Knowledge, Attitude, and Practice towards Influenza Vaccination among Older Adults in Southern China during the COVID-19 Pandemic

Round 1

Reviewer 1 Report

This article has a sociological character. I positively assess the work as a whole, I would like to make a number of comments.

1. In recent years 2020-22, influenza vaccination coverage in the world has not been fully disclosed. The authors indicate individual countries (England, Scotland, USA). There is no information on the countries of the EU, Central Asia, Transcaucasia, Russia.

2. Authors should be given information about the composition of actual influenza vaccines recommended by WHO.

3. The authors should have mentioned the high variability of influenza viruses, which is why vaccination is so important. People who have already received the vaccine should understand that immunity is not lifelong.

4. The study was conducted at the beginning of the flu season, which somewhat reduces its value.

Author Response

This article has a sociological character. I positively assess the work as a whole, I would like to make a number of comments.

We appreciate your valuable and useful suggestions.

1. In recent years 2020-22, influenza vaccination coverage in the world has not been fully disclosed. The authors indicate individual countries (England, Scotland, USA). There is no information on the countries of the EU, Central Asia, Transcaucasia, Russia.

Response 1: We intended to compare available influenza vaccination coverages in some representative developed countries and regions with that of China. We have added the latest reported coverages among the elderly in France, and Russia in line 55-56.

2. Authors should be given information about the composition of actual influenza vaccines recommended by WHO.

Response 2: We have added the information about the composition of actual influenza vaccines recommended by WHO in line 36.

3. The authors should have mentioned the high variability of influenza viruses, which is why vaccination is so important. People who have already received the vaccine should understand that immunity is not lifelong.

Response 3: We have added this point in line 34.

4. The study was conducted at the beginning of the flu season, which somewhat reduces its value.

Response 4: Yes. We have mentioned this limitation in our study. We conducted the survey at the beginning of the 2021 flu season, but the survey asked participants about the practice of influenza vaccination as our main outcome which focused on actions before the interview time and in the specific 2020 influenza season.

 

Reviewer 2 Report

The authors report on an interesting cross-sectional study about Knowledge, attitude, and practice towards influenza vaccination among older adults in China.

The topic is timely with potentially useful implications. However, I feel that the quality of the report needs to be improved, as I will outline in detail below.

 

1)    Please explain whether the survey used to assess knowledge, attitude and practice is validated. The validation processes should have been completed using a representative sample, demonstrating adequate reliability and validity. 

2)    Tables 4-5-6 are not so easy to read. Consider using another type of table or less data within those tables.

3)    In Table 8 and multivariate regression, consider using trend analysis p, where applicable, for ordinal variables.

4)    In the discussion section, be careful to use the sentence “it is urgent to promote influenza and influenza vaccination-related information in China, especially for risky populations, including older adults, pregnant women, children aged between 6 months to 5 years, individuals with chronic diseases as well as healthcare workers”, because it is unclear whether this is a study finding (which only analyzes individuals over the age of 65) or just a quote.

5)    The conclusions could be improved by focusing on knowledge, attitude and practice in older adults. 

 

 

Author Response

The authors report on an interesting cross-sectional study about Knowledge, attitude, and practice towards influenza vaccination among older adults in China.

The topic is timely with potentially useful implications. However, I feel that the quality of the report needs to be improved, as I will outline in detail below.

We appreciate your valuable and useful suggestions.

1)    Please explain whether the survey used to assess knowledge, attitude and practice is validated. The validation processes should have been completed using a representative sample, demonstrating adequate reliability and validity. 

Response 1: Yes, we have validated the survey and detailed information has been added in line 96. Before this questionnaire was made available to all participants, a pilot study was conducted in a small sample of older participants (n=30) to ensure that the questionnaire was easily understandable and completed.

2)    Tables 4-5-6 are not so easy to read. Consider using another type of table or less data within those tables.

Response 2: We have revised Table 4-5-6.

3)    In Table 8 and multivariate regression, consider using trend analysis p, where applicable, for ordinal variables.

Response 3: Thank you for your suggestions. Multivariate regression models were used in two groups of participants with two references groups respectively. Considering many variables being binary in our model along, with a binary dependent variable, conducting trend analysis is not applicable due to the absence of temporal progression. For the three-category variables, trend analysis is not imperative as the existing OR values adequately capture the changes in the association strength with increasing levels of the independent variables.

