-->PONE-D-25-10068-->-->Parental hesitancy on COVID-19 vaccination of children under the age of 16: A cross-sectional mixed-methods study among factory workers-->-->PLOS ONE

Dear Dr. Htun,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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This manuscript is in need of a major revision. Thus, please address our reviewers' concerns and improve this manuscript. Thank you!

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Please submit your revised manuscript by May 10 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Harapan Harapan, MD, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #2: Partly

Reviewer #3: Yes

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-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #2: Yes

Reviewer #3: Yes

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-->3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

Reviewer #3: Yes

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-->4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #2: No

Reviewer #3: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #2: A review report of the manuscript entitled “Parental hesitancy on COVID-19 vaccination of children under the age of 16: A cross- sectional mixed-methods study among factory workers”

- (page 3, lines 43-44) The opening sentence would be better to rewrite this way: “Thanks to the development of COVID-19 vaccines, now they can be safely and effectively used to guard COVID-19 patients against severe illness, hospitalization, and even mortality.”

- (page 3, line 53) "A total of 170 factory workers having children under the age of 16 in this study" is incomplete. You could say, "A total of 170 factory workers with children under the age of 16 participated in this study."

- (page 5, lines 86-88) This sentence “COVID-19 is continuing to spread around the world with more than 758 million confirmed cases and more than 6.8 million deaths...” also shares the same idea with a similar study by Duta et al. entitled “Essential oil for COVID-19 management: A systematic review of randomized controlled trials” Kindly include this reference to make the sentence stronger.

- (page 5, line 105) As authors have defined the acronym of WHO earlier in this manuscript (line 83), there’s no need to give its full definition anymore on the next mention. So, using only WHO here is already enough.

- (page 6, lines 112-121) This paragraph “Vaccine hesitancy, which expresses the unwillingness to get vaccines when vaccination services are available and accessible, is one of the greatest threats to global health…” will be more significant if it’s also supported by another relevant study. For example, from Hassan et al. entitled “Global acceptance and hesitancy of COVID-19 vaccination: A narrative review”

- (page 8, lines 159-160) The sentence "All parents having children under 16-year-old were working at…" is grammatically incorrect. I would suggest writing it this way "All parents of children under 16 years old working at Tri Star Tyre Factory were recruited for this study."

- (page 8, lines 166-168) The authors stated that “In the first section, there were 6 items related socioeconomic characteristics of the parents such as sex, age, level of education, occupational status, monthly family income, and family members.” My concern is what kind of data has been taken from “family members”. Was that the number of them in a family? Please clarify.

- Authors are suggested to proofread the manuscript after addressing all comments to avoid any typological, grammatical, and lingual mistakes and errors. For example, “questionaries” on page 9 line 182; full stop missing on page 10 line 216; “their children received the had higher attitude scores” on page 27 line 526.

- (page 11, line 231) Please give the meaning of IDIs abbreviation on the first mention.

- (page 13, lines 279-280) “In the educational status, (64.1%) participants graduated…” Do the authors mean “bachelor graduate” here?

- (page 13, lines 284-285) “…monthly family income of the participants was 317,500 (150,000) kyats with a range of 150,000 to 900,000 kyats…” It would be clearer if authors gave the US dollar estimation of the salary received by the factory workers here. So please add the amount of the money they receive as salary in both kyats and USD.

- (page 23, lines 430-431) “It showed that acceptance of COVID-19 vaccine hesitancy was increasing in adults and vaccination rates tend to be increasing.” This sentence contradicts the previous sentences as the authors used the “hesitancy” word in it. It should be revised.

- (page 23, lines 435-436) “In this study, the most trusted source of information for the respondents regarding COVID-19 vaccination was social media (70.0%), followed by television (55.3%).” This is totally new information, as authors did not mention/report it previously in the methods and results sections.

Reviewer #3: Thank you for the opportunity to review your manuscript entitled “Parental Hesitancy on COVID-19 Vaccination of Children Under the Age of 16: A Cross-Sectional Mixed-Methods Study Among Factory Workers.” I very much enjoyed reading your manuscript.

Summary:

This study investigates parental hesitancy toward COVID-19 vaccination for children under 16 among factory workers in Myanmar, utilizing a cross-sectional mixed-methods design. Quantitative data were gathered through structured interviews with 170 factory workers and analyzed using binary logistic regression to determine factors associated with vaccine hesitancy. The qualitative component involved in-depth interviews with 12 participants to explore reasons for hesitancy and non-hesitancy. The results indicate that 18.2% of parents were hesitant, 25.9% were unsure, and 55.9% were non-hesitant. Key factors associated with hesitancy included male gender (AOR: 3.04, 95% CI: 1.35–6.84) and lack of prior SARS-CoV-2 infection (AOR: 2.66, 95% CI: 1.06–6.70). Common concerns included child age, vaccine safety, uncertainty about effectiveness, and distrust in vaccine origin. The study suggests that health education programs and media campaigns should be strengthened to address misinformation and improve vaccination rates. While the study provides valuable insights into vaccine hesitancy within a specific workforce, further multi-center studies with a larger sample size and comparative analysis across different occupational groups could enhance its generalizability.

Major Comments:

1. Literature Review:

- You may expand the discussion on global vaccine hesitancy trends, particularly in occupational settings, to contextualize the study findings.

- You may provide more comparative insights into vaccine hesitancy among factory workers versus the general population in Myanmar or similar settings.

- You may include recent studies on COVID-19 vaccine acceptance among parents to strengthen the theoretical background.

2. Theoretical Contribution:

- You may clearly define how this study adds to the existing body of knowledge on vaccine hesitancy in occupational settings.

- You may highlight the novelty of the findings. Does the study reveal new factors influencing hesitancy, or does it align with prior research?

3. Methods:

- You may clarify how participants were selected for in-depth interviews and whether selection bias may have influenced the qualitative findings.

4. Results:

- You may include a comparative table of hesitant versus non-hesitant groups to highlight key differences in demographics and attitudes.

5. Figures:

- Figure 1: An in-text citation to is missing. You may mention where it is cited in the text.

- You may include a flow diagram of participant selection to improve transparency.

- You may ensure that figure numbering matches in-text citations.

Minor Comments:

1. Abbreviations: You may define abbreviations at their first mention (e.g., IDIs at line 231).

2. Title: You may consider adding “A Pilot Study” at the end of the title, as the study sample is relatively small.

3. Tables:

- You may add a footnote explaining abbreviations and statistical significance levels used in the tables.

- Table 4: You may ensure consistent formatting of the table and fill every cell, if applicable.

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-->6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #2: No

Reviewer #3: Yes:  Ibrahim Saleh

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-->PONE-D-25-10068R1-->-->Parental hesitancy on COVID-19 vaccination of children under the age of 16: A cross-sectional mixed-methods study among factory workers-->-->PLOS ONE

Dear Dr. Htun,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 29 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:-->

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

-->If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Harapan Harapan, MD, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: No

Reviewer #3: Yes

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The authours have apprporiately responded to almost all cmoments by the reviewers. However , in line 251 of the revised manuscrpit they refer to Figure 1-Flow chart of participant selection and data collection process .Similarly in line 322 they also refer to Figure 2-main sources of information on COVID--19 Vaccine among participants. The two figures were not included in the manuscript. These had been recommended by one of the reviewers, they should be included.

Reviewer #3: Thank you for giving me the opportunity to review your manuscript entitled “Parental hesitancy on COVID-19 vaccination of children under the age of 16: A cross-sectional mixed-methods study among factory workers” I very much enjoyed reading your manuscript.

Comments:

Thanks for addressing the previous reviewer comments. I have no further comments.

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-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .-->

Reviewer #1: Yes:  Edison Mworozi Arwanire

Reviewer #3: Yes:  Ibrahim Saleh

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.-->

Parental hesitancy on COVID-19 vaccination of children under the age of 16: A cross-sectional mixed-methods study among factory workers

PONE-D-25-10068R2

Dear Dr. Htun,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Harapan Harapan, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The Authours are commended for having fully responded to the comments/recommdations by the reviewers

Reviewer #3: Thank you for your thoughtful and detailed responses to the reviewers’ comments. I have no additional comments.

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-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .-->

Reviewer #1: Yes:  Edison Mworozi Arwanire

Reviewer #3: Yes:  Ibrahim Saleh

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