Psychological distress symptoms among healthcare professionals are significantly influenced by psychosocial work context, Ethiopia: A cross-sectional analysis.

BACKGROUND: Work-related psychosocial hazards result in numerous adverse effects on physical and psychological health, a reduction in quality of life and a decline in performance capacity to workers. While the condition is widespread across various occupations, healthcare sectors are acknowledged to be at high risk. In developing countries such as Ethiopia, however, the lack of reliable data on psychosocial hazards including psychological distress (PD) often hampers officials from planning for preventive actions. This study assessed the magnitude and influencing factors of PD among healthcare professionals in Gondar city, Ethiopia.
METHODS: We employed a cross-sectional survey of 422 healthcare professionals selected with a stratified random sampling technique between April and March 2019. The symptoms of psychological distress were assessed with a standardized 10 items Kessler Psychological Distress Scale instrument. Bivariate and multivariate analyses were conducted by use of SPSS program version 20. Factors associated with psychological distress symptoms were ascertained at < 0.05 p-value. Adjusted odds ratio (AOR) with a confidence interval (CI) of 95% was used to determine the strength of associations.
RESULTS: In total, 417questionnaires fully completed and returned with a response rate of 98.8%. Age ranges from 23 to 57 with a mean of 31.00 (± 8.219 SD) years. Work-related psychological distress symptoms in the past 4weeks stood at 44.4% (N = 185) [95%CI (39.8, 49.4)]. Being female worker [AOR: 2.07; 95% CI (1.29, 3.32)], high job demand [(AOR: 1.53; 95% CI (1.10, 2.57)] and low job control [AOR: 2.54; 95% CI (1.60, 4.04)] were significant factors of psychological distress.
CONCLUSION: This study underscores the level of psychological distress among healthcare professionals is high. The experiences of psychological distress symptoms were significantly influenced by socio-demographic factors including sex and psychosocial job characteristics such as job demand and job control. Efforts to prevent the mental health of workers including psychological distress symptoms need to focus on individual attributes and job contexts.

Introduction

Newly emerging risks, such as psychosocial hazards in various contemporary workplaces have become major threats to workers, employers and the society. The healthcare sector is one of the vulnerable sectors conceivably linked with exposure to psychosocial and other traditional risks at the same time [1-3]. Psychosocial job characteristics such as a work-related psychosocial distress (PD) in healthcare sectors are important to employees and healthcare systems [3-6]. The consequences of work-related high psychosocial distress in healthcare is much more sizable [4].

First and foremost, the effects are greater for the workers involved, for instance, in terms of in experiencing physical and psychological adverse health effects [7], a decrease in performance capability [8], and a decline in quality of life [5, 9, 10]. In addition, studies have documented that psychological ill health contributes substantially to the overall global disease burden [11, 12], and leads to substantial claims for occupational illnesses [13]. In healthcare, the effects of psychosocial distress can also be explained in relation to the quality of service provided, resulting in low patient satisfaction and higher medical costs [14].

Several epidemiological data have confirmed that the incidence of work-related psychological symptoms varies from 47% in china [15] to 64.6% India [16], 29.9% in Ethiopia [17] to 44.1% Nigeria [18]. The relation of work-related psychological distress and various socio-demographic factors including sex, age, marital status, and experience [19, 20] has been well explored. There is ample evidence that highlights the associations of psychosocial work contents such as high job demand, shift work [21-23], job control [23], and job dissatisfaction [24] with the experiences of psychological distress symptoms. Further, psychological distress symptoms are also affected by life style behavior including alcohol consumption [25], Khat chewing [26], cigarette smoking [27, 28].

In developing countries such as Ethiopia, however, the lack of reliable data on psychosocial hazards including PD often impedes officials from planning for preventive actions [29, 30]. In Ethiopia, the healthcare industry is growing with the subsequent increase in the number of healthcare professionals (HCPs). However, programs to ensure the psychosocial job characteristics which lead to physical and ill mental health are negligible in the country. Addressing the symptoms of PD is imperative not only to protect the health and well-being of workers but also to ensure the quality of care and safety of patients [31]. In this study, we analyzed the prevalence and factors associated with work-related PD among healthcare professionals in Gondar city, Northwest Ethiopia.

Materials and methods

Study design, aim, period, and setting

A cross - sectional study design was employed to assess the prevalence and factors of work related PD based on a sample of healthcare professionals in Gondar city from March to April 2019. The city is located in the state of Amhara, 747 km from the capital of Ethiopia, Addis Ababa. There were nine public health facilities in the city; one hospital (Gondar Comprehensive Specialized Hospital) and eight health centers (Teda, Azezo, Maraki, Ginbot 20, Gabriel, Poli, Woleka, and Bilajig) working for the population of Gondar and nearby. According to the administrative zone health department's plan and program report, there were 2350 health care professionals working in hospitals and health centers at the time of the study.

Source and study populations

All healthcare professionals in Gondar city administration were the source population. The randomly selected healthcare professionals in the selected public health facilities were our study population. Healthcare professionals who had worked for at least 6 months in the study area prior to the study and who were present and working in the selected health facilities during the study period were included, whereas those who were on sick, annual, maternity, and family leaves were excluded.

Sample size determination and sampling procedures

The single population proportion formula [32] was used to calculate the sample size with the following assumptions: p (proportion of work-related PD0.5since this would yield the maximum sample size), d (margin of error = 0.05and Zα/2 (standard score value for 95% confidence level = 1.96), the minimum sample size (n) was became 422 having considered 10% non-response rate. We used stratified followed by simple random sampling technique to recruit eligible samples. List of healthcare professionals was obtained from Human resource (HR) departments of each healthcare facility. Numbered lists of all healthcare professionals in Gondar city were made and 422 study subjects were randomly selected using the random number generator software. The sample size was proportionally allocated to each health institution based on the number of healthcare professionals working in the respective health facilities. Participants were approached at their respective worksite.

Data collection tools and variable measurement

Data were collected through a pre-tested and structured self-administered data collection technique. The Kessler 10 Psychological Distress Scale (K10) [33] was used to assess the prevalence of work-related PD. The scale consists of 10 questions that have been asked about the experiences of distress over the last four weeks. Responses were scored on a five-point ordinal scale reflecting how much of the participants had experienced 10 symptoms over the past four weeks, such as "feeling tired for no good reason" and "sad or depressed." Every item on a scale from 1 to 5, ranges in the severity from 'none of the time' to 'all of the time. 'The total K10 score for each participant was calculated by summing all 10 items, which then ranged from a minimum of 10 to a maximum of 50. In line with prior research, we dichotomized the variable, so that participants with scores less than 22 were regarded as not distressed and participants with scores > = 22 considered distressed [34, 35]. The K10 has shown reliability and validity in previous research Cronbach’s alpha coefficient for the K10 was 0.91 [36]. K10 scale has also previously been validated in Ethiopia [37] and yielded good internal consistency of 0.93, sensitivity of 84.2%, and specificity of 77.8%. On top of this, language validity was performed to make sure that the local language questionnaire is equivalent to the English questionnaire. Therefore, it was reasonable to apply for this study. For this study, Cronbach's α was 0.83. Job content questionnaire (JCQ) [38], a widely validated and reliable measure, was used to measure demands, control, relationships and social support. It is usually used to assess psychosocial factors at work. Job demand was assessed with five items (Cronbach’sα = 0.70). Job control was measured with seven items; Cronbach’s α of the seven-item scale was 0.73. For social support two indicators, with each four items, were used referring to both supervisor support (α = 0.87) and colleague support (α = 0.71), respectively. For each respondent, the mean value was calculated then higher numbers implied higher demands, greater control, and good relationships and support [39]. These measures have shown validity and reliability in previous studies [40, 41].Job satisfaction of participants was assessed using the 10-item generic job satisfaction scale with 32 or above as a cut-off point [42]. Moreover, several demographics were included: age, gender, marital status, work experience, monthly salary, family number, education level and profession. They were also asked about behavioral factors including alcohol use, smoking, and khat chewing.

