short communications paper, no full text study and unpublished data b) Data reported in continuous or qualitative format c) Outcomes were not clearly defined by validated tools d) Depression, anxiety, stress, burnout, fear and resilience were reported as independent data e) Technical error was present in the reported data f) After full-text articles have been assessed for eligibility, those outcomes were grouped into category of severities which were different from our operational definition Comment 6. Did you do a manual search (based on Google Scholar citation or check the references of each article) Answer: We didn’t perform manual search as there may not have add on value in view of there were 148 studies with big sample size recruited in this systematic review. Comment 7. Please improve the quality of Forest plots (All Figures). Answer: We have improved the quality of Forest plots by changing PNG to tiff with 300 dpi. Comment 8. Please discuss the causes of high heterogeneity in this study (in discussion section). Answer: We have added the causes of high heterogeneity in the discussion session, second last paragraph to read as: High heterogeneity was found in this systematic review, and possible reasons include variation from the participants’ characteristics, outcome level and research setting [186]. Firstly, the high heterogeneity for the overall prevalence of psychological distress found in this study could be due to differences in the screening methods and diagnostic criteria in different countries with different ethnicities and research settings (S4 Table). For example, different screening tools were used to determine burnout such as Maslach Burnout Inventory (MBI) ProQOL Scale of Chinese Version and Olenburg Burnout Inventory (OLBI); whereas scales like Patient Health Questionnaaire (PHQ), Depression-Anxiety-Stress Scale-21 (DASS-21), Beck Depression Inventory (BDI), Hamilton depression rating scale (HAMD), etc were used for depression screening. Next, different categories for the severity of disease were reported in different studies. Moreover, even though in the same country, there were different diagnostic criteria applied for psychological distress studies. For example, in China, ten different diagnostic tools were used to detect depression compared with three diagnostic tools used in India, which give rise to a broad range of prevalence of depression in China (31.7%-41.2%) and India (27.9%-39.3%). In our meta-analysis, there was a wide gap in terms of sample size in all 148 studies, ranged from 100 to 14,825 in this review. All these factors would explain why there was a high heterogeneity for the prevalence of psychological distress, for instance, depression in this study. Comment 9. Please explain the reason for publication bias in this study (in discussion section) Answer: We have added the causes of high heterogeneity in the discussion session, last paragraph to read as: Multiple factors contributed to publication bias, comprises of study design, sample size, decision of authors, journal editors and reviewers [187]. We had excluded all the unpublished data and studies with a sample size of below 100 in this review. However, we need to weigh the advantage and disadvantages as those published studies have gone through a rigorous review process, which gave a more reliable result compared with those unpublished data. Furthermore, we also excluded studies with outcomes that did not fulfil our operational definition of psychological distress. This systematic only included manuscripts wrote in English due to constraint of resources. Thus, we had to interpret the results of this systematic review carefully within the context of its limitations level and research setting [186]. Attachments Attachment Submitted filename: Response to reviewer 060921.docx https://doi.org/10.1371/journal.pone.0257983.r002
15 Sep 2021 Decision Letter - Ali Rostami, Editor Psychological Distress Among Healthcare Providers During COVID-19 In Asia: Systematic Review and Meta-Analysis PONE-D-21-21203R1 Dear Dr. Cheong, 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, Ali Rostami Academic Editor PLOS ONE Additional Editor Comments (optional): The manuscript is acceptable, but references should be re-formatted according to journal's style. Reviewers' comments: https://doi.org/10.1371/journal.pone.0257983.r003
Formally Accepted
21 Sep 2021 Acceptance Letter - Ali Rostami, Editor PONE-D-21-21203R1 Psychological Distress Among Healthcare Providers During COVID-19 In Asia: Systematic Review and Meta-Analysis Dear Dr. Cheong: 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. Ali Rostami Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0257983.r004

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