Conflicting and complementary notions of responsibility in caregiver's and health care workers' vaccination narratives in the Philippines.

Background: Vaccine hesitancy (VH) continues to pose a public health threat globally. Understanding the attitudes and perceptions about vaccination of key stakeholders in vaccine decision-making (such as health care workers (HCWs) and caregivers) about vaccination can pave the way toward novel approaches to bolster vaccine confidence. In this study, we explored the role of notions of responsibilities among HCWs and caregivers in shaping vaccination interactions and decision-making in the Philippines. Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with 44 vaccine-hesitant caregivers, seven HCWs, and 20 community health workers (barangay health workers) in the Philippines between August 2020 and March 2021. The interviews and focus groups were conducted online, transcribed verbatim, and analysed through the reflexive thematic analysis approach. Results: Caregivers highlighted responsibility in terms of being a good caregiver, managing risk to one's own child, and seeking and validating information. Meanwhile, HCWs highlighted responsibility as: being a good HCW, managing risk to children and to the community, and providing and transforming information. Our findings suggest that responsibility manifests differently in HCWs' and caregivers' narratives, and that these notions can be both conflicting and complementary, shaping the interaction between stakeholders and, ultimately, their vaccine decision-making. We also found that fostering a good relationship between HCWs and caregivers through communication techniques such as motivational interviewing could help bridge the gap created by mistrust in vaccinations. HCWs sharing their own experiences as parents who vaccinate their own children also resonate with caregivers. Conclusions: Notions of responsibility can underpin collaborative and divisive interactions between HCWs and caregivers. Public health messaging and interventions related to vaccination must consider strategies that align with these notions to address VH.

Keeping the Customer Satisfied: Applying a Kano Model to Improve Vaccine Promotion in the Philippines.

INTRODUCTION: The success of global health interventions heavily relies on reaching populations in a way that aligns with their priorities and needs. This warrants novel approaches to determine the design of meaningful interventions and targeted delivery pathways. To date, global health scholarship and practice have largely underused approaches already established in fields that emphasize customer satisfaction, such as quality management or consumer psychology. METHODS: In our study, we apply Kano methodology-originally designed to understand how product attributes nonlinearly influence customer satisfaction-to inform design decisions regarding a video-based vaccine intervention in the Philippines. Between September 2021 and April 2022, we administered a Kano questionnaire to 205 caregivers of small children. Data were analyzed following routine Kano approaches, supplemented by cultural consensus analysis (CCA), which is an approach used largely in anthropology to identify distinct cultural groups and competencies. RESULTS: Applying Kano and CCA methodologies allowed us to make informed design decisions in terms of optimizing accessibility and credibility of an intervention that ultimately proved successful in bolstering vaccine intentions. Results guided us to include national and international logos, to appreciate the value of summarizing key messages, and to recognize the importance of fact- or story-based communication as attributes that influenced respondent satisfaction one-dimensionally. We found that involving trusted messengers and including text-based information were required to avoid dissatisfaction. Interacting with someone after viewing the product and creating opportunities to share the promotional material via social media were attractive attributes whose presence would increase satisfaction but would not spark severe dissatisfaction if omitted. Other attributes (short duration, video- or animation-based intervention, delivering the intervention at health centers or in group settings) played a limited role in respondent satisfaction. CONCLUSIONS: Global health research and practice can benefit from applying approaches established in other fields when making evidence-based prioritization decisions to tailor interventions.

Human-centred design bolsters vaccine confidence in the Philippines: results of a randomised controlled trial.

