Association of COVID-19 Vaccine Hesitancy Among University Students with Concerns About the Plurality of Testing Regimes

Round 1

Reviewer 1 Report

The main issue with this paper is that sometimes it is unclear what specific period covers each claim covering data. Compare your methodology with others in terms of robustness. ‘Surveys were administered between the 1st and 21st of June 2021 and 25th and 28th of October 2021’ – why submitting this research so late? Comparisons with other research results should be more detailed. 5. Conclusions’ is too short. You should better clarify the originality and soundness of your research.

The main issue with this paper is that sometimes it is unclear what specific period covers each claim covering data. ‘Effectiveness for several vaccine programmes depends on both vaccine efficacy in individuals and on herd protection resulting from achieving sufficient vaccine uptake for reduced transmission [6-8]’, ‘The multiple reasons given by individuals for vaccine hesitancy are summarised within the 5Cs model: complacency, confidence, convenience, calculation, and collective responsibility [10, 11, 14]’, ‘Beyond individual-level determinants, some scholars argue that vaccine hesitancy has been used as a scapegoat, obscuring the role of systemic racism and structural inequities in shaping disparities in vaccine uptake [18-21]’, ‘COVID-19 infection rates were nearly twice as high in 18–23-year-olds in university towns compared with their peers in non-university towns [29-31]’ – develop and clarify the specific contribution of each cited source. ‘Over the past decade, global vaccine hesitancy has grown, contributing to rises in vaccine-preventable diseases [9]. Vaccine hesitancy is now considered a major public health concern and is classified by the WHO classifying as one of the top ten global health threats [9]’ – avoid citing the same source 2 times in a row. Even 4 times: ‘Complacency is defined as people perceiving the vaccine as being of low priority due to the disease not being a threat [14]. Confidence refers to people’s trust in the effectiveness and safety of the vaccine and healthcare system [14]. Convenience relates to the barriers in accessing the vaccine such as physical or economic barriers [14]. Calculation is the weighing up an individual’s perceived risks and benefits of being vaccinated. Collective responsibility refers to the willingness to be vaccinated in order to help achieve herd immunity and protect other people from the disease [14]’. “delay in acceptance or refusal of safe vaccines despite availability of vaccination services” – quotes require pages, but I suggest rephrasing them though. ‘2020, [23]’ – remove the comma. ‘and the general’, ‘side-effects [23]’, etc. – check for no or extra spaces. Compare your methodology with others in terms of robustness. ‘Surveys were administered between the 1st and 21st of June 2021 and 25th and 28th of October 2021’ – why submitting this research so late? Comparisons with other research results should be more detailed. ‘question . Another’ - question. Another. ‘‘other ’option’ - ‘other’ option. ‘response bias, The survey’ - response bias. The survey. – check for such editorial issues. ‘5. Conclusions’ is too short. You should better clarify the originality and soundness of your research. The reference list is not properly edited.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

After reviewing the manuscript and its supplementary materials, the study addresses an important and timely topic: COVID-19 vaccine hesitancy, uptake, and perceptions of on-campus pop-up vaccination clinics among university students. The research question is relevant, the overall design is appropriate, and the manuscript fits well within the scope of public health and behavioral sciences. Nevertheless, several aspects require revision to strengthen methodological transparency, analytical rigor, and interpretive clarity.

First, the analytical decisions in the Methods section require clearer justification. In particular, the dichotomization of the VAX score should be explicitly justified. The manuscript should explain why the selected cut-off was chosen, whether it is supported by prior literature or empirical distributional considerations, and how this choice may influence interpretation of vaccine hesitancy as a continuum rather than a binary construct. The implications of this decision should be acknowledged in the limitations.

Second, the handling of missing data needs a clearer explanation. While the use of complete-case analysis is stated, the authors should report the proportion of missing data for key variables and briefly discuss the potential for selection bias or reduced representativeness resulting from case exclusion. This is particularly important given the relatively modest sample size.

Third, the selection of covariates in multivariable analyses should be better justified. The adjusted models include a limited number of socio-demographic variables despite the availability of additional characteristics. The manuscript should explain why ethnicity and non-term residence were prioritized and whether other variables were tested but excluded. Clarifying whether the models are intended to be explanatory rather than predictive would further improve transparency.

Fourth, the presentation of results should be streamlined to reduce redundancy. Several findings are repeated across the main text, tables, and supplementary materials.

Fifth, the interpretation of findings in the Discussion requires more cautious language. Some statements attribute observed associations to trust, confidence, or structural barriers without sufficient acknowledgment of the cross-sectional design. The authors should consistently emphasize that the findings reflect associations rather than causal relationships and temper interpretations accordingly.

Sixth, the integration of supplementary materials could be improved. The manuscript would benefit from clearer cross-referencing to supplementary tables and a brief explanation of how these materials complement the main analyses, rather than presenting them as parallel outputs.

Finally, the public health implications should be contextualized more carefully. While the discussion of pop-up vaccination clinics and targeted communication strategies is valuable, the authors should more explicitly address the limits of generalizability beyond a single university setting and discuss conditions under which these strategies might be transferable to other contexts.

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The integrative value of this research in the literature is quite unclear.

The integrative value of this research in the literature is quite unclear.

Author Response

Reviewer comment: The integrative value of this research in the literature is quite unclear.

Response: We thank the reviewer for raising this issue. We have throughout the manuscript reference relevant literature and attempted to relate our findings to other published findings. This integration is however not exhaustive as this is a research article. It is our view that our data will prove valuable and will be useful for meta reviews where the attitudes of university students are assessed and compared to the wider population. The reviewer has however highlighted the absence of a general statement on the potential utility of our data and so we have added the following sentence to the end of the Conclusion section "Finally, our study will provide baseline data for follow up surveys to inform pandemic preparedness or disease outbreak control involving university students". We hope that this addition helps contextualise our work and will lead to other considering our findings when reviewing this field.