Literature DB >> 34813620

Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: A cross-sectional study.

Jude Alawa1, Lucas Walz2, Samir Al-Ali3, Nikhil Harle3, Eleanor Wiles4, Mohamed Abdullahi Awale5, Deqo Mohamed6, Kaveh Khoshnood2.   

Abstract

BACKGROUND: Somalia is considered severely underprepared to contain an outbreak of COVID-19, with critical shortages in healthcare personnel and treatment resources. In limited-resource settings such as Somalia, providing healthcare workers with adequate information on COVID-19 is crucial to improve patient outcomes and mitigate the spread of the SARS-CoV-2 virus. This study assessed the knowledge of, preparedness for, and perceptions toward COVID-19 prevention and treatment among Somali healthcare workers.
METHODS: A descriptive, cross-sectional survey was completed by 364 Somali healthcare workers in summer of 2020 utilizing a convenience sampling method.
RESULTS: Participants' most accessed sources of COVID-19 information were from social media (64.8%), official government and international health organization websites (51.1%,), and traditional media sources such as radio, TV, and newspapers (48.1%). A majority of participants demonstrated strong knowledge of treatment of COVID-19, the severity of COVID-19, and the possible outcomes of COVID-19, but only 5 out of 10 symptoms listed were correctly identified by more than 75% of participants. Although participants indicated seeing a median number of 10 patients per week with COVID-19 related symptoms, access to essential medical resources, such as N95 masks (30.2%), facial protective shields (24.5%), and disposable gowns (21.4%), were limited. Moreover, 31.3% agreed that Somalia was in a good position to contain an emerging outbreak of COVID-19. In addition, 40.4% of participants agreed that the Somali government's response to the pandemic was sufficient to protect Somali healthcare professionals.
CONCLUSION: This study provides evidence for the need to equip Somali healthcare providers with more information, personal protective equipment, and treatment resources such that they can safely and adequately care for COVID-19 patients and contain the spread of the virus. Social media and traditional news outlets may be effective outlets to communicate information regarding COVID-19 and the Somali government's response to frontline healthcare workers.

Entities:  

Mesh：

Year:  2021        PMID： 34813620      PMCID： PMC8610262          DOI： 10.1371/journal.pone.0259981

Source DB:  PubMed          Journal:  PLoS One        ISSN： 1932-6203            Impact factor:   3.240


Introduction

The 2019 novel coronavirus (COVID-19) causes an infectious respiratory illness that spreads through saliva and nasal droplets [1]. The first cases of COVID-19 surfaced in China at the end of 2019, and the World Health Organization declared the disease a pandemic on March 11th, 2020 [2]. As of April 4th, 2021, there were over 131.1 million confirmed cases of COVID-19 globally [3]. The true extent of COVID-19, however, is difficult to assess in many limited resource countries, where the infrastructure, guidance and resources necessary to control an outbreak are scarce. According to the Global Health Security Index, Somalia ranks 194 out of 195 countries in preparedness for a globally catastrophic biological event [4]. The Somali Ministry of Health announced the nation’s first confirmed case of COVID-19 on March 16th, 2020. Though the Ministry has reported approximately 11,500 cases and 530 deaths as of April 2021, it is likely that the true number of cases in Somalia is much higher due to a severe lack of testing capabilities [5,6]. In addition, as a result of more than three decades of violent conflict and natural disasters, the Somali healthcare system has remained extremely weak, poorly resourced, and deeply inequitable [5,6]. The lack of available health resources directly impacts the accessibility and quality of healthcare in Somalia. Along with a significant shortage of healthcare workers, there is a national deficit in essential equipment to treat severe COVID-19 infections, with no ventilators and only two intensive care units available across the entire country [7-10]. Similarly, only half of Somali health centers have consistent access to electricity [10,11]. A 2017 report found that, at only $33 per person, Somalia spends the least on healthcare out of 184 countries examined [12]. In order to control the spread of COVID-19 in limited-resource settings, preventative measures and adequate education are crucial. To address the threat of COVID-19 in Somalia, many organizations have scaled up water, sanitation, and hygiene (WASH) services, increased surveillance, and developed awareness campaigns [6,13-16]. In the same way, it is important that healthcare workers in Somalia are equipped with the knowledge and skills necessary to prevent the spread of COVID-19 and treat existing cases appropriately [17]. Some previous studies have shown that healthcare workers had a lack of knowledge and attitude toward MERS and SARS [18-20]. As such, this study aims to assess the knowledge of, preparedness for, and perceptions toward COVID-19 among healthcare workers in Somalia. These findings will be essential to understand the COVID-19 situation in Somalia, to inform the development of COVID-19 educational programs, and to develop an effective strategy to control the spread of COVID-19 in Somalia.

Methods

Design and instrument

Using survey tools from previous published studies and reports assessing knowledge, attitudes, and practices among healthcare workers, a descriptive, cross-sectional survey tool was designed to assess knowledge of and preparedness for COVID-19 among Somali healthcare professionals [21-26]. Our tool assessed healthcare workers’ knowledge of COVID-19, access to essential COVID-19 resources, and perception of the Somali government’s initial national response to the pandemic. The first section focused on demographic information as well as sources of information on COVID-19 and changes in the number of patients seen since the onset of the pandemic in Somalia. The second section of the survey assessed knowledge of COVID-19 through eight multiple-choice questions regarding COVID-19 transmission, incubation period, symptoms, treatments, and preventative measures. The final section of the survey consisted of 15-items to assess healthcare workers’ perceptions of COVID-19, the importance and availability of essential COVID-19 resources, and the strengths and weaknesses in Somalia’s national COVID-19 response (.

Sample and setting

A convenience sample of 364 healthcare workers in Somalia was obtained between June and August 2020. Eligibility requirements for participation in this study included being 18 years or older, physically able to complete the survey, willing to take part in the study, and working within a healthcare profession. Trained staff from the Hagarla Institute, a non-profit organization dedicated to furthering clinical research, capacity-building, and skills transfer for medical personnel across Africa, visited healthcare-delivering institutions within their network in and around Mogadishu and thereafter identified and recruited healthcare professionals who satisfied the aforementioned eligibility requirements. Within each hospital or clinic, Hagarla Institute staff approached potential participants in-person during their working hours to assess eligibility and willingness to participate. If eligibility criteria were met, a brief presentation of the purpose, procedure, and requirements for participation were given privately. Participants were told that they could withdraw from the study at any time and that their participation was entirely voluntary. Given the setting, population of interest, eligibility requirements, and the limited risks associated with participation, verbal, as opposed to written, consent was obtained from participants to facilitate timely recruitment. Verbal, informed consent was witnessed and documented for each participant by Hagarla Institute staff. After receiving consent from participants, Hagarla Institute staff interview-administered each survey. All responses were anonymous and kept confidential. This study received approval from the ethics board at SIMAD University in Somalia and was deemed exempt from review by the Yale Human Subjects Committee (ID #2000028344).

Data analysis

Responses were analyzed using SAS Studio 3.8. Sample descriptive statistics were used to report survey results, and bivariate and multivariate analyses were carried out to demonstrate the relationships between scores on COVID-19-related questions, gender, age, healthcare profession, having received information on how to best treat COVID-19 patients, number of COVID-19 symptoms correctly identified, and having reported an increase in patient caseload. These findings are presented with 95% confidence intervals. An alpha of 0.05 was adopted for all analyses.

Results

Survey demographics

The demographic characteristics of survey participants (n = 364) are shown in Table 1. The majority (60.2%, n = 219) of respondents identified as male. Most participants were comparatively young, with 73.1% (n = 266) under the age of 35 and only 6.0% (n = 22) over the age of 64. Physicians (30.2%, n = 110) and nurses (19.8%, n = 72) were the most well-represented healthcare workers among respondents. Conversely, community health workers only made up 12.1% (n = 44) of the sample.
Table 1

Respondent characteristics.

CharacteristicN (%)a,b,
Sex
    Female145 (39.8)
    Male219 (60.2)
Age
    18–24136 (37.4)
    25–34130 (35.7)
    35–4438 (10.4)
    45–6438 (10.4)
    65+22 (6.0)
Profession
    Physician110 (30.2)
    Nurse72 (19.8)
    Midwife28 (7.7)
    Pharmacist38 (10.4)
    Dentist15 (4.1)
    Community Health Worker44 (12.1)
    Other Health Workersc57 (15.7)

a n = 364.

b Values reflect frequency (percentage).

c Other health workers included medical students, public health professionals, laboratory workers, etc. One response, from a self-identified shopkeeper, was excluded.

a n = 364. b Values reflect frequency (percentage). c Other health workers included medical students, public health professionals, laboratory workers, etc. One response, from a self-identified shopkeeper, was excluded.

Sources of and exposure to COVID-19 information

Respondents’ exposure to COVID-19-related information and the specific sources accessed are shown in Table 2. A majority of respondents (69.8%) indicated that they had heard about COVID-19 prior to the confirmation of the first COVID-19 case in Somalia. Similarly, 77.5% of respondents reported that they had received lectures or participated in discussions about COVID-19. Respondents’ most accessed forms of information pertaining to COVID-19 were social media (64.8%, n = 236), official government and international health organization websites (51.1%, n = 186), and traditional sources of media such as radio, TV, and newspapers (48.1%, n = 175). Only 18.4% and 19.2% of respondents received information about COVID-19 through academic journals (n = 67) and informational calls or text messages (n = 70), respectively.
Table 2

Exposure to COVID-19 information and specific sources accessed among Somali healthcare workers.

SourceN (%)a,b
Exposure to COVID-19 Information
    Have heard about COVID-19364 (100)
    Heard about COVID-19 before March 26th (date of first confirmed case in Somalia)254 (69.8)
    Have received lectures or discussions about COVID-19282 (77.5)
Sources of Information
    News, Media (e.g. TV, Radio, Newspapers)175 (48.1)
    Informational calls/SMS70 (19.2)
    Social Media (e.g. Facebook, Twitter, WhatsApp, YouTube, Instagram, Snapchat)236 (64.8)
    Official Government/International Websites (e.g. MoH, DoH, WHO, CDC)186 (51.1)
    Family Members, Colleagues, Friends67 (18.4)
    Employer, Work Colleagues, and Others at Work55 (15.1)
    Non-Governmental Organizations (NGOs)58 (15.9)
    Local or Community Leaders60 (16.5)
    Academic Journals67 (18.4)
    Other Sources of Information9 (2.5)

a n = 364.

b Values reflect frequency (percentage).

a n = 364. b Values reflect frequency (percentage).

Respondent knowledge of COVID-19

Responses to a series of questions probing participants’ knowledge surrounding COVID-19 are shown in Table 3. A majority of participants demonstrated knowledge of the current possible treatment of COVID-19, the severity of COVID-19, and the possible outcomes of COVID-19. However, less than a third of participants correctly identified fecal-oral transmission as a way of spreading COVID-19 (26.4%, n = 96). At least 77% of participants correctly identified the main methods of preventing COVID-19 transmission, but only 66.2% of participants identified death as a possible outcome for patients infected with COVID-19 (n = 241). While 8 out of 10 of the symptoms of COVID-19 listed above were identified by a majority of respondents, only “Shortness of Breath or Difficulty Breathing,” “Dry Cough,” and “Fever” were correctly identified by over 80% of participants. In particular, “Diarrhea” (30.2%, n = 110) and “Runny Nose or Nasal Congestion” (36.5%, n = 133) were the least frequently identified COVID-19 symptoms.
Table 3

Knowledge of COVID-19 among Somali healthcare workers.

QuestionbCorrect N (%)a,cIncorrect/Don’t Know N (%)a,c
Is COVID-19 transmitted through:
    Airborne Transmission (Yes)348 (95.6)16 (4.4)
    Direct Contact of Bodily Fluids (Yes)235 (64.6)129 (35.4)
    Waterborne Transmission (No)320 (87.9)44 (12.1)
    Fecal-Oral Transmission (Yes)96 (26.4)268 (73.6)
What is the incubation period of COVID-19?
    2–14 days (Yes)146 (40.1)218 (59.9)
How would you evaluate the severity of COVID-19?
    Severe Disease which can be fatal in certain cases (Yes)260 (71.4)104 (28.6)
What is the current possible treatment of COVID-19?
    Supportive Care (Yes)317 (87.1)47 (12.9)
Can COVID-19 lead to:
    Pneumonia (Yes)252 (69.2)112 (30.8)
    Respiratory Failure (Yes)329 (90.4)35 (9.6)
    Death (Yes)241 (66.2)123 (33.8)
Can one reduce the risk of COVID-19 transmission by:
    Hand hygiene (Yes)354 (97.3)10 (2.7)
    Covering their nose & face when coughing (Yes)295 (81.0)69 (19.0)
    Freezing food that may be contaminated (No)303 (83.2)61 (16.8)
    Avoiding places where a large number of people are gathering (Yes)294 (80.8)70 (19.2)
    Avoiding sick contacts (Yes)283 (77.8)81 (22.3)
Do symptoms of COVID-19 include:
    Headache (Yes)275 (75.6)89 (24.4)
    Fever (Yes)334 (91.8)30 (8.2)
    Dry Cough (Yes)339 (93.1)25 (6.9)
    Sore Throat (Yes)245 (67.3)119 (32.7)
    Runny Nose or Nasal Congestions (Yes)133 (36.5)231 (63.5)
    New Loss of Taste and/or Smell (Yes)281 (77.2)83 (22.8)
    Shortness of Breath or Difficulty Breathing (Yes)318 (87.4)46 (12.6)
    Diarrhea (Yes)110 (30.2)254 (69.8)
    Muscle or Body Aches (Yes)195 (53.6)169 (46.4)
    Fatigue or Malaise (Yes)185 (50.8)179 (49.2)

a n = 364.

b Correct answers displayed.

c Values reflect frequency (percentage).

a n = 364. b Correct answers displayed. c Values reflect frequency (percentage).

Treatment of COVID-19 and accessibility of medical resources

The frequency of COVID-19 patients seen by respondents and respondents’ access to preventative and treatment resources is shown in Table 4. Notably, 62.1% (n = 226) of respondents reported seeing more patients since March 26th and saw a median of 10 patients with COVID-19 symptoms per week, although this number varied substantially. The most common symptoms seen in suspected COVID-19 patients were shortness of breath (84.6%, n = 308), fever (82.4%, n = 300), dry cough (77.2%, n = 281), and new loss of taste and/or smell (75.6%, n = 275) (S1 File). Despite the volume of patients suspected to have COVID-19, respondents generally reported a scarcity of medical resources required to safely treat patients. In particular, only 21.4% and 30.2% of respondents had access to disposable gowns (n = 78) and N95 masks (n = 110), respectively. The three resources identified by participants as the most important to protect oneself against exposure to COVID-19 were also reported by participants to be the most easily accessible resources, with 65.1%, 58.2%, and 58.2% reporting that it would be somewhat easy or very easy to acquire hand sanitizer (n = 237), disposable gloves (n = 212), and disposable masks (n = 212).
Table 4

Patient frequency and access to medical resources among Somali healthcare workers.

SourceN (%)a,b
Patient Frequency
    Number who reported an increase in patients seen since March 26th226 (62.1)
    Patients seen with COVID-19 symptoms per week10 ± 128
Access to Medical Resources 237 (65.1)
    Hand Sanitizer212 (58.2)
    Disposable Gloves78 (21.4)
    Disposable Gowns212 (58.2)
    Disposable Masks110 (30.2)
    N95 Masks89 (24.5)
    Facial Protective Shields103 (28.3)
    Telemedicine Capacities103 (28.3)

a n = 364.

b Values reflect frequency (percentage) for categorical variables and median ± standard deviation for continuous variables.

a n = 364. b Values reflect frequency (percentage) for categorical variables and median ± standard deviation for continuous variables.

Evaluation of national action against COVID-19

Respondents’ level of agreement with statements evaluating Somali government’s initial response to the COVID-19 pandemic are presented in Table 5. While 71.2% of respondents agreed that the Somali lockdown was effective in reducing the spread of COVID-19 (n = 259), 31.3% agreed that Somalia was in a good position to contain an emerging outbreak of COVID-19 (n = 114). Moreover, despite support for a lockdown, participants expressed that the lockdown did not make treatment services more accessible, with only 36.8% (n = 134) and 28.8% (n = 105) reporting that the lockdown made it easier for COVID-19 patients and non-COVID-19 patients with pre-existing conditions to receive treatment, respectively. Furthermore, less than half of respondents agreed that the Somali government’s response to the pandemic was sufficient to protect Somalia’s residents and healthcare professionals, with only 45.3% (n = 165) and 40.4% (n = 114) of participants affirming these statements, respectively.
Table 5

Evaluation of national action against COVID-19 among Somali healthcare workers.

StatementAgree or Strongly Agree N(%)a,bDisagree or Strongly Disagree N (%)a,bNot Sure N (%)a,b
The Somali lockdown has been effective in reducing cases and transmission of COVID-19259 (71.2)89 (24.5)16 (4.4)
The Somali lockdown has made it easier for COVID-19 patients to receive continued treatment    134 (36.8)151 (41.5)79 (21.7)
The Somali lockdown has made it easier for patients without COVID-19 and with pre-existing conditions to receive continued treatment105 (28.8)177 (48.6)82 (22.5)
I am aware of Somalia’s public health response to the COVID-19 outbreak284 (78.0)51 (14.0)29 (8.0)
The Somali government is doing enough to protect its residents from an emerging COVID-19 outbreak165 (45.3)132 (36.3)67 (18.4)
The Somali government is doing enough to protect its healthcare professionals from an emerging COVID-19 outbreak147 (40.4)145 (39.8)72 (19.8)
Somalia is in a good position to contain an emerging COVID-19 outbreak114 (31.3)144 (39.6)106 (29.1)

a n = 364.

b Values reflect frequency (percentage).

a n = 364. b Values reflect frequency (percentage).

Bi- and multivariate analyses examining high scores on COVID-19 knowledge-related questions

In an adjusted model shown in Table 6, respondents who were fairly young, who did not see more patients since the first confirmed Somali case of COVID-19, and who correctly identified more COVID-19 symptoms displayed significantly higher odds of scoring at or above 75% on questions assessing knowledge of COVID-19 (Table 3). Specifically, survey participants who were 34 years of age or younger had almost twice the odds to have scored 75% or higher (1.94; 95% CI: 1.14–3.31). Interestingly, respondents who reported seeing more patients since the diagnosis of the first COVID-19 patient in Somalia had just over half the odds of scoring at or over 75% on a set of COVID-19 related questions compared to respondents who did not report seeing more patients (0.61; 95% CI: 0.38–1.00). Lastly, compared to those who correctly identified only 0–5 symptoms of COVID-19, respondents who identified 6–7 symptoms of COVID-19 had over four times the odds to have correctly answered at least 75% of COVID-19 knowledge-related questions (4.51; 95% CI: 2.52–8.05), and respondents who identified 8–10 symptoms of COVID-19 had over seven times higher odds to have scored at or higher than 75% (7.43; 95% CI: 4.17–13.23).
Table 6

Bivariate and multivariable associations between study variables and scores of 75% or higher on a set of questions probing knowledge of COVID-19 among Somali healthcare workers.

CharacteristicN (364)N(%) scoring at or over 75% on a set of questions probing knowledge of COVID-19Unadjusted OR (95% CI)Un- adjusted p-valueAdjusted OR (95% CI)Adjusted p-value
Gender
    Male219111 (50.7)1.001.00
    Female14583 (57.2)1.30 (0.85–1.99)0.220--
Age (years)
    35+9866 (67.4)1.001.00
    18–34266128 (48.1)2.22 (1.37–3.61)0.0011.94 (1.14–3.31)0.015
Profession
    Other18291 (50.0)1.001.00
    Nurse7231 (43.1)0.76 (0.44–1.31)0.3190.78 (0.42–1.44)0.419
    Physician11072 (65.5)1.90 (1.16–3.09)0.0101.40 (0.82–2.41)0.223
Received information about how to best handle COVID-19 patients
    No6436 (56.3)1.001.00
    Yes300158 (52.7)0.87 (0.50–1.49)0.602--
Number of COVID-19 symptoms identified
    0–512230 (24.6)1.001.00
    6–710968 (62.4)5.09 (2.89–8.96)<0.0014.51 (2.52–8.05)<0.001
    8–1013396 (72.2)7.96 (4.55–13.93)<0.0017.43 (4.17–13.23)<0.001
Reporting increased patient volume since first confirmed Somalian case of COVID-19
    No13885 (61.6)1.001.00
    Yes226109 (48.2)0.58 (0.38–0.89)0.0140.61 (0.38–1.00)0.048

Discussion

To our knowledge, this is the first study examining knowledge of COVID-19, access to essential COVID-19 prevention and treatment resources, and attitudes toward Somalia’s pandemic response among Somali healthcare professionals. Somalia is particularly vulnerable to the spread of pandemic disease, with weak public health infrastructure, 2.6 million internally displaced persons [27], and a hampered national response given a political crisis that resulted in the ousting of Prime Minister Hassan Ali Khaire in July of 2020 [28]. Healthcare workers serve at the forefront against COVID-19 and are vital in the fight against its rapid spread. Therefore, it is imperative that all patient-facing healthcare workers be as familiar as possible with modes of transmission, disease progression, established prevention procedures, and treatment strategies [29]. Even while controlling for inadequate personal protective equipment, healthcare workers remain at an increased risk of becoming infected [30]. While some large studies in the United States have estimated that almost 40% of healthcare workers are at an elevated risk for developing severe COVID-19 illness [31], our sample’s demographics suggest that the healthcare workforce in Somalia is not facing the same level of risk for developing severe COVID-19 disease [32], as 73.1% of respondents were younger than 35 and only 6.0% were 65 or older. These results should not discount the importance of ensuring proper facilities and personal protective equipment access to all Somali healthcare workers, as other underlying risk factors such as smoking history may increase vulnerability to developing severe COVID-19 disease among young people to almost one in three [33]. While 62.1% of respondents reported having seen an increase of patients since the beginning of the pandemic, the current status of personal protective equipment availability in Somalia remains low; only hand sanitizer, disposable gloves, and disposable masks were reported as widely accessible by a majority of respondents. Our study demonstrated significant variation in terms of COVID-19-related knowledge. While the vast majority of respondents were able to correctly identify dry cough as a symptom of COVID-19 (93.1%), that the virus is spread through airborne transmissions by way of respiratory droplets (95.6%), and that the virus could lead to respiratory failure (90.4%), less than half of participants correctly identified COVID-19’s incubation period (40.1%) or fecal-oral as a route of transmission for the virus (26.4%). In addition, only about two in three respondents believed that COVID-19 could lead to death (66.2%). In our multivariate model, being under 35, correctly identifying 5 or more COVID-19 symptoms, and having not seen an increase in patients since March 2020 were predictive of correctly answering COVID-19 knowledge questions. In comparison to studies examining COVID-19 knowledge among healthcare workers in neighboring countries, results continue to show significant variability. A study of 442 healthcare workers in Ethiopia discovered that only 66% of respondents believed that COVID-19 may be transmitted through respiratory droplets and 52% were able to accurately identify the incubation period of the disease [34]. Meanwhile, another study of 408 healthcare workers in Northwest Ethiopia found that 94.9% were able to correctly identify COVID-19’s incubation period [35]. Novel methods to disseminate COVID-19 related information are necessary. This investigation and the study conducted in Northwest Ethiopia both report that social media, traditional news media, and official governmental and non-governmental reports were the top three sources of COVID-19 information for healthcare workers [35]. As such, utilizing social media and traditional outlets such as television and radio may be effective in circulating key COVID-19 information as a part of national information campaigns. These outlets may be used to target groups with less COVID-19 knowledge to ensure that the entire healthcare workforce is properly equipped with the necessary information to combat the COVID-19 pandemic. In addition to improving the dissemination of information about COVID-19, these data demonstrate that the Somali government should more effectively share their response plan with healthcare workers. Less than 80% of respondents indicated that they were familiar with the Somali government’s national response to combat the COVID-19 pandemic in their own country. In addition, 45.3% of respondents reported that Somalia was not doing enough to protect its residents from the emerging disease, while just over 40% believed that it was doing enough to protect its healthcare professionals. Of the existing preventive measures instituted by the Somali government, there is preliminary evidence of declining adherence, leading to more widespread infections [36]. In addition, qualitative research has shown that, without financial support, many Somali residents are having their livelihoods disparaged by structural and social factors and burdened by lockdown and disease transmission [37]. The Somali government needs to build upon its most recent quest to disseminate information with the launching of the toll-free #449 hotline, which connects over 3,000 callers per day with healthcare professionals to answer COVID-19-related questions [38].

Limitations

This study is subject to various limitations. First, this study utilized a convenience sample, which is likely not representative of the entire Somali healthcare workforce. In addition, the sampling method’s reliance on connections to the Hagarla Institute may produce a sampling bias geared towards healthcare workers located closer to Mogadishu. These biases may be partially responsible for our sample’s younger age profile. Similarly, given challenges associated with data collection in the field, especially during a COVID-19 wave, this study did not collect information relating to non-respondents. As such, this may also bias the generalizability of the study findings. Furthermore, because our multivariate analysis did not adjust for potential confounding factors, residual confounding may have been introduced. Finally, as this study utilized a cross-sectional design, it cannot be used to analyze the evolution of COVID-19 knowledge, access to personal protective equipment, and perceptions of the Somali national response over an extended period of time. This study took place during Somalia’s first wave of COVID-19. Since then, larger waves have been recorded, which is expected to have impacted knowledge of and preparedness for COVID-19 among Somali healthcare professionals. Although this study does not capture the progression of Somalia’s COVID-19 situation, the study findings provide valuable insights into pertinent factors that must be considered in preparing for and choosing how to disseminate information during future outbreaks. These findings also have direct implications for the development of future research priorities and interventions related to COVID-19 in Somalia, as well as other similar resource-constrained settings. This is a context where very little methodologically rigorous research has been conducted, and we are hopeful that this study will serve as a reference point for future public health and research initiatives being developed currently and beyond the COVID-19 pandemic.

Conclusion

This study provides evidence for the need to improve access to COVID-19 information among healthcare professionals in Somalia, a nation that is ill-equipped to resolve dramatic health inequities due to inadequate health infrastructure and shortages of healthcare personnel. It highlights a perception of inadequate access to telemedicine services and basic personal protective equipment, such as disposable gowns and N95 masks, in Somalia. This investigation also reveals a disconnect between healthcare workers and the Somali national response, which was widely perceived as failing to protect residents and healthcare workers from COVID-19. In order to sufficiently communicate with its frontline workers about developing COVID-19 information and the government’s response, the Somali government must utilize the channels healthcare workers identified as highly utilized, namely social media, traditional news outlets, and the official governmental website.

Dataset.

(XLSX) Click here for additional data file.

Study questionnaire in English.

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To ensure patient confidentiality, we would recommend removing the columns with IP address, latitude, and longitude. Additional guidance on preparing raw clinical data for publication can be found in our Data Policy FAQs (https://journals.plos.org/plosone/s/data-availability#loc-clinical-data). 4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed the survey or questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the questionnaire is published, please provide a citation to the (1) questionnaire and/or (2) original publication associated with the questionnaire. 5. We note that you have included the phrase “data not shown” in your manuscript. Unfortunately, this does not meet our data sharing requirements. PLOS does not permit references to inaccessible data. We require that authors provide all relevant data within the paper, Supporting Information files, or in an acceptable, public repository. Please add a citation to support this phrase or upload the data that corresponds with these findings to a stable repository (such as Figshare or Dryad) and provide and URLs, DOIs, or accession numbers that may be used to access these data. Or, if the data are not a core part of the research being presented in your study, we ask that you remove the phrase that refers to these data. 6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [Note: HTML markup is below. Please do not edit.] 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: Partly ********** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know 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: This is a nicely conceived, executed and written up research project that is worthy of publication due to its sound and interesting findings. It should be tweaked presentationally in some small respects. It says "Moreover, only 31.3% agreed that Somalia was in a good position to contain an emerging outbreak of COVID-19. In addition, only 40.4% of participants agreed that the Somali government’s response to the pandemic was sufficient to protect Somali healthcare professionals." Considering Somalia's extreme underpreparedness, it is a puzzle that so many participants agreed that the Somalia was in a good position to contain the outbreak or protect Somali healthcare professionals and so in both cases 'only' seems to be the wrong word. My speculation is that the participants had such low expectations that they were impressed by what little was done. Reviewer #2: It is a bit surprising that this questionnaire was completed in 2020 and the results are only now sent out for publication. According to (https://www.worldometers.info/coronavirus/country/somalia/) Somalia was experiencing its first COVID wave in June 2020, albeit with a low number of cases reported per day. However, since then a larger wave was recorded and this would be expected to have impacted the knowledge and perceptions of the healthcare workers, making the information collected through this survey somewhat outdated. In order to gather data that would be more relevant to the current moment in the pandemic’s course, I would encourage the authors to reapply the questionnaire in summer 2021 and to compare the results with those of the survey from 2020. Furthermore, it would be important to also present data on how the questionnaire was applied, who was invited to participate, how the invitations were sent and what fraction of the invitations were accepted. Also, if there is information regarding non-respondents, it would important to also present this data, in order to better understand to whom this information is generalizable. As a side note, I am a bit worried about the authors choosing to share as supplementary file the excel file which includes IP address as well as longitude and latitude, as this may lead to identification of participants, or their home address. ********** 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: Eric Herring 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. 6 Aug 2021 August 6th, 2021 Dear Editor, Thank you very much for your review of our manuscript for PLOS One entitled, "Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional study." We appreciate the editors’ and reviewers’ time and believe the edits have strengthened the manuscript considerably. We have addressed the editors’ and reviewers’ feedback below and have submitted a revised manuscript with tracked changes that correspond to the edits outlined in this letter. I hope that we have addressed all the concerns and that the manuscript is now suitable for publication. Please do not hesitate to contact me if you have any questions or comments. Sincerely, Kaveh Khoshnood, PhD, MPH Response to Reviewers for “Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional study” Comments from the Editor: Comment 1: The recommendations from two reviewers are mixed. Please confirm the reliability of data and also pay attention to the individual privacy. Response 1: We thank the reviewers and editors for their thorough review of our manuscript. We understand that the recommendations from the two reviewers are mixed, and we hope that our responses and revisions have improved the manuscript such that it is now suitable for publication. Given the timeliness of this research, the limited research on COVID-19 in the Somali context, and Somalia’s severe underpreparedness to address the COVID-19, we believe our study provides valuable findings that can be used to inform future research and local interventions. We have reviewed the manuscript to confirm the reliability of the data. Per Response 4, we have addressed concerns regarding individual privacy. We have revised the dataset file and can now confirm that the data shared are specific to this study, are in accordance with patient consent, and do not contain any personal identifying information. A new version of our Supporting Information dataset file, entitled “S1_File” has been attached. Comments regarding Journal Requirements: Comment 2: 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 Response 2: Thank you for providing these instructions and guidelines. We have revised the manuscript according to PLOS ONE’s style requirements, including those for file naming. Comment 3: Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please describe how verbal consent was documented and witnessed, and why written consent was not obtained. Please also state whether consent was informed. Response 3: Thank you for this important comment. We have added further information in the Methods section and online submission portal to reflect the process by which verbal consent was documented and witnessed, and why written consent was not obtained. We have also confirmed that consent was informed. This subsection now reads as: “A convenience sample of 364 healthcare workers in Somalia was obtained between June and August 2020. Eligibility requirements for participation in this study included being 18 years or older, physically able to complete the survey, and willing to take part in the study. If these criteria were met, a brief presentation of the purpose, procedure, and requirements for participation were given privately. Participants were told that they could withdraw from the study at any time and that their participation was entirely voluntary. Given the setting, population of interest, eligibility requirements, and the limited risks associated with participation, verbal, as opposed to written, consent was obtained from participants to facilitate timely recruitment. Informed consent was witnessed and documented for each participant by trained staff from the Hagarla Institute, who interview-administered surveys and recruited potential participants from healthcare-delivering institutions in and around Mogadishu, Somalia. The Hagarla Institute is a non-profit organization dedicated to furthering clinical research, capacity-building, and skills transfer for medical personnel across Africa. All responses were anonymous and kept confidential. This study received approval from the ethics board at SIMAD University in Somalia and was deemed exempt from review by the Yale Human Subjects Committee (ID #2000028344).” Comment 4: Thank you for sending us the data set underlying the results presented in your PLOS ONE submission. We notice that some of the information included in the supplemental data set may be potentially identifying. Please ensure that the data shared are in accordance with participant consent and provide only the data that are used in this specific study. To ensure patient confidentiality, we would recommend removing the columns with IP address, latitude, and longitude. Additional guidance on preparing raw clinical data for publication can be found in our Data Policy FAQs (https://journals.plos.org/plosone/s/data-availability#loc-clinical-data). Response 4: Thank you for bringing this critical information to our attention. We have revised the dataset file and can confirm that the data shared are specific to this study, are in accordance with patient consent, and do not contain any personal identifying information. A new version of our Supporting Information dataset file, entitled “S1_File” has been attached. Comment 5: Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed the survey or questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the questionnaire is published, please provide a citation to the (1) questionnaire and/or (2) original publication associated with the questionnaire. Response 5: Thank you for your comment. We have now attached, with appropriate captioning, another Supporting Information file (S2_File) containing the questionnaire used for this study, which was created and administered in English. We have also ensured that the details provided in the manuscript are sufficient for others to replicate our findings and analyses. Comment 6: We note that you have included the phrase “data not shown” in your manuscript. Unfortunately, this does not meet our data sharing requirements. PLOS does not permit references to inaccessible data. We require that authors provide all relevant data within the paper, Supporting Information files, or in an acceptable, public repository. Please add a citation to support this phrase or upload the data that corresponds with these findings to a stable repository (such as Figshare or Dryad) and provide and URLs, DOIs, or accession numbers that may be used to access these data. Or, if the data are not a core part of the research being presented in your study, we ask that you remove the phrase that refers to these data. Response 6: Thank you for bringing this to our attention. To ensure all of our referenced data is available and easily accessible to readers per PLOS One guidelines, we have included the most relevant material in the body of the manuscript and included the remainder of our data in a Supporting Information file containing our entire dataset. The file is called “S1_File.” We have now removed the “data not shown” reference and replaced it with an in-text reference to the Supporting Information file, S1_File. Comment 7: Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response 7: Thank you for your comment. We have now added captions for the Supporting Information files, including our dataset and study questionnaire, at the end of the manuscript. We have also updated in-text citations referring to these files. Reviewer comments: Comment 8: 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: Partly Response 8: We thank the reviewers for their assessment of our manuscript. We have reviewed the manuscript to ensure that the methods are clearly described and that conclusions drawn based on our findings are technically sound and based on rigorous statistical analyses. We have made all of our data available in the manuscript and Supporting Information files to demonstrate that our conclusions are supported by the data collected and analyses described. Comment 9: 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes Response 9: We thank the reviewers for their thorough review of our analyses. Our statistical analysis utilized conventional bivariate and multivariate models to rigorously test correlations between scores on COVID-19-related questions, gender, age, healthcare profession, having received information on how to best treat COVID-19 patients, number of COVID-19 symptoms correctly identified, and having reported an increase in patient caseload. All of our statistical findings are presented in their entirety, with all variables, measures of correlation, and confidence intervals appropriately and clearly notated. Comment 10: 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 Response 10: Thank you for your attention to this. We can confirm as well that all data underlying the finds in our manuscript have been made fully available. Comment 11: 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 Response 11: We thank the reviewers for their thorough review of our manuscript. We have proofread the manuscript once again to confirm that the language used is presented in an intelligible fashion and written in standard English. Comment 12: Reviewer #1 Comment 12.1: This is a nicely conceived, executed and written up research project that is worthy of publication due to its sound and interesting findings. It should be tweaked presentationally in some small respects. It says "Moreover, only 31.3% agreed that Somalia was in a good position to contain an emerging outbreak of COVID-19. In addition, only 40.4% of participants agreed that the Somali government’s response to the pandemic was sufficient to protect Somali healthcare professionals." Considering Somalia's extreme underpreparedness, it is a puzzle that so many participants agreed that the Somalia was in a good position to contain the outbreak or protect Somali healthcare professionals and so in both cases 'only' seems to be the wrong word. My speculation is that the participants had such low expectations that they were impressed by what little was done. Response 12.1: Thank you for your favorable review of our manuscript and for your comments. We are deeply appreciative of your time, and we are eager to share our findings on this timely and important topic in Somalia, a country that is facing monumental challenges in addressing COVID-19’s impact on their population’s health and safety. With respect to your comment, we have edited the sentences mentioned above to remove the word “only” in each case. Comment 13: Reviewer #2: Comment 13.1: It is a bit surprising that this questionnaire was completed in 2020 and the results are only now sent out for publication. According to (https://www.worldometers.info/coronavirus/country/somalia/) Somalia was experiencing its first COVID wave in June 2020, albeit with a low number of cases reported per day. However, since then a larger wave was recorded and this would be expected to have impacted the knowledge and perceptions of the healthcare workers, making the information collected through this survey somewhat outdated. In order to gather data that would be more relevant to the current moment in the pandemic’s course, I would encourage the authors to reapply the questionnaire in summer 2021 and to compare the results with those of the survey from 2020. Response 13.1: Thank you for your review of our manuscript and for your important comments and suggestions. We are deeply appreciative of your time and consideration. We recognize that the data used for this study was collected in 2020 and is now being considered for publication. Several of our research team members have been working hard to actively address the COVID-19 situation on-the-ground in Somalia and to utilize our study findings to inform future research initiatives and interventions in the field. While we recognize that larger waves of COVID-19 have been recorded since our data has been collected, we strongly believe that the information presented in our manuscript is still timely and can provide health fieldworkers with valuable insight into Somali healthcare professionals’ knowledge of and preparedness for COVID-19. In addition, we believe our findings are relevant to understanding the health situation in Somalia beyond solely the COVID-19 pandemic. For example, the findings indicating healthcare professionals’ preferred sources by which to receive developing and novel information may expedite the sharing of information in future outbreaks, COVID-19-related or otherwise. Furthermore, our research has direct implications for the development of future research priorities and interventions related to COVID-19 in Somalia, as well as other similar resource-constrained settings. This is a context where very little methodologically rigorous research has been conducted, and we are hopeful that our study will serve as a reference point for future public health and research initiatives being developed currently and beyond the COVID-19 pandemic. We are grateful for the reviewer’s suggestion to reapply the questionnaire as our team has been continuing to work in the field on research efforts to further elucidate the COVID-19 situation in Somalia. Comment 13.2: Furthermore, it would be important to also present data on how the questionnaire was applied, who was invited to participate, how the invitations were sent and what fraction of the invitations were accepted. Also, if there is information regarding non-respondents, it would important to also present this data, in order to better understand to whom this information is generalizable. Response 13.2: Thank you very much for your important suggestions. In the Methods section, under Sample and Setting, we have added further information about how the questionnaire was applied, who was invited to participate, and how participants were recruited. Unfortunately, given challenges associated with data collection in the field, especially during a COVID-19 wave, we do not have data regarding non-respondents, which may bias the generalizability of our findings. We recognize this as a limitation and have incorporated it into the Limitations section within the manuscript. Comment 13.3: As a side note, I am a bit worried about the authors choosing to share as supplementary file the excel file which includes IP address as well as longitude and latitude, as this may lead to identification of participants, or their home address. Response 13.3: We thank the reviewer for bringing our attention to this critical point. In accordance with Response 4, we have revised the dataset file, and we can confirm that the data shared are specific to this study, are in accordance with patient consent, and do not contain any personal identifying information. We have removed any information relating to IP address, latitude, and longitude. A new version of our Supporting Information dataset file, entitled “S1_File” has been attached. Submitted filename: Response to Reviewers.docx Click here for additional data file. 1 Oct 2021 PONE-D-21-11430R1Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional studyPLOS ONE Dear Dr. Khoshnood, 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 Nov 15 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, Jianguo Wang, PhD Academic Editor PLOS ONE Journal Requirements: Additional Editor Comments (if provided): [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 #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 #2: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? 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 #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 #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 #2: - I would suggest that the authors include their response to my previous query, or at least a part of it, in the Study limitations section, so that it is also available to the readers: Response 13.1. - Sample and setting: The following information has been added: “If these criteria were met, a brief presentation of the purpose, procedure, and requirements for participation were given privately.” However, it is still not clear to whom this presentation was given? How were these participants identified and chosen? From a specific hospital? Hospital network? Professional society? From social media? A hint on this is given in the lines below, but it is still not clear: “recruited potential participants within healthcare-delivering institutions in and around Mogadishu, Somalia” ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #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. 6 Oct 2021 October 6th, 2021 Dear Editor, Thank you very much for your review of our manuscript for PLOS One entitled, "Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional study." We appreciate the editors’ and reviewers’ time and believe the edits have strengthened the manuscript considerably. We have addressed the editors’ and reviewers’ feedback below and have submitted a revised manuscript with tracked changes that correspond to the edits outlined in this letter. I hope that we have addressed all the concerns and that the manuscript is now suitable for publication. Please do not hesitate to contact me if you have any questions or comments. Sincerely, Kaveh Khoshnood, PhD, MPH Response to Reviewers for “Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional study” Reviewer comments: Comment 1: I would suggest that the authors include their response to my previous query, or at least a part of it, in the Study limitations section, so that it is also available to the readers: Response 13.1. Response 1: Thank you for this important suggestion. We have incorporated our response (Response 13.1) to your previous query in our Limitations section. The section now reads: "This study is subject to various limitations. First, this study utilized a convenience sample, which is likely not representative of the entire Somali healthcare workforce. In addition, the sampling method’s reliance on connections to the Hagarla Institute may produce a sampling bias geared towards healthcare workers located closer to Mogadishu. These biases may be partially responsible for our sample’s younger age profile. Similarly, given challenges associated with data collection in the field, especially during a COVID-19 wave, this study did not collect information relating to non-respondents. As such, this may also bias the generalizability of the study findings. Because our multivariate analysis did not adjust for potential confounding factors, residual confounding may also have been introduced. Furthermore, as this study utilized a cross-sectional design, it cannot be used to analyze the evolution of COVID-19 knowledge, access to personal protective equipment, and perceptions of the Somali national response over an extended period of time. This study took place during Somalia’s first wave of COVID-19. Since then, larger waves have been recorded, which is expected to have impacted knowledge of and preparedness for COVID-19 among Somali healthcare professionals. Although this study does not capture the progression of Somalia’s COVID-19 situation, the study findings provide valuable insights into pertinent factors that must be considered in preparing for and choosing how to disseminate information during future outbreaks. These findings also have direct implications for the development of future research priorities and interventions related to COVID-19 in Somalia, as well as other similar resource-constrained settings. This is a context where very little methodologically rigorous research has been conducted, and we are hopeful that this study will serve as a reference point for future public health and research initiatives being developed currently and beyond the COVID-19 pandemic." Comment 2: Sample and setting: The following information has been added: “If these criteria were met, a brief presentation of the purpose, procedure, and requirements for participation were given privately.” However, it is still not clear to whom this presentation was given? How were these participants identified and chosen? From a specific hospital? Hospital network? Professional society? From social media? A hint on this is given in the lines below, but it is still not clear: “recruited potential participants within healthcare-delivering institutions in and around Mogadishu, Somalia.” Response 2: Thank you for bringing this point to our attention. We recognize the need for further detail as to how participants were identified and have added further information in the Sample and Setting subsection of the Methods section. The subsection now reads: "A convenience sample of 364 healthcare workers in Somalia was obtained between June and August 2020. Eligibility requirements for participation in this study included being 18 years or older, physically able to complete the survey, willing to take part in the study, and working within a healthcare profession. If these criteria were met, a brief presentation of the purpose, procedure, and requirements for participation were given privately. Participants were told that they could withdraw from the study at any time and that their participation was entirely voluntary. Given the setting, population of interest, eligibility requirements, and the limited risks associated with participation, verbal, as opposed to written, consent was obtained from participants to facilitate timely recruitment. Verbal, informed consent was witnessed and documented for each participant by trained staff from the Hagarla Institute, a non-profit organization dedicated to furthering clinical research, capacity-building, and skills transfer for medical personnel across Africa. Hagarla Institute personnel visited healthcare-delivering institutions within their network in and around Mogadishu and identified and recruited healthcare professionals who satisfied the aforementioned eligibility requirements. After receiving consent from participants, Hagarla Institute staff interview-administered each survey. All responses were anonymous and kept confidential. This study received approval from the ethics board at SIMAD University in Somalia and was deemed exempt from review by the Yale Human Subjects Committee (ID #2000028344)." Submitted filename: Response to Reviewers_2nd.docx Click here for additional data file. 12 Oct 2021 PONE-D-21-11430R2Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional studyPLOS ONE Dear Dr. Khoshnood, 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. ============================== ACADEMIC EDITOR: Please insert comments here and delete this placeholder text when finished. Be sure to:============================== Please carefully address teh comments from reviewers. Please submit your revised manuscript by Nov 26 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: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. 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 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, Jianguo Wang, PhD 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. [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 #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 #2: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? 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 #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 #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 #2: Unfortunately, the authors have not addressed my previous comment: “Sample and setting: The following information has been added: “If these criteria were met, a brief presentation of the purpose, procedure, and requirements for participation were given privately.” However, it is still not clear to whom this presentation was given? How were these participants identified and chosen? From a specific hospital? Hospital network? Professional society? From social media? A hint on this is given in the lines below, but it is still not clear: “recruited potential participants within healthcare-delivering institutions in and around Mogadishu, Somalia”” I would suggest that the authors briefly explain how they identified potential participants. For example, did they use an existing database of medical personnel from a certain hospital or a certain profession society? Or were participants approached in their own hospital during their working hours? Also, this section should clarify through which means they reached out to study participants, by phone, email, in person, etc. ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #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. 15 Oct 2021 October 15th, 2021 Dear Editor, Thank you very much for your review of our manuscript for PLOS One entitled, "Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional study." We appreciate the editors’ and reviewers’ time and believe the edits have strengthened the manuscript considerably. We have addressed the editors’ and reviewers’ feedback below and have submitted a revised manuscript with tracked changes that correspond to the edits outlined in this letter. I hope that we have addressed all the concerns and that the manuscript is now suitable for publication. Please do not hesitate to contact me if you have any questions or comments. Sincerely, Kaveh Khoshnood, PhD, MPH Response to Reviewers for “Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional study” Reviewer comments: Comment 1: Unfortunately, the authors have not addressed my previous comment: “Sample and setting: The following information has been added: “If these criteria were met, a brief presentation of the purpose, procedure, and requirements for participation were given privately.” However, it is still not clear to whom this presentation was given? How were these participants identified and chosen? From a specific hospital? Hospital network? Professional society? From social media? A hint on this is given in the lines below, but it is still not clear: “recruited potential participants within healthcare-delivering institutions in and around Mogadishu, Somalia”” I would suggest that the authors briefly explain how they identified potential participants. For example, did they use an existing database of medical personnel from a certain hospital or a certain profession society? Or were participants approached in their own hospital during their working hours? Also, this section should clarify through which means they reached out to study participants, by phone, email, in person, etc. Response 1: Thank you very much for this important suggestion. We recognize the need for further detail as to how potential participants were identified. As such, we had added more information to clarify that participants were reached out to in-person and that participants were approached in their own hospital during their working hours. Trained staff from the Hagarla Institute visited health facilities within their network and approached potential participants in-person during their working hours to assess eligibility and willingness to participate. The subsection now reads: “A convenience sample of 364 healthcare workers in Somalia was obtained between June and August 2020. Eligibility requirements for participation in this study included being 18 years or older, physically able to complete the survey, willing to take part in the study, and working within a healthcare profession. Trained staff from the Hagarla Institute, a non-profit organization dedicated to furthering clinical research, capacity-building, and skills transfer for medical personnel across Africa, visited healthcare-delivering institutions within their network in and around Mogadishu and thereafter identified and recruited healthcare professionals who satisfied the aforementioned eligibility requirements. Within each hospital or clinic, Hagarla Institute staff approached potential participants in-person during their working hours to assess eligibility and willingness to participate. If eligibility criteria were met, a brief presentation of the purpose, procedure, and requirements for participation were given privately. Participants were told that they could withdraw from the study at any time and that their participation was entirely voluntary. Given the setting, population of interest, eligibility requirements, and the limited risks associated with participation, verbal, as opposed to written, consent was obtained from participants to facilitate timely recruitment. Verbal, informed consent was witnessed and documented for each participant by Hagarla Institute staff. After receiving consent from participants, Hagarla Institute staff interview-administered each survey. All responses were anonymous and kept confidential. This study received approval from the ethics board at SIMAD University in Somalia and was deemed exempt from review by the Yale Human Subjects Committee (ID #2000028344).” Submitted filename: Response to Reviewers_3rd.docx Click here for additional data file. 2 Nov 2021 Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional study PONE-D-21-11430R3 Dear Dr. Khoshnood, 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, Jianguo Wang, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): 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 #2: All comments have been addressed ********** 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 #2: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? 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 #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 #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 #2: I thank the authors for addressing my previous comments. I now have no further comments at this point. ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #2: No 15 Nov 2021 PONE-D-21-11430R3 Knowledge of and preparedness for COVID-19 among Somali healthcare professionals: a cross-sectional study Dear Dr. Khoshnood: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Jianguo Wang Academic Editor PLOS ONE
  19 in total

1.  COVID-19 and Iranian Medical Students; A Survey on Their Related-Knowledge, Preventive Behaviors and Risk Perception.

Authors:  Mohammad Hossein Taghrir; Roham Borazjani; Ramin Shiraly
Journal:  Arch Iran Med       Date:  2020-04-01       Impact factor: 1.354

2.  Prioritization in Somali health system strengthening: a qualitative study.

Authors:  Abdihamid Warsame; Jibril Handuleh; Preeti Patel
Journal:  Int Health       Date:  2015-09-29       Impact factor: 2.473

3.  COVID-19: protecting health-care workers.

Authors: 
Journal:  Lancet       Date:  2020-03-21       Impact factor: 79.321

4.  Beneficiaries of conflict: a qualitative study of people's trust in the private health care system in Mogadishu, Somalia.

Authors:  Abdi A Gele; Mohamed Yusuf Ahmed; Prabhjot Kour; Sadiyo Ali Moallim; Abdulwahab Moallim Salad; Bernadette Kumar
Journal:  Risk Manag Healthc Policy       Date:  2017-08-01

5.  Knowledge and Attitude of Dental Health Professionals about Middle East Respiratory Syndrome in Saudi Arabia.

Authors:  Sameer Abdullah Althomairy; Mohammad Abdul Baseer; Mansour Assery; Abdulrahman Dahham Alsaffan
Journal:  J Int Soc Prev Community Dent       Date:  2018-04-24

6.  Personal Safety during the COVID-19 Pandemic: Realities and Perspectives of Healthcare Workers in Latin America.

Authors:  Diego Delgado; Fernando Wyss Quintana; Gonzalo Perez; Alvaro Sosa Liprandi; Carlos Ponte-Negretti; Ivan Mendoza; Adrian Baranchuk
Journal:  Int J Environ Res Public Health       Date:  2020-04-18       Impact factor: 3.390

7.  Knowledge and Perceptions of COVID-19 Among Health Care Workers: Cross-Sectional Study.

Authors:  Akshaya Srikanth Bhagavathula; Wafa Ali Aldhaleei; Jamal Rahmani; Mohammadjavad Ashrafi Mahabadi; Deepak Kumar Bandari
Journal:  JMIR Public Health Surveill       Date:  2020-04-30

8.  Medical Vulnerability of Young Adults to Severe COVID-19 Illness-Data From the National Health Interview Survey.

Authors:  Sally H Adams; M Jane Park; Jason P Schaub; Claire D Brindis; Charles E Irwin
Journal:  J Adolesc Health       Date:  2020-07-13       Impact factor: 5.012

9.  Knowledge and attitude towards COVID-19 and associated factors among health care providers in Northwest Ethiopia.

Authors:  Belayneh Ayanaw Kassie; Aynishet Adane; Yared Tadesse Tilahun; Eskeziaw Abebe Kassahun; Amare Simegn Ayele; Aysheshim Kassahun Belew
Journal:  PLoS One       Date:  2020-08-28       Impact factor: 3.240

10.  Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study.

Authors:  Long H Nguyen; David A Drew; Mark S Graham; Amit D Joshi; Chuan-Guo Guo; Wenjie Ma; Raaj S Mehta; Erica T Warner; Daniel R Sikavi; Chun-Han Lo; Sohee Kwon; Mingyang Song; Lorelei A Mucci; Meir J Stampfer; Walter C Willett; A Heather Eliassen; Jaime E Hart; Jorge E Chavarro; Janet W Rich-Edwards; Richard Davies; Joan Capdevila; Karla A Lee; Mary Ni Lochlainn; Thomas Varsavsky; Carole H Sudre; M Jorge Cardoso; Jonathan Wolf; Tim D Spector; Sebastien Ourselin; Claire J Steves; Andrew T Chan
Journal:  Lancet Public Health       Date:  2020-07-31
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