BACKGROUND: The public's confidence in vaccinations has eroded, and anti-vaccination movements have gained traction around the world, including in the Philippines. 'Salubong', a Filipino term, refers to welcoming someone back into one's life and elicits ideas about friendship and family relationships. We extended this concept to vaccines in efforts to design an intervention that would re-welcome vaccines into homes. METHODS: Using human-centred design, we developed and refined a story-based intervention that engages Filipino families, community leaders and community health workers. We conducted a randomised controlled trial among 719 caregivers of small children to test the developed intervention against a control video. We assessed the binary improvement (improvement vs no improvement) and the amount of improvement in vaccine attitudes and intentions after intervention exposure. RESULTS: Although the intervention group began with marginally higher baseline vaccine attitude scores, we found that 62% of the intervention group improved their vaccine attitude scores versus 37% of the control group (Fisher's exact, p<0.001). Among individuals whose scores improved after watching the assigned video, the intervention group saw higher mean attitude score improvements on the 5-point scale (Cohen's d=0.32 with 95% CI 0.10 to 0.54, two-sided t-test, p<0.01). We observed similar patterns among participants who stated that they had previously delayed or refused a vaccine for their child: 67% of 74 in the intervention group improved their vaccine attitude scores versus 42% of 54 in the control group (Fisher's exact, p<0.001). Among the subset of these individuals whose scores improved after watching the assigned video, the intervention group saw higher mean attitude score improvements on the 5-point scale that were marginally significant (Cohen's d=0.35 with 95% CI -0.01 to 0.70, two-sided t-test, p=0.06). CONCLUSIONS: Our results provide solid evidence for the potential of co-designed vaccine confidence campaigns and regulations.

Bargaining and gendered authority: a framework to understand household decision-making about childhood vaccines in the Philippines.

INTRODUCTION: Targeted vaccination promotion efforts aimed at building vaccine confidence require an in-depth understanding of how and by whom decisions about vaccinating children are made. While several studies have highlighted how parents interact with other stakeholders when discussing childhood vaccination, less is known about the way in which vaccination uptake is negotiated within households. METHODS: We conducted 44 in-depth interviews with caregivers of children under five in the Philippines who had delayed or refused vaccination. Interviews were conducted between August 2020 and March 2021 and were audio-recorded, transcribed verbatim and translated into English. Notions of intra-household vaccination bargaining emerged early during systematic debriefings and were probed more pointedly throughout data collection. RESULTS: Parents as well as paternal and maternal families proved to be dominant stakeholders in intra-household bargaining for childhood vaccination. Although bargaining among these stakeholders was based on engrained, gender-based power imbalances, disadvantaged stakeholders could draw on a range of interrelated sources of bargaining power to nevertheless shape decision-making. Sources of bargaining power included, in descending order of their relevance for vaccination, (1) physical presence at the household (at the time of vaccination decision-making), (2) interest in the topic of vaccination and conviction of one's own position, (3) previous vaccination and caregiving experience, and (4) access to household resources (including finances). The degree to which each household member could draw on these sources of bargaining power varied considerably over time and across households. CONCLUSION: Our findings highlight how bargaining due to intra-household disagreement coins decisions regarding childhood vaccination. Considering the risks for public health associated with vaccine hesitancy globally, we advocate for acknowledging intra-household dynamics in research and practice, such as by purposefully targeting household members with decision-making capacity in vaccination promotion efforts, aligning promotion efforts with available bargaining capacity or further empowering those convinced of vaccination.

Misinformation, infighting, backlash, and an 'endless' recovery; policymakers recount challenges and mitigating measures after a vaccine scare in the Philippines.