Data quality control

We recruited six final year Environmental and Occupational Health and Safety students for data collection and two Occupational Health lecturers, and one psychiatry professionals as supervisors. Two days training was offered for data collectors and supervisors on topics related to research objectives, clarity of questions, the confidentiality of information and consent in the study. The training was given in lecture and discussion ways. The questionnaires were pre-tested on 15samples that were not included in the final analysis and the relevant modifications were made before the actual data collection was conducted.

Data management and statistical analysis

The data were checked for completeness and entered into EPI info version 7.1.5.2, and exported to IBM SPSS 20 software for analysis. Frequency distributions, percentages, means, and standard deviations were used for description of the results. Using a binary logistic regression analysis, we fitted each predictor variable in to a bivariate logistic regression model separately to explore associations with the dependent variable (self-reported work-related PD). Explanatory variables with p-value < 0.2 in the bivariate analysis were exported to the multivariable logistic regression model using backward variable selection method. Hosmer and Lemeshow goodness-of-fit test was used to check the model fitness (P>0.05). A multi co-linearity assumption was checked using Variance Inflation Factor (VIF <5). Odds ratios (OR) with 95% confidence intervals (CI) and p -value< 0.05 were applied to establish the significance of associations.

Ethics approval and consent to participate

Ethical approval was obtained from the ethical committee of the Department of Environmental and Occupational Health & Safety, College of Medicine and Health Sciences, University of Gondar. Participants were informed about the objective of the research by data collectors. Written informed consent was obtained from each study participant. To keep privacy of the information obtained, only aggregate data were used for analysis and interpretations of the results. There were no risks due to participation in this research project. The collected data were used for this research purpose only and kept with complete confidentiality.

Results

Socio-demographic and individual characteristics of the respondents

Out of 422 respondents selected, 417 participated and completed the questionnaire giving an overall response rate of 98.8%. The majority, (230, 55.2%) of the participants were males. The mean age was 31.00 years (SD = 8.219; range 23–57 years). Most of the respondents were married (221, 53%). A high proportion of the respondents had a BSc degree (344, 82.5%), above degree (49, 11.8%), and few (24, 5.8%) of the participants had a diploma as their highest level of qualification. The professional status of the participants was (233, 55.9%) Nurses, (57, 13.7%) Physician, (48, 11.5%) Midwifery, and (79, 18.9%) categorized in others. Most participants (193, 46.3%) had a monthly salary of less than 4466 Ethiopian Birr (ETB) and (85, 20.4%) reported their monthly salary was > 6176 ETB. A total of (367, 88%) participants were non- smokers (Table 1).

Table 1

Socio-demographic and individual characteristics of respondents among healthcare professionals working in healthcare facilities in Gondar city, Northwest Ethiopia, 2019.

Variables(n = 417)	Frequency	Percent (%)
Sex
Male	230	55.2
Female	187	44.8
Age in years
<30	247	59.2
> = 30	170	40.8
Educational level
Diploma	24	5.8
Degree	344	82.5
Above degree	49	11.8
Marital status
Married	221	53.0
Single	196	47.0
Monthly salary (ETB)
<4466	193	46.3
4466–6176	139	33.3
>6176	85	20.4
Profession
Physician	57	13.7
Nurses	233	55.9
Midwifery	48	11.5
Othersb	79	18.9
Work experience
½-5years	327	78.4
Greater than 5years	90	21.6
Family number
Less than 4	305	73.1
4 and above	112	26.9
Religion
Orthodox	284	68.1
Muslim	73	17.5
Protestant	51	12.2
Othersa	9	2.2
Cigarette smoking
Smoker	50	12.0
Non-smoker	367	88.0
Khat chewing
Chewer	74	17.7
Non chewer	343	82.3

Keys: a = Catholic, Jewish; b = Laboratory, Environmental health, Pharmacist, Physiotherapy, Health officers; ETB = Ethiopian Birr (1$USD = 34.73ETB currency).

