F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.145483.1 Research Article Articles Prevalence of psychological distress: a scientific approach towards the mental health and wellbeing of population during the SARS-COV-2 outbreak

[version 1; peer review: 1 approved, 1 approved with reservations]

 Tauqir Saman Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing 1 Shah Inayat Data Curation Formal Analysis Investigation Methodology Resources Writing – Original Draft Preparation 1 Alsubaie Ahmed Data Curation Formal Analysis Investigation Methodology Resources Writing – Original Draft Preparation 2 Noreen Sara Data Curation Investigation Visualization Writing – Review & Editing 3 Sadaf Shazia Data Curation Formal Analysis Investigation Methodology Resources Writing – Original Draft Preparation 4 Ali Saqib Conceptualization Data Curation Formal Analysis Methodology Supervision Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-2421-0753 a 2 Department of Physiology, Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia Department of Medicine, Khyber Teaching Hospital, Peshawar, Pakistan Department of Dental Education, College of Dentistry, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia samali@iau.edu.sa

No competing interests were disclosed.

 23 4 2024 2024 13 339 27 3 2024 Copyright: © 2024 Tauqir S et al. 2024 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

The global challenge of the novel coronavirus has led to an unprecedented downturn, adversely affecting the health and mental wellbeing of communities worldwide. The objective of this study is to assess mental health and psychological distress levels within the general population of Peshawar, Pakistan amidst the ongoing COVID-19 pandemic.

 Method

A cross-sectional online study was conducted among 715 individuals residing in Peshawar city, Pakistan. A questionnaire containing details about demographics, socioeconomic status, and residential area was employed. To assess the mental wellbeing of participants a Modified K10, Kesslers psychological distress Scale was used. Descriptive statistics, including mean and standard deviations, were utilized for data analysis. Statistical analyses were performed using Statistical Package for Social Science (SPSS, IBM USA,version 22).

 Results

A total of 715 responses were collected. The comprehensive psychological distress score was identified as 25.55, signifying moderate stress levels. Among the respondents, 53.3% were females, 46.7% had completed a bachelor’s degree, 41% were employed, 78.7% were single, 93.1% were non-smokers, and 69.4% resided in urban areas. The study revealed that both gender (p=0.001) employment status (p=0.018) were linked to a more pronounced psychological impact of the outbreak.

 Conclusions

The present study indicates that age, gender, employment status, and urbanization are influential factors contributing to psychological distress during the outbreak. As we confront the challenges of the new normal, it is crucial for policymakers to acknowledge and tackle the growing mental health concerns within the population.

 COVID-19 Kesseler scale SARS-CoV-2 Mental health Pandemic Pakistan The author(s) declared that no grants were involved in supporting this work. Inroduction

The emergence of Coronavirus Disease 2019 (COVID-19) in Wuhan, China, in December 2019 swiftly escalated into a global pandemic within months. 1 The consequences of this public health crisis have significantly impacted the mental well-being of the population, giving rise to a surge in psychological crises. 2 , 3 Identifying populations experiencing early-stage psychological crises is crucial for the effective implementation of intervention strategies. Despite a widespread increase in mental distress reported among both the general public and frontline medical personnel, the specific determinants of psychological distress remain unidentified across the diverse populations affected by the COVID-19 pandemic. 2 , 3 , 4

Traumatic public health emergencies can induce feelings of insecurity, driven by the fear of infection and mortality. Symptoms such as anxiety, stress, insomnia, and fear are frequently observed during pandemics. 5 Various studies conducted during the pandemic have reported increased psychological distress in the general population and a significant proportion of healthcare professionals. 6 , 7 The fear of infection, economic downturn, job losses, vaccination and reduced income due to prolonged lockdowns are collectively contributing to mental health disorders in society, ultimately leading to depression and suicidal thoughts. 3 , 8 , 9

The mental health implications of the COVID-19 pandemic are of paramount importance, affecting the general population on multiple fronts. 10 , 11 Our frontline heroes, including all medical professionals directly engaged with COVID-19-infected and quarantined patients, endure constant and substantial psychological trauma. 10 Stress predictors for these individuals include persistent fears of contracting the virus, overwhelming workloads, and the emotional toll of witnessing COVID-19 patients passing away in isolation. 11

It is crucial to acknowledge and address the psychological traumas and mental health challenges faced by individuals in the wake of the pandemic. Implementing measures like lockdowns, while necessary for control, can induce anxiety responses and contribute to increased fear and prejudice against those infected or affected. 12 Studies examining the impact of COVID-19 on mental well-being not only shed light on critical areas of concern but also offer insights into how healthcare services can be equipped with essential information and support to provide mental health treatment to those in need. 13 Consequently, prioritizing public mental health is paramount, necessitating the adaptation of policies to support individuals in navigating the challenges posed by the “new normal.” The primary objective of this study is to assess mental health and psychological distress levels within the general population of Peshawar, Pakistan amidst the ongoing COVID-19 pandemic.

