In-person training on COVID-19 case management and infection prevention and control: Evaluation of healthcare professionals in Bangladesh.

BACKGROUND: As COVID-19 was declared a global pandemic, the major focus of healthcare organizations shifted towards preparing healthcare systems to handle the inevitable COVID-19 burden at different phases and levels. A series of in-person training programs were operated in collaboration with government and partner organizations for the healthcare workers (HCW) of Bangladesh. This study aimed to assess the knowledge of HCWs regarding SARS-CoV-2 infection, their case management, infection prevention and control to fight against the ongoing pandemic.
METHODS: As a part of the National Preparedness and Response Plan for COVID-19 in Bangladesh, the training program was conducted at four district-level hospitals and one specialized hospital in Bangladesh from July 1, 2020 to June 30, 2021. A total of 755 HCWs participated in the training sessions. Among them, 357 (47%) were enrolled for the evaluation upon completion of the data, collected from one district hospital (Feni) and one specialized hospital (National Institute of Mental Health).
RESULTS: The mean percentage of pre-test and post-test scores of all the participants were found to be 57% (95% CI 8.34-8.91; p 0.01) and 65% (95% CI 9.56-10.15; p <0.001) respectively. The difference of score (mean) between the groups was significant (p<0.001). After categorizing participants' knowledge levels as poor, average and fair, doctors' group has shown to have significant enhancement from level of average to fair compared to that of the nurses. Factors associated with knowledge augmentation of doctors were working in primary health care centers (aOR: 4.22; 95% CI: 1.80, 9.88), job experience less than 5 years (aOR: 4.10; 95% CI: 1.01, 16.63) and experience in caring of family member with COVID-19 morbidity (aOR: 2.06; 95% CI: 1.03, 4.10), after adjusting for relevant covariates such as age, sex and prior COVID-19 illness.
CONCLUSION: Considering the series of waves of COVID-19 pandemic with newer variants, the present paper underscores the importance of implementing the structured in-person training program on case management, infection prevention and control for the HCWs that may help for successful readiness prior to future pandemics that may further help to minimize the pandemic related fatal consequences.

Background

The novel Coronavirus emerged in Wuhan, China in late December 2019, and Bangladesh had reported its first case on 8th March 2020 [1, 2]. Researchers identified the basic reproductive number of the virus, which is higher than many deadly infectious diseases, that eventually overwhelmed healthcare facilities in developing as well as developed nations [3]. The health care system in Bangladesh is typical of any developing country setting and was not fully capable of handling the raging Coronavirus pandemic [4]. However, as the first responders, healthcare workers (HCWs) immediately responded with team efforts in delivering health care and essential services to save lives [5]. In the battle against SARS-CoV-2, Bangladesh has lost nearly 9,400 healthcare workers including 3,106 doctors, 2,281 nurses and 4,015 other individuals related to health service delivery [6]. The sudden spread of the pandemic with fear of contracting the deadly disease abruptly halted all types of in-person skilled training when it was a dire need [2].

In a developing country like Bangladesh, the healthcare workforce is already burdened with routine health care as well as with public health threat issues, including undernutrition, non-communicable diseases, etc., which might impede adopting preventive measures and facilitating care of COVID-19 [7]. A recent study estimated the high workload of Bangladeshi physicians and nurses with a coverage of 3.04 and 1.07 per 10,000 individuals respectively [8]. Due to heavy workload, HCWs often could not practice and follow the critical preventive health measures such as frequent hand hygiene [9]. Moreover, the case-fatality-rate from COVID-19 among the doctors is highest in Bangladesh compared to other affetcted countries [10]. Considering the intensifying health risk, the Government of Bangladesh conducted a National Preparedness and Response Plan for COVID-19, jointly with international development partners, which indicated the need for hands-on training for doctors, nurses and clinical care support staff [11]. This ranges from prevention of the infection that the health system staff members will be allowed to practice as preventative measures to be consistently followed later by the HCWs to protect themselves and facilitate infection control, and treatment of COVID-19 patients [12].

Despite developing various guidelines for the infection prevention and control procedures and case management of COVID-19 by the Government of Bangladesh, the pandemic triggered the shut-down of all in-person educational activities. Consequently this placed the unprepared health workforce at utmost risk and simultaneously made them susceptible to spread the transmission [13]. During the COVID-19 pandemic, scientific sessions, conferences and training events were switched to a virtual platform. Although considering a better forum for networking, information exchange and group-based peer learning, we preffered conventional in-person trainings.Under these circumstances, an in-person training program was conducted emphasizing on epidemiology, microbiology, prevention and control and treatment of COVID-19 for the HCWs of different districts of Bangladesh from 1st July 2020 to 30th June 2021 with support from Global Affairs Canada (GAC). Such endeavor was carried out by a dedicated team comprising of physicians, nurses and infection prevention and control specialist from icddr,b.

Literature review indicated that in-person training on an acute emergency disorder encouraged team building in healthcare delivery, leadership and thus improved the performance of caregivers [14]. The objective of our study was to explore the effectiveness of the training program by comparing the pre-test and post-test scores of the participants and formulate better strategies for designing more in-person training in future during any large-scale outbreak in Bangladesh.

