Editorial: Measuring vaccination perception, confidence, and uptake: advancing instrument development and validation

Abstract

Two contributions in this Research Topic directly advance the measurement science that motivated this Topic. Subramaniam et al. ground the development of a new general measure of adult vaccine hesitancy for U.S. adults in the 3C framework, reporting content and face validity findings, including a content validity index derived from expert panel review, for an instrument intended to capture hesitancy across vaccine types rather than a single indication. Meiklejohn et al. report the development and psychometric evaluation of the Vaccine Hesitancy and Perception Scale toward COVID-19 vaccination (VHAPS-CV19), employing principal axis factoring with varimax rotation to derive a two-factor structure that distinguishes a hesitancy factor (confidence, complacency, and convenience) from a perception-and-trust factor (perceived benefit, barrier, susceptibility, severity, and trust), together with internal consistency estimates for each subscale. Together, the two studies trace the stages that valid measurement of a construct this complex demands, from item generation and content validity through factor structure and reliability testing, and they leave the field with two complementary tools, one general-purpose and one vaccine-specific, for future validation and cross-cultural adaptation work.Several contributions in this Topic examine hesitancy and uptake among healthcare workers, a population whose own vaccination behavior and patient communication directly shape public confidence. Zhang et al. investigated uptake, willingness, and practices toward seasonal influenza vaccination among healthcare workers in China using a cross-sectional design. Lien et al. similarly employed a cross-sectional survey to explore attitudes toward COVID-19 vaccination among healthcare workers at a national infectious disease center in Singapore, while Aksoy et al. surveyed community pharmacists in Türkiye regarding their knowledge, attitudes, and barriers toward vaccination, extending the focus to frontline advocates outside the hospital setting. Heinze et al. took a distinct, qualitative approach, interviewing healthcare workers at a London hospital to identify barriers and facilitators to measles vaccination uptake; this design complements the quantitative work elsewhere in the Topic, surfacing workplace, informational, and interpersonal factors that structured surveys tend to miss.A second cluster of contributions addresses hesitancy and uptake determinants in community and general-population samples, extending the scope of this Topic beyond influenza and COVID-19 to additional vaccine types and life stages. Rounding out the collection, Ali et al. provide a narrative review of enablers and barriers to influenza vaccine uptake among healthcare workers in Gulf Cooperation Council countries, synthesizing evidence from a regional context that is comparatively underrepresented in the vaccine hesitancy literature relative to North America, Europe, and East Asia. Xu et al. contribute a distinct but complementary perspective, presenting a multivariate analysis of risk factors for adverse events following rabies vaccination using real-world data. This work centers on vaccine safety rather than perception, but it is a reminder that confidence in vaccination rests on lived experience with tolerability as much as on attitudes and access, and that perception-focused instruments are best read alongside pharmacovigilance data.A few patterns stand out across this collection (Figure 1; Table 1). Geographically, contributions concentrate in China (six studies), with additional representation from the United States, Singapore, Türkiye, Vietnam, the United Kingdom, and the Gulf Cooperation Council region; populations in Sub-Saharan Africa, South Asia, and Latin America are absent, which limits how far these findings generalize and points to a direction for future Research Topics. Methodologically, most contributions rely on cross-sectional, self-report surveys. These designs are useful for generating hypotheses about correlates of hesitancy, but they cannot establish temporal precedence between attitude and behavior, and they remain vulnerable to social desirability and recall bias. Only one contribution employed qualitative interview methods, and none employed a longitudinal or experimental design; this concentration of designs mirrors the broader hesitancy literature and marks a gap that future work should close.Taken together, the contributions to this Research Topic make clear that vaccine decision-making has many layers. Hesitancy and confidence are shaped at once by individual psychology, professional role, cultural context, service accessibility, and direct experience with vaccine safety. The instrument development studies respond to a real methodological gap: the field needs measurement tools that are psychometrically sound and adaptable across populations. The determinant studies argue the opposite case for context. Findings from healthcare workers in the Gulf region, older adults in western China, and pharmacists in Türkiye are not interchangeable; each offers insight for the setting studied rather than a universal account of vaccine hesitancy.A few gaps remain for future research. Cross-cultural validation of the instruments introduced here, including measurement invariance testing and comparison against benchmarks such as the WHO SAGE Vaccine Hesitancy Scale (2), would strengthen confidence in their applicability across populations. Longitudinal designs tracking how measured hesitancy or confidence relates to actual vaccination behavior over time, rather than to intention alone, would help close the well-documented gap between attitudinal measurement and uptake outcomes. Greater use of qualitative and mixed-methods designs, alongside the cross-sectional surveys predominant here, would help clarify mechanisms that quantitative models identify but cannot fully explain. Finally, as vaccine platforms and communication environments evolve, measurement tools will need periodic re-validation to remain sensitive to emerging determinants of hesitancy.