Psychological distress and burnout among healthcare worker during COVID-19 pandemic in India—A cross-sectional study

Geetha R. Menon; Jeetendra Yadav; Sumit Aggarwal; Ravinder Singh; Simran Kaur; Tapas Chakma; Murugesan Periyasamy; Chitra Venkateswaran; Prashant Kumar Singh; Rakesh Balachandar; Ragini Kulkarni; Ashoo Grover; Bijaya Kumar Mishra; Maribon Viray; Kangjam Rekha Devi; K. H. Jitenkumar Singh; K. B. Saha; P. V. Barde; Beena Thomas; Chandra Suresh; Dhanalakshmi A.; Basilea Watson; Pradeep Selvaraj; Gladston Xavier; Denny John; Jaideep Menon; Sairu Philip; Geethu Mathew; Alice David; Raman Swathy Vaman; Abey Sushan; Shalini Singh; Kiran Jakhar; Asha Ketharam; Ranjan Prusty; Jugal Kishore; U. Venkatesh; Subrata Kumar; Srikanta Kanungo; Krushna Sahoo; Swagatika Swain; Anniesha Lyngdoh; Jochanan Diengdoh; Phibawan Syiemlieh; AbuHasan Sarkar; Gajanan Velhal; Swapnil Kharnare; Deepika Nandanwar; M. Vishnu Vardhana Rao; Samiran Panda

