Practice of preventive measures and vaccine hesitance for COVID 19 among households in The Gambia, 2021: Study protocol.

The first imported confirmed case of COVID 19 was reported in The Gambia on 16th of March 2020 which led to the implementation of relevant public health interventions to prevent further importation and spread of the virus. However, by 8th November 2021, the country had registered cumulatively 9.980 COVID-19 confirmed infection and 341 deaths. The country has developed and implemented Risk Communication and Community Engagement (RCCE) Action Plan since the declaration by WHO that COVID-19 outbreak was a global public health threat and its subsequent proclamation that outbreak was a pandemic. Despite these efforts to sensitize the communities, some Gambians are in denial and/or misinformed of the existence of infection in the country. It is also evident that social distancing and other restrictions have not been adequately implemented by the citizenry. Less 14% of The Gambian population have been vaccinated, and there is evidence of gross vaccine hesitancy and disbelief. There is urgent need to investigate the knowledge, attitude and practices among Gambians about preventive practices especially regarding accepting vaccination to control COVID 19. The proposed study will enrol 1200 households from seven Local Government Areas (LGAs). The findings of this study will inform the messaging and health promotion activities that will be used to better inform the population to ensure compliance and practice of preventive approaches (e.g., use of mask, vaccination)necessary to reduce the negative impact of COVID 19 outbreak in The Gambia. This will thus quicken the recovery process and the return to new normal life.

Background

Coronavirus disease 2019 (COVID 19) is a respiratory tract infection caused by a newly emergent coronavirus, that was first recognized in Wuhan, China, in December 2019 [1]. Subsequently WHO published a declaration of a global outbreak which was later upgraded to a pandemic [2, 3]. Genetic sequencing of the virus suggested that it is a beta-coronavirus closely linked to the SARS virus [4] A meta-analysis study reported that people with mild, moderate to severe COVID 19 infection might manifest symptoms and signs such as: cough, sore throat, high temperature, diarrhoea, headache, muscle or joint pain, fatigue, and loss or disturbance of sense of smell and taste [5]. These researchers revealed that patients with symptoms such as cough and fever had 21% increased risk to turn COVID 19 positive. Furthermore manifestation of loss of sense of smell or taste substantially increased the likelihood of COVID 19 infection by 8% [5]. The discoveries of some asymptomatic participants in different studies complicates the fight against such a pandemic [5]. Another meta-analysis study has found a post COVID 19 pandemic vaccination era mortality prevalence of 15%, associated with hospital admissions [6]. This study established that patients with acute respiratory distress syndrome were eight times more likely to die as compare to those who did not have the syndrome [6]. This resulted to the development of anxiety and worries among two third of the world population as demonstrated in a study [7]. Countries had implemented different public health strategies to prevent and/or contain the spread of the outbreak. These involved national lockdowns, border closures, social distancing, mask wearing and quarantine. The implementation of these intervention has led to a change from global social norms to a new world order. People in different parts of the world embraced, complied or adjusted to these new changes differently. For instance compliance rates for Covid-19 control measures in Tonga and Egypt were 93% and 43%, respectively [7].

The rapid evolution of mutant variants of COVID 19 increase the potential for the spread and severity of the disease. This setbacks back the global response plan to curb the pandemic. Hence, the only hope to revive and re-establish normalcy in global lifestyle was the discovery, approval and vaccination of the global populace. COVID 19 vaccines were approved in late 2020 and early 2021 for public use in countries across the world and the success of this public intervention will depended not only on vaccine safety and effectiveness but coverage rate to achieve herd immunity [8]. COVID 19 vaccine hesitancy meta-analysis study revealed that vaccine acceptance rate is region and country specific [8]. High acceptance were reported in Ecuador (97.0%), Malaysia (94.3%), Indonesia (93.3%) and China (91.3%); moderate acceptance was reported in Jordan (28.4%), Italy (53.7), Russia (54.9%), Poland (56.3%), US (56.9%), and France (58.9%) and lowest acceptance was reported in Kuwait (23.6%), Jordan (28.4%), from the Democratic Republic of the Congo (27.7%) Low rates of COVID 19 vaccine acceptance were also reported in the Middle East, Russia, Africa and several European countries [9]. Studies that investigate the factors leading to vaccine hesitancy are particularly needed in the Middle East and North Africa, Sub-Saharan Africa, Eastern Europe, Central Asia, Middle and South America. Addressing the scope of COVID 19 vaccine hesitancy in various countries is recommended as an initial step for building trust in COVID 19 vaccination efforts [9].

In response to the rapid spread of the virus, the World Health Organization (WHO) declared COVID 19 as a Public Health Emergency of International Concern (PHEIC) on 30th January 2020, and a pandemic on 11th March 2020. The Gambia embarked on developing and implement the National Preparedness and Response Plan (Response plan) [10]. The Gambia registered its first case of COVID 19 on the 16th of March 2020 and thus the Public Health Emergency Operational Centre was operationalized to using the Incidence Management System to guide and coordinate the national response to the outbreak [11, 12]. The country adopted and implemented an incident management plan that involves several measures to interrupt importation and transmission of the virus nationwide [13]. These include the closing of schools, suspension of public gathering, closure of all non-essential public places, spatial distancing, and respiratory etiquette, restriction on number of passengers allowed on public transport, Airport closure by 17 March 2020 as well as, mandatory quarantine of travellers, isolation and care for infected and suspected cases. These measures led to the discomfort of the populace and such victims [14]. Massive community engagements activities were conducted to raise awareness about COVID 19 prevention and control practices and the provision of masks, hand sanitizers and hand washing facilities. A toll-free helpline (1025) which was instituted during the 2014 Ebola outbreak was reactivated. The call centre was operated 24 hours and 7 days by Ministry of Health [11]. These have facilitated the citizenry to make inquiries on COVID-19, seek support and advice if they notice any signs and symptoms or report possible suspects or complaints regarding people defying control measures [11]. However, by July 2020 most of the COVID 19 restrictions were loosened and the Airport was opened but testing continued for both returning and departing travellers that use the Airport [11, 15]. These travellers accounted for 90% of the daily testing’s of COVID 19 samples at the National Public Health Laboratories. The COVID 19 rapid test has been introduced and testing facilities scaled up nation-wide. As per the 399th national situation COVID 19 report, a total of 341 COVID 19 related death (Crude Case-Fatality Ratio, 3.4%), with Cumulative confirmed cases of 9,980 was registered. The country witnessed intermittent outbreaks of COVID 19 in the following period July to September 2020 then a mild second wave in January to April 2021 and severe wave which was mainly associated with the delta variant from July to September 2021 [11]. COVID 19 virus lineages A and B have been detected and associated with the cause of second wave of the national outbreak. Lineage B constitutes almost 98% of the total genomes sequenced, with the sub-lineage B.1 being the most prevalent [16] whilst the third COVID 19 outbreak wave is confirmed to be mainly associated with the transmission of the delta variant [17]. Nationally, a study had phylogenetically confirmed two reinfections among healthy individuals, with a time lag of 5 months and 6 months, respectively [18]. This necessitated the introduction of vaccination to increase the attainment of herd immunity and thus the introduction of the public health intervention on 15th March 2021 [11]. As of 8th November the national COVID 19 coverage of targeted population with completed vaccination dose was 14.2% and whilst coverage of at least one dose was 15.1%. COVID 19 vaccination has the least coverage among all the vaccines ever administered in the country. This could be associated with misinformation and lack of belief in the existence of the outbreak and other associated factors [11]. There is limited information to explain why people are hesitant to take the COVID 19 vaccine despite massive community engagement activities being carried out. A lot of misinformation and conspiracy theories about the vaccine are spread through social platforms such as WhatsApp groups, Facebook and other electronic channels. There is an urgent need to understand the general public’s awareness and perceptions on COVID 19. This is particularly important as the adherence to the control measures by the public has been viewed to be suboptimal. The information from this survey will not only provide data for further assessments but will help to develop targeted strategies to rapidly improve current behavioural and risk communication interventions. The objective of this study is to establish public knowledge, attitude and practice towards COVID 19 infection and its preventive measures; and to describe the factors associated with COVID 19 vaccine hesitancy in The Gambia.