Method

Study site

The training was conducted in four district and one specialized hospitals (including 21 health facilities). The district hospitals have secondary level health facility (location in Chandpur, Narail, Magura, and Feni) whereas the specialized hospital named National Institute of Mental Health (NIMH) has tertiary level health facility. As per the National Health Service (NHS), medical care is provided in two main ways: primary care (by general practioners and community services) and secondary care (hospitals and specialists). Difference between primary and secondary healthcare: day-to-day healthcare in every local area is considered as primary health care, whereas secondary healthcare is the specialist treatment and support provided by doctors and other health professionals for patients who are referred to them for specific expert care, most often provided in hospitals.

These facilities were selected as they were directly involved in providing optimal care for COVID-19 cases or prepared to hospitalize and manage in case of exceeding the number of cases of COVID-19. Both the health facilities are from urban and sub-urban locality.

Study participants

Participants were selected by the hospital authority considering their engagement in clinical work and overseeing roles in the team. Moreover, from each hospital, one focal person was selected as an Infection Prevention and Control (IPC) lead who would continue conducting the similar in-house sessions for other staff members after the completion of their training. Among the total 755 participants, 294 were physicians, 335 were nurses and 126 were clinical support staff. If we divide them district wise, the distribution seems like- in Chandpur (n = 79), Narail (n = 141), Magura (n = 97), Feni (n = 264) and, (n = 174) in Dhaka.

We have purposively selected 357 members of the health workforce for the current study, where we aimed to explore the improvement of knowledge by the training program by evaluating their performance in pre-test and post-test assessment sessions.

Inclusion criteria

Participants from NIMH (specialized hospital) and one district hospital (Feni) were selected for the comparison of this pre and post study at the targeted level of scores.

Exclusion criteria

We excluded participants from the analysis if either of the pre-test or the post-test performance was incomplete by the respective member of the health workforce.

Study design

This was a cross-sectional study. The study participants of this analysis were the individuals who received training in a COVID-19 training program that aimed at the capacity development of healthcare workers in taking care of COVID-19 cases in Bangladesh.

Instruments

A self-directed, semi-structured questionnaire (S1 Questionnaire) was developed by the investigators of the study where identity of the participants was masked. The questionnaire was in English and attached as a S1 Questionnaire. We have used the identical 15 questions for both pre-test and post-test. Thus four domains (epidemiology, clinical manifestation, case management, and infection prevention and control) had 3, 2, 2 and 8 questions respectively. We categorized the knowledge as poor, average and fair if the participant scored 0–5, 6–10 and 11–15 respectively.The questionnaire was validated in-house among trainee physicians of Dhaka Hospital of icddr,b as a piloting approach. In addition, there were questions about the respondent’s age, sex, educational background, workplace, current working position with joining date, COVID-19 morbidity experience (either self-infection or the infection of a family member) and their feedback regarding their liking and disliking of the training. All the course materials were provided to the participants in the form of handout of presentation.

Description of training

As a part of the National Preparedness and Response Plan for COVID-19 in Bangladesh, a rapid facility assessment for national health facility readiness and preparedness for COVID-19 was commissioned. The Directorate General of Health Services (DGHS) initiated the process with support from development partners, UN agencies, and other national and international agencies. USAID’s Medicine, Technologies and Pharmaceuticals Services (MTaPS) Program, implemented in Bangladesh by Management Sciences for Health (MSH), supported DGHS with the assessment. It was a two-day session for doctors, one day session for nurses and other support staff members.

For doctors and nurses, different sets of training curriculum and training materials were used as appropriate considering the compatible topics and modules focusing on their levels of understanding. After each module, a comforting refreshment break was arranged in every training session. A flexible approach was adopted for delivering the training materials, that included theoretical sessions, practical demonstrations and interactive discussions.

Curriculum of the training

The goal of the training was to empower the healthcare workforce to fight COVID-19 by achieving confident, skills and knowledge and simultaneously implementing evidence-based strategies in healthcare settings. Thus, the training modules were designed to document knowledge, attitude and practice of the participants related to COVID-19 pandemic.

The IPC modules included the importance of triage, principles of IPC, standard precautions and transmission-based precautions, waste management and environmental decontamination and vaccine development. The case management modules included: the epidemiology of SARS-CoV-2; clinical manifestations of COVID-19; diagnostic strategy and treatment of COVID-19 cases.

Sample size

We have collected information from 357 participants (214 from district level hospitals and 143 from a tertiary level/specialized hospital) after excluding 12 participants (8 and 4, respectively) because of their incomplete response in either of the two sessions.

Assuming 20% of the participants might lack in improvement of knowledge and skill after the training sessions, the estimated sample size with 80% power at a 95% confidence limit and 5% precision was 246, which is convenient for the present evaluation. The evaluation was purposively selected after meeting the exclusion criteria based on unintended to comply with providing personal and job related information

Statistical analysis

The data entry, coding, and editing were performed using SPSS version 20 (Chicago, IL, USA). The SPSS file was then imported into Stata 15 software and all statistical analyses were performed using Stata (Stata Statistical Software: Release 15, College Station, Texas 77,845, USA: Stata Corp LLC). Descriptive statistics included frequencies, percentages, mean, standard deviation which were used to summarize data. Statistical plots such as cluster diagram, and pie charts were reviewed for data visualization. To estimate the inferential statistics, odds ratio with 95% confidence interval was used. We compared the baseline characteristics of the training participants by using chi-square tests, and t-test was used to see the significance of mean difference between pre-test and post-test scores. Logistic regression analysis revealed the more distinctive association between participants’ characteristics and pre-test and post-test scores.

Ethical approval

Ethical approval for the training activity was obtained from the Research Review Committee and Ethical Review Committee of the International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b)(ACT-01112) on 25th June 2020. All participants provided voluntary written consent and actively participated in the pre-test and post-test sessions.

Results

From 1st July 2020 to 30th June 2021, a total of 755 health care providers participated in the training sessions. Among them, 357 (47%) participants (doctors and nurses) were assessed by the pre-test and post-test. Out of the 357, 208 (58.26%) were nurses with a diploma in Nursing (72%). Among the physicians, nearly one-fourth had specialization either in medicine or surgery (Fig 1).

Fig 1

Academic contexts of the participating doctors and nurses.

Table 1 summarizes the characteristics of the study population. The mean age of the population was (32.82±4.99) years for doctors and (35.46±8.31) years for nurses. About 72% of the total respondents were female. More than half (59.94%) of the participants were from primary and secondary level healthcare facilities. Approximately 80% of doctors had an average working experience of less than five years, whereas one-third of the nurses had a working experience of more than ten years (Table 1). The doctors suffered from COVID-19 more often than the nurses as well as they had witnessed sufferings of family members more frequently than the nurses.

Table 1

Demographic and occupational characteristics of the participants.

Variables	Overall (N = 357)	Doctors (n = 149) (%)	Nurses (n = 208) (%)	p-value
Age, mean±SD	-	32.82±4.99	35.46±8.31	0.005
Female sex	256	64 (42.95)	192 (92.31)	<0.001
Training site, n (%)	357
Specialized hospital	143	53 (35.57)	90 (43.27)	0.143
District hospital	214	96 (64.43)	118 (56.73)
Current working station, n (%)	357
Primary health care facility (sub-district facility)	118	61 (40.94)	57 (27.40)	0.027
Secondary health care facility (district facility)	96	35 (23.49)	61 (29.33)
Years of experience, n (%)	217
<5 years		91 (81.25)	59 (56.19)	<0.001
5–10 years		16 (14.29)	12 (11.43)
>10 years		5 (4.46)	34 (32.38)
COVID-19 infection, n (%)	67	42 (37.84)	25 (23.81)	0.026
COVID-19 exposure from the family, n (%)	55	50 (45.05)	5 (22.73)	0.052

Table 2 shows the participants’overall pre-test and post-test scores according to their current working location. Participants working in the primary healthcare facility achieved higher scores in pre-test and post-test assessments than the other participants from secondary or tertiary level facilities. Nurses working in the primary healthcare facilities achieved higher post-test scores than the other nurses. However, doctors working in all three settings achieved similar post-test scores of more than 80%.

Table 2

Current working station wise comparison of pre-test and post-test scores of the participants.

		Pre-test score (n = 357), Mean %	Post-test score (n = 357), Mean %	p value
Primary Healthcare Centre	Overall	63.39	71.58	<0.001
	Doctors	75.30	81.64	<0.001
	Nurses	50.64	60.82	<0.001
Secondary Healthcare Centre	Overall	56.18	65.21	<0.001
	Doctors	72.95	81.33	<0.001
	Nurses	46.56	55.96	<0.001
Tertiary Healthcare Centre	Overall	53.61	61.17	<0.001
	Doctors	68.05	80.38	<0.001
	Nurses	45.11	49.85	<0.001

The knowledge levels regarding epidemiology, clinical manifestation, case management and infection prevention and control are presented in Table 3. The results observed that all the participants achieved more than 50% pre-test scores and significantly higher post-test scores in all four domains.

Table 3

Comparison of pre-test and post-test scores of all the participants on the basis of four domains of different questions.

Domain Name	Pre-test score (n = 357), Mean %	Post-test score (n = 357), Mean %	p value
Epidemiology	72.36	82.17	<0.001
Clinical manifestations	52.24	62.04	<0.001
Case management	56.44	67.65	<0.001
Infection prevention and control	53.61	59.98	<0.001

We have presented the knowledge of the participants into three categories. Table 4 shows the distribution of participants’ knowledge level according to the characteristics of the participants before and after conducting the training. There was an overall significant improvement in the scores from an average level to a fair level. A significant improvement of scores from an average level to acceptable fair level was observed among participants of all categories except those who experienced COVID-19 morbidity.

Table 4

Comparative characteristics of the participants between different results level of pre-test and post-test.

	Results	Pre-test (n = 357)	Post-test (n = 357)	p-value
		Frequency (%)	Frequency (%)
Overall	Poor level (0–5)	41(11.48)	27(7.56)	0.074
	Average level (6–10)	210(58.82)	173(48.46)	0.005
	Fair level (11–15)	106(29.69)	157(43.98)	0.000
Age (<35)	Poor (0–5)	11(7.80)	7(4.96)	0.330
	Average (6–10)	70(49.65)	58(41.13)	0.151
	Fair (11–15)	60(42.55)	76(53.90)	0.057
Age (≥35)	Poor (0–5)	16(21.62)	9(12.16)	0.125
	Average (6–10)	43(58.11)	36(48.65)	0.249
	Fair (11–15)	15(20.27)	29(39.19)	0.012
Male	Poor (0–5)	3(2.97)	3(2.97)	1.000
	Average (6–10)	43(42.57)	22(21.78)	0.002
	Fair (11–15)	55(54.46)	76(75.25)	0.002
Female	Poor (0–5)	38(14.84)	24(9.38)	0.058
	Average (6–10)	167(65.23)	151(58.98)	0.145
	Fair (11–15)	51(19.92)	81(31.64)	0.002
Tertiary Healthcare Center	Poor (0–5)	22 (15.38)	15(10.49)	0.217
	Average (6–10)	91(63.64)	81(56.64)	0.227
	Fair (11–15)	30(20.98)	47(32.87)	0.023
Primary and Secondary Healthcare Center	Poor (0–5)	19(8.88)	12(5.61)	0.192
	Average (6–10)	119(55.61)	92(42.99)	0.009
	Fair (11–15)	76(35.51)	110(51.40)	0.001
COVID-19 infection	Poor (0–5)	5(7.46)	4(5.97)	0.730
	Average (6–10)	33(49.25)	25(37.31)	0.163
	Fair (11–15)	29(43.28)	38(56.72)	0.120
Not-infected with COVID-19	Poor (0–5)	22(14.77)	13(8.72)	0.105
	Average (6–10)	81(54.36)	69(46.31)	0.164
	Fair (11–15)	46(30.87)	67(44.97)	0.012
COVID-19 exposure from the family	Poor (0–5)	1(1.82)	2(3.64)	0.558
	Average (6–10)	21(38.18)	6(10.91)	0.001
	Fair (11–15)	33(60.00)	47(85.45)	0.003
Not exposed to COVID-19 from family	Poor (0–5)	4(5.13)	1(1.28)	0.173
	Average (6–10)	37(47.44)	23(29.49)	0.021
	Fair (11–15)	37(47.44)	54(69.23)	0.006

Fig 2 shows the categorical evaluation of the scores of both doctors and nurses. There is an obvious improvement of knowledge score for the doctors compared to the nurses. There was a significant decrease in the proportion of average level in post-test (11%) than pre-test (40%)(p<0.001) and increased significantly in the proportion of fair level in post-test (87%) than pre-test (59%). On the other hand, there was no remarkable change in the scores of the nurses.

Fig 2

Pretest-posttest score level of doctors and nurses.

Results of unadjusted (uOR) and adjusted odds ratios (aOR) computed by logistic regression are shown in Table 5. The observed improvement is reflected as an increase in scores in case of doctors (aOR: 16.27; 95% CI: 5.68, 46.56). Participants currently working in a secondary healthcare facility (aOR: 2.88; 95% CI: 1.07, 7.72) and primary healthcare facility (aOR: 4.22; 95% CI: 1.80, 9.88), having working experience of 5–10 years (aOR: 4.72; 95% CI: 1.15, 19.39) or less than 5 years (aOR: 4.10; 95% CI: 1.01, 16.63) were more likely to achieve a better post-test score. Participants who experienced in caring of a family member with COVID-19 (aOR: 2.06; 95% CI: 1.03, 4.10) achieved significantly higher post-test scores (Table 5).

Table 5

Associated factors of the participants with pretest and posttest scores.

Indicators	Unadjusted OR (95% CI)	p-value	Adjusted OR (95% CI)	p-value
Age
≥35	Reference		Reference
<35	2.20 (1.44, 3.36)	<0.001	1.16 (0.52, 2.59)	0.711
Sex
Female	Reference		Reference
Male	5.31 (3.74, 7.54)	<0.001	1.38 (0.70, 2.72)	0.348
Position
Nurses	Reference		Reference
Doctors	22.47 (15.03, 33.57)	<0.001	16.27 (5.68, 46.56)	<0.001
Current working station
Tertiary Healthcare Center	Reference		Reference
Secondary Healthcare Center	1.49 (1.00, 2.21)	0.048	2.88 (1.07, 7.72)	0.036
Primary Healthcare Center	2.71 (1.88, 3.91)	<0.001	4.22 (1.80, 9.88)	0.001
Years of experience
>10 years	Reference		Reference
5–10 years	10.14 (3.98, 25.88)	<0.001	4.72 (1.15, 19.39)	0.032
<5 years	9.87 (4.40, 22.17)	<0.001	4.10 (1.01, 16.63)	0.049
COVID-19 infection
No	Reference		Reference
Yes	1.64 (1.08, 2.47)	0.019	1.07 (0.56, 2.07)	0.831
COVID-19 exposure from the family
No	Reference		Reference
Yes	1.90 (1.12, 3.23)	0.016	2.06 (1.03, 4.10)	0.041

After adjusting for relevant covariates, there was no significant association between scores and the participants by age, sex, and who infected by COVID-19.

Discussion

The COVID-19 pandemic has revealed deep inequities in the global healthsystem to mitigate health emergency prevention response. A number of independent reviews have identified numerous gaps and weaknesses in the health system preparedness for any pandemic, moreover the condition is worse in developing country.The present study underpins one of the very few published studies assessing knowledge and preventive behaviors of healthcare workforce towards COVID-19 management in Bangladesh. Government reports have identified high COVID-19 burden districts of Bangladesh, where in-person training impacted meaningfully in managing COVID-19 cases [15]. The major strength of our research paper is the larger sample size and district-wise distribution of working-location of participants, which provided a better insight of the scenario towards COVID-19 care in Bangladesh. The aim of our study was to quantify the knowledge gained through the COVID-19 on-site training in Bangladesh.

