Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study

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Shetty" }, { "@type": "Person", "name": "Bhaskaran Unnikrishnan" }, { "@type": "Person", "name": "Prasanna Mithra" }, { "@type": "Person", "name": "Ramesh Holla" }, { "@type": "Person", "name": "Darshan Bhagwan" }, { "@type": "Person", "name": "Avinash Kumar" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": "Background: Vaccine hesitancy (VH) has been identified by the World Health Organization as one among the top ten threats to global public health. There is limited literature regarding VH from developing countries like India. Methods: In this facility based cross-sectional study, 172 mothers of under-five children were assessed regarding VH using the parental attitude towards childhood vaccination questionnaire (PACV). Results: The prevalence of VH was 3.4% (n=6). Only 7.6% (n=13) of the study participants had ever refused vaccination for their child and the most common reason cited for their refusal was that they thought it was not safe (n=6). Government health facilities was the place of routine immunization for 60.5% (n=104) participants. Health care providers (n =79, 46%) were the major source of information regarding vaccines. Conclusions: Our study highlights the presence of very low prevalence of VH in Mangalore compared to similar studies from India and other parts of the world. The limited number of participants had refused vaccination due to concerns related to vaccine safety." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/10-186/v3", "name": "Vaccine hesitancy among mothers of under-five children in Coastal..." } } ] } Home Browse Vaccine hesitancy among mothers of under-five children in Coastal... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Thapar R, Kumar N, Surendran P et al. Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.12688/f1000research.28293.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] Rekha Thapar https://orcid.org/0000-0003-2278-1445 1 , Nithin Kumar https://orcid.org/0000-0003-4665-9401 1 , Priya Surendran 2 , [...] Aleemath Shahdiya 2 , Vibha Mahendran 2 , Ranjitha Ramesh 2 , Deepali J. Shetty 2 , Bhaskaran Unnikrishnan https://orcid.org/0000-0003-0892-8551 1 , Prasanna Mithra https://orcid.org/0000-0002-7153-411X 1 , Ramesh Holla https://orcid.org/0000-0002-2296-3719 1 , Darshan Bhagwan https://orcid.org/0000-0003-2365-7534 1 , Avinash Kumar 1 Rekha Thapar https://orcid.org/0000-0003-2278-1445 1 , Nithin Kumar https://orcid.org/0000-0003-4665-9401 1 , [...] Priya Surendran 2 , Aleemath Shahdiya 2 , Vibha Mahendran 2 , Ranjitha Ramesh 2 , Deepali J. Shetty 2 , Bhaskaran Unnikrishnan https://orcid.org/0000-0003-0892-8551 1 , Prasanna Mithra https://orcid.org/0000-0002-7153-411X 1 , Ramesh Holla https://orcid.org/0000-0002-2296-3719 1 , Darshan Bhagwan https://orcid.org/0000-0003-2365-7534 1 , Avinash Kumar 1 PUBLISHED 16 Sep 2021 Author details Author details 1 Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Manipal, India 2 Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Manipal, India Rekha Thapar Roles: Conceptualization, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Nithin Kumar Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Priya Surendran Roles: Data Curation, Investigation Aleemath Shahdiya Roles: Data Curation, Investigation Vibha Mahendran Roles: Data Curation, Investigation Ranjitha Ramesh Roles: Data Curation, Methodology Deepali J. Shetty Roles: Data Curation, Investigation Bhaskaran Unnikrishnan Roles: Conceptualization, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Prasanna Mithra Roles: Formal Analysis, Writing – Original Draft Preparation Ramesh Holla Roles: Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Darshan Bhagwan Roles: Writing – Original Draft Preparation Avinash Kumar Roles: Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Manipal Academy of Higher Education gateway. This article is included in the Sociology of Health gateway. This article is included in the Sociology of Vaccines collection. Abstract Background: Vaccine hesitancy (VH) has been identified by the World Health Organization as one among the top ten threats to global public health. There is limited literature regarding VH from developing countries like India. Methods: In this facility based cross-sectional study, 172 mothers of under-five children were assessed regarding VH using the parental attitude towards childhood vaccination questionnaire (PACV). Results: The prevalence of VH was 3.4% (n=6). Only 7.6% (n=13) of the study participants had ever refused vaccination for their child and the most common reason cited for their refusal was that they thought it was not safe (n=6). Government health facilities was the place of routine immunization for 60.5% (n=104) participants. Health care providers (n =79, 46%) were the major source of information regarding vaccines. Conclusions: Our study highlights the presence of very low prevalence of VH in Mangalore compared to similar studies from India and other parts of the world. The limited number of participants had refused vaccination due to concerns related to vaccine safety. READ ALL READ LESS Keywords Vaccine Hesitancy, PACV, Mothers, Vaccination coverage, Mangalore Corresponding Author(s) Nithin Kumar ( [email protected] ) Close Corresponding author: Nithin Kumar Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2021 Thapar R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Thapar R, Kumar N, Surendran P et al. Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.12688/f1000research.28293.3 ) First published: 08 Mar 2021, 10 :186 ( https://doi.org/10.12688/f1000research.28293.1 ) Latest published: 16 Sep 2021, 10 :186 ( https://doi.org/10.12688/f1000research.28293.3 ) Revised Amendments from Version 2 The article has been further revised as per the suggestions of the reviewer. In the previous version of the article, in table 4 - Factors associated with vaccine hesitancy (N=172), it was mentioned whether P value was 0.05 for each of the factors. The exact value of P was not mentioned. In the current version, the exact value of P has been mentioned as per the reviewer's suggestion. Also, in the beginning of paragraph 8 of the discussion, the reviewer felt that the statement ""In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)" was confusing. The reviewer suggested us a corrected version of the statement. We have incorporated the corrected version which reads as follows -""Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, mother’s educational status, religion, place of residence, place of immunization and socio-economic status (P>0.05)". The article has been further revised as per the suggestions of the reviewer. In the previous version of the article, in table 4 - Factors associated with vaccine hesitancy (N=172), it was mentioned whether P value was 0.05 for each of the factors. The exact value of P was not mentioned. In the current version, the exact value of P has been mentioned as per the reviewer's suggestion. Also, in the beginning of paragraph 8 of the discussion, the reviewer felt that the statement ""In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)" was confusing. The reviewer suggested us a corrected version of the statement. We have incorporated the corrected version which reads as follows -""Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, mother’s educational status, religion, place of residence, place of immunization and socio-economic status (P>0.05)". See the authors' detailed response to the review by Giriyanna Gowda See the authors' detailed response to the review by Aida Kalok READ REVIEWER RESPONSES Introduction One of the most effective and economical health interventions in recent times, immunization, has brought down the incidence of under-five morbidity and mortality. The effectiveness of a vaccine is subject to a significant number of people in the community being immunized. Unvaccinated children make those vaccinated susceptible to a disease due to waning herd immunity, as seen in poliomyelitis ( Grassly et al. , 2012 ). To achieve maximum immunization coverage, the Global Vaccine Action Plan 2011-2020 (GVAP) called for countries to achieve =90% immunization coverage by 2020 for all vaccines by incorporating it in their National Immunization Schedule ( Peck et al. , 2019 ). The highly ambitious Sustainable Development Goals (SDGs), to be achieved by 2030, includes immunization indictors to measure the progress made by countries in their journey towards ensuring healthy lives and promote well-being of all age groups. The percentage of children up to one year of age who have received three doses of diphtheria-tetanus and pertussis vaccine (DTP3) is taken as proxy indicator for full immunization ( WHO, 2017 ). These estimates of DTP3 are used to monitor the performance of the health system, measure the effectiveness of the immunization program in terms of service delivery, and implement strategies for disease eradication and elimination ( Measure Evaluation, n.d. ). The global coverage for DTP1 and DTP3 in 2018 was estimated to be 90% and 86% and 86% for the first dose of measles-containing vaccine (MCV1). In India, even though maternal and neonatal tetanus has been eliminated and the country certified polio free, the coverage of routine immunization continues to remain low (UNICEF, n.d.). Only 62% of children were fully immunized, with the coverage of DTP3 and measles first dose estimated at 78.4% and 81.1%, respectively (Ministry of Health and Family Welfare, [ MoHFW, 2015a ]). The lower vaccination coverage and dropouts may be attributed to populations who are either hard to reach or hard to vaccinate. Hard to reach are those residing in conflict zones or in difficult geographical terrain where vaccination is poor due to inadequate or irregular supply of vaccines. Hard to vaccinate population are those who despite having access to vaccination do not get their children immunized. This group poses a big challenge to immunization programs across the world ( Peck, 2019 ). “Vaccine hesitancy [VH] refers to the delay in acceptance or refusal of vaccinations despite availability of vaccination services” ( WHO, 2014 ). Vaccine hesitant individuals may be those who have doubts about the vaccine but still get their children vaccinated, or individuals who either refuse or delay a vaccine but receive others, or individuals who reject all vaccines. VH is usually suspected to be present when the immunization coverage is low despite having adequate health services and provision of regular health communication by grass root level workers. This has threatened to reverse the progress made over the years in achieving adequate immunization coverage (WHO, n.d.1). VH has been identified by the WHO as one among the top ten threats to global public health (WHO, n.d.2), and was reported to be a significant problem by 74% of WHO member countries. These countries cited issues related to risk and benefits of vaccines as the most important reason for VH ( MacDonald, Butler & Dube, 2018 ). However, VH is a complex and context specific phenomenon driven by behavioral and social factors which influence an individual’s decision of accepting a vaccine, and not just limited to the safety concerns regarding a vaccine ( MacDonald, Butler & Dube, 2018 , Thomson, Robinson & Vallee-Tourangeau, 2016 ). The reason for VH also varies across geographical regions and for different vaccines. The reasons for VH have been explained by the three ‘C’s model - confidence, complacency and convenience. Lack of confidence in health systems and/or professionals regarding immunization services and provision of information complacency resulting in a belief that the vaccine is no longer needed once there is a decrease in incidence of disease, and ( Edwards and Hackelle, 2016 ) vaccination convenience in terms of availability, affordability, accessibility and quality of services provided, and communication offered by health workers can also affect vaccination uptake ( MacDonald, 2015 ). Adverse effects of the vaccines, pain and fever following immunization, wrong and misleading information from mass media, unfavorable incidents following immunization reported by relatives and friends and lack of awareness and social factors are the reasons for VH in many countries ( LaClair, Smith & Woodword, 2014 ). There is limited literature regarding VH from Mangalore, where the proportion of children fully immunized (children between 12-23 months who have received measles, BCG and 3 doses of DPT and OPV) is 77.3% This is higher than the overall state average of 62.6% (Ministry of Health and Family Welfare, [ MoHFW, 2015c ]) and the National average of 62.9% (Ministry of Health and Family Welfare, [ MoHFW, 2015a ]). However, for a district with high literacy rate and, the immunization coverage rates are expected to be more than 80%. With this background, we carried out this study to find the prevalence and reasons for VH among mothers of under-five children in Mangalore. Methods Study area Mangalore, the major commercial and district headquarter of Dakshina Kannada in the South Indian state of Karnataka, India is known for its numerous educational institutes. It has a literacy rate of 93.4% with male literacy being 96.03% and female literacy 90.84%, which is better than the national urban average of 85% ( Census, 2001 ). The performance of the district in achieving key health care indicators including immunization coverage is also better than the state and national average. Participants In this facility-based cross-sectional study, mothers of under-5 children visiting hospitals affiliated to Kasturba Medical College, Mangalore were assessed regarding VH. The study was carried out during the months of March and April 2017. Based on a previous study ( Dubé et al ., 2016 ), where VH was found to be 40.2%, the sample size was calculated to be 172 with a relative precision of 20%, confidence level of 95%, power 80% and adding a non-response error of 20%. Participants were approached in the waiting area of the outpatient departments of the hospitals and were briefed about the purpose and objectives of the study. After obtaining a written informed consent, data was collected from the willing participants by interviewing them personally using a questionnaire. Mothers with at least one child visiting the obstetric and pediatrics outpatient departments were included in the study using non-random (convenient) sampling technique. This study was approved by the Institutional Ethics Committee of Kasturba Medical College, Mangalore (IEC KMC MLR 03-17). Data collection Information was collected using a semi-structured questionnaire which had the following sections: - Section A: Socio-demographic information of the participants (age, education, occupation, marital status, education and occupation of spouse, family income, number of family members, religion, place of residence, place of routine immunization, number of children, gender of the children); - Section B : Core VH survey questions ( Larson et al. , 2015 ); - Section C : Parental attitude towards childhood vaccination (PACV) ( Opel et al. , 2011 ). The PACV is a validated questionnaire which assesses the attitude of mothers towards vaccination under three domains: immunization behavior, beliefs about vaccine safety and efficacy and trust. The questionnaire was translated to the local vernacular language, Kannada ( Extended data ( Rekha et al. , 2021 )) and was pretested and content validated for the language. The pretesting was done on 30 mothers visiting the outreach clinics of the department of community medicine. Based on the responses, the questionnaire was modified for the language without changing the content. The content validation of the questionnaire was done by the subject expert. Socioeconomic status was evaluated using Modified B.G Prasad scale ( Singh, Sharma & Nagesh, 2017 ). Questionnaires were checked for completeness and only the completed questionnaires were considered for final analysis. Data management and analysis The collected data was entered in and analyzed using IBM SPSS (Statistical Package for Social Sciences) Statistics for Windows Version 25.0. Armonk, NY: IBM Corp) and expressed using mean (Standard Deviation), and proportions. The calculated PACV scores ranged from 0-100: participants who scored between 0-49 were considered to have no VH, and those with scores from 50-100 were considered to be vaccine hesitant. The factors associated with VH was assessed using Chi-square test and P<0.05 was considered a statistically significant association. Results A total of 172 mothers were assessed regarding VH. The mean age of the participants was 29.4 (±5.2) years, with majority (n=112, 65.1%) in the age group between 26-35 years. A higher proportion (n=61, 35.5%) of the participants had completed high school and were from middle socio-economic status. (n=30, 30%) Government health facilities were the place of routine immunization for 60.5% (n=104) of the participants. The socio-demographic characteristics of the study participants is depicted in Table 1 . Table 1. Socio-demographic characteristics of the study participants (N=172). Variables n (%) Age of mother (years) ≤25 40 (23.3) 26-35 112 (65.1) >35 20 (11.6) Education of mother Illiterate 13 (7.6) Primary school 5 (2.9) Middle school 50 (29.1) High school 61 (35.5) Post high school diploma 11 (6.4) Graduate 25 (14.5) Profession or Honors 7 (4.0) Occupation of mother Unemployed 116 (67.4) Unskilled worker 32 (18.6) Semi-skilled worker 7 (4.1) Skilled worker 3 (1.7) Clerical/Shop-owner/Farmer 4 (2.3) Professional 10 (5.8) Religion Hindus 132 (76.7) Muslims 34 (19.8) Christian 6 (3.5) Socioeconomic status (B.G. Prasad scale) [N=100] Upper class 19 (19.0) Upper middle class 18 (18.0) Middle class 30 (30.0) Lower middle class 24 (24.0) Lower class 9 (9.0) Place of residence Urban 86 (50.0) Rural 86 (50.0) Place of routine immunization Government hospital 104 (60.5) Private hospital 41 (23.8) Anganwadi 27 (15.7) Health care providers (n =79, 46%) were the major source of information regarding vaccines, followed by the child’s primary doctor (n= 52, 30.2%). Family members, television, newspaper magazine and internet comprised the rest of the sources. Table 2 shows the findings of the baseline VH survey among the study participants. Only 7.6% (n=13) of the study participants had refused vaccination for their child at some point of them and the most common reason cited for vaccine refusal was that they thought it was not safe (n=6). Table 2. Baseline vaccine hesitancy survey findings among the study participants (N=172). Variable n (%) Belief that vaccines can protect children from serious diseases 169 (98.3) Belief that most parents get their children vaccinated with all recommended vaccines 167 (97.1) Reluctant/hesitant to get a vaccination for the child 19 (11.0) Refused a vaccination for the child 13 (7.6) Reasons for vaccine refusal (N=13) * Did not think the vaccine was safe 6 (46.2) Distance of the immunization clinic 4 (30.8) Did not know where to get reliable information 4 (30.8) Someone else told me that the vaccine was not safe 4 (30.8) Long waiting period in the immunization clinic 3 (23.1) Heard or read negative media 3 (23.1) Someone else told me that their child had a bad reaction 3 (23.1) Fear of needles 3 (23.1) Time needed to get to the clinic 2 (15.4) Did not know where to get vaccinated 2 (15.4) Not possible to leave other work 2 (15.4) Did not think the vaccine was effective 2 (15.4) Timings of the clinic 1 (7.7) Had a bad experience or reaction with previous vaccination 1 (7.7) * Multiple responses. The perception of the participants regarding vaccine safety and efficacy, trust and their immunization behavior as assessed by PACV is shown in Table 3 . A lower proportion of the participants (14%, n=24) opined that children get more vaccines than that are good for them. A higher proportion (80.8%, n=139) of the participants worried about their child having serious side effects from the vaccine. However, the majority (91.8%, n=158) of the participants trust the information provided to them regarding vaccines. A very small proportion (n=6, 3.5%) of the study participants had refused getting their child immunized and 5.8% (n=10) were hesitant about childhood vaccination. Table 3. Perception of the study participants regarding vaccine safety and efficacy, trust and their immunization behavior as assessed by PACV (N=172). Vaccine safety and efficacy Strongly agree/ Agree Not sure Strongly disagree/ Disagree Children get more shots than are good for them. 24 (14.0) 36 (20.9) 112 (65.1) Many of the illness’s shots prevent are severe 133 (77.3) 28 (16.3) 11 (6.4) Better for the child to develop immunity by getting sick than to get a shot 22 (12.8) 44 (25.6) 106 (61.6) Better for children to get fewer vaccines at the same time 31 (18.0) 40 (23.3) 101 (58.7) Not at all concerned/ Not too concerned Not sure Somewhat concerned/ Very concerned Concerned about the child having a serious side effect from a shot 130 (75.6) 9 (5.2) 33 (19.2) Concerned that any one of the childhood vaccines may not be safe 139 (80.8) 11 (6.4) 22 (12.8) Concerned that a shot might not prevent the disease? 143 (83.1) 21 (12.2) 8 (4.7) Trust Strongly agree/ Agree Not sure Strongly disagree/ Disagree I trust the information I receive about shots 158 (91.8) 12 (7.0) 2 (1.2) I can openly discuss my concerns about shots with my child’s doctor. 141 (82.0) 5 (2.9) 26 (15.1) Immunization behavior Yes No Don’t know Delayed getting vaccine for reasons other than illness or allergy 14 (08.1) 157 (91.3) 1 (0.6) Refused a vaccine for reasons other than illness or allergy 6 (3.5) 166 (96.5) - Follow the recommended schedule if the mother had another infant 149 (86.6) 19 (11.1) 4 (2.3) Overall hesitancy about childhood vaccination Not at all hesitant/ Not too hesitant Not sure Somewhat hesitant / Very hesitant 153 (89.0) 9 (5.2) 10 (5.8) The median PACV score among participants was 10.0 with a total of 166 parents (96.5%). Only 6 (3.5%) participants were found to be vaccine hesitant. Among the participants who were found to have no VH, a higher proportion were under the age of 30 years, urban residents, belonged to Hindu religion and utilized government facility for immunization. Among the vaccine hesitant mothers, majority of them had studied up to high school (83.3%) and were unemployed (66.7%). No statistical significance association was observed between VH and mothers educational and employment status (P>0.05) ( Table 4 ). Table 4. Factors associated with vaccine hesitancy (N=172). Factors Vaccine hesitancy Chi Square, P value Yes (N=6) n (%) No (N=166) n (%) Age of the mother (years) ≤30 4 (66.7) 104 (62.7) 0.040, P>0.841 >30 2 (33.3) 62 (37.3) Educational status of the mother Up to high school 5 (83.3) 124 (74.7) 0.230, P>0.532 Beyond high school 1 (16.7) 42 (25.3) Employment status of the mother Unemployed 4 (66.7) 112 (67.5) 0.002, P>0.637 Employed 2 (33.3) 54 (32.5) Religion Hindu 1 (16.7) 131 (78.9) 3.238, P0.341 Rural 2 (33.3) 84 (50.6) Place of immunization Government facility 5 (83.3) 126 (75.9) 0.309, P>0.629 Private facility 1 (16.7) 40 (24.1) Socioeconomic status N = 4 N = 96 (N=100) n (%) n (%) Upper and upper middle class 3 (75.0) 34 (35.4) 2.581, P>0.142 Middle, lower middle and lowerclass 1 (25.0) 62 (64.6) Discussion The success of immunization programs relies on high vaccination coverage and vaccine uptake rates. Maintaining a high timely vaccination coverage has resulted in effective control of vaccine preventable diseases (VPDs), among those vaccinated, as well as the unvaccinated by virtue of herd immunity. However, recent outbreaks of VPDs like measles and diphtheria in both developed and developing countries, has undermined the progress made by immunization programs implemented all over the world. High vaccination coverage rates are misleading and do not reflect the number of under-vaccinated and unvaccinated section of the population ( Kumar et al. , 2016 ). The global vigilance on immunization programs in developed countries has attributed recent outbreaks of measles to VH ( Shukla, 2019 ). However, the trend of VH is universal and not just limited to developed countries. The analysis of WHO/ UNICEF Joint Reporting Form data for VH for the years 2015-2017 revealed that VH was reported by more than 90% of the WHO member countries ( Lane et al. , 2018 ). In our study, a very low proportion (3.5%) of the participants were found to be vaccine hesitant. Though the immunization coverage rate of 77% of the study area is higher than the national average, it is still low. Being a health facility based study, the low VH in our study does not reflect VH in the general population. The lower VH among the participants could be due to high literacy rate, better immunization coverage and services, and creation of awareness by grass root level workers which has resulted in high vaccine uptake rates. With an educational index of 0.958 and an overall Human Development Index (HDI) of 0.830, Mangalore has always been one of the better performing regions in the State of Karnataka (Shodhganga. Profile of Dakshina Kannada, n.d.) There is huge variation in the estimates of VH reported in primary studies from various parts of the world. This variation may be attributed to the use of different questionnaires and cut-off scores to categorize VH among the population. Assessment of hesitancy for an individual vaccine or the entire immunization schedule, as well as the age group of target population may also result in VH estimates of varying proportions. The VH reported in studies from different parts of India ranged between 14.1% to 83% ( Krishnamoorthy et al. , 2019 , Agarwal et al. , 2019 , Narayanan, Jayaraman & Gopichandran, 2018 , Dasgupta et al. , 2018 ). Similar variation in the prevalence of VH is also observed in studies from other parts of the world. The VH was as low as 1.1% in a study in Guatemala ( Domek et al. , 2018 ) while in a study in Nigeria it was 76% (Larsen et al, 2015b). Other studies have reported VH in the range of 11.6% to 66% ( Dubé et al , 2016 , Lane et al. , 2018 , Mohd Azizi, Kew, Moy, 2017 , Giambi et al. , 2018 , Ferrante et al. , 2019 , Napolitano, D’Alessandro & Angelilo, 2018 , Ray et al. , 2018, Paterson, Chantler & Larson, 2018 ). It is evident that irrespective of the measurement tool used, VH is widely prevalent across countries, having an impact on the coverage rates of immunization and vaccine uptake among the targeted population. Hence, it is imperative to first identify these vaccine hesitant groups, and strategically work towards restoring their trust and belief towards the health system in general and vaccination ( Marti et al. , 2017 ). Although by definition, it includes people who delay or refuse vaccination, people who chose to vaccinate in spite of having doubts about the same should also be identified and their concerns addressed. This will ensure a better immunization coverage in the future. Identifying and overcoming the reasons for VH is one of the most important challenge faced by immunization and program managers. VH is usually limited to a subgroup of the population whose decision-making process is driven by their socio-cultural, religious, and political standing and cannot be overcome by strengthening the health system or increasing vaccination services alone. Studies have shown that there is not one particular reason for refusing or delaying vaccination. The reasons are diverse and can vary from one person to another in a vaccine hesitant population. Globally, the three most common reasons cited for VH during the year 2015, 2016 and 2017 were concerns related to vaccine safety (22%, 23%, 23%), lack of knowledge and awareness regarding immunization and its benefit (15%, 13%, 10%), and religious and cultural beliefs (10%, 9%, 12%) ( Marti et al. , 2017 ). The reasons for VH varied across WHO regions and socio-economic status of the countries within these regions. In the European Region, South East Asian Region and Western Pacific Region, concerns about safety of vaccines and fear of side effects were predominant, while issues revolving around religion and cultural beliefs were common in the Americas. Inadequate knowledge or information regarding vaccines and their benefits as well as poor awareness were mainly reported from African Region and Eastern Mediterranean Region. Adverse events following immunization and safety of the vaccine were the most important driver for VH in upper-middle income countries, while inadequate knowledge and awareness regarding vaccines and immunization services were predominantly seen in lower-middle income countries. VH due to religious influences were seen across countries of all strata of income and in most of the WHO regions (The History of Vaccines. n.d.). Apprehensions regarding the risks and benefit of vaccines were the most common reasons for VH in our study which was also reported by a study in Chennai. The other reasons for influencing VH cited in that study were lack of trust for the newer vaccines ( Narayanan, Jayaraman & Gopichandran, 2108 ). In a study in Siliguri, unwillingness and having no reliable information on the vaccine were the major reasons cited for VH ( Dasgupta et al. , 2018 ). Primary studies from different part of the world have also reported a heterogeneous group of reasons. The most frequently cited reason leading to VH in a study in England were the presence of porcine gelatin in the vaccine and issues related to vaccine effectiveness and side effects ( Lane et al. , 2018 ). Meanwhile, in a study in Guatemala, health system related factors like distance of the clinic, cost incurred to get to the clinic and timing of the clinic and waiting at the clinic were the predominant reasons for VH ( Domek et al. , 2018 ). A study conducted in Quebec found that fear of adverse effects and low perceived vulnerability of the child or severity of the disease were the most common reasons for VH ( Dubé et al. , 2016 ). Religious influences for VH are the most challenging to address in any immunization program since they arise out of individual’s core belief and driven by their faith. Use of human tissues in creating a vaccine or the belief that the body should be healed naturally by God and not by chemicals are some of the points for refusing vaccines ( McKee & Bohannon, 2016 ). Unlike other reasons for VH, they do not arise out of lack of knowledge or awareness regarding immunization, but is a by-product of an individual’s or a group’s religious conviction thus making it difficult to change their attitude towards immunization ( McKee & Bohannon, 2016 ). Issues related to vaccine safety and side effects is one of the most important reasons for refusal of vaccines by the parents. Parents are bombarded with information on vaccine safety and adverse effects, and opinions on vaccination through mass media and social media. Such information can be overwhelming at times, creating enough doubts to make an informed decision, thus leading them to ultimately refuse vaccination ( McKee & Bohannon, 2016 ). Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, mother's educational status, religion, place of residence, place of immunization and socio-economic status (P>0.05). Mother’s age ( Krishnamoorthy et al. , 2019 ), lower educational status of mother ( Agarwal et al. , 2019 , Dasgupta et al. , 2018 ) nuclear family ( Agarwal et al. , 2019 , Dasgupta et al. , 2018 ), and past history of incomplete immunization ( Agarwal et al. , 2019 ) were found to be significantly associated with VH in other studies from India. Some of the factors associated with VH reported in studies from other parts of the world include younger parents ( Mohd Azizi, Kew & Moy, 2017 ), unemployed parents ( Mohd Azizi, Kew & Moy, 2017 ), higher educational status ( Ferrante et al. , 2019 ), contact with parents of children who had experienced serious side effects ( Giambi, 2018 ), not advised by a pediatrician to complete the full course of immunization ( Giambi, 2018 ), and lack of trust on the pediatrician ( Napolitano, 2018 ). Limitations This being a facility-based study, our findings cannot be extrapolated to the general population. Conclusion Our study highlights the presence of very low prevalence of VH in Mangalore compared to similar studies from India and other parts of the world. The limited number of participants who had refused vaccination, refused due to concerns related to vaccine safety. Recommendations Hesitancy to vaccines follows the iceberg phenomenon, with the tip of the iceberg representing the population who refuse vaccination, while the submerged proportion representing the vaccine hesitant population. Identifying these vaccine hesitant subgroups is important for the success of any immunization program. Population-based studies covering a larger sample and multicentric studies would throw more evidence towards the presence of VH as a reason for a lower vaccination. Such studies also give an insight into the various reasons for VH existing in different population groups. Data availability Underlying data Open Science Framework: Vaccine Hesitancy among mothers of Under-5 children in Coastal South India - A facility-based study, https://doi.org/10.17605/OSF.IO/A3XJU ( Rekha et al. , 2021 ). 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Reference Source World Health Organization: Ten threats to global health in 2019.no date Reference Source Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 08 Mar 2021 ADD YOUR COMMENT Comment Author details Author details 1 Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Manipal, India 2 Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Manipal, India Rekha Thapar Roles: Conceptualization, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Nithin Kumar Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Priya Surendran Roles: Data Curation, Investigation Aleemath Shahdiya Roles: Data Curation, Investigation Vibha Mahendran Roles: Data Curation, Investigation Ranjitha Ramesh Roles: Data Curation, Methodology Deepali J. Shetty Roles: Data Curation, Investigation Bhaskaran Unnikrishnan Roles: Conceptualization, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Prasanna Mithra Roles: Formal Analysis, Writing – Original Draft Preparation Ramesh Holla Roles: Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Darshan Bhagwan Roles: Writing – Original Draft Preparation Avinash Kumar Roles: Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (3) version 3 Revised Published: 16 Sep 2021, 10:186 https://doi.org/10.12688/f1000research.28293.3 version 2 Revised Published: 16 Aug 2021, 10:186 https://doi.org/10.12688/f1000research.28293.2 version 1 Published: 08 Mar 2021, 10:186 https://doi.org/10.12688/f1000research.28293.1 Copyright © 2021 Thapar R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Thapar R, Kumar N, Surendran P et al. Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.12688/f1000research.28293.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 3 VERSION 3 PUBLISHED 16 Sep 2021 Revised Views 0 Cite How to cite this report: Kalok A. Reviewer Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.77220.r94488 ) The direct URL for this report is: https://f1000research.com/articles/10-186/v3#referee-response-94488 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 27 Sep 2021 Aida Kalok , Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia, Universiti Kebangsaan Malaysia Medical Centre, Selangor, Malaysia Approved VIEWS 0 https://doi.org/10.5256/f1000research.77220.r94488 Thank you for adding the p values in table 4. You should however state ... Continue reading READ ALL Thank you for adding the p values in table 4. You should however state the value as 'p equals( p = )', instead of using > or <. Thanks. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Maternal health, General Obstetrics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Kalok A. Reviewer Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.77220.r94488 ) The direct URL for this report is: https://f1000research.com/articles/10-186/v3#referee-response-94488 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 2 VERSION 2 PUBLISHED 16 Aug 2021 Revised Views 0 Cite How to cite this report: Kalok A. Reviewer Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.58578.r91978 ) The direct URL for this report is: https://f1000research.com/articles/10-186/v2#referee-response-91978 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 24 Aug 2021 Aida Kalok , Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia, Universiti Kebangsaan Malaysia Medical Centre, Selangor, Malaysia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.58578.r91978 Thank you for the revised version. A couple more comments prior to my approval of this manuscript: Please include the exact p-value of each chi-square test in Table 4. ... Continue reading READ ALL Thank you for the revised version. A couple more comments prior to my approval of this manuscript: Please include the exact p-value of each chi-square test in Table 4. This statement is quite confusing: "In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)". Please consider rephrasing it to "Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, religion, urban residence, etc." Competing Interests: No competing interests were disclosed. Reviewer Expertise: Maternal health, General Obstetrics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Kalok A. Reviewer Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.58578.r91978 ) The direct URL for this report is: https://f1000research.com/articles/10-186/v2#referee-response-91978 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 16 Sep 2021 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Manipal, India 16 Sep 2021 Author Response Thank you for taking time and reviewing our article. We have made the changes in the manuscript and uploaded the revised version. Kindly find the point-by-point clarification/reply to your comments. ... Continue reading Thank you for taking time and reviewing our article. We have made the changes in the manuscript and uploaded the revised version. Kindly find the point-by-point clarification/reply to your comments. Please include the exact p-value of each chi-square test in Table 4. Thank you. The exact P value is incorporated in table 4 as per your suggestion. This statement is quite confusing: "In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)". Please consider rephrasing it to "Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, religion, urban residence, etc." Thank you for your suggestion. We have rephrased the statement as per your suggestion. Thank you for taking time and reviewing our article. We have made the changes in the manuscript and uploaded the revised version. Kindly find the point-by-point clarification/reply to your comments. Please include the exact p-value of each chi-square test in Table 4. Thank you. The exact P value is incorporated in table 4 as per your suggestion. This statement is quite confusing: "In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)". Please consider rephrasing it to "Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, religion, urban residence, etc." Thank you for your suggestion. We have rephrased the statement as per your suggestion. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 16 Sep 2021 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Manipal, India 16 Sep 2021 Author Response Thank you for taking time and reviewing our article. We have made the changes in the manuscript and uploaded the revised version. Kindly find the point-by-point clarification/reply to your comments. ... Continue reading Thank you for taking time and reviewing our article. We have made the changes in the manuscript and uploaded the revised version. Kindly find the point-by-point clarification/reply to your comments. Please include the exact p-value of each chi-square test in Table 4. Thank you. The exact P value is incorporated in table 4 as per your suggestion. This statement is quite confusing: "In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)". Please consider rephrasing it to "Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, religion, urban residence, etc." Thank you for your suggestion. We have rephrased the statement as per your suggestion. Thank you for taking time and reviewing our article. We have made the changes in the manuscript and uploaded the revised version. Kindly find the point-by-point clarification/reply to your comments. Please include the exact p-value of each chi-square test in Table 4. Thank you. The exact P value is incorporated in table 4 as per your suggestion. This statement is quite confusing: "In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)". Please consider rephrasing it to "Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, religion, urban residence, etc." Thank you for your suggestion. We have rephrased the statement as per your suggestion. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 08 Mar 2021 Views 0 Cite How to cite this report: Kalok A. Reviewer Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.31291.r82849 ) The direct URL for this report is: https://f1000research.com/articles/10-186/v1#referee-response-82849 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 04 May 2021 Aida Kalok , Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia, Universiti Kebangsaan Malaysia Medical Centre, Selangor, Malaysia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.31291.r82849 The introduction is quite lengthy. Sample size - please state the number of participants required based on the sample size calculation. Did this study reach its required sample size? ... Continue reading READ ALL The introduction is quite lengthy. Sample size - please state the number of participants required based on the sample size calculation. Did this study reach its required sample size? What was the study hypothesis? Data collection: Did the participants complete the questionnaire themselves? What about the illiterate mothers? Data analysis: Was there any association between VH and maternal employment/level of education/socio-economic status? Please include this in the results/discussion. Discussion: Please discuss why with such a low VH rate, the proportion of immunised children in Mangalore is still around 77%. The study was conducted in a health facility; women who sought/received health care were most likely to demonstrate a lower level of vaccine hesitancy. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Maternal health, General Obstetrics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Kalok A. Reviewer Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.31291.r82849 ) The direct URL for this report is: https://f1000research.com/articles/10-186/v1#referee-response-82849 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 09 Jul 2021 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Mangalore, 575001, India 09 Jul 2021 Author Response We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the ... Continue reading We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. The introduction is quite lengthy. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. Sample size - please state the number of participants required based on the sample size calculation. Did this study reach its required sample size? Based on the sample size calculation, a total of 172 participants were required to be included in the study. We were able to achieve the sample size. The same has been added to the Methods section in the manuscript. What was the study hypothesis? Even though the study area has a good health system and a literacy rate that is higher than the national figures, the immunization coverage has consistently remained below 90 per cent. The study hypothesis was “Vaccine hesitancy is present in the study area”. Data collection: Did the participants complete the questionnaire themselves? What about illiterate mothers? All the participants were interviewed while they were waiting in the respective OPDs. The same has been included in the methods section of the manuscript. Data analysis: Was there any association between VH and maternal employment/level of education/socio-economic status? Please include this in the results/discussion. Crosstabulation between the presence of vaccine hesitancy and educational status, employment status and socioeconomic status is incorporated in the results and discussion section. However, no statistically significant association was observed between VH and maternal employment, level of education and socio-economic status. Discussion: Please discuss why with such a low VH rate, the proportion of immunized children in Mangalore is still around 77%. Being a health facility-based study, our finding of low VH among the study participants does not reflect the status of VH in Mangalore. Population-based studies covering a larger sample / multicentric studies would throw more evidence towards the presence of VH as a reason for a lower vaccination coverage in the study area. Also, since the study was conducted in a health facility; the women who sought/received health care were most likely to demonstrate a better health seeking behavior which is also reflected in a lower vaccine hesitancy among the participants. The study was conducted in a health facility; women who sought/received health care were most likely to demonstrate a lower level of vaccine hesitancy. Yes. we agree with the observation. We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. The introduction is quite lengthy. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. Sample size - please state the number of participants required based on the sample size calculation. Did this study reach its required sample size? Based on the sample size calculation, a total of 172 participants were required to be included in the study. We were able to achieve the sample size. The same has been added to the Methods section in the manuscript. What was the study hypothesis? Even though the study area has a good health system and a literacy rate that is higher than the national figures, the immunization coverage has consistently remained below 90 per cent. The study hypothesis was “Vaccine hesitancy is present in the study area”. Data collection: Did the participants complete the questionnaire themselves? What about illiterate mothers? All the participants were interviewed while they were waiting in the respective OPDs. The same has been included in the methods section of the manuscript. Data analysis: Was there any association between VH and maternal employment/level of education/socio-economic status? Please include this in the results/discussion. Crosstabulation between the presence of vaccine hesitancy and educational status, employment status and socioeconomic status is incorporated in the results and discussion section. However, no statistically significant association was observed between VH and maternal employment, level of education and socio-economic status. Discussion: Please discuss why with such a low VH rate, the proportion of immunized children in Mangalore is still around 77%. Being a health facility-based study, our finding of low VH among the study participants does not reflect the status of VH in Mangalore. Population-based studies covering a larger sample / multicentric studies would throw more evidence towards the presence of VH as a reason for a lower vaccination coverage in the study area. Also, since the study was conducted in a health facility; the women who sought/received health care were most likely to demonstrate a better health seeking behavior which is also reflected in a lower vaccine hesitancy among the participants. The study was conducted in a health facility; women who sought/received health care were most likely to demonstrate a lower level of vaccine hesitancy. Yes. we agree with the observation. Competing Interests: NA Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 09 Jul 2021 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Mangalore, 575001, India 09 Jul 2021 Author Response We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the ... Continue reading We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. The introduction is quite lengthy. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. Sample size - please state the number of participants required based on the sample size calculation. Did this study reach its required sample size? Based on the sample size calculation, a total of 172 participants were required to be included in the study. We were able to achieve the sample size. The same has been added to the Methods section in the manuscript. What was the study hypothesis? Even though the study area has a good health system and a literacy rate that is higher than the national figures, the immunization coverage has consistently remained below 90 per cent. The study hypothesis was “Vaccine hesitancy is present in the study area”. Data collection: Did the participants complete the questionnaire themselves? What about illiterate mothers? All the participants were interviewed while they were waiting in the respective OPDs. The same has been included in the methods section of the manuscript. Data analysis: Was there any association between VH and maternal employment/level of education/socio-economic status? Please include this in the results/discussion. Crosstabulation between the presence of vaccine hesitancy and educational status, employment status and socioeconomic status is incorporated in the results and discussion section. However, no statistically significant association was observed between VH and maternal employment, level of education and socio-economic status. Discussion: Please discuss why with such a low VH rate, the proportion of immunized children in Mangalore is still around 77%. Being a health facility-based study, our finding of low VH among the study participants does not reflect the status of VH in Mangalore. Population-based studies covering a larger sample / multicentric studies would throw more evidence towards the presence of VH as a reason for a lower vaccination coverage in the study area. Also, since the study was conducted in a health facility; the women who sought/received health care were most likely to demonstrate a better health seeking behavior which is also reflected in a lower vaccine hesitancy among the participants. The study was conducted in a health facility; women who sought/received health care were most likely to demonstrate a lower level of vaccine hesitancy. Yes. we agree with the observation. We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. The introduction is quite lengthy. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. Sample size - please state the number of participants required based on the sample size calculation. Did this study reach its required sample size? Based on the sample size calculation, a total of 172 participants were required to be included in the study. We were able to achieve the sample size. The same has been added to the Methods section in the manuscript. What was the study hypothesis? Even though the study area has a good health system and a literacy rate that is higher than the national figures, the immunization coverage has consistently remained below 90 per cent. The study hypothesis was “Vaccine hesitancy is present in the study area”. Data collection: Did the participants complete the questionnaire themselves? What about illiterate mothers? All the participants were interviewed while they were waiting in the respective OPDs. The same has been included in the methods section of the manuscript. Data analysis: Was there any association between VH and maternal employment/level of education/socio-economic status? Please include this in the results/discussion. Crosstabulation between the presence of vaccine hesitancy and educational status, employment status and socioeconomic status is incorporated in the results and discussion section. However, no statistically significant association was observed between VH and maternal employment, level of education and socio-economic status. Discussion: Please discuss why with such a low VH rate, the proportion of immunized children in Mangalore is still around 77%. Being a health facility-based study, our finding of low VH among the study participants does not reflect the status of VH in Mangalore. Population-based studies covering a larger sample / multicentric studies would throw more evidence towards the presence of VH as a reason for a lower vaccination coverage in the study area. Also, since the study was conducted in a health facility; the women who sought/received health care were most likely to demonstrate a better health seeking behavior which is also reflected in a lower vaccine hesitancy among the participants. The study was conducted in a health facility; women who sought/received health care were most likely to demonstrate a lower level of vaccine hesitancy. Yes. we agree with the observation. Competing Interests: NA Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Gowda G. Reviewer Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.31291.r81112 ) The direct URL for this report is: https://f1000research.com/articles/10-186/v1#referee-response-81112 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 22 Mar 2021 Giriyanna Gowda , Department of Community Medicine, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India Approved VIEWS 0 https://doi.org/10.5256/f1000research.31291.r81112 Comments: The introduction is too lengthy; please make it specific and concise and based on the needs of the study. In the abstract, it is mentioned that the prevalence of vaccine ... Continue reading READ ALL Comments: The introduction is too lengthy; please make it specific and concise and based on the needs of the study. In the abstract, it is mentioned that the prevalence of vaccine hesitance is 3.4 % and also that 7.6 % had refused vaccination for their child. Please clarify this. Recommendations are not based on results. Kindly specify it. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: epidemiology, clinical trials I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Gowda G. Reviewer Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.31291.r81112 ) The direct URL for this report is: https://f1000research.com/articles/10-186/v1#referee-response-81112 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 09 Jul 2021 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Mangalore, 575001, India 09 Jul 2021 Author Response We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the ... Continue reading We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. Response to the Comments: 1.The introduction is too lengthy; please make it specific and concise and based on the needs of the study. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. 2. In the abstract, it is mentioned that the prevalence of vaccine hesitance is 3.4 % and that 7.6 % had refused vaccination for their child. Please clarify this. One of the questions in the Core vaccine hesitancy Survey tool directed towards the mothers was “Have you ever refused a vaccination for your child? Yes/No”. Only 7.6% of the study participants had refused vaccination for their child at some point of time. The prevalence of vaccine hesitancy was calculated based on the scores obtained from the Parental Attitude Towards Childhood Vaccination Questionnaire (PACV). Participants who scored between 50 -100 were vaccine hesitant. Only 3.4% of the study participants were vaccine hesitant. We have clarified it in abstract. 3. Recommendations are not based on results. Kindly specify it. Recommendations have been made specific to the conclusions drawn from the study. We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. Response to the Comments: 1.The introduction is too lengthy; please make it specific and concise and based on the needs of the study. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. 2. In the abstract, it is mentioned that the prevalence of vaccine hesitance is 3.4 % and that 7.6 % had refused vaccination for their child. Please clarify this. One of the questions in the Core vaccine hesitancy Survey tool directed towards the mothers was “Have you ever refused a vaccination for your child? Yes/No”. Only 7.6% of the study participants had refused vaccination for their child at some point of time. The prevalence of vaccine hesitancy was calculated based on the scores obtained from the Parental Attitude Towards Childhood Vaccination Questionnaire (PACV). Participants who scored between 50 -100 were vaccine hesitant. Only 3.4% of the study participants were vaccine hesitant. We have clarified it in abstract. 3. Recommendations are not based on results. Kindly specify it. Recommendations have been made specific to the conclusions drawn from the study. Competing Interests: NA Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 09 Jul 2021 Nithin Kumar , Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Mangalore, 575001, India 09 Jul 2021 Author Response We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the ... Continue reading We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. Response to the Comments: 1.The introduction is too lengthy; please make it specific and concise and based on the needs of the study. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. 2. In the abstract, it is mentioned that the prevalence of vaccine hesitance is 3.4 % and that 7.6 % had refused vaccination for their child. Please clarify this. One of the questions in the Core vaccine hesitancy Survey tool directed towards the mothers was “Have you ever refused a vaccination for your child? Yes/No”. Only 7.6% of the study participants had refused vaccination for their child at some point of time. The prevalence of vaccine hesitancy was calculated based on the scores obtained from the Parental Attitude Towards Childhood Vaccination Questionnaire (PACV). Participants who scored between 50 -100 were vaccine hesitant. Only 3.4% of the study participants were vaccine hesitant. We have clarified it in abstract. 3. Recommendations are not based on results. Kindly specify it. Recommendations have been made specific to the conclusions drawn from the study. We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. Response to the Comments: 1.The introduction is too lengthy; please make it specific and concise and based on the needs of the study. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. 2. In the abstract, it is mentioned that the prevalence of vaccine hesitance is 3.4 % and that 7.6 % had refused vaccination for their child. Please clarify this. One of the questions in the Core vaccine hesitancy Survey tool directed towards the mothers was “Have you ever refused a vaccination for your child? Yes/No”. Only 7.6% of the study participants had refused vaccination for their child at some point of time. The prevalence of vaccine hesitancy was calculated based on the scores obtained from the Parental Attitude Towards Childhood Vaccination Questionnaire (PACV). Participants who scored between 50 -100 were vaccine hesitant. Only 3.4% of the study participants were vaccine hesitant. We have clarified it in abstract. 3. Recommendations are not based on results. Kindly specify it. Recommendations have been made specific to the conclusions drawn from the study. Competing Interests: NA Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 08 Mar 2021 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 3 (revision) 16 Sep 21 read Version 2 (revision) 16 Aug 21 read Version 1 08 Mar 21 read read Giriyanna Gowda , Kempegowda Institute of Medical Sciences, Bangalore, India Aida Kalok , National University of Malaysia, Universiti Kebangsaan Malaysia Medical Centre, Selangor, Malaysia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2021 Kalok A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 27 Sep 2021 | for Version 3 Aida Kalok , Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia, Universiti Kebangsaan Malaysia Medical Centre, Selangor, Malaysia 0 Views copyright © 2021 Kalok A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for adding the p values in table 4. You should however state the value as 'p equals( p = )', instead of using > or <. Thanks. Competing Interests No competing interests were disclosed. Reviewer Expertise Maternal health, General Obstetrics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Kalok A. Peer Review Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.77220.r94488) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-186/v3#referee-response-94488 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2021 Kalok A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 24 Aug 2021 | for Version 2 Aida Kalok , Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia, Universiti Kebangsaan Malaysia Medical Centre, Selangor, Malaysia 0 Views copyright © 2021 Kalok A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the revised version. A couple more comments prior to my approval of this manuscript: Please include the exact p-value of each chi-square test in Table 4. This statement is quite confusing: "In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)". Please consider rephrasing it to "Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, religion, urban residence, etc." Competing Interests No competing interests were disclosed. Reviewer Expertise Maternal health, General Obstetrics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 16 Sep 2021 Nithin Kumar, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Manipal, India Thank you for taking time and reviewing our article. We have made the changes in the manuscript and uploaded the revised version. Kindly find the point-by-point clarification/reply to your comments. Please include the exact p-value of each chi-square test in Table 4. Thank you. The exact P value is incorporated in table 4 as per your suggestion. This statement is quite confusing: "In our study, mothers aged less than 30 years, educated up to high school and unemployed, residing in an urban area, belonging to Muslim religion, and availing immunization services from a government facility were found to be vaccine hesitant, though these factors were not significant (P>0.05)". Please consider rephrasing it to "Vaccine hesitancy among the cohort was not significantly associated with factors such as maternal age, employment, religion, urban residence, etc." Thank you for your suggestion. We have rephrased the statement as per your suggestion. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Kalok A. Peer Review Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.58578.r91978) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-186/v2#referee-response-91978 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2021 Kalok A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 04 May 2021 | for Version 1 Aida Kalok , Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia, Universiti Kebangsaan Malaysia Medical Centre, Selangor, Malaysia 0 Views copyright © 2021 Kalok A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The introduction is quite lengthy. Sample size - please state the number of participants required based on the sample size calculation. Did this study reach its required sample size? What was the study hypothesis? Data collection: Did the participants complete the questionnaire themselves? What about the illiterate mothers? Data analysis: Was there any association between VH and maternal employment/level of education/socio-economic status? Please include this in the results/discussion. Discussion: Please discuss why with such a low VH rate, the proportion of immunised children in Mangalore is still around 77%. The study was conducted in a health facility; women who sought/received health care were most likely to demonstrate a lower level of vaccine hesitancy. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Maternal health, General Obstetrics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 09 Jul 2021 Nithin Kumar, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Mangalore, 575001, India We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. The introduction is quite lengthy. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. Sample size - please state the number of participants required based on the sample size calculation. Did this study reach its required sample size? Based on the sample size calculation, a total of 172 participants were required to be included in the study. We were able to achieve the sample size. The same has been added to the Methods section in the manuscript. What was the study hypothesis? Even though the study area has a good health system and a literacy rate that is higher than the national figures, the immunization coverage has consistently remained below 90 per cent. The study hypothesis was “Vaccine hesitancy is present in the study area”. Data collection: Did the participants complete the questionnaire themselves? What about illiterate mothers? All the participants were interviewed while they were waiting in the respective OPDs. The same has been included in the methods section of the manuscript. Data analysis: Was there any association between VH and maternal employment/level of education/socio-economic status? Please include this in the results/discussion. Crosstabulation between the presence of vaccine hesitancy and educational status, employment status and socioeconomic status is incorporated in the results and discussion section. However, no statistically significant association was observed between VH and maternal employment, level of education and socio-economic status. Discussion: Please discuss why with such a low VH rate, the proportion of immunized children in Mangalore is still around 77%. Being a health facility-based study, our finding of low VH among the study participants does not reflect the status of VH in Mangalore. Population-based studies covering a larger sample / multicentric studies would throw more evidence towards the presence of VH as a reason for a lower vaccination coverage in the study area. Also, since the study was conducted in a health facility; the women who sought/received health care were most likely to demonstrate a better health seeking behavior which is also reflected in a lower vaccine hesitancy among the participants. The study was conducted in a health facility; women who sought/received health care were most likely to demonstrate a lower level of vaccine hesitancy. Yes. we agree with the observation. View more View less Competing Interests NA reply Respond Report a concern Kalok A. Peer Review Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.31291.r82849) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-186/v1#referee-response-82849 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2021 Gowda G. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 Mar 2021 | for Version 1 Giriyanna Gowda , Department of Community Medicine, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India 0 Views copyright © 2021 Gowda G. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Comments: The introduction is too lengthy; please make it specific and concise and based on the needs of the study. In the abstract, it is mentioned that the prevalence of vaccine hesitance is 3.4 % and also that 7.6 % had refused vaccination for their child. Please clarify this. Recommendations are not based on results. Kindly specify it. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise epidemiology, clinical trials I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 09 Jul 2021 Nithin Kumar, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Mangalore, 575001, India We thank you for taking out your valuable time to review our article. We have incorporated all the changes and corrections suggested by you in the manuscript. Kindly find the response letter below. Response to the Comments: 1.The introduction is too lengthy; please make it specific and concise and based on the needs of the study. Thank you for the suggestion. We have made the introduction concise and specific, in line with the objectives of the study. 2. In the abstract, it is mentioned that the prevalence of vaccine hesitance is 3.4 % and that 7.6 % had refused vaccination for their child. Please clarify this. One of the questions in the Core vaccine hesitancy Survey tool directed towards the mothers was “Have you ever refused a vaccination for your child? Yes/No”. Only 7.6% of the study participants had refused vaccination for their child at some point of time. The prevalence of vaccine hesitancy was calculated based on the scores obtained from the Parental Attitude Towards Childhood Vaccination Questionnaire (PACV). Participants who scored between 50 -100 were vaccine hesitant. Only 3.4% of the study participants were vaccine hesitant. We have clarified it in abstract. 3. Recommendations are not based on results. Kindly specify it. Recommendations have been made specific to the conclusions drawn from the study. View more View less Competing Interests NA reply Respond Report a concern Gowda G. Peer Review Report For: Vaccine hesitancy among mothers of under-five children in Coastal South India: a facility-based cross-sectional study [version 3; peer review: 2 approved] . F1000Research 2021, 10 :186 ( https://doi.org/10.5256/f1000research.31291.r81112) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-186/v1#referee-response-81112 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });