Cultural adaptation of the 5c scale of antecedents of vaccination to assess vaccination behaviour in Pakistan

Abstract

This research study explored psychological factors that contribute to vaccine hesitancy among the Pakistani population, translating a standard vaccine hesitancy scale into Urdu language and utilizing it to examine its cultural adaptation and reception. The 5C scale is a validated tool to assess five psychological factors related to vaccination- Confidence, Complacency, Constraints, Calculation and Collective Responsibility. A mixed-method approach was employed, which included population based quantitative surveys of the 5C Scale, Think-Aloud sessions to assess questionnaire usability and suitability, and focus group discussions to evaluate face validity and review of translated items within an expert group. Age of questionnaire evaluation participants (n=26) ranged between 18 to 75 years; 61.5% were females, 38.5% were Government of Pakistan’s employees and 26.9% were housewives. Descriptive results showed that 76.9% of participants received Covid-19 vaccine recently; 61.5% received it by choice and 15.4% reported they received the Covid-19 vaccine to avoid Government restrictions. 9 participants participated in the focus group due to their experience of the vaccination process in Pakistan. Participants mean scores of 5C constructs align with their vaccination behaviour scores, it shows that the constructs effectively predict or explain participants' decisions to get vaccinated based on their attitudes and perceptions. Three of the five subscales in the 5C(PK) questionnaire, Confidence, Constraints, and Calculations, met the criterion for internal consistency (Cronbach’s alpha ≥ 0.7) whereas, the Complacency and Collective Responsibility subscales did not meet this threshold in the population sample. This suggests that the items within these sub-scales may not be consistently measuring the intended constructs. There may be variability in how participants interpret or respond to these items. This deviated from expectations in previous literature. Correlation analysis of population data revealed the strength and direction of the linear relationships between five constructs of vaccination hesitancy using Pearson's correlation analysis in the sample. A strong negative correlation between Confidence and Complacency, aligning with previous research highlights the crucial role of Confidence in shaping vaccine attitudes. Think-Aloud and qualitative study revealed challenges in comprehending questions, highlighting the importance of culturally sensitive survey design. Expert Focus group discussions indicated generally positive attitudes of vaccination acceptance in Pakistan during COVID-19, with suggestions for cultural adaptations to enhance the 5C Scale's relevance. Participants generally validated significance of 5C constructs Confidence, Complacency, Constraints, Calculation, and Collective Responsibility in shaping vaccination behaviour, emphasizing trust in the Pakistan healthcare system. In conclusion, this study provides essential insights into the need for cultural adaptation of the 5C Scale for use in Pakistan. The study findings support the predictive capability of 5C constructs in determining vaccination behaviour among the Pakistani population. The knowledge gained opens avenues for further research and validation, potentially offering a tool to understand and address vaccine hesitancy in Pakistan in future.