Our study observed female-dominated cluster of participants. However, both males and females performed equally in assessment tests.While searching for the gender-wise acquaintances of knowledge on COVID-19, reports showed that male participants achieved better knowledge than their female counterpart [16, 17], which differed in our research.

Due to easier accessibility of information in urban areas, previous studies have reported a higher level of knowledge among individuals living in urban areas [16, 18], although our study has shown contrasting findings. Participants assigned to rural healthcare facilities like primary healthcare facilities (sub-district health facilities) and, secondary health care facilities (district health facilities) have demonstrated better performance in training assessment. This can be explained by the knowledge saturation of the urban participants through easier accessibility of educational modules on COVID-19 [19].

Our study explored the association of length of working experience with better knowledge gain among the participants. The study revealed the fact that knowledge gain was inversely related to the year of job experience. From the Bangladesh Government civil service perspective, it is prudent to mention that those who have fewer years of job experience belong to younger age group. It is prudent to mention that young people are wel-motivated in acquiring and systhesising of new knowledge than the older people. Moreover, there were some restriction of in-person involvement of patient care in the age group of over forty. As younger health care workers involved actively in patient care from the beginning of pandemic, they were more engaged in the training, hence acquired better knowledge compared to their older peers. In other word, it is obvious from previous literatures that young people are better achievers of learning new knowledge and skills [20] compared to the aged people [21]. Moreover, participants exposed to a COVID-19 sick family member performed better in the assessment tests. Previous studies also reported that healthcare workers were in constant mental worries for potential transmission of the virus to their family members [22] and therefore, would be better experienced in COVID-19 patient care if having practical experience in caring for their sick family members [23].

Nurses and clinicians are two major pillars of any healthcare facility and are instrumental in the case management of COVID-19 pandemic. In particular, it is necessary to assess the knowledge gained in a conventional way of in-person training, which is followed by an impact assessment of the training, to ascertain the future needs of the training program during a pandemic situation. The study’s outcome could be helpful while developing an effective and productive infrastructure.

The study is not devoid of limitations. Firstly, we could not include all the participants who received training that could have resulted in difference in the evaluation. In addition, we assessed the effectiveness of the on-site training program by performing pre-test and post-test that can measure only short-term memory. On the other hand, the real-time practice of IPC and COVID-19 management was not evaluated through observations for a sufficient time period in case of this training. Lastly, we were not able to adjust for the changes in trainers for different modules of the training.

In conclusion, the results of our training clearly indicate that the HCWs were benifitted by attending structured training on COVID-19 case management, infection prevention and control. To nurture their expertise more training program need to be developed and implemented on both preventive and curative care of COVID-19 patients in different hospitals that may further help for rapid preparedness and optimal implementation planning for any pandemic similar to COVID-19.

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Change of knowledge between pre-test and post-test among participants.

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6 Apr 2022

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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 “Evaluation of structured in-person COVID-19 case management and infection prevention and control training for healthcare professionals in Bangladesh” by Shahrin et. al., describes the importance of implementing the structured in-person training program for healthcare workers regarding case management in a pandemic.

Authors showed all participants achieved significantly higher post-test scores in Epidemiology, Clinical manifestation, case management and infection prevention and control.

The manuscript needs editorial assistance because of some grammatical mistakes.

Comments are listed below:

1. Authors mentioned semi-structured questionnaire developed by the investigators are in the supplementary file. But this reviewer couldn’t find any.

2. Authors preferred conventional in-person trainings. Is there any virtual training data?

3. Please mention if these healthcare facilities are from rural/sub-urban/urban area.

4. One third of the participants remained in poor post-test score category. About 6% and 9% participants demoted from average and fair category respectively. Did the authors supply any quick access guide?

5. Figures 1 & 2 are of poor quality. This reviewer couldn’t read the scale or what is written there. Please use high quality figure.

6. Do not mention COVID-19 as COVID-10.

7. Please check the typographical errors throughout.

8. Shortened the Title.

Reviewer #2: SUMMARY

The aim of this study was to measure levels of knowledge and preparedness to manage COVID-19 infections among physicians and nurses in Bangladesh.

The COVID-19 pandemic not only puts healthcare workers (HCWs) who treat patients in critical care at high risk but also challenges healthcare systems to respond to the crisis. Adequate training in preventive measures and control are critical for workers’ preparedness and to develop the capacity to handle the inevitable heath care emergency.

In this work, the authors explored the effectiveness of a structured in-person training program directed to HCWs comparing participants’ test scores (pre and post training) with the objective to plan better strategies to effectively navigate current and future large-scale disease outbreaks in Bangladesh.

A similar study was conducted by Muhammed Elhadi et al. in Libya, and was published in 2020 in The American Journal of Tropical Medicine and Hygiene (DOI: https://doi.org/10.4269/ajtmh.20-0330).

The training program was conducted in hospitals from July1, 2020 to June 30, 2021. Seven hundred and fifty-five HCWs participated in the study, which included doctors and nurses. Participants were tested before and after the training, and their knowledge was scored as poor, average and fair.

The results highlight the benefit of implementing structured in-person education and training programs for HCWs, which contributes to successful case management and COVID-19 infection prevention and control. In addition, the authors showed the importance of organized and collaborative partnership between Bangladesh government and international organizations.

MERITS

Critical preparedness, readiness, and knowledge regarding COVID-19 are needed for physicians and nurses working on the front line. Few researchers have addressed the overall issues of preparedness of healthcare systems for COVID-19 and their ability to maintain control of the epidemic. The study highlights the importance of educational initiatives to help countries improve their capacity to control and prevent COVID-19 infection.

COMMENTS

1. The manuscript has language and editing issues in all sections. I suggest the authors work with a scientific editor to improve the flow and readability of the text.

2. Background

a) Lines 128-133: the statements included in this paragraph do not connect well. I suggest the authors delete the first sentence (128-130). The information about the study participants is already included in the methods section.

b) Please define the acronym icddr,b.

3. Methods

c) Sites and study participants:

• Information about participants and sites is mixed up and it’s difficult to follow. Splitting the section in two sub-sections (1. Sites; 2. Participants) maybe helpful for the reader and reviewers to understand the study characteristics.

• Please state the difference between primary and secondary facilities.

• Are the secondary and tertiary level facilities included in the district and specialized hospitals? Please clarify.

d) Study design: in which language was the questionnaire administered? Please include a copy as supplementary material.

e) Training description:

• The information provided in lines 188-189 about the health care facilities is redundant. It was cited in line 186 and in the sites and participants section.

• This sub-section needs editing. The information provided is mixed up (facilities with participants) and therefore it’s difficult to follow.

f) Training curriculum: the information provided in lines 205-207 is redundant because it was already included in precedent sub-sections.

g) Sample size:

• Please explain/edit the sentence starting on line 216: “We could not communicate…”

• Please explain/edit the sentence starting on line 218: “The sample size was adequate…” how did you come to the conclusion that the sample size was adequate?

I suggest the authors move this information to the results section.

4. Results

h) Please note that the quality of Figures 1 and 2 is not good enough for the reader to see the numbers or legends.

i) Line 250: please explain the meaning of the word “destruction” in this sentence.

j) Line 268-270: please clarify this sentence.

k) Line 273: please change “mentioned” to “shown”.

l) Table 1: please change “COVID-19 sufferer” by “COVID-19 infection”

m) Table 4:

• Please change “COVID-19 sufferer” by “COVID-19 infection”

• Please change “not-sufferer by COVID-19 ” by “Non-infected with COVID-19”

n) Table 5:

• Please explain the use of the term “reference” in this table.

• Please change “COVID-19 sufferer” by “COVID-19 infection”.

5. Discussion

o) Line 286-287: please clarify what you want to communicate with “…hospitals will not meet

the entire epidemic burden”.

p) Line 289: please clarify to which study you refer with “the major strength is the ….”.

q) Line 308: did you also find that young people were better achievers than aged people? Please clarify this paragraph.

r) Lines 327-330: this sentence is too long and needs editing.

**********

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.

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Reviewer #1: No

Reviewer #2: No

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20 Apr 2022

Cover letter

Date: April 20, 2022

To: Dr Sanjai Kumar

Academic Editor, PLoS ONE

From: Dr Lubaba Shahrin

Corresponding author

Manuscript Ref. : PONE-D-22-01969

Subject: Response on the comments of the academic editor and the reviewers of PLoS ONE on manuscript Ref.: PONE-D-22-01969 entitled “In-person training in COVID-19 Case management and infection prevention and control: Evaluation of healthcare professionals’ knowledge in Bangladesh”

Dear Dr Sanjai Kumar,

Thank you for providing us the opportunity to resubmit our manuscript following revision. We greatly appreciate the helpful comments of the reviewers and have attempted to address them in full. We now submit two drafts of the revised manuscript, one clean version and one which highlights the changes that we have made in red, as well as this letter which provides a point-by-point response to the reviewers’ comments.

Kindly consider our revised draft for further in your prestigious journal. Please find the reviewers response as below.

Reviewer’s comments:

Reviewer #1: The manuscript “Evaluation of structured in-person COVID-19 case management and infection prevention and control training for healthcare professionals in Bangladesh” by Shahrin et. al., describes the importance of implementing the structured in-person training program for healthcare workers regarding case management in a pandemic.

Authors showed all participants achieved significantly higher post-test scores in Epidemiology, Clinical manifestation, case management and infection prevention and control.

The manuscript needs editorial assistance because of some grammatical mistakes.

Response: Thank you for your kind concern. We have reviewed the draft by our in-house scientific editor. We hope this draft is now in better shape.

Comments are listed below:

1. Authors mentioned semi-structured questionnaire developed by the investigators are in the supplementary file. But this reviewer couldn’t find any.

Response: We apologies for the inconvenience. The questionnaire is attached here with the supplementary files

2. Authors preferred conventional in-person trainings. Is there any virtual training data?

Response: Although we found some research on knowledge, attitude and practice elsewhere, we do not have any data on virtual or online training. In in-person training we were able to arrange some hands-on activity on infection prevention and practice, which would be missed in virtual training. For your kind convenience we have put one article on online training:

Knowledge, attitudes, and fear of COVID-19 during the Rapid Rise Period in Bangladesh

M. A. Hossain, M. I. K. Jahid, K. M. A. Hossain, L. M. Walton, Z. Uddin, M. O. Haque, et al.

PloS one 2020 Vol. 15 Issue 9 Pages e0239646

3. Please mention if these healthcare facilities are from rural/sub-urban/urban area.

Response: Thank you for your query. In the study site we have clarify about the level of health facilities in Bangladesh. The district level hospital is a secondary level health facility. Both are from urban facilities.