BACKGROUND: Vaccine scares undermine longstanding global health achievements. Remarkably little data has documented the lived experiences of policymakers working amidst vaccine scares and navigating their fallout. As a result, chances and challenges of large-scale national recuperation efforts are poorly understood. OBJECTIVE: This study aims to explore the perspectives of policymakers involved in ongoing efforts to boost vaccine confidence in the Philippines following a 2017 Dengvaxia scare and the current COVID-19 pandemic. METHODS: Between August and November 2020, we conducted 19 semi-structured narrative interviews with purposively selected policymakers from governmental agencies and non-governmental organizations in the Philippines. Interviews were conducted online, transcribed, and analyzed following the tenets of reflexive thematic analysis. RESULTS: We present results as an emerging model that draws on a chronology conveyed by policymakers in their own words. The Dengvaxia scare proved 'a decisive wedge' that splintered Filipino society and pitted governmental agencies against one another. The scare stoked distorted vaccination narratives, which were 'accelerated rapidly' via social media, and ignited feelings of uncertainty among policymakers of how to convey clear, accurate health messaging and how to prevent drops in care-seeking more broadly. CONCLUSIONS: Efforts to regain trust placed exceptional burdens on an already-strained health system. Respondent-driven recommendations on how to reinforce vaccine confidence and improve vaccination rollout include: developing clear vaccine messages, fostering healthcare providers' and policymakers' communication skills, and rebuilding trust within, toward and across governmental agencies. Further research on how to build enabling environments and rebuild trust in and across institutions remains paramount.

Nudging toward vaccination: a systematic review.

BACKGROUND: Vaccine hesitancy (VH) and the global decline of vaccine coverage are a major global health threat, and novel approaches for increasing vaccine confidence and uptake are urgently needed. 'Nudging', defined as altering the environmental context in which a decision is made or a certain behaviour is enacted, has shown promising results in several health promotion strategies. We present a comprehensive synthesis of evidence regarding the value and impact of nudges to address VH. METHODS: We conducted a systematic review to determine if nudging can mitigate VH and improve vaccine uptake. Our search strategy used Medical Subject Headings (MeSH) and non-MeSH terms to identify articles related to nudging and vaccination in nine research databases. 15 177 titles were extracted and assessed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The final list of included articles was evaluated using the Mixed Methods Appraisal Tool and the Grading of Recommendations, Assessment, Development and Evaluations framework. FINDINGS: Identified interventions are presented according to a framework for behaviour change, MINDSPACE. Articles (n=48) from 10 primarily high-income countries were included in the review. Nudging-based interventions identified include using reminders and recall, changing the way information is framed and delivered to an intended audience, changing the messenger delivering information, invoking social norms and emotional affect (eg, through storytelling, dramatic narratives and graphical presentations), and offering incentives or changing defaults. The most promising evidence exists for nudges that offer incentives to parents and healthcare workers, that make information more salient or that use trusted messengers to deliver information. The effectiveness of nudging interventions and the direction of the effect varies substantially by context. Evidence for some approaches is mixed, highlighting a need for further research, including how successful interventions can be adapted across settings. CONCLUSION: Nudging-based interventions show potential to increase vaccine confidence and uptake, but further evidence is needed for the development of clear recommendations. The ongoing COVID-19 pandemic increases the urgency of undertaking nudging-focused research. PROSPERO REGISTRATION NUMBER: CRD42020185817.

Scared, powerless, insulted and embarrassed: hesitancy towards vaccines among caregivers in Cavite Province, the Philippines.

BACKGROUND: Several studies have highlighted that vaccine hesitancy (VH) is among the most important threats to global health, especially in low- and middle-income countries, including the Philippines. However, there is a dearth of literature exploring family experiences of-or concerns related to-childhood vaccinations that gives voice to vaccine hesitant caregivers (VHCs) of small children. Here, we present insights from VHCs from the Philippines. METHODS: This research draws on in-depth interviews (IDIs) with 44 VHCs who had previously delayed or refused vaccination for their children in rural and urban communities in Cavite Province, the Philippines. Amid the COVID-19 pandemic, we conducted IDIs via an online platform of the respondents' choosing (ie, Facebook messenger call, Skype and Zoom). All interviews were recorded, transcribed, translated and analysed drawing from the tenets of constructivist grounded theory. We use the social ecological model to structure our results. RESULTS: Among the reasons for delay or refusal of childhood vaccinations, a fear of side effects emerged as the most salient concern, exacerbated by previous negative experiences (including trauma) from a dengue vaccine controversy in 2017. Respondents cited the dengue vaccine controversy as they expressed reluctance (regarding any new vaccines) and suspicion (towards school-based vaccination, the distribution channel used for the dengue vaccine). Heads of households opposing vaccines, perceptions that vaccines are non-essential and influences from the social and traditional media or neighbours contributed to further refusal and delay. Upon probing, VHCs recounted health system concerns particularly with regards to healthcare workers who are sometimes unable to answer their questions and can be dismissive or disrespectful regarding caregivers' concerns. CONCLUSION: Understanding VH from the lens of VHCs highlights pathways for interventions to regain trust and bolster confidence towards vaccines. Our findings may serve as linchpins in the development of VH interventions aiming at changing behaviour on a population scale.

