Predictors of Willingness to Receive Monkeypox Vaccine in Palestine: A Cross-Sectional Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I was invited to revise the paper entitled "Predictors of Willingness to Receive Monkeypox Vaccine in Palestine: A Cross-Sectional Study". It was a cross-sectional study aimed to evaluate the attitudes toward monkey pox vaccination in Palestine. THe topic is interesting but I have several observations:

• Introduction section lacks in information on vaccine type and its availability inPalestine. The vaccination schedule and categories in which vaccination was reccomended should also be discussed.
• Authors reported in Figure 1 information on VTI but it has some limitations: VTI is a score so it should be reported as median instead of mean;
• Table 1 p-values should be corrected for multiple comparisons;
• Logistic regression analysis should be better described. in particular, Authors should better descride how model was developed. In particular no information of multicollinearity were reported. Also, binomial logistic regression was based on binomial outcomes, so Authors should better describe how the outcome was construted;
• THe paper presents an important selection bias. Mpox is an infection with specific transmission modality, so patients enrolled for a specific study, such as the present study that was based on the willingness to get covid vaccination;
• Mpox vaccination was reccomended to specific patients with high risk of transmission. In palestine no specific outbreak were registered during the study period, so results could be biased by a poor knowledge and by a misperception of the disease trasmission;
• Authors stated that "Vaccine Trust Indicator correlated significantly with the willingness to vaccinate" but no correlation analyses were performed;
• It is unknown what Authors will do after this study. Training to improve the knowledge? Imorove vaccination? Improve surveillance?

Author Response

Dear Reviewer,

We really appreciate the reviewer's thorough and constructive comments, which have significantly improved our article. We carefully addressed each concern mentioned, and we feel the adjustments improved the clarity and scientific rigour of our work. Below are our point-by-point responses to each comment.

• The introduction section lacks in information on vaccine type and its availability in Palestine. The vaccination schedule and categories in which vaccination was recommended should also be discussed.

Mpox vaccines are currently not available in the country.  However, the Palestinian Authority is enhancing its surveillance for early detection of Mpox cases, along with capacity building of healthcare professionals on proper identification of cases.   Several cases have been identified in neighbouring countries, Jordan and Israel, in the past few years.

Line 68, we added this sentence: “Although the MPXV vaccines are currently not available in Palestine, the Palestinian Authority is enhancing its surveillance for early detection of MPXV cases, along with capacity building of healthcare professionals on proper identification of cases.”

The authors reported in Figure 1 information on VTI, but it has some limitations: VTI is a score so it should be reported as median instead of mean;

In this figure (Figure 1), we reported the VTI using cutoff points for the scale. The Vaccine Trust Indicator (VTI) score is divided into 3 categories. The first is a level below 40 that indicates “low trust in vaccines,” the second level is a score ranging from 40 to 70 that signifies “moderate trust in vaccines,” and the third level is a score exceeding 70 that represents “high trust in vaccines.

We reported the median in line  146.

• Table 1 p-values should be corrected for multiple comparisons;

We added a column in Table 1

In line 161 we added this sentence:  “Because multiple chi-square comparisons were conducted in Table 1, we applied Holm–Bonferroni correction to adjust p-values”.

• Logistic regression analysis should be better described. in particular, Authors should better describe how the model was developed. In particular, no information on multicollinearity was reported. Also, binomial logistic regression was based on binomial outcomes, so the Authors should better describe how the outcome was constructed;

Under Table 4, we presented the model variables.   The outcome in this model is Vaccination Willingness, as stated in the table title, which is the main study outcome variable. 

For multicollinearity, we checked it, and the VIF values were below 5 for all variables in the model

In line 133, we added the following sentence: “All variables in the model were tested for multicollinearity, and we checked.  The VIF values were below 5 for all variables in the model.”

• The paper presents an important selection bias. Mpox is an infection with a specific transmission modality, so patients enrolled for a specific study, such as the present study, that was based on the willingness to get the COVID-19 vaccination.

Thank you for raising this issue.  Yes, selection bias cannot be ignored in this study, and it should always be a valid consideration in observational studies.   We wrote in the limitations that the use of snowball sampling likely introduced selection bias, meaning our sample's demographic composition may not accurately reflect the national distribution.

We added the point you raised and added the following sentence (line 403 “Also, individuals who are willing to receive COVID-19 vaccination may differ from the general population at risk for MPXV. Therefore, our findings should be interpreted within the context of individuals with healthcare-seeking behavior. ”

• Mpox vaccination was recommended to specific patients with high risk of transmission. In Palestine, no specific outbreaks were registered during the study period, so results could be biased by a poor knowledge and by a misperception of the disease transmission.

We acknowledge that the absence of mpox outbreaks in Palestine during the study period may have influenced participants' knowledge and risk perception of the disease. This context is crucial for understanding our results. We think that this actually makes our study more useful because it shows baseline knowledge and attitudes in a setting where the disease is not very common, which is useful for public health preparedness. Recognizing knowledge deficiencies and misconceptions before an outbreak can guide focused educational initiatives and preparedness plans. We have now made this context clearer in the discussion and pointed out that our results show how people feel before an outbreak, which may be different from how people feel when an outbreak is happening.

We added this sentence in line 418. “The absence of MPXV outbreaks in Palestine during the study period may have influenced participants' knowledge and risk perception of the disease. Nonetheless, our study is more useful because it shows baseline knowledge and risk perception in a setting where the disease is not very common, which is useful for public health preparedness. Identifying knowledge gaps and misunderstandings before an outbreak can inform targeted educational programs and preparedness strategies”.

 

Authors stated that "Vaccine Trust Indicator correlated significantly with the willingness to vaccinate" but no correlation analyses were performed;

Line 430: We corrected this sentence with “Vaccine Trust Indicator was significantly associated with the willingness to vaccinate.”

• It is unknown what the Authors will do after this study. Training to improve the knowledge? Improve vaccination? Improve surveillance?

Already, several talks on TV were concerned with mpox since many cases are now diagnosed in Jordan and Israel, and in many countries in the Middle East.   So education about the disease and its vaccination is crucial as part of a preparedness plan.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript presents a timely and relevant investigation into attitudes toward monkeypox vaccination in Palestine. Given the global rise in mpox cases and the need to understand vaccination readiness in resource-limited and politically constrained settings, the topic is of clear public health importance. The study may contribute valuable regional data to inform risk communication, vaccination strategies, and future outbreak preparedness.

However, while the research question is well justified, several issues in the depth of interpretation should be addressed to strengthen the manuscript.

1. Convenience sampling may have introduced selection bias, particularly favoring younger and more educated participants with internet access. The implications of this bias for generalizability should be more explicitly acknowledged in the Discussion.
2. Clarify the construction and validation of knowledge and attitude scales.

3. The Discussion sometimes overstates causality; as a cross-sectional study, causation cannot be inferred.

4. The influence of cultural, political, and media contexts in Palestine should be explored more deeply, as these factors likely shape vaccine perceptions. Deepen the social-contextual interpretation, particularly regarding health system trust, access barriers, and historical vaccine experiences.

Author Response

Dear Reviewer,

We really appreciate the reviewer's thorough and constructive comments, which have significantly improved our article. We carefully addressed each concern mentioned, and we feel the adjustments improved the clarity and scientific rigour of our work. Below are our point-by-point responses to each comment.

1. Convenience sampling may have introduced selection bias, particularly favoring younger and more educated participants with internet access. The implications of this bias for generalizability should be more explicitly acknowledged in the Discussion.

Thank you for your comment, we added this in the limitation section

“The online survey format and use of snowball sampling likely introduced selection bias, meaning our sample's demographic composition may not accurately reflect the national distribution. Also, individuals who are willing to receive COVID-19 vaccination may differ from the general population at risk for MPXV. Therefore, our findings should be interpreted within the context of individuals with healthcare-seeking behavior. Therefore, our results should be generalized with caution”

1. Clarify the construction and validation of knowledge and attitude scales.

Line 122: Knowledge scale:  The internal consistency coefficient, Cronbach’s α, was 0.72.

 

We do not have an attitude scale; we have a risk perception scale.  Line 104, coefficient (Cronbach’s α) of our study was 0.80.

 

1. The Discussion sometimes overstates causality; as a cross-sectional study, causation cannot be inferred.

We reviewed the discussions and edited sentences where there was confusion in using the term, and we used association as a term

1. The influence of cultural, political, and media contexts in Palestine should be explored more deeply, as these factors likely shape vaccine perceptions. Deepen the social-contextual interpretation, particularly regarding health system trust, access barriers, and historical vaccine experiences.

Thank you for your comment.  We modified this part in the discussion

Line 283, we wrote “In Palestine, public trust in health authorities is often low due to fragmented governance, lack of resources, fragmented healthcare infrastructure across different administrative zones, and inconsistent communication. Additionally, cultural beliefs, including community-based health information sharing and traditional health beliefs, and limited access to accurate health information contribute to varied perceptions of disease severity and vaccine acceptance. 

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

It can accepted now