Behavioral and Social Drivers of Routine Childhood Immunization in Selected Low Coverage Areas in the Philippines

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Declining immunization rates led to outbreaks of vaccine preventable diseases such as measles, polio, and pertussis. This study aimed to identify the factors affecting childhood vaccine uptake by exploring the perspectives of community members, program managers, and coordinators. Methodology: Three regions with low vaccine coverage in the Philippines were selected as study sites. We conducted focus groups with adult caregivers of vaccinated and unvaccinated children aged 0–11 years recruited by barangay (community) health workers. Key informant interviews were also conducted with immunization program managers and coordinators from different administrative levels. Focus group and interview guides were informed by the World Health Organization’s Behavioural and Social Drivers (BeSD) of Vaccination framework, which include the following domains influencing vaccine uptake: “Thinking and feeling”, “Social processes'', “Motivation”, and “Practical issues''. Transcripts were analyzed by themes and deductive axial coding was used to categorize themes into BeSD domains and socioecological levels. Results Twelve focus groups (n = 143) and 57 key informant interviews were done. Under the ‘Thinking and feeling’ domain of the BeSD, at the intrapersonal level, the perception of benefits and negative side effects of routine vaccines were clear drivers of vaccination. In the ‘Social processes’ domain, factors at multiple socioecological levels such as influence of family, barangay health workers, and community leaders were identified. Incentives such as candies and hygiene kits were also a driver to vaccination. Practical issues such as the availability of vaccines and accessibility of vaccination sites remain a barrier to vaccination despite implementation of strategies such as outreach vaccination activities and house-to-house visits by health center personnel. Conclusions Availability of routine vaccines and accessibility to vaccination sites are major challenges in the Philippines. Acceptability of routine vaccines continue to be affected by previous controversies around the Dengue vaccine and the recent COVID-19 pandemic. Enhancing training for health care workers on health promotion education regarding vaccination may contribute to increased vaccine uptake. Integration of immunization with other population-based health programs could be explored. Routine childhood vaccination behavioural and social drivers vaccine hesitancy Philippines Figures Figure 1 Figure 2 Figure 3 Introduction Routine childhood vaccination is a vital public health strategy that reduces the burden of life-threatening vaccine preventable diseases. Additionally, growth, cognition, and schooling benefits have been observed among fully vaccinated children 1 . However, global immunization rates declined in 2020 and 2021, due to the multifactorial impacts of the COVID-19 pandemic 2 , 3 . In 2021, there were 18.2 million “zero-dose” children, or children who have received no vaccines – an increase of 5 million annually since 2019 4 . While some recovery has been noted in 2022 and 2023 5 , millions of children are still being left behind, particularly in low- and middle-income countries like the Philippines 6 . In the Philippines, vaccines for children under the age of 5 years are provided free of charge through the National Immunization Program (NIP), formerly known as the Expanded Programme on Immunization. The country comprises 17 regions, which are subdivided into provinces, highly urbanized cities and municipalities, and barangays or villages. Immunization service delivery is managed by the central office of the Department of Health Disease Prevention and Control Bureau with program managers at regional levels that provide technical and logistic support. Program coordinators at the provincial and municipal levels oversee the implementation of the program at the barangay levels. Coverage for routine childhood immunization in the Philippines has been well below the target 95% vaccination rate since 2014 5 . Low coverage has led to outbreaks of vaccine preventable diseases such as polio in 2019–2020, measles in 2016–2019, and pertussis in 2024 7–9 . The Philippines has a high number of zero-dose children, placed fifth in terms of numbers globally in 2022 10 . According to the World Health Organization’s (WHO) Behavioural and Social Drivers (BeSD) of Vaccination framework, the factors affecting vaccine uptake includes what people think and feel about vaccines, social influences and processes, motivation, or hesitancy to vaccinate, and practical or logistical issues 11 . In the Philippines, one potential factor contributing to low coverage is distrust in vaccines due to the Dengvaxia controversy in 2017, when the new dengue vaccine allegedly caused fourteen deaths in vaccinated children before the vaccine program was stopped 12 . The controversy fueled the distrust not only in