PONE-D-22-06102Factors Associated With Willingness to Take COVID-19 Vaccine among Pregnant Women at Gondar Town, Northwest Ethiopia: A Multicenter Institution-Based Cross-Sectional StudyPLOS ONE

Dear Dr. Aynalem,

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. Editor's comments:

My understanding that “a lottery method” is a “random selection”. While “lottery method” might be understandable term, but not widely used. I would suggest using “random selection” instead.

Make sure the manuscript meets the PLOS One journal requirements in style and format.

It looks like the authors used a systematic random selection approach when recruiting participants. What are the limitations of such approach?

Who are the language experts? Bilingual translators?

More information is needed to understand reliability and validity of the questionnaire in the study population. Was the questionnaire pre-tested? If yes, how many participants responded? Any modifications were introduced? How experts assessed the validity of the items? What approach was undertaken to perform the expert review? Have the authors assess internal validity of the questionnaire? Have the authors performed confirmatory or exploratory factor analysis to assess interrelationships of items? Have the authors used any methods to validate the questionnaire? Have the authors accounted for the complex survey design in all statistical analyses? Without proper accounting for survey design, estimates and corresponding confidence intervals might be incorrectly calculated.

Please submit your revised manuscript by Jul 20 2022 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,

Alpamys Issanov

Academic Editor

PLOS ONE

Journal Requirements:

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

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

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

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service. 

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services.  If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following:

The name of the colleague or the details of the professional service that edited your manuscript

A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

A clean copy of the edited manuscript (uploaded as the new *manuscript* file)”

3. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. 

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

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

Reviewer #1: I read the manuscript entitled "" by ??? et al with great interest and would like to congratulate the authors for their effort. However, there are some minor points to improve the quality of manuscript:

1) In introduction authors discuss previous reports of vaccination COVID among pregnant women as follow:

"The refusal to accept the COVID-19 vaccine is estimated to be high and greatly differs between

countries (19). For example, an online survey of pregnant women in 16 countries found that

COVID-19 vaccine acceptance was more than 80% in Mexico and India, but lower than 45% in

the United States, Australia, and Russia (20). In Switzerland (7), the United Kingdom (21), China

4 (22), and Ethiopia (23) the willingness to accept the COVID-19 vaccine among pregnant women

was found 62.1%, 29.7%, 77.4%, and 70.7% respectively (7, 21, 22). The main factors that

determine an individual’s intent to take the COVID-19 vaccine include gender, age, educational

status, occupational status, income, pre-existence of chronic disease, attitude towards and

knowledge of COVID-19 (23-28). Moreover, multiple myths and conspiracy theories on vaccines

and COVID-19 (5, 29, 30) would also potentially affect the COVID-19 vaccine acceptance."

Please add the recent meta-analysis published evaluating the global acceptance rate of covid-19 vaccine among pregnant women. PMID: 34670322 DOI: 10.1055/a-1674-6120

2) Page7 (methods) How about the history of TdP or flu vaccine in pregnancy and the chance of accepting COVID-19 vaccination?

3) Page 8 (methods) move ethics to the beginning of the methods.

4) Page 13 and 14. it is not clear for which variables the adjustment model has been performed?

Reviewer #2: Authors performed an interesting cross-sectional study in Northwest Ethiopia, exploring the acceptance rate of covid-19 vaccine among pregnant women. They observed a low rate of acceptance, and found that women would get it when there is enough knowledge and attitude towards the vaccine. Indeed, this is the proof that when people tend to get information, the fear of unknown and unproven consequences lowers, with the effect of favoring higher uptake of vaccines. Therefore, governments should push on informative politics and campaigns with reinforcement of positive news about vaccines against SARS-CoV-2 as recent literature is showing.

The study is quite well conducted and reported. However, here are some remarks:

- there are no line numbers and this makes difficult to refer to certain sentence. When authors will resubmit the manuscript, please use line numbers

- please reformulate the methods section in the abstract which although quite understandable is not very clearly written and difficult to read especially in relation to statistical analysis, as well as the corresponding section of methods in the manuscript

- The discussion needs to be implemented: first of all, authors referred to various surveys conducted through the world, but missed to mention the first two performed in Italy, which was one of the first country that faced the diffusion of the infection after China (Carbone L, Mappa I, Sirico A, Di Girolamo R, Saccone G, Di Mascio D, Donadono V, Cuomo L, Gabrielli O, Migliorini S, Luviso M, D’antonio F, Rizzo G, Maruotti GM. Pregnant women perspectives on SARS-COV-2 vaccine. Am J Obstet Gynecol MFM. 2021 Mar 23:100352. Doi: 10.1016/j.ajogmf.2021.100352. Epub ahead of print. ----- Mappa I, Luviso M, Distefano FA, Carbone L, Maruotti GM, Rizzo G. Women perception of SARS-CoV-2 vaccination during pregnancy and subsequent maternal anxiety: a prospective observational study. J Matern Fetal Neonatal Med. 2021 Apr 11:1-4. doi: 10.1080/14767058.2021.1910672. Epub ahead of print.)

- In addition, a systematic review found more or less a similar percentage of uptake, and well discuss mechanism for the implementation of vaccine uptake (Shamshirsaz AA, Hessami K, Morain S, Afshar Y, Nassr AA, Arian SE, Asl NM, Aagaard K. Intention to Receive COVID-19 Vaccine during Pregnancy: A Systematic Review and Meta-analysis. Am J Perinatol. 2021 Oct 20. doi: 10.1055/a-1674-6120. Epub ahead of print. PMID: 34670322.)

- in this regard, in the last part of the discussion, authors could focus on how local policies could be implemented according to local healthcare issues and pregnancy management facilities

Corrections:

- introduction page 3, “in the movement”: please reformulate

- Introduction page 3, “cesarian” should be “cesarean”

- introduction page 3, “such the above-mentioned” could be “the abovementioned”

- introduction page 3, “particularly in pregnancy continues….” Please reformulate

- please delete the ORCID URL placed in page 5, in the middle of the methods, before figure 1

- methods, Data collection instrument and Study variables, page 7, “by reviewing different literature” could more properly be “after exhaustive literature search”

- methods, Data collection instrument and Study variables, page 7, “it was the outcome variable of the study” should be “it represents the main outcome of the study”

- discussion, page 15, I suggest to not use the term “perfect solution” when referring to the vaccine against SARS-CoV-2. Indeed, is a very useful and protective tool which has demonstrated to be effective in reducing the risk of contracting the infection but also reducing the severity of the eventual illness. However, “perfect solution” seems too much

- please report the references consistently among them and as per journal guidelines

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Kamran Hessami

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-22-06102R1Factors Associated With Willingness to Take COVID-19 Vaccine among Pregnant Women at Gondar Town, Northwest Ethiopia: A Multicenter Institution-Based Cross-Sectional StudyPLOS ONE

Dear Dr. Aynalem,

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.

 Editor's comments:

1. I would recommend expanding on this statement “Third, the nature of the study design, being cross-sectional, does not show the exact connection between cause and effect.” Why do the authors believe that it is challenging to determine causality?
2. Please add limitations of the systematic random sampling in the limitations section.
3. Numbers in the tables can be rounded to one or two decimal places.
4. What was the conceptual framework for examining the research question? I do see that the independent variables were selected based on the threshold of p<0.2. But have the authors considered epidemiologically, conceptually important variables to be included in the model? Or was the analysis purely explorative/descriptive? I would encourage to include a visual representation of the theoretical framework of the study so a reader can relate to it.
5. When the authors stated that “[variables]…were entered into the multivariable analysis to control for possible confounders”, it seems a bit counterintuitive to the research question. The study aims to find factors associated with the vaccine acceptance, while adjusting for confounding factors usually is done in the causative research question (one primary exposure variable). I would recommend aligning the research question with the selected analysis.
6. I also noticed that confidence intervals for some independent variables were extremely large. For example, for age 35+. Have the authors attempted to perform sensitivity analysis with different categorization of age?
7. While I appreciate the authors adding information on how the survey tool was developed, I am still concerned about the validity and reliability of the tool. For example, the authors stated that the reliability of the tool was tested using the Cronbach’s alpha which was equal to 0.87. However, my understanding is that there are several constructs in the questionnaire and one reliability measurement is not enough.
8. I am also curious how the final 10 questions for vaccine knowledge and attitude were derived? What were the initial questions and what were the number of questions? How were they selected?
9. Have the authors considered different thresholds when selecting for attitude and vaccine knowledge constructs? What were the results?
10. In the analytical part, have the authors considered potential multicollinearity in the analysis? Some of the constructs may have overlapping areas that could cause collinearity. Whether this concern could have affected the results?
11. Please include the questionnaire as a supporting document.

Please submit your revised manuscript by Sep 23 2022 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,

Alpamys Issanov

Academic Editor

PLOS ONE

Reviewers' comments:

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Factors Associated With Willingness to Take COVID-19 Vaccine among Pregnant Women at Gondar Town, Northwest Ethiopia: A Multicenter Institution-Based Cross-Sectional Study

PONE-D-22-06102R2

Dear Dr. Aynalem,

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,

Alpamys Issanov

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: