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

BACKGROUND: Refugees are at increased risk for COVID-19 infection in part due to their living conditions, which make it harder to adopt and adhere to widely accepted preventive measures. Little empirical evidence exists about what refugees know about COVID-19 and what they do to prevent infection. This study explored what refugee women and their health care workers understand about COVID-19 prevention, the extent of their compliance to public health recommendations, and what influences the adoption of these measures.
METHODS: In October 2020, we conducted 25 in-depth interviews with facility and community health care staff (n = 10) and refugee women attending antenatal and postnatal care services (n = 15) in Eastleigh, Nairobi.
FINDINGS: While researchers found a high level of awareness about COVID-19 and related prevention and control measures among refugee women, various barriers affected compliance with such measures, due in part to poverty and in part to rampant misconceptions informed by religious beliefs and political narratives about the virus.
CONCLUSIONS: These findings indicated that Kenya's Ministry of Health needs to institute a concerted and continuous education program to bring refugee communities up to speed about COVID-19 and its prevention. In addition to disseminating information about the need to wear masks and repeatedly wash hands, supplies-masks, soap and access to water-need to be made available to poor refugee communities. Future research could explore which measures for disseminating factual information work best in refugee populations with different cultural norms and how best to target interventions to these groups.

Background

Across the globe, concerns have developed that governments have failed to address the needs of refugees in dealing with COVID-19 since the virus was identified. The global health community has been particularly worried about refugees’ heightened risk for COVID-19 infection due to their high mobility and living conditions that make it harder to adopt and adhere to preventive measures such as social distancing, wearing masks, self-isolation and regular hand washing [1-5]. In addition to endemic poverty, lack of migrant-inclusive health policies and dense living conditions, refugees also face language barriers, social stigma, lack of access to water and basic sanitation and minimal access to health care services due to the lack of medical insurance and refugee-tailored, inclusive health facilities [2-5]. Furthermore, the majority of refugees living in sub-Saharan Africa are hosted in countries with weak health and social protection systems [4, 5].

Even before the onset of COVID-19, studies reported disease outbreaks across many refugee and migrant centres due to the dire conditions. Modelling studies predicted increased infections in refugee communities [6, 7]. A modelling study in Bangladesh, for instance, indicated that steep investments in health care capacity and infrastructure would be required to combat the potentially disastrous impact of the COVID-19 epidemic in one refugee settlement, but given Bangladesh’s fragile and overburdened economy, such an investment was not possible [7].

The COVID-19 pandemic has worsened the economic situation of urban refugees, many of whom were already living below the poverty line before the pandemic [4-7]. Furthermore, equitable health service delivery is hampered by refugees’ tendency to disperse throughout urban areas [4, 5]. Refugee women, who frequently have limited access to maternal health services, are more likely to experience poor pregnancy outcomes. All these conditions persisted during the COVID-19 pandemic [1, 8, 9], which clearly exacerbated the existing health care gap for refugee women—specifically perinatal refugee women residing in urban Kenya.

Little empirical evidence is available on how COVID-19 affected refugee communities and particularly refugee women, what they know about COVID-19, what they do to prevent infection and the role of health care workers. In this paper, we report on refugee women’s knowledge, their understanding of COVID-19 and key influences on compliance to public health recommendations. This is the second in a series of papers from our study that explored the impact of COVID-19 on women’s access to antenatal and postnatal services and their knowledge and understanding of COVID-19 preventive measures. Our first paper from this study reported on the impact of COVID-19 in increasing women’s preference for home deliveries [1]. We hope these papers will shed light on some of the issues faced by refugees living in low-resource settings, guide policy and exploration through future research.

Methodology

Social and cultural context

This study was conducted in Eastleigh, a semi-cosmopolitan centre in Kamukunji sub-county, Nairobi, in October 2020. Eastleigh is a vibrant business hub with a rich socio-cultural mix of people from the countries of the horn of Africa: Kenyans, Somalians, Eritreans, Ugandans, Tanzanians, Ethiopians, Rwandese, Burundians and Sudanese. The majority of the population in this area are from Somalia, are of the Muslim faith, and have lived in the area for many years, some even decades.

Following the detection of the first COVID-19 cases in Kenya in March 2020, the Kenya Ministry of Health devised lockdown measures which deterred the movement of people to and from Nairobi. Due to dense population and high refugee mobility in the Eastleigh area, COVID-19 infection spread fast, and the government prohibited movement to and from Eastleigh for one month, from 6 May to 6 June 2020. While this lockdown was intended to stop rapid infection of COVID-19 to other parts of the city, by and large these measures infuriated the residents of Eastleigh as they considered them to be marginalising due to their vulnerable refugee status. The lockdown led to delayed care as well as an increase in women preferring home delivery of babies [1]. By the time this study was conducted in October 2020, Eastleigh had resumed business activities. The socio-cultural and economic context of Eastleigh is documented in more detail in our first paper from this study [1].

Study design

This was a rapid qualitative study employing in-depth individual interviews [IDIs].

Aim

This paper reports our findings on the knowledge, understanding and influences on compliance with COVID-19 preventive measures identified by antenatal and postnatal refugee women and their health care workers.

Study population and sampling methods

To broaden and deepen our comprehension of how COVID-19 impacted access to and utilization of health care services, we conducted in-depth interviews [IDIs] with three facility-based health care workers [FHCWs], seven community health volunteers [CHVs] and 15 refugee women receiving antenatal care services [ANC] [n = 10] or postnatal care services [PNC] [n = 5]. Facility Health Care workers were recruited for this study because they play a central role in keeping records at the International Organization for Migration [IOM] clinic in Eastleigh that specifically serves the refugee community. Their inclusion was based on the premise that they could provide vital information on the refugees’ attendance and uptake of services at the facility during the early periods of the pandemic as well as provide some information on what measures were undertaken at the facility to help staff and patients comply with COVID-19 preventive measures. Community health volunteers (CHVs) who served the refugee community were deemed an appropriate population for exploring their observed experience working with refugees in the communities and linking them to the facility services. Table 1 below illustrates the study sample characteristics.

Table 1

Summary of the study sample and population description.

Categories	Total number of participants interviewed	Description of participants
Facility health care workers	3	• More than one year of experience working with refugees
		• Experience working with maternal child health services, such as antenatal, postnatal and HIV patient care
		• Provided services to the communities including counselling
		• Native Kenyans
Community health care workers	7	• More than one year of experience working with refugee community
		• Facilitated antenatal and postnatal referrals from the refugee communities
		• Six of Somali origin and Muslim, with the exception of one CHV who was a native Kenyan
		• Roles were varied, including linking patients from the community to facility care, following up on contact tracing for tuberculosis patients, conducting household disease surveillance, promoting community hygiene and facilitating antenatal and postnatal uptake of services
Antenatal patients	10	• Participants by nationality: Somalis (n = 6), Tanzanians (n = 2), Ugandans (n = 1), Eritreans (n = 1)
		• Had more than three children; the largest family had 10 children
		• Aged 19 to 29, all unemployed, had lived in Eastleigh for at least one year and were married
Postnatal patients	5	• All were Somalis and had delivered during the pandemic
		• Minimum number of children in the family was two and highest was nine
		• All married, unemployed, of Muslim religion and lived in Eastleigh

Data collection

We conducted data in October 2020 after ethical approvals were obtained from the Aga Khan University, Kenya Institutional Ethics Review Committee [Ref: 2020/IERC-84 (V2)] on 3 August 2020. Research was licensed by the National Commission for Science, Technology and Innovation [NACOSTI/P/20/6507] on 11 September 2020. Further approval was sought from Nairobi Metropolitan Services [Ref: EOP/NMS/HS/7/VOL.1/RS/30] on 5 October 2020.

Considering the diversity of the refugees, the study guide was developed in both English and Kiswahili, with separate components for the health care workers, antenatal women and postnatal women. First, the research team from IOM and the Department of Population Health (DPH) at the Aga Khan University (AKU) met regularly for 4 months to develop the interview guides. Teams of qualified social scientists further reviewed the study tools to identify gaps. Secondly, following the review of the English version of the tools, the guides were given to IOM-qualified translators with many years of experience working with the refugee communities to translate the guide from English to Kiswahili. Upon completion of the translation, the questions were reviewed by the AKU principal investigator (AL), and an initial pilot of the guide was conducted with a health care worker and an antenatal clinic patient who were not included in the final study. Concerns raised included, for instance, the need to simplify the complex meaning of some words, such as antenatal, for the refugees. We therefore decided that, during the interview, a Somali translator would be available before the start of all interviews, and any of the refugee participants needing to converse in any of the Somali languages would be supported. Lastly, the principal investigator trained the research assistant and a part-time qualitative consultant who conducted some of the interviews. Issues around COVID-19 preventive measures and adherence during field work were discussed, and we impressed upon the research team the importance to adhere to COVID-19 preventive measures during data collection. For example, the research team had available face masks and hand washing gel which they provided to all participants before the start of the interviews.

Our participants were recruited by staff working at the Eastleigh clinic who had direct links with all the CHVs and postnatal [PNC] and antenatal [ANC]women in the communities. The study principal investigator provided information about the study to the recruiting team, which they explained to potential participants before accepting them into the study. The recruitment of ANC and PNC women occurred at the IOM clinic during their weekly appointments, and they were given a time and day for the interview. Some participants were recruited through phone calls from FHCWs at the IOM clinic.

During the interview, the research team supplied study information to the participants, including the importance of adhering to COVID-19 preventive measures during the interviews, the objective of the study, the importance of confidentially, voluntary participation, benefits and possible risks involved and what they should do should they feel uncomfortable. Information sheets and informed consent, available in both English and Kiswahili, were provided in participants’ preferred language. Interviews began after participants provided informed consent. Because some of the participants were illiterate, they signed consent forms using a thumb pad with the help of the study translator.

Five of the 15 refugee women interviewed did not speak Kiswahili or English, so we worked with an interpreter who was a trained community health volunteer directly linked to the Eastleigh Clinic. The IDIs for the FHCWs and CHVs were led by the study principal investigator, a Kenyan social scientist with more than 16 years’ experience in research, while the IDIs with refugee women were conducted by a trained qualitative researcher and a research assistant. The IDIs were held in private clinical rooms within the clinic, which was considered a convenient and confidential environment for the interviewees.

Data collected included participants’ socio-demographic information, knowledge and understanding of COVID-19, what training had been offered and by whom, compliance with COVID-19 preventive measures, challenges faced in complying with COVID-19 measures and possible enablers to compliance with public health recommendations, among other data.

Data management and analysis

All audio-recorded interviews were transcribed verbatim from Kiswahili to English by a professional consultant and uploaded to a Department of Population Health password-protected laptop. The research team (AL and SO) listened to the audio-recorded transcripts and compared them with the transcribed data and reflective notes developed during the interviews. We then anonymised the transcripts by deleting references to names and roles and uploaded them in NVivo 12, a qualitative data analysis software program.

We first reviewed three transcripts, developed codes separately and then compared codes and developed the initial coding framework that was used to code the remaining transcripts. Initial codes that we developed were charted into categories and then thematic areas as shown below. A Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist, S1 Appendix, was used in reporting our study findings.

Results

1. Refugee women’s knowledge about COVID-19

Refugee women participants for this study were asked to share their experiences regarding their current knowledge, attitudes and perceptions towards COVID-19. In particular, they were asked what they knew about COVID-19 and associated health risks and what information they had received. Refugee women demonstrated an awareness, and understanding, of COVID-19 preventative measures.

Washing of hands, wearing of masks. Yes, one must wash hands properly, regular sanitizing of hands and one has to wash their hands when they get back home.

We were sensitized [by CHVs and IOM staff] that we should not walk along the roads with the child, we avoid being close to each other, we should not get out without a mask, we shouldn’t even stay without washing hands, we avoid shaking of hands.

Some refugee women were aware of the symptoms and risks associated with COVID-19. Awareness of the severity of the disease was also very high, with some of the participants describing COVID-19 as ‘a deadly disease’ and ‘kills directly’.

It is a disease which comes and kills directly. Signs and symptoms are coughing, flu.

A person with corona presents with body fever and cough mixed with fluid like mucus. That is what corona is.

Corona is deadly disease, according to what I have heard, it can kill people.

Overall, we found a universal awareness of COVID-19 and preventive measures among the refugee women, indicating that their knowledge is appropriate. The findings indicate that wearing masks, hand washing, social distancing, avoiding handshakes and restricted movement were the most commonly identified prevention and control measures. The narratives also demonstrate that the government and CHVs had provided ongoing sensitization about COVID-19 among the urban refugee communities. However, only some of the women could identify a few of the symptoms of COVID-19.

2. Refugee women’s sources of information about COVID-19

Sources of information about COVID-19 ranged from the local news (television and radio) to informal networks and the CHVs’ outreach services.

Local news as a source of COVID-19 information

The local news media, particularly radio and television, and healthcare workers in the local hospitals in which they visited were identified as sources of information about COVID-19 and associated prevention and control measures.

I heard it over the radio. When I listen to the news over radio, you are supposed to protect yourselves, you don’t walk around or to sit in groups, you must follow instructions. When you go to the shops you must have your masks.

I heard from hospital and even from news. From the television, also, I have heard it even from the government hospital when I visit there.

Informal networks

Informal social networks and word of mouth in residential areas were also primarily identified as authoritative sources of information on COVID-19, with newspaper and television cited as complementary sources.

I heard from other people that there is a disease from China, then after while it arrived in Kenya but we took it lightly…. It is true; it is even common in our estate to find people seated together in groups as they chat and say that there is no corona.

The Role of CHVs as a source of information for refugee communities

Although the refugee women reported that their main sources of information were the media and their informal networks, narratives from the CHVs working with the refugee communities indicated that they also played a significant role in educating the community about COVID-19 preventive measures and symptoms. Detailed findings on how refugees delivered education about COVID-19 is reported in detail in our separate paper focusing exclusively on this communication. In the following quotes, some CHVs explain how they helped families reluctant to follow preventive measures.

: Yes, because this has also helped our community as you would find people with small children never bothered to wash their hands, and we encouraged them to wash their hands after every 10–20 minutes and ensure they take care of their children, they avoid crowded places and, if they must, they should wear a mask. We advised them that it was not safe for a pregnant woman to contract corona.

CHVs applied various approaches, including the use of megaphones and designated vehicles, for wider coverage in the refugee community.

After being trained we were to pass the information to the community. We even moved all over Kamukunji sensitizing people using a [megaphone] to make sure they get the information properly. We could use a vehicle rotating, we could stop to educate people on prevention and control measures. It was like we were TOTs [trainer of trainers].

Further, CHVs provided telephone numbers for the refugee women and their families experiencing COVID-19 signs to call in case of emergency. Additional efforts were made to provide simple information using posters as well as translating the information into languages well understood by refugees.

: The training I was given regarding COVID-19 is that I was to educate my community on what COVID-19 is, the symptoms and where they can get assistance and the number to call just in case there is a person in the household who has those symptoms.

After receiving the information, we dedicated time and explained to people, because there are those people, especially refugees, that don’t want to know about these facts. They claimed it was not possible for them to observe the social distance so it was difficult for us at first, but when the numbers spiked up, they started getting convinced.

These quotes illustrate how empowering CHVs with training on the early onset of epidemic can be an efficient in the dissemination of knowledge and information among marginalized people such as refugees.

3. Influences on Refugee Women’s Compliance with COVID-19 preventive measures

Findings predominantly from CHVs revealed that in the 2 months following the first COVID-19 diagnosis in Kenya, most refugees did not believe that COVID-19 really existed, and by the time this study was conducted (October 2020), some community members still doubted that COVID-19 was a reality. Political and religious factors, fear of contracting COVID-19 and non-compliance with COVID-19 preventive messages and measures were mentioned as contributing to the spread of the disease.

Political influences

Findings largely from HCWs and CHVs showed that local and international political narratives concerning COVID-19 might have had a negative bearing on how refugees first reacted to and complied with COVID-19 measures. Refugee women did not trust government messages about COVID-19. They believed that information about COVID-19 was created for political gain and therefore saw no need to follow the guidance on using masks when attending the health facilities. Some asked for evidence of people dying from COVID-19.

What they were telling us [refugees], if at all there is corona, let the government say the person or show the picture of that person who has died because of corona. That was [their] response.

Because some believed that COVID-19 guidelines were politically motivated, they did not take mask wearing seriously and only carried a mask in case they encountered police.

Some of them could come in [to the health clinic] even without a mask. When you ask them, they say we don’t have corona, our politicians are using that excuse to get money. That is how they came in with information. Some of them could be having the masks, just hanging it but not using it effectively because they say if I don’t have a mask the policeman will catch me outside there, so I will have to keep it here, if I see them, I just put it on.

Findings indicate that information given to refugees about preventive measures conflicted with international news suggesting that wearing of masks was equivalent to inhaling carbon monoxide. Conflicting messages may have made it difficult for refugees to change their behaviours considering, for instance, that some of these statements were coming from the siting United States president. Importantly, these findings may indicate how quickly marginalised communities can be influenced by politicians.

: There is big gap. It seems like they forgot everything they were taught. They need to be reminded every time. Sometimes they watch news, there was a debate in US [presidential debate] they heard [from the siting president] that if you are using a mask you are inhaling carbon monoxide, it is affecting you [more] than helping yourself. So, some of them don’t even use that mask because of that information that came out.

In general, and in contrast to the narratives from the refugee women, HCWs and CHVs reported that refugees did not follow guidance on wearing masks and held misconceptions about COVID-19, including, for instance, that it was a product of politicians’ imaginations to gain political mileage. The US presidential debate also convinced some that masks would cause them to suffocate. The perspectives of FHCWs and CHVs indicated the level of misinformation about COVID-19 and a lack of compliance with COVID-19 guidelines among refugee women.

Religious influences

The study data suggest that, predominantly Muslim refugee communities initially believed that COVID-19 could affect only Christians as a punishment from God and that Muslims would be protected if they continued to pray five times a day. In the following quote, a CHV working with both the host and refugee communities explains how religious beliefs may have influenced compliance with COVID-19.

: They always say that God produced that corona virus to punish the Christians, not the Muslims. … There are some rumours that went spreading that corona is not for Muslims and that it is for the Christians and that one should keep on praying five times a day and you won’t have corona.

Further, religious factors also shifted perceptions about COVID-19. For example, researchers found that the death of a well-known imam from COVID-19 might have caused Muslim refugees to shift their perceptions about ‘COVID-19 not being real’ and consequently to improve their compliance with preventive measures.

At first, they [refugee community] were so negative but after and when we continuously explained to them and did awareness [about COVID-19 preventive measures] …there was one refugee, who is their imam, who died of COVID-19 in the mosque…, this made refugees realize that it was serious. How the mode of burial was conducted and the COVID-19 protocols made the people’s mentality changed and they became positive [began to comply to preventive measures].

: Finally, they had to see the reality of it.

: After hearing that there was imam who passed away, then they realized there’s corona and they took a turn to take precautions….

Religious leaders across Africa in many denominations wield a lot of influence on their congregants. In many parts they are expected to provide leadership including provision of timely information. As we have seen, the death of the imam played a huge role in shifting perceptions among the refugee population as they could then identify someone in power, they could relate to who was actually affected by COVID-19. This may show that the need for tangible evidence among communities is real, and documenting living stories, experiences and views of community influencers is an important aspect of risk communication. When no evidence is available of the disease following its course and resulting in severe death or illness, communities may find it difficult to accept the stated impacts.

Family size and economic challenges

The data suggest that refugee family size and the economic challenges they faced might have influenced whether they adhered to COVID-19 measures. The findings indicate that the refugees tend to have families of up to 15 members residing in a single household, which can impede social distancing and mask wearing. The inability to afford masks and soap for hand washing was also cited as a barrier to compliance across all categories of participants.

In the house they are maybe more than ten to fifteen members. And I do not expect that if they are at home, they will be using the masks. So that is the problem because if it was social distance and they are so many on the house and they don’t use the mask, I don’t think they could come out of the house and practice that. So, they carried that kind of social life from their own families to the community.

Some of them when they came to the facility and when asked at the entrance about a mask, the answer was, we don’t have money to buy. That barred them from seeing a doctor, as they could not access a doctor without wearing a mask, and such refugees returned home without receiving services.

The findings indicate the impracticality of control measures in households characterized by a large number of family members where social distancing may be difficult to practice. Further, many of the refugees could not afford masks and soap due to their low economic status.

Discussion

Our findings show that refugee women are aware of COVID-19 symptoms and of globally accepted measures to prevent infection. The information has been widely disseminated through television, radio and CHVs’ outreach services. The findings confirm that, in marginalized communities, CHVs play a key role in disseminating information. They also confirm the finding of earlier studies that, in low- and middle-income countries (LMIC), CHVs who reach out to marginalized communities can significantly increase their use of public health services [9].

Our study further revealed how misinformation spread by religious and political leaders has deeply affected refugees’ beliefs, attitudes and behaviour with regard to COVID-19. Religious leaders propagated and perpetuated the misconception that Muslims are immune to COVID-19, and this idea was strongly endorsed by many followers. That the death of a well-known imam from COVID-19 helped shift notions about the virus among Muslim refugees underscores the crucial role religious leaders across the African continent could play in bringing about beneficial changes in behaviour. It demonstrates the need for public health practitioners and Ministry of Health staff to enlist the help of religious leaders in the fight against COVID-19. Studies have shown that in patriarchal communities, male engagement in promoting behaviour change is key for the success of interventions [10]. We suggest that in marginalised communities’, male religious leaders such as the imams, bishops and priests could be trained in preventive interventions and given simple messages to disseminate to their congregants.

Politicians have also greatly affected refugee communities’ desire to comply with recommended COVID-19 prevention measures. The baseline position of most refugees—who have a strong ingrained mistrust of government that may be based on experience—was that COVID-19 was a ploy created by the government. Political misinformation also derailed compliance. ‘Fake news’ circulating locally and abroad played a significant role in influencing the refugee population. This and other forms of misinformation created confusion and left refugees sceptical about the efficacy of preventive measures and, therefore, the need to adopt them.

Our interviews show how such misinformation has undermined adherence to recommended COVID-19 prevention measures. Because of political officials’ authority in the community, their posture on health issues exerts a clear effect on public behaviour. During a pandemic, marginalized and vulnerable communities, which may not have access to varied sources of information, can be highly influenced by political rhetoric.

This finding underscores the need to strengthen health care and prevention programs in marginalized communities and to empower them with factual information. In addition to engaging men and religious leaders to help get the message across, the programs need to work with CHVs to promote beneficial behaviours. In addition to the work predominantly conducted by female CHVs in this community, behaviour change can also be brought about by having other key influencers in Muslim refugee communities—such as mothers-in-law [11], grandmothers and male CHVs—disseminate messages about COVID-19.

Women refugees are greatly affected by poverty. To them, getting by on a daily basis required a steep effort even before COVID-19. Lack of jobs and other sources of livelihood made it very difficult to purchase masks, water, soap and sanitizers, which play an essential role in prevention at the community and family levels. Poverty was amplified by large family household arrangements characteristically exhibited by the refugee communities, making it difficult to maintain social distancing and purchase masks, water and sanitizers. Besides these barriers, however, the awareness and sensitization programs carried out by the CHVs and HCWs improved awareness and understanding of the disease.

Recommendations

Although these findings are from a small group of refugees, primarily of Somali origin in Eastleigh, Nairobi, they provide some insights that may be applicable to refugee communities living in other resource-constrained settings. Local governments need to work closely with organizations serving refugees and migrants, as well as partner with the World Health Organization to initiate tailored trainings and capacity building among refugee communities and their health care workers.

We have seen the role religious beliefs and political rhetoric play in influencing both positive and negative compliance to COVID-19 preventive measures; therefore, religious and political leaders should be involved in mass training and public health messaging. Developing relevant behaviour change materials for refugees may require a focused effort due to their high mobility, mistrust and suspicion of the host countries and their reluctance to change. Local governments and the United Nations International Organization for Migration should work together and increase funding and the health care work force to work patiently with refugees in emergencies such as the COVID 19-pandemic to shift some of their behaviors.

Our findings suggest a need for more research to test refugees’ knowledge and compliance with COVID-19 preventive measures, as well as the mode of messaging that works best for them, and to determine who can disseminate these messages most effectively. Given the confusion at the onset of COVID-19 about whether it was politically instigated, comparable studies should be conducted in other refugee settings and non-refugee settings to establish to what extent religious and political inclinations influenced compliance.

Conclusions

This study suggested that awareness of COVID-19 is near universal among refugee women living in urban Kenya. Evidence gleaned from our research indicates an urgent need to develop and disseminate targeted guidelines and programs to help refugee women and their families in Kenyan cities prevent the spread of COVID-19. Future research could explore measures for disseminating factual information that work best in refugee populations with different cultural norms, help to hone targeted interventions and poll key stakeholders to find out what the community needs to protect itself from COVID-19 infection.

Study limitations and strengths

This study’s limitations include a small number of participants, the majority from a highly specific population (Muslim refugee women accessing ANC and PNC services) and language barriers that may have resulted in loss of vital information through translation. Despite these limitations, this study improved our knowledge of the experiences of refugee women and their families in the early periods of the pandemic and deepened our understanding of key influences on compliance with preventive measures.

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

(DOCX)

Click here for additional data file.

23 Jul 2021

PONE-D-21-14476

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

PLOS ONE

Dear Dr. Lusambili,

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 Sep 06 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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Susan A. Bartels, MD, MPH, FRCPC

Academic Editor

PLOS ONE

Journal Requirements:

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

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

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

and

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

2. When reporting the results of qualitative research, we suggest consulting the COREQ guidelines or other relevant checklists listed by the Equator Network, such as the SRQR, to ensure complete reporting (http://journals.plos.org/plosone/s/submission-guidelines#loc-qualitative-research). In this case, please consider including more information on the recruitment of participants. Moreover, please provide the interview guide used as a Supplementary file.

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

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

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

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

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

4. Please amend the manuscript submission data (via Edit Submission) to include author Sharon Ochieng,and Stanley Luchters.

5. Please amend your authorship list in your manuscript file to include author Constance Shumba.

[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: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: I Don't Know

**********

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

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

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

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

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

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

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

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

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

Line159 - 166

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

Line287

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

Line325

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

Line 383-391

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

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

Line 393-397

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

Line403-404

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

Line 412-413

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

Line 447

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

The other two points are fine.

**********

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: No

Reviewer #2: Yes: Dr Siyana Mahroof-Shaffi

[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.

7 Aug 2021

N/A

18 Oct 2021

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

Dear Dr. Lusambili,

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

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

Please include the following items when submitting your revised manuscript: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,

Susan A. Bartels, MD, MPH, FRCPC

Academic Editor

PLOS ONE

Journal Requirements:

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

Additional Editor Comments (if provided):

[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: All comments have been addressed

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: Partly

**********

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

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

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

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

**********

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 #1: Yes: Dr Behrouz Nezafat Maldonado

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

[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.

Submitted filename: PLOS ONE review Oct 2021.pdf

Click here for additional data file.

30 Oct 2021

Dr Adelaide Lusambili

Department of Population Health

Aga Khan University Medical University

P.O. Box 30270-00100. Nairobi, Kenya

Email: Adelaide.lusambili@aku.edu

28th/Oct/2021

PLOS ONE Editorial Office

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

Thank you for your letter and the opportunity to revise our paper

The suggestions offered by the reviewers have been immeasurably helpful in improving this paper. Reviewers comments have been individually addressed – all marked red.

All the co-authors have approved the revisions, and I am still the corresponding author. We have also uploaded both tracked and a clean revised manuscript to your online system.

We hope the revised manuscript will better suit PLOS ONE and we are happy to consider further revisions.

Sincerely

Dr Adelaide Lusambili

A REBUTTAL LETTER

PONE-D-21-14476R1

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

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.

Thanks. I have checked the references and amended. I have removed

1. Reference 10 because it is unpublished paper. It is indicated in the tracked copy

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 #1: All comments have been addressed

Reviewer #2: (No Response)

Thank you.

________________________________________

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

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

Reviewer #1: Yes

Reviewer #2: Partly

Noted. We recognize reviewer 2s concerns. This is due to the small sample size, which we have acknowledged in our conclusions.

________________________________________

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

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know. Thank you. This was a qualitative study.

________________________________________

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Thank you noted. ________________________________________

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

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

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

6. Review Comments to the Author

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

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

Thank you for reviewing this manuscript.

Reviewer #2: see attached. I found the tracked section of the new document difficult to follow...hope my comments make sense.

Thanks. I have addressed your questions in the attached PDF form as follows

________________________________________

UPLOADED REVIEWERS COMMENTS [Comments by Dr.Siyana Mahroof-Shaffi]

47

It is questionable whether high mobility is an issue during various lockdowns. Our experience was that the refugee camps were the first to become ‘locked’ with limited movement in and out of the camps. Elaborate on issues such as poor hygiene in facilities/ access to WASH facilities and probable overcrowding.

Ref: (https://via.hypothes.is/https://www.medrxiv.org/content/10.1101/2020.07.07.20140996v2#annot

ations:Q3NC_sCNEeqwwYO0MegHbw).ef Tucker et al:

The refugees we interviewed were not living in facilities but rather in a semi-urban [EASTLEIGH} area that hosts refugees from the horn of Africa. While poor hygiene in facilities and access to WASH is a recognized issue in refugee populations, however, the purpose of this study was to understand their knowledge, information and sources of these informations and the effect of COVID 19 on the utilization of maternal and neonatal services.

111 (Study population)

Very Low numbers already acknowledged. It would be good to understand how this compares to the size of the population being studied. How many in total are in the area? Also men vs women?

The purpose of the study was to do a rapid qualitative study to provide to promote our understanding on what was happening among this vulnerable group. We did not do a statistical comparative study which would have required as to compare data across age, gender etc as you have requested. We did not interview men, our focus was PNC and ANC women and the healthcare providers.

In our paper, cited reference 1, we have noted under social cultural context that …” Most of the refugees are of Somali origin. The 2019 national census put refugees at 55% of the overall Kamukunji sub -county population (147,551 out of 268,276), of which 51% are men and 49% are women”.

244

Typo= ‘visited” DONE

370-401

This section could be perceived as being quite biased. It is based on the commentary of three community workers. It would be interesting to know which faith background the workers come from?

I agree that it contrasts with the interviews with the patients themselves were far less loaded. I would suggest taking this section out as it seems unnecessarily inflammatory.

In general, there has been a lot of blame COVID (eg US blaming China...then China laughing as US cases soared). The take home message instead could be that despite all our technological and scientific success- there has been no rational explanation for the onset of this pandemic. More than one faith followers have expressed the phenomenon of this being a sign of the ‘end of the world’ and so it seems a bit harsh to penalise just the Muslims. In UK for example, various communities had continued to gather (eg Jewish wedding/ secret parties amongst youngsters)...ultimately the focus has to be on ignorance or defiance which can affect any group of people and not limited to certain faiths only.

Thank you.

• In the Table 1 in the manuscript I have indicated that all the CHVs were of Somali origin and Muslim by religion with an exception of one who was a native. Now, in the quotes, we cannot identify their religion because it is easy for the public to link these quotes to them. We have the responsibility to anonymize all the data and maintain confidentiality of our interviewees.

• I have reworded the sentences to be inclusive – that these biasness happens across all religions and that religious leaders have influence over their congregants. These are views that were reported in the interviews – and deleting firsthand information from CHVs considered insiders in their own communities invalidates the purpose of this research. Religious influences in Africa where 90% of the population is affiliated to a religion is real and cannot be ignored. All CHVs interviewed revealed how difficult it was to convince refugees in the early onset of COVID19 due to religious beliefs. These are important insights that should prompt further research that can provide future pandemic preparedness for different groups.

517-518

I rest my case…! This study cannot conclude anything based on the small and select group of interviewees.

We have acknowledged the study limitation –however –important to note is that –qualitative studies usually have a small sample.

Thank you. I agree –however-as we have stated, being a rapid study in a population that is poorly studied and underrepresented in research, this study provides first hand insights that could be tested further in large studies in refugee context as well as non-refugee context of different religious affiliation to determine communities early experience during COVID 19.

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 #1: Yes: Dr Behrouz Nezafat Maldonado

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

[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.

________________________________________

1 Dec 2021

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

PONE-D-21-14476R2

Dear Dr. Lusambili,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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,

Susan A. Bartels, MD, MPH, FRCPC

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

10 Dec 2021

PONE-D-21-14476R2

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

Dear Dr. Lusambili:

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. Susan A. Bartels

Academic Editor

PLOS ONE