 Methods Study design

The research design employed for this study was cross-sectional, conducted among the population of Peshawar city Pakistan using an online survey. The survey was distributed to the public through diverse social platforms, including WhatsApp, Twitter, emails, and Facebook messengers.

 Ethics

Approval for ethical considerations was granted by the Ethics Review Committee of the Khyber Medical University (approval number: DIR/KMU-EB/PS/000109, granted on 02-02-2022). This study was conducted conferring to declaration of Helsinki. Written informed consent was obtained from participants via a consent statement for participation incorporated before the survey, stating, “Your involvement in this study is entirely voluntary. There are no anticipated risks associated with this project. However, if you find any questions uncomfortable, you have the option to withdraw from the survey at any point.” Thus, participation in the survey was considered as implicit consent to participate.

 Participants

Survey participants encompassed individuals of both genders, aged between 15 and 60, and representing various educational backgrounds. The study targeted individuals with internet access, encompassing a diverse group, including undergraduate students, engineers, medical professionals, government employees, retirees, lawyers, business professionals, and individuals from various other professions. Prior to survey completion, informed consent was obtained from all participants, and their responses were kept confidential and anonymous. The survey took approximately five to seven minutes to finish.

 Data collection

Data collection for this study utilized an online survey conducted through Google Forms. The questionnaire for this study was structured into sections, covering demographic characteristics (gender, education level, marital status, job status and area of residing whether urban or rural).

For assessing distress, K10 was used which serves as a concise screening method to assess various levels of distress. The Kessler Psychological Distress Scale (K10) is a straightforward tool for gauging psychological distress. 14 Comprising 10 questions regarding emotional states, each with a five-level response scale.

 Scoring criteria

Scoring for each item ranges from one, indicating ‘none of the time,’ to five, indicating ‘all of the time.’ The scores for the 10 items are then totaled, resulting in a minimum score of 10 and a maximum score of 50. Lower scores suggest minimal psychological distress, while higher scores indicate elevated levels of psychological distress.

In terms of score interpretation, cut-off scores as a reference for screening psychological distress are as follows: 15

K10 Score: Likelihood of having a mental disorder (psychological distress)

10-19: Likely to be well

20-24: Likely to have a mild disorder

25-29: Likely to have a moderate disorder

30-50: Likely to have a severe disorder.

 Statistical analysis

Descriptive statistics, including mean and standard deviations, were utilized for data analysis. Statistical analyses were performed using Statistical Package for Social Science (SPSS, IBM USA,version 22), applying one-way ANOVA based on the number of groups and items to be compared. Results were presented as means and ± Standard Deviation SD, and differences were deemed statistically significant if p≤0.05. This comprehensive methodology ensured a rigorous and systematic approach to understanding the mental health dynamics in the specified population during the challenging times of the COVID-19 pandemic.

 Results Participant sociodemographic characteristics

The study included 715 respondents, reflecting a diverse participant profile ( Table 1). The overall psychological distress score averaged 25.55, indicating a moderate level of stress. Key sociodemographic characteristics revealed that the majority of participants were female (53.3%), held a bachelor's degree (46.7%), were employed (41%), single (78.7%), non-smokers (93.1%), and resided in urban areas (69.4%).

Showing the demographics with percentages and frequencies.
Demographics Percentage % Number of respondents n
Age 15-20 32% 229
21-30 50.6% 336
31-40 12% 86
41-50 3.6% 26
51-60 1.3% 9
60 and above 0.4% 3
Gender Male 46.7% 334
Female 53.3% 381
Location Urban 30.6% 218
Rural 69.4% 495
Smoking Smoker 6.9% 49
Non-smoker 93.1% 666
Marital status Single 78.7% 563
Married 20.1% 144
Widowed 0.7% 5
Divorced 0.4% 3
Profession Doctor 21.7% 155
Engineer 1.8% 13
Lawyers 2.8% 20
Business person 3.1% 22
Unemployed 5.3% 38
Retired 1% 7
Government service 1.3% 9
Private job 4.2% 30
Student 58% 415
Unemployed due to COVID-19 0.8% 6
Psychological responses during the lockdown

Table 2 presents the psychological responses of the respondents to the Kessler scale during the lockdown in Peshawar, Pakistan. Analyzing the data from Table 2, it is observed that 22.7% (162 respondents) reported feeling tired most of the time in the last month, with 7% (50 respondents) expressing constant fatigue over the 30-day period. Approximately 15.9% (114 respondents) noted feeling nervous most of the time during the pandemic, while 30.3% (217 respondents) experienced occasional nervousness. Conversely, 2.7% (19 respondents) reported constant nervousness throughout the pandemic. Furthermore, 10.1% (72 respondents) felt uncalmable during the past month, whereas 41.4% (296 respondents) indicated a sense of calmness, suggesting adaptation to the new normal. Unfortunately, 6.6% (47 respondents) felt hopeless about the ongoing situation, while 35.5% (254 respondents) remained hopeful for improvement. Additionally, 31% (222 respondents) experienced restlessness at times, and 25.9% (185 respondents) felt so restless that they could not stand still. Finally, 19.6% (140 respondents) reported feeling depressed most of the time, and 7.7% (55 respondents) expressed constant depression due to the outbreak of the viral disease. These findings provide a comprehensive understanding of the psychological responses of the participants during the specified period, shedding light on the multifaceted impact of the COVID-19 pandemic on mental well-being.

Participants' Responses to Kessler’s Questions on a 5-Point Likert Scale (1 none of the time) to (5 all of the time).
SNO. Parameters tested None of the time (n)% A little of the time (n)% Some of the time (n)% Most of the time (n)% All of the time (n)%
1 How often did you feel tired out for no good reason? (131) 18.3% (162) 22.7% (210) 29.4% (162) 22.7% (50) 7%
2 How often did you feel nervous? (157) 22% (208) 29.1% (217) 30.3% (114) 15.9% (19) 2.7%
3 How often did you feel so nervous that nothing could calm you down? (296) 41.4% (193) 27% (139) 19.4% (72) 10.1% (15) 2.1%
4 How often did you feel hopeless? (254) 35.5% (161) 22.5% (146) 20.4% (107) 15% (47) 6.6%
5 How often did you feel restless or fidgety? (139) 19.4% (222) 31% (195) 27.3% (128) 17.9% (31) 4.3%
6 How often did you feel so restless you could not sit still? (303) 42.2% (185) 25.9% (137) 19.2% (70) 9.8% (20) 2.8%
7 How often did you feel depressed? (149) 20.8% (198) 27.7% (173) 24.2% (140) 19.6% (55) 7.7%
8 How often did you feel that everything was an effort? (138) 19.4% (165) 23.1% (182) 25.5% (157) 22% (72) 10.1%
9 How often did you feel so sad that nothing could cheer you up? (194) 27.1% (20.8) 29.1% (173) 24.2% (103) 14.4% (37) 5.2%
10 How often did you feel worthless? (238) 33.3% (186) 26% (152) 21.3% (90) 12.6% (49) 6.9%
Psychological distress measures

Table 3 presents the mean values and corresponding standard deviations of each question on the Kessler Scale 10, which measures psychological distress. The data provides insights into the frequency and intensity of various stress-related parameters among the surveyed individuals in Peshawar, Pakistan during the COVID-19 pandemic. Additionally, the table includes the 95% confidence intervals of the mean differences, offering a statistical perspective on the reliability of the reported values.

Mean Values of each question of Kessler Scale 10.
SNO. Parameters tested Mean ± SD 95% CI of diff
1 How often did you feel tired out for no good reason? 2.773 1.190 -1.935 to -1.612
2 How often did you feel nervous? 2.483 1.081 -1.644 to -1.321
3 How often did you feel so nervous that nothing could calm you down? 2.045 1.095 -1.207 to -0.8829
4 How often did you feel hopeless? 2.345 1.278 -1.507 to -1.184
5 How often did you feel restless or fidgety? 2.566 1.120 -1.728 to -1.405
6 How often did you feel so restless you could not sit still? 2.566 1.120 -1.728 to -1.405
7 How often did you feel depressed? 2.656 1.224 -1.818 to -1.494
8 How often did you feel that everything was an effort? 2.801 1.262 -1.963 to -1.640
9 How often did you feel so sad that nothing could cheer you up? 2.414 1.177 -1.576 to -1.252
10 How often did you feel worthless? 2.337 1.247 -1.499 to -1.175

CI=Confidence Interval, SD= Standard Deviation.

 Demographic determinants of stress

A comparison of Kessler Scores across different demographic factors, exploring the determinants of stress among the surveyed individuals is presented in Table 4. It shows the mean values, standard deviations, and p-values for various demographic categories. The Kessler scores of females were found to be significantly higher than those of male participants (27.36 vs. 23.48, p = 0.001). Similarly, employed participants exhibited higher scores compared to their non-employed counterparts (25.72 vs. 22.47, p = 0.018), suggesting potential variations in stress levels based on gender and employment status Table 4.

Comparison of Kessler Scores Across Demographic Factors.
Determents of stress Mean SD P-value
Gender Male 23.4880 7.90663 0.001
Female 27.3622 8.19853
Living Urban 25.8444 8.29114 0.127
Rural 24.8165 8.23745
Employment Employed 25.7253 8.34065 0.018
Unemployed 22.4737 6.62402

SD= Standard Deviation.

This table provides an overview of the demographic distribution of survey participants, including percentages and frequencies. The categories encompass age groups, gender, location, smoking habits, marital status, and profession. The legend offers a comprehensive understanding of the respondents' diverse characteristics and backgrounds.

This table presents the detailed responses of participants to Kessler’s questions, each assessed on a 5-point Likert scale ranging from “None of the time” to “All of the time.” The parameters tested include feelings of tiredness, nervousness, hopelessness, restlessness, depression, and worthlessness. The legend provides a breakdown of participant responses across various levels of frequency for each parameter, offering insights into the mental well-being of the surveyed individuals.

This table displays the mean values and standard deviations of each question in the K10 assessment. The parameters tested include feelings of tiredness, nervousness, hopelessness, restlessness, depression, and worthlessness. Additionally, the 95% confidence intervals of the differences are provided, offering insights into the variability of responses and the overall mental health assessment based on the participants' mean scores for each parameter.

Table 4 reveals that females Kessler score was significantly higher than male participants (27.36 vs 23.48, p – 0.001). Similarly, the score was higher in employed participants (25.72 vs 22.47, p – 0.018). However, living in Urban and Rural site (25.84 vs 24.81, p – 0.127).

 Discussion

In our cross-sectional study, we sought to dissect the effects of the COVID-19 pandemic on the mental health of the population in Peshawar Pakistan. The study's results reveal a significant impact of the COVID-19 pandemic on the mental health of individuals in Peshawar, Pakistan. The detailed psychological responses during the lockdown underscore the multifaceted nature of the pandemic's impact, encompassing fatigue, nervousness, feelings of hopelessness, and varied experiences of restlessness and depression.

The study reports an overall psychological distress score of 25.55 suggesting moderate level of stress among the diverse group of 715 respondents. Notable gender disparities were observed, with females exhibiting significantly higher distress scores than males (27.36 vs 23.48, p=0.001) ( Table 4). Employed individuals demonstrated higher distress scores (p =0.018) ( Table 4). In line with our results a studies in Nepalian populations and population of the United Kingdom reports high stress during the pandemic suggesting that there is a crucial need to carry out psychological interventional programs to cope with the situation effectively. 16 , 17

Our study reports the stress score of 27.36 in females indicating moderate stress levels. These findings are in line with the findings of a study conducted by Farooq et al. 18 , revealing that females exhibited 2.5 times higher levels of stress compared to males (39.4% vs. 23.3%, respectively) ( Table 4). Another investigation found that the prevalence of depressive symptoms were 66% among women, contrasting 33% among men. 19 Globally conducted studies, including those in China, 1 India, 20 and Spain, 21 support these findings by reporting elevated stress symptoms among females. Recently Qiu et al., reported from China that the female gender and younger population were at a higher risk for different mental health outcomes and suffered from anxiety and stress. 22 , 23 These findings are also in line with another cross-sectional study carried out in Turkey which also reported that the group most affected psychologically by the pandemic were females, and the urban population. Priority might therefore be attached to these in future psychiatric planning. 5 Similarly, an Iranian study also reported the high prevalence of stress and depression among the females (95%) of Iranian during the pandemic. 24 Plausible explanations for the heightened prevalence of stress in women include biological factors, socioeconomic disadvantages, a loss of social status, maladapted coping strategies, and a lack of support systems in the country. 25 Additionally, socio-cultural norms in Pakistani households often lead women to juggle both household and professional responsibilities, while men are typically less involved in domestic activities. The ‘stay home, stay safe’ policy during the pandemic has intensified the workload for women as men spend more time at home.

These findings could be of great use in proposing new policies for global mental health related problems during the new normal.

Employment status also played a role, as employed individuals demonstrated higher distress scores compared to their unemployed counterparts (25.72 vs 22.47, p =0.018) ( Table 4). Anticipated salary cuts and a decline in job opportunities, coupled with heightened uncertainty and potential fear, may contribute to an increase in stress. 12 Furthermore, the closure of offices due to travel restrictions has resulted in a shift to remote work for most employees. The lack of in-person interaction with colleagues could impact workers' motivation, job satisfaction, and overall productivity. 12 , 26 The inability to meet deadlines and achieve targets, compounded by the added responsibilities of managing household affairs, may elevate anxiety levels among employees. 12

The SARSCoV-2 2019 is a highly contagious virus spreading via droplets or direct contact. Such viruses are transmitted easily in urban areas compared to rural areas with thick populations. 27 Therefore, a higher prevalence of mental distress is evident in both urban and semi-urban settings. This may be attributed to the increased incidence of COVID-19 in urban areas, where the lockdown has significantly impacted densely populated cities throughout Pakistan, effectively putting the lives of their residents at risk. 28 , 29 Our study reports a greater psychological impact of the virus on the individuals living in urban areas 25.8 ( Table 4) having access to communication and latest chaos caused by pandemic reporting. The results are corroborated by a Chinese investigation that demonstrated a higher occurrence of psychological health issues among individuals residing in urban areas. This trend is attributed to the substantial number of COVID-19 cases concentrated in cities, with urban areas serving as epicenters of the disease. 30

Developing countries face different challenges providing e-mental health care services due to lack of useful online interventions. 31 Responsible organizations of the country should design and enforce a gender-sensitive psychosocial protocol in form of videos or phone calls to ensure mental wellbeing in the nation. NGOs are efficient and effective mode to be used in this regard because of their close relation with communities, therefore they should be brought to proper use in this area.

 Conclusion

In conclusion, our cross-sectional study in Peshawar, Pakistan, reports a moderate overall psychological distress score of 25.55 indicates a noteworthy level of stress among the diverse group of 715 respondents. Notable gender disparities highlight that females exhibit significantly higher distress scores than males. Employment status also plays a role, with employed individuals demonstrating higher distress scores. Urban areas, acting as epicenters of the disease, experience a higher prevalence of mental distress, emphasizing the urban-rural divide in the impact of the virus. Our study provides a platform for the policy health care policy makers of our country to prioritize mental health issues in the time of new normal.

Limitations

While our study provides valuable insights into the psychological state during the “new normal,” it is essential to acknowledge its limitations. The survey's cross-sectional nature limits our ability to make conclusions regarding the long-term effects of the pandemic, representing a notable study limitation. Additionally, potential selection bias exists as the survey relied on an online questionnaire, excluding individuals without Internet access or those unable or unwilling to use smartphones and emails.

 Recommendations

Future research, particularly among healthcare workers and their families, is recommended to further explore the profound mental health impact within this high-risk group. Measures therefore should be taken to psychologically support these citizens of the state. There is a need to carry out psychological interventional activities through various mediums like web videos, e-massages, advertisements, and mental helpline services to help people become more resilient during the COVID-19 pandemic. The government should take time sensitive decisions and steps to introduce e-mental health to reduce mental stress in the time of pandemic.

 Data availability Underlying data

Figshare: Prevalence of psychological distress: A Scientific approach towards the mental health and wellbeing of population during the SARS-COV-2 outbreak. https://doi.org/10.6084/m9.figshare.24638121.v1. 32

This project contains the following underlying data:

data (2).xlsx

 Extended data

Figshare: Prevalence of psychological distress: A Scientific approach towards the mental health and wellbeing of population during the SARS-COV-2 outbreak. https://doi.org/10.6084/m9.figshare.24638121.v1. 32

This project contains the following extended data:

kessler.pdf (copy of questionnaire)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Acknowledgments

The authors extend their thanks to the participants.

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Competing interests: No competing interests were disclosed.

 11 6 2024 Copyright: © 2024 Alam A 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

The presented study briefly encapsulates the essence of your study on the assessment of mental health and psychological distress within the general population of Peshawar, Pakistan, during the COVID-19 pandemic. Here are some suggestions and comments for potential refinement and further consideration:

1.    Introduction: It's concise and effectively sets the stage for the study's relevance. You might want to add a brief note on why Peshawar specifically was chosen, if there's a unique context that makes this study particularly important for the region.

2.    Expand Background Context: Provide more background on the mental health impacts of pandemics historically or from recent events prior to COVID-19. This could help frame the significance of your study within a broader context.

3.    Method: This section is clear about the study's design and tools used for data collection. It could be enhanced by briefly mentioning the rationale behind using the Kessler Psychological Distress Scale specifically, which could help non-specialist readers understand its relevance and validity in this context.

4.    The conclusion rightly emphasizes the implications for policy. It could be strengthened by explicitly recommending specific policy measures or interventions that could be implemented based on the study findings.

5.    Address Bias and Generalizability in your limitations. More thoroughly discuss how the method of survey distribution (online) might limit the generalizability of the findings. For instance, does this method potentially exclude older populations or those without internet access?

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Public Health, maternal and Child Health, Nutrition, Research designs, environmental health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Ali Saqib BDS Department, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

Competing interests: No competing interests were disclosed.

 10 10 2024

Dear Reviewer 

Many thanks for the constructive feedback. We have addressed all the comments and did the modifications accordingly. Please find below the responses to all your comments.

Reviewer comment: The presented study briefly encapsulates the essence of your study on the assessment of mental health and psychological distress within the general population of Peshawar, Pakistan, during the COVID-19 pandemic. Here are some suggestions and comments for potential refinement and further consideration:

1. Introduction: It's concise and effectively sets the stage for the study's relevance. You might want to add a brief note on why Peshawar specifically was chosen, if there's a unique context that makes this study particularly important for the region.

Author response: Thank you for your positive feedback on the introduction. We appreciate your suggestion to provide more context on why Peshawar was specifically chosen for this study.

Peshawar was selected due to its status as a major healthcare hub in Pakistan, hosting several tertiary care hospitals that serve a large and diverse population. The city’s healthcare institutions train a substantial number of dental professionals, including interns and postgraduates, who experience unique challenges and stressors related to their demanding schedules and high patient load. Additionally, factors such as cultural attitudes, lifestyle, and socioeconomic conditions in Peshawar may contribute to sleep disorders in ways that differ from other regions, making it a valuable location for this study.

We will incorporate these points into the introduction to highlight the significance of studying sleep disorders among dental professionals specifically in Peshawar, providing a stronger rationale for the study’s relevance to the region. Thank you for this helpful suggestion.

Reviewer comment: 2. Expand Background Context: Provide more background on the mental health impacts of pandemics historically or from recent events prior to COVID-19. This could help frame the significance of your study within a broader context.

Author response: Thank you for the suggestion to expand the background context by exploring the mental health impacts of pandemics from a historical perspective. This is a valuable idea, as it can help frame the significance of our study within a broader context.

Historically, pandemics have had profound impacts on mental health, as observed in past events such as the Spanish Flu of 1918, which led to widespread anxiety, grief, and psychological distress due to high mortality rates and societal disruption. Similarly, during the SARS outbreak in 2003, studies reported increased levels of depression, anxiety, and post-traumatic stress symptoms among healthcare workers and the general population. Research from the Ebola outbreak in West Africa in 2014 also highlighted severe psychological consequences, including stigma, isolation, and an increase in mental health disorders among survivors and healthcare professionals.

These historical events demonstrate that pandemics often lead to substantial mental health challenges, including heightened stress, anxiety, and depression, due to factors such as fear of infection, prolonged isolation, and socioeconomic strain. By framing the COVID-19 pandemic within this broader historical context, we can underscore the importance of addressing mental health impacts as an integral part of pandemic response and recovery efforts.

We will incorporate this background into the study to emphasize the relevance of examining mental health impacts during pandemics and provide a richer context for our research. Thank you for this insightful recommendation.

Reviewer comment: 3. Method: This section is clear about the study's design and tools used for data collection. It could be enhanced by briefly mentioning the rationale behind using the Kessler Psychological Distress Scale specifically, which could help non-specialist readers understand its relevance and validity in this context.

Author response: Thank you for your feedback on the methods section. We appreciate your suggestion to include a brief rationale for using the Kessler Psychological Distress Scale (K10) in this study.

The K10 scale was selected due to its strong validity and reliability in measuring psychological distress across diverse populations and its sensitivity to detecting symptoms of anxiety and depression. It consists of 10 questions that assess the frequency of emotional states associated with psychological distress, making it an efficient tool for identifying individuals at risk for mental health disorders. The scale is widely used in public health research due to its ease of administration and its ability to provide a quick, standardized measure of distress levels, which is particularly useful in large-scale studies like ours.

Including the K10 allows us to accurately quantify levels of psychological distress among participants, enabling comparisons across different groups. This choice is especially relevant for our study, as it provides a validated measure to assess mental health impacts in the context of the pandemic, making the findings more robust and generalizable.

We will incorporate this explanation into the methods section to clarify the rationale behind choosing the Kessler Psychological Distress Scale, especially for readers who may not be familiar with the tool. Thank you for the valuable suggestion.

Reviewer comment: 4. The conclusion rightly emphasizes the implications for policy. It could be strengthened by explicitly recommending specific policy measures or interventions that could be implemented based on the study findings.

Author response: Thank you for your feedback on the conclusion. We appreciate your suggestion to strengthen it by providing specific policy recommendations based on the study’s findings.

To make the implications for policy more actionable, we propose to include recommendations for targeted interventions. For example, based on our findings, we can recommend implementing mental health support programs specifically tailored for healthcare professionals, such as stress management workshops, counseling services, and peer support networks within hospitals. Additionally, policies that promote regular screening for psychological distress using tools like the Kessler Psychological Distress Scale could be introduced as part of routine health check-ups for healthcare workers, especially during periods of heightened stress, such as pandemics.

Further, workplace policies that encourage reasonable work hours, regular breaks, and sufficient leave days can help mitigate stress and improve overall well-being among healthcare staff. These measures, supported by healthcare institutions and policymakers, could help address and prevent psychological distress more effectively, promoting a healthier, more resilient workforce.

We will incorporate these specific policy recommendations into the conclusion to provide a more concrete foundation for translating our findings into practical interventions. Thank you for your helpful suggestion to enhance this section.

Reviewer comment: 5. Address Bias and Generalizability in your limitations. More thoroughly discuss how the method of survey distribution (online) might limit the generalizability of the findings. For instance, does this method potentially exclude older populations or those without internet access?

Author response: Thank you for highlighting the importance of addressing potential biases and limitations related to survey distribution. We agree that discussing how the online survey method may impact the generalizability of our findings is essential.

In the limitations section, we will expand on the potential biases introduced by using an online survey format. Specifically, we recognize that relying on online distribution may exclude certain demographics, such as older individuals who may not be as comfortable with digital technology or those without consistent internet access. This limitation could lead to an underrepresentation of these groups, potentially skewing our findings towards younger, more tech-savvy participants. Additionally, the online format may introduce selection bias, as those experiencing higher levels of psychological distress may be more inclined to participate in a survey on this topic.

To improve generalizability in future studies, we recommend complementing online surveys with alternative distribution methods, such as paper surveys or in-person interviews, especially in settings where internet access is limited. By acknowledging these limitations, we aim to provide a balanced interpretation of our findings and offer suggestions for future research to mitigate these biases.

Thank you for your valuable suggestion to enhance this aspect of our discussion on study limitations.

 10.5256/f1000research.159438.r272714 Reviewer response for version 1 Ali Niaz 1 Referee College of Medicine, Shaqra University, Shaqra, Riyadh Province, Saudi Arabia

Competing interests: No competing interests were disclosed.

 31 5 2024 Copyright: © 2024 Ali N 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The study is done extensively and is of interest but it needs major revisions so it can be of greater benefit for the community. Please find my detailed comments below. All the very best.

1. Please check the manuscript for grammatical errors and typos. Some sentences are too long to follow.

2. Consider refining the use of passive voice where possible, to active voice, which can make the abstract more engaging and easier to read.

3. Ensure consistency in statistical reporting, for example, always use the same number format for p-values (e.g., p < 0.001 or p = 0.001).

4. If space allows in the body of the article, it would be valuable to include more detailed analysis or discussion about the impact of COVID-19 on different age groups or between genders. This can provide deeper insights into which sub-groups are most vulnerable.

5. In the recommendations, besides general calls for policy action, suggest specific mental health resources or programs that have been effective in similar contexts.

6. Ensure all references are up to date and correctly formatted, and check if the latest statistics or studies might provide more recent insights into the COVID-19 impact on mental health globally and locally.

7. The abstract provides a solid overview of your research and its importance to public health discourse in Pakistan. By tightening the focus a bit more on specific actionable insights and perhaps providing a bit more context about the tools and demographic influences, it can serve as a robust entry point for readers into the study's full findings.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Social Science, Pharmacology, Medical Education, Dental Education, Psychological,

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Ali Saqib BDS Department, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

Competing interests: No competing interests were disclosed.

 10 10 2024

Dear Reviewer

Many thanks for the constructive feedback. We have addressed all the comments suggested and improved the manuscript per your suggestions which are as below:

The study is done extensively and is of interest but it needs major revisions so it can be of greater benefit for the community. Please find my detailed comments below. All the very best.

1. Please check the manuscript for grammatical errors and typos. Some sentences are too long to follow.

Response: Thank you for your feedback regarding grammatical errors and sentence structure. We will thoroughly review the manuscript for any typos and grammatical mistakes to ensure clarity and accuracy. Additionally, we will revise overly long sentences to improve readability and ensure that the flow of ideas is smooth and easy to follow.

In particular, we will focus on breaking down complex or lengthy sentences into shorter, more concise ones where possible. This will help make the content more accessible to readers and improve the overall presentation of the manuscript.

2. Consider refining the use of passive voice where possible, to active voice, which can make the abstract more engaging and easier to read.

Response: We will review the abstract carefully and rephrase sentences in active voice wherever appropriate. For example, rather than saying, "Data was collected from participants," we can change it to, "We collected data from participants." This adjustment will help create a more direct and dynamic tone, making the content easier to follow and more compelling.

3. Ensure consistency in statistical reporting, for example, always use the same number format for p-values (e.g., p < 0.001 or p = 0.001).

Response: Thank you for pointing out the need for consistency in statistical reporting. We will review the manuscript to ensure that all statistical values, particularly p-values, follow a uniform format throughout (e.g., consistently using "p < 0.001" or "p = 0.001"). This will improve the clarity and professionalism of the presentation.

4. If space allows in the body of the article, it would be valuable to include more detailed analysis or discussion about the impact of COVID-19 on different age groups or between genders. This can provide deeper insights into which sub-groups are most vulnerable.

Response: Thank you for your suggestion to expand the analysis on the impact of COVID-19 across different age groups and genders. We agree that a more detailed examination of how various demographic sub-groups are affected could provide valuable insights into which populations may be more vulnerable to psychological distress.

If space permits in the body of the article, we will include an analysis that breaks down the mental health impacts of COVID-19 by age and gender. This could involve examining whether certain age groups, such as older adults or young adults, experience higher levels of anxiety or depression. Additionally, we can explore any gender-based differences in psychological responses, which may help identify specific needs for targeted intervention strategies.

5. In the recommendations, besides general calls for policy action, suggest specific mental health resources or programs that have been effective in similar contexts.

Response: Thank you for your suggestion to include specific mental health resources and programs in our recommendations. We agree that mentioning effective programs from similar contexts can provide actionable insights for policymakers and healthcare providers. We will update it.

6. Ensure all references are up to date and correctly formatted, and check if the latest statistics or studies might provide more recent insights into the COVID-19 impact on mental health globally and locally.

Response: Thank you for your feedback on ensuring reference accuracy and currency. We will review all references to confirm they are up-to-date and correctly formatted. Additionally, we will search for the latest studies and statistics on COVID-19's global and local mental health impact to provide the most current insights in our discussion.

7. The abstract provides a solid overview of your research and its importance to public health discourse in Pakistan. By tightening the focus a bit more on specific actionable insights and perhaps providing a bit more context about the tools and demographic influences, it can serve as a robust entry point for readers into the study's full findings.

Response: Thank you for your feedback. We will tighten the abstract’s focus on specific actionable insights and add brief context about the tools used and demographic influences. These updates will create a clearer and more engaging entry point for readers into our study's findings.