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

Esraa S A Alfadul; Malaz Mohammed Idrees Abdalmotalib; Salma Salah Khalid Alrawa; Rama Osman Abdelrahman Osman; Hadiea Mosaab AhmedElbashir Hassan; Alsamany taha albasheir; Elfatih A Hasabo; Sagad O O Mohamed; Kamil Mirghani Ali Shaaban

doi:10.1371/journal.pone.0288638

. 2023 Jul 21;18(7):e0288638. doi: 10.1371/journal.pone.0288638

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

Esraa S A Alfadul ^1,^*, Malaz Mohammed Idrees Abdalmotalib ¹, Salma Salah Khalid Alrawa ¹, Rama Osman Abdelrahman Osman ¹, Hadiea Mosaab AhmedElbashir Hassan ¹, Alsamany taha albasheir ¹, Elfatih A Hasabo ¹, Sagad O O Mohamed ¹, Kamil Mirghani Ali Shaaban ²

Editor: Syed Ghulam Sarwar Shah³

PMCID: PMC10361487 PMID: 37478101

Abstract

Background

Burnout prevalence and its consequences on healthcare workers during the Omicron wave are not well investigated in Sudan. This study aims to assess the prevalence of burnout and its associated factors among doctors and nurses during the omicron wave in COVID-19 isolation centres in Khartoum, Sudan.

Method

This cross-sectional survey study was conducted at multiple COVID-19 isolation centres in Khartoum state during the omicron wave of Coronavirus Disease 2019 between 20th February 2022 and 10th April 2022. A total of 306 doctors and nurses filled out the questionnaire, with a response rate of 64.8℅. They were recruited from 5 isolation centers scattered in the three cities of Khartoum Metropolis. The level of burnout was assessed using an online semi-structured questionnaire based on the Oldenburg Burnout Inventory questionnaire. Descriptive statistics were used for continuous variables and frequencies with percentages for categorical variables. The Chi-square test and Fisher exact test were used to identify variables associated with burnout. Logistic regression was used to determine the factors associated with burnout, and the p-value of ≤ .05 is considered statistically significant.

Results

The prevalence of burnout was 45.7%. Doctors were more likely to have burnout than nurses (OR: 2.01, CI 95% 1.24–3.27; p = 0.005). Also, married healthcare workers were more likely to suffer burnout than single healthcare workers (OR: 3.89, CI 95% 1.41–12.5; P = 0.013). The number of household members (p = 0.035) was associated with burnout among participants.

Conclusion

There is a high prevalence of burnout among healthcare workers in Khartoum Isolation Centers, which is more apparent among doctors.

Introduction

The Coronavirus Disease 2019 (COVID-19) is an infectious respiratory disease caused by the SARS-CoV-2 virus with varying degrees of morbidity and mortality depending on the age and fitness of the individual [1]. The virus emerged on 31st December 2019 in Wuhan, Hubei Province, China [2] and was declared a global health emergency on 30th January 2020 and a global pandemic on 11th March 2020 by the World Health Organization [3–5] Sudan reported the first COVID-19 case on 13th March 2020; after the declaration of the first case, the Sudan Federal Ministry of Health enhanced the measures to combat the spread of the virus. On 13th April, after the registration of 10 cases of COVID-19, the authorities announced a total lockdown in the state of Khartoum—the most populated state in Sudan -suspending all gatherings, even prayers in mosques, as the virus spread beyond Khartoum, reaching other states. On 25th May, five isolation centers were established in Khartoum to isolate and deal with COVID-19 cases. Later, the number of isolation centers increased in proportion to the high infection rate of the virus, reaching to 14,401 cases with 1,116 deaths by 11th November 2020, reflecting a high fatality rate of 7.7%. By 7th July 2022, there were 62,745 confirmed cases of COVID-19, with 4,952 deaths in Sudan [6–9].

Although public health measures, such as lockdowns, and social distancing, are crucial to reducing the spread of COVID-19, they were found to increase stress, anxiety, and mental disorders [10]. The World Health Organization has recognized "burnout" as an "occupational phenomenon", as lockdowns have significantly affected our work-life balance and work environment. Much research has ascertained burnout and its contributing factors [11].

COVID-19 has a critical psychological impact on the community [12]. The length of the pandemic period -more than two years-, the low evidence regarding the virus treatment protocols, 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.

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 prevention strategies, and urgency in instructing interpretation, all incredibly highlight peaking of burnout among healthcare providers [13–16].

Burnout is a critical issue that generates inefficiency in healthcare organizations [13] It lowers the quality of healthcare and negatively impacts patient prognosis [17]. Burnout affects the psychological well-being of the staff leading to medical errors. It makes the health system waste a lot of money and resources- because some workers leave their jobs, compelling the system to recruit new staff and offer a new training program. It impedes the process of psychological support for patients, which is part of the treatment [17, 18] Healthcare providers who are emotionally exhausted -express burnout- can neither support patients psychologically nor make fateful medical decisions.

While the pandemic affects the world, studies show that developed countries are affected less than developing ones in terms of fatality, as it has a higher rate of transmission to elderly coupled with poor access to healthcare facilities [19]. Africa is the most vulnerable region for the impact of higher mortality and morbidity, especially among healthcare providers [16].

Sudan’s revolution, the terrible economic status, collapsing health system, end-stage arrival of cases due to the centralized isolation centers, difficulty of transportation, and stigmatization of COVID-19 cases all affect the mental well-being of healthcare providers. There is no present data regarding burnout among healthcare providers in Sudan. Many published papers confirmed the high prevalence of burnout -in various countries during the pandemic due to diversified factors- leaving no doubt that the crisis is more exacerbated in Sudan [20, 21].

The term ‘Burnout’ entails emotional exhaustion, reduced feelings of achievement, and we personalization [22]. According to studies, the prevalence of burnout among healthcare providers varies from 49.3% to 58% worldwide, and intensivists, emergency department doctors, and nurses are particularly susceptible [23].

Burnout prevalence and its consequences on healthcare workers are not well investigated in Sudan. Still, the stigmatization of mental problems in Sudan and the professional stigma of mental illness proposes that healthcare providers repress their mental suffering, navigating to more emotional stress and susceptibility to burnout [24]. Sudan’s health system has been facing critical challenges, including a lack of personal protective equipment and other necessary medical equipment. As a result, healthcare workers must deal with COVID-19 without the basic equipment to protect the patients and themselves from the infection. Consequently, this puts tremendous pressure on the doctors, largely due to the poor infection control policies and frustration over being unable to deliver the best possible patient care [25].

The extent of burnout, its distribution between workers in different Isolation centers, and its predictors and protective factors are essential for decision-makers. In our study, we will measure the prevalence of burnout among healthcare providers exposed to COVID-19 patients, so we can contribute with data helping decision-makers fight the battle of the COVID-19 pandemic and the hidden pandemic -burnout -.

Material and methods

Study design and settings

This study employed a facility-based cross-sectional design conducted from February 20th, 2022 to April 10th, 2022, during the Omicron wave of the COVID-19 pandemic. The study focused on ten isolation centers situated in Khartoum state, encompassing the cities of Khartoum, Omdurman, and Bahri, which together form the Sudanese Metropolis. The selected isolation centers were Ibrahim Malik Teaching Hospital, Haj El-Mardi Hospital, Al-Shaab Teaching Hospital, Omdurman, Alnaw Hospital, Ahmed Gasim Teaching Hospital, Bahri Teaching Hospital, Jabra Hospital for emergency and injuries, Omdurman, and Khartoum Teaching Hospital. To ensure representation, the largest and smallest isolation centers were chosen from each of the three cities, based on number of beds(capacity).

However, due to Ahmed Gasim Hospital being inactive during the Omicron wave, only two centers, Alnaw Hospital and Omdurman Hospital from Omdurman, Al-Shaab Teaching Hospital, and Jabra Hospital for emergency and injuries from Khartoum, alongside Bahri Teaching Hospital from Bahri, were included in the study.

Participants

The participants in this study consisted of all doctors and nurses working in the selected centers during the designated period, with no exclusions. Convenience sampling was employed for recruitment, wherein collaborators from each facility were contacted, and online surveys using Google Forms were provided to them for distribution among healthcare practitioners. Two reminders were sent to encourage participation. The targeted number of healthcare practitioners was 472, comprising 182 doctors and 290 nurses. Ultimately, 306 respondents, including doctors and nurses, completed the questionnaire, resulting in a response rate of 64.8%.

Data collection and tool

Data were collected using an online self-administered questionnaire distributed by Google Forms. The questionnaire was self-assembled and piloted for clarity and practicality. The questionnaire was structured into five sections. The first section encompassed socio-demographic characteristics, such as age, gender, residence, marital status, number of household members, presence of older family members in the household, history of comorbidities, and history of mental illness. The second section focused on professional characteristics, including the isolation center, job title, years of experience, involvement in ICU, working hours, extra duties, and experience with COVID-19 infection. The third section explored predictors of burnout, including exposure to COVID-19 among relatives, colleagues, the morbid status of the patients. fear of infection, satisfaction with hospital protective measures, and feelings of despair regarding COVID-19 patients. The fourth section examined adaptive behaviors among participants, such as exercise, spirituality, smoking, professional support, self-care, mental breaks, and procrastination. Finally, the fifth section assessed burnout using the Oldenburg Burnout Inventory (OLBI) questionnaire [26], a validated tool comprising 16 items. The items consisted of positively and negatively worded questions related to exhaustion and disengagement, recorded on a four-point Likert scale ranging from 1 (Strongly Agree) to 4 (Strongly Disagree). A higher score indicated a higher level of burnout. Disengagement refers to distancing oneself from the content of one’s work, while exhaustion refers to fatigue, loss of energy, feelings of emptiness, and a strong need for rest [27–29]. Participants meeting the thresholds of 2.1 or higher for exhaustion subscales and 2.25 or higher for disengagement subscales, with a cut-off point of 35 [29], were considered at high risk of burnout.

Ethical approval

Ethical approval for conducting this research was obtained from the Ministry of Health—Khartoum state / Directorate General of Curative Medicine / No: 44, Sudan.

The participants were asked to give consent that they agree to participate in the study by filling the questionnaire for research purposes in the online form, and all the participants provided informed written consent after providing a clear explanation of the study purpose. Data collection was anonymized, and the confidentiality of the study participants was maintained.

Statistical analysis plan

Data were extracted in an excel sheet, cleaned, and imported into the R software version 4.0.2 and SPSS version 28 (SPSS Inc., Chicago, IL, USA). The normality of distribution was tested using Kolmogorov- Smirnov test. Descriptive statistics were used for calculating the mean and Standard deviation for the continuous variables and frequencies with percentages for categorical variables. The Chi-square test and Fisher exact test were used to identify variables associated with burnout. A multiple logistic regression analysis was performed to identify factors associated with a state of burnout. Those the variables that showed a statistically significant relationship at the bivariate analysis level were included at the multiple analysis level. The p-value of ≤ .05 was set as the significance level of the study.

Results

Participants information

A total of 306 healthcare workers, with the majority being between 26–30 years. More than half of the participants were males (n = 156, 51.0%), and the majority were living in Omdurman (45.1%), followed by Khartoum (42.8%). Also, most of them were singles (83.3%), nurses (58.5%), and only 30 participants (9.8%) were suffering from comorbidities. Regarding the status of COVID-19 in their relatives, 39% stated that their relatives had been infected with COVID-19, while 17.0% were infected and then died. (Table 1).

Table 1. Baseline characteristics and demographic data of included participants.

			burnout
Variables	N	Overall, N = 306¹	No, N = 166¹	Yes, N = 140¹	p-value²
Age	306				0.5
20–25		118 (39%)	65 (39%)	53 (38%)
26–30		163 (53%)	85 (51%)	78 (56%)
More than 30		25 (8.2%)	16 (9.6%)	9 (6.4%)
Gender	306				0.8
Female		150 (49%)	80 (48%)	70 (50%)
Male		156 (51%)	86 (52%)	70 (50%)
Residency	306				0.9
Bahari		37 (12%)	19 (11%)	18 (13%)
Khartoum		131 (43%)	70 (42%)	61 (44%)
Omdurman		138 (45%)	77 (46%)	61 (44%)
Marital status	306				0.001
Single		255 (83%)	140 (84%)	115 (82%)
Widowed		3 (1.0%)	1 (0.6%)	2 (1.4%)
Engaged		26 (8.5%)	20 (12%)	6 (4.3%)
Married		22 (7.2%)	5 (3.0%)	17 (12%)
Number of household members	299				0.035
<5		55 (18%)	21 (13%)	34 (24%)
>10		19 (6.4%)	12 (7.5%)	7 (5.0%)
5–10		225 (75%)	127 (79%)	98 (71%)
Do you live with an elderly household member who has a chronic disease?	306				0.3
No		175 (57%)	90 (54%)	85 (61%)
Yes		131 (43%)	76 (46%)	55 (39%)
Do you suffer from any comorbidities?	306				0.4
No		276 (90%)	152 (92%)	124 (89%)
Yes		30 (9.8%)	14 (8.4%)	16 (11%)
Do you have a history of a mental illness?	306				0.3
No		299 (98%)	164 (99%)	135 (96%)
Yes		7 (2.3%)	2 (1.2%)	5 (3.6%)
Do you have relative/s who have been infected/died from Covid-19?	306				0.7
Infected		118 (39%)	64 (39%)	54 (39%)
Infected and died		52 (17%)	31 (19%)	21 (15%)
None		136 (44%)	71 (43%)	65 (46%)
Do you have colleague/s who have been infected/died from Covid-19?	306				0.8
Infected		230 (75%)	127 (77%)	103 (74%)
Infected and died		17 (5.6%)	8 (4.8%)	9 (6.4%)
None		59 (19%)	31 (19%)	28 (20%)
What was your COVID-19 Screening test result?	306				0.088
Not tested		131 (43%)	72 (43%)	59 (42%)
Tested negative		106 (35%)	64 (39%)	42 (30%)
Tested positive		69 (23%)	30 (18%)	39 (28%)
What is your Job title?	306				0.003
Doctor		127 (42%)	56 (34%)	71 (51%)
Nurse		179 (58%)	110 (66%)	69 (49%)
What is your perceived average income?	306				>0.9
High		5 (1.6%)	3 (1.8%)	2 (1.4%)
Low		116 (38%)	64 (39%)	52 (37%)
Medium		185 (60%)	99 (60%)	86 (61%)
How many years have you been working in this job?	306				0.7
<2 years		148 (48%)	77 (46%)	71 (51%)
>6 years		4 (1.3%)	2 (1.2%)	2 (1.4%)
2–6 years		154 (50%)	87 (52%)	67 (48%)
In which isolation center do you work?	306				0.8
AlNaw Teaching Hospital		19 (6.2%)	12 (7.2%)	7 (5.0%)
AlShaab Hospital		44 (14%)	21 (13%)	23 (16%)
Bahri Hospital		23 (7.5%)	12 (7.2%)	11 (7.9%)
Jebra Isolation center		118 (39%)	65 (39%)	53 (38%)
Omdurman Teaching Hospital		102 (33%)	56 (34%)	46 (33%)
What was your way of employment?	306				>0.9
Appointed by the Ministry of Health		49 (16%)	26 (16%)	23 (16%)
Attachment		22 (7.2%)	13 (7.8%)	9 (6.4%)
Compulsory service		19 (6.2%)	11 (6.6%)	8 (5.7%)
Contracts: appointed by the hospital		216 (71%)	116 (70%)	100 (71%)
Did you work in isolation centers in the previous Covid-19 waves other than the current Omicron wave?	306				0.6
No		105 (34%)	55 (33%)	50 (36%)
Yes		201 (66%)	111 (67%)	90 (64%)
Do you work extra duty or extra hours per week?	306				0.065
No		112 (37%)	53 (32%)	59 (42%)
Yes		194 (63%)	113 (68%)	81 (58%)
In the isolation center, do you work in the ward or in the intensive care unit (ICU)?	306				0.6
ICU		164 (54%)	91 (55%)	73 (52%)
The ward		142 (46%)	75 (45%)	67 (48%)
Working hours per week	306				>0.9
40–60		144 (47%)	79 (48%)	65 (46%)
Less than 40		109 (36%)	58 (35%)	51 (36%)
More than 60		53 (17%)	29 (17%)	24 (17%)
I’m afraid of getting infected by Covid-19 throughout my work.	306				<0.001
Strongly Agree		85 (28%)	61 (37%)	24 (17%)
Agree		44 (14%)	29 (17%)	15 (11%)
Neutral		99 (32%)	44 (27%)	55 (39%)
Disagree		43 (14%)	19 (11%)	24 (17%)
Strongly Disagree		35 (11%)	13 (7.8%)	22 (16%)
I feel safe with the protective measures taken by the hospital.	306				0.002
Strongly Agree		71 (23%)	46 (28%)	25 (18%)
Agree		77 (25%)	44 (27%)	33 (24%)
Neutral		90 (29%)	48 (29%)	42 (30%)
Disagree		41 (13%)	23 (14%)	18 (13%)
Strongly Disagree		27 (8.8%)	5 (3.0%)	22 (16%)
I feel the patient would die no matter what I did.	306				>0.9
Strongly Agree		17 (5.6%)	10 (6.0%)	7 (5.0%)
Agree		34 (11%)	19 (11%)	15 (11%)
Neutral		66 (22%)	38 (23%)	28 (20%)
Disagree		92 (30%)	49 (30%)	43 (31%)
Strongly Disagree		97 (32%)	50 (30%)	47 (34%)

