Introduction
The availability of concise and valid instruments for measuring vaccination attitudes across different countries or populations is limited. The 12-item four-subscale Vaccination Attitudes Examination (VAX) scale designed to assess vaccination hesitancy has been validated in more than 20 languages.
Aim
This study aimed to validate the Arabic translation of VAX.
Methods
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 translated VAX was distributed to the citizens of Saudi Arabia in March 2023 through an online survey system and the authors' networks. Factorial structure and factor measurement reliability were examined using confirmatory factor analysis (CFA). Known-group validity was assessed based on COVID-19 vaccination status using t-tests.
Results
Responses from 164 participants who fully answered the questionnaire were analyzed. The mean age was 40 years, 77% were females, 90% were fully vaccinated against COVID-19, with one-third receiving booster doses. CFA confirmed well-fit four-factor structure: CFI=0.954 (good fit ≥0.90¹), TLI=0.936 (good fit ≥0.90¹), RMSEA=0.097 (good fit <0.08¹), SRMR=0.059 (good fit <0.08¹). All items loaded well with their factors: standardized regression weight values ranged from 0.69 to 0.96 (p<0.001). Correlations between the four factors ranged from 0.47 to 0.79 (p<0.001). Factor measurement reliability was good: CR ranged from 0.712 to 0.799, AVE ranged from 0.880 to 0.922 (acceptable threshold for both ≥0.700¹). As expected, the mean scores of all subscales were lower in those fully vaccinated compared to the unvaccinated. The differences between the fully vaccinated with a booster dose and the unvaccinated were statistically significant (p<0.05).
Discussion
The Arabic translation of the VAX exhibited a well-defined factorial structure with good factor measurement 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.

¹ Kline R. Principles and Practice of Structural Equation Modeling. 3rd ed. New York: The Guilford Press; 2011