'Unfocused groups': lessons learnt amid remote focus groups in the Philippines.

The ongoing COVID-19 pandemic has required tremendous shifts in data collection techniques. While an emerging body of research has described experiences conducting remote interviews, less attention has been paid to focus group discussions (FGDs). Herein, we present experiences conducting remote FGDs (n=9) with healthcare workers and caretakers of small children in the Philippines. We used 'Facebook Messenger Room' (FBMR), the preferred platform of participants. Despite some success, we generally encountered considerable challenges in terms of recruiting, retaining and moderating remote FGDs, particularly among caretakers of small children. Finding a quiet, private place proved unfeasible for many participants, who were juggling family demands in tight, locked down quarters. Connectivity issues and technological missteps compromised the flow of FGDs and minimised the ability to share and compare opinions. For the research team, remote FGDs resulted in a dramatic role shift for notetakers-from being passive observers to active tech supporters, chatbox referees and co-moderators (when audio disruptions occurred). Finally, we note that remote FGDs via FBMR are associated with ethical complexities, particularly as participants often chose to use their personal Facebook accounts, which can compromise anonymity. We developed and continuously refined strategies to mitigate challenges, but ultimately decided to forgo FGDs. We urge fellow researchers with more successful experiences to guide the field in terms of capturing high-quality data that respond to research questions, while also contending with privacy concerns, both in online spaces, as well as physical privacy despite lockdowns in tight quarters.

How can human-centered design build a story-based video intervention that addresses vaccine hesitancy and bolsters vaccine confidence in the Philippines? A mixedmethod protocol for project SALUBONG.

INTRODUCTION: Since the onset of a dengue vaccine controversy in late 2017, vaccine confidence has plummeted in the Philippines, leading to measles and polio outbreaks in early 2019. This protocol outlines a human-centered design (HCD) approach to co-create and test an intervention that addresses vaccine hesitancy (VH) via narrative and empathy with and among families and healthcare workers. METHODS AND ANALYSIS: 'Salubong' is a Filipino term that means to welcome someone back into one's life, reinforcing notions of family ties and friendships. We apply this sentiment to vaccines. Following the phases of HCD, guided by a theoretical framework, and drawing from locally held understandings of faith and acceptance, we will conduct in-depth interviews (IDIs) and focus group discussions (FGDs) in rural and urban Filipino communities that witnessed dramatic increases in measles cases in recent years. During qualitative engagements with caretakers, providers, and policymakers, we will collect narratives about family and community perceptions of childhood vaccinations, public health systems and opportunities to restore faith. IDIs and FGDs will continuously inform the development of (and delivery mechanisms for) story-based interventions. Once developed, we will test our co-created interventions among 800 caretakers and administer a VH questionnaire prior to and immediately following the intervention encounter. We will use the feedback gained through the survey and Kano-style questionnaires to further refine the intervention. Considering the data collection challenges posed by the ongoing COVID-19 pandemic, we have developed workarounds to conduct data collection primarily online. We will use systematic online debriefings to facilitate comprehensive participation of the full research team. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Institutional Review Board of the Research Institute for Tropical Medicine (number 2019-44) and Ethical Commission of Heidelberg University, Faculty of Medicine (S-833/2019). Study findings will be disseminated in scientific conferences and published in peer-reviewed journals.