Vaccine confidence and hesitancy among mothers of children under six years of age in Salvador, Brazil: The role of sociodemographic factors and health service experience

Claudia Nery Teixeira Palombo; Ednir Assis Souza; Érica Marvila Garcia; Ráren Paulo da Silva Araújo; Lucas Regis de Oliveira Santos; Marcelle Lemos Leal; Aline Anne Cavalcante de Oliveira; Ana Paula Sayuri Sato; Clariana Vitória Ramos de Oliveira

doi:10.1371/journal.pone.0344742

Peer Review History

Original SubmissionMay 2, 2025
5 Aug 2025 Decision Letter - Luísa da Matta Machado Fernandes, Editor -->PONE-D-25-23001-->-->Vaccine confidence and hesitancy among mothers of children under six years of age in Salvador, Brazil: The role of sociodemographic factors and health service experience-->-->PLOS ONE Dear Dr. Palombo, 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. The article makes significant contributions to the field, and the revisions requested by the reviewers are pertinent to enhancing its overall quality and reproducibility. In particular, careful attention should be given to the reviewers' specific requests concerning the methods section. 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Abstract: OK Background: In Lines 62-64 (Vaccine hesitancy, the delay in acceptance or refusal of vaccines despite availability, has become a significant public health challenge, contributing to declining immunization coverage worldwide), get the literature references about this. Methods: -Why did the authors decide to use 2010 IBGE, if there are data from 2022 IBGE and SINASC 2022 for children, and if the study is from 2023? - Line 112- 113 - How did they calculate the 95% confidence level, 5% margin of error, to add the 20% to account for potential losses? - Why were children with neurological diseases excluded? - If the mothers were interviewed, was it a questionnaire or forms? Have validation? Was it an adaptation from the other validated instrument of data collection? Is this instrument present in the supplementary annex of the article? - The Inclusion and Exclusion Criteria section should be more details. - L138-145: The parameters about the Vaccine Hesitancy Scale need to be put in a square. - Ethical considerations should be the last section. - Statistical analyses are not clear. Is the population a normal curve? Or is non-parametric analyses there are needs? Why didn't the authors decide on a regression model? -See: How to Write Your Methods - PLOS. Available in https://plos.org/resource/how-to-write-your-methods/?utm_medium=email&utm_source=internal&utm_campaign=modnewsletters&utm_content=modnewsletter. - See: Akel KB, Masters NB, Shih SF, Lu Y, Wagner AL. Modification of a vaccine hesitancy scale for use in adult vaccinations in the United States and China. Hum Vaccin Immunother. 2021 Aug 3;17(8):2639-2646. doi: 10.1080/21645515.2021.1884476. Epub 2021 Mar 26. PMID: 33769209; PMCID: PMC8475604. -See: Daniel Kotz, Jochen W.L. Cals, Effective writing and publishing scientific papers, part IV: methods, Journal of Clinical Epidemiology, Volume 66, Issue 8,2013, Page 817, ISSN 0895-4356, https://doi.org/10.1016/j.jclinepi.2013.01.003.(https://www.sciencedirect.com/science/article/pii/S089543561300019X Results - The authors should improve the presentation of results. - See: Kotz, D., & Cals, J. W. (2013). Effective writing and publishing scientific papers, part V: results. Journal of Clinical Epidemiology, 66(9), 945. https://doi.org/10.1016/j.jclinepi.2013.04.003 -See: Duquia RP, Bastos JL, Bonamigo RR, González-Chica DA, Martínez-Mesa J. Presenting data in tables and charts. An Bras Dermatol. 2014;89(2):280-285. doi:10.1590/abd1806-4841.20143388 -See: Daniel Kotz, nJochen W.L. Cals. Effective writing and publishing scientific papers, part VII: tables and figures. WRITING TIPS SERIES\|VOLUME 66, ISSUE 11, P1197, NOVEMBER 01, 2013, Open AccessPublished:August 19, 2013DOI:https://doi.org/10.1016/j.jclinepi.2013.04.016 Discuss - Rewrite according to alterations in Methods and results. - See: Cals, J. W., & Kotz, D. (2013). Effective writing and publishing scientific papers, part VI: discussion. Journal of Clinical Epidemiology, 66(10), 1064. https://doi.org/10.1016/j.jclinepi.2013.04.017 Reviewer #2: The manuscript presents a relevant and timely investigation into vaccine hesitancy among mothers of children under six years of age in Salvador, Brazil. The topic is of great public health interest and contributes new evidence from a regional context that is still underexplored in national literature. The study design is appropriate, the sample size is robust, and the methodology is clearly described. The use of the WHO/SAGE Vaccine Hesitancy Scale and the application of both exploratory and confirmatory factor analysis add strength to the findings. Statistical methods were rigorously applied, and the conclusions are well supported by the data. The manuscript is clearly written in standard English and well structured. However, I suggest minor improvements to the discussion section, such as including specific examples of interventions (e.g., extramural vaccination strategies, community health worker engagement, and digital communication initiatives). Additionally, I recommend providing the full version of the adapted 10-item hesitancy scale in an appendix for transparency. Regarding data availability, while the ethical justification is understood, the current statement imposes restrictions. Authors should be encouraged to consider anonymizing and depositing a version of the dataset in a public repository if feasible, in alignment with PLOS ONE's data sharing policy. Minor suggestions for improvement: Include in the discussion specific recommendations for interventions involving community health workers, outreach vaccination, and digital communication strategies. Consider adding an appendix with the final adapted version of the scale (translated and applied 10-item tool). Include a final paragraph on “implications for public policies”. Reviewer #3: This manuscript analyzes the association between socio demographic and healthcare factors and vaccine hesitancy between mothers of children under 6 in Salvador. It uses secondary data. A scale is used as an outcome to explore its associations with selected covariates. It is an interesting and well written paper. However, would benefit from some adjustments in terms of clarity as well as having a more detailed presentation on how the research was conducted. For example: Line 62. Requires reference “Vaccine hesitancy, the delay in … worldwide”. Line 88. Please name the study where the current is included “part of a larger study…” or add a reference for this larger study. Line 156. Please confirm if mean and SD was also used for categorical variables or just continuos. Line 165. Clarify if this was a question from the survey or in the scale? Would be important having the questionnaire as Appendix. Line 175. Please list out all the variables used from the initial analysis OR cross-reference with a Table in case it is shown in any of the Tables presented. Line 212. Please describe in more detail the construction of the factors "lack of confidence" and "risk perception" , how these relate to the EFA. Line 317. “One of the most concerning aspects identified is the impact of misinformation and fake news” : Linking misinformation and fake news to the conclusions of this study may go beyond what we can conclude. Otherwise, please explain in more detail why you reached this conclusion. This was actually refered as a limitation. Also align w/ conclusion. Line 323. Again, “the broader influence of fake news on PH reamins significant” please add reference. Line 338 As bias also need to include the profile of people who usually approach and use healthcare services in Brazil if representative of the whole population. ****** -->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. 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: Karen Cordovil Reviewer #2: Yes: Márcio Cristiano de Melo Reviewer #3: No ******** [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.--> Attachments Attachment Submitted filename: PONE-D-25-23001_revKC150625.pdf https://doi.org/10.1371/journal.pone.0344742.r001
Revision 1
13 Oct 2025 Author Response Response to Reviewers – Manuscript PONE-D-25-23001 Title: Confidence and Vaccine Hesitancy Among Mothers of Children Under Six Years Old in Salvador, Brazil: The Role of Sociodemographic Factors and Experience with Health Services Dear Academic Editor, Dear Reviewers, We sincerely thank you for your thoughtful comments and valuable suggestions, which have significantly contributed to the improvement of our manuscript. Below, we present our point-by-point responses, indicating the changes made or justifications provided for each observation. ________________________________________ Reviewer #1 – Dr. Karen Cordovil 1. Lines 62–64 – Reference on vaccine hesitancy: ✔️ We have included updated references supporting the statement regarding the impact of vaccine hesitancy on global immunization coverage. 2. Use of IBGE 2010 data: ✔️ We have justified the use of 2010 data within the manuscript. 3. Sample calculation (lines 112–113): ✔️ We have detailed the sample calculation process. 4. Exclusion of children with neurological conditions: ✔️ We clarified that this exclusion aimed to avoid bias in maternal perceptions of vaccination, given the specific clinical history of these children. 5. Data collection instrument: ✔️ We specified that a structured questionnaire was used, adapted from a previously validated instrument. The full version has been included as a supplementary appendix. 6. Inclusion/exclusion criteria: ✔️ This section was expanded to include detailed information on the criteria applied. 7. Lines 138–145 – Vaccine Hesitancy Scale: ✔️ The parameters were organized into a table to facilitate visualization. 8. Ethical considerations: ✔️ We repositioned this section to the end of the Methods, as suggested. 9. Statistical analyses: ✔️ We clarified that data distribution was assessed and, as it did not follow a normal curve, non-parametric tests were used. ________________________________________ Reviewer #2 – Dr. Márcio Cristiano de Melo 1. Discussion – Examples of interventions: ✔️ We included examples of outreach strategies, community health worker involvement, and digital initiatives, as suggested. 2. Appendix with adapted scale: ✔️ The final version of the 10-item scale, translated and applied, was included as an appendix. 3. Implications for public policy: ✔️ We added a final paragraph in the Discussion addressing practical implications for immunization policy development. ________________________________________ Reviewer #3 – Anonymous 1. Line 62 – Reference on vaccine hesitancy: ✔️ Reference added. 2. Line 88 – Larger study: ✔️ We named the main study and included the corresponding reference. 3. Line 156 – Mean and standard deviation: ✔️ We clarified that these were used only for continuous variables. 4. Line 165 – Origin of the question: ✔️ We indicated that the question is part of the applied scale. The complete questionnaire was included as an appendix. 5. Line 175 – Variables in initial analysis: ✔️ We listed all variables used and referenced the corresponding table. 6. Line 212 – Construction of factors: ✔️ We detailed the process of constructing the “lack of confidence” and “risk perception” factors based on exploratory factor analysis. 7. Lines 317 and 323 – Fake news and misinformation: ✔️ We rewrote these sections to align with the study data and included references supporting the discussion on misinformation. 8. Line 338 – User profile bias: ✔️ We included a reflection on the profile of health service users and its implications for sample representativeness. ________________________________________ We reiterate our gratitude for the opportunity to improve this work. We hope the revisions meet the expectations of the editorial team and reviewers. Sincerely, Claudia Palombo and co-authors Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0344742.r002
17 Dec 2025 Decision Letter - Martin Yakum, Editor -->PONE-D-25-23001R1-->-->Vaccine confidence and hesitancy among mothers of children under six years of age in Salvador, Brazil: The role of sociodemographic factors and health service experience-->-->PLOS One Dear Dr. Palombo, 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 Jan 31 2026 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. 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The authors have effectively integrated all reviewer suggestions. The paper contributes original insights into the determinants of vaccine hesitancy in Brazil and provides valuable implications for public health planning. Recommendation: Accept with minor editorial adjustments (stylistic polishing and optional table relocation). Reviewer #3: (No Response) ****** -->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? 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Revision 2
20 Feb 2026 Author Response Dear Dr. Yakum, We sincerely thank you and the reviewers for the constructive comments on our manuscript entitled “Confidence and hesitancy regarding vaccination among mothers of children under six years in Salvador, Brazil: the role of sociodemographic factors and experiences with health services.” We greatly value the opportunity to revise and resubmit our work to PLOS ONE. Below, we present our point-by-point responses: 1. Ethical statement The manuscript has been revised to explicitly state that informed consent was obtained from the parents or legal guardians of the participating children. We clarified that assent does not apply to children under six years of age, in accordance with standard ethical terminology in research. 2. Statistical analysis In response to Reviewer #2, we included explicit results of the R² values to better convey the explanatory power of the models. 3. Writing style Minor editorial adjustments were made to eliminate repetitions in the final paragraphs and to enhance the overall clarity of the text. We believe that these revisions address all concerns raised and strengthen the manuscript. We are grateful for the reviewers’ recognition of its scientific merit and relevance to public health policy. We look forward to the consideration of our revised submission. Attachments Attachment Submitted filename: Response to reviewers2_.docx https://doi.org/10.1371/journal.pone.0344742.r004
25 Feb 2026 Decision Letter - Martin Yakum, Editor Vaccine confidence and hesitancy among mothers of children under six years of age in Salvador, Brazil: The role of sociodemographic factors and health service experience PONE-D-25-23001R2 Dear Dr. Palombo, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Martin Ndinakie Yakum, Ph.D, MPH, Bsc Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0344742.r005
Formally Accepted
Acceptance Letter - Martin Yakum, Editor PONE-D-25-23001R2 PLOS One Dear Dr. Palombo, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Martin Ndinakie Yakum Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0344742.r006

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