Dengvaxia but in vaccines in general 13 . Vaccine confidence was also affected by the COVID-19 pandemic, with UNICEF reporting in 2023 that vaccine confidence in the Philippines dropped by 25% from 2020-2022 14 . Aside from this, the COVID-19 pandemic also hindered the implementation of many healthcare services and programs including the NIP 15 . People were hesitant to avail of public health services in their local health centers due to fear of exposure to the COVID-19 virus and infection 16 . Moreover, health resources, which were already limited to start with, were diverted to COVID-19 response measures, exacerbating existing accessibility and availability issues 17 . Specific data on the drivers of vaccine uptake in low coverage areas from the perspective of both those seeking and those facilitating vaccination is needed to inform tailored interventions. Therefore, this study aimed to identify the social and behavioral drivers of routine childhood immunization according to caregivers and health officials to identify targeted strategies to improve uptake. Methodology Study Design In this qualitative study, we applied a constructivist approach, conducting focus group discussions (FGDs) with primary caregivers and key informant interviews (KIIs) with immunization program managers and coordinators to gather data on their experiences and perspectives on routine childhood vaccination. This study is presented using the Consolidated Criteria for Reporting Qualitative (COREQ) research 18 . Study Sites In consultation with the Department of Health Public Health Operations Center, Regions IV-B, V, and VIII were identified as study sites with low routine vaccination coverage. The main sources of livelihood in these regions are agriculture, gold mining, tourism, livestock, and fisheries. The languages spoken include Tagalog (all), Bicolano (parts of Region V), and Waray (Region VIII), and there are Indigenous Peoples communities in Regions IV-B and VIII. Under these Regions, the provinces, municipalities, and barangays with low NIP coverage were selected in consultation with the Department of Health Centers for Health Development of the Region and the respective local health authorities. The vaccination coverage rates of the selected municipalities are described in Table 1 . Table 1 Immunization coverage in selected study sites in 2022 STUDY REGIONS STUDY PROVINCES STUDY MUNICIPALITIES Fully immunized coverage (FIC)* % IV-B Palawan Aborlan 53% Narra 59% Oriental Mindoro Naujan 27% Victoria 52% V Camarines Norte Paracale 54% Vinzons 64% Camarines Sur Caramoan 10% Gainza 41% VIII Leyte Palo 67% Tanuan 54% Samar Basey 47% Sta. Rita 54% Source: FIC data of municipalities were obtained from PHO/RHU, while FIC data of the provinces, regions, and the whole country were retrieved from the FHSIS. *Defined as children who completed their 1 dose of BCG, 3 doses of DPT-Hib-HepB vaccine, 3 doses of OPV, and 2 doses of MCV on or before 1 year of age. The projected under-1 year old population was used as the denominator to calculate the FIC coverage 19 . Conceptual Framework The study was guided by the WHO BeSD framework 11 and the Socioecological Model (SEM) as outlined by Olaniyan and colleagues 20 . The BeSD framework identifies four domains of behavioural drivers, or factors that may be either barriers or facilitators to vaccine uptake. These are thinking and feeling about vaccines, social processes, motivational factors, and practical issues involved in seeking and receiving vaccination. The BeSD model, though, is primarily focused on the individual and does not cover broader influences such as political and other socio-economic factors 21 . To capture the broader contextual and multi-leveled factors affecting vaccine uptake, we also applied the SEM. This model has been used in various studies looking into factors that shape health behavior 20 , 22 – 24 . Using this model, the factors that affect the uptake of vaccination can be categorized into five socioecological levels. The intrapersonal level includes factors that are intrinsic to the individual such as perceptions, knowledge, and beliefs regarding vaccination. The interpersonal level constitutes factors associated with the relationships between an individual and significant individuals and social groups that can influence an individual’s vaccination decisions. The institutional level pertains to factors referring to the health facility and local health service delivery. The community level refers to factors found within the environment where the individual lives. Lastly, the policy level factors include vaccination policies, programs and activities on immunization that are implemented by the state. Participant Recruitment Key informant interviews (KIIs) KIIs were conducted to get the perspective of program managers from the different levels of the Department of Health and coordinators from local government units at the provincial and municipal levels about NIP vaccination. Key informants (KIs) were identified through purposive methods and were invited by a member