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¹n (%)

²Pearson’s Chi-squared test; Fisher’s exact test

Most respondents were from Jabra Isolation Center (39%) and Omdurman Teaching Hospital (33%). About 54% of the participants reported working in an ICU and 23% reported having COVID-19. (Table 1).

Burnouts among participants

Responses to the Oldenburg Burnout Inventory (OLBI) are shown in (Table 2). Burnout prevalence was 45.7% among study participants. The number of household members (p = 0.035) and being a doctor (p = 0.003) were associated with burnout among participants. Also, marital status was significantly associated with burnout (p = 0.001) (Table 1). Not surprisingly, fear of infection (p < 0.001) and satisfaction with hospital safety measures (p = 0.002) were associated with burnout.

Table 2. Responses to questions of the burnout tool.

Variables	Overall, N = 306¹	Burnout		p-value²
Variables	Overall, N = 306¹	No, N = 166¹	Yes, N = 140¹	p-value²
I always find new and interesting aspects in my work.				<0.001
Strongly Agree	113 (36.9%)	76 (45.8%)	37 (26.4%)
Agree	118 (38.6%)	62 (37.3%)	56 (40.0%)
Disagree	51 (16.7%)	18 (10.8%)	33 (23.6%)
Strongly Disagree	24 (7.8%)	10 (6.0%)	14 (10.0%)
There are days when I feel tired before I arrive at work.				<0.001
Strongly Agree	135 (44.1%)	94 (56.6%)	41 (29.3%)
Agree	108 (35.3%)	56 (33.7%)	52 (37.1%)
Disagree	42 (13.7%)	9 (5.4%)	33 (23.6%)
Strongly Disagree	21 (6.9%)	7 (4.2%)	14 (10.0%)
It happens more and more often that I talk about my work in a negative way.				0.005
Strongly Agree	62 (20.3%)	43 (25.9%)	19 (13.6%)
Agree	99 (32.4%)	59 (35.5%)	40 (28.6%)
Disagree	77 (25.2%)	33 (19.9%)	44 (31.4%)
Strongly Disagree	68 (22.2%)	31 (18.7%)	37 (26.4%)
After work, I tend to need more time than in the past in order to relax and feel better.				<0.001
Strongly Agree	137 (44.8%)	98 (59.0%)	39 (27.9%)
Agree	92 (30.1%)	39 (23.5%)	53 (37.9%)
Disagree	52 (17.0%)	23 (13.9%)	29 (20.7%)
Strongly Disagree	25 (8.2%)	6 (3.6%)	19 (13.6%)
I can tolerate the pressure of my work very well.				<0.001
Strongly Agree	113 (36.9%)	77 (46.4%)	36 (25.7%)
Agree	121 (39.5%)	63 (38.0%)	58 (41.4%)
Disagree	54 (17.6%)	21 (12.7%)	33 (23.6%)
Strongly Disagree	18 (5.9%)	5 (3.0%)	13 (9.3%)
Lately, I tend to think less at work and do my job almost mechanically.				<0.001
Strongly Agree	71 (23.2%)	57 (34.3%)	14 (10.0%)
Agree	123 (40.2%)	68 (41.0%)	55 (39.3%)
Disagree	66 (21.6%)	22 (13.3%)	44 (31.4%)
Strongly Disagree	46 (15.0%)	19 (11.4%)	27 (19.3%)
I find my work to be a positive challenge.				<0.001
Strongly Agree	131 (42.8%)	89 (53.6%)	42 (30.0%)
Agree	109 (35.6%)	57 (34.3%)	52 (37.1%)
Disagree	48 (15.7%)	15 (9.0%)	33 (23.6%)
Strongly Disagree	18 (5.9%)	5 (3.0%)	13 (9.3%)
During my work, I often feel emotionally drained.				<0.001
Strongly Agree	99 (32.4%)	72 (43.4%)	27 (19.3%)
Agree	104 (34.0%)	59 (35.5%)	45 (32.1%)
Disagree	63 (20.6%)	18 (10.8%)	45 (32.1%)
Strongly Disagree	40 (13.1%)	17 (10.2%)	23 (16.4%)
Over time, one can become disconnected from this type of work.				<0.001
Strongly Agree	93 (30.4%)	67 (40.4%)	26 (18.6%)
Agree	110 (35.9%)	61 (36.7%)	49 (35.0%)
Disagree	70 (22.9%)	25 (15.1%)	45 (32.1%)
Strongly Disagree	33 (10.8%)	13 (7.8%)	20 (14.3%)
After working, I have enough energy for my leisure activities.				0.3
Strongly Agree	38 (12.4%)	25 (15.1%)	13 (9.3%)
Agree	79 (25.8%)	44 (26.5%)	35 (25.0%)
Disagree	77 (25.2%)	37 (22.3%)	40 (28.6%)
Strongly Disagree	112 (36.6%)	60 (36.1%)	52 (37.1%)
Sometimes I feel sickened by my work tasks.				<0.001
Strongly Agree	83 (27.1%)	63 (38.0%)	20 (14.3%)
Agree	109 (35.6%)	63 (38.0%)	46 (32.9%)
Disagree	81 (26.5%)	30 (18.1%)	51 (36.4%)
Strongly Disagree	33 (10.8%)	10 (6.0%)	23 (16.4%)
After my work, I usually feel worn out and weary.				<0.001
Strongly Agree	133 (43.5%)	100 (60.2%)	33 (23.6%)
Agree	97 (31.7%)	49 (29.5%)	48 (34.3%)
Disagree	56 (18.3%)	15 (9.0%)	41 (29.3%)
Strongly Disagree	20 (6.5%)	2 (1.2%)	18 (12.9%)
This is the only type of work that I can imagine myself doing.				<0.001
Strongly Agree	57 (18.6%)	45 (27.1%)	12 (8.6%)
Agree	67 (21.9%)	49 (29.5%)	18 (12.9%)
Disagree	106 (34.6%)	48 (28.9%)	58 (41.4%)
Strongly Disagree	76 (24.8%)	24 (14.5%)	52 (37.1%)
Usually, I can manage the amount of my work well.				<0.001
Strongly Agree	112 (36.6%)	75 (45.2%)	37 (26.4%)
Agree	140 (45.8%)	73 (44.0%)	67 (47.9%)
Disagree	41 (13.4%)	15 (9.0%)	26 (18.6%)
Strongly Disagree	13 (4.2%)	3 (1.8%)	10 (7.1%)
I feel more and more engaged in my work.				<0.001
Strongly Agree	76 (24.8%)	63 (38.0%)	13 (9.3%)
Agree	140 (45.8%)	79 (47.6%)	61 (43.6%)
Disagree	65 (21.2%)	18 (10.8%)	47 (33.6%)
Strongly Disagree	25 (8.2%)	6 (3.6%)	19 (13.6%)
When I work, I usually feel energized				<0.001
Strongly Agree	79 (25.8%)	59 (35.5%)	20 (14.3%)
Agree	131 (42.8%)	64 (38.6%)	67 (47.9%)
Disagree	67 (21.9%)	31 (18.7%)	36 (25.7%)
Strongly Disagree	29 (9.5%)	12 (7.2%)	17 (12.1%)
Score	34.2 ± 5.3	30.4 ± 3.1	38.8 ± 3.5	<0.001

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¹ n (%)

² Pearson’s Chi-squared test; Fisher’s exact test

Note: 1 = Strongly Agree; 2 = Agree; 3 = Disagree; 4 = Strongly Disagree

The most frequent adaptive behaviors were taking brief mental breaks throughout the day (42.2%) and exercising (37.6%) (Table 3). Interestingly the following factors were not statistically significantly associated with burnout: average income, working years, working hours, extra hours, previous working experience in COVID-19 centers, working center, working site, and fear of patient death despite all measures. (Table 1).

Table 3. Adaptive behaviour among the participants.

Variables	Overall, N = 306¹	Burnout		p-value²
Variables	Overall, N = 306¹	No, N = 166¹	Yes, N = 140¹	p-value²
Exercise	115 (37.6%)	61 (36.7%)	54 (38.6%)	0.7
spiritual habits	107 (35.0%)	63 (38.0%)	44 (31.4%)	0.2
Smoking	35 (11.4%)	18 (10.8%)	17 (12.1%)	0.7
Seek professional support to cope with moral distress and grief	41 (13.4%)	32 (19.3%)	9 (6.4%)	0.001
Take brief mental breaks throughout the day	129 (42.2%)	75 (45.2%)	54 (38.6%)	0.2
Performing Self-care Routines	108 (35.3%)	56 (33.7%)	52 (37.1%)	0.5
Poor Time Management and Procrastination	80 (26.1%)	49 (29.5%)	31 (22.1%)	0.14

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¹ n (%)

² Pearson’s Chi-squared test; Fisher’s exact test

The multiple logistic regression showed doctors were more likely to have burnout than nurses (OR: 2.01, CI 95% 1.24–3.27; p = 0.005). Also, married healthcare workers were more likely to suffer burnout than single healthcare workers (OR: 3.89, CI 95% 1.41–12.5; P = 0.013) (Table 4).

Table 4. Multiple logistic regression for predictors of burnout among healthcare workers.

		95% CI¹
variables	OR¹	Lower Limit	Upper Limit	p-value
Marital status
Single	—
Married	3.89	1.41	12.5	0.013
Widowed	2.04	0.19	45.2	0.6
Engaged	0.38	0.13	0.96	0.052
Number of household members
<5	—
5–10	0.66	0.34	1.25	0.2
>10	0.54	0.17	1.65	0.3
What is your Job title?
Nurse	—
Doctor	2.01	1.24	3.27	0.005

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¹OR = Odds Ratio, CI¹ = Confidence interval

Discussion

Currently, the spread of the novel coronavirus has been deemed a major source of uncertainty, fear and anxiety for a lot of healthcare workers around the world, affecting their physical and psychological health [30]. The current study has assessed burnout among doctors and nurses and provided a better understanding of the problem in sudan. Approximately half of the doctors and nurses in the COVID-19 isolation centers in Khartoum that were included in the present study suffered high levels of work-related stress and burnout in terms of emotional exhaustion and a lack of personal accomplishment and engagement. Physical and emotional well-being of healthcare staff is critical to pandemic containment. However, high burnout rates pose a significant threat to the delivery of safe and effective healthcare, and negatively influence healthcare providers, patients, and the healthcare system.

The prevalence of burnout reported in the current study is In line with previous studies assessing burnout among Sudanese healthcare workers during COVID-19. For instance, 71% of resident physicians in Sudan met the criteria for burnout using the OLBI tool [31]. Another study using the Maslach Burnout Inventory assessment tool revealed that 86.1% of resident physicians in Gezira State’s teaching hospitals had burnout syndrome [32]. Further, these findings align with other countries that have reported high rates of burnout among healthcare workers during COVID-19 pandemic [33–37].

The high rates of burnout in this study can be explained by the psychological demands of the profession and the high level of socioeconomic pressure and work-related stress that lead healthcare workers to burnout [35]. The country’s weak healthcare system, economic meltdown, security situation, political instability and conflicts during this period have placed more pressure on the healthcare system and professionals [36–38]. Moreover, dealing with a high number of patients with poor infrastructure, lack of suitable accommodation and transportation during the lockdown period, concerns about the lack of treatment supplies and personal protective equipment, and the fear of contracting the disease and infecting their families add to the problem [38–40]. Nevertheless, COVID-19 has been ongoing for over two years, and the constant strain may exhaust healthcare workers’ coping mechanisms.

Most of the socio-demographic and other variables assessed in this study were not statistically associated with burnout, reflecting the wide distribution of the problem among the participants despite such differences. We found that a lower number of household members, unmarried individuals, and physician jobs were the only variables associated with burnout among the participants. However, previous studies revealed inconsistent results on burnout risk factors among healthcare workers, and it is unclear whether that burnout follows a specific socio-demographic pattern among healthcare workers [31, 33, 37]. However, some of these associations with socio-demographic factors can be explainable. Among different medical professions, there are differences in the working duties, which put doctors at higher risk of violence and abuse. In our setting, doctors are the front-liners who deal with angry patients and their relatives, particularly when counselling them about their COVID-19 diagnosis and condition or when breaking the news that a patient has passed away [25, 39]. Furthermore, they are responsible for dealing with critically ill patients with a higher risk of complications and mortality [25].

Regarding the habits used to lessen burnout symptoms, seeking professional support to cope with moral distress and grief was significantly associated with lower rates of burnout among the participants. The participants have used other habits to alleviate the burnout symptoms, such as exercising, spiritual habits, and taking brief mental breaks throughout the day. However, none showed a significant association with burnout rates in this study.

The findings of this study acknowledge a high demand for appropriate support interventions and necessitate the search for more effective strategies to be implemented to reduce the risk of burnout among healthcare workers. Using different approaches to reduce burnout, such as training to improve stress-coping skills, can avoid or recover from emotional exhaustion and disengagement. In addition, managing the workplace and environment, improving systems, providing regular psychosocial support, and recruiting additional workers can help address organizational and workplace defects because hostile Working conditions contribute to stress and job dissatisfaction, resulting in depersonalization, emotional exhaustion, and lack of accomplishment [40, 41].

Strengths and limitations

This is one of the few studies assessing the burnout burden among doctors and nurses in Sudan. The sample size of the participants, considered a low response population, is representative of generalizability to overall COVID-19 isolation centers in Khartoum, Sudan. The findings of this study need to be considered in the context of some limitations; as this is a cross-sectional study, it will be challenging to draw causative relationships. The self-reported nature of the study could raise the possibility of recall bias. Also, the study was done in five sites which might limit results generalization for all healthcare workers in all settings in the country and could compromise representativeness.

Conclusion

Our study has shown that nearly half of the healthcare workers in isolation centers in Khartoum have suffered from burnout during COVID-19. Several socio-demographic factors have contributed to the increased level of burnout, and multiple coping mechanisms have accounted for a lower level of burnout among healthcare workers. The findings of this study address the high demand for appropriate interventions to be implemented to reduce the risk of burnout among frontline healthcare workers.

Supporting information

S1 Data. Anonymised dataset.

(XLSX)

Click here for additional data file.^{(69.9KB, xlsx)}

Acknowledgments

We want to thank Ahmed Abdalhalim Mohamed Omer, Omer Abdulmajed, Aya Zakareya Noor Hamid, Asmaa Mohamed Abbas, Aldoma Mohammed Adam Ismail, Elhadi elsiddig Elhadi, Mohammed AFEFE Hasan Salim, and Tagwa Badawe for their help in collecting the data and Mazin S. Haroun for his help in the research. Also, we would like to thank healthcare workers for participating in our study.

Data Availability

"All relevant data are within the paper and its Supporting Information files."

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0288638.r001

Decision Letter 0

Syed Ghulam Sarwar Shah

22 Dec 2022

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

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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.

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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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PLoS One. 2023 Jul 21;18(7):e0288638. doi: 10.1371/journal.pone.0288638.r002

Author response to Decision Letter 0

5 Feb 2023

27-janouary-2023

Author’s response to reviews

Subject: Revision and resubmission of PONE-D-22-28346

Dear reviewer,

On behalf of all the contributing authors, I would like to express our sincere appreciation of the reviewers’ constructive comments concerning our article entitled “Burnout and its associated factors among healthcare workers in Khartoum's COVID-19 isolation centers: A cross-sectional study”. We have revised our manuscript according to the reviewers’ comments, questions, and suggestions. We believe that the manuscript has been further improved and the revised paragraphs were highlighted in yellow in the manuscript . If there are any other modifications we could make, we would very much like to modify them and we appreciate your help. Below are point-by-point responses to the reviewers' comments.

Your sincerely

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. The 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.

response to reviewer 1:

Thank you for your comment. The manuscript was revised and corrected, and the discussion section was improved according to your note.

Reviewer #2:

Comment: In abstract you should show prevalence of burnout

Response: done

Comment: -There should not be any abbreviations in the abstract.

Response: all abbreviations in the abstract were removed

Comment: -In introduction you should give a definition of job burnout

Response: a brief description of burnout was added (end of page 3)

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

Response: more description was added to the introduction section (end of page 3)

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

Response: discussion section was revised and edited according to your note. We think the reviewer meant ‘doctors’ not nurses in his comment (see table 4)

Comment: 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

Response: we re-checked all references to ensure that all of them are not older than 2018

Attachment

Submitted filename: Response to Reviewers.docx

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PLoS One. doi: 10.1371/journal.pone.0288638.r003

Decision Letter 1

Syed Ghulam Sarwar Shah

11 Apr 2023

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,

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.

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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'.

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

[Note: HTML markup is below. Please do not edit.]

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?

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?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: No

**********

6. Review Comments to the Author

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

**********

Attachment

Submitted filename: PONE-D-22-28346_R1.pdf

Click here for additional data file.^{(1.6MB, pdf)}

PLoS One. 2023 Jul 21;18(7):e0288638. doi: 10.1371/journal.pone.0288638.r004

Author response to Decision Letter 1

27 Jun 2023

24 June 2023

Author’s response to reviews

Subject: Revision and resubmission of PONE-D-22-28346

Dear Editor,

On behalf of all the contributing authors, I would like to express our sincere appreciation of the reviewers’ constructive comments concerning our article entitled “Burnout and its associated factors among healthcare workers in COVID-19 isolation centres in Khartoum, Sudan: A cross-sectional study”. We have revised our manuscript according to the reviewers’ comments, questions, and suggestions. We believe that the manuscript has been further improved and the revised paragraphs were highlighted in yellow in the manuscript . If there are any other modifications we could make, we would very much like to modify them and we appreciate your help. Below are point-by-point responses to the reviewers' comments.

Your sincerely

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’.

We thank the editor for recommending a better sentence to clarify the meaning, we used the recommended sentence.

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.

Done

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.

We thank the editor for recommending a better sentence to clarify the meaning, we used the recommended sentence in the abstract and made use of it in the method section.

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

The included healthcare workers were doctors and nurses , after your note we updated the term.

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

We thank the editor for this suggestion. We adopted the (omicron wave) term throughout the study.

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

The sampling technique and response rate are updated in the methods section.

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

The questionnaire has five sections and are detailed in (data collection and tool) section of the method.

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

Done

We define engaged healthcare providers as individuals who are in a committed relationship but not married. However, we found that this distinction does not significantly impact the results compared to married healthcare workers, who have a higher odds ratio than their single counterparts. Therefore, we have removed the above sentence and replaced it with the following: "Married healthcare workers were more likely to suffer burnout compared to single healthcare workers (OR: 3.89, CI 95% 1.41–12.5; P = 0.013)."

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

We updated the sentence to be "The number of household members (p= 0.035) was associated with burnout among participants." please refer to table 1

The prevalence of burnout was reported in results section and highlighted

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

Do you mean this sentence "Significant relations show a positive effect on burnout".

If it is, we removed it.

INTRODUCTION:

We updated the sentence to be: Coronavirus Disease 2019 (COVID-19) is an infectious respiratory disease caused by the SARS-CoV-2 virus.

We changed the present tense in the first paragraph to past tense and highlighted the verbs.

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….”

We changed it to ‘infection rate’

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

We changed it to ‘reaching to’

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

The 2 sentences has been connected as follows: ‘The World Health Organization has recognized "burnout" as an "occupational phenomenon" as lockdowns have significantly affected our work-life balance and work environment. Much research 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.

We changed it to ‘the low evidence regarding treatment protocols’.

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.”

We divided the sentence into 3 short sentences as follows: ‘COVID-19 has a critical psychological impact on the community. 12 The length of the pandemic period -more than two years-, the lack of evidence regarding 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. 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 prevention 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.

Yes, we meant that ‘it lowers the quality of healthcare’.

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

We changed it from ‘cannot support patients psychologically nor make fateful medical decisions’ to ‘can neither support patients psychologically nor make fateful medical decisions’.

We updated the sentence to be : "in terms of fatality, as it has a higher rate of transmission to elderly coupled with poor access to healthcare facilities" (16).

11. Revise: Could you please revise the following sentence, preferably 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.”

We revised the sentence and divided it into 2 sentences as follows: ‘There is no present data regarding 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.’

We removed this sentence since it is irrelevant.

METHODS

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

We update it as recommended in another comment to (This study employed a facility-based cross-sectional design)

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

The dates are correct. As doctors and nurses are busy, the collaborators -who are doctors themselves- asked for a longer period to collect the data.

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

We changed it to Sudanese Metropolis across the study, and explained what it means.

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?

We mean cities and have updated the term in the methods

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

This was based on the number of beds (capacity) and updated in the method.

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

We named them and added the update in the method section.

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 nurses instead of either healthcare professionals or healthcare practitioners. Please be consistent throughout the paper.

We used doctors and nurses consistently in this version.

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

We reported the sampling method and type.

We thank the reviewer for this suggestion. We updated the sentence.

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

We meant the morbid status of the patient and updated it

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?

We updated the recruitment method in the participants section.

12. 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?

We adapted it from previous studies. OLBI is a well known used tool that is already validated. We only checked for the clarity and practicality of the questionnaire after adding other sections we updated this in the method.

13. The author reports 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?

The items 2, 3, 4, 6, 8, 9, 11 and 12, are negative so the scale is reversed, with Strongly Agree answers scoring 4 and Strongly Disagree answers scoring 1, then summing up with the scores of others questions and using 35 as cut off to categorize participants as having burnout or not.

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

We removed this sentence since it is really irrelevant. The higher the score, the greater the level of burnout.

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

We used Google form and updated the method.

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…’.

We updated the sentence.

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

We reported it in the statistical analysis plan

________________________________________

RESULTS

Done

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?

The association was assessed using a test of significance (Table 1), however "married" status was significantly associated with burnout ((OR: 3.89, CI 95% 1.41 – 12.5; p = 0.013)).(Table 4)

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

By "mental breaks," we refer to the practice of regularly taking breaks during one's shifts in order to minimize stress. It is not necessary to be a spiritual break.

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

Done

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.

Done

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 highlight this in the results in the abstract and main results section.

Done

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 member who has a chronic disease?

- Do you suffer from any comorbidities?

- Do you have a history of mental illness?

We reported them and reran the analysis. Please see table (1)

We used the recommended categories. Please, see table (1)

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 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

Done

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.

Done

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

Due to the absence of standardized income categorization in Sudanese research, each paper tends to utilize its own categorization method. We refrain from using specific numerical values and instead allow participants to categorize their income based on their own perspective. Our belief is that stress is linked to individuals' perception of their income, rather than the actual numerical figures.

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

Done

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.

Done we changed the title into" Adaptive behavior among the participants"

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

Done

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.

We thank the reviewers for this comment, we updated the sentences to be:" Currently, the spread of the novel coronavirus has been deemed a major source of uncertainty, fear and anxiety for a lot of healthcare workers around the world, affecting their physical and psychological health"

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’.

We followed your advice in these two comments and updated the sentence to be : "The current study has assessed burnout among doctors and nurses and provided a better understanding of the problem in sudan"

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

We updated it to healthcare staff

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

We are sorry about this mistake , it is corrected and highlighted in the discussion

We clarified the statement and hence it became : This is one of the few studies assessing the burnout burden among doctors and nurses in Sudan.

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

Done

PLoS One. doi: 10.1371/journal.pone.0288638.r005

Decision Letter 2

Syed Ghulam Sarwar Shah

2 Jul 2023

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:

PLoS One. doi: 10.1371/journal.pone.0288638.r006

Acceptance letter

Syed Ghulam Sarwar Shah

13 Jul 2023

PONE-D-22-28346R2

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

Dear Dr. Alfadul:

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. Syed Ghulam Sarwar Shah

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Data. Anonymised dataset.

(XLSX)

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Attachment

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

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Attachment

Submitted filename: Response to Reviewers.docx

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Attachment

Submitted filename: PONE-D-22-28346_R1.pdf

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Data Availability Statement

"All relevant data are within the paper and its Supporting Information files."

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PERMALINK

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

Esraa S A Alfadul

Malaz Mohammed Idrees Abdalmotalib

Salma Salah Khalid Alrawa

Rama Osman Abdelrahman Osman

Hadiea Mosaab AhmedElbashir Hassan

Alsamany taha albasheir

Elfatih A Hasabo

Sagad O O Mohamed

Kamil Mirghani Ali Shaaban

Roles

Abstract

Background

Method

Results

Conclusion

Introduction

Material and methods

Study design and settings

Participants

Data collection and tool

Ethical approval

Statistical analysis plan

Results

Participants information

Table 1. Baseline characteristics and demographic data of included participants.

Burnouts among participants

Table 2. Responses to questions of the burnout tool.

Table 3. Adaptive behaviour among the participants.

Table 4. Multiple logistic regression for predictors of burnout among healthcare workers.

Discussion

Strengths and limitations

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Syed Ghulam Sarwar Shah

Roles

Author response to Decision Letter 0

Decision Letter 1

Syed Ghulam Sarwar Shah

Roles

Author response to Decision Letter 1

Decision Letter 2

Syed Ghulam Sarwar Shah

Roles

Acceptance letter

Syed Ghulam Sarwar Shah

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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