4)    In the discussion section, be careful to use the sentence “it is urgent to promote influenza and influenza vaccination-related information in China, especially for risky populations, including older adults, pregnant women, children aged between 6 months to 5 years, individuals with chronic diseases as well as healthcare workers”, because it is unclear whether this is a study finding (which only analyzes individuals over the age of 65) or just a quote.

Response 4: We have revised this sentence in line 374-375.

5)    The conclusions could be improved by focusing on knowledge, attitude and practice in older adults. 

Response 5: Thank you for your suggestions. We have revised the conclusions.

 

Reviewer 3 Report

The manuscript (ID: vaccines-2438843) aimed to investigate the knowledge, attitude, and practice towards influenza vaccination among older adults in southern China during the Covid-19 pandemic.      

But, some issues in this manuscript require major revision (pay attention to ethical issues):   

• Lines 10-25: In the Abstract, the most important information on the topic of this work is presented in a high-quality manner, including the motive for the realization of the study, the design of the study, the target population, the appropriate statistical methodology, and the key results. 
• Lines 19-20: A suggestion for Abstract - Explain whether it can be said `People receiving Covid-19 vaccination were more likely to receive influenza vaccination (OR 1.92, 95% CI 1.32-2.80).`, because a cross-sectional study design was applied in this research.
• Lines 27-70: Overall, the Introduction section is written in a high-quality manner, all the information is presented in a logical flow and in a comprehensive manner, and citing relevant references. Along with a description of the magnitude of the problem that influenza represents throughout the world, data for China is presented in detail. It is particularly significant that the data on vaccination against influenza in China are presented in great detail, with indications for vaccination, coverage by vaccination, whether and for whom vaccination against influenza is free or not, etc. Starting from low vaccination coverage among older adults (as one of vaccination-prioritized populations) in China, authors aimed to investigate the knowledge, attitude, and practice towards influenza vaccination among older adults in southern China during the Covid-19 pandemic, and identify associated influenza-related factors that had a significant impact on their actions of vaccination.
• Line 64: Given that the Abstract highlights an important result (`People receiving Covid-19 vaccination were more likely to receive influenza vaccination (OR 1.92, 95% CI 1.32-2.80).`), add a new paragraph that will describe when vaccination against COVID-19 started in China, as well as what indications were provided for vaccination against COVID-19 at that time.   
• Lines 88-116: Specify in the Data collection section whether the respondents filled out the questionnaire themselves (paper and pencil) or whether the direct interview method was used (interviewers asked questions from the survey to each participant in the study and wrote down the answers). 
• Lines 140-143: Was written-informed-voluntary consent to participate in this study obtained at any time during the conduct of this study? If not, explain.    
• Lines 146-148: The data presented in that sentence correspond with the results only on Table 6, on Lines 217-218. Correct this.  
• Lines 183-185: Make Table 3 more clear and transparent, pay special attention to Q3, maybe bold the P values. 
• Lines 335-348: Given that the flu vaccination coverage in the 2020 season was 46.6%, that is, less than the % of those who ever received the flu vaccine (55.6%), as the authors explain the finding in this paper that `Covid-19 vaccination history had an impact on the actions of influenza vaccination during the pandemic.`. Note:
• It is clear that the flu vaccination in the 2021 season practically should not be taken into account because the survey was conducted from September 24 to October 20, 2021, that is practically before the start of the flu vaccination.  
• A cross-sectional study design was used in this research.   
• Lines 377-386: In the Conclusions section, the important results of this study are highlighted. 
• Manuscript in whole: Avoid words such as `We conducted; we identified ...; we found; we only included …; We performed statistical analysis  ... ; we used  ...; ...`. Correct it throughout the work.

 

 

 

The quality of English language is appropriate.  

 

Author Response

The manuscript (ID: vaccines-2438843) aimed to investigate the knowledge, attitude, and practice towards influenza vaccination among older adults in southern China during the Covid-19 pandemic.      

We appreciate your valuable and useful suggestions.

But, some issues in this manuscript require major revision (pay attention to ethical issues):   

• Lines 10-25: In the Abstract, the most important information on the topic of this work is presented in a high-quality manner, including the motive for the realization of the study, the design of the study, the target population, the appropriate statistical methodology, and the key results. 

Response line 10-25: Thanks for your comments.

 

• Lines 19-20: A suggestion for Abstract - Explain whether it can be said `People receiving Covid-19 vaccination were more likely to receive influenza vaccination (OR 1.92, 95% CI 1.32-2.80).`, because a cross-sectional study design was applied in this research.

Response line 19-20: We have revised this sentence in line 19-20.

 

• Lines 27-70: Overall, the Introduction section is written in a high-quality manner, all the information is presented in a logical flow and in a comprehensive manner, and citing relevant references. Along with a description of the magnitude of the problem that influenza represents throughout the world, data for China is presented in detail. It is particularly significant that the data on vaccination against influenza in China are presented in great detail, with indications for vaccination, coverage by vaccination, whether and for whom vaccination against influenza is free or not, etc. Starting from low vaccination coverage among older adults (as one of vaccination-prioritized populations) in China, authors aimed to investigate the knowledge, attitude, and practice towards influenza vaccination among older adults in southern China during the Covid-19 pandemic, and identify associated influenza-related factors that had a significant impact on their actions of vaccination.

Response line 27-70: Thanks for your comments.

 

• Line 64: Given that the Abstract highlights an important result (`People receiving Covid-19 vaccination were more likely to receive influenza vaccination (OR 1.92, 95% CI 1.32-2.80).`), add a new paragraph that will describe when vaccination against COVID-19 started in China, as well as what indications were provided for vaccination against COVID-19 at that time.   

Response line 64: We have added the description of the Covid-19 vaccination for older adults in line 45-48.

 

• Lines 88-116: Specify in the Data collection section whether the respondents filled out the questionnaire themselves (paper and pencil) or whether the direct interview method was used (interviewers asked questions from the survey to each participant in the study and wrote down the answers). 

Response 88-116: Thanks for your suggestions. We used the direct interview method and we have added the information in line 94-96.

• Lines 140-143: Was written-informed-voluntary consent to participate in this study obtained at any time during the conduct of this study? If not, explain.    

Response 140-143: The data collection period was from September 24 to October 20, 2021. We have indicated oral informed consent from participants who were included during this time period before interviewers administered and distributed the structured questionnaire, which was described in line 150-151.

Lines 146-148: The data presented in that sentence correspond with the results only on Table 6, on Lines 217-218. Correct this.  

Response 146-148: We have deleted the description of vaccination coverage which only showed in Table 6 and did not show in Table 1. The vaccination coverage showed in “3.4 Practices of influenza vaccination”.

 

• Lines 183-185: Make Table 3 more clear and transparent, pay special attention to Q3, maybe bold the P values. 

Response 183-185: Thanks for your suggestions. We have made Table 3 more clear, bolded the P values and put the detailed information of Q3’s answers in the footnote.

• Lines 335-348: Given that the flu vaccination coverage in the 2020 season was 46.6%, that is, less than the % of those who ever received the flu vaccine (55.6%), as the authors explain the finding in this paper that `Covid-19 vaccination history had an impact on the actions of influenza vaccination during the pandemic.`. Note:
• It is clear that the flu vaccination in the 2021 season practically should not be taken into account because the survey was conducted from September 24 to October 20, 2021, that is practically before the start of the flu vaccination.  

1. Yes. We have mentioned this limitation in our study. We conducted the survey at the beginning of the 2021 flu season, but the survey asked participants about the practice of influenza vaccination as our main outcome which focused on actions before the interview time and in the specific 2020 influenza season.

• A cross-sectional study design was used in this research.   

2. Thanks for your suggestions. We have revised the wording to avoid casual inference throughout the paper.

 

• Lines 377-386: In the Conclusions section, the important results of this study are highlighted.

Response 377-386: Thanks for your comments.

• Manuscript in whole: Avoid words such as `We conducted; we identified ...; we found; we only included …; We performed statistical analysis  ... ; we used  ...; ...`. Correct it throughout the work.

 Response manuscript in whole: Thanks for your suggestions. We have revised the wording throughout this work.

 

 

Round 2

Reviewer 3 Report

Thank you for the opportunity to re-review the manuscript ID: vaccines-2438843. The authors have addressed all of the issues highlighted in my review and satisfactorily responded to my questions. The authors made the necessary changes to the manuscript. The revised manuscript is more clear, readable and informative and will provide a valuable findings for this issue. Thank you to the authors for their responses to my comments.                  

 

 

 

The quality of English language is appropriate. 

 

 

Author Response

Thank you very much once again for acknowledging our study and your time in reviewing our paper.