Do Vaccination Attitudes Mediate the Link between Critical Consciousness and COVID-19 Vaccination Behaviour? A Cross-Sectional Study

Round 1

Reviewer 1 Report

Authors explained "Critical reflection and Covid-19 vaccination behaviour: the mediating role of vaccination attitudes". This is a good concern and still the hot topic but some corrections are required:

1. Paper seems theoretical but without inclusion of figures and tables. It creates touch situation to easily understand the manuscript. Result section is not much clear to me here.

2. Consider some good work like: a) A Hybrid Convolutional Neural Network Model for Diagnosis of COVID-19 Using Chest X-ray Images b) Blockchain Enabled Transparent and Anti-Counterfeiting Supply of COVID-19 Vaccine Vials c) An intelligent fine-tuned forecasting technique for covid-19 prediction using neuralprophet model

3. Somehow the english writing is not good like "The survey task took around 15–20 minutes to complete". 

4. Contributions are not so clear in the manuscript. 

5. A comparison of existing work is foremost required here.

Author Response

June 17^th, 2022

Mr. Zachary Zhang, MDPI Sustainability Editorial OfficeSustainability 

            We want to thank you and the reviewers for the thoughtful comments and observations to our manuscript, entitled. We revised the manuscript in accordance with all the reviewers' comments. We will detail all the changes made, so that all our modifications can be easily identified throughout the text.

 

Reviewers' comments:

Reviewer 1

Comments to the Author

sustainability-1758928 Review

1. 
   Paper seems theoretical but without inclusion of figures and tables. It creates touch situation to easily understand the manuscript. Result section is not much clear to me here.

 

• Thank you for the suggestions made. Tables and figures are embeded in the text. The results section has been improved by adding further clarification:

 

“Table 2 reports the Spearman correlations for all the correlations involving vaccination behaviour, and Pearson’s correlations, Cronbach’s alpha reliability index, means and standard deviations between the investigated variables. Critical reflection showed significant correlations with mistrust of vaccine benefits and worries about unforeseen effects in the investigated directions. Specifically, critical reflection is negatively associated with mistrust of vaccine benefits and worries about unforeseen effects, and positively associated with vaccination behaviour. Moreover, we explored the relationship between critical reflection and vaccination behaviour, and the linking mechanisms by exploring the mediation role of vaccination attitudes. Due to the non-significant correlations, hence the lack of a linear relationship between critical action, critical motivation, and vaccination attitudes, we decided to no longer include critical action and critical motivation in the analysis as predictors. (…) Overall, the results partially support our hypothesised mediation model (see Figure 2), revealing that the link between critical reflection and vaccination behaviour is mediated by vaccination attitudes (see Table 4). Using a post-hoc power calculator [50], the statistical power for the indirect effect for the used sample was shown to be 91 % at p < 0.05 with 20,000 Monte Carlo replications.”

 

2. Consider some good work like: a) A Hybrid Convolutional Neural Network Model for Diagnosis of COVID-19 Using Chest X-ray Images b) Blockchain Enabled Transparent and Anti-Counterfeiting Supply of COVID-19 Vaccine Vials c) An intelligent fine-tuned forecasting technique for covid-19 prediction using neuralprophet model.

 

• Thank you for your observation. The above references have been included in the manuscript on pages 1 and 10 as folows:

 

“Besides good forecasting and diagnosis techniques [51; 52], fostering the psychological factors that can also impact vaccination behaviours is also necessary.” and “Since the development and global-level distribution of vaccines [2], there have been reports concerning vaccination intention [3; 4] and vaccine hesitancy [4; 5]”

 

 

3. Somehow the english writing is not good like "The survey task took around 15–20 minutes to complete". 

 

• Thank you for this important English language has been improved in the manuscript. For example: “The study received approval from the Research Ethics Committee of the University. The research took place during October and December 2021. The participants were recruited from various social media groups. Announcements regarding the research were posted on Facebook groups and on Instagram. They contained the link to the online form containing the questionnaires. The participants were invited to read the informed consent form and provide their demographic information. Before starting the study, the respondents were informed that participation was voluntary, and they could withdraw from the study at any point. They also received information regarding data gathering, security and maintenance. The questionnaire took around 15–20 minutes to complete.”

