Psychometric properties of the adapted measles vaccine hesitancy scale in Sudan

PLOS ONE RESEARCH ARTICLE Psychometric properties of the adapted measles vaccine hesitancy scale in Sudan Majdi M. Sabahelzain ID1,2*, Eve Dubé3, Mohamed Moukhyer4, Heidi J. Larson5,6, Bart van den Borne2, Hans Bosma ID7 1 Department of Public Health, School of Health Sciences, Ahfad University for Women, Omdurman, Sudan, 2 Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands, 3 Institut National de Santé Publique du Québec (INSPQ), Québec City, Québec, Canada, 4 Education Development and Quality Unit, College of Applied Medical Sciences, Jazan University, Jazan, Kingdom of Saudi Arabia, 5 Vaccine Confidence Project, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom, 6 Department of Health Metrics Sciences, University of Washington, Seattle, Washington, University of America, 7 Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 * Abstract Background OPEN ACCESS Citation: Sabahelzain MM, Dubé E, Moukhyer M, Larson HJ, van den Borne B, Bosma H (2020) Psychometric properties of the adapted measles vaccine hesitancy scale in Sudan. PLoS ONE 15(8): e0237171. https://doi.org/10.1371/journal. pone.0237171 Editor: Charles S. Wiysonge, South African Medical Research Council, SOUTH AFRICA Received: February 15, 2020 Accepted: July 21, 2020 Published: August 6, 2020 Copyright: © 2020 Sabahelzain et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. There is a need for reliable and validated tools to identify, classify, and quantify vaccine-hesitancy in low and middle-income countries, such as Sudan. We evaluated the psychometric properties of an adapted version of the measles vaccine hesitancy scale by assessing its reliability, convergent validity, and criterion validity in Sudan. The vaccine hesitancy scale (VHS) was originally developed by the WHO/SAGE Working Group of Vaccine Hesitancy. Methods A community-based survey among parents was conducted in February 2019 in Khartoum state. We conducted exploratory and confirmatory factor analysis to examine the structure of the adapted measles VHS (aMVHS). We computed Cronbach’s alphas, correlations with other vaccine hesitancy measurements including the Parental Attitude towards Childhood Vaccination (PACV) and the Vaccine Confidence Index (VCI), and performed a Mann-Whitney U test for assessing the reliability and the convergent and criterion validity, respectively. Moreover, to examine whether the aMVHS can predict the child’s vaccination status, the area under the curve (AUC) was estimated using receiver operator characteristic (ROC) curves. Results The questionnaire was completed by 500 parents. Most were women (87.2%) between the ages of 20 and 47 (M = 31.15, SD = 5.74). The factor analyses indicated that the aMVHS comprises of two factors (sub-scales): ’confidence’ and ’complacency’. The aMVHS subscales correlated weakly to moderately with the PACV and VCI scales. The area under the curve was 0.499 at most (P >0.05) and the aMVHS score did hardly differ between actually vaccinated and non-vaccinated children. PLOS ONE | https://doi.org/10.1371/journal.pone.0237171 August 6, 2020 1 / 12 PLOS ONE Psychometric Properties of the Adapted Measles Vaccine Hesitancy Scale in Sudan Conclusion Our findings underscore that the aMVHS and its confidence and complacency sub-scales are reliable and have a moderately good convergent validity. However, the aMVHS has a limitation in predicting the concurrent child’s vaccination status. More work is needed to revise and amend this aMVHS, particularly by additionally including the ’convenience’ construct and by further evaluating its validity in other contexts. 1. Introduction In 2019, the World Health Organization has named vaccine hesitancy as one of the top ten global health threats, as it contributes to low vaccination coverage in both high-income and low and middle-income countries (LMICs) [1–3]. Although the definition of “vaccine hesitancy” has been debated, the Strategic Advisory Group of Experts on vaccine hesitancy (SAGE) has defined vaccine hesitancy as the "delay in acceptance or refusal of vaccines despite availability of vaccination services. Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines." Moreover, vaccine hesitancy is influenced by some key factors defined in a model called the “3Cs”–Complacency (perceived risks of vaccine-preventable diseases are low and no vaccines are needed), Convenience (access issues and constraints), and Confidence (level of trust in a vaccin) [4–8]. The magnitude, factors, and causes of vaccine hesitancy as well as possible interventions to address it, have been studied and evaluated widely in high-income countries [9–12] with a paucity of research in LMIC [2, 13, 14]. There is no consensus on a global and standardized metric for measuring vaccine hesitancy [2, 14–18]. Even the existing ones were criticized by some researchers as not being comprehensive enough to address multiple dimensions of vaccine hesitancy [7, 8]. For instance; the Vaccine Confidence Index™ focuses on investigating the confidence component of the “3Cs” [1]. Additionally, the Parental Attitude towards Childhood Vaccination (PACV) scale, though it assesses three concepts (i.e. vaccination attitudes, beliefs about vaccine safety and effectiveness and behavior), these three concepts were considered part of the confidence construct [8]. Additionally, PACV-15 items has been criticized for being quite lengthy which may increase the parental burden [8, 19]. This study will contribute to the recognized need for more research in LMIC, bringing an Africa focus, in particular Khartoum state in Sudan, to the growing global portfolio of tools to measure vaccine hesitancy and its multiple domains. [2, 8, 13, 14] To develop a global metric for vaccine hesitancy, WHO/SAGE developed tools based on its ’3Cs’ model which includes confidence, convenience, and complacency [15]. The WHO/ SAGE recommended evaluating and researching these tools in different contexts to determine if they could be used as the basis for measuring vaccine hesitancy and be adapted to low and middle-income country settings [4, 15]. As a response to this recommendation, the Vaccine Hesitancy Scale (VHS), one of these tools which has the potential to quantify and compare vaccin (...truncated)