Perceptions Toward COVID-19 Vaccines and Factors Associated with COVID-19 Vaccine Acceptance in Peshawar, Pakistan

Round 1

Reviewer 1 Report

Contribution on a regional level of impact of COVID-19 on different socio-economic population groups. Data presented can contribute to already existing ones for imroved management of future pandemics.

The methodology is well structured and the data analysis provide information on the above. The authors do not mention if similar studies were performed in other regions of Pakistan in order to compare results. Also, a larger study group and from other regions could be utilized.

Author Response

Comments 1: Major comments: Contribution on a regional level of impact of COVID-19 on different socio-economic population groups. Data presented can contribute to already existing ones for improved management of future pandemics.

Response 1: We thank the reviewer for their comments and feedback.

Comments 2: Detailed comments: The methodology is well structured and the data analysis provide information on the above. The authors do not mention if similar studies were performed in other regions of Pakistan in order to compare results. Also, a larger study group and from other regions could be utilized.

Response 2: We thank the reviewer for this helpful comment. Due to operational constraints and limited funding (this study was conducted using internal resources), we focused on regions where our organization was already active. While a larger, multi-regional study would indeed have strengthened the analysis, it was beyond the scope of our current resources. However, we have referenced studies conducted by other groups in both the same region and other parts of Pakistan to provide broader context and comparison. These references are included in the Introduction and Discussion sections of the manuscript.

Reviewer 2 Report

The integration of quantitative and qualitative findings enhances the interpretability and contextualization of the data. However, the manuscript would benefit from improved clarity in the presentation of some results, more rigorous integration of qualitative findings into the discussion, and a more comprehensive account of limitations and methodological considerations.

In general:

• Clarify and streamline the literature review in the Introduction.

• Provide additional methodological detail (e.g., rationale for sampling, pilot exclusion).

• Condense and simplify overly detailed tables.

• Integrate qualitative data more robustly into both Results and Discussion.

• Expand critical reflection in the Discussion section, particularly regarding limitations and cultural frameworks.

• Improve balance between descriptive and analytical narrative in discussion

In detail:

Regarding the abstract, I suggest to consider explicitly stating the sample size in the abstract. The abstract could briefly clarify what “social network support” entails, as it is a key finding.
In the introduction, the literature review could benefit from greater synthesis and less redundancy; several points (e.g., about polio vaccine distrust) are repeated. I think is useful to incorporate more data or citing more sources where available with with a more in-depth discussion about the process that led to the onset of COVID vaccine hesitation, such as how to find an effective vaccine in the early stages of the pandemic. Moreover, Also in general, I think it is appropriate to argue the problem of vaccine hesitation in minors and in the context of a parental refusal to vaccinate. (in this sense I suggest the authors to read and compare the extensive literature on these topics: e.g. https://doi.org/10.1093/infdis/jiaa216 ; https://doi.org/10.12688/f1000research.25998.1 ; https://doi.org/10.1590/0102-311x00195519 ; https://doi.org/10.3390/medicina61030421 ).
In methods section, I noted that the justification for purposive selection of union councils and its implications for external validity is insufficiently addressed and no rationale is given for the exclusion of pilot data. It is necessary to explain whether thematic saturation was reached in qualitative data collection and to provide further details on the training of data collectors and the tools used for translation and transcription.
In results, some proportions are repeated verbatim from earlier sections (e.g., vaccine hesitancy rates) without added interpretation; hence, I suggest to integrate the quantitative and qualitative findings more explicitly where possible.
Finally, the discussion is at times descriptive rather than analytical, especially when reiterating findings and I noted that there is limited critique of the study’s own potential biases (e.g., social desirability bias in self-reported data). For this reason I suggest to strengthen the discussion of cultural factors influencing female vaccine hesitancy by incorporating more sociological or anthropological frameworks and to compare more explicitly the findings with similar mixed-methods studies in other LMICs. 

In conclusion, in my opinion this study is methodologically sound and contextually relevant, but requires refinement in presentation, critical depth, and analytical coherence to strengthen its scientific contribution.

Kind regards

Author Response

Comments 1: Major comments: The integration of quantitative and qualitative findings enhances the interpretability and contextualization of the data. However, the manuscript would benefit from improved clarity in the presentation of some results, more rigorous integration of qualitative findings into the discussion, and a more comprehensive account of limitations and methodological considerations.

In general:

• Clarify and streamline the literature review in the Introduction.
• Provide additional methodological detail (e.g., rationale for sampling, pilot exclusion).
• Condense and simplify overly detailed tables.
• Integrate qualitative data more robustly into both Results and Discussion.
• Expand critical reflection in the Discussion section, particularly regarding limitations and cultural frameworks.
• Improve balance between descriptive and analytical narrative in discussion

Response 1: We appreciate the reviewer’s careful review and valuable feedback. We have addressed these points in the detailed comments below.

Detailed comments:

Comments 2: Regarding the abstract, I suggest to consider explicitly stating the sample size in the abstract. The abstract could briefly clarify what “social network support” entails, as it is a key finding.
Response 2: We thank the reviewer for these helpful suggestions and have revised the abstract accordingly. Please note that in line 24, the survey sample size was included. We have added the quantity of FGDs and IDIs for the qualitative component. Additionally, we have added some details to help explain the term “social network support”.

Comments 3: In the introduction, the literature review could benefit from greater synthesis and less redundancy; several points (e.g., about polio vaccine distrust) are repeated. I think is useful to incorporate more data or citing more sources where available with with a more in-depth discussion about the process that led to the onset of COVID vaccine hesitation, such as how to find an effective vaccine in the early stages of the pandemic. Moreover, Also in general, I think it is appropriate to argue the problem of vaccine hesitation in minors and in the context of a parental refusal to vaccinate. (in this sense I suggest the authors to read and compare the extensive literature on these topics: e.g. https://doi.org/10.1093/infdis/jiaa216 ; https://doi.org/10.12688/f1000research.25998.1 ; https://doi.org/10.1590/0102-311x00195519 ; https://doi.org/10.3390/medicina61030421 ).

Response 3: Thank you for this valuable feedback. We have revised the paragraph on polio vaccines to remove redundancies, as suggested. We have also added content on the early stages of the COVID-19 vaccine rollout, including several key challenges that impacted vaccine uptake during that period. Thank you as well for sharing the references on vaccine hesitancy among minors in the context of parental refusal. While this is an important and interesting subtopic, we have chosen not to include it in our manuscript, as all of our study participants were over the age of 18 and therefore, we are unable to comment on this topic using the data we collected.

Comments 4: In methods section, I noted that the justification for purposive selection of union councils and its implications for external validity is insufficiently addressed and no rationale is given for the exclusion of pilot data. It is necessary to explain whether thematic saturation was reached in qualitative data collection and to provide further details on the training of data collectors and the tools used for translation and transcription.
Response 4: We thank the reviewer for these helpful suggestions. We have added a justification for the purposive selection of the four Union Councils, noting that two rural Union Councils were selected based on IMC’s operational presence, while the 2 urban Union Councils were chosen by the Health Department. In our Limitations section, we have details addressing the implications for external validity, where we explain that “This study is limited due to its focus on Peshawar District and non-random sampling of union councils which limits generalizability to other parts of Pakistan or other countries.” We have included the reason why we excluded pilot data from our analysis, noting that the pilot test was conducted solely to refine the survey tool.

For the qualitative component, we aimed to achieve thematic saturation to the greatest extent possible, given the challenging circumstances of data collection during the COVID-19 pandemic and prevailing insecurity in the area. We have added the following: “Despite the challenges of data collection during the COVID-19 pandemic and local in-security, emerging themes were reviewed throughout the process and showed consistent patterns across responses, indicating that thematic saturation was likely reached.” In the manuscript, we have indicated that transcription was done manually. No special tools were used for translation of transcripts.

Comments 5: In results, some proportions are repeated verbatim from earlier sections (e.g., vaccine hesitancy rates) without added interpretation; hence, I suggest to integrate the quantitative and qualitative findings more explicitly where possible.
Response 5: Thank you for this suggestion. Where possible, we have revised relevant sections to better integrate the quantitative and qualitative findings. We hope this changes the overall coherence and flow of this section. In addition, we have reformatted the tables and hope they are clearer.

Comments 6: Finally, the discussion is at times descriptive rather than analytical, especially when reiterating findings and I noted that there is limited critique of the study’s own potential biases (e.g., social desirability bias in self-reported data). For this reason I suggest to strengthen the discussion of cultural factors influencing female vaccine hesitancy by incorporating more sociological or anthropological frameworks and to compare more explicitly the findings with similar mixed-methods studies in other LMICs. 

Response 6: We thank the reviewer for this helpful feedback. We clarify that we have used one of the most widely validated sociological frameworks used for explaining health behaviors including vaccine hesitancy, the Health Beliefs Model (HBM) which incorporates cultural influences on health decisions. This framework allowed us to understand some of the factors influencing female vaccine hesitancy, although future research may allow more in-depth understanding of this complex issue. We have revised the discussion section accordingly, including a comparison of our findings on factors influencing female vaccine hesitancy with other studies conducted in Pakistan during the COVID-19 pandemic. Additionally, we have added recommendations to support more equitable access to COVID-19 vaccination for women. As requested, we added the following details to the limitations paragraph to address the social desirability bias in our self-reported data: “As with all self-reported data, there is a potential for social desirability bias, particularly in responses related to COVID-19 vaccine attitudes and behaviors. Efforts to minimize this included ensuring participant confidentiality and using trained local interviewers.”