Commitment to protective measures during the COVID-19 pandemic in Syria: A nationwide cross-sectional study

Mosa Shibani; Mhd Amin Alzabibi; Abdul Fattah Mohandes; Humam Armashi; Tamim Alsuliman; Angie Mouki; Marah Mansour; Hlma Ismail; Shahd Alhayk; Ahmad abdulateef Rmman; Hala Adel Almohi Alsaid Mushaweh; Elias Battikh; Naram Khalayli; Bisher Sawaf; Mayssoun Kudsi

doi:10.1371/journal.pone.0275669

. 2022 Oct 14;17(10):e0275669. doi: 10.1371/journal.pone.0275669

Commitment to protective measures during the COVID-19 pandemic in Syria: A nationwide cross-sectional study

Mosa Shibani ^1,^*,^#, Mhd Amin Alzabibi ^1,^#, Abdul Fattah Mohandes ², Humam Armashi ¹, Tamim Alsuliman ³, Angie Mouki ⁴, Marah Mansour ⁵, Hlma Ismail ¹, Shahd Alhayk ¹, Ahmad abdulateef Rmman ¹, Hala Adel Almohi Alsaid Mushaweh ², Elias Battikh ⁶, Naram Khalayli ⁷, Bisher Sawaf ⁷, Mayssoun Kudsi ^1,⁸

Editor: Syed Ghulam Sarwar Shah⁹

¹Faculty of Medicine, Syrian Private University, Damascus, Syria

²Faculty of Medicine, University of Aleppo, Aleppo, Syria

³Hematology and Cell Therapy Department, Saint-Antoine Hospital, AP-HP Sorbonne University, Paris, France

⁴Faculty of Pharmacy, Maykop State Technological University, Maykop, Russia

⁵Faculty of Medicine, Tartous University, Tartous, Syria

⁶Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar

⁷Faculty of Medicine, Damascus University, Damascus, Syria

⁸Department of Rheumatology, Almowasa University Hospital, College of Medicine, Damascus University, Damascus, Syria

⁹Oxford University Hospitals NHS Foundation Trust, UNITED KINGDOM

Competing Interests: The authors have declared that no competing interests exist.

^✉

* E-mail: Moosa.shibani@gmail.com

Contributed equally.

Roles

Mosa Shibani: Conceptualization, Methodology, Resources, Supervision, Writing – original draft

Mhd Amin Alzabibi: Conceptualization, Methodology, Resources, Supervision, Writing – original draft

Abdul Fattah Mohandes: Data curation, Methodology, Resources, Writing – original draft

Humam Armashi: Data curation, Resources, Writing – review & editing

Tamim Alsuliman: Conceptualization, Formal analysis, Supervision, Writing – review & editing

Angie Mouki: Methodology, Writing – review & editing

Marah Mansour: Data curation, Methodology

Hlma Ismail: Conceptualization, Data curation, Writing – original draft

Shahd Alhayk: Data curation, Methodology, Resources, Writing – original draft

Ahmad abdulateef Rmman: Data curation, Methodology, Resources

Hala Adel Almohi Alsaid Mushaweh: Data curation, Methodology, Resources

Elias Battikh: Data curation, Methodology, Resources

Naram Khalayli: Data curation, Investigation, Methodology, Resources, Software

Bisher Sawaf: Conceptualization, Investigation, Methodology, Resources, Supervision, Writing – review & editing

Mayssoun Kudsi: Conceptualization, Supervision, Writing – review & editing

Syed Ghulam Sarwar Shah: Editor

PMCID: PMC9565665 PMID: 36240156

Abstract

Background

Severe acute respiratory syndrome coronavirus 2 continues to impose itself on all populations of the world. Given the slow pace of vaccination in the developing world and the absence of effective treatments, adherence to precautionary infection control measures remains the best way to prevent the COVID-19 pandemic from spiraling out of control. In this study, we aim to evaluate the extent to which the Syrian population adheres to these measures and analyze the relationship between demographic variables and adherence.

Methods

This cross-sectional study took place in Syria between January 17 and March 17, 2021. A structured self-administered questionnaire was used to collect the data. The questionnaire was distributed in both electronic and printed versions. Our sample consisted of 7531 individuals. Collected data were analyzed using SPSS v.25. The chi-square test was used to address the correlation between adherence and demographic variables.

Results

Of the 10083 reached out, only 8083 responded, and 7531 included in the final analysis with an effective response rate of 74.7%. Of them, 4026 (53.5%) were women, 3984 (52.9%) were single, and 1908 (25.3%) had earned university degrees. 5286 (70.25) were in the high level of adherence category to protective measures. Statistically significant differences were documented when investigating the correlation between commitment to preventive measures and age, sex, marital status, financial status, employment, and educational attainment. Furthermore, those who believed that COVID-19 poses a major risk to them, or society were more committed to preventive measures than those who did not.

Conclusion

The participants in this study generally showed a high level of adherence to the preventive measures compared to participants in other studies from around the world, with some concerns regarding the sources of information they depend on. Nationwide awareness campaigns should be conducted and focus on maintaining, if not expanding, this level of commitment, which would mitigate the pandemic’s impact on Syrian society.

Background

The continued spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)—the causative agent of coronavirus disease 2019 (COVID-19)—has impacted all aspects of life worldwide, with over 250 million cases and over 5 million deaths as of 13 December 2021 [1]. On 11 March 2020, the World Health Organization (WHO) officially declared COVID-19 to be a global pandemic [2], and recommended comprehensive strategies to prevent the spread of the virus [3]. Since person-to-person transmission mainly occurs via respiratory droplets, close contact with infected individuals during talking, sneezing, coughing, and indirect contact with contaminated objects or surfaces [4, 5], the most important recommendations include self-isolation, physical distancing, wearing face masks, and practicing hand hygiene [3, 6]. Many governments have implemented these virus-mitigation measures to contain the spread of the virus and protect vulnerable populations from infection. These cooperative efforts are important in lowering mortality rates and preventing health care systems from being overburdened. However, populations must be highly committed to these measures to ensure their success. In the absence of effective treatments and in light of recent evidence showing decreased vaccine-induced immunity after 5–7 months [7], preventive infection-control measures remain the best hope for containing the disease. The Syrian government began implementing precautionary measures to pre-empt the spread of the disease before the first case was even reported on 22 March 2020 [8, 9]. All schools, colleges, commercial and leisure centers, gyms, and places of worship were closed, and a 6 pm-to-6 am curfew was put into effect. However, these measures lasted only for two months (March to May 2020) [8]. A recent nationwide study in Syria reported good levels of awareness among the Syrian population regarding COVID-19 in general and preventive measures in particular [10]. Almost all participants (99%) were aware that proper hand hygiene, avoidance of crowded places, isolation at home, and wearing face masks in public places are the main preventive measures [10]. Information about the Syrian population’s general knowledge regarding infection control will not only help to inform policy-makers as they make important decisions on how to best confront this pandemic, but it is also important to measure the extent to which the population adheres to these measures so that gaps between knowledge and practice can be addressed. As of 10 November 2021, 45,468 laboratory-confirmed cases and 2,637 casualties of COVID-19 have been reported by the Syrian Ministry of Health [11]. However, considering that testing has been limited in scale and that the cost of test kits is relatively high, it is likely that official numbers are deceptively low and do not reflect the severity of the pandemic in Syria. The war in Syria has raged for over 10 years and continues to impose massive burdens on the population, including economic, social, and educational challenges [12]. A consequence of this widespread conflict is the largest refugee crisis since World War II [13]. The Syrian healthcare system, already devastated by the war and suffering staffing, supply, and funding shortages, has all but collapsed in the face of the pandemic. The Syrian economy has been particularly hard hit, and due to recent inflation, the number of people in need (PIN) is expected to increase from 11 million in 2020 to 13.3 million in 2021 [12]. The rising price of personal protective equipment and medical supplies, as well as other COVID-19 related factors that have increased the cost of living, has resulted in the majority of Syrian families being unable to afford leaving their jobs and sacrificing income to self-isolation and physical distancing measures [14]. In this study, we aim to measure the commitment of the Syrian population to infection prevention and control (IPC) measures (such as hand washing, wearing masks and gloves, and avoidance of handshaking and face-touching), measure perceived risk regarding COVID-19, and study the correlation between commitment and some demographic variables.

Methods

Study design, setting, and participants

A nationwide cross-sectional study was performed between January 17 to March 17, 2021. Data was collected using a structured self-administered questionnaire which was distributed to a sample of Syrian people. We developed the questionnaire based on previous studies and made some modifications to be suitable for Syrian society [15–17]. It was then piloted on a sample of 15 people to ensure clarity, and adjustments were made based on their feedback. Chain-referral (snowball sampling) and convenience sampling methods were employed by distributing the questionnaire in two formats: electronically as a Google Form survey via social media and messaging platforms (Facebook, Whatsapp, Twitter), and physically as hard copies to patients, their companions, and workers in public hospitals in each of Damascus, Aleppo, Homs, Tartous, Hama, and Sweida governorates. The sample size was calculated using OpenEpi online software available at “https://www.openepi.com/SampleSize/SSPropor.htm”. According to data from the United Nations, the estimated population of Syria in 2019 was about 18 million [18]; based on this figure, the sample which is required to represent the total population was calculated to be at least 7336, with a confidence level of 95% and a confidence interval of 1.14.

Inclusion criteria were that the person is: (1) 18 years old or above, (2) literate, (3) a Syrian citizen living in Syria, and (4) willing to complete the questionnaire. In order to reach our desired sample size, initially, we reached out to 10083 individuals. Of them, 8083 agreed to participate. Of these 8083 participants, 551 were excluded for not meeting the inclusion criteria as follow: (17 withdrew their consent to participate, 543 were not Syrians or lived outside of Syria), yielding a final sample size of 7,531 responses which underwent statistical analysis.

Measures

The questionnaire consisted of 32 questions divided into 3 sections:

Socio-demographic characteristics:

13 questions about age, gender, marital status, nationality, governorate of origin, place of residence (urban or rural), financial status, employment status, educational level, father’s and mother’s educational level, health insurance coverage, and work or study in a healthcare-related field. Financial status was asked as four categories: low, middle, good and Excellent. Age was divided into 4 groups: 18–24, 25–44, 45–65, and >65 years. Governorates were divided into 5 categories based on geographical location: 1- Central governorates (Damascus, Rif Dimashq, Hama, Homs), 2- Eastern governorates (Deir ez-Zor, Al-Hasakah, Ar-Raqqah), 3- Western governorates (Latakia, Tartous), 4- Northern governorates (Aleppo, Idlib), 5-Southern governorates (Daraa, Quneitra, As-Suwayda).
COVID-19 general information:

5 questions about prior infection with SARS-CoV-2, the risk this virus poses to the individual and to Syrian society as a whole, and participants’ source of information.
Commitment to infection prevention and control (IPC) measures.

12 yes-no statements about various IPC measures including: wearing a face mask, social event cancellation or postponement, self-isolation, cleaning or disinfecting touched items, carrying sanitizing hand-gel, reduced face-touching, healthy diet, avoiding people who have cold or flu-like symptoms, using tissues when sneezing or coughing, and washing hands with soap and water.

Statistical analysis

Data from the hard copy questionnaires were entered manually by the investigators (MS, MAA, SA, and HI) to the original Google Forms online questionnaire that was used to collect online data, after which it was exported to a Microsoft Excel spreadsheet. The raw data was then encoded in Excel to make it compatible with the statistics software. A 13-point scale developed by the investigators was used to measure the level of commitment to IPC measures. Each individual measure was given one point (lowest = 0, highest = 13), then each participant was categorized into one of three categories based on how many protective measures he/she applied: 1- Low commitment (0–3 protective measures), 2- Moderate commitment (4–8 protective measures) and 3- High commitment (9–12 protective measures). We used Statistical Package for Social Sciences version 25.0 (SPSS Inc., Chicago, IL, United States) to analyze the data. Categorical variables were reported as frequencies and percentages. Pearson’s chi-square test was used to study the associations between categorical groups. A p-value < 0.05 was considered statistically significant.

Ethical considerations

The study protocol was approved by the respective Research Ethics Committee at each of Damascus, Aleppo, Tartous, and Syrian Private Universities, and the ethics committees of each hospital from which data was collected. Written informed consent was obtained from every participant as each questionnaire had an informed consent form (the first page in the hard copy version and the first question in the digital one) needs to be signed by the respondents prior to participation. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Results

Participant characteristics

Of the 10083 person reached out, 8083 agreed to participate and 7531 fully completed the questionnaire and their responses were analyzed (effective response rate = 74.7%). Most of the respondents were females and the dominant age group was 18–24 years old. Over the half of the study population originated from the central governorates, and the lowest proportion were from the western governorates. Regarding marital status, over half of the participants were single. Most participants were financially middle class and only 371 (4.9%) had excellent financial status. University students and university graduates represented the majority of responders. When asked if employed or studying in a healthcare-related field, over half of the participants answered “no”. (Table 1).

Table 1. Participant’s characteristics.

Variables		Total (%)
Variables		n = 7531
Age range (years)	18–24	3124 (41.5%)
	25–44	2338 (31%)
	45–65	1686 (22.4%)
	> 65	383 (5.1%)
Gender	Male	3505 (46.5%)
Gender	Female	4026 (53.5%)
Marital status	Single	3984 (52.9%)
	Married	2825 (37.5%)
	In relationship	500 (6.6%)
	Widow	222 (2.9%)
Do you have health insurance?	Yes	1489 (19.8%)
Do you have health insurance?	No	6042 (80.2%)
Educational level	No formal education	324 (4.3%)
	Elementary school	422 (5.6%)
	Secondary school	550 (7.3%)
	Highschool	782 (10.4%)
	University student	2906 (38.6%)
	University graduate	1908 (25.3%)
	Postgraduate degree	639 (8.5%)
Do you work or study in the healthcare system	Yes	2595 (34.5%)
Do you work or study in the healthcare system	No	4936 (65.5%)
Mother’s educational level	No formal education	1225 (16.3%)
	Primary school	1834 (24.4%)
	Secondary school	1656 (22%)
	University degree	2625 (34.9%)
	Postgraduate degree	191 (2.5%)
Father’s educational level	No formal education	760 (10.1%)
	Primary school	1971 (26.2%)
	Secondary school	1512 (20.1%)
	University degree	2776 (36.9%)
	Postgraduate degree	512 (6.8%)
Residency	City	5711 (75.8%)
Residency	Countryside	1820 (24.2%)
Geographical origin	Eastern Syria	365 (4.8%)
	Northern Syria	1272 (16.9%)
	Middle Syria	4376 (58.1%)
	Southern Syria	353 (4.7%)
	Western Syria	1165 (15.5%)
Financial status	Low	1268 (16.8%)
	Middle	3241 (43%)
	Good	2651 (35.2%)
	Excellent	371 (4.9%)
Employment	Unemployed	1635 (21.7%)
	Part-time job	1114 (14.8%)
	Full-time job	1688 (22.4%)
	Student	2653 (35.2%)
	Student + Part-time job	290 (3.9%)
	Student + Full-time job	131 (1.7%)
	Part-time + Full-time jobs	20 (0.3%)

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COVID-19 related information

When asked about a previous infection with COVID-19, the majority of participants answered “no", and only a small proportion had a PCR-confirmed infection. On the other hand, when the participants were asked if they know someone who has had a PCR-confirmed infection, most of them said “yes". Regarding the imposed risk of COVID-19 on Syrian society, more than half of the respondents believe it poses a major risk. However, when asked about the extent to which the virus poses a personal risk a considerably less proportion replied “major risk” (Table 2). Healthcare workers and social media (Facebook, Whatsapp, Youtube, Telegram, Instagram, etc.) were the main source of COVID-19 related information. (Fig 1).

Table 2. COVID-19 related information.

		N (%)
Do you believe you have had coronavirus?	No	4549 (60.4)
	Yes, with PCR	240 (3.2)
	Yes, with symptoms	2742 (36.4)
Do you personally know anyone (excluding yourself) who has had a PCR-confirmed COVID-19?	No	2960 (39.3)
	Yes	4571 (60.7)
To what extent do you think COVID-19 poses a risk to people in Syria?	No risk at all	314 (4.2)
	Minor risk	1621 (21.5)
	Major risk	464 (61.6)
	Do not know	956 (12.7)
To what extent do you think COVID-19 poses a risk to you personally?	No risk at all	834 (11.1)
	Minor risk	3224 (42.8)
	Major risk	2218 (29.5)
	Do not know	1255 (16.7)

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Commitment to preventive measures

The vast majority of participants showed good commitment (Table 3).

Table 3. Level of commitment to protective measures.

The number of preventive measures used by the participants
Number of measures	N(%)	Level of commitment	N(%)
0	91(1.2%)	Low commitment	357(4.7%)
1	67(0.9%)
2	93(1.2%)
3	106(1.4%)
4	159(2.1%)	Moderate commitment	1888(25.1%)
5	221(2.9%)
6	328(4.4%)
7	461(6.1%)
8	719(9.5%)
9	932(12.4%)	High commitment	5286(70.2%)
10	1278(17.0%)
11	1511(20.1%)
12	1565(20.8%)

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The most-practiced preventive measure among the study population was “covering the mouth/nose when coughing or sneezing” followed by “hand washing with soap and water more often than usual”. Half of the study population started to follow a healthy diet and over half of them reduced their attendance at school, college, university or work. (Table 4).

Table 4. Specific preventive measures.

	Yes (N%)	No (N%)
Wore a face mask when in crowded places or when public places	6577 (87.3)	954 (12.7)
Reduced the amount you go to school, college, university or work	4950 (65.7)	2581 (34.3)
Cancelled or postponed a social event such as meeting friends, eating out or going to a sporting event	5508 (73.1)	2023 (26.9)
Reduced the number of times you go to shops	5764 (76.5)	1767 (23.5)
Kept away from crowded places?	6317 (83.9)	1214 (16.1)
Cleaned or disinfected things you might touch (doorknob or hard surfaces)	5517 (73.3)	2014 (26.7)
Carried sanitizing hand gel with you when you were out?	5557 (73.8)	1974 (26.2)
Reduced the amount you touch your eyes, nose, and\or mouth?	5722 (76)	1809 (24)
Followed a healthy diet or took vitamins supplements	3747 (49.8)	3784 (50.2)
Tried to avoid people who have cold or flu-like symptoms?	6645 (88.2)	886 (11.8)
Usually used tissues when sneezing or coughing	6887 (91.4)	644 (8.6)
Washed your hands with soap and water more often than usual?	6637 (88.1)	894 (11.9)

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Correlations between commitment to preventive measures and participants characteristics

Chi-square univariate analysis showed a statistically significant difference between males and females regarding commitment to preventive measures. 76.4% of females and 63.1% of males were categorized as highly committed, while only 3.4% of females and 6.2% of males were categorized as poorly committed (χ² = 160.683, p-value<0.001). A significant association was found between age groups and adherence to preventive measures: 25–44 year old participants were most committed to IPC measures with 1780(76.1%) categorized as ‘high’, followed by 18–24, 45–65 and >65 age groups: 2269(72.6%), 1022(60.6%) and 215(56.1%) respectively (χ² = 204.974, p-value <0.001). Participants in relationships (76.6%, χ² = 92.002, p-value <0.001) and those from the western governorates of Syria (78.8%, χ² = 184.079, p-value <0.001) were more committed to IPC measures than their single counterparts and those in other parts of the country. Commitment to preventive measures was significantly associated with residency and financial status, with urban residents (71.6% vs. 35.4%, χ² = 59.106, p-value <0.001) and those in good financial status (76.6%, χ² = 279.195, p-value <0.001) were the most committed groups. Participants with post-graduate education (80.6%, χ² = 640.976, p-value <0.001) and students with full time jobs (77.1%, χ² = 129.431, p-value <0.001) were the most committed to preventive measures. (Table 5) Our results revealed that people who believe that COVID-19 poses a major risk to Syrian society were more committed to IPC measures, with 77.4% being highly committed compared to 59.5% from the ‘minor risk’ group and 43.0% from the ‘no risk at all’ group. Similarly, those who believe that COVID-19 poses a major risk to them personally were more committed to preventive measures, as (79.5%) of them were in the high commitment category. (Table 6).

Table 5. Correlation between demographic characteristics and level of commitment to protective measures.

Demographic characteristics		Level of commitment			Chi-Square value	P-value
Demographic characteristics		Low	Moderate	High	Chi-Square value	P-value
Age (years)	18–24 (n = 3124)	82 (2.6%)	773(24.7%)	2269(72.6%)	204.974	<0.001^*
	25–44 (n = 2338)	101(4.3%)	457(19.5%)	1780(76.1%)
	45–65 (n = 1686)	137(8.1%)	527(31.3%)	1022(60.6%)
	> 65 (n = 383)	37(9.7%)	131(34.2%)	215(56.1%)
Gender	Male (n = 3505)	219(6.2%)	1075(30.7%)	2211(63.1%)	160.683	<0.001^*
Gender	Female (n = 4026)	138(3.4%)	813(20.2%)	3075(76.4%)	160.683	<0.001^*
marital status	Single (n = 3984)	134(3.4%)	978(24.5%)	2872(72.1%)	92.002	<0.001^*
	Married (n = 2825)	202(7.2%)	719(25.5%)	1904(67.4%)
	in relationship (n = 500)	6(1.2%)	111(22.2%)	383(76.6%)
	Widow (n = 222)	15(6.8%)	80(36.0%)	127(57.2%)
origin	Eastern (n = 365)	25(6.8%)	121(33.2%)	219(60.0%)	184.079	<0.001^*
	Northern (n = 1272)	128(10.1%)	384(30.2%)	760(59.7%)
	Middle (n = 4376)	164(3.7%)	1072(24.5%)	3140(71.8%)
	Southern (n = 353)	12(3.4%)	92(26.1%)	249(70.5%)
	Western (n = 1165)	28(2.4%)	219(18.8%)	918(78.8%)
residency	City (n = 5711)	213(3.7%)	1409(24.7%)	4089(71.6%)	59.106	<0.001^*
residency	Countryside (n = 1820)	144(7.9%)	479(26.3%)	1197(65.8%)	59.106	<0.001^*
financial status	Low (n = 1268)	150(11.8%)	420(33.1%)	698(55.0%)	279.195	<0.001^*
	Middle (n = 3241)	134(4.1%)	814(25.1%)	2293(70.7%)
	Good (n = 2654)	59(2.2%)	561(21.2%)	2031(76.6%)
	Excellent (n = 371)	14(3.8%)	93(25.1%)	264(71.2%)
employment	Unemployed (n = 1635)	148(9.1%)	427(26.1%)	1060(64.8%)	129.431	<0.001^*
	part-time (n = 1114)	75(6.7%)	274(24.6%)	765(68.7%)
	full-time (n = 1688)	60(3.6%)	404(23.9%)	1224(72.5%)
	Student (n = 2653)	64(2.4%)	675(25.4%)	1914(72.1%)
	part-time + student (n = 290)	5(1.7%)	77(26.6%)	208(71.7%)
	full-time + student (n = 131)	4(3.1%)	26(19.8%)	101(77.1%)
	part-time + full-time(n = 20)	1(5.0%)	5(25.0%)	14(70.0%)
academic level	no education (n = 324)	81(25.0%)	129(39.8%)	114(35.2%)	640.976	<0.001^*
	Elementary (n = 422)	61(14.5%)	151(35.8%)	210(49.8%)
	Secondary (n = 550)	35(6.4%)	182(33.1%)	333(60.5%)
	High school (n = 782)	40(5.1%)	212(27.1%)	530(67.8%)
	university student (n = 2906)	78(2.7%)	721(24.8%)	2107(72.5%)
	university graduate (n = 1908)	39(2.0%)	392(20.5%)	1477(77.4%)
	post-university study (n = 639)	23(3.6%)	101(15.8%)	515(80.6%)
father’s educational level	no education (n = 760)	142(18.7%)	257(33.8%)	361(47.5%)	482.949	<0.001^*
	primary education (n = 1971)	95(4.8%)	543(27.5%)	1333(67.6%)
	secondary education (n = 1521)	40(2.6%)	368(24.3%)	1104(73.0%)
	university degree (n = 2776)	69(2.5%)	628(22.6%)	2079(74.9%)
	post- university (n = 512)	11(2.1%)	92(18.0%)	409(79.9%)
mother’s educational level	no education (n = 1225)	170(13.9%)	408(33.3%)	647(52.8%)	391.734	<0.001^*
	primary education (n = 1834)	72(3.9%)	494(26.9%)	1268(69.1%)
	secondary education (n = 1656)	52(3.1%)	391(23.6%)	1213(73.2%)
	university degree (n = 2625)	58(2.2%)	560(21.3%)	2007(76.5%)
	post-university (191)	5(2.6%)	35(18.3%)	151(79.1%)

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* P-value<0.05 considered statistically significant

Table 6. Correlation between risk perception and commitment to preventive measures.

		Level of commitment			Chi-Square	p.value
		Low	Moderate	Good	Chi-Square	p.value
To what extent do you think coronavirus poses a risk to people in Syria?	No risk at all	54(17.2%)	125(39.8%)	135(43.0%)	433.437	<0.001^*
	Minor risk	126(7.8%)	531(32.8%)	964(59.5%)
	Major risk	102(2.2%)	947(20.4%)	3591(77.4%)
	Do not know	75(7.8%)	285(29.8%)	596(62.3%)
To what extent do you think coronavirus poses a risk to you personally?	No risk at all	119(14.3%)	311(37.3%)	404(48.4%)	402.271	<0.001^*
	Minor risk	98(3.0%)	858(26.6%)	2268(70.3%)
	Major risk	50(2.3%)	405(18.3%)	1763(79.5%)
	Do not know	90(7.2%)	314(25.0%)	851(67.8%)

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* P-value<0.05 considered statistically significant

Discussion

The COVID-19 pandemic has significantly impacted humanity and forced governments across the world to adopt extensive infection prevention and control measures with varying degrees of severity [19]. Therefore most of the COVID-19 cases are asymptomatic or very mild. Syria is a low-income country that has been ravaged by civil war for over a decade, diminishing the ability to adequately respond to the pandemic and impose meaningful quarantines. As such, results of measures adopted by other countries and regions cannot be relied upon to predict the course of the pandemic in Syria, and the extraordinary difficulties facing the country and the realities on the ground must be taken into account when uniquely assessing the situation in Syria. The efficiency and impact of infection prevention and control (IPC) measures can be optimized by obtaining insights into the population’s current commitment to such measures. To the best of our knowledge, this is the first nationally representative study to offer insights into people’s adherence to preventive measures during the COVID-19 pandemic in Syria. Our findings revealed that 70.2% of the population claim to adhere to most of the preventive measures asked about in the questionnaire. This level of adherence is similar to that found in a Belgian study, and better than that from an Ethiopian study [20, 21]. The majority of our participants were young, and the age distribution of our population was generally consistent with the demographic data reported by the Central Bureau of Statistics (CBS), Damascus, Syria [22]. According to the latest CBS report, 40% of the Syrian population were below 24 years old, and 25.5% were 25–44 years old (compared to 41.5% and 31%, respectively, of our study population) [22]. The importance of face masks in reducing the spread of the virus is supported by numerous studies [23, 24]. One study suggests that complete eradication of the disease can be achieved if 80% of the population uses face masks effectively [25]. The vast majority of our participants (87.3%) were committed to wearing face masks in public spaces. This proportion is predictably lower than those from studies in China (98.0%) and Hong Kong (98.8%), where mask-wearing has been ingrained in the culture for decades, but considerably higher than in studies from Northwest Ethiopia (32.42%), Ethiopia (13.9%), Saudi Arabia (56.4%), and the United Kingdom (3.1%) [15, 21, 26–28].

Low income and unemployment were correlated with lower adherence to IPC measures, while higher income and gainful employment was correlated with higher adherence; only 55% of low income responders were highly committed to IPC measures, compared to 76.6% of those with good financial status. This may owe to the high cost of commitment to protective measures, which is prohibitively expensive for a significant proportion of the Syrian population. The Syrian pound has lost 35% of its value against the US dollar in the last year alone [14], and the percentage of the population living in poverty is 90% and rising [29]. While screening tests and social distancing might be considered cost-effective elsewhere in the world, this is not the case for the Syrian population (PCR screens cost $50 each and are not subsidized). Infection control measures such as sweeping lockdowns have only recently affected most of the world’s economies, whereas the Syrian economy, already suffering from a decade of war and crippling sanctions, has been devastated by lockdowns and other pandemic-related economic pressures. As such, Syria’s population and healthcare system are in desperate need of international support in the form of financial grants and donations of personal protective equipment, drugs, medical supplies, and vaccines. Income and employment-related results are in line with studies from China and Ethiopia, but do not align with those of a study from Saudi Arabia, likely due to vastly different socio-economic dynamics [15, 26, 28].

UNICEF reported that after a decade of war in Syria, more than half of children continue to be deprived of education [30]. The enormous scale of the education crisis is extremely worrying, as it threatens not only the future of an entire generation of children and the country as a whole, but also the important role of schools as conduits for health literacy and education about diseases and the importance of infection control. Our study revealed an important correlation between education and adherence to IPC measures, with commitment increasing significantly as the level of education increases. On one end of the spectrum, only 35.2% of uneducated participants adhere to protective measures, compared to 80.6% of participants with postgraduate education on the other end. These findings are consistent with studies from China, Ethiopia, and Germany [16, 26, 28].

Numerous studies have shown that risk perception can be considered a determinant of individual behavior during a disease outbreak [31–33]. The more risk perceived, the more likely people are to adhere to preventive measures. Some studies go even further and suggest that it is important to differentiate between the ‘experiential’ and ‘affective’ components of risk perception [34, 35]. Earlier research demonstrated that experiential risk perception, "the gut feeling of being vulnerable to risk", was positively associated with applying personal protective actions, such as vaccination and sun protection [36, 37]. Our study seems to support this assumption, and other studies in Italy, Northwest Ethiopia reported the same observation [21, 38].

Several previous studies showed that the level of knowledge correlates directly with adherence to preventive measures [28, 39]. Ideally, the public should be well-informed by reliable sources of information. Unfortunately, our participants’ reliance on untrusted sources on social media is part of a global trend in which misinformation is rampant and pervasive. Social media tends to be the most expedient means of obtaining information for many people, and studies have shown that social media is a fertile and target-rich environment for spreading misinformation and conspiracy theories that negatively affect the quality of the public’s knowledge [40–42]. Since it is impossible to fully control what is published on social media, local and global health authorities must enhance their presence on these platforms and use engaging content and effective methods to spread awareness and accurate information. Studying the public’s perception and behavior toward COVID-19 provides valuable insight which can help policymakers and healthcare providers to address the knowledge gaps that negatively affect people’s perception and behavior, thereby improving the national response to this pandemic. We encourage all concerned institutions to invest the time, resources, and expertise necessary to successfully and significantly leverage social media platforms to drive public health education and COVID-19 awareness campaigns. The rebuilding and rehabilitation of schools must be prioritized, and infection control measures incorporated into the curriculum. Special accommodations should be made for low-income people and families, in the form of distributing infection control kits (composed of a reusable face mask and hand sanitizer) and securing their income when proven to be sick to encourage them to self-quarantine.

Conclusion

Despite the high level of commitment to infection prevention and control (IPC) measures demonstrated by the participants in our study, it is necessary to stress the importance of continuing this commitment throughout the pandemic. It is recommended that local and international health authorities carry out continuous awareness campaigns with the aim of reminding the population of the importance of consistently applying IPC measures. Moreover, the population should be educated about how to identify and avoid misinformation on social media and to rely on reliable sources of information. Because of the economic and humanitarian situation in war-torn Syria, it is necessary for all concerned bodies and organizations to take serious action and provide appropriate assistance to the healthcare system to help contain this pandemic.

Limitations

This study is subject to some limitations. First, as a cross-sectional study it may not be able to determine causation, therefore more longitudinal studies are recommended. Second, distributing the questionnaire online only will lead to selection bias, as most people with internet access tend to be younger and wealthier. To minimize this bias we distributed the questionnaire both online and as hard copies. Third, many questions were subject to recall bias. Finally, the economic status question was subjective since the value of the Syrian pound is not stable and the exchange rate continues to fluctuate. This continues to affect the purchasing power of the local currency, with many families whose income was once adequate falling below the poverty line.

Supporting information

S1 Data

(XLSX)

Click here for additional data file.^{(1MB, xlsx)}

Acknowledgments

We would like to express our thanks to all the people and organizations that helped in distributing this survey, especially: Syrian Researchers Organization, Impact Makers Team, Syrian Drugs Up To Date Platform, MedDose Organization (NGO). We would also like to acknowledge the valuable help provided by Dr. Dana Alakhrass in revising this manuscript.

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0275669.r001

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6 Jan 2022

PONE-D-21-39441Commitment to protective measures during COVID-19 pandemic in Syria: a nationwide cross-sectional study.PLOS ONE

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Reviewer #1: In this paper entitled "Commitment to protective measures during COVID-19 pandemic in Syria: a nationwide cross-sectional study", the authors evaluate the extent to which the Syrian population adheres to these measures and analyze the relationship between demographic variables and adherence. The manuscript is well written and intelligently presented. The study is nicely designed, and the sample size is calculated using OpenEpi online software. All the data is analyzed using Statistical Package for Social Sciences version 25.0. The results are presented in a tabular form that gives a complete overview of the data collected. In addition, percentage, correlation and p-value are calculated to provide statistical stringency to the manuscript. I congratulate the authors for this work and recommend this work for publication. The manuscript is suitable for publications and should be formally accepted once it meets all technical requirements. Although it has one or two typos in the manuscript (lines 229,230),it needs to provide high-resolution fig 1 or remove it from the manuscript.

Reviewer #2: The manuscript entitled “Commitment to protective measures during COVID-19 pandemic in Syria: a nationwide cross-sectional study.” written by Shibani et al investigated the extent to which the Syrian population adheres to precautionary infection control measures and analyze the relationship between demographic variables and adherence. Authors did a cross-sectional study in Syria between January 17 and March 17, 2021 using a structured self-administered questionnaire. Authors concluded that this study generally showed a high level of adherence to the preventive measures compared to participants in other studies from around the world, with some concerns regarding risk perception and the sources of information they depend on. This manuscript requires minor revision prior to its publication in PLOS One as follows:

Suggestions: -

1. The background section can be updated with minor information such as health, diet and immunity, the natural COVID-19 preventive measures and various variants of COVID-19 i.e. doi: 10.1007/s12088-020-00893-4; doi: 10.1007/s12088-020-00908-0; doi: 10.1007/s15010-021-01734-2.

2. Figures quality may be improved with high resolution images (minor).

3. It would be required to provide one illustrative Figure as to highlight the summary or future prospect of this study.

4. Did authors ask about vaccination status in their survey (vaccinated/not vaccinated/will receive vaccination/reluctant for vaccination?

5. The English of manuscript can be polished (minor).

6. The authors should cross-check all abbreviations in the manuscript. Initially, define in full name followed by abbreviation.

Reviewer #3: This study investigated the commitment status of Syrian population to the protective measures against SARS-CoV-2 viral infection during COVID-19 pandemic. The manuscript is well organized and worth to be published. Yet, given the high contagious nature of the SARS-CoV-2 virus, commitment to the protective measures may only help to delay the infection to some limited extent, and eventually all members of the public will get infected by the virus in the long time. So, the paper will be more attractive if the authors can also provide some insightful understanding about infectious diseases like the SARS-CoV-2 infection, so that the public know what to do to avoid to develop into severe case of COVID-19 if they are infected by SARS-CoV-2 virus.

In talking about infectious diseases, it would be better if we distinguish infections from diseases. Infection is the presence of pathogen, which is not a sufficient condition for disease. [1]

Like most of the other viral and bacterial infections, the SARS-COV-2 viral infection is self-limiting [2]. When the human cells are infected by virus or bacteria, the human immunity will actively induce cell self-destruction (programmed cell deaths like necroptosis [3] and pyroptosis [4]) to stop the intracellular infection and reuse the nutrition from the degradation of these destroyed cells and the microorganisms in these cells to rebuild the tissue cells [5]. So by actively destroy damaged somatic cells, the viral and bacterial infections are also removed and become self-limiting [6]. Therefore most of the COVID-19 cases are asymptomatic or very mild.

Most of the severe cases of infectious diseases are the result of the overreaction of the strong yet malfunctioning immune system, as Sir William Osler stated more than 100 years ago: "Except on few occasions, the patient appears to die from the body’s response to infection rather than from it. Sir William Osler (1904)" [7]. As the human immune system also plays a virtual role in nutrition acquisition from the degradation of viral damaged epithelial cells, the nutrition surge coupled with the overnutrition state in some patients with obesity or metabolic syndromes may contribute to lipotoxicity and damage in non-adipose tissues, triggering hyperinflammation and contribute to the malfunction of the immune system. So the SARS-CoV-2 viral infection is only the trigger for the COVID-19 disease, and the real cause for the severe cases of COVID-19 disease are autoimmune disorder [8] caused by overnutrition which leads to the hyperinflammation and cytokine storm in these patients.

References:

1. V Humphries DL, Scott ME, Vermund SH (2021) Pathways linking nutritional status and infectious disease: causal and conceptual frameworks. In: Nutrition and infectious diseases, Shifting the Clinical Paradigm (eds DL Humphries, ME Scott, SH Vermund), pp. 3–22. Cham, Switzerland: Humana. DOI: 10.1007/978-3-030-56913-6_1

2. Kumar S, Veldhuis A, Malhotra T (2021) Neuropsychiatric and Cognitive Sequelae of COVID-19. Front Psychol 12:577529. DOI: 10.3389/fpsyg.2021.577529.

3. Nailwal, H., Chan, F.KM. Necroptosis in anti-viral inflammation. Cell Death Differ 26, 4–13 (2019). DOI: 10.1038/s41418-018-0172-x

4. Jorgensen I, Miao EA (2015) Pyroptotic cell death defends against intracellular pathogens. Immunological Reviews. 265 (1): 130-142. DOI:10.1111/imr.12287

5. Maitre Y, Mahalli R, Micheneau P, Delpierre A, Amador G, Denis F (2021) Evidence and Therapeutic Perspectives in the Relationship between the Oral Microbiome and Alzheimer's Disease: A Systematic Review. Int J Environ Res Public Health 18(21):11157. DOI: 10.3390/ijerph182111157.

6. Levin BR, Baquero F, Ankomah P, McCall IC (2017) Phagocytes, Antibiotics, and Self-Limiting Bacterial Infections. Trends in Microbiology, 25(11):878-892. DOI: 10.1016/j.tim.2017.07.005

7. Dobson GP, Biros E, Letson HL and Morris JL (2021) Living in a Hostile World: Inflammation, New Drug Development, and Coronavirus. Front. Immunol. 11:610131. DOI: 10.3389/fimmu.2020.610131

8. Halpert G, Yehuda Shoenfeld Y (2020) SARS-CoV-2, the autoimmune virus. Autoimmunity Reviews 19(12):102695. DOI: 10.1016/j.autrev.2020.102695.

**********

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PLoS One. 2022 Oct 14;17(10):e0275669. doi: 10.1371/journal.pone.0275669.r002

Author response to Decision Letter 0

27 Feb 2022

Response letter

We would like to thank the editor and reviewers for taking their valuable time to review this manuscript. We have thoroughly assessed the comments and implemented them into our revised manuscript, now that this article has been made suitable we aspire to have this article published in your journal.

The following letter will report the responses to the reviewers’ comments.

Journal 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

Author response: All style requirements have been addressed, including those for file naming.

2. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Author response: We apologize for this mistake and have deleted The ethical statement from the other sections.

Author response: The reference list have been revised thoroughly.

Review Comments to the Author

Author response: We apologize for this mistake and have revised this manuscript thoroughly for any other typos. We also provided a high-resolution copy of figure 1.

Suggestions:

Author response: We thank the reviewer for the guidance, and have used the valuable information provided above to enhance our paper quality. These amendments have been made to the manuscript text and where these can be viewed (Background section, lines 67-68)

2. Figures quality may be improved with high resolution images (minor).

Author response: We apologize for the inconvenience and have provided a high-resolution copy of figure 1.

3. It would be required to provide one illustrative Figure as to highlight the summary or future prospect of this study.

Author response: We thank the reviewer for this comment, and would like to ask for further instructions about how to address this point.

4. Did authors ask about vaccination status in their survey (vaccinated/not vaccinated/will receive vaccination/reluctant for vaccination?

Author response: We thank the reviewer for this comment, and would like to clarify that at the time when this study was conducted, no vaccine were available in Syria, so our main focus was to study the commitment to personal protective measures regardless of the availability of the vaccines. However, there is another study was conducted at the same period regarding this manner i.e.: https://doi.org/10.1186/s12889-021-12186-6

5. The English of manuscript can be polished (minor).

Author response: We apologize for this mistake and have revised this manuscript thoroughly for language editing.

6. The authors should cross-check all abbreviations in the manuscript. Initially, define in full name followed by abbreviation.

Author response: We apologize for this mistake and have revised this manuscript thoroughly for abbreviations.

In talking about infectious diseases, it would be better if we distinguish infections from diseases. Infection is the presence of pathogen, which is not a sufficient condition for disease. [1] Like most of the other viral and bacterial infections, the SARS-COV-2 viral infection is self-limiting [2]. When the human cells are infected by virus or bacteria, the human immunity will actively induce cell self-destruction (programmed cell deaths like necroptosis [3] and pyroptosis [4]) to stop the intracellular infection and reuse the nutrition from the degradation of these destroyed cells and the microorganisms in these cells to rebuild the tissue cells [5]. So by actively destroy damaged somatic cells, the viral and bacterial infections are also removed and become self-limiting [6]. Therefore most of the COVID-19 cases are asymptomatic or very mild. Most of the severe cases of infectious diseases are the result of the overreaction of the strong yet malfunctioning immune system, as Sir William Osler stated more than 100 years ago: "Except on few occasions, the patient appears to die from the body’s response to infection rather than from it. Sir William Osler (1904)" [7]. As the human immune system also plays a virtual role in nutrition acquisition from the degradation of viral damaged epithelial cells, the nutrition surge coupled with the overnutrition state in some patients with obesity or metabolic syndromes may contribute to lipotoxicity and damage in non-adipose tissues, triggering hyperinflammation and contribute to the malfunction of the immune system. So the SARS-CoV-2 viral infection is only the trigger for the COVID-19 disease, and the real cause for the severe cases of COVID-19 disease are autoimmune disorder [8] caused by overnutrition which leads to the hyperinflammation and cytokine storm in these patients.

References:

2. Kumar S, Veldhuis A, Malhotra T (2021) Neuropsychiatric and Cognitive Sequelae of COVID-19. Front Psychol 12:577529. DOI: 10.3389/fpsyg.2021.577529.

3. Nailwal, H., Chan, F.KM. Necroptosis in anti-viral inflammation. Cell Death Differ 26, 4–13 (2019). DOI: 10.1038/s41418-018-0172-x

4. Jorgensen I, Miao EA (2015) Pyroptotic cell death defends against intracellular pathogens. Immunological Reviews. 265 (1): 130-142. DOI:10.1111/imr.12287

6. Levin BR, Baquero F, Ankomah P, McCall IC (2017) Phagocytes, Antibiotics, and Self-Limiting Bacterial Infections. Trends in Microbiology, 25(11):878-892. DOI: 10.1016/j.tim.2017.07.005

7. Dobson GP, Biros E, Letson HL and Morris JL (2021) Living in a Hostile World: Inflammation, New Drug Development, and Coronavirus. Front. Immunol. 11:610131. DOI: 10.3389/fimmu.2020.610131

8. Halpert G, Yehuda Shoenfeld Y (2020) SARS-CoV-2, the autoimmune virus. Autoimmunity Reviews 19(12):102695. DOI: 10.1016/j.autrev.2020.102695.

Author response: We really appreciate the efforts made by the reviewer and have used his/her guidance to further improve our manuscript. and we hope that the study is now better than before These amendments have been made to the manuscript text and where these can be viewed (Background section, line 69-76, and Discussion section, line 240-249)

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(20.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0275669.r003

Decision Letter 1

Syed Ghulam Sarwar Shah

29 Jun 2022

PONE-D-21-39441R1Commitment to protective measures during COVID-19 pandemic in Syria: a nationwide cross-sectional study.PLOS ONE

Dear Dr. Shibani,

Please submit your revised manuscript by Jul 21 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Syed Ghulam Sarwar Shah, M.B.B.S., M.A., M.Sc., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Thanks for your revised manuscript, which is has following issues that need to be addressed.

Title: Please add ‘the’ before COVID-19 pandemic.

Abstract:

1. Please report the sample size and sample type in the methods section of abstract.

2. Please report the total number of respondents and the response rate in the results section.

3. Please revise this sentence as it is not clear “Statistically significant differences across age, sex, marital status, financial status, employment, and educational attainment when correlated against commitment to preventive measures.”

4. Please reconcile your statements about adherence to preventive measures in the abstract because in the results section you report ‘good adherence ‘while in the conclusion section you state ‘high level of adherence’. Good and High level are not same thing. Moreover, you have reported ‘Low’, ‘Moderate’ and ‘High’ categories of commitment in the methods section (lines 155-156). Therefore, please be consistent and report the level of commitment that was found.

Backgrounds:

1. Could you please report the date on which there were ‘…over 250 million cases and over 5 million deaths (1)’.

2. Please refer to your statement about the possible impact of nutrition and immunity reported in lines 67-76. This information is not relevant because your study is about the commitment and adherence to the preventive measures and nutrition is not one of the measures. Could you please remove this text along with the references cited in this paragraph?

3. Please change ‘6pm-to-6am’to ‘6 pm-to-6 am’ (line 79).

4. Could you please change ‘wearing masks’ to ‘wearing face masks’ (line 83).

5. Could you please report the exact date instead of writing: ‘As of this writing’ in the following sentence ‘As of this writing, 45,468 laboratory-confirmed cases and 2,637 casualties.. (Line 88).

METHODS:

6. Study design, setting, and participants: Please report your total sample size (how many people were invited /approached to complete the survey questionnaire) because there are different numbers reported in the manuscript. For example, in the abstract sample size is ‘10083’ reached out’ while in the methods section you report calculated sample size = 7336 and then you report 8083 people completed the survey and thereafter ‘final sample size of 7,531 participants. Please clearly report your calculated sample size as well as how many people were invited/reached out (if there is difference between these then give reasons for it). Then how many responses were received and how many cases were excluded and final sample size / responses that were analysed. In the abstract you report your final sample size included in the analysis as well as effective response rate.

7. Could you please provide more information about how your sample was ‘nationally representative sample’? (Line 110).

8. You report ‘Chain-referral and convenience sampling methods were employed...’. These might include ‘snowball sampling’? If so, please report it here as well as in the abstract.

9. Please refer to you statement: ‘The questionnaire, based on a previous study,..’ (Line 110). Could you please provide a reference/cite this study that used this questionnaire originally?

10. Could you please report in the methods section how financial status was categorised because Table 5 includes categories of the financial status of the participants.

11. Statistical analysis: Could you please add the abbreviation of names of the researchers who manually entered data in the following sentence: ‘Data from the hard copy questionnaires were entered manually by the investigators (AB, XY, etc) (lines 149-150).

12. ‘A 13 point scale was used to measure the level of commitment (Line 152) was this scale created by the authors of this study or it was already reported in the original questionnaire adopted from earlier studies (which ones?).

13. Please report the lowest and highest scores in the 13-point scale.

14. Ethics & Consent: The authors report that ‘Informed consent was obtained from every participant…’ (line 164). Could you please report how consent from participants was obtained and in which form it was obtained?

RESULTS:

15. Participant characteristics: The authors report that ‘Of 10083 participants, 7531 agreed to participate,’ (Line 170) whereas in the methods section they report that 8083 people completed the survey (Line 123). Please report the actual number of participants who completed the survey and then how many surveys were fully completed. You might like to say: ‘Of 8083 retuned surveys, 7531 surveys were fully completed and analysed’. Then you can report your affective response rate.

16. Participant characteristics: Please avoid reporting same information in the text as well as in Tables. For example: ‘…3505 (46.5%) were males and 4026 (53.5%) were females. 172 The dominant age group was 18-24 years old: 3124 (41.5%), followed by 25 - 44 years old: 2338 173 (31%), 45-65 years old: 1686 (22.4%), and > 65 years: 383 (5.1%).’ (Lines 171-173. Here your repot counts and % of items/variables that are also given in Table 1. Report only the main / major findings in the text and refer to table for numbers and %. For example: Most of the respondents were women and the dominant age group was 18-24 years (Table 1).

17. Please revise this sentence: Over the half of the study population originated from the central governorates: 4376 (58.1%), and 1165 (15.5%) from the western governorates. (Lines 174-175). You might like to report as: Just more than half of the respondents originated from the central governorates while the lowest respondents were from the western governorates.

18. Please revise the text reported in lines 176-181 as suggested above.

19. Please revise the text about the findings about ‘COVID-19 related information’ and ‘Commitment to preventive measures’ as suggested in comments 15-16 above.

20. Please revise ‘…showed poor commitment. (Table 3).’ As ‘...showed low commitment. (Table 3).’ (Line 201).

21. Table 3: In this table commitment levels are reported as ‘Bad, Moderate, and Good’, whereas in the methods section commitment levels reported are: ‘Low’, ‘Moderate’ and ‘High’ (lines 155-156). Please be consistent and report the level of commitment as reported in the methods section.

22. Table 4, Please start each statement with a capital letter i.e. wearing as Wearing, cancelled as Cancelled and so on in this Table.

23. P-values: Please report p-values as <0.001 for all values 0.000 or <0.0001 in the section about ‘Correlations between commitment to preventive measures and participants characteristics’ (lines 212-233), Table 5, Table 6 and elsewhere.

24. Table 5 & Table 6: Please revise ‘Bad’ to ‘Low’ in column ‘Level of commitment’ in these tables and elsewhere.

DISCUSSION

25. Please remove the text in the first paragraph in lines 240-248 “In talking about infectious diseases,…………. also removed and become self-limiting (28).” This information is about issues that are different from the focus of this study which is about the commitment to preventive measures to prevent the spread of COVID-19. Please remove all references (23-27) cited in this para.

26. The authors argue that ‘This level of adherence is similar to that found in a Belgian study’; however, comparison between Belgium and Syria does not seem to be reasonable because the two countries are very different in many aspects social, economic and so on. The authors might like to revise this argument. Similarly in the following sentence the authors compare their findings with the UK and Germany also. The authors should compare their findings with the countries in their region and with similar socio-economic situation.

27. Please change ‘The majority of our sample were young...’ (Line 261) to ‘The majority of our participants were young…’

28. The authors report that ‘Low income and unemployment were correlated with lower adherence to IPC measures, while higher income and gainful employment was correlated with higher adherence’ (Lines 273-274). Table 5 shows similar findings about the low education level and vice versa. The authors could include the findings about the education level in this sentence. These findings are important from the policy perspective and could be included/highlighted in the conclusion.

CONCLUSIONS

29. Conclusion reported in the abstract and in the main manuscript should convey the same message so please revise your conclusion at both places.

[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: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Reviewer #1: In this paper, the authors evaluate how the Syrian population adheres to these measures and analyze the relationship between demographic variables and adherence. The manuscript is well written and intelligently presented. In addition, the study is nicely designed. I congratulate the authors on this work. The manuscript is suitable for publication.

Reviewer #2: This manuscript entitled "Commitment to protective measures during COVID-19 pandemic in Syria: a nationwide cross-sectional study" has improved.

Reviewer #3: As the authors have addressed all my concerns in my previous review comments, the manuscript can be accepted for publication in its present form.

Reviewer #4: Thank you for the opportunity to review this manuscript. It is an interesting and very well written and structured work that looks at public compliance with preventive measures in Syria during the COVID-19 pandemic. The results are interesting and informative. I think that the authors have successfully addressed the concerns and provided an important addition to the literature. My only suggestion would be to maybe add absolute as well as relative frequencies to Figure 1 to more easily identify the distribution based on sample size.

**********

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: No

Reviewer #2: Yes: Vinay Kumar

Reviewer #3: Yes: Ligen Yu

Reviewer #4: No

**********

PLoS One. 2022 Oct 14;17(10):e0275669. doi: 10.1371/journal.pone.0275669.r004

Author response to Decision Letter 1

20 Jul 2022

Response letter

We would like to thank the editor for taking the valuable time to review this manuscript. We have thoroughly assessed the comments and implemented them into our revised manuscript, now that this article has been made suitable, we aspire to have this article published in your journal.

The following letter will report the responses to the comments.

Editor comments:

- Title: Please add ‘the’ before COVID-19 pandemic.

Author response: We thank the editor for the guidance, and have made the asked amendment

Abstract:

1- Please report the sample size and sample type in the methods section of abstract.

Author response: We thank the editor for the guidance, and have made the asked amendment. These amendments have been made to the manuscript text and where these can be viewed (Abstract section, line 34-35)

2- Please report the total number of respondents and the response rate in the results section.

Author response: the total number of respondents and the response rate have been added in the results section, which can be viewed in (Abstract section, line 38)

3- Please revise this sentence as it is not clear “Statistically significant differences across age, sex, marital status, financial status, employment, and educational attainment when correlated against commitment to preventive measures.”

Author response: We thank the editor for the guidance, and have revised this sentence and made it more clear. This can be viewed (Abstract, line 41-44)

4- Please reconcile your statements about adherence to preventive measures in the abstract because in the results section you report ‘good adherence ‘while in the conclusion section you state ‘high level of adherence’. Good and High level are not same thing. Moreover, you have reported ‘Low’, ‘Moderate’ and ‘High’ categories of commitment in the methods section (lines 155-156). Therefore, please be consistent and report the level of commitment that was found.

Author response: We understand the editor’s point, and have revised the manuscript to ensure we have used the same term and classification in all sections, and correction to the mentioned sentence were made. these can be viewed (Abstract, line 40 -41)

Background:

1- Could you please report the date on which there were ‘…over 250 million cases and over 5 million deaths (1)’

Author response: We apologize for this mistake, and have reported the date. These amendments have been made to the manuscript text and where these can be viewed (Background, line 57-58)

2- Please refer to your statement about the possible impact of nutrition and immunity reported in lines 67-76. This information is not relevant because your study is about the commitment and adherence to the preventive measures and nutrition is not one of the measures. Could you please remove this text along with the references cited in this paragraph?

Author response: We agree with the editor, and have removed this paragraph from the manuscript. These amendments have been made to the manuscript text and where these can be viewed in the track change manuscript (Background, line 70-79)

3- Please change ‘6pm-to-6am’to ‘6 pm-to-6 am’ (line 79)

Author response: We apologize for this mistake and have made the asked modifications. (Background, line 82)

4- Could you please change ‘wearing masks’ to ‘wearing face masks’ (line 83).

Author response: We apologize for this mistake and have made the asked modifications. (Background, line 87)

5- Could you please report the exact date instead of writing: ‘As of this writing’ in the following sentence ‘As of this writing, 45,468 laboratory-confirmed cases and 2,637 casualties.. (Line 88).

Author response: We understand the editor’s point, and have mentioned the exact date for these figures. These amendments have been made to the manuscript text and where these can be viewed (Background section, line 91-92)

METHODS:

6- Study design, setting, and participants: Please report your total sample size (how many people were invited /approached to complete the survey questionnaire) because there are different numbers reported in the manuscript. For example, in the abstract sample size is ‘10083’ reached out’ while in the methods section you report calculated sample size = 7336 and then you report 8083 people completed the survey and thereafter ‘final sample size of 7,531 participants. Please clearly report your calculated sample size as well as how many people were invited/reached out (if there is difference between these then give reasons for it). Then how many responses were received and how many cases were excluded and final sample size / responses that were analysed. In the abstract you report your final sample size included in the analysis as well as effective response rate.

Author response: We understand the editor’s point and would like to clarify that initially the sample size calculation software suggested a minimum sample size of 7336. In order to achieve this goal, we reached out to 10083 individuals, and of these only 8083 responded back to us. After reviewing these responses we excluded those who did not meet our inclusion criteria, which eventually gave us a final figure of 7531. This clarification was made to the manuscript where it can be viewed (Method section, line 124- 132)

7- Could you please provide more information about how your sample was ‘nationally representative sample’? (Line 110).

Author response: We thank the editor for this comment, and have removed this statement from the methods section as it is fully explained later on the discussion section. These amendments have been made to the manuscript text and where these can be viewed (Method section, line 113)

8- You report ‘Chain-referral and convenience sampling methods were employed...’. These might include ‘snowball sampling’? If so, please report it here as well as in the abstract.

Author response: We agree with the editor, and yes indeed, snowball sampling is a synonym for chain-referral sampling. We added this term appropriately in the method section where these can be viewed (methods section, line 116)

9- Please refer to you statement: ‘The questionnaire, based on a previous study,..’ (Line 110). Could you please provide a reference/cite this study that used this questionnaire originally?

Author response: We thank the editor for the guidance. However, the questionnaire we used is a newly developed one based on multiple different questionnaires from multiple previous studies (references 15-17). We modified this sentence and made this idea clear which can be viewed in (Method section, line 113-114)

10- Could you please report in the methods section how financial status was categorised because Table 5 includes categories of the financial status of the participants

Author response: We thank the editor for the guidance. We mentioned the categories in the method section as required (Methods section, line139-140)

11- Statistical analysis: Could you please add the abbreviation of names of the researchers who manually entered data in the following sentence: ‘Data from the hard copy questionnaires were entered manually by the investigators (AB, XY, etc) (lines 149-150).

Author response: We agree with the editor, and have added the initials of the authors who manually entered the data. These amendments have been made to the manuscript text and where these can be viewed (Methods section, line 155-156).

12- ‘A 13 point scale was used to measure the level of commitment (Line 152) was this scale created by the authors of this study or it was already reported in the original questionnaire adopted from earlier studies (which ones?).

Author response: We understand the editor’s point and would like to clarify that the scale was developed by the investigators for this study. We also clarified this point in the manuscript. These amendments have been made to the manuscript text and where these can be viewed (Method section, line 158-159)

13- Please report the lowest and highest scores in the 13-point scale.

Author response: We thank the editor for the guidance. We added the lowest and highest scores in the 13-point scale (Methods section, line160)

14- Ethics & Consent: The authors report that ‘Informed consent was obtained from every participant…’ (line 164). Could you please report how consent from participants was obtained and in which form it was obtained?

Author response: We thank the editor for the guidance. We clarified that a written informed consent was obtained from every participant as each questionnaire had an informed consent form (the first page in the hard copy version and the first question in the digital one) needs to be signed by the respondents prior to participation. (Methods section, line171 - 173)

RESULTS:

15- Participant characteristics: The authors report that ‘Of 10083 participants, 7531 agreed to participate,’ (Line 170) whereas in the methods section they report that 8083 people completed the survey (Line 123). Please report the actual number of participants who completed the survey and then how many surveys were fully completed. You might like to say: ‘Of 8083 retuned surveys, 7531 surveys were fully completed and analysed’. Then you can report your affective response rate

Author response: We thank the editor for the guidance. We addressed this point and made it clear in both results and Methods sections. (Methods section, line1791 - 181)

18. Please revise the text reported in lines 176-181 as suggested above.

19. Please revise the text about the findings about ‘COVID-19 related information’ and ‘Commitment to preventive measures’ as suggested in comments 15-16 above.

Author response: We thank the editor for the guidance. We addressed this point were appropriate across all result sections.

20. Please revise ‘…showed poor commitment. (Table 3).’ As ‘...showed low commitment. (Table 3).’ (Line 201).

Author response: We thank the editor for the guidance. We addressed this issue across all result sections.

22. Table 4, Please start each statement with a capital letter i.e. wearing as Wearing, cancelled as Cancelled and so on in this Table.

Author response: We thank the editor for the guidance. We addressed this issue and corrected all statements.

Author response: We thank the editor for the guidance. We addressed this issue across the manuscript

24. Table 5 & Table 6: Please revise ‘Bad’ to ‘Low’ in column ‘Level of commitment’ in these tables and elsewhere.

Author response: We thank the editor for the guidance. We addressed this issue across the manuscript

DISCUSSION

Author response: We agree with editor’s point of view and have removed this paragraph and the corresponding references.

Author response: We understand the editor’s point of view and we would like to clarify that we compared our results with results from countries with different ranking because we believe that it is important to understand our country’s situation compared to the world.

27. Please change ‘The majority of our sample were young...’ (Line 261) to ‘The majority of our participants were young…’

Author response: We thank the editor for the guidance and have made the required modification (Discussion section, line 273)

Author response: We thank the editor for the guidance. However, we talked about the correlation between educational level and commitment to protective measures later in the discussion with its own paragraph (Discussion section, line 303-312)

CONCLUSIONS

29. Conclusion reported in the abstract and in the main manuscript should convey the same message so please revise your conclusion at both places.

Author response: We thank the editor for the guidance. We modified the conclusion in the abstract to convey the main message as the main conclusion.

Attachment

Submitted filename: Response letter.docx

Click here for additional data file.^{(25.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0275669.r005

Decision Letter 2

Syed Ghulam Sarwar Shah

4 Aug 2022

PONE-D-21-39441R2Commitment to protective measures during the COVID-19 pandemic in Syria: a nationwide cross-sectional study.PLOS ONE

Dear Dr. Shibani,

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 18 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Syed Ghulam Sarwar Shah, M.B.B.S., M.A., M.Sc., Ph.D.

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:

Comments from the Academic Editor:

Many thanks for addressing issues raised by AE. However, there are still few issues that need to be addressed as suggested below.

1. Authorship: A new author named ‘Dana Alakhrass’ with affiliation no. 6 has been added in this version of the manuscript. This person was not a author in the original and revised submission R1. This person could not be added as an author at this stage. If this person helped in the latest revision of the manuscript, then their name could be reported in the acknowledgments. Please refer to the PLOS ONE Guidelines for the authorship for further guidance on the issue.

2. Abstract; Conclusion- Please change 'a nationwide awareness campaigns ' to either 'A nationwide awareness campaign' or 'Nationwide awareness campaigns' in the conclusion in the abstract.

3. Background: Lines 58-59. Please correct the following sentence 'to the date of writing in December 2021'. It could be ‘as of XX December 2021' (put a particular date instead of to the date of writing).

4. Methods: Lines 115-116, Please change from 'based on a previous studies' to 'based on previous studies'

5. Financial status in Table 1 and other text: Please change financial status category of 'bad' to 'low', which reads better. Make this change in all places where you have reported 'bad' financial status.

6. Table 4: Specific preventive measures: Some of these statements start with a past tense while other use different tense. Could you please correct these statements so that they are in the same tense? All these statements should start with a capital letter.

7. Table 4: What do you mean by the amount in the following sentence 'Reduce the amount you go to shops'? Is it the 'time' or 'number of times' or something else? Please change accordingly.

8. Legends of figures and table captions: Please put full stop after the number. Change from Table .1 to Table 1. Please do the same for all figures and tables.

9. References: please update your references and include the vol. issue and page numbers as well as DOI for all journal articles and URLs for internet / website sources. In some reference year is written twice, please report it only once.

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Reviewers' comments:

PLoS One. 2022 Oct 14;17(10):e0275669. doi: 10.1371/journal.pone.0275669.r006

Author response to Decision Letter 2

7 Sep 2022

We would like to thank the editors for taking their valuable time to review this manuscript. We have thoroughly assessed the comments and implemented them into our revised manuscript, now that this article has been made suitable we aspire to have this article published in your journal.

The following letter will report the responses to the reviewers’ comments.

Comments from the Academic Editor:

Author response: We apologize for this mistake and have removed this person name from the authorship list to the acknowledgment section These amendments have been made to the manuscript text and where these can be viewed (acknowledgment section, lines 332-333)

2. Abstract; Conclusion- Please change 'a nationwide awareness campaigns ' to either 'A nationwide awareness campaign' or 'Nationwide awareness campaigns' in the conclusion in the abstract.

Author response: We thank the academic Editor for the guidance, and have changed 'a nationwide awareness campaigns ' to 'Nationwide awareness campaigns'. These amendments have been made to the manuscript text and where these can be viewed (Abstract section, lines 48-49)

Author response: We thank the AE for the comment, and have added the exact date corresponding with the numbers to the manuscript. These amendments have been made to the manuscript text and where these can be viewed (Introduction section, lines 56-57)

4. Methods: Lines 115-116, Please change from 'based on a previous studies' to 'based on previous studies'

Author response: We apologize for this mistake and have revised the sentence. These amendments have been made to the manuscript text and where these can be viewed (methods section, line104)

Author response: We thank the AE for the comment, and have changed the financial status category of 'bad' to 'low' throughout the manuscript.

Author response: We thank the academic Editor for the guidance, and have changed the tenses of all statements to be in the past tense. These amendments have been made to the manuscript text and where these can be viewed (Table 4)

7. Table 4: What do you mean by the amount in the following sentence 'Reduce the amount you go to shops'? Is it the 'time' or 'number of times' or something else? Please change accordingly.

Author response: We apologize for this mistake and have clarified the exact meaning of the question by changing 'Reduce the amount you go to shops'? to 'Reduce the number of times you go to shops'? . These amendments have been made to the manuscript text and where these can be viewed (Table 4.)

8. Legends of figures and table captions: Please put full stop after the number. Change from Table .1 to Table 1. Please do the same for all figures and tables.

Author response: We apologize for this mistake and have applied the required amendments. (Tables and figures legends section, lines 335-342)

Author response: We have updated the references list to include the vol. issue and page numbers as well as DOI for all journal articles and URLs for internet / website sources.

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PLoS One. doi: 10.1371/journal.pone.0275669.r007

Decision Letter 3

Syed Ghulam Sarwar Shah

21 Sep 2022

Commitment to protective measures during the COVID-19 pandemic in Syria: a nationwide cross-sectional study.

PONE-D-21-39441R3

Dear Dr. Shibani,

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

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Syed Ghulam Sarwar Shah, M.B.B.S., M.A., M.Sc., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for addressing all issues raised by the AE and reviewers in your revised manuscript.

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0275669.r008

Acceptance letter

Syed Ghulam Sarwar Shah

5 Oct 2022

PONE-D-21-39441R3

Commitment to protective measures during the COVID-19 pandemic in Syria: a nationwide cross-sectional study.

Dear Dr. Shibani:

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. Syed Ghulam Sarwar Shah

Academic Editor

PLOS ONE

Associated Data

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Data Availability Statement

All relevant data are within the paper and its Supporting information files.

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PERMALINK

Commitment to protective measures during the COVID-19 pandemic in Syria: A nationwide cross-sectional study

Mosa Shibani

Mhd Amin Alzabibi

Abdul Fattah Mohandes

Humam Armashi

Tamim Alsuliman

Angie Mouki

Marah Mansour

Hlma Ismail

Shahd Alhayk

Ahmad abdulateef Rmman

Hala Adel Almohi Alsaid Mushaweh

Elias Battikh

Naram Khalayli

Bisher Sawaf

Mayssoun Kudsi

Roles

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Study design, setting, and participants

Measures

Statistical analysis

Ethical considerations

Results

Participant characteristics

Table 1. Participant’s characteristics.

COVID-19 related information

Table 2. COVID-19 related information.

Fig 1. Participants sources of information.

Commitment to preventive measures

Table 3. Level of commitment to protective measures.

Table 4. Specific preventive measures.

Correlations between commitment to preventive measures and participants characteristics

Table 5. Correlation between demographic characteristics and level of commitment to protective measures.

Table 6. Correlation between risk perception and commitment to preventive measures.

Discussion

Conclusion

Limitations

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Sanjay Kumar Singh Patel

Roles

Author response to Decision Letter 0

Decision Letter 1

Syed Ghulam Sarwar Shah

Roles

Author response to Decision Letter 1

Decision Letter 2

Syed Ghulam Sarwar Shah

Roles

Author response to Decision Letter 2

Decision Letter 3

Syed Ghulam Sarwar Shah

Roles

Acceptance letter

Syed Ghulam Sarwar Shah

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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