-->PONE-D-25-13866-->-->Age and Vaccine Information Sources Drive Vaccine Hesitancy: A Household Survey in Central-Western Brazil-->-->PLOS One

Dear Dr. Falcão de Oliveira,

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 reviewers provided valuable and consistent feedback, highlighting the relevance of the topic and the potential contribution of this manuscript to the literature on vaccine hesitancy in Brazil and the Global South. The paper would benefit from further methodological clarification, conceptual precision, and a more parsimonious statistical presentation.

In revising the manuscript, the authors should include a clear justification for the sampling calculations, preferably in an appendix, detailing the assumptions and parameters employed. The rationale for selecting Campo Grande as the study site must also be expanded, explaining how this case contributes to understanding the broader research problem, particularly given its geographical, socioeconomic, and informational specificities. The authors are further encouraged to provide a more detailed description of the cultural adaptation process of the SAGE Work Group Questionnaire for the Brazilian context, ensuring the validity and comparability of the instrument. The operational definitions of hesitant participants (HP) and non-hesitant participants (NHP) should be clarified to reinforce analytical transparency. In the statistical section, a more concise and parsimonious presentation of the bivariate models is recommended, with non-essential details moved to supplementary materials. Throughout the discussion, speculative formulations such as “may have” or “maybe” should be avoided to maintain a scientific tone and restrict interpretations to what the evidence allows to be demonstrated. Finally, the reference to the “neoliberal system” introduced in the discussion requires conceptual elaboration, since the term is not developed elsewhere in the manuscript. Defining it succinctly and connecting it to the behavioral and structural determinants of vaccine hesitancy will enhance theoretical coherence. Overall, the manuscript is promising and well-grounded empirically. Addressing these points will strengthen the methodological robustness, analytical precision, and international relevance of the journal, aligning it more closely with PLOS ONE’s standards.

Please submit your revised manuscript by Jan 25 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. 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,

Ivan Filipe de Almeida Lopes Fernandes, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following in the Competing Interests section:

I have read the journal’s policy and the authors of this manuscript have the following competing interests: EFO is an Academic Editor of PLOS ONE.

Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

4. We note that your Data Availability Statement is currently as follows: All relevant data are within the manuscript and its Supporting Information files.

Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition).

For example, authors should submit the following data:

- The values behind the means, standard deviations and other measures reported;

- The values used to build graphs;

- The points extracted from images for analysis.

Authors do not need to submit their entire data set if only a portion of the data was used in the reported study.

If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories.

If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access.

5. Please include a separate caption for each figure in your manuscript.

6. We note that Figure 1 in your submission contain map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright

We require you to either (a) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (b) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figure 1 to publish the content specifically under the CC BY 4.0 license.

We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text:

“I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.”

Please upload the completed Content Permission Form or other proof of granted permissions as an ""Other"" file with your submission.

In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].”

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

The following resources for replacing copyrighted map figures may be helpful:

USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/

The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/

Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html

NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/

Landsat: http://landsat.visibleearth.nasa.gov/

USGS EROS (Earth Resources Observatory and Science (EROS) Center) (public domain): http://eros.usgs.gov/#

Natural Earth (public domain): http://www.naturalearthdata.com/

7. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

The reviewers provided valuable and consistent feedback, highlighting the relevance of the topic and the potential contribution of this manuscript to the literature on vaccine hesitancy in Brazil and the Global South. The paper would benefit from further methodological clarification, conceptual precision, and a more parsimonious statistical presentation.

In revising the manuscript, the authors should include a clear justification for the sampling calculations, preferably in an appendix, detailing the assumptions and parameters employed. The rationale for selecting Campo Grande as the study site must also be expanded, explaining how this case contributes to understanding the broader research problem, particularly given its geographical, socioeconomic, and informational specificities. The authors are further encouraged to provide a more detailed description of the cultural adaptation process of the SAGE Work Group Questionnaire for the Brazilian context, ensuring the validity and comparability of the instrument. The operational definitions of hesitant participants (HP) and non-hesitant participants (NHP) should be clarified to reinforce analytical transparency. In the statistical section, a more concise and parsimonious presentation of the bivariate models is recommended, with non-essential details moved to supplementary materials. Throughout the discussion, speculative formulations such as “may have” or “maybe” should be avoided to maintain a scientific tone and restrict interpretations to what the evidence allows to be demonstrated. Finally, the reference to the “neoliberal system” introduced in the discussion requires conceptual elaboration, since the term is not developed elsewhere in the manuscript. Defining it succinctly and connecting it to the behavioral and structural determinants of vaccine hesitancy will enhance theoretical coherence. Overall, the manuscript is promising and well-grounded empirically. Addressing these points will strengthen the methodological robustness, analytical precision, and international relevance of the journal, aligning it more closely with PLOS ONE’s standards.

[Note: HTML markup is below. Please do not edit.]

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 #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

-->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 #1: No

Reviewer #2: Yes

Reviewer #3: No

**********

-->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 #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

-->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 #1:

Dear Editor,

I consider the topic relevant and current, with important repercussions for discussions regarding vaccine hesitancy, non-vaccination, and refusal. Furthermore, it presents a careful critique of the shortcomings in access to vaccines through health services. The text is quite thought-provoking, simple, and harmonious, motivating reading without causing fatigue or difficulty in interpretation. The study aims to measure vaccine hesitancy and its associated factors among residents of Campo Grande, the capital of the state of Mato Grosso do Sul, Brazil.

This is a very important topic for current discussions regarding vaccination coverage, which has been declining in the country, where the Immunization Program is powerful and recognized as one of the best in the world. The authors very well justify the importance of conducting the study and, of course, publishing the results, which makes it reasonable to consider its publication in a journal like PlosOne as timely.

Regarding materials and methods

The authors state that this is a cross-sectional study, aligned with a household survey conducted in Campo Grande to estimate vaccination coverage in the municipality, with data collected between September 2022 and October 2023.

In this section, I initially had doubts regarding the methodology; it wasn't entirely clear that this article is part of the results of the household survey (also conducted by them?) used for a different purpose (to estimate vaccination coverage). By stating in the first part of this section that the objective was to estimate vaccination coverage, the initial impression is that there was a change in the objective of the work. I believe a small correction will make the text clearer.

Regarding the study population and data collection, the methodology employed is very well described, allowing for the replication of the study for both sampling and survey application.

The statistical analysis employed is also appropriate for the purpose of the study. The results were presented clearly, and the discussion considered previous studies showing possible comparisons.

Reviewer #2: The article presents a theme of significant importance for public health, as it examines health vulnerability within diverse social contexts. The research displays appropriate scientific rigor and complies with ethical requirements. I endorse its publication.

Reviewer #3: This manuscript addresses a highly relevant and policy-sensitive topic—vaccine hesitancy—in the Brazilian context. The dataset is valuable, and the survey is methodologically sound, offering potential for a meaningful contribution to global public health discussions. However, to meet the standards expected in a high-impact international journal such as PLOS ONE, the paper requires major revisions in several areas of structure, contextualization, and theoretical framing.

1. Literature Review and Theoretical Framework

The literature review is currently too narrow and must be substantially expanded.

While the 3C and 5C models are important conceptual tools for understanding vaccine hesitancy, the manuscript should also engage with other established frameworks in the health and behavioral sciences.

Classic public health literature has long discussed the trade-off between self-protection and vaccination, noting that in periods of lower perceived risk, individuals tend to vaccinate less—a phenomenon well documented before the COVID-19 era.

The authors should also incorporate literature on risk perception, behavioral economics, and health communication, as well as the political economy of vaccination in contexts of misinformation and institutional fragmentation. The Brazilian case is particularly relevant here, as federal authorities—including the former president—publicly questioned vaccination and containment measures, contributing to public confusion. This political dimension must be reflected and supported with appropriate scholarly references.

2. Contextualization of the Brazilian Case

Brazil has one of the world’s most longstanding and successful immunization programs, established in the 1970s during the military regime, which achieved major public health milestones through strong coordination, communication, and outreach.

The authors should discuss:

The historical trajectory of the National Immunization Program (PNI) and its role in shaping public trust.

The recent decline in vaccination coverage since 2016, linked to fiscal constraints and reduced federal investment in vaccination campaigns.

The loss of public health communication capacity—propaganda, media campaigns, and health education—which used to sustain confidence in vaccines.

Campo Grande should also be contextualized geographically and socioeconomically. How representative is this municipality within Brazil’s continental diversity? Is it a border region influenced by migration, poverty, or digital misinformation networks?

3. Data Presentation and Statistical Rigor

The paper presents interesting results, but it lacks sufficient statistical detail and transparency.

The authors should:

Include appendices or supplementary materials with the full survey instrument, descriptive tables, and regression outputs.

Explore heterogeneity across age groups, given that older generations experienced robust vaccination programs, while younger individuals were socialized in an era of digital disinformation.

Discuss how social media usage patterns and regional political contexts might interact with hesitancy. Including a map or stratification by clusters could strengthen the empirical contribution.

4. Discussion and Policy Implications

The discussion needs to move beyond description. The authors should draw clearer policy lessons from their findings—how public health systems can rebuild confidence, counter misinformation, and restore vaccination coverage.

Comparative insights from other Latin American or Global South contexts could make the paper more internationally relevant. The authors could also explore policy alternatives, such as communication strategies, digital literacy programs, and targeted outreach to younger populations.

5. Overall Assessment

The study is promising and empirically rich, but its current framing makes it read more as a localized case study than as a paper contributing to global public health theory.

With a deeper theoretical engagement, a stronger connection to Brazil’s historical and political context, and a clearer presentation of data, the manuscript has real potential to make an important contribution to the literature on vaccine hesitancy, health communication, and pandemic governance.

**********

-->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: No

Reviewer #2: No

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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Age and Vaccine Information Sources Drive Vaccine Hesitancy: A Household Survey in Central-Western Brazil

PONE-D-25-13866R1

Dear Dr. Falcão de Oliveira,

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,

Ivan Filipe de Almeida Lopes Fernandes, Ph.D.

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 #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 #3: Yes

**********

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

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 #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 #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 #3: I am satisfied. TThe authors addressed all comments. Congratularions. I hope to see the paper soon published.

**********

-->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 #3: Yes:GUSTAVO ANDREY DE ALMEIDA LOPES FERNANDES

**********