Psychosocial work environment of the study participants

More than half of the respondents (227, 54.4%) reported that they had high job demand. One hundred and sixty-four (39.3%) of the participants indicated they had poor relationships with their staffs, and (239, 57.3%) respondents were satisfied with their current job (profession). The majority of respondents (242, 58%) revealed that they had low control over their job (Table 2).

Table 2

Psychosocial working characteristics of respondents among healthcare professionals working in healthcare facilities in Gondar city, Northwest Ethiopia, 2019.

Variables (N = 417)	Frequency (n)	Percent (%)
Job demand
Low	190	45.6
High	227	54.4
Job control
High	175	42.0
Low	242	58.0
Relationships
Good	253	60.7
Poor	164	39.3
Job Satisfaction
Dissatisfied	178	42.7
Satisfied	239	57.3
Social support
Low	229	54.9
High	188	45.1

Prevalence of work-related psychological distress

The prevalence of work-related PD in the past 4weeks was found to be44.4% (N = 185) [95%CI (39.8–49.4)].

Factors associated with work-related psychological distress

In a bivariate analysis, predictor variables including sex, educational status, monthly salary, work experience, family size, professional status, habits of cigarette smoking, khat chewing, high job demand, low job control, poor staff relationships, job dissatisfaction, and low perceived organizational support were explored to considerably influence work-related PD.

After controlling for confounders in a multivariable logistic regression analysis, sex, high job demand, and low job control remained to significantly influence the experience of self-reported work-related PD. Accordingly, the probability of having work-related PD was 2.07 times higher among female study participants than males [AOR: 2.07; 95% CI (1.29, 3.32)].Moreover, the chance of suffering from work-related PD was 1.53 times higher among participants who encountered high job demand than those who reported low job demand [(AOR: 1.53; 95% CI (1.10, 2.57)]. As well, the probable occurrence of work-related PD was increased by two and half among respondents who did not able to control their jobs than among those who have capacity to control their job [AOR: 2.54; 95% CI (1.60, 4.04)] (Table 3).

Table 3

Factors associated with work-related psychological distress among healthcare professionals working in healthcare facilities in Gondar city, northwest Ethiopia, 2019.

Variable(N = 417)	Work-related PD		COR(95%CI)	AOR (95%CI)
	No	Yes
Sex
Male	137	93	1	1
Female	95	92	1.43 (0.97, 2.11)	2.07(1.29, 3.32)**
Age
<30	157	90	0.45 (0.30, 0.67)	0.42 (0.37, 1.06)
> = 30	75	95	1	1
Educational level
Diploma	15	9	0.74(0.27, 2.0)	0.69 (0.39,1.91)
Degree	190	154	1.00 (0.55, 1.82)	0.92 (0.77, 3.92)
Above degree	27	22	1	1
Marital status
Married	115	106	1.37 (0.93, 2.01)	1.01 (0.62,1.65)
Single	117	79	1	1
Monthly salary (ETB)
<4466	134	59	0.52 (0.31, 0.88)	0.49 (0.27,1.04)
4466–6176	52	87	1.97 (1.14, 3.41)	1.56 (0.82,2.97)
>6176	46	39	1	1
Work experience(years)
½ -5 years	185	142	0.84 (0.53, 1.34)	1.04 (0.55, 2.01)
>5years	47	43	1	1
Family number
Less than 4	165	140	1	1
4 and Above	67	45	0.79 (0.51, 1.22)	0.72 (0.62,1.61)
Profession
Physician	23	34	2.55 (1.27, 5.13)	2.53 (0.98, 5.21)
Nurses	138	95	1.19 (0.70, 2.01)	1.15 (0.81, 2.52)
Midwifery	21	27	2.22(1.07, 4.61)	2.20 (0.96,4.58)
Othersb	50	29	1	1
Cigarette smoking
Smoker	25	25	1.29 (0.72, 2.34)	1.74 (0.89,3.41)
Not smoker	207	160	1	1
Khat chewing
chewer	36	38	1.41 (0.85, 2.33)	1.39 (0.95,3.11)
Non chewer	196	147	1	1
Job demand
High	115	112	1.56 (1.06, 2.31)	1.53 (1.10, 2.57)***
Low	117	73	1	1
Job control
High	125	50	1	1
Low	107	135	3.15 (2.08, 4.78)	2.54 (1.60, 4.04)***
Relation ships
Good	134	119	1	1
Poor	98	66	0.76 (0.51, 1.13)	1.33(0.80,2.23)
Job satisfaction
Satisfied	121	118	1	1
Dissatisfied	111	67	0.62 (0.42, 0. 92)	0.59 (0.51, 1.08)
Social support
Low	138	91	0.66 (0.45, 0.98)	0.69 (0.55, 1.39)
High	94	94	1

Keys: **statistically significant at p < 0.01|***statistically significant at p < 0.0001 | b = Laboratory, Environmental health, Pharmacist, Physiotherapy, Health officers.

Discussion

Because of the changing nature of contemporary workplaces, work-related psychosocial hazards are becoming important areas of study. However, little has been recorded in developing countries like Ethiopia, despite its pervasiveness among workers of various occupations. The aim of this study was to quantify the prevalence of psychological distress and its influencing factors among healthcare professionals in Gondar city, Northwest Ethiopia. This study demonstrated the prevalence of work-related psychological distress among health professionals in the previous4 weeks was 44.4% (N = 185). In Ethiopia, a suboptimal workplace setup coupled with the traumatic events of daily life possibly aggravates the mental health status of employees, including PD. A study in Nigeria reported a comparable finding to the current investigation (44.1) [43]. The possible explanations for this correspondence might be that in developing countries, socio-economic status and the inherent nature of work characteristics in healthcare facilities such as the lack of adequate resources (human and material), job insecurity, and poorly arranged work conditions invariably likely similar.

Our result is higher than the reports from Sri Lank (21%) [44] and Canada (25.4%) [4]. This might explain that the current study employed a relatively shorter time frame (4 weeks) experience of the workers, which can enhance a recalling capacity of the participants to report recent experiences. However, in this study, symptoms of psychological distress were detected at a lower magnitude than a literature in China (85.5%) [45]. This disparity could be attributed to reporting cultures, definitions, and degrees of perceptions of psychological distress symptoms across the countries.

In accordance with abundant epidemiological data [45-48], psychological distress symptom is markedly influenced by sex of employees in our investigation. Females often tend to shoulder greater responsibilities and accountabilities including caring for children, the elderly, and involving household and social roles in several ways. The combined effects of household/workplace duties eventually predispose females to detrimental psychosocial characteristics such as time pressure and job control. Studies have also elucidated that women are vulnerable to psychological distress because they may perceive discrimination at work, encounter violence, and use emotional oriented coping strategies [47-49]. Furthermore, in developing countries including Ethiopia, the majorities of female workers are engaged in low-level employment status with low incomes, routine, and zero tolerance for deadline, which places females at high risk of developing psychological ill health.

Scholars have widely reported that a low job control is a significant contributor to the symptoms of psychological distress [50, 51]. Our analysis also supported those reports. Employees with a low job control/autonomy might perceive that job differently, may not be satisfied with, may be stressed/distressed, and may eventually experience ill mental health symptoms in general.

In the multivariable analysis, the incidence of psychological distress was significantly related to a work demand. This finding reproduced a report from another studies [50, 51]. Working in a healthcare setting is indeed a challenging because employees usually need to handle intensive tasks involving work overload, extended working hours, high effort and energy, and limited professionals/lack of support. Even though the stressful nature of working in healthcare facilities is basically similar everywhere, in developing countries like Ethiopia, such challenges are far beyond empirical witness due to a lack of an effective distribution of resources for health.

This study bestows great opportunities for healthcare officials and other stakeholders to account for workplace context when planning for mental health prevention programs. In Ethiopia, the relation of diverse psychosocial job characteristics and ill psychological symptoms has been little researched and therefore the current study inculcates other researchers to shift their interests to this pivotal concern. However, the result needs to be interpreted with cautions when drawing a conclusion. First, the study was a cross-sectional survey of limited healthcare facilities which might preclude the findings from conclusion to other workplaces. Second, because the data obtained were past experiences of workers self-reporting, underreporting cannot be overlooked. To minimize such bias, we restricted only to the recent experiences. Future investigators need to incorporate diverse workplaces to explicitly comprehend the relations of various work characteristics and psychological distress.

Conclusion

This study underscores the level of psychological distress among healthcare professionals is high. The experiences of psychological distress symptoms were significantly influenced by socio-demographic factors including sex and psychosocial job characteristics such as job demand and job control. Efforts to prevent the mental health of workers including psychological distress symptoms need to focus on individual and job context.

This is data set used in analysis.

(XLSX)

Click here for additional data file.

3 Jul 2020

PONE-D-20-14581

Psychological distress symptoms among healthcare professionals are significantly influenced by psychosocial work context, Ethiopia: A cross-sectional analysis

PLOS ONE

Dear Dr. Kabito,

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 17 2020 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

We look forward to receiving your revised manuscript.

Kind regards,

Amir H. Pakpour, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

[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

**********

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

Reviewer #1: 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: 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

**********

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 is generally well written with clear descriptions in the study purpose. However, some minor points need to be addressed in the revision.

1. Please adhere to the use of defined abbreviations. For example, in line 77, there is a "psychological distress" term. However, the psychological distress has been defined as PD at the very beginning of the manuscript. Line 73 also has the similar problem. I do not point out all of them, the authors should check by themselves throughout the manuscript.

2. Line 118. Here comes a term of "K10". After re-read the manuscript, I can identify that the K10 indicates the Kessler Psychological Distress Scale. However, the authors did not define the K10 when they mention the Kessler Psychological Distress Scale.

3. Line 119. Research cannot be counted. Therefore, the authors should correct "researches" into "research".

4. Line 138. The Data quality control section is the biggest problem in the manuscript. It is unclear why the authors define these actions as data quality control. The section reads like the descriptions of language validity. Moreover, some descriptions are confusing in the section. Specifically, back-translation indicates translating local language back to English. I cannot understand why the authors can back translate the English to local language. Also, did the authors conduct a forward translation? Moreover, ensuring language validity (i.e., make sure that the local language questionnaire is equivalent to the English questionnaire) is not about data quality. The language validity ensures the questionnaire validity.

5. Following the previous comment. If the authors want to present how they control the data, they should inform the readers how they make sure that the data input and data collections have no errors.

6. Table 1. Not everyone is familiar with the Ethiopian Birr. Please provide an exchange rate of the Ethiopian Birr with USD.

7. Also Table 1. I think that the footnote a should go earlier than footnote b.

8. Table 3. I cannot understand why the authors mentioned "Hosmer and Lemeshow test = 0.754 showed that the model fitted well" here. Also, there is a superscript b for Others in the Profession category. However, there is no footnote to explain the meaning of b.

**********

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

[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.

23 Aug 2020

we have uploaded as a separate file of the responses to the editors and reviewers

Submitted filename: Responses of authors to reviewers.docx

Click here for additional data file.

4 Sep 2020

Psychological distress symptoms among healthcare professionals are significantly influenced by psychosocial work context, Ethiopia: A cross-sectional analysis

PONE-D-20-14581R1

Dear Dr. Kabito,

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,

Amir H. Pakpour, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

10 Sep 2020

PONE-D-20-14581R1

Psychological distress symptoms among healthcare professionals are significantly influenced by psychosocial work context, Ethiopia: A cross-sectional analysis

Dear Dr. Kabito:

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. Amir H. Pakpour

Academic Editor

PLOS ONE