Validation of the Arabic Translation of the Vaccination Attitudes Examination (VAX) Scale

"Given that vaccine hesitancy hampers the adoption of vaccines, understanding and measuring it are crucial for predicting vaccination behaviors and developing effective public health campaigns to ensure the success of vaccination efforts."

Multiple studies conducted globally to understand vaccine hesitancy have revealed various reasons for refusing vaccines. However, the availability of concise and valid instruments for measuring vaccination attitudes across different countries or populations is limited. The Vaccination Attitudes Examination (VAX) scale, which is designed to assess vaccination hesitancy, has been validated in more than 15 languages. To gain a clearer understanding of vaccine hesitancy attitudes in Saudi Arabia and to be able to compare hesitancy rates across different Arabic-speaking countries, as well as between Arabic-speaking and other countries worldwide, this study aimed to translate and validate the VAX scale in the Arabic language.

The VAX scale consists of 12 statements covering 4 subscales: (i) mistrust of vaccine benefits, (ii) worries over unforeseen future effects, (iii) concerns about commercial profiteering, and (iv) preference for natural immunity. Participants express their level of agreement with each statement using a 6-point Likert scale, where 1 signifies complete disagreement and 6 signifies complete agreement.

For the study, VAX was translated from Danish to Arabic following the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcome Measures. (The fact that the Arabic translation of the VAX scale was done not directly from the original English but from a validated Danish version was driven by practical considerations, as the translation took place in Denmark as part of another study comparing vaccination hesitancy between the native population and Arabic-speaking minorities in Denmark. It's worth noting that the Danish VAX, translated from the original English, exhibited a good structure and construct validity, mitigating this limitation to some extent.) The translated VAX was distributed to the citizens of Saudi Arabia in March 2023 through an online survey system and the authors' networks.

Responses from 164 participants who fully answered the questionnaire were analysed. The researchers confirmed a well-fit 4-factor structure. All items loaded well with their factors: standardised regression weight values ranged from 0.69 to 0.96. Correlations between the 4 factors ranged from 0.47 to 0.79. Cronbach α ranged from 0.874 to 0.930. As expected, the mean scores of all subscales were higher in those unvaccinated (against COVID-19) compared to those who were fully vaccinated as well as those fully vaccinated with a booster dose (p < 0.05). The researchers explain that the underlying factors influencing vaccine hesitancy and acceptance are thought to be similar for all vaccines, making their "choice of COVID-19 vaccination status suitable for known-group validity tests. Furthermore, the reliability of answers regarding COVID-19 vaccination status is likely to be better compared to potential responses to a question about vaccination status with other vaccines, namely due to the recent pandemic and a better recall of vaccination behaviors."

In conclusion: "The Arabic translation of the VAX exhibited a well-defined factorial structure with good internal consistency reliability and known-group validity. It is a valuable tool for measuring vaccination hesitancy in Arabic-speaking countries or populations, enabling the comparison of vaccine hesitancy across different countries and cultures."