4. One third of the participants remained in poor post-test score category. About 6% and 9% participants demoted from average and fair category respectively. Did the authors supply any quick access guide?

Response: We supplied the all the presentation handout delivered in the training. We have included this in study instrument section.

5. Figures 1 & 2 are of poor quality. This reviewer couldn’t read the scale or what is written there. Please use high quality figure.

Response: We regret for the inconvenience, we have re-created the figures of 300 dpi as per journal’s requirement for your kind consideration.

6. Do not mention COVID-19 as COVID-10.

Response: We apologies for the typing error.

7. Please check the typographical errors throughout.

Response: We have checked and corrected them diligently.

8. Shortened the Title.

Response: Thank you for your suggestions. We have modified the title as “In-person training on COVID-19 case management and infection prevention and control: Evaluation of healthcare professionals in Bangladesh” for your kind contemplation.

Reviewer #2: SUMMARY

The aim of this study was to measure levels of knowledge and preparedness to manage COVID-19 infections among physicians and nurses in Bangladesh.

The COVID-19 pandemic not only puts healthcare workers (HCWs) who treat patients in critical care at high risk but also challenges healthcare systems to respond to the crisis. Adequate training in preventive measures and control are critical for workers’ preparedness and to develop the capacity to handle the inevitable heath care emergency.

In this work, the authors explored the effectiveness of a structured in-person training program directed to HCWs comparing participants’ test scores (pre and post training) with the objective to plan better strategies to effectively navigate current and future large-scale disease outbreaks in Bangladesh.

A similar study was conducted by Muhammed Elhadi et al. in Libya, and was published in 2020 in The American Journal of Tropical Medicine and Hygiene (DOI: https://doi.org/10.4269/ajtmh.20-0330).

Response: Thank you for kindly sharing this important article that we have also included in the first draft (described in line109 in the introduction with the reference number 7).

The training program was conducted in hospitals from July1, 2020 to June 30, 2021. Seven hundred and fifty-five HCWs participated in the study, which included doctors and nurses. Participants were tested before and after the training, and their knowledge was scored as poor, average and fair.

The results highlight the benefit of implementing structured in-person education and training programs for HCWs, which contributes to successful case management and COVID-19 infection prevention and control. In addition, the authors showed the importance of organized and collaborative partnership between Bangladesh government and international organizations.

Response: We are very grateful to the reviewer for their treasuring comments.

MERITS

Critical preparedness, readiness, and knowledge regarding COVID-19 are needed for physicians and nurses working on the front line. Few researchers have addressed the overall issues of preparedness of healthcare systems for COVID-19 and their ability to maintain control of the epidemic. The study highlights the importance of educational initiatives to help countries improve their capacity to control and prevent COVID-19 infection.

COMMENTS

1. The manuscript has language and editing issues in all sections. I suggest the authors work with a scientific editor to improve the flow and readability of the text.

Response: Thank you for your suggestions. We have reviewed this draft by our in-house scientific editor, identical native language fluency.

2. Background

a) Lines 128-133: the statements included in this paragraph do not connect well. I suggest the authors delete the first sentence (128-130). The information about the study participants is already included in the methods section.

Response: Thanks for the suggestion, it is deleted.

b) Please define the acronym icddr,b.

Response: The full form is International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) mentioned in line 29 and line 236.

3. Methods

c) Sites and study participants:

• Information about participants and sites is mixed up and it’s difficult to follow. Splitting the section in two sub-sections (1. Sites; 2. Participants) maybe helpful for the reader and reviewers to understand the study characteristics.

Response: Thanks for the suggestion. We have done accordingly

• Please state the difference between primary and secondary facilities.

Response: Included in the study site from line 141-146

• Are the secondary and tertiary level facilities included in the district and specialized hospitals? Please clarify.

Response: The district hospitals are secondary level health facility and specialized hospitals are tertiary level health facility. Included in the above-mentioned section.

d) Study design: in which language was the questionnaire administered? Please include a copy as supplementary material.

Response: The language is in English. The questionnaire was included in supplementary material

e) Training description:

• The information provided in lines 188-189 about the health care facilities is redundant. It was cited in line 186 and in the sites and participants section.

Response: Thank you for noticing this, we have removed this.

• This sub-section needs editing. The information provided is mixed up (facilities with participants) and therefore it’s difficult to follow.

Response: We apologies, now we have sorted the sections and remove the duplications.

f) Training curriculum: the information provided in lines 205-207 is redundant because it was already included in precedent sub-sections.

Response: Thank you for the suggestion, we have corrected this.

g) Sample size:

• Please explain/edit the sentence starting on line 216: “We could not communicate…”

Response: We have edited that sentence and remove the redundant part.

• Please explain/edit the sentence starting on line 218: “The sample size was adequate…” how did you come to the conclusion that the sample size was adequate?

I suggest the authors move this information to the results section.

Response: We quite concur with you. The statement is rephrased as “Assuming 20-40% of the participants might lack in improvement of knowledge and skill after the training sessions, the estimated sample size with 80% power, at a 95% confidence limit and 5% effect size/precision was 246 - 369, which was achieved for the present study evaluation”.

4. Results

h) Please note that the quality of Figures 1 and 2 is not good enough for the reader to see the numbers or legends.

Response: We regret for the inconvenience occurred, we have re-created figures of 300 dpi as per journal’s requirement for your kind consideration.

i) Line 250: please explain the meaning of the word “destruction” in this sentence.

Response: We apologies for the unclear statement, we meant that doctors suffered COVID-19 more than nurses, they also evident suffering of family members more than nurses. But we are now rephrasing the statement for a clearer message.

j) Line 268-270: please clarify this sentence.

Response: It means, in figure 2, there is an obvious improvement of knowledge score for doctors compare to nurses. We have rephrased the sentence.

k) Line 273: please change “mentioned” to “shown”.

Response: Changed

l) Table 1: please change “COVID-19 sufferer” by “COVID-19 infection”

Response: We agree with the reviewer. Corrected or changed throughout the draft.

m) Table 4:

• Please change “COVID-19 sufferer” by “COVID-19 infection”

Response: Corrected

• Please change “not-sufferer by COVID-19” by “Non-infected with COVID-19”

Response: Corrected

n) Table 5:

• Please explain the use of the term “reference” in this table.

Response: Corrected. For an independent variable, we selected a group as a base line and compared the other group(s) with the base line group to identify any association with the dependant variable by calculating the odds ratio. For each independent variable, the baseline group is the reference group (table 5).

• Please change “COVID-19 sufferer” by “COVID-19 infection”.

Response: Corrected

5. Discussion

o) Line 286-287: please clarify what you want to communicate with “…hospitals will not meet

the entire epidemic burden”.

Response: This COVID-19 pandemic has revealed the fact that health system is unprepared to tackle any health emergency and the condition is worse in developing countries.

We have rephrased the sentence and revised accordingly.

p) Line 289: please clarify to which study you refer with “the major strength is the ….”.

Response: The sentence should be “the major strength of our research paper is”. Corrected accordingly.

q) Line 308: did you also find that young people were better achievers than aged people? Please clarify this paragraph.

Response: Yes, references are included. We have further clarified in recent draft.

r) Lines 327-330: this sentence is too long and needs editing.

Response: Thanks for your suggestion, we have rephrased accordingly.

Submitted filename: Rebuttal Letter_200422.doc

Click here for additional data file.

9 Jun 2022

22 Jun 2022

Reviewer’s comments:

Reviewer #1: The manuscript “In-person training in COVID-19 Case management and infection prevention and control: Evaluation of healthcare professionals’ knowledge in Bangladesh” by Shahrin et. al., describes the importance of implementing the structured in-person training program for healthcare workers regarding case management in a pandemic.

Authors of this manuscript showed the effectiveness of in-person training program, where they compared participants’ pre and post training scores in epidemiology, clinical manifestation, management of case and infection prevention. Healthcare workers were clearly benefitted through this training program which was planned for better preparedness in controlling current or future disease outbreaks in Bangladesh.

I consider that the manuscript of Shahrin et. al., is clearly written and their claims are fully supported by well-designed study and proper statistical analysis. They obtained proper ethical approval for this study. Authors have responded to the issues found in earlier review. Authors recreated figure 1 & 2, which are now very clear to the readers. After revision with scientific editor the quality of the manuscript improved a lot.

So, I recommend the publication of this manuscript in PLOS ONE after minor correction.

Comments: Thank you very much for the encouraging comments

Minor comments: But still there are some minor typographical errors, that needs to be corrected in my opinion. Like in line 143, 184, 186, 197-198, 202, 208, 226 (The approval had ID-ACT-01112).

Comments: We have addressed the above-mentioned comments point by point and marked in underlined in the track changed version.

We hope and pray that the respected reviewer and academic editor will accept the revised drafts and allow us for the publication.

Submitted filename: Rebuttal Letter_22062022.doc

Click here for additional data file.

16 Aug 2022

In-person training on COVID-19 case management and infection prevention and control:Evaluation of healthcare professionals in Bangladesh

PONE-D-22-01969R2

Dear Dr. Shahrin,

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,

Humayun Kabir, MSc in Epidemiology

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors,

Do some copy editing throughout the manuscript during proofreading.

For example, software STATA was written as "Stata" and "STATA". Please, choose any format.

Thanks!

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: 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: In this re-revised manuscript “In-person training on COVID-19 case management and infection prevention and control: Evaluation of healthcare professionals in Bangladesh” by Shahrin et. al., describes the importance of implementing the structured in-person training program for healthcare workers regarding COVID-19 case management in Bangladesh.

I consider that the manuscript of Shahrin et. al., is clearly written and their claims are fully supported by well-designed study and proper statistical analysis. They obtained proper ethical approval for this study. Authors addressed all the minor issues pointed out in the earlier review. I wish them all the very best.

So, I recommend the publication of this manuscript in the esteemed journal PLOS ONE.

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: Nirmallya Acharyya

Reviewer #2: No

**********

11 Sep 2022

PONE-D-22-01969R2

In-person training on COVID-19 case management and infection prevention and control: Evaluation of healthcare professionals in Bangladesh

Dear Dr. Shahrin:

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

Mr. Humayun Kabir

Academic Editor

PLOS ONE