of the study team to take part in an individual or group interview. Participants provided written informed consent prior to participation. Approximately 14 KIs were invited from each region/province. Focus group discussions (FGDs) FGDs were conducted to gather community perspectives on vaccination, particularly on factors relevant to vaccine uptake and hesitancy. We recruited primary caregivers of children aged 0–11 years from each study site through the cooperation of Barangay Health Workers (BHWs). Caregivers of children that were vaccinated and unvaccinated were purposively selected to capture a range of perspectives and experiences. Caregivers included BHWs in some locations as well. Interested participants were invited to attend a meeting in a central location in the barangay during the day, where they could take part in a survey (described elsewhere) and/or an FGD. When people arrived, the study team greeted them, described the study, assessed their eligibility, and provided information and consent materials. FGD participants provided written informed consent. We recruited approximately 8–15 participants for each FGD. Data Collection Both KIIs and FGDs were facilitated by a member of the research team with qualitative research expertise (SND, female, PhD, medical anthropology; ML, female, MA, anthropology), with other members of the research team present to take notes and occasionally probe responses. Key informant interviews (KIIs) The respondents were asked about their duties and responsibilities, vaccine uptake and hesitancy within the communities, training, coordination mechanism, and recommendations were asked. Some respondents were interviewed individually, while others were interviewed in a group setting with other relevant people from the same office. KIIs were conducted in Filipino and/or English. The interviews lasted approximately 60 minutes and were audio recorded and transcribed by a member of the research team. Field notes were also taken during the interview. Participants did not receive reimbursement for their participation, as it was conducted during their workday with management approval. A non-monetary token of gratitude for participating in the study was given. Focus group discussion (FGD) FGDs were conducted in a room in the local health center or in the barangay hall . Participants were asked about their knowledge of the process of vaccination, reasons for vaccination and non-vaccination. A sample promotional audio-visual material used during the Department of Health's Supplemental Immunization Activity was also shown to the FGD participants for their assessment. The language used during the FGDs was Filipino, a major language in the country. A staff member from the Rural Health Unit (RHU) was present to translate the questions and responses from the participants to the local language, whenever necessary. The FGD guide was pretested and edited accordingly. FGDs lasted 60–90 minutes. These were audio recorded and transcribed by a member of the research team, supplemented by contemporaneous notes. Participants were given non-monetary tokens of gratitude for their participation in the study. Data Analysis Transcripts were analyzed by SND and ML, using both inductive and deductive thematic analysis 25 . First, themes were inductively identified. SND, ML and JK (female, PhD, public health) then performed deductive axial coding to categorize the themes according to the domains of the BeSD model and the levels under the SEM. Results Participants A total of 57 KIIs were conducted in Regions IV-B, V and VIII covering six provinces, and 12 municipalities. At the national level, eight program managers from the Department of Health Public Health Operations Center, Disease Prevention and Control Bureau, Epidemiology Bureau and Health Promotion Bureau were interviewed. At the regional level, the KIs were the NIP program managers and health education and promotion officers. At the provincial level, Provincial Health Officers and NIP coordinators were interviewed. All Provincial Health Officers except one were represented in the KIIs. At the municipal level, 12 Municipal Health Officers, 12 NIP coordinators, two midwives and two nurses from the Department of Health were interviewed. Table 2 shows the number of KIIs conducted per administrative level. Table 2 Number of KIIs conducted per administrative level Administrative level Number of KIIs Central 8 Regional 9 Provincial 12 Municipal 28 Total 57 From the six study sites in the three different regions, a total of 143 participants engaged in the FGDs (see Table 3 ). Most (97.9%) were female primary caregivers. The age range of the participants was 19 to 76 years old, and the number of their children ranged from 1 to 10. In terms of educational attainment, 29 (20.3%) attained elementary level education, 89 (62.2%) participants reached high school level education, and 22 (15.4%) attained college level education. Most of the participants were housewives (62.1%), and only a few were employed. In most FGDs, a few BHWs with children aged 0