Review Reports

Response to Reviewer 1

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files. 

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Is the research design appropriate? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are the methods adequately described? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are the results clearly presented? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are the conclusions supported by the results? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are all figures and tables clear and well-presented? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: The article is already fit for publication, but the authors might consider the following small adjustments to enhance it further. 

The summary tables on pages 8 and 9 are extremely helpful for the reader but lack a formal title (e.g., "Table 2: Key Survey Findings on Social and Behavioral Drivers"). Adding titles would make the document even more formal and easier to navigate. 

Response 1: Thank you so much for pointing this out. We have added formal titles to both the tables.  

Comments 2: In the "Limitations" section, the authors excellently explain the difficulties in recruiting intersex participants. They could consider adding a sentence in the "Conclusions" section to explicitly frame this challenge as a critical direction for future research. This would turn a limitation into a powerful call for future studies that develop even more targeted methodologies to build trust and ensure the inclusion of the intersex community.  

Response 2: Agreed, It would provide a better picture of the challenges faced by the communities and lead to a good closing of what seems like and open end. We have added a few lines on the challenges faced in terms of intersex community in the conclusions sections.

“Due to stigma, lack of support structures, and confidentiality related concerns along with past negative and intrusive  experiences with the medical system; recruiting intersex participants in health research has proved to be extremely difficult. This particular limitation further underlines the exclusion of  intersex individuals from public health programs due to structural and social challenges and not neglect. Future research should engage directly with intersex-led groups, build trust, and provide resources that address their lived experiences  and needs. ”

4. Response to Comments on the Quality of English Language

Point 1: The English is fine and does not require any improvement.

Response 1: Thank you for your encouraging feedback!

Response to Reviewer 2

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files. 

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references? 

Yes/Can be improved/Must be improved/Not applicable

.We have tried to flesh out the introduction but highlighting more explicitly the gaps in literature that we are addressing.

Is the research design appropriate? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are the methods adequately described? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are the results clearly presented? 

Yes/Can be improved/Must be improved/Not applicable

We have tried to expand more on them.

Are the conclusions supported by the results? 

Yes/Can be improved/Must be improved/Not applicable

 We have tried to make the linkages stronger

Are all figures and tables clear and well-presented? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: This is a relevant study that addresses inequities in COVID-19 vaccine access among transgender and gender-diverse (TGD) persons and persons with disabilities (PwD) in India. The manuscript demonstrates methodological rigor by utilizing the WHO BeSD framework, which was adapted through community-based participatory research (CBPR). Its emphasis on systemic barriers, rather than individual hesitancy, makes a substantial contribution to the discourse on health equity in vaccination. The study’s integration of reflexivity and positionality is also a strength, reflecting good ethical and participatory practices. The manuscript is solid, yet strangely presentable. However, clarifications on psychometric findings, population scope, and tighter alignment of policy recommendations with empirical results will enhance clarity and impact. Therefore, moderate revisions are required before being accepted for publication.

1-While internal consistency (α = 0.85) is reported, the factor analytic results (number of factors retained, item loadings, explained variance) should be described more explicitly to substantiate psychometric claims. 

Response 1: Thank you so much for pointing this out; we discussed how much in detail we would want to go with the psychometric details of the tool. We came to the conclusion that since this particular issue focuses on challenges it would be out of context to add psychometric details as it might confuse the readers or add unnecessary details that are not relevant to what we are stating in conclusion. We felt that those details could be better suited for a publication that focuses on tool development and validation.

Comments 2: Provide more detail on descriptive findings (e.g., percentage of participants reporting specific barriers like documentation mismatch, mobility challenges)

Response 2: Yes, it is correct that there is plenty of space to add more details on descriptive findings. We have added the details of the percentages that we have referred to in discussion and conclusions sections.

Comments 3: The introduction and methods specify TGD and PwD populations, but the conclusions and recommendations include intersex persons. Please clarify whether intersex participants were included in the sample or if this is an extrapolation from the data.

Response 3: 

 Thank you, that is a really important point. We have explicitly stated the gap in literature in two places in the introduction.

“In fact, the lack of reliable disaggregated data for both communities has also been a barrier to accountability. For instance, the Indian government on two different occasions provided contradictory data for vaccination coverage rates among people with disabilities [6]. Further, one the vaccination appointment booking portal the unclear category of “Others” was provided instead of “Transgender” [7].”

“To address this gap in vaccination frameworks and the subsequent lack of disaggregated data on vaccine acceptance among TGD, intersex and disability communities in India,, the present study aimed to adapt and apply the BeSD framework to understand COVID-19 vaccination experiences among intersex and TGD communities and persons with disabilities in India.”

Comments 4: Some recommendations are very broad (e.g., “ensure inclusive healthcare environments”). Consider explicitly linking each recommendation to a relevant study finding for clarity and policy relevance.

Response 4: Thank you for pointing this out; we have added connectors from results and tried to make the recommendations more specific.

Comments 5: Discuss limitations regarding generalizability beyond the studied networks, since recruitment relied on community organizations and may not reflect those outside these support structures.

Response 5:This was missed in manuscript although discussed in calls. We have added the limitation. 

“Also, as snowball sampling was used keeping CBOs at the centre of data collection, community members that might not have access to the networks of the organizations could not be reached which limits the generalizability of the tool.”

Comment 6: The introduction could more explicitly state the knowledge gap, e.g., lack of disaggregated vaccination access data for TGD and PwD in India. 

Response 6: Thank you, that is a really important point. We have explicitly stated the gap in literature in two places in the introduction.

“In fact, the lack of reliable disaggregated data for both communities has also been a barrier to accountability. For instance, the Indian government on two different occasions provided contradictory data for vaccination coverage rates among people with disabilities [6]. Further, one the vaccination appointment booking portal the unclear category of “Others” was provided instead of “Transgender” [7].”

“To address this gap in vaccination frameworks and the subsequent lack of disaggregated data on vaccine acceptance among TGD, intersex and disability communities in India,, the present study aimed to adapt and apply the BeSD framework to understand COVID-19 vaccination experiences among intersex and TGD communities and persons with disabilities in India.” 

Comment 7: Improve flow in some places: currently, sections of results and conclusions partly repeat the same findings; condensation could help. 

Response 7: This was really helpful. It did get repetitive at some ends. We have tried to make it shorter but were not able to reduce it extensively because some findings felt compelling in the specific place.

Comment 8: Ensure consistency: sometimes “TGD” is used, elsewhere “transgender, gender-diverse, intersex.” Be clear whether “intersex” is included throughout or only in recommendations. 

Response 8: Fully agreed that consistency matters; otherwise shuttling between two terms would increase confusion. We have tried to make it more consistent by using TGD and PwD in the manuscript once the terms have been established as acronyms in the beginning.

4. Response to Comments on the Quality of English Language

Point 1: The text requires a minor to moderate improvement in English. Some verb tenses and sentence construction need improvement. 

Response 1: We have improved the grammar and consistency across the manuscript.

Response to Reviewer 3

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files. 

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Is the research design appropriate? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are the methods adequately described? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are the results clearly presented? 

Yes/Can be improved/Must be improved/Not applicable

We have tried to make the results clearer.

Are the conclusions supported by the results? 

Yes/Can be improved/Must be improved/Not applicable

Thank you, noted.

Are all figures and tables clear and well-presented? 

Yes/Can be improved/Must be improved/Not applicable

We have added labels to tables.

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: The authors developed and validated a survey instrument to examine the behavioral and social drivers of COVID-19 vaccine uptake. The overall procedure was clearly described and well documented in the paper. 

A majority of the 220 Indian participants were from Backward Classes, and over half (52%) held a higher degree or above. While the study includes participants with disabilities and individuals identifying as transgender, it would be helpful for the authors to clarify the rationale for their inclusion, particularly if no comparisons were intended across these groups. Presenting the results for these groups side by side in a clearly labeled table (e.g., Table 2) would also improve clarity and allow readers to interpret the findings more easily. 

Response 1:Since we used snowball sampling was used, where CBOs were central and respondents from their networks were contacted.  We have shared the demographics of the participants to give an idea of the background of where their experiences might be coming from. However the inclusion criteria is as stated in the methods section.

Comments 2: Some aspects of the data may warrant further discussion. For instance, while 73% of the transgender participants reported being unemployed, more than half (53.8%) selected “Unable to leave work” as a barrier—this apparent inconsistency could be addressed to strengthen the credibility of the findings. 

Response 2: The vagueness pointed out is apparent; thank you for flagging it. We have tried to add some more context to the statement. Since the question was only asked to people who had picked  the ‘employed’ or ‘part time employed’ option; the percentage indicated a proportion of that. Hopefully this sentence make it clearer

“54% of the respondents who reported as being employed full time or part time said it was difficult to leave work duties to attend vaccination,”

Comments 3: Given the rich demographic data collected, it would be valuable to explore whether certain subgroups experience distinct challenges or levels of trust in authorities—for example, comparing participants with higher education levels to others. In future research, applying the same instrument to non-backward classes could provide a broader perspective and highlight specific issues uniquely faced by disadvantaged groups, offering deeper insights into vaccine behavior. 

Response 3: Thank you for flagging this. We will keep this in mind for future research.

Comments 4: Figures and tables can be improved 

Response 4: We have added labels to figures.

4. Response to Comments on the Quality of English Language

Point 1: The English is fine and does not require any improvement.

Response 1: Thank you for your encouraging feedback!