 

4. Contributions are not so clear in the manuscript.

 

• Thank you for this recommendation. The contributions have been improved as follows:

 

“Considering the persistent issue of vaccination hesitancy in Eastern Europe, the present study approached vaccination behaviour from a different perspective. Besides good forecasting and diagnosis techniques [51; 52], fostering the psychological factors that can also impact vaccination behaviours is also necessary.”

 

“Our results are in line with other findings that evaluated the development of critical consciousness to support health-related behaviours, especially regarding the AIDS epidemic [23; 42; 43]. Collectively, these results show that the development of critical consciousness can be an impactful way to reduce the negative effects of large-scale health crises.”

 

 

5. A comparison of existing work is foremost required here

 

• Thank you for this suggestions. Comparisons have included:

 

“Moreover, critical consciousness was previously related to well-being during the COVID-19 pandemic. Critical reflection was linked to both higher anxiety and higher hopefulness [53]. This could explain the associations we found between critical reflection, vaccination attitudes and vaccination behaviours. When people recognise the inequalities and disparities in their environment, they could become more aware of the dangers of the pandemic, as well as more hopeful that they overcome them. Thus, they become less susceptible to misinformation and develop more positive attitudes towards vaccination, which, in turn, can act as a strong incentive to vaccinate.” (…) “Also, mistrust in authorities was shown to be an important determinant of vaccine hesitancy, while also being related to negative attitudes towards the vaccines [55; 56].In order to foster critical consciousness and thus decrease the negative vaccination attitudes and behaviours, the authorities can work towards increasing peoples’ opportunities to become involved in local community organizations, and in community decision making, giving them more citizen power and more chances to know and appreciate communal help in increasing positive behaviours [43].”

“Moreover, the research sample characteristics are also a source of limitations as it consisted mostly of female, young and well-educated participants, which limits the generalisation of the results. Although the sample was large, given that we used convenience sampling, the characteristics of our participants also followed the general characteristics of the population that usually use social media. Thus, we cannot generalise the results on other age groups except young adults. Therefore, future research should consider samples with similar ratios of men and women. Also, given that senior individuals are especially at risk and that their lifestyle was particularly altered during the pandemic [34], future studies could expend our results by taking into consideration more elderly populations.”

Reviewer 2 Report

This is a succinct and well-presented manuscript that focusing on the assessment of the relationship between critical consciousness components, vaccination attitudes related to Covid-19 and vaccination behaviours in a large sample of adults.The introduction is comprehensive and informative. Study design and presentation of the results are quite appropriate for the scope of the manuscript. However, there are some issues and questions that should be addressed in the study.

 

1- I think it is quite difficult to generalize the results of this study on the whole Romanian population that had been mentioned several times throughout the study for many factors, some are mentioned in the limitations of the study and others are not mentioned, like the source of the studied group, the sampling technique used for their inclusion in the study and the limited inclusion of the people aged 40+. It should be explained why the study population consisted mostly of female participants and how the age range was chosen.

 

2- They should mention how the data collection tool and questionnaire were developed and if they test its validity.

 

3-Finally, some recent and relevant studies could enrich your manuscript.

 

- Sonmezer, M.C.; Sahin, T.K.; Erul, E.; Ceylan, F.S.; Hamurcu, M.Y.; Morova, N.; Rudvan Al, I.; Unal, S. Knowledge, Attitudes, and Perception towards COVID-19 Vaccination among the Adult Population: A Cross-Sectional Study in Turkey. Vaccines 2022, 10, 278. https://doi.org/10.3390/vaccines10020278

 

- Chaudhuri, K., Chakrabarti, A., Chandan, J.S. et al. COVID-19 vaccine hesitancy in the UK: a longitudinal household cross-sectional study. BMC Public Health 22, 104 (2022). https://doi.org/10.1186/s12889-021-12472-3

Author Response

June 17^th, 2022

Mr. Zachary Zhang, MDPI Sustainability Editorial OfficeSustainability 

            We want to thank you and the reviewers for the thoughtful comments and observations to our manuscript, entitled. We revised the manuscript in accordance with all the reviewers' comments. We will detail all the changes made, so that all our modifications can be easily identified throughout the text.

 

Reviewers' comments:

Reviewer 2

Comments to the Author

sustainability-1758928 Review

1- I think it is quite difficult to generalize the results of this study on the whole Romanian population that had been mentioned several times throughout the study for many factors, some are mentioned in the limitations of the study and others are not mentioned, like the source of the studied group, the sampling technique used for their inclusion in the study and the limited inclusion of the people aged 40+. It should be explained why the study population consisted mostly of female participants and how the age range was chosen.

 

 

• Thank you for the suggestions made. The participants section has been improved by adding further clarification on pages 6 and 12:

 

“The participants were recruited from various social media groups. Announcements regarding the research were posted on Facebook groups and on Instagram. They contained the link to the online form containing the questionnaires.(…)

 

 Moreover, the research sample characteristics are also a source of limitations as it consisted mostly of female, young and well-educated participants, which limits the generalisation of the results. Although the sample was large, given that we used convenience sampling, the characteristics of our participants also followed the general characteristics of the population that usually use social media. Thus, we cannot generalise the results on other age groups except young adults. Therefore, future research should consider samples with similar ratios of men and women. Also, given that senior individuals are especially at risk and that their lifestyle was particularly altered during the pandemic [34], future studies could expend our results by taking into consideration more elderly populations.”

 

2. They should mention how the data collection tool and questionnaire were developed and if they test its validity.

• Indeed, deeper care for wording and some explanations are needed here. To address your valuable suggestion, we rephrased (p. 7):

“The construct validity of the measure was tested by employing confirmatory factor analysis (CFA) and Alpha Cronbach reliability index. The Cronbach’s alpha coefficient ranges from of .72 for critical motivation and .75 for critical action to .81 for critical reflection. The confirmatory factor analysis carried out indicated a good model fit (χ2 (71) = 651.75, p < .001; RMSEA = .063 (90% CI = [.058, .067]); CFI = .935; TLI = .916).

 

Vaccination attitudes

The Vaccination Attitudes Examination (VAX) Scale [44] investigates four distinct attitudes to the vaccine: mistrust of vaccine benefit, worries about unforeseen effects, concern about commercial profiteering and preference for natural immunity. Each factor includes three items, and each statement is evaluated on a six-point Likert-type scale ranging from strongly agree to strongly disagree. For this study, the validity of this scale was tested by employing confirmatory factor analysis and Alpha Cronbach reliability coefficient. The confirmatory factor analysis indicates a good model fit (χ2 (48) = 465.26, p < .001; RMSEA = .065 (90% CI = [.059, .070]); CFI = .976; TLI = .967). The Cronbach’s alpha coefficients were .72 for worries about unforeseen effect, .84 for preference for natural immunity, .88 for concerns about commercial profit and.94 for mistrust of vaccine benefits. Although this short-scale represents a general vaccination attitude measure, the respondents were asked to rate their responses thinking of the Covid-19 vaccination. The authors acknowledge that attitudes towards vaccination can change by vaccine type, but negative attitudes may co-occur. Therefore, a single measure may be the most suitable way to identify individuals that harbour vaccine-related concerns [44].”

 

 

 

 

• Thank you for your observation. The above references have been included in the manuscript on pages 1 and 10 as folows:

 

“Besides good forecasting and diagnosis techniques [51; 52], fostering the psychological factors that can also impact vaccination behaviours is also necessary.” and “Since the development and global-level distribution of vaccines [2], there have been reports concerning vaccination intention [3; 4] and vaccine hesitancy [4; 5]”

 

 

3. Somehow the english writing is not good like "The survey task took around 15–20 minutes to complete". 

 

• Thank you for this important English language has been improved in the manuscript. For example: “The study received approval from the Research Ethics Committee of the University. The research took place during October and December 2021. The participants were recruited from various social media groups. Announcements regarding the research were posted on Facebook groups and on Instagram. They contained the link to the online form containing the questionnaires. The participants were invited to read the informed consent form and provide their demographic information. Before starting the study, the respondents were informed that participation was voluntary, and they could withdraw from the study at any point. They also received information regarding data gathering, security and maintenance. The questionnaire took around 15–20 minutes to complete.”

 

4. Contributions are not so clear in the manuscript.

 

• Thank you for this recommendation. The contributions have been improved as follows:

 

“Considering the persistent issue of vaccination hesitancy in Eastern Europe, the present study approached vaccination behaviour from a different perspective. Besides good forecasting and diagnosis techniques [51; 52], fostering the psychological factors that can also impact vaccination behaviours is also necessary.”

 

“Our results are in line with other findings that evaluated the development of critical consciousness to support health-related behaviours, especially regarding the AIDS epidemic [23; 42; 43]. Collectively, these results show that the development of critical consciousness can be an impactful way to reduce the negative effects of large-scale health crises.”

 

 

5. A comparison of existing work is foremost required here

 

• Thank you for this suggestions. Comparisons have included:

 

“Moreover, critical consciousness was previously related to well-being during the COVID-19 pandemic. Critical reflection was linked to both higher anxiety and higher hopefulness [53]. This could explain the associations we found between critical reflection, vaccination attitudes and vaccination behaviours. When people recognise the inequalities and disparities in their environment, they could become more aware of the dangers of the pandemic, as well as more hopeful that they overcome them. Thus, they become less susceptible to misinformation and develop more positive attitudes towards vaccination, which, in turn, can act as a strong incentive to vaccinate.” (…) “Also, mistrust in authorities was shown to be an important determinant of vaccine hesitancy, while also being related to negative attitudes towards the vaccines [55; 56].In order to foster critical consciousness and thus decrease the negative vaccination attitudes and behaviours, the authorities can work towards increasing peoples’ opportunities to become involved in local community organizations, and in community decision making, giving them more citizen power and more chances to know and appreciate communal help in increasing positive behaviours [43].”

 

“Moreover, the research sample characteristics are also a source of limitations as it consisted mostly of female, young and well-educated participants, which limits the generalisation of the results. Although the sample was large, given that we used convenience sampling, the characteristics of our participants also followed the general characteristics of the population that usually use social media. Thus, we cannot generalise the results on other age groups except young adults. Therefore, future research should consider samples with similar ratios of men and women. Also, given that senior individuals are especially at risk and that their lifestyle was particularly altered during the pandemic [34], future studies could expend our results by taking into consideration more elderly populations.”

 

3-Finally, some recent and relevant studies could enrich your manuscript.

 

- Sonmezer, M.C.; Sahin, T.K.; Erul, E.; Ceylan, F.S.; Hamurcu, M.Y.; Morova, N.; Rudvan Al, I.; Unal, S. Knowledge, Attitudes, and Perception towards COVID-19 Vaccination among the Adult Population: A Cross-Sectional Study in Turkey. Vaccines 2022, 10, 278. https://doi.org/10.3390/vaccines10020278

 

- Chaudhuri, K., Chakrabarti, A., Chandan, J.S. et al. COVID-19 vaccine hesitancy in the UK: a longitudinal household cross-sectional study. BMC Public Health 22, 104 (2022). https://doi.org/10.1186/s12889-021-12472-3

 

• Thank you for you suggestions. The indicated references have improved our manuscript as can be noticed on pages 1 and 2.

 

• “In the Turkish general population, age was negatively related to vaccination behaviour, while education and past experiences with other vaccines or with COVID-19 had positive association with intention [11].”

 

“ Also, a positive attitude towards government officials was related to higher intention to get vaccinated in the UK [14].”

 

 

Reviewer 3 Report

I am grateful for the opportunity to review this paper. The pandemic of COVID-19 has become a major threat to global public health. Actually, the vaccination campaign is the first method to counteract the COVID-19 pandemic; however, sufficient vaccination coverage is conditioned by the people’s acceptance of these vaccines. In this context, the paper under review is aimed exanimating critical consciousness, Covid-19 vaccination attitudes, and vaccination behavior in a consistent sample of young adults. The subject under study is certainly important, especially in the historical period we are experiencing. The article presents interesting results but, but it must be improved, especially for its local impact. I would like to encourage authors to consider several issues to be improved.

 Title: it must be improved, underling the main object but also the type of study.

 Introduction: The authors should make clearer what is the gap in the literature that is filled with this study. The authors must better frame their study within the vast literature evidences addressing the issue of knowledge and belief concerning the COVID-19 vaccine also in other population groups and other countries (refer to article with DOI: https://doi.org/10.3390/ijerph182010872). What is the possible international contribution of the study to the literature? What are the implications of the study? The objectives should be better explained at the end of the section.

Methods. It is not clear if the survey was conducted using a non-standard questionnaire. The use of an unreliable instrument is a serious and irreversible limitation of the study. No mention to a validation process of the questionnaire is reported. The enrolment procedure must be better specified. How did the authors choose the way to select the sample? This can represent a great bias origin. How did they avoid the selection bias? What is the reference population? what is the minimum sample size? How was it calculated?

Ethical Issue: the approval number by a competent Ethical body must be reported.

Discussion: I also suggest expanding. Emphasize the contribution of the study to the literature. The Authors should add more practical recommendations for the reader, based on their findings and comparison with other international findings in other population groups too. Also, the section of limitations and future search is also very short, the Authors could elaborate on that.

Author Response

June 17^th, 2022

Mr. Zachary Zhang, MDPI Sustainability Editorial OfficeSustainability 

            We want to thank you and the reviewers for the thoughtful comments and observations to our manuscript, entitled. We revised the manuscript in accordance with all the reviewers' comments. We will detail all the changes made, so that all our modifications can be easily identified throughout the text.

 

Reviewers' comments:

Reviewer 3

Comments to the Author

sustainability-1758928 Review

1. 
   Title: it must be improved, underling the main object but also the type of stud

 

• Thank you for this valuable suggestion. The title was changed and improved:

 

“Does Vaccination Attitudes Mediate the Link Between Critical Consciousnes and Covid-19 Vaccination Behaviour? A Cross-sectional Study.”

2. Introduction: The authors should make clearer what is the gap in the literature that is filled with this study. The authors must better frame their study within the vast literature evidence addressing the issue of knowledge and belief concerning the COVID-19 vaccine also in other population groups and other countries (refer to article with DOI: https://doi.org/10.3390/ijerph182010872). What is the possible international contribution of the study to the literature? What are the implications of the study? The objectives should be better explained at the end of the section

 

• Thank you for you observations we answered to the above questions in the Introduction and in The present study section as folows:

 

“Previous research emphasised the role of critical consciousness in structuring health-related attitudes and behaviours; however, the impact on vaccination attitudes and behaviour has remained unexplored. The first aim of this study was to explores how critical consciousness can predict Covid-19 vaccination behaviour. Also, we aimed to study the impact critical consciousness can have on the attitudes towards vaccination. Such attitudes may manifest as mistrust of vaccine benefit and concern regarding future effects, about commercial profiteering and preference for natural immunity. Finally, we were interested in verifying the mediation role of vaccination-related attitudes in the relationship between critical consciousness and vaccination behaviour. “

 

“Also, by taking into consideration the relatively reduced rates of vaccination acceptance in Eastern Europe [45] this study would shed some light on an important issue regarding this region.“

 

 

 

3. Methods.It is not clear if the survey was conducted using a non-standard questionnaire. The use of an unreliable instrument is a serious and irreversible limitation of the study. No mention to a validation process of the questionnaire is reported. The enrolment procedure must be better specified. How did the authors choose the way to select the sample? This can represent a great bias origin. How did they avoid the selection bias? What is the reference population? what is the minimum sample size? How was it calculated?

 

• Thank you for your observation. Indeed, deeper care for wording and some explanations are needed here. To address your valuable suggestion, we rephrased regarding questionnare validity on page 7 and added information regarding the selection bias on page 10:

 

“The construct validity of the measure was tested by employing confirmatory factor analysis (CFA) and Alpha Cronbach reliability index. The Cronbach’s alpha coefficient ranges from of .72 for critical motivation and .75 for critical action to .81 for critical reflection. The confirmatory factor analysis carried out indicated a good model fit (χ2 (71) = 651.75, p < .001; RMSEA = .063 (90% CI = [.058, .067]); CFI = .935; TLI = .916).

 

Vaccination attitudes

The Vaccination Attitudes Examination (VAX) Scale [44] investigates four distinct attitudes to the vaccine: mistrust of vaccine benefit, worries about unforeseen effects, concern about commercial profiteering and preference for natural immunity. Each factor includes three items, and each statement is evaluated on a six-point Likert-type scale ranging from strongly agree to strongly disagree. For this study, the validity of this scale was tested by employing confirmatory factor analysis and Alpha Cronbach reliability coefficient. The confirmatory factor analysis indicates a good model fit (χ2 (48) = 465.26, p < .001; RMSEA = .065 (90% CI = [.059, .070]); CFI = .976; TLI = .967). The Cronbach’s alpha coefficients were .72 for worries about unforeseen effect, .84 for preference for natural immunity, .88 for concerns about commercial profit and.94 for mistrust of vaccine benefits. Although this short-scale represents a general vaccination attitude measure, the respondents were asked to rate their responses thinking of the Covid-19 vaccination. The authors acknowledge that attitudes towards vaccination can change by vaccine type, but negative attitudes may co-occur. Therefore, a single measure may be the most suitable way to identify individuals that harbour vaccine-related concerns [44].”

 

 

“Using a post-hoc power calculator [50], the statistical power for the indirect effect for the used sample was shown to be 91 % at p < 0.05 with 20,000 Monte Carlo replications.”

 

 

4. Ethical Issue: the approval number by a competent Ethical body must be reported

 

 

• Thank you for this recommendation. The approval number of the Ethics Committee has been included:

 

“This study was carried out following the recommendations of the Code of Ethics of the University. The protocol was approved by the Ethics Committee for Research of the Faculty of Psychology and Educational Sciences (No. 1220/09.06.2021). Following, the Declaration of Helsinki, all participants gave written informed consent for their participation in the study.”

 

5. Discussion: I also suggest expanding. Emphasize the contribution of the study to the literature. The Authors should add more practical recommendations for the reader, based on their findings and comparison with other international findings in other population groups too. Also, the section of limitations and future search is also very short, the Authors could elaborate on that.

 

 

• Thank you for this suggestions. Discussion section has been improved:

 

“Our results are in line with other findings that evaluated the development of critical consciousness to support health-related behaviours, especially regarding the AIDS epidemic [23; 42; 43]. Collectively, these results show that the development of critical consciousness can be an impactful way to reduce the negative effects of large-scale health crises.”

(…)

“Moreover, critical consciousness was previously related to well-being during the COVID-19 pandemic. Critical reflection was linked to both higher anxiety and higher hopefulness [53]. This could explain the associations we found between critical reflection, vaccination attitudes and vaccination behaviours. When people recognise the inequalities and disparities in their environment, they could become more aware of the dangers of the pandemic, as well as more hopeful that they overcome them. Thus, they become less susceptible to misinformation and develop more positive attitudes towards vaccination, which, in turn, can act as a strong incentive to vaccinate”

(…)

“Also, mistrust in authorities was shown to be an important determinant of vaccine hesitancy, while also being related to negative attitudes towards the vaccines [55; 56].In order to foster critical consciousness and thus decrease the negative vaccination attitudes and behaviours, the authorities can work towards increasing peoples’ opportunities to become involved in local community organizations, and in community decision making, giving them more citizen power and more chances to know and appreciate communal help in increasing positive behaviours [43].”

(…)

“young and well-educated participants, which limits the generalisation of the results. Although the sample was large, given that we used convenience sampling, the characteristics of our participants also followed the general characteristics of the population that usually use social media. Thus, we cannot generalise the results on other age groups except young adults. Therefore, future research should consider samples with similar ratios of men and women. Also, given that senior individuals are especially at risk and that their lifestyle was particularly altered during the pandemic [34], future studies could expend our results by taking into consideration more elderly populations.”

 

 

Round 2

Reviewer 3 Report

The paper was improved following the comments provided