PONE-D-22-28346Burnout and its associated factors among healthcare workers in Khartoum's COVID-19 isolation centers: A cross-sectional studyPLOS ONE

Dear Dr. Hasabo,

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.

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We look forward to receiving your revised manuscript.

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Syed Ghulam Sarwar Shah, M.B.B.S., M.A., M.Sc., Ph.D.

Academic Editor

PLOS ONE

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Additional Editor Comments:

Please address all of the reviewers' concerns and resubmit your revised manuscript.

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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: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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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: Yes

**********

5. Review Comments to the Author

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

Reviewer #1: The manuscript although it gets the meaning across is not very well written. It should be re-written to bring the standard close to that of the Journal's. Discussion Section in particular can be improved; although studies have been included but their findings have not been connected with those of the study being discussed.

Reviewer #2: Your research is well planned and the methodology is well described. Research can be replicated and therefore there is nothing to add.

Also, your manuscript is interesting but I need you to answer some minor questions:

-In abstract you should show prevalence of burnout

-There should not be any abbreviations in the abstract.

-In introduction you should give a definition of job burnout

-You should describe more literature on their association and on their prevalence in healthcare professionals during the covid 19 pandemic

-The discussion needs significant reworking. It does not explicate the reasons for nurses to have burnout.

-Many bibliographies are obsolete. The bibliographic citations used are more than 5 years old. The authors must update and arrange the bibliography.

-Some references are incomplete or have errors. The authors should review this section.

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Reviewer #1: No

Reviewer #2: No

**********

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Attachment

Submitted filename: PONE-D-22-28346.pdf

PONE-D-22-28346R1Burnout and its associated factors among healthcare workers in Khartoum's COVID-19 isolation centers: A cross-sectional studyPLOS ONE

Dear Dr. Alfadul,

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 May 26 2023 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: https://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,

Syed Ghulam Sarwar Shah, M.B.B.S., M.A., M.Sc., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Please address the following issues:

Title: The authors need to revise the title especially because of ‘Khartoum's COVID-19 isolation centers; which could be changed to ‘COVID-19 isolation centres in Khartoum, Sudan’.

ABSTRACT

Background: Please change ‘Khartoum isolation centers’ to ‘COVID-19 isolation centers in Khartoum. Were these centres in Khartoum City or Khartoum state? Please report as appropriate.

Methods: Please what do you mean by ‘multi Centre facility-based? Please revise the following sentence: ‘A multi Centre facility-based cross-sectional study was conducted between 20th February and 10th April 2022 during the last wave of Coronavirus Disease 2019.’ You might like to say: This cross-sectional survey study was conducted at multiple COVID-19 isolation centres in Khartoum during the omicron wave of Coronavirus Disease 2019 between 20th February 2022 and 10th April 2022.

Methods: Please report who is included in ‘healthcare workers’ in your study.

Methods: You mention the ‘last wave’ in the methods while in the background you state the ‘omicron wave’, please use the term consistently.

Methods: Please report the sample type and total sample size (how many participants were invited to the survey) and then report the number.

Methods: Please report the number of respondents and the response rate in the results section. Hence, move the following info to the results section. “A total of 306 doctors and nurses filled out the questionnaire, with a response rate of 64.8℅.”

Methods: Please report the main parts of the survey and how it was administered.

Results: Please change ‘Multivariate logistic regression showed doctors’ to ‘Doctors were …’

Results: What do you mean by engaged healthcare workers? Are these married or not? Please revise the following sentence: Also, engaged healthcare workers were less likely to suffer from burnout than single healthcare workers.

Results: Please what do you mean by ‘A low number of household members’? Could you state the exact number of household members?

Results: You report in the conclusion that there was a high prevalence of burnout in healthcare workers but there is no such information in the results section. Could you please report the prevalence of burnout in your sample.

Conclusion: Please remove the following sentence because it is unclear and does not make a sense.

INTRODUCTION

1. The authors write that the ‘The Coronavirus Disease 2019 (COVID-19) is a respiratory disease’. Could you please report what type of a respiratory disease it is and what is it’s causative agent.

2. Grammar: The authors have used the present tense in the first paragraph while they has used the past tense in the subsequent paras. Please use the same tense, preferably the past tense because you are reporting the past activities/actions.

3. Language: Could you please change the term ‘attack rate’ to ‘infection rate’ or some other appropriate term in the following sentence: “…the high attack rate of the virus….”

4. Language: please change ‘reaching 14,401 cases..’ to ‘reaching to 14,401 cases….’

5. Language: Could you please make a connection between the following sentences:

The World Health Organization has recognized "burnout" as an "occupational phenomenon. And "As lockdowns have significantly affected our work-life balance and work environments, much research has ascertained burnout and its contributing factors.1research has ascertained burnout and its contributing factors.11

6. Language: What do you mean by “the shortage of data about the virus treatment”? Please revise.

7. Long sentences: Please avoid using very long sentence such as the following sentence, which should be divided in 2-3 small sentences:

“ COVID-19 has a critical psychological impact on the community.12 The length of the pandemic period more than two years -, the shortage of data about the virus treatment, and the unknown destiny of the pandemic resulted in many studies that showed a significant increase in cases of anxiety, psychological stress, and depressive disorders worldwide, and because the medical staff worked under severe psychological pressure: being highly stressed by losing patients and colleagues, preference of having long shifts to protect their families, having no clear curing strategies, and urgency in instructing interpretation, all incredibly highlight peaking of burnout among healthcare providers.13-16.”

8. Language: Please what do you mean by ‘It lowers the quality of healthcare systems’? Do you mean ‘It lowers the quality of healthcare? If so, please revise the sentence.

9. Change: Please change ‘cannot support patients psychologically nor make fateful medical decisions’ to ‘can neither support patients psychologically nor make fateful medical decisions’.

10. Clarification: The authors state that “While the pandemic affects the world, studies show that developed countries are affected less than developing ones.” Could you please add more information i.e. in which ways the pandemic has affected developing countries more than the developed countries.

11. 1Revise: Could you please revise the following sentence, perferably by dividing it in 2 sentences: “Although, at present, no data considering the burnout among healthcare providers in Sudan, many published papers confirmed the high prevalence of burnout -among various countries during the pandemic due to diversified factors - leaving no doubt that the crisis is more exacerbated in Sudan.”

12. Check: Please which studies are you referring to in the following sentence: ‘These studies attributed the risk of burnout among healthcare providers to work-related, pandemic-related, and socio-demographic factors. “ This sentence does not seem to be relevant here. If so, please remove it.

METHODS

1. The authors state that “This facility-based cross-sectional study” but they do not state what type of study it is.

2. Please check the dates in the following sentence: ‘between 20th February 2022 and 10th April 2020’.

3. Could the authors describe what they mean by Sudanese metropolis because have used different terms like Khartoum state, Khartoum and Sudanese metropolis.

4 Please refer to ‘from the three parts of the Sudanese metropolis’ What do you mean by the ‘parts’? Do you mean districts or subdistricts of Khartoum city or Khartoum state?

5. Could you please report the criteria for determining the largest and the smallest isolation centers.

6. Could you please report the names of three parts of the Sudanese metropolis/Khartoum that are included in this study.

7. The authors have used different terms such as healthcare workers and healthcare practitioners to describe doctors and nurses. These terms could include other health professionals. Could the authors use doctors and nurse instead of either healthcare professionals or healthcare practitioners. Please be consistent throughout the paper.

8. Could you please report your sampling methods and type.

9. Could you please revise “The burnout level of the participants was assessed using an online self-administered questionnaire” to “Data were collected using an online self-administered questionnaire” because the questionnaire did not collect data on only burnout level but also other variables.

10. Could you please check what do you mean ‘the patient himself’ as a predictor of burnout included in the third part of the questionnaire

11. Please report: how did you recruit and invite the participants? how you administered the survey questionnaire? Did you send any reminders? If yes, how many and when?

!2. Please report whether you developed the survey questionnaire or adapted it from an existing survey. Did you pilot test it before the main study? What was found in the pilot, and did you make any changes in the survey? Who and how many participants were involved in the pilot testing?

13. The author report that the OLBI questionnaire consists of positively

and negatively worded questions. Which questions are negatively worded and how did you manage scores of these negatively worded questions?

14. Could you please check what do you mean by ‘one point designated the lowest burnout and four designated the highest’?

15. Could you please report which online tools did you use for online survey?

16. could you please change: ‘Descriptive statistics were used in mean and Standard deviation…’ to ‘ Descriptive statistics were used for calculating the mean and Standard deviation…’.

17. Could you please report what for did you use the Multiple logistic regression analysis?

RESULTS

1 Please change ‘Among all participants, 22.5% tested positive for COVID-19, and nearly (53.6%) were working in the ICU” to ‘About 54% of the participants reported working in an ICU and 22.5% reported having COVID-19.’

2. The authors report that “Also, marital status was significantly associated with burnout (p = 0.001). Could you please report which marital status was associated with burnout?

3. Could you please explain what do you mean by mental breaks?

4. Please check ‘working hours (0.8) and correct it.

5. Please take out p values information from the following sentence and report that these factors were not statistically significantly associated with burnout and refer to the relevant table.

“Interestingly the following factors were not associated with burnout: average income (p >0.9), working years (p = 0.8), working hours (0.8), extra hours (p = 0.065), previous working experience in COVID-19 centers (p = 0.6) working center ( p = 0.8) and site (p= 0.6) and fear of patient death despite all measure ( p > 0.9)’

6. Could you please describe what do you mean by ‘engaged’ in the following sentence: “Also, engaged healthcare workers were less likely to suffer

burnout than unmarried healthcare workers”. Does it mean engaged but not married yet. Please revise it appropriately.

7. Refer to table 4, which shows that married participants had higher ORs for burnout compared to respondents who were single. Could you high light this in the results in the abstract and main results section.

7. In Table 1, please report categories of the following variables and re-do statistical analysis.7

- Age

-Number of household members

- Do you live with an elderly household member who has a chronic disease?

- Do you suffer from any comorbidities?

- Do you have a history of mental illness?

8. Table 1: Please check your sub-groups for years of working in this job. The categories are overlapping each other, which should not. Moreover, what is 0 years? Please re-categories this variable as < 2 years, 2-6 years and more than 6 years. Then please rerun the statistical tests to check whether there are any statistically significant differences.

9. Table 1. In the following Qs, you have reported the number of participants who reported yes only. Please report the data about the participants who answered No to these Qs.

- Did you work in isolation centers in the previous Covid-19 waves other than the current Omicron wave?

- Do you work extra duty or extra hours per week?

10. Table 1: Please report what are the answer options for the following Q: Working hours per week? Then rerun the data analysis in 2-3 major categories.

11. Table 1. Could you please report a range of local currency for high, medium and low income.

12. Table 1 and 2. Could you please report agree, disagree etc instead of numbers 1, 2 …5

13. Table 3: This table includes different things but the title says habits. Habits for what? Could you please revise the title that shows items/variables reported in this table.

14. Table 4. Please add categories of number of family members and re-run the analysis.

DISCUSSION

1. The first two sentences report almost the same information so could you please revise them. Also provide some references to support these statements.

2. The authors state that ‘The current study addressed a significant issue’ but do not report the name of the issue. Could you please say that you have studied burnout.

3. please change ‘a low-income country’ to ‘Sudan’.

4. please change ‘health staff’ to ‘healthcare staff’

5. please change ‘can be explainable’ to ‘can be explained’.

6. please check whether the following statement is in relation to Sudan or in general because there are several studies on burnout in Drs and nurses during the COVID-19 pandemic. Therefore, please correct the statement. “This is one of the few studies assessing the burnout burden among healthcare workers.”

REFERENCES

Please report abbreviated names of the following journals:

-International Journal of Environmental Research and Public Health

- Cochrane Database of Systematic Reviews

- Archives of Rehabilitation Research and Clinical Translation

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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: All comments have been addressed

**********

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

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

Reviewer #1: Yes

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: Yes

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: 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: (No Response)

Reviewer #2: Thank you for your great work.

**********

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: Yes: Rasoul Goli

**********

[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: PONE-D-22-28346_R1.pdf

Burnout and its associated factors among healthcare workers in COVID-19 isolation centres in Khartoum, Sudan: A cross-sectional study

PONE-D-22-28346R2

Dear Dr. Alfadul,

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,

Syed Ghulam Sarwar Shah, M.B.B.S., M.A., M.Sc., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Many thanks for submitting the revised manuscript.

Reviewers' comments: