PONE-D-21-14476

Knowledge, Understanding and Socio-Cultural Influences to Refugees Compliance to COVID-19 Preventive Measures: A Qualitative Inquiry of Health Care Workers and Refugee Women attending antenatal and postnatal health services in Urban Kenya.

PLOS ONE

Dear Dr. Lusambili,

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Susan A. Bartels, MD, MPH, FRCPC

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PLOS ONE

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Reviewers' comments:

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Comments to the Author

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

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Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: I Don't Know

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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

Reviewer #1: Thank you for the opportunity to peer review this important piece of work. This qualitative inquiry of health care workers and refugee women in urban Kenya aimed to report findings on knowledge, understand and influences to refugees compliance to COVID-19 preventive measures. The authors used in-depth individual interviews with 10 health care workers/volunteers and 15 refugee women to explore their knowledge, understanding and influences to compliance with COVID-19 IPC. This work highlights the high level of awareness and prevention control measures among refugee women, together with poor level of compliance and goes on to explore what may be underpinning this. This is an important piece of original work, with an appropriate study design and ethics approval, carried out during a pandemic with a vulnerable group in urban Kenya and the findings could inform future pandemic preparedness plans.

I believe the manuscript requires minor editing, and I note some suggestions below.

I would welcome further details on the methodology, particularly on the social cultural context as this is key to explain what may underpin refugee women’s knowledge, understanding and influences. If possible, it would be important to know about the socio-demographics profile of the participants in the study e.g., family size, socio-economic status etc and this should be presented with the results.

Regarding the aim (line 77), it is important to justify what the added value is of also interviewing FHCWs and CHVs as well refugee women – this could be detailed in the introduction or the methods section. Finally in lines 81-86 please ensure you are consistent with your writing style and use either numbers or words to describe the number of participants sampled. Building on that, I would welcome further details around the context of COVID-19 in October 2020 in this area of Kenya. This will help to make a judgement of what the knowledge of the study participants should be, it will also be useful to know about any public health communications campaigns that may have been carried out on this topic.

Overall, the conclusions made are supported by the results presented. However, it would be valuable to discuss the results further considering previous evidence around compliance of IPC measures and refugee groups for example.

Finally, I think it would be important to have a paragraph discussing future policy implications of your findings and recommendations to policymakers, especially in view of your findings that highlight the impact of pollical factor on refugee’s compliance to COVID-19 preventive measures.

This manuscript is important for the field of migrant health and pandemic preparedness and the qualitative findings can inform future health policy and planning.

Reviewer #2: PLOS Peer Review Jul 2021 (DRSMS)

Knowledge, Understanding and Socio-Cultural Influences to Refugees Compliance to COVID-19 PReventative Measures: A Qualitative Inquiry of Health Care Workers and Refugee Women attending antenatal and postnatal health services in Urban Kenya. Lusambili et al

Line159 - 166

This is comparable to our experiences in Camp Moria in Lesvos where 18000 people were residing in extremely unhygienic and overcrowded. As the main primary medical provider inside the camp during the early months and throughout the pandemic, we observed much-reduced numbers in the clinic as people lived fearfully of contracting this fatal illness. Conversely, the authorities and the local Greeks assumed that the refugees were unaware and chose to live complacently. The truth is - they had very little choice- often not even running water. This great sense of fear led the refugees to believe that their lives did not matter and that they would be left to die.

Line287

If this is indeed true...that Trump could even influence even these poor people- it’s a good thing that he is gone. However, I wonder if this sample size is too small to conclude anything like this.

Line325

Because of the small sample size again, it would be helpful to understand what religious faith group the refugees interviewed belonged to. Were they all Muslims? If not - what was the breakdown. It can come across as slightly biased. It may also be helpful to know the faith background (if any) of the HCW. Additionally, was it not Trump again who may have started the bigotted idea that ‘China was being punished’ at the onset of the pandemic- due to unconventional choices of food. The world was a confused place as the pandemic developed...until finally we all knew- this virus affected all equally. Something about this needs to be acknowledged in the discussion.

Line 383-391

Surely it was not just the refugees’ community who were confused by ‘fake news’ and misinformation and mistrusting political agendas. Many groups of people from across the globe suffered similar sceptiscm.

The role of healthcare worker advocacy and education in this regard should be stressed on more-> as HCW are in the best position to influence those they care for.

Line 393-397

Does this section seem to indicate that the local HCW were relatively powerless to overcome the political and religious rhetoric. Is there enough evidence for this conclusion based on the interviews in this study? Was there any indication that if health promotion activities were undertaken- which type did the women find most helpful eg leaflets/ one-to-one or group teaching sessions?

Line403-404

Again I am made to assume that the majority/ all of the refugees women interviewed were from the Muslim faith. Is this a fact? I think this is answered in 418-419- but it really would be helpful to have this mentioned earlier in the paper.

Line 412-413

It would be good to see these bits elaborated. How did HCW/ CHV’s improve awareness? What did they do exactly?

Line 447

This point needs to be revised. Is there enough evidence from these small numbers to indicate that the refugee population alone was influenced by this? Surely the population at large (including the host country) would be affected by political and religious influences. Without comparative data on the host population- I would not agree that this research paper can conclude this.

The other two points are fine.

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Reviewer #1: No

Reviewer #2: Yes: Dr Siyana Mahroof-Shaffi

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PONE-D-21-14476R1‘ It is a disease which comes and kills directly’: What refugees know about COVID-19 and key influences of compliance with preventive measures.PLOS ONE

Dear Dr. Lusambili,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 02 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Susan A. Bartels, MD, MPH, FRCPC

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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

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

Reviewer #1: Yes

Reviewer #2: Partly

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

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #1: Thank you for addressing the peer review comments. I believe the revised manuscript reads better than previous drafts. The aims and objectives are clearer and the changes to the title and certain sections are welcomed. No further comments.

Reviewer #2: see atatched. I found the tracked section of the new docuement difficult to follow...hoep my commnets make sense.

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Reviewer #1: Yes: Dr Behrouz Nezafat Maldonado

Reviewer #2: Yes: Dr S. Mahroof-Shaffi

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Submitted filename: PLOS ONE review Oct 2021.pdf

‘ It is a disease which comes and kills directly’: What refugees know about COVID-19 and key influences of compliance with preventive measures.

PONE-D-21-14476R2

Dear Dr. Lusambili,

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.

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Kind regards,

Susan A. Bartels, MD, MPH, FRCPC

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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