Hypothesis

High rate of misbelief of COVID 19 infection and effectiveness of its vaccine among household members have resulted to low vaccination coverage and adherence to preventive measure.

What is the level of knowledge about COVID 19 prevention, control and associated vaccination among household members?

What is the attitude of household members towards COVID 19 prevention, control and associated vaccinations?

What are the practices of household members towards COVID 19 prevention, control and associated vaccinations?

Methodology

Study design

A cross-sectional study design will be employed to explore the knowledge, attitude and practices of households in the context of COVID 19 prevention and control practices which includes the willingness to accept vaccination.

Study sites

Enumerated areas from the seven LGAs in the country will be randomly selected. These LGAs will be further stratified as rural, urban, peri-urban areas to determine the disparity of understanding and practices of prevention and control measures of COVID 19 in the country amidst access to social amenities.

:

Individuals identified for recruitment into the selected Enumeration Areas (EAs) and households in particular.

:

Participants less than 18 years of age.

Sampling methodology

Sample design and selection

Sample size

Considering that the true variability of the characteristic of interest in the population is unknown in advance, sample size in this survey was computed taking into account the total number of households in the country, the sample design and method of estimation, and the response rate. Due to lack of a key indicator (P) to be measured by the survey, a value to 50% is assumed to give the maximum level of variability. Given that it’s satisfactory if the true population proportion is within ±5, an anticipated response rate of 90% was used to effectively achieve the desired precision for the estimates. Thus, the sample size for the survey is computed as follows:

For the purpose of the Survey, the following assumptions inform the sample size calculation:

P = 50% or 0.5

Sample size and design effect = 1.5

Level of Confidence = 95% i.e. α = 0.05

Margin of Error = ± 5%

Response rate = 90% or 0.90

Using the formula and the parameters above, a minimum sample size of 900 was computed at the national level. This sample size will give a coefficient of variation (CV) which is also known as relative standard error (RSE) of 5 per cent at the national level. Adjusting the sample using a response rate of 90 per cent will give 1,000 household interviews. Given that the country is administratively divided into eight LGAs, a multi-stage cluster sampling will be used to select samples in three stages from the frame. In the first stage, after sorting the frame by LGA and Region (i.e. Urban and Rural), 100 EAs will be independently selected using probability proportional to household size. Table 1 below shows a summary of the sample design.

Table 1

Allocation of Enumeration Areas (EAs) to different strata.

LGA	Total EAs	Total Urban	Total Rural	Total Selected EAs	Selected Urban EAs	Selected Rural EAs
Banjul	74	74	-	2	2	-
Kanifing	773	773	-	22	22	-
Brikama	1,466	1,338	128	45	23	22
Kerewan	493	106	387	4	2	2
Mansakonko	204	32	172	8	5	3
Kuntaur	237	16	221	5	2	3
Janjanbureh	297	43	254	6	3	3
Basse	554	158	396	8	2	6
Total	4,098	2,540	1,558	100	61	39

Sample frame

The list containing Enumeration Areas (EAs) of all the eight geographic and administrative regions in The Gambia and their respective households and population obtained from 2013 Gambia Population and Housing Census Frame will be used as the sampling frame as shown in Fig 1. Consequently, with the data and cartographic information, all the EAs will be selected at the first stage based on the design proposed for this study.

Fig 1

Sampling framework.

Sample design

For this study, a multi-stage stratified cluster sample design will be used to select the eligible respondents in three stages. In the first stage, after sorting the frame, EAs will be selected using Probability Proportional to the Size (PPS) of EA. As defined in the 2013 Population and Housing Census, EA size is the number of residential households residing in the EA during the population census.

Selection scheme

In the second stage, EAs will be sorted and stand as strata in the new frame. In each of the respective selected EAs, 10 households will be selected using equal probability systematic sampling procedures. Before the data collection, a household listing operation for each of the selected EAs will be carried out by field supervisors and enumerators. All the households will be listed and ten (10) households will be selected using simple random sampling (third stage). The identified households to be interviewed will be visited by the field staff. Strictly, it is important to note that survey interviewer must interview only the selected households. To prevent bias, no replacements and no changes of the selected households will be permitted in the implementing stages. One individual aged 18 years and above will be selected randomly for the interview using knish grid.

below gives the allocation of selected EAs in the various domains. The population of those 18 years and above from the 2018 Labour Force Survey was used in allocating the sample to the urban and rural strata in each LGA in order to ensure that the sample is representative of the target group.

Distribution of selected households for various LGAs is shown in Table 2.

Table 2

Distribution of selected households per local government areas.

LGA	Total Households	Selected Households
Banjul	7272	20
Kanifing	69890	220
Brikama	103664	450
Kerewan	11965	40
Mansakonko	27862	80
Kuntaur	10957	50
Janjanbureh	14451	60
Basse	34641	80
Total	280,702	1,000

Listing procedures

All 100 selected EAs will be listed in order to update the number of households in each frame as in Fig 1. The currently ongoing Integrated Household Survey 2020/2021 listing template will be used to obtain the total eligible households per cluster. This is a very crucial step as the computation of the second-stage probability of selection will depend entirely on the accuracy and reliability of these numbers. It is imperative to explore digital data collection this time around to enable the coordinating team ensure quality as well as select unbiased second-stage samples at the central level. Also, the coordinates of the selected structures can easily be drawn on the map for easy identification thereby saving the enumerators from identifying the wrong structures selected to participate in the survey.

Weighting procedures

By design, complex sampling involving selection at different stages will be used in the study. Inclusion probabilities will be calculated from each stage of selection and as a result, sampling weights will be computed and used for the analysis to ensure representativeness of the sample. The selection probabilities at each stage will be documented and the inverse of these probabilities is the basic weight also known as the design weight.

The household design weight is the inverse of the overall selection probability of the household which is computed as the product of the first stage (PSU/cluster) selection probability and the second stage (household) selection probability.

The number of eligible individuals per household multiplied by the corresponding household design weight in the cluster gives the individual weights.

Survey Instrument and Variables.

A questionnaire was adapted to The Gambia context from the standardized IFRC, UNCIF and WHO Risk Communication and Community Engagement (RCCE) Action Plan [19] will be used for the survey(provided as supporting documents). Although it has been adapted to the local context, the questionnaire will be pretested and findings will be used to further refine the questions. The survey items are organised in four sections namely demographics, knowledge, attitudes and practices and consists of primarily close-ended questions. Consent will be obtained before administration of the questionnaire.

Data management, analysis and presentation

Data collection will be done by trained and experienced enumerators. A virtual meeting with enumerators will be held daily to review the process and identify challenges and successes. An exploratory data analysis (EDA) will be conducted after the collection of the data in order to make a quick check into the consistency and validity of the data. Subsequently, necessary data cleaning will be done to prepare the data for analysis. Analysis of the data collected will be conducted using the International Business Machines Statistical Package for Social Sciences (IBM SPSS). Frequencies will be run to explore missing responses and out-of-range values for each of the demographic variables as well as those used for the main analysis. The distribution of the data will be subjected to normality test using the Shapiro-Wilk test of normality. As the data collection is premised on assessing the knowledge, attitude and practices towards COVID 19 and willingness to accept vaccination, analysis will focus on key demographic variables such as gender, location and age. Cross tabulations with independent variables and KAP of COVID 19 prevention will be done to obtain answer the set study objectives. The analysis of the data will focus on the three components of the survey namely knowledge, attitude and practice and association with willingness to accept COVID 19 vaccinations. Knowledge assesses the amount of knowledge respondents have about COVID 19 and the source(s) of information and associated vaccination belief using chi square at p value of less than or equal to 0.05. Attitude questions will address people’s attitude towards the pandemic such as their belief that it is a reality while practice questions will focus on the activities people are engaged in in preventing themselves, their families and their neighbours from the disease through vaccination and other practices. Key results will be presented in the form of tables and graphs and the necessary statistical interpretations will be done in the form of an analytical report for policy makers. The study finding will be presented stakeholders, partners in COVID 19 response.

Potential risks

There is anticipated risk of infection to the public or data collectors given that we are in an active pandemic. Therefore, to minimise such risk all data collectors and drivers will be trained on basic IPC procedures, must be vaccinated. In addition, interviews will be conducted maintaining the WHO-recommended social distancing guidelines, and compulsory wearing of face mask.

Ethical consideration

The study has been approved The Gambia Government/MRCG Laboratories Joint Ethics Committee (Project ID/ethics ref: 22699) and from the Ministry of Health for the study protocol and procedures of informed consent. Written informed consent will be obtained from all participants. The participants will be provided with adequate information about purpose of the study in a language they best understand. Information from participants will be treated confidentially and will not be shared with anyone except study team members.

Expected outcome and implication of findings

This survey will reveal an accurate picture of what the general population knows about the pandemic and their attitudes and practices towards prevention and control measures for this disease and their willingness to accept vaccination. It will assess the huge investment the government and partners and donors had facilitate the implementation of the Communication and Community Engagement (RCCE) Action Plan. This will help to guide the review and updating RCCE plan to impact better behavioural change toward eventually positive acceptance and practices prevention and control of COVID 19 and subsequent increase for vaccination coverage which will assure the attainment of herd immunity. The finding of this study will be published in peer open journals and the dataset will be freely accessible and shared with the publishing journals.

Covid19 kap information sheet & consent form.

(DOCX)

Click here for additional data file.

COVID 19 kap survey tool questionnaires.

(DOCX)

Click here for additional data file.

16 Nov 2021

Submitted filename: Response letter_COVID KAP_2021.doc

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29 Nov 2021

Submitted filename: reviewers comments.pdf

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30 Nov 2021

Letter responding to the reviewers comments has been uploaded.

Submitted filename: Response letter_COVID KAP_30 11 V 3.doc

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20 Jan 2022

29 Jan 2022

Upload as letter

Submitted filename: Response letter_COVID KAP_30 11 V 3.doc

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11 Mar 2022

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'.

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

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

We look forward to receiving your revised manuscript.

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Sheikh Mohd Saleem, MBBS, MD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #2: Yes

Reviewer #4: Yes

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #2: Partly

Reviewer #4: Yes

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #2: Yes

Reviewer #4: Yes

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4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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

Reviewer #4: Yes

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

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Reviewer #2: Yes

Reviewer #4: No

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Topic selections and plan of execution of this research well explained. This study will definetly help to find the KAP regarding COVID-19 among the people. Comments has been well addressed.

Reviewer #4: (Corrections below refer to the WORD version clean copy of the covid 19 manuscript _ Revised 2022.docx accessed via click)

Summary of the research and overall impression

The topic of this study protocol is of public health significance at the moment .The investigation into people’s practice of COVID 19 prevention and control measures and factors associated with vaccine hesitance is not only interesting but the results will be useful in the Gambia and other sub-Saharan African settings with similar observed resistance to these best practices. The manuscript is presented in an intelligible fashion but the english could be improved upon to bring it up to standard. There are quite a number of grammatical errors in the Abstract and Background sections. The manuscript would benefit from grammar editing. If the following major revisions are carried out, I strongly recommend it for publication in PLOS ONE.

Major Revision

Title: A preferred title (or a similar one along these lines) would be “Knowledge, Attitude towards COVID19 and its prevention; practice of preventive measures; and COVID 19 vaccine hesitance among Households in the Gambia, 2021: Study protocol.

The problems with the title as written by the authors are:

- “practices of COVID 19”. It’s the preventive measures of Covid 19 that are practiced and not COVID 19.

- Knowledge and attitude towards COVID 19 prevention is not clearly brought out in the title. However, one may assume it is subsumed in just COVID 19.

Abstract: Would benefit from grammar editing.

The following statement should include the other issue being investigated i.e vaccine hesitance “There is urgent need to investigate the knowledge, attitude and practices among the Gambians about preventive practices to control COVID-19”.

Background:

Would benefit from grammar editing.

The following sentences should be rewritten for clarity, their meanings are not clear.

- “It was alluded that some of the study participants were positive for COVID 19 different studies had no signs and symptoms of COVID 19 and thus blurring the fight against such a pandemic[5].”

- “In the post vaccination era of COVID 19 pandemic the pooled prevalence of 15% mortality with found to the associated in hospital admissions [6].

Could the authors provide a reference for this statement from previous studies if available “This is particularly important as the adherence to the control measures by the public has been viewed to be suboptimal”.

The authors state “ There is limited information to explain why people are hesitant to take the COVID 19 vaccinations despite massive community engagement activities done”. While this is true, the authors are advised to cite what little information is available after a thorough search of recent literature”.

The last sentence which states the objectives of the study should be changed to “The objective of this study is to establish the knowledge, attitude towards COVID 19 infection and its prevention; practice of preventive measures; and describe the factors associated with Covid 19 vaccination hesitance in the Gambia”.

Hypothesis:

Could the hypothesis be rephrased in a more scientific in language

Research questions:

The authors should add “prevention and control” after “COVID 19” in the three Research questions. Also a fourth research question is needed to cover “the factors associated with Covid 19 vaccination hesitance” mentioned in the objective of the study.

Sampling Methodology:

The title of Table 2 was same title of Table 1. This must be an error. The correct title would appear to be the sentence above the table i.e “Distribution of selected households for various LGAs”

Data Management, Analysis and Presentation:

The data analysis should include an analysis of factors associated with vaccine hesitance as stated in the objectives: suggested are cross tabulations with independent variables and KAP of COVID 19 prevention

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Reviewer #2: No

Reviewer #4: No

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27 Mar 2022

The response to varied comments and concerns have been addressed in the uploaded letter to the reviewer.

Submitted filename: Response letter_COVID KAP_30 11 V 3.doc

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7 Apr 2022

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'.

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Sheikh Mohd Saleem, MBBS, MD

Academic Editor

PLOS ONE

Additional Editor Comments:

Kindly address the comments provided by the reviewers

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Reviewers' comments:

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

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22 Apr 2022

We have reviewed comments of the reviewer and all comments were addressed in the latest version of the submission

Submitted filename: Response letter_COVID KAP 18 04_2022.doc

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8 Jun 2022

: Practice of preventive measures and vaccine hesitance for COVID 19 among Households in The Gambia, 2021: Study protocol.

PONE-D-21-36320R4

Dear Dr. Sanneh,

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Kind regards,

Sheikh Mohd Saleem, MBBS, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #4: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #4: Yes

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #4: Yes

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4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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 #4: Yes

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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 #4: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: The issues of concern raised in the previous review have been addressed. However, references for the following statements in the "Background" have still not been provided: “This is particularly important as the adherence to the control measures by the public has been viewed to be suboptimal” .“There is limited information to explain why people are hesitant to take the COVID 19 vaccinations despite massive community engagement activities done”. If no references could be found , I suggest the authors state this and if it is anecdotal evidence, state as much. Also minor grammar editing is still needed, for example, the word "to" should be inserted between "presented" and "stakeholders" in the last line in the "Data Management, Analysis and Presentation" section.

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Reviewer #4: Yes: Dr Adaoha Pearl AGU

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10 Aug 2022

PONE-D-21-36320R4

Practice of preventive measures and vaccine hesitance for COVID 19 among Households in The Gambia, 2021: Study protocol.

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