doi:10.1371/journal.pone.0264956

Peer Review History

Original SubmissionAugust 17, 2021
20 Sep 2021 Decision Letter - M. Shamim Kaiser, Editor PONE-D-21-26475Psychological Distress and Burnout among Healthcare Worker during COVID-19 Pandemic in India- A cross-sectional studyPLOS ONE Dear Dr. Menon, 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 Nov 04 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 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: I Don't Know 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: No 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: No ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The authors conducted a cross sectional study and explored the psychological distress and burnout rate among the healthcare workers during COVID-19 pandemic. The aim of the study was to determine the burnout levels and factors associated with the risk of psychological distress among healthcare workers (HCW) engaged in the management of COVID-19 in India. This is an interesting representation of data and several significant insights were found which may help in future pandemic management. However, the authors need to address some issues before acceptance of the manuscript. 1. A table on questionnaire need to be added. Why did the authors specifically choose the GHQ-5 and ICMR-NIOH questionnaires? Why not other questionnaires ? 2. The authors did not mention the sampling procedure of the study. It should be mentioned. 3. Several statistical tests have been performed. A short description of tests may help the readers to understand the article even better. 4. There was no city wise distribution of burnout levels and psychological distress rate which need to be done. A comparison with average covid cases with the burnout and psychological distress may be interesting. 5. This manuscript lacks visual representation of data. More visual representation may be added which will help the reader to understand the data. 6. There were several typos, comma and spacing problems. 7. Results written in abstract need to be rewritten. It was not clear to the reviewer. 8. Causes of psychological distress can be shown in pictorial form which may increase the readability of the article. 9. Overall writing needs to be improved. Reviewer found difficulty in understanding the result discussion. 10. A specific section for abbreviation or terminology maybe added which will increase the readability. Reviewer #2: This paper proposes Psychological Distress and Burnout among Healthcare Worker during COVID-19 Pandemic in India- A cross-sectional study. In this paper the authors took 12 different cities for study purpose but didn’t give any justification of choosing those cities for research purpose. The authors failed to mention what time of a day they have conducted the interview which may have a major impact while researching on psychological impact of healthcare workers for this study. The authors should include a functional diagram in the paper to explain the flow of the work as well as mathematical modelling to explain the multiple logistic regression process that has been used for adjusting the risk factors. All the figures are too blur to understand and therefore should be redraw. There are grammatical errors in the paper which reduce the readability of the article. These errors should be corrected. ****** 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.0264956.r001
Revision 1
26 Oct 2021 Author Response Author’s response to the Editor’s comments Comment: 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 labelled 'Response to Reviewers'. Response: Rebuttal letter uploaded as a separate file Comment: A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labelled 'Revised Manuscript with Track Changes'. Response: A marked up copy of the manuscript “PONE-D-21-26475_marked up” uploaded Comment: An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labelled 'Manuscript' Response: An unmarked version of the manuscript” Manuscript” uploaded Author’s response to the Reviewer’s comments Please find the comments and their respective responses below Reviewer #1 comments and Author’s responses: Comments: The authors conducted a cross sectional study and explored the psychological distress and burnout rate among the healthcare workers during COVID-19 pandemic. The aim of the study was to determine the burnout levels and factors associated with the risk of psychological distress among healthcare workers (HCW) engaged in the management of COVID-19 in India. This is an interesting representation of data and several significant insights were found which may help in future pandemic management. However, the authors need to address some issues before acceptance of the manuscript. Response: We wish to thank the reviewer for motivating feedback. The authors are grateful to the esteemed reviewer for appreciating the relevance of our work. We have considered all the suggestions given by reviewer# 1 in the revised version of the manuscript. Our detailed reply to each and every point raised by the Reviewer #1 is given below: Query 1: A table on questionnaire need to be added. Why did the authors specifically choose the GHQ-5 and ICMR-NIOH questionnaires? Why not other questionnaires? Response: Thanks to the reviewer for this important observation. The questionnaire has been attached as a supporting document (S1). The reason for using GHQ-5 and ICMR-NIOH is given below and the same has been incorporated in the revised version of the manuscript. The GHQ-5, is a shorter screening tool (not a diagnostic tool) which has 5 questions with better discriminators for psychological distress derived from GHQ-12 that involves royalty for usage. GHQ-5 is validated on the Indian population with a sensitivity of 86%, specificity of 95.8% and misclassification rate of 8.3% (Reference). For this study that was done telephonically and needed quick assessment of the psychological state of the respondent with minimum number of questions, GHQ-5 was found to be an effective tool with regard to time and process. It is also available for use in public domain as compared to GHQ-12. Reference: C. Shamasunder, T. G. Sriram, S. G. Murali Raj, and V. Shanmugham, “Validity of a short 5-item version of the general health questionnaire (g.h.q).,” Indian J. Psychiatry, vol. 28, no. 3, pp. 217–9, Jul. 1986. ICMR-NIOH burnout questionnaire is a shortened and easier version of the Maslach Burnout inventory (MBI) (Reference 1). The questionnaire is a 19 item tool that covers three dimensions of burnout: a) emotional exhaustion (EE, 11 items); (b) depersonalisation (DP, 5 items) and (c) personal accomplishment (PA, 3 items) on a 3-point scale starting from 1,” never,” 2, “sometimes” and 3, “always”. Higher scores on the EE and DP subscales and lower scores on the PA subscale indicate high degrees of experienced burnout. It was developed by the scientists of the ICMR-National Institute of Occupational Health (NIOH) and was under validation for Indian settings during the study. Now it has been validated and published (Reference 2). It was freely available for use whereas the MBI inventory is copyrighted and cannot be reproduced without permission from the developers. Due to the ongoing pandemic and need to make a quick assessment of burnout among healthcare workers, we used the ICMR-NIOH questionnaire. Reference 1: C. Maslach, S. E. Jackson, and M. P. Leiter, “Maslach Burnout Inventory: Third edition.,” in Evaluating stress: A book of resources., Lanham, MD, US: Scarecrow Education, 1997, pp. 191–218. Reference 2. S. Balachandar, R., Ketharam, A., & Bharath, “Development and validation of tool for screening occupational mental health and workplace factors influencing it,” PsyArXiv. July 1., pp. 1–17, 2021. Query 2: The authors did not mention the sampling procedure of the study. It should be mentioned. Response: Thanks for your observation. The detailed sampling procedure and selection of participants has been described in the revised version of the manuscript. Query 3: Several statistical tests have been performed. A short description of tests may help the readers to understand the article even better. Response: Thanks for your observation. The step by step statistical procedures/tests with equation have been added in the statistical analysis section of the revised manuscript. Query 4: There was no city wise distribution of burnout levels and psychological distress rate which need to be done. A comparison with average COVID cases with the burnout and psychological distress may be interesting. Response: The purpose of the study was to gain a quick insight on the psychological state and burnout levels of healthcare workers in India when state wise COVID infection rates were varying. A representative sample in each state was difficult to obtain due to the government restrictions on travel and shorter duration of the study. A minimum sample size of 904 was determined to obtain the distribution at the national level and not at the city/state level. Hence it would be inappropriate to provide the city wise data in the manuscript. We appreciate the reviewers comment to compare the COVID cases with the burnout levels and psychological distress. However, we could not do this since the data on number of COVID cases was not verified from official records due to the inability of the investigators to physically approach the facility because of ongoing pandemic and lockdown. Query 5: This manuscript lacks visual representation of data. More visual representation may be added which will help the reader to understand the data. Response: We thank the reviewer for the observation. We have displayed the results in graphics (Fig1-6) for better visual representation in the revised manuscript. Query 6: There were several typos, comma and spacing problems. Response: We appreciate the observation. We have corrected for grammatical errors in the revised version of the paper. Query 7: Results written in abstract need to be rewritten. It was not clear to the reviewer. Response: We have rewritten the results in the abstract. Query 8: Causes of psychological distress can be shown in pictorial form which may increase the readability of the article. Response: We appreciate the reviewer for this observation. The factors associated with risk of psychological distress has been shown in pictorial form in the revised manuscript Fig3-4. Query 9: Overall writing needs to be improved. Reviewer found difficulty in understanding the result discussion. Response: We appreciate the observation. Overall writing has been improved to bring more clarity in the revised manuscript. Query 10: A specific section for abbreviation or terminology maybe added which will increase the readability. Response: We have added a section on list of acronyms. Reviewer’s #2 comments and Authors’ responses: Comment: Reviewer #2: This paper proposes Psychological Distress and Burnout among Healthcare Worker during COVID-19 Pandemic in India- A cross-sectional study. Response: The authors are grateful to the esteemed reviewer for appreciating the relevance of our work. We have considered all the suggestions given by reviewer# 2 in the revised version. Our detailed reply to each and every point raised by the Reviewer’s #2 is given below: Comment 1: In this paper the authors took 12 different cities for study purpose but didn’t give any justification of choosing those cities for research purpose. Response: The study was an ICMR multicentric Task Force project. The sites were chosen based on the response of the site investigators to a call for proposals by the ICMR National Task Force on Operation Research on COVID-19. We selected those implementing agencies who submitted the concept proposal with similar objectives. These agencies were located in 10 states that broadly represented different regions of the country. Due to the lockdown rules and travel regulations in different cities, from each state one city was selected where the implementing agency was located except in Kerala and Odisha where two cities were selected as per the convenience of site investigators. Comment 2: The authors failed to mention what time of a day they have conducted the interview which may have a major impact while researching on psychological impact of healthcare workers for this study. Response: Thanks for your observation. As mentioned in the revised manuscript the investigators fixed an appointment with the healthcare workers as per their convenience so as to ensure that their duty time or leisure time was not disturbed. Comment 3: The authors should include a functional diagram in the paper to explain the flow of the work as well as mathematical modelling to explain the multiple logistic regression process that has been used for adjusting the risk factors. Response: We have added the functional diagram (S2) and have described the mathematical modelling procedures in the statistical analysis section of the revised manuscript. Comment 4: All the figures are too blur to understand and therefore should be redraw. Response: We appreciate the observation of the reviewer and all the figures have been redrawn Fig1-6. Comment 5: There are grammatical errors in the paper which reduce the readability of the article. These errors should be corrected. Response: We appreciate the observation. We have corrected for grammatical errors in the revised version of the paper. Attachments Attachment Submitted filename: Authors response to reviewers comments PONE-D-21-26475.docx https://doi.org/10.1371/journal.pone.0264956.r002
31 Jan 2022 Decision Letter - M. Shamim Kaiser, Editor PONE-D-21-26475R1Psychological Distress and Burnout among Healthcare Worker during COVID-19 Pandemic in India- A cross-sectional studyPLOS ONE Dear Dr. Menon, 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 Mar 17 2022 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. 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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: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: I am satisfied with how the authors addressed my comments. With some minor revisions, I accept the manuscript. Make sure that every figure is clear and well-illustrated. Captions should be self-explanatory. Particularly, Figures 3, 4, and 5 are blurry and difficult to read. Reviewer #2: (No Response) ****** 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: Md Jaber Al Nahian Reviewer #2: Yes:** Dr. Risala Tasin Khan [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.0264956.r003
Revision 2
4 Feb 2022 Author Response Author’s response to the Reviewer’s comments Please find the comments and their respective responses below Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed Response: Thanks for the reviewer’s appreciation 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 Response: Thanks for the reviewer’s appreciation 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Response: Thanks for the reviewer’s appreciation 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 Response: Thanks for the observation. We have now uploaded the data as per the PLOS DATA POLICY Reviewer #2: Yes Response: Thanks for the valuable comments 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Response: Thanks for the reviewer’s appreciation 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 am satisfied with how the authors addressed my comments. With some minor revisions, I accept the manuscript. Make sure that every figure is clear and well-illustrated. Captions should be self-explanatory. Particularly, Figures 3, 4, and 5 are blurry and difficult to read. Response: Thanks for the accepting the manuscript. The authors appreciate the reviewers for their valuable inputs. We have now uploaded then revised figures. Reviewer #2: (No Response) Response: Thanks to the reviewer. Attachments Attachment Submitted filename: Authors response to reviewers comments PONE-D-21-26475 R2.docx https://doi.org/10.1371/journal.pone.0264956.r004
22 Feb 2022 Decision Letter - M. Shamim Kaiser, Editor Psychological Distress and Burnout among Healthcare Worker during COVID-19 Pandemic in India- A cross-sectional study PONE-D-21-26475R2 Dear Dr. Menon, 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, M. Shamim Kaiser, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): NA Reviewers' comments: NA https://doi.org/10.1371/journal.pone.0264956.r005
Formally Accepted
28 Feb 2022 Acceptance Letter - M. Shamim Kaiser, Editor PONE-D-21-26475R2 Psychological Distress and Burnout among Healthcare Worker during COVID-19 Pandemic in India- A cross-sectional study Dear Dr. Menon: 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. M. Shamim Kaiser Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0264956.r006

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