PONE-D-22-31498The effect of COVID-19 vaccine tele-educational program on vaccine hesitancy and receiving the vaccine among women planning for pregnancy, pregnant or breast-feeding mothersPLOS ONE

Dear Dr. Masa'Deh,

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. comments and notes: 

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5. correct the following spelling mistakes:

page 5, line 4 vaccination instead of vaccines

page5, line 10 change declining to decline

page6, line 7 correct spelling of COVID-19

page6, line 32 change Statisitics to Statistics

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11. 1. please consider adding the following articles of a similar topic and discussed the topic you are discussing and published form Jordan:

A. Aloweidi A, Bsisu I, Suleiman A, et al.: Hesitancy towards COVID-19 vaccines: an analytical cross-sectional study. Int J Environ Res Public Health. 2021, 18:5111. 10.3390/ijerph18105111

B. Abdullah M, Shahait A D, Qaisieh R, et al. (June 26, 2022) Perspectives on COVID-19 Vaccines and Its Hesitancy Among Jordanian Population. Cureus 14(6): e26337. doi:10.7759/cureus.26337

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Mohamad Abdullah, M.D., CHM.G/S., MRCS.

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PLOS ONE

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PONE-D-22-31498R1The Effect of COVID-19 Vaccine Tele-educational Program on Vaccine Hesitancy and Receiving the Vaccine Among Women Planning for Pregnancy, Pregnant or Breast-feeding MothersPLOS ONE

Dear Dr. Masa'Deh,

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.

Thank you for submitting this article to PLOS one journal, this article has been reviewed by two reviewers, you can find the reviewer comments bellow.  please read the comments carefully and make the required changes according to the reviewer comments

Please submit your revised manuscript by Mar 31 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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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,

Mohamad Abdullah, M.D., CHM.G/S., MRCS.

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):

comments from reviewers :

reviewer 1:

The article is presented in a logical and scientific way. Although the language needed to be enhanced to a standard level. Data availability section should be added.

This study has been performed in 2021, I suggest the authors should go and see the state of the art in the topic and enrich the introduction and discussion.

The sample is not quite representative as doesn't include women from south Jourdan.

reviewer 2:

This study has a significant added value to the literature, as it is one of the first interventional studies to investigate the effect of a tele-educational program on vaccine hesitancy among pregnant, planning for pregnancy, or breast-feeding mothers and examined detailed COVID-19 vaccine acceptance among such a vulnerable group in an Eastern Mediterranean developing country. The manuscript is well-written, and the study findings would interest the readers of PlosOne journal. The title and abstract cover the critical aspects of the work. The Introduction provides background and information relevant to the study. The methods are straightforward and replicable. The results are novel and easy to follow, and the statistical tests used are appropriate and answer the study questions. However, there are some comments and suggestions that are doable and will improve the quality of the article if done appropriately.

My main concern is that many of the analysis steps and tests are described in the Results section rather than the Methods section of the manuscript. Also, the results section is not the right place for conclusions. The Results section should include the study findings without details on the study strategy, analysis steps, or conclusions. This point is described in detail in the following comments.

Introduction:

1. The first paragraph of the Introduction is too long. Thus, I encourage the authors to divide the Introduction into 2 or 3 paragraphs rather than one paragraph. For example:

The second paragraph could be started with “Global studies found that pregnant women ………”

The third paragraph from “Based on risk-benefit calculations……….”

2. Also, I prefer to include in the first paragraph of the Introduction section more information about seroprevalence and vaccine coverage worldwide and in developing countries. Also, you could mention the benefits of vaccination over traditional precautionary measures, such as curfews, isolation, sealing the borders …..etc. These benefits could be included in the Introduction and Discussion sections of the manuscript. You could use the following references:

A. https://ourworldindata.org/covid-vaccinations

B. Sheikh Ali S, Kheirallah KA, Sharkas G, et al. SARS-CoV-2 Seroepidemiological Investigation in Jordan: Seroprevalence, Herd Immunity, and Vaccination Coverage. A Population-Based National Study. Int J Gen Med. 2022;15:7053-7062. Published 2022 Sep 5. doi:10.2147/IJGM.S371711.

C. Ramadan M, Hasan Z, Saleh T, et al. Beyond knowledge: Evaluating the practices and precautionary measures towards COVID-19 amongst medical doctors in Jordan. Int J Clin Pract. 2021;75(6):e14122. doi:10.1111/ijcp.14122.

D. Al-Mistarehi AH, Kheirallah KA, Yassin A, et al. Determinants of the willingness of the general population to get vaccinated against COVID-19 in a developing country. Clin Exp Vaccine Res. 2021;10(2):171-182. doi:10.7774/cevr.2021.10.2.171

E. Samrah SM, Al-Mistarehi AW, Ibnian AM, et al. COVID-19 outbreak in Jordan: Epidemiological features, clinical characteristics, and laboratory findings. Ann Med Surg (Lond). 2020;57:103-108. Published 2020 Jul 18. doi:10.1016/j.amsu.2020.07.020

Methods:

3. In the Ethical considerations subsection, could you clarify the organizations from which participants were recruited?

4. Did the participants receive any compensation or rewards for participating in the study? Please, include this point in the manuscript.

5. Are there any missing data during the collection process? If yes, how did you deal with it?

6. Do the authors have data about the number of women who refused to participate and their reasons?

Results:

7. In the first paragraph, you mentioned again, “Before the program, none of them received the COVID-19 vaccine.” This point is redundant for the inclusion criteria, and I prefer to remove it here.

8. Could you calculate and add the p-values to table 1 to compare the two groups? Also, please raise up the age variable in table 1 to the third raw (Directly after the group variable)

9. This paragraph is redundant for what was previously mentioned in the Methods: “Three analysis steps were done to determine the effect of a tele-educational program on vaccine hesitancy among women planning for pregnancy and pregnant and breast-feeding mothers. Firstly, an independent t-test was used to examine any difference in the mean score of the hesitancy to get the vaccine before conducting the program between the intervention group and the control group” >>> The Results section should include the study findings with no details on the study strategy and analysis steps. These points should be just mentioned in the Methods section of the manuscript.

10. Similarly, the following paragraph should be omitted from the Results section: “Secondly, an independent t-test was used to examine any difference in the mean score of the hesitancy to get the vaccine between the intervention group and the control group after conducting the program.”

11. In table 2, the p-value of 000 should be presented as (<0.001). As well as, the p-values in table 3 and table 4 should be corrected.

12. Also, the following paragraph is redundant and should be omitted from the Results section: “Thirdly, a paired samples t-test was conducted to examine any difference in the mean score of the hesitancy to get the vaccine for the intervention group and control group before and after the program.”

13. This paragraph should be transferred from the Results section to the Methods section: “Concerning COVID-19 vaccination, related samples McNemar test was conducted to examine any vaccine rate difference before and after the program.”

14. The last paragraph in the Results section should be transferred to the Discussion and Conclusion sections of the manuscript: “To conclude, there was no significant difference in the hesitancy of COVID-19 vaccination …………………… of COVID-19 vaccination and increasing the tendency to get the vaccine in the interventional group only.”

Discussion:

15. The discussion should be extended with more details to include more information about vaccination hesitancy and determinants in developing countries, particularly among women planning to be pregnant, and how this study will solve this significant issue. Also, as previously mentioned, I prefer to include the benefits of vaccination over traditional precautionary measures, such as curfews, isolation, sealing the borders …..etc. In addition, this study’s findings should be compared with previous studies in the literature.

I would refer you to the following helpful references:

a. Al-Mistarehi AH, Kheirallah KA, Yassin A, et al. Determinants of the willingness of the general population to get vaccinated against COVID-19 in a developing country. Clin Exp Vaccine Res. 2021;10(2):171-182. doi:10.7774/cevr.2021.10.2.171

b. Wainstock T, Sergienko R, Orenshtein S, Sheiner E. Factors associated with COVID-19 vaccination likelihood during pregnancy [published online ahead of print, 2023 Jan 18]. Int J Gynaecol Obstet. 2023;10.1002/ijgo.14680. doi:10.1002/ijgo.14680

c. Blakeway H, Prasad S, Kalafat E, et al. COVID-19 vaccination during pregnancy: coverage and safety. Am J Obstet Gynecol. 2022;226(2):236.e1-236.e14. doi:10.1016/j.ajog.2021.08.007

d. Bechini A, Moscadelli A, Pieralli F, et al. Impact assessment of an education course on vaccinations in a population of pregnant women: a pilot study. J Prev Med Hyg. 2019;60(1):E5-E11. Published 2019 Mar 29. doi:10.15167/2421-4248/jpmh2019.60.1.1093

16. Study strengths:

a) I do not think the study sample size is one of the strengths.

b) One of its strengths is the study’s quasi-experimental interventional design, timeliness, and target population of women who did not take the COVID-19 vaccine.

c) Most vitally, this is one of the first studies that obtained insights into the effect of a tele-educational program on vaccine hesitancy among pregnant, planning for pregnancy, or breast-feeding mothers and examined detailed COVID-19 vaccine acceptance among such a vulnerable group in an Eastern Mediterranean developing country. Thus, this study tried to fill the gap in the literature regarding such issues outside Western countries.

17. Study limitations:

A. The study sample size is relatively small. However, the sample was collected from different areas throughout the country.

B. The selection bias can not be excluded as the study participants were collected from prenatal/maternity clinics. Thus, the results are unlikely to be generalizable beyond those who responded.

C. Also, the point mentioned in the manuscript: “Although the study aimed to include only pregnant women, planning for pregnancy, and breast-feeding mothers, their answers may vary from the general population and people in other situations.”

[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: (No Response)

Reviewer #2: (No Response)

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: No

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: No

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: The article is presented in a logical and scientific way. Although the language needed to be enhanced to a standard level. Data availability section should be added. This study has been performed in 2021, I suggest the authors should go and see the state of the art in the topic and enrich the introduction and discussion. The sample is not quite representative as doesn't include women from south Jourdan.

Reviewer #2: This study has a significant added value to the literature, as it is one of the first interventional studies to investigate the effect of a tele-educational program on vaccine hesitancy among pregnant, planning for pregnancy, or breast-feeding mothers and examined detailed COVID-19 vaccine acceptance among such a vulnerable group in an Eastern Mediterranean developing country. The manuscript is well-written, and the study findings would interest the readers of PlosOne journal. The title and abstract cover the critical aspects of the work. The Introduction provides background and information relevant to the study. The methods are straightforward and replicable. The results are novel and easy to follow, and the statistical tests used are appropriate and answer the study questions. However, there are some comments and suggestions that are doable and will improve the quality of the article if done appropriately.

My main concern is that many of the analysis steps and tests are described in the Results section rather than the Methods section of the manuscript. Also, the results section is not the right place for conclusions. The Results section should include the study findings without details on the study strategy, analysis steps, or conclusions. This point is described in detail in the following comments.

Introduction:

1. The first paragraph of the Introduction is too long. Thus, I encourage the authors to divide the Introduction into 2 or 3 paragraphs rather than one paragraph. For example:

The second paragraph could be started with “Global studies found that pregnant women ………”

The third paragraph from “Based on risk-benefit calculations……….”

2. Also, I prefer to include in the first paragraph of the Introduction section more information about seroprevalence and vaccine coverage worldwide and in developing countries. Also, you could mention the benefits of vaccination over traditional precautionary measures, such as curfews, isolation, sealing the borders …..etc. These benefits could be included in the Introduction and Discussion sections of the manuscript. You could use the following references:

A. https://ourworldindata.org/covid-vaccinations

B. Sheikh Ali S, Kheirallah KA, Sharkas G, et al. SARS-CoV-2 Seroepidemiological Investigation in Jordan: Seroprevalence, Herd Immunity, and Vaccination Coverage. A Population-Based National Study. Int J Gen Med. 2022;15:7053-7062. Published 2022 Sep 5. doi:10.2147/IJGM.S371711.

C. Ramadan M, Hasan Z, Saleh T, et al. Beyond knowledge: Evaluating the practices and precautionary measures towards COVID-19 amongst medical doctors in Jordan. Int J Clin Pract. 2021;75(6):e14122. doi:10.1111/ijcp.14122.

D. Al-Mistarehi AH, Kheirallah KA, Yassin A, et al. Determinants of the willingness of the general population to get vaccinated against COVID-19 in a developing country. Clin Exp Vaccine Res. 2021;10(2):171-182. doi:10.7774/cevr.2021.10.2.171

E. Samrah SM, Al-Mistarehi AW, Ibnian AM, et al. COVID-19 outbreak in Jordan: Epidemiological features, clinical characteristics, and laboratory findings. Ann Med Surg (Lond). 2020;57:103-108. Published 2020 Jul 18. doi:10.1016/j.amsu.2020.07.020

Methods:

3. In the Ethical considerations subsection, could you clarify the organizations from which participants were recruited?

4. Did the participants receive any compensation or rewards for participating in the study? Please, include this point in the manuscript.

5. Are there any missing data during the collection process? If yes, how did you deal with it?

6. Do the authors have data about the number of women who refused to participate and their reasons?

Results:

7. In the first paragraph, you mentioned again, “Before the program, none of them received the COVID-19 vaccine.” This point is redundant for the inclusion criteria, and I prefer to remove it here.

8. Could you calculate and add the p-values to table 1 to compare the two groups? Also, please raise up the age variable in table 1 to the third raw (Directly after the group variable)

9. This paragraph is redundant for what was previously mentioned in the Methods: “Three analysis steps were done to determine the effect of a tele-educational program on vaccine hesitancy among women planning for pregnancy and pregnant and breast-feeding mothers. Firstly, an independent t-test was used to examine any difference in the mean score of the hesitancy to get the vaccine before conducting the program between the intervention group and the control group” >>> The Results section should include the study findings with no details on the study strategy and analysis steps. These points should be just mentioned in the Methods section of the manuscript.

10. Similarly, the following paragraph should be omitted from the Results section: “Secondly, an independent t-test was used to examine any difference in the mean score of the hesitancy to get the vaccine between the intervention group and the control group after conducting the program.”

11. In table 2, the p-value of 000 should be presented as (<0.001). As well as, the p-values in table 3 and table 4 should be corrected.

12. Also, the following paragraph is redundant and should be omitted from the Results section: “Thirdly, a paired samples t-test was conducted to examine any difference in the mean score of the hesitancy to get the vaccine for the intervention group and control group before and after the program.”

13. This paragraph should be transferred from the Results section to the Methods section: “Concerning COVID-19 vaccination, related samples McNemar test was conducted to examine any vaccine rate difference before and after the program.”

14. The last paragraph in the Results section should be transferred to the Discussion and Conclusion sections of the manuscript: “To conclude, there was no significant difference in the hesitancy of COVID-19 vaccination …………………… of COVID-19 vaccination and increasing the tendency to get the vaccine in the interventional group only.”

Discussion:

15. The discussion should be extended with more details to include more information about vaccination hesitancy and determinants in developing countries, particularly among women planning to be pregnant, and how this study will solve this significant issue. Also, as previously mentioned, I prefer to include the benefits of vaccination over traditional precautionary measures, such as curfews, isolation, sealing the borders …..etc. In addition, this study’s findings should be compared with previous studies in the literature.

I would refer you to the following helpful references:

a. Al-Mistarehi AH, Kheirallah KA, Yassin A, et al. Determinants of the willingness of the general population to get vaccinated against COVID-19 in a developing country. Clin Exp Vaccine Res. 2021;10(2):171-182. doi:10.7774/cevr.2021.10.2.171

b. Wainstock T, Sergienko R, Orenshtein S, Sheiner E. Factors associated with COVID-19 vaccination likelihood during pregnancy [published online ahead of print, 2023 Jan 18]. Int J Gynaecol Obstet. 2023;10.1002/ijgo.14680. doi:10.1002/ijgo.14680

c. Blakeway H, Prasad S, Kalafat E, et al. COVID-19 vaccination during pregnancy: coverage and safety. Am J Obstet Gynecol. 2022;226(2):236.e1-236.e14. doi:10.1016/j.ajog.2021.08.007

d. Bechini A, Moscadelli A, Pieralli F, et al. Impact assessment of an education course on vaccinations in a population of pregnant women: a pilot study. J Prev Med Hyg. 2019;60(1):E5-E11. Published 2019 Mar 29. doi:10.15167/2421-4248/jpmh2019.60.1.1093

16. Study strengths:

a) I do not think the study sample size is one of the strengths.

b) One of its strengths is the study’s quasi-experimental interventional design, timeliness, and target population of women who did not take the COVID-19 vaccine.

c) Most vitally, this is one of the first studies that obtained insights into the effect of a tele-educational program on vaccine hesitancy among pregnant, planning for pregnancy, or breast-feeding mothers and examined detailed COVID-19 vaccine acceptance among such a vulnerable group in an Eastern Mediterranean developing country. Thus, this study tried to fill the gap in the literature regarding such issues outside Western countries.

17. Study limitations:

A. The study sample size is relatively small. However, the sample was collected from different areas throughout the country.

B. The selection bias can not be excluded as the study participants were collected from prenatal/maternity clinics. Thus, the results are unlikely to be generalizable beyond those who responded.

C. Also, the point mentioned in the manuscript: “Although the study aimed to include only pregnant women, planning for pregnancy, and breast-feeding mothers, their answers may vary from the general population and people in other situations.”

**********

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Reviewer #1: No

Reviewer #2: Yes: Abdel-Hameed Al-Mistarehi

**********

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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.

The Effect of COVID-19 Vaccine Tele-educational Program on Vaccine Hesitancy and Receiving the Vaccine Among Women Planning for Pregnancy, Pregnant or Breast-feeding Mothers

PONE-D-22-31498R2

Dear Dr. Masa'Deh,

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.

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Kind regards,

Mohamad Abdullah, M.D., CHM.G/S., MRCS.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: