Development and Validation of the BELIEF Scale: A Theory-Integrated Measure of Hepatitis B Vaccination Motivation Among Health Sciences Students in Vietnam

Development and Validation of the BELIEF Scale: A Theory-Integrated Measure of Hepatitis B Vaccination Motivation Among Health Sciences Students in Vietnam | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and Validation of the BELIEF Scale: A Theory-Integrated Measure of Hepatitis B Vaccination Motivation Among Health Sciences Students in Vietnam Nguyen Thao Quyen, Ngo Thi Hai Ly, Le Thi Kim Phan, Nguyen Thi My Lam, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8989201/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Health sciences students are at increased occupational risk of hepatitis B virus infection due to early clinical exposure. Although vaccination is highly effective, uptake among healthcare trainees remains suboptimal. Existing studies often rely on ad hoc instruments and rarely integrate established behavioral theories within a validated measurement framework. This study aimed to develop and validate a theory-informed scale to assess motivational beliefs toward hepatitis B vaccination among Vietnamese health sciences students. Methods A cross-sectional instrument development and validation study was conducted among undergraduate health sciences students at a large medical university in Vietnam. Item generation was theory-driven, integrating constructs from the Health Belief Model and Protection Motivation Theory, and followed COSMIN recommendations for scale development. Content validity was assessed by expert review. Structural validity was examined using exploratory and confirmatory factor analyses. Internal consistency was evaluated using Cronbach’s alpha and composite reliability, while convergent and discriminant validity were assessed using average variance extracted and the Fornell–Larcker criterion. Results A total of 1,633 students participated. Exploratory factor analysis supported an eight-factor structure, and confirmatory factor analysis demonstrated good model fit (χ²/df = 4.82; CFI = 0.95; TLI = 0.94; RMSEA = 0.05). The final BELIEF-V30 scale showed high overall internal consistency (Cronbach’s α = 0.91). Subscale reliability ranged from 0.64 to 0.93, with lower values observed in constructs with fewer items. Convergent and discriminant validity were supported. Perceived susceptibility and perceived vulnerability converged into a unified risk appraisal construct. Conclusions The BELIEF scale is a psychometrically supported, theory-integrated instrument for assessing hepatitis B vaccination motivational beliefs among health sciences students. The scale is suitable for group-level research, educational evaluation, and public health intervention design in HBV-endemic settings. scale validation vaccine hepatitis B students Figures Figure 1 1. Introduction Vietnam remains among the countries with the highest prevalence of hepatitis B virus (HBV) infection worldwide, with adult prevalence in Southeast Asia estimated at 6–12% [ 1 ]. HBV is highly infectious and poses a significant occupational risk to healthcare workers and students engaged in clinical training [ 2 ]. Although hepatitis B vaccination has been included in Vietnam’s Expanded Program on Immunization since 2003 and is highly effective, vaccination coverage among adults and healthcare trainees remains suboptimal [ 3 – 7 ]. Health sciences students—including nursing, midwifery, laboratory sciences, anesthesia and resuscitation, rehabilitation, and medical imaging—are particularly vulnerable due to early clinical exposure and frequent contact with blood and body fluids. Behavioral theories have been widely applied to explain vaccination uptake. The Health Belief Model (HBM) conceptualizes vaccination behavior through perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy [ 8 – 10 ], and has been validated in multiple vaccination contexts, including COVID-19 vaccination in Vietnam and neighboring countries [ 11 – 13 ]. Protection Motivation Theory (PMT) extends this perspective by emphasizing threat appraisal (perceived severity and perceived vulnerability) and coping appraisal (response efficacy, self-efficacy, and response costs), providing a broader motivational framework for protective health behaviors [ 14 – 17 ]. Despite their widespread use, HBM and PMT have rarely been integrated within a single validated measurement model for vaccination beliefs. Notably, both frameworks include constructs related to perceived risk, yet conceptualize them differently. Perceived susceptibility in HBM primarily reflects a cognitive estimation of infection likelihood, whereas perceived vulnerability in PMT incorporates both probabilistic judgment and emotional threat appraisal. Whether these constructs are empirically distinguishable or converge within a unified scale remains unclear, particularly among health sciences students in endemic settings. From a psychometric perspective, this limitation is compounded by methodological gaps. Most vaccination studies have relied on adapted or ad hoc instruments, rather than scales developed according to established measurement standards. International guidelines, such as those proposed by COSMIN and DeVellis, emphasize systematic item development, content validity assessment, pilot testing, and evaluation of structural validity and internal consistency using exploratory and confirmatory factor analyses. However, few studies in Vietnam have applied these principles to the development of hepatitis B vaccination belief measures, limiting confidence in construct validity and cross-study comparability. Furthermore, no validated instrument currently exists to comprehensively assess multidimensional motivational beliefs toward hepatitis B vaccination among Vietnamese health sciences students—a population at elevated occupational risk and a key target for preventive interventions. Existing scales have primarily focused on parents, general adults, or COVID-19 vaccination contexts [ 18 – 20 ] restricting their applicability to hepatitis B prevention in healthcare training environments. Therefore, this study aimed to develop and validate a belief-based motivation scale for hepatitis B vaccination among Vietnamese health sciences students, integrating HBM and PMT constructs within a COSMIN-informed psychometric framework to ensure content validity, structural validity, and reliability. 2. Methods 2.1. Phase I: Development of belief-based motivation scale for Hepatitis B vaccination The development of the BELIEF (Beliefs Empowering Lifesaving Immunization for Eliminating Hepatitis B Fear) scale followed a systematic five-step process to ensure scientific rigor, reliability, and validity of the measurement tool. Step 1: Construction of the initial English version (BELIEF-E) BELIEF-E was developed based on a systematic review of published research on vaccination behavior as showed in Table 1 (see Additional file 1). Selection criteria required that items be grounded in HBM and PMT, directly relevant to vaccination behavior, and validated in prior studies. Items 1–11 reflected four HBM components: perceived susceptibility (KNMB), perceived severity (NT), perceived benefits (LI), and perceived barriers (RC). These were adapted from a Vietnamese parental scale [18], with personal pronouns modified from “my child” to “I” to suit student respondents. Items 12–15 incorporated two additional HBM constructs: cues to action (TD) and self-efficacy (TH), adapted from a Vietnamese COVID-19 vaccination scale [19]. Items 16–33 were derived from PMT studies in Iran [20] and China [21] addressing threat appraisal (severity – DD, vulnerability – MB) and coping appraisal (response efficacy – HQ, self-efficacy – NTBT, response cost – TT). Step 2: Translation and linguistic adaptation (BELIEF-E → BELIEF-V1) The initial English version was translated into Vietnamese using a word-for-word approach, followed by adjustments for grammar, vocabulary, and semantic clarity. Terminology such as “vaccination,” “immunization,” and “inoculation” was standardized as “tiêm chủng” (vaccination). Some items were converted from questions to statements for consistency. COVID-19 references in the original items were adapted to hepatitis B vaccination. Step 3: Pilot testing and revision (BELIEF-V1 → BELIEF-V2) The BELIEF-V1 version was piloted with 104 third- and fourth-year students to assess clarity, comprehension, logical flow, and response feasibility. Results indicated a need for restructuring item groupings and improving language precision. Adjustments produced BELIEF-V2. Step 4: Expert consultation and content refinement (BELIEF-V2 → BELIEF-V) Experts in epidemiology, health behavior, and psychometrics reviewed BELIEF-V2. Major revisions included reordering items from cognition and emotion to behavior and environment for logical flow, distinguishing between external (e.g., service access) and internal (e.g., personal decision-making) self-efficacy, and refining terminology. For example, item 6 was rephrased to include both “present and future” vaccination intention, highlighting continuity of behavior. Step 5: Finalization of BELIEF-V The finalized BELIEF-V contained 33 items across 11 theoretical constructs (HBM and PMT) as showed in Table 2 (see Additional file 2). 2.2. Phase 2: Validation of BELIEF-V Study design and participants A cross-sectional instrument development and validation study was conducted among undergraduate health sciences students (years 1–4) enrolled in clinically oriented programs at the University of Medicine and Pharmacy at Ho Chi Minh City, including nursing, midwifery, laboratory sciences, anesthesia and resuscitation, rehabilitation, and medical imaging technology. These programs involve early clinical exposure and comparable occupational risk for HBV infection. Eligible participants were aged ≥18 years, had received at least one dose of hepatitis B vaccine, and provided informed consent. Students with incomplete questionnaires or invariant responses across all items were excluded. The study was approved by the institutional ethics committee, and participation was voluntary and anonymous. Content validity Content validity was evaluated by three independent experts in epidemiology, health behavior, and psychometrics using item-level content validity indices (I-CVI) and a scale-level index (S-CVI/Ave). Items meeting recommended COSMIN thresholds (I-CVI ≥ 0.78; S-CVI ≥ 0.90) were retained for psychometric evaluation. Internal consistency (reliability) Internal consistency was evaluated using Cronbach’s alpha and composite reliability (CR), with values ≥0.70 considered acceptable at the construct level, acknowledging that lower values may occur in constructs with few items. Structural validity Structural validity was first examined using exploratory factor analysis (EFA). Prior to EFA, sampling adequacy was confirmed using the Kaiser–Meyer–Olkin (KMO) measure and Bartlett’s test of sphericity. Principal Component Analysis (PCA) with Promax rotation was employed to explore the underlying dimensional structure. Although common factor analysis methods (e.g., principal axis factoring) are often preferred for latent construct modeling, PCA was selected in this study for two reasons. First, the primary objective at this stage was data reduction and identification of a stable, interpretable factor structure in a newly developed instrument with a relatively large number of initial items. Second, PCA has been widely used in early-stage scale development studies and is considered acceptable under COSMIN when the aim includes identifying dominant components prior to confirmatory testing. The limitations of PCA for latent variable estimation were acknowledged and addressed through subsequent confirmatory factor analysis (CFA). The number of factors was determined using a combination of Kaiser’s criterion (eigenvalue > 1) and inspection of the scree plot. Items with factor loadings ≥ 0.50 and minimal cross-loadings were retained. Confirmatory factor analysis (CFA) was conducted to evaluate the fit of the factor structure identified in EFA. Model fit was assessed using multiple indices in accordance with COSMIN guidance: χ²/df (0.90), Comparative Fit Index (CFI >0.90), Tucker–Lewis Index (TLI >0.90), Root Mean Square Error of Approximation (RMSEA 0.05). EFA and CFA were conducted using the same dataset. This approach was adopted due to practical constraints related to sample allocation and to ensure adequate statistical power for both analyses. Consistent with COSMIN recommendations, this methodological choice is acknowledged as a limitation, as it may increase the risk of capitalizing on chance. The stability of the factor structure should therefore be confirmed in independent samples in future studies. Modification indices were examined to improve model fit. Correlated error terms were added only when theoretically and linguistically justifiable. Specifically, correlations were permitted between item error terms representing closely related wording or shared contextual meaning (e.g., items addressing similar aspects of vaccine effectiveness or risk perception phrased in parallel language). These correlations were interpreted as reflecting shared method variance rather than substantive latent constructs and were applied conservatively to avoid overfitting. Convergent and discriminant validity Convergent validity was assessed using average variance extracted (AVE), and discriminant validity was examined using the Fornell–Larcker criterion, consistent with COSMIN standards for construct validity Data analysis All analyses were conducted using SPSS version 20.0 and AMOS version 26.0. Statistical significance was set at p < 0.05. 3. Results 3.1. Epidemiological characteristics of study objects A total of 1633 students participated in the questionnaire. The students had an average age of 20.8 ± 1.3 years. The study participants consisted of up to 78.1% female students and 21.9% male students. The study sample included students from six participating majors: Nursing (29.1%) had the highest proportion, followed by laboratory students (23.2%) and midwifery students (15%). Students participating in the study were distributed from the first year to the fourth year, with proportions of 20.5%, 20.4%, 26.7%, and 32.4% respectively. Most (95.7%) of the students in the study were healthy; however, there were still 4.3% students who reported having underlying diseases (Table 3). Table 3. Socio-demographic characteristics of the study sample 3.2. Internal consistency (reliability) The overall scale demonstrated high internal consistency (Cronbach’s α = 0.91). At the subscale level, Cronbach’s alpha values ranged from 0.64 to 0.93 (Table 4, see Additional file 3), while CR values ranged from 0.59 to 0.93 (Table 5, see Additional file 4). Several subscales particularly those comprising two to three items, demonstrated alpha values slightly below the conventional threshold of 0.70. In line with COSMIN guidance, these subscales were considered acceptable given their limited number of items and adequate CR values. Accordingly, these constructs are regarded as provisional subscales , suitable for group-level research and exploratory applications , rather than for individual-level decision making. Future refinement through item expansion is recommended to enhance reliability. One construct (self-efficacy in coping appraisal) was represented by a single item. While single-item constructs may capture narrowly defined concepts, they preclude assessment of internal consistency and should be interpreted cautiously. This construct was retained due to its theoretical importance within PMT, but future studies should consider developing additional indicators to strengthen measurement precision. 3.3. Validity 3.2.1. Content validity Content validity assessment demonstrated complete agreement among experts. All items achieved an I-CVI of 1.00, indicating perfect expert agreement regarding item relevance. The scale-level content validity index calculated using the averaging method was 1.00 (S-CVI/Ave = 1.00), demonstrating excellent content validity. Therefore, all items were retained for subsequent psychometric analyses. 3.2.2. Structural validity EFA was initially conducted on 33 observed variables. Three items (NT1, NT2, and TD1) were excluded (Table 6, see Additional file 5), and the remaining 30 observed variables were retained for the second EFA. The KMO measure of sampling adequacy was 0.92, indicating that the data were suitable for factor analysis. Bartlett’s test of sphericity was statistically significant (p < 0.05), confirming sufficient correlations among the observed variables. The EFA identified eight factors with eigenvalues greater than 1, with the lowest eigenvalue being 1.013. The total variance explained by the extracted factors was 70.94%, exceeding the recommended threshold of 50%. The cumulative variance explained increased progressively across factors, accounting for 32.68% after the first factor, 44.09% after the second, 51.18% after the third, 55.75% after the fourth, 60.04% after the fifth, 63.94% after the sixth, 67.57% after the seventh, and reaching 70.95% after the eighth factor. Item factor loadings ranged from 0.47 to 0.91, with minimal cross-loadings, indicating satisfactory item–factor relationships. The rotated factor matrix indicated that item TD2 had a factor loading close to 0.5 showed in Table 7 (see Additional file 6); therefore, it was retained for subsequent CFA. CFA was subsequently conducted to evaluate the hypothesized eight-factor measurement model. After theoretically justified model refinement, the final model demonstrated acceptable to good fit across all indices (χ²/df = 4.82; GFI = 0.92; CFI = 0.95; TLI = 0.94; RMSEA = 0.05; PCLOSE = 0.85), supporting the structural validity of the eight-factor solution (Table 8). Figure 1. Results of the CFA analysis (after modification) 3.2.3. Convergent and discriminant validity Five constructs achieved AVE values ≥ 0.50, indicating adequate convergent validity. Although three constructs demonstrated AVE values below the recommended threshold, their CR values exceeded or approached 0.70, suggesting that the majority of variance was attributable to the latent construct rather than measurement error. Consistent with COSMIN recommendations, convergent validity was considered acceptable in these cases. Discriminant validity was supported, as the square root of AVE for each construct exceeded its correlations with other constructs, indicating satisfactory differentiation among the eight latent dimensions (Table 5, see Additional file 4). 3.4. Summary of measurement properties Overall, the BELIEF scale demonstrated adequate structural validity, good internal consistency at the total scale level, and acceptable construct validity for an early-stage, theory-integrated instrument. While several subscales should be considered provisional and one construct was measured using a single item, the scale provides a psychometrically defensible framework for assessing hepatitis B vaccination motivational beliefs at the population and group levels. 4. Discussions In this study, we developed a scale that was designed to measure HBV vaccination motivational beliefs among Vietnamese population. The current study revealed a eight-factor structure with (1) perceived effectiveness of vaccination; (2) perceived severity of hepatitis B; (3) perceived susceptibility to the disease; (4) consideration of vaccination-related costs; (5) perceived benefits of vaccination; (6) perceived self-efficacy in obtaining vaccination; (7) perceived personal barriers to vaccination; and (8) perceived environmental barriers to vaccination. The measure was developed in a multistage procedure from qualitative to quantitative data to form a local scale to evaluate Vietnamese medical students’ HBV vaccination motivational beliefs. The process yielded a conclusive 30-item assessment comprising eight distinct dimensions. The assessment displayed commendable psychometric soundness, characterized by a factor arrangement that remained consistent across samples. The average age of the students participating in the study was 20.8 ± 1.3 years, which is a stage when students begin to form a clearer awareness of personal health and disease prevention measures. At the same time, they are also at a higher risk of exposure to infectious factors due to the characteristics of collective living environments in dormitories or large study groups. These factors can directly affect the formation of beliefs and the evaluation of the effectiveness of vaccination activities, thereby helping to explain the suitability of the components in the CFA model of the scale. In addition, the sample consisted mainly of female students, which may lead to differences in vaccination beliefs and motivations between the two genders – a factor that needs to be considered in subsequent analyses. The selection of study subjects from different disciplines and spanning from first to fourth years not only reflects the diversity in personal characteristics but also helps to provide a more comprehensive view of vaccination behavior in the medical student community. Differences in living conditions, access to health information and health care services, and the level of interest in disease prevention may significantly influence the study results. Additionally, financial factors – with the majority of students (97.4%) relying on their families for education costs – may be a potential barrier to vaccination decisions. Finally, current health status and medical history play an important role in shaping perceptions of disease risk, which in turn directly impacts students’ attitudes and behaviors toward vaccination. Structural validity and theoretical integration The eight-factor structure identified through exploratory and confirmatory factor analyses provides empirical support for integrating HBM and PMT within a single measurement framework. Notably, constructs related to perceived susceptibility (HBM) and perceived vulnerability (PMT) converged empirically, forming a unified risk appraisal dimension. This finding suggests that, in the context of health sciences students in an HBV-endemic setting, probabilistic risk estimation and experiential threat perception may function as a single latent construct rather than as fully distinct dimensions. This convergence does not indicate theoretical redundancy, but rather reflects contextual integration of overlapping cognitive and affective risk perceptions during early professional training. The distinction between threat appraisal (severity and vulnerability) and coping appraisal (response efficacy, response cost, self-efficacy, benefits, and barriers) remained conceptually and empirically coherent, consistent with PMT theory [ 14 – 17 ]. In addition, separating personal barriers from environmental barriers allowed the scale to capture both individual-level and contextual constraints relevant to vaccination behavior in healthcare training environments, extending the explanatory scope of traditional HBM-based instruments [ 18 , 22 ]. Reliability and construct validity The BELIEF scale demonstrated high internal consistency at the total scale level, supporting its use as a composite measure of vaccination motivational beliefs. At the subscale level, several constructs exhibited lower Cronbach’s alpha values, particularly those comprising a small number of items. In line with COSMIN recommendations, internal consistency was therefore interpreted alongside composite reliability and structural validity rather than in isolation. The affected constructs demonstrated acceptable composite reliability and clear factor loadings, supporting their adequacy for group-level research and exploratory applications. Accordingly, these subscales are described as provisional constructs, appropriate for population-level comparisons rather than individual-level decision making. Future studies will refine these domains through item expansion and further validation. Convergent and discriminant validity results further support the construct validity of the BELIEF scale. While some constructs demonstrated AVE values below conventional thresholds, composite reliability and discriminant validity criteria were satisfied, indicating that the latent constructs were adequately represented and empirically distinguishable within the measurement model. Model refinement and methodological considerations Confirmatory factor analysis required limited model refinement through the introduction of correlated error terms between closely worded items. These refinements were theoretically justified and reflect shared wording or contextual similarity rather than substantive overlap between latent constructs. Such adjustments are consistent with COSMIN guidance when applied conservatively and transparently, and they contributed to improved model fit without altering the underlying factor structure. EFA and CFA were conducted using the same dataset, which may increase the risk of sample-specific optimization. While this approach ensured adequate statistical power, replication in independent samples is necessary to confirm the stability of the factor structure. This limitation underscores the importance of future cross-validation studies rather than detracting from the internal validity of the present findings. Generalizability and population considerations The study was conducted at a single university, which may limit generalizability to other institutions or regions. However, the inclusion of students from multiple health sciences disciplines and academic years provides heterogeneity in clinical exposure, training stage, and perceived occupational risk. These characteristics enhance the relevance of the findings to similar healthcare training settings in Vietnam and other HBV-endemic contexts. Nevertheless, future validation studies across multiple institutions and geographic regions are required to establish broader applicability and measurement invariance. Practical application and scoring guidance The BELIEF scale is intended for use in research, educational evaluation, and public health intervention design. A total BELIEF score may be used to capture overall motivational orientation toward hepatitis B vaccination at the group level. Subscale scores may be employed to identify dominant belief patterns (e.g., threat appraisal versus coping appraisal) or to inform targeted educational or policy interventions. Given the provisional nature of some subscales, interpretation should focus on comparative and population-level trends rather than individual diagnosis or risk stratification. At present, no diagnostic cut-off scores are recommended. Instead, relative comparisons across groups, time points, or intervention conditions are most appropriate. As additional validation studies are conducted, including test–retest reliability assessment and measurement invariance testing across sex, discipline, and training stage, more refined scoring and interpretive guidelines may be developed [ 23 ]. Implications and future directions The BELIEF scale addresses an important gap in vaccination research by providing a theory-informed, psychometrically evaluated instrument tailored to health sciences students in an HBV-endemic setting. Future research should focus on longitudinal validation, expansion of provisional constructs, assessment of temporal stability, and evaluation of responsiveness to intervention. These steps will further strengthen the utility of the scale for both research and practice. 5. Conclusions This study developed and validated the BELIEF scale, a theory-integrated instrument grounded in the HBM and PMT to assess motivational beliefs toward hepatitis B vaccination among health sciences students. The eight-factor structure demonstrated adequate structural validity, internal consistency, and construct validity for group-level applications. By empirically integrating perceived susceptibility and perceived vulnerability into a unified risk appraisal construct and distinguishing personal from environmental barriers, the scale offers a context-sensitive framework for understanding vaccination motivation in healthcare training settings. While some subscales should be considered provisional and further validation is warranted, the BELIEF scale provides a valuable tool for research, educational evaluation, and the design of targeted vaccination interventions in HBV-endemic contexts. Declarations Ethics approval and consent to participate This cross-sectional study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of the University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (Approval No. IRB-VN01002/IRB00010293FWA00023448; Date of approval 12/02/2025). All participants were adult medical students and were fully informed about the study objectives, procedures, potential risks, and benefits prior to participation. Written informed consent was obtained from all participants before data collection. Participation was voluntary, and participants were informed of their right to withdraw from the study at any time without any academic or personal consequences. All collected data were anonymized and handled confidentially. No identifying information was included in the analysis or publication of the results. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Authors' contributions TQ and KP conceived the study. TQ and LA designed the research methodology. TQ, HL, KP and ML coordinated data collection. TQ, HL, KP performed data analysis. TQ drafted the manuscript. TQ and LA provided critical revisions for important intellectual content. LA supervised the project. All authors read and approved the final manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank the lecturers in charge of the different student cohorts across the study programs for their general support and assistance during the implementation of this study. Funding This research was funded by the University of Medicine and Pharmacy at Ho Chi Minh City under contract numbe 234/2024/HĐ-ĐHYD, dated 10/09/2024 References Ministry of Health (Vietnam). Việt Nam thuộc nhóm 10 quốc gia có số ca viêm gan B và C cao nhất thế giới. Sức khỏe & Đời sống. 2025. Available from: https://suckhoedoisong.vn/viet-nam-thuoc-nhom-10-quoc-gia-co-so-ca-viem-gan-b-va-c-cao-nhat-the-gioi-169250320150344281.htm . Accessed 19 Feb 2026. Centers for Disease Control and Prevention. 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Health Belief Model applied to non-compliance with HPV vaccine among female university students. Public Health. 2014;128(3):268–73. https://doi.org/10.1016/j.puhe.2013.12.004 . Podsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: a critical review and recommended remedies. J Appl Psychol. 2003;88(5):879–903. https://doi.org/10.1037/0021-9010.88.5.879 . Tables Table 1, 2, 4, 5, 6 and 7 are available in the Supplementary Files section. Table 3. Socio-demographic characteristics of the study sample Characteristics Frequency (n= 1622) Proportion (%) Age (Mean ± SD) 20,8 ± 1,3 Sex Male 356 21,9 Female 1266 78,1 Religion No Yes 1280 342 78,9 21,1 Field of study Nursing 472 29,1 Midwifery Imaging Technology Anesthesia Resuscitation Rehabilitation Laboratory Techniques 244 168 215 147 376 15,0 10,4 13,3 9,1 23,2 Year of study Year 1 333 20.5 Year 2 331 20.4 Year 3 432 26.7 Year 4 526 32.4 Academic Results Excellent 90 5,5 Good 53 3,3 Quite good Average 232 697 14,3 43,0 Poor 550 33,9 Residence Dormitory 115 7.1 Boarding houses 762 47,0 Living with family/relatives 698 43.0 Private house 47 2.9 Financial resources Family 1580 97.4 University 3 0,2 Other 39 2.4 Part-time job Yes 1243 76.6 No 379 23.4 Underlying disease No 1553 95,7 Yes 4,3 Table 8. Mapping of retained BELIEF factors to theoretical frameworks Retained factor Conceptual label Theoretical origin COSMIN domain Factor 1 (HQ) Response efficacy of vaccination PMT (Coping appraisal) Structural validity Factor 2 (DD) Perceived severity of HBV PMT (Threat appraisal) Structural validity Factor 3 (MB/KNMB) Perceived vulnerability / susceptibility PMT + HBM (Integrated risk appraisal) Structural validity Factor 4 (TT) Response cost PMT (Coping appraisal) Structural validity Factor 5 (LI) Perceived benefits HBM Structural validity Factor 6 (TH) Self-efficacy HBM / PMT Structural validity Factor 7 (RCBT) Personal barriers HBM Structural validity Factor 8 (RCMT) Environmental barriers HBM Structural validity Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8989201","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606469672,"identity":"bb11521a-f3c9-4b15-91b8-a34c7fd12294","order_by":0,"name":"Nguyen Thao Quyen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYBADOQjFRrwOA2PStSQ2EK2F70aO4ePCHX/SN1w7e4DhQ9lhBoPbDfi1SN7IMTaeecYgd8PtvATGGeeAWu4cIOCiGzlm0rxtIC05Bsy8bYcZJGckENRi/huoJd0ApOUvkVrMgIYbJIC1MAK18EsQ0CJ55lkx0GHGhjOBfjnYcy6dh6AWvuPJGz/ztsnJ893OPfjgR5m1HBshLQwHOAygLB6GA2CSIDjA/gCuZRSMglEwCkYBVgAAmoRDJgQz/RcAAAAASUVORK5CYII=","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":true,"prefix":"","firstName":"Nguyen","middleName":"Thao","lastName":"Quyen","suffix":""},{"id":606469673,"identity":"d78a201d-e37c-4a93-97aa-b0116eb231f4","order_by":1,"name":"Ngo Thi Hai Ly","email":"","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Ngo","middleName":"Thi Hai","lastName":"Ly","suffix":""},{"id":606469674,"identity":"45c3a6ae-54ad-4283-a83b-244c9dc418a4","order_by":2,"name":"Le Thi Kim Phan","email":"","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Le","middleName":"Thi Kim","lastName":"Phan","suffix":""},{"id":606469675,"identity":"5b115cbb-7c9d-4e59-8b68-636edbd1d2c4","order_by":3,"name":"Nguyen Thi My Lam","email":"","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Nguyen","middleName":"Thi My","lastName":"Lam","suffix":""},{"id":606469676,"identity":"626dc40a-cd5b-43e9-92f6-562ad31b973c","order_by":4,"name":"Pham Le An","email":"","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Pham","middleName":"Le","lastName":"An","suffix":""}],"badges":[],"createdAt":"2026-02-27 14:38:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8989201/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8989201/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104817313,"identity":"e88dcd43-655c-483a-a4ef-96ff72d300e3","added_by":"auto","created_at":"2026-03-17 13:42:33","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1040197,"visible":true,"origin":"","legend":"\u003cp\u003eResults of the CFA analysis (after modification)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8989201/v1/d6539ffb0ea03cad72c1f44a.jpeg"},{"id":105728986,"identity":"66c14e02-2c36-42b4-a352-d5b6b1c1957a","added_by":"auto","created_at":"2026-03-30 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13:42:26","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":36801,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile6.docx","url":"https://assets-eu.researchsquare.com/files/rs-8989201/v1/766d19f51ff41d23de274014.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and Validation of the BELIEF Scale: A Theory-Integrated Measure of Hepatitis B Vaccination Motivation Among Health Sciences Students in Vietnam","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eVietnam remains among the countries with the highest prevalence of hepatitis B virus (HBV) infection worldwide, with adult prevalence in Southeast Asia estimated at 6\u0026ndash;12% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. HBV is highly infectious and poses a significant occupational risk to healthcare workers and students engaged in clinical training [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although hepatitis B vaccination has been included in Vietnam\u0026rsquo;s Expanded Program on Immunization since 2003 and is highly effective, vaccination coverage among adults and healthcare trainees remains suboptimal [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Health sciences students\u0026mdash;including nursing, midwifery, laboratory sciences, anesthesia and resuscitation, rehabilitation, and medical imaging\u0026mdash;are particularly vulnerable due to early clinical exposure and frequent contact with blood and body fluids.\u003c/p\u003e \u003cp\u003eBehavioral theories have been widely applied to explain vaccination uptake. The Health Belief Model (HBM) conceptualizes vaccination behavior through perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and has been validated in multiple vaccination contexts, including COVID-19 vaccination in Vietnam and neighboring countries [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Protection Motivation Theory (PMT) extends this perspective by emphasizing threat appraisal (perceived severity and perceived vulnerability) and coping appraisal (response efficacy, self-efficacy, and response costs), providing a broader motivational framework for protective health behaviors [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eDespite their widespread use, HBM and PMT have rarely been integrated within a single validated measurement model for vaccination beliefs. Notably, both frameworks include constructs related to perceived risk, yet conceptualize them differently. Perceived susceptibility in HBM primarily reflects a cognitive estimation of infection likelihood, whereas perceived vulnerability in PMT incorporates both probabilistic judgment and emotional threat appraisal. Whether these constructs are empirically distinguishable or converge within a unified scale remains unclear, particularly among health sciences students in endemic settings.\u003c/p\u003e\u003cp\u003eFrom a psychometric perspective, this limitation is compounded by methodological gaps. Most vaccination studies have relied on adapted or ad hoc instruments, rather than scales developed according to established measurement standards. International guidelines, such as those proposed by COSMIN and DeVellis, emphasize systematic item development, content validity assessment, pilot testing, and evaluation of structural validity and internal consistency using exploratory and confirmatory factor analyses. However, few studies in Vietnam have applied these principles to the development of hepatitis B vaccination belief measures, limiting confidence in construct validity and cross-study comparability.\u003c/p\u003e\u003cp\u003eFurthermore, no validated instrument currently exists to comprehensively assess multidimensional motivational beliefs toward hepatitis B vaccination among Vietnamese health sciences students\u0026mdash;a population at elevated occupational risk and a key target for preventive interventions. Existing scales have primarily focused on parents, general adults, or COVID-19 vaccination contexts [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] restricting their applicability to hepatitis B prevention in healthcare training environments.\u003c/p\u003e\u003cp\u003eTherefore, this study aimed to develop and validate a belief-based motivation scale for hepatitis B vaccination among Vietnamese health sciences students, integrating HBM and PMT constructs within a COSMIN-informed psychometric framework to ensure content validity, structural validity, and reliability.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"2. Methods","content":"\u003ch2\u003e\u003cstrong\u003e2.1. Phase I: Development\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ebelief-based motivation scale for Hepatitis B vaccination\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe development of the BELIEF (Beliefs Empowering Lifesaving Immunization for Eliminating Hepatitis B Fear) scale followed a systematic five-step process to ensure scientific rigor, reliability, and validity of the measurement tool.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 1: Construction of the initial English version (BELIEF-E)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBELIEF-E was developed based on a systematic review of published research on vaccination behavior as showed in Table 1 (see Additional file 1). Selection criteria required that items be grounded in HBM and PMT,\u0026nbsp;directly relevant to vaccination behavior, and validated in prior studies. Items 1\u0026ndash;11 reflected four HBM components: perceived susceptibility (KNMB), perceived severity (NT), perceived benefits (LI), and perceived barriers (RC). These were adapted from a Vietnamese parental scale [18], with personal pronouns modified from \u0026ldquo;my child\u0026rdquo; to \u0026ldquo;I\u0026rdquo; to suit student respondents. Items 12\u0026ndash;15 incorporated two additional HBM constructs: cues to action (TD) and self-efficacy (TH), adapted from a Vietnamese COVID-19 vaccination scale [19]. Items 16\u0026ndash;33 were derived from PMT studies in Iran [20] and China [21] addressing threat appraisal (severity \u0026ndash; DD, vulnerability \u0026ndash; MB) and coping appraisal (response efficacy \u0026ndash; HQ, self-efficacy \u0026ndash; NTBT, response cost \u0026ndash; TT).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 2: Translation and linguistic adaptation (BELIEF-E \u0026rarr; BELIEF-V1)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initial English version was translated into Vietnamese using a word-for-word approach, followed by adjustments for grammar, vocabulary, and semantic clarity. Terminology such as \u0026ldquo;vaccination,\u0026rdquo; \u0026ldquo;immunization,\u0026rdquo; and \u0026ldquo;inoculation\u0026rdquo; was standardized as \u0026ldquo;ti\u0026ecirc;m chủng\u0026rdquo; (vaccination). Some items were converted from questions to statements for consistency. COVID-19 references in the original items were adapted to hepatitis B vaccination.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStep 3: Pilot testing and revision (BELIEF-V1 \u0026rarr; BELIEF-V2)\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe BELIEF-V1 version was piloted with 104 third- and fourth-year students to assess clarity, comprehension, logical flow, and response feasibility. Results indicated a need for restructuring item groupings and improving language precision. Adjustments produced BELIEF-V2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 4: Expert consultation and content refinement (BELIEF-V2 \u0026rarr; BELIEF-V)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExperts in epidemiology, health behavior, and psychometrics reviewed BELIEF-V2. Major revisions included reordering items from cognition and emotion to behavior and environment for logical flow, distinguishing between external (e.g., service access) and internal (e.g., personal decision-making) self-efficacy, and refining terminology. For example, item 6 was rephrased to include both \u0026ldquo;present and future\u0026rdquo; vaccination intention, highlighting continuity of behavior.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 5: Finalization of BELIEF-V\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe finalized BELIEF-V contained 33 items across 11 theoretical constructs (HBM and PMT) as showed in Table 2 (see Additional file 2).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.2. Phase 2: Validation\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of BELIEF-V\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e\u003cstrong\u003eStudy design and participants\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA cross-sectional instrument development and validation study was conducted among undergraduate health sciences students (years 1\u0026ndash;4) enrolled in clinically oriented programs at the University of Medicine and Pharmacy at Ho Chi Minh City, including nursing, midwifery, laboratory sciences, anesthesia and resuscitation, rehabilitation, and medical imaging technology. These programs involve early clinical exposure and comparable occupational risk for HBV infection.\u003c/p\u003e\n\u003cp\u003eEligible participants were aged \u0026ge;18 years, had received at least one dose of hepatitis B vaccine, and provided informed consent. Students with incomplete questionnaires or invariant responses across all items were excluded. The study was approved by the institutional ethics committee, and participation was voluntary and anonymous.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eContent validity\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eContent validity was evaluated by three independent experts in epidemiology, health behavior, and psychometrics using item-level content validity indices (I-CVI) and a scale-level index (S-CVI/Ave). Items meeting recommended COSMIN thresholds (I-CVI \u0026ge; 0.78; S-CVI \u0026ge; 0.90) were retained for psychometric evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInternal consistency (reliability)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInternal consistency was evaluated using Cronbach\u0026rsquo;s alpha and composite reliability (CR), with values \u0026ge;0.70 considered acceptable at the construct level, acknowledging that lower values may occur in constructs with few items.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStructural validity\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eStructural validity was first examined using exploratory factor analysis (EFA). Prior to EFA, sampling adequacy was confirmed using the Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) measure and Bartlett\u0026rsquo;s test of sphericity. Principal Component Analysis (PCA) with Promax rotation was employed to explore the underlying dimensional structure. Although common factor analysis methods (e.g., principal axis factoring) are often preferred for latent construct modeling, PCA was selected in this study for two reasons. First, the primary objective at this stage was data reduction and identification of a stable, interpretable factor structure in a newly developed instrument with a relatively large number of initial items. Second, PCA has been widely used in early-stage scale development studies and is considered acceptable under COSMIN when the aim includes identifying dominant components prior to confirmatory testing. The limitations of PCA for latent variable estimation were acknowledged and addressed through subsequent confirmatory factor analysis (CFA). The number of factors was determined using a combination of Kaiser\u0026rsquo;s criterion (eigenvalue \u0026gt; 1) and inspection of the scree plot. Items with factor loadings \u0026ge; 0.50 and minimal cross-loadings were retained.\u003c/p\u003e\n\u003cp\u003eConfirmatory factor analysis (CFA) was conducted to evaluate the fit of the factor structure identified in EFA. Model fit was assessed using multiple indices in accordance with COSMIN guidance: \u0026chi;\u0026sup2;/df (\u0026lt;5), Goodness-of-Fit Index (GFI \u0026gt;0.90), Comparative Fit Index (CFI \u0026gt;0.90), Tucker\u0026ndash;Lewis Index (TLI \u0026gt;0.90), Root Mean Square Error of Approximation (RMSEA \u0026lt;0.06), and PCLOSE (\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003eEFA and CFA were conducted using the same dataset. This approach was adopted due to practical constraints related to sample allocation and to ensure adequate statistical power for both analyses. Consistent with COSMIN recommendations, this methodological choice is acknowledged as a limitation, as it may increase the risk of capitalizing on chance. The stability of the factor structure should therefore be confirmed in independent samples in future studies.\u003c/p\u003e\n\u003cp\u003eModification indices were examined to improve model fit. Correlated error terms were added only when theoretically and linguistically justifiable. Specifically, correlations were permitted between item error terms representing closely related wording or shared contextual meaning (e.g., items addressing similar aspects of vaccine effectiveness or risk perception phrased in parallel language). These correlations were interpreted as reflecting shared method variance rather than substantive latent constructs and were applied conservatively to avoid overfitting.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConvergent and discriminant validity\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eConvergent validity was assessed using average variance extracted (AVE), and discriminant validity was examined using the Fornell\u0026ndash;Larcker criterion, consistent with COSMIN standards for construct validity\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAll analyses were conducted using SPSS version 20.0 and AMOS version 26.0. Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1. Epidemiological characteristics of study\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eobjects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 1633 students participated in the questionnaire. The students had an average age of 20.8 \u0026plusmn; 1.3 years. The study participants consisted of up to 78.1% female students and 21.9% male students. The study sample included students from six participating majors: Nursing (29.1%) had the highest proportion, followed by laboratory students (23.2%) and midwifery students (15%). Students participating in the study were distributed from the first year to the fourth year, with proportions of 20.5%, 20.4%, 26.7%, and 32.4% respectively. Most (95.7%) of the students in the study were healthy; however, there were still 4.3% students who reported having underlying diseases (Table 3).\u003c/p\u003e\n\u003ch3\u003eTable 3. Socio-demographic characteristics of the study sample\u003c/h3\u003e\n\u003ch2\u003e\u003cstrong\u003e3.2.\u0026nbsp;Internal consistency (reliability)\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe overall scale demonstrated high internal consistency (Cronbach\u0026rsquo;s \u0026alpha; = 0.91). At the subscale level, Cronbach\u0026rsquo;s alpha values ranged from 0.64 to 0.93 (Table\u0026nbsp;4, see Additional file 3), while CR values ranged from 0.59 to 0.93 (Table\u0026nbsp;5, see Additional file 4).\u003c/p\u003e\n\u003cp\u003eSeveral subscales particularly those comprising two to three items, demonstrated alpha values slightly below the conventional threshold of 0.70. In line with COSMIN guidance, these subscales were considered acceptable given their limited number of items and adequate CR values. Accordingly, these constructs are regarded as \u003cstrong\u003eprovisional subscales\u003c/strong\u003e, suitable for \u003cstrong\u003egroup-level research and exploratory applications\u003c/strong\u003e, rather than for individual-level decision making. Future refinement through item expansion is recommended to enhance reliability.\u003c/p\u003e\n\u003cp\u003eOne construct (self-efficacy in coping appraisal) was represented by a single item. While single-item constructs may capture narrowly defined concepts, they preclude assessment of internal consistency and should be interpreted cautiously. This construct was retained due to its theoretical importance within PMT, but future studies should consider developing additional indicators to strengthen measurement precision.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e3.3.\u0026nbsp;Validity\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e\u003cstrong\u003e3.2.1. Content validity\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eContent validity assessment demonstrated complete agreement among experts. All items achieved an I-CVI of 1.00, indicating perfect expert agreement regarding item relevance. The scale-level content validity index calculated using the averaging method was 1.00 (S-CVI/Ave = 1.00), demonstrating excellent content validity. Therefore, all items were retained for subsequent psychometric analyses.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e3.2.2.\u0026nbsp; \u0026nbsp;Structural validity\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eEFA was initially conducted on 33 observed variables. Three items (NT1, NT2, and TD1) were excluded (Table 6, see Additional file 5), and the remaining 30 observed variables were retained for the second EFA. The KMO measure of sampling adequacy was 0.92, indicating that the data were suitable for factor analysis. Bartlett\u0026rsquo;s test of sphericity was statistically significant (p \u0026lt; 0.05), confirming sufficient correlations among the observed variables.\u003c/p\u003e\n\u003cp\u003eThe EFA identified eight factors with eigenvalues greater than 1, with the lowest eigenvalue being 1.013. The total variance explained by the extracted factors was 70.94%, exceeding the recommended threshold of 50%. The cumulative variance explained increased progressively across factors, accounting for 32.68% after the first factor, 44.09% after the second, 51.18% after the third, 55.75% after the fourth, 60.04% after the fifth, 63.94% after the sixth, 67.57% after the seventh, and reaching 70.95% after the eighth factor. Item factor loadings ranged from 0.47 to 0.91, with minimal cross-loadings, indicating satisfactory item\u0026ndash;factor relationships. The rotated factor matrix indicated that item TD2 had a factor loading close to 0.5 showed in Table 7 (see Additional file 6); therefore, it was retained for subsequent CFA.\u003c/p\u003e\n\u003cp\u003eCFA was subsequently conducted to evaluate the hypothesized eight-factor measurement model. After theoretically justified model refinement, the final model demonstrated acceptable to good fit across all indices (\u0026chi;\u0026sup2;/df = 4.82; GFI = 0.92; CFI = 0.95; TLI = 0.94; RMSEA = 0.05; PCLOSE = 0.85), supporting the structural validity of the eight-factor solution (Table 8).\u003c/p\u003e\n\u003cp\u003eFigure 1. Results of the CFA analysis (after modification)\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e3.2.3. Convergent and discriminant validity\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eFive constructs achieved AVE values \u0026ge; 0.50, indicating adequate convergent validity. Although three constructs demonstrated AVE values below the recommended threshold, their CR values exceeded or approached 0.70, suggesting that the majority of variance was attributable to the latent construct rather than measurement error. Consistent with COSMIN recommendations, convergent validity was considered acceptable in these cases.\u003c/p\u003e\n\u003cp\u003eDiscriminant validity was supported, as the square root of AVE for each construct exceeded its correlations with other constructs, indicating satisfactory differentiation among the eight latent dimensions (Table 5, see Additional file 4).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e3.4. Summary of measurement properties\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOverall, the BELIEF scale demonstrated adequate structural validity, good internal consistency at the total scale level, and acceptable construct validity for an early-stage, theory-integrated instrument. While several subscales should be considered provisional and one construct was measured using a single item, the scale provides a psychometrically defensible framework for assessing hepatitis B vaccination motivational beliefs at the population and group levels.\u003c/p\u003e"},{"header":"4. Discussions","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIn this study, we developed a scale that was designed to measure HBV vaccination motivational beliefs among Vietnamese population. The current study revealed a eight-factor structure with (1) perceived effectiveness of vaccination; (2) perceived severity of hepatitis B; (3) perceived susceptibility to the disease; (4) consideration of vaccination-related costs; (5) perceived benefits of vaccination; (6) perceived self-efficacy in obtaining vaccination; (7) perceived personal barriers to vaccination; and (8) perceived environmental barriers to vaccination. The measure was developed in a multistage procedure from qualitative to quantitative data to form a local scale to evaluate Vietnamese medical students\u0026rsquo; HBV vaccination motivational beliefs. The process yielded a conclusive 30-item assessment comprising eight distinct dimensions. The assessment displayed commendable psychometric soundness, characterized by a factor arrangement that remained consistent across samples.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe average age of the students participating in the study was 20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 years, which is a stage when students begin to form a clearer awareness of personal health and disease prevention measures. At the same time, they are also at a higher risk of exposure to infectious factors due to the characteristics of collective living environments in dormitories or large study groups. These factors can directly affect the formation of beliefs and the evaluation of the effectiveness of vaccination activities, thereby helping to explain the suitability of the components in the CFA model of the scale. In addition, the sample consisted mainly of female students, which may lead to differences in vaccination beliefs and motivations between the two genders \u0026ndash; a factor that needs to be considered in subsequent analyses. The selection of study subjects from different disciplines and spanning from first to fourth years not only reflects the diversity in personal characteristics but also helps to provide a more comprehensive view of vaccination behavior in the medical student community. Differences in living conditions, access to health information and health care services, and the level of interest in disease prevention may significantly influence the study results. Additionally, financial factors \u0026ndash; with the majority of students (97.4%) relying on their families for education costs \u0026ndash; may be a potential barrier to vaccination decisions. Finally, current health status and medical history play an important role in shaping perceptions of disease risk, which in turn directly impacts students\u0026rsquo; attitudes and behaviors toward vaccination.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStructural validity and theoretical integration\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe eight-factor structure identified through exploratory and confirmatory factor analyses provides empirical support for integrating HBM and PMT within a single measurement framework. Notably, constructs related to perceived susceptibility (HBM) and perceived vulnerability (PMT) converged empirically, forming a unified risk appraisal dimension. This finding suggests that, in the context of health sciences students in an HBV-endemic setting, probabilistic risk estimation and experiential threat perception may function as a single latent construct rather than as fully distinct dimensions. This convergence does not indicate theoretical redundancy, but rather reflects contextual integration of overlapping cognitive and affective risk perceptions during early professional training.\u003c/p\u003e \u003cp\u003eThe distinction between threat appraisal (severity and vulnerability) and coping appraisal (response efficacy, response cost, self-efficacy, benefits, and barriers) remained conceptually and empirically coherent, consistent with PMT theory [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In addition, separating personal barriers from environmental barriers allowed the scale to capture both individual-level and contextual constraints relevant to vaccination behavior in healthcare training environments, extending the explanatory scope of traditional HBM-based instruments [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eReliability and construct validity\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe BELIEF scale demonstrated high internal consistency at the total scale level, supporting its use as a composite measure of vaccination motivational beliefs. At the subscale level, several constructs exhibited lower Cronbach\u0026rsquo;s alpha values, particularly those comprising a small number of items. In line with COSMIN recommendations, internal consistency was therefore interpreted alongside composite reliability and structural validity rather than in isolation. The affected constructs demonstrated acceptable composite reliability and clear factor loadings, supporting their adequacy for group-level research and exploratory applications. Accordingly, these subscales are described as provisional constructs, appropriate for population-level comparisons rather than individual-level decision making. Future studies will refine these domains through item expansion and further validation.\u003c/p\u003e \u003cp\u003eConvergent and discriminant validity results further support the construct validity of the BELIEF scale. While some constructs demonstrated AVE values below conventional thresholds, composite reliability and discriminant validity criteria were satisfied, indicating that the latent constructs were adequately represented and empirically distinguishable within the measurement model.\u003c/p\u003e \u003cp\u003e \u003cb\u003eModel refinement and methodological considerations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eConfirmatory factor analysis required limited model refinement through the introduction of correlated error terms between closely worded items. These refinements were theoretically justified and reflect shared wording or contextual similarity rather than substantive overlap between latent constructs. Such adjustments are consistent with COSMIN guidance when applied conservatively and transparently, and they contributed to improved model fit without altering the underlying factor structure.\u003c/p\u003e \u003cp\u003eEFA and CFA were conducted using the same dataset, which may increase the risk of sample-specific optimization. While this approach ensured adequate statistical power, replication in independent samples is necessary to confirm the stability of the factor structure. This limitation underscores the importance of future cross-validation studies rather than detracting from the internal validity of the present findings.\u003c/p\u003e \u003cp\u003e \u003cb\u003eGeneralizability and population considerations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study was conducted at a single university, which may limit generalizability to other institutions or regions. However, the inclusion of students from multiple health sciences disciplines and academic years provides heterogeneity in clinical exposure, training stage, and perceived occupational risk. These characteristics enhance the relevance of the findings to similar healthcare training settings in Vietnam and other HBV-endemic contexts. Nevertheless, future validation studies across multiple institutions and geographic regions are required to establish broader applicability and measurement invariance.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePractical application and scoring guidance\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe BELIEF scale is intended for use in research, educational evaluation, and public health intervention design. A total BELIEF score may be used to capture overall motivational orientation toward hepatitis B vaccination at the group level. Subscale scores may be employed to identify dominant belief patterns (e.g., threat appraisal versus coping appraisal) or to inform targeted educational or policy interventions. Given the provisional nature of some subscales, interpretation should focus on comparative and population-level trends rather than individual diagnosis or risk stratification.\u003c/p\u003e \u003cp\u003eAt present, no diagnostic cut-off scores are recommended. Instead, relative comparisons across groups, time points, or intervention conditions are most appropriate. As additional validation studies are conducted, including test\u0026ndash;retest reliability assessment and measurement invariance testing across sex, discipline, and training stage, more refined scoring and interpretive guidelines may be developed [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications and future directions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe BELIEF scale addresses an important gap in vaccination research by providing a theory-informed, psychometrically evaluated instrument tailored to health sciences students in an HBV-endemic setting. Future research should focus on longitudinal validation, expansion of provisional constructs, assessment of temporal stability, and evaluation of responsiveness to intervention. These steps will further strengthen the utility of the scale for both research and practice.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis study developed and validated the BELIEF scale, a theory-integrated instrument grounded in the HBM and PMT to assess motivational beliefs toward hepatitis B vaccination among health sciences students. The eight-factor structure demonstrated adequate structural validity, internal consistency, and construct validity for group-level applications. By empirically integrating perceived susceptibility and perceived vulnerability into a unified risk appraisal construct and distinguishing personal from environmental barriers, the scale offers a context-sensitive framework for understanding vaccination motivation in healthcare training settings. While some subscales should be considered provisional and further validation is warranted, the BELIEF scale provides a valuable tool for research, educational evaluation, and the design of targeted vaccination interventions in HBV-endemic contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of the University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (Approval No. IRB-VN01002/IRB00010293FWA00023448; Date of approval 12/02/2025).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants were adult medical students and were fully informed about the study objectives, procedures, potential risks, and benefits prior to participation. Written informed consent was obtained from all participants before data collection. Participation was voluntary, and participants were informed of their right to withdraw from the study at any time without any academic or personal consequences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll collected data were anonymized and handled confidentially. No identifying information was included in the analysis or publication of the results.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTQ and KP conceived the study. TQ and LA designed the research methodology. TQ, HL, KP and ML coordinated data collection. TQ, HL, KP performed data analysis. TQ drafted the manuscript. TQ and LA provided critical revisions for important intellectual content. LA supervised the project. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the lecturers in charge of the different student cohorts across the study programs for their general support and assistance during the implementation of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the University of Medicine and Pharmacy at Ho Chi Minh City under contract numbe 234/2024/HĐ-ĐHYD, dated 10/09/2024\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health (Vietnam). Việt Nam thuộc nh\u0026oacute;m 10 quốc gia c\u0026oacute; số ca vi\u0026ecirc;m gan B v\u0026agrave; C cao nhất thế giới. 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Vaccines. 2021;9(4):380. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/vaccines9040380\u003c/span\u003e\u003cspan address=\"10.3390/vaccines9040380\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonadiki EM, Jim\u0026eacute;nez-Garc\u0026iacute;a R, Hern\u0026aacute;ndez-Barrera V, et al. Health Belief Model applied to non-compliance with HPV vaccine among female university students. Public Health. 2014;128(3):268\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.puhe.2013.12.004\u003c/span\u003e\u003cspan address=\"10.1016/j.puhe.2013.12.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePodsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: a critical review and recommended remedies. J Appl Psychol. 2003;88(5):879\u0026ndash;903. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/0021-9010.88.5.879\u003c/span\u003e\u003cspan address=\"10.1037/0021-9010.88.5.879\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1, 2, 4, 5, 6 and 7 are available in the Supplementary Files section.\u003c/p\u003e\n\u003ch3\u003eTable 3. Socio-demographic characteristics of the study sample\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"615\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u0026nbsp;(n= 1622)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eAge (Mean \u0026plusmn; SD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e20,8 \u0026plusmn; 1,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e21,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e1266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e78,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e1280\u003c/p\u003e\n \u003cp\u003e342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e78,9\u003c/p\u003e\n \u003cp\u003e21,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 615px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eField of study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eNursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e29,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eMidwifery\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eImaging Technology\u003c/p\u003e\n \u003cp\u003eAnesthesia Resuscitation Rehabilitation\u003c/p\u003e\n \u003cp\u003eLaboratory Techniques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e244\u003c/p\u003e\n \u003cp\u003e168\u003c/p\u003e\n \u003cp\u003e215\u003c/p\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003cp\u003e376\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e15,0\u003c/p\u003e\n \u003cp\u003e10,4\u003c/p\u003e\n \u003cp\u003e13,3\u003c/p\u003e\n \u003cp\u003e9,1\u003c/p\u003e\n \u003cp\u003e23,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear of study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eYear 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eYear 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e331\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eYear 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e432\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eYear 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e32.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 615px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcademic Results\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e5,5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Quite good\u003c/p\u003e\n \u003cp\u003eAverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e232\u003c/p\u003e\n \u003cp\u003e697\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e14,3\u003c/p\u003e\n \u003cp\u003e43,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e550\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e33,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 615px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eDormitory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eBoarding houses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e47,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eLiving with family/relatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e698\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e43.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePrivate house\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinancial resources\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eFamily\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e1580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e97.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 615px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePart-time job\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e1243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e76.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e23.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 615px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnderlying disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e1553\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e95,7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch4\u003eTable 8. Mapping of retained BELIEF factors to theoretical frameworks\u003c/h4\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRetained factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eConceptual label\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTheoretical origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCOSMIN domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactor 1 (HQ)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eResponse efficacy of vaccination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePMT (Coping appraisal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStructural validity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactor 2 (DD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePerceived severity of HBV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePMT (Threat appraisal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStructural validity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactor 3 (MB/KNMB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePerceived vulnerability / susceptibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePMT + HBM (Integrated risk appraisal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStructural validity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactor 4 (TT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eResponse cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePMT (Coping appraisal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStructural validity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactor 5 (LI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePerceived benefits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHBM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStructural validity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactor 6 (TH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSelf-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHBM / PMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStructural validity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactor 7 (RCBT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePersonal barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHBM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStructural validity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFactor 8 (RCMT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEnvironmental barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHBM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStructural validity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"scale validation, vaccine, hepatitis B, students","lastPublishedDoi":"10.21203/rs.3.rs-8989201/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8989201/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealth sciences students are at increased occupational risk of hepatitis B virus infection due to early clinical exposure. Although vaccination is highly effective, uptake among healthcare trainees remains suboptimal. Existing studies often rely on ad hoc instruments and rarely integrate established behavioral theories within a validated measurement framework. This study aimed to develop and validate a theory-informed scale to assess motivational beliefs toward hepatitis B vaccination among Vietnamese health sciences students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional instrument development and validation study was conducted among undergraduate health sciences students at a large medical university in Vietnam. Item generation was theory-driven, integrating constructs from the Health Belief Model and Protection Motivation Theory, and followed COSMIN recommendations for scale development. Content validity was assessed by expert review. Structural validity was examined using exploratory and confirmatory factor analyses. Internal consistency was evaluated using Cronbach\u0026rsquo;s alpha and composite reliability, while convergent and discriminant validity were assessed using average variance extracted and the Fornell\u0026ndash;Larcker criterion.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 1,633 students participated. Exploratory factor analysis supported an eight-factor structure, and confirmatory factor analysis demonstrated good model fit (χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;4.82; CFI\u0026thinsp;=\u0026thinsp;0.95; TLI\u0026thinsp;=\u0026thinsp;0.94; RMSEA\u0026thinsp;=\u0026thinsp;0.05). The final BELIEF-V30 scale showed high overall internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.91). Subscale reliability ranged from 0.64 to 0.93, with lower values observed in constructs with fewer items. Convergent and discriminant validity were supported. Perceived susceptibility and perceived vulnerability converged into a unified risk appraisal construct.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe BELIEF scale is a psychometrically supported, theory-integrated instrument for assessing hepatitis B vaccination motivational beliefs among health sciences students. The scale is suitable for group-level research, educational evaluation, and public health intervention design in HBV-endemic settings.\u003c/p\u003e","manuscriptTitle":"Development and Validation of the BELIEF Scale: A Theory-Integrated Measure of Hepatitis B Vaccination Motivation Among Health Sciences Students in Vietnam","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-17 13:40:01","doi":"10.21203/rs.3.rs-8989201/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"35359a89-9f32-4f73-8902-a47aacd835cf","owner":[],"postedDate":"March 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T07:13:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-17 13:40:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8989201","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8989201","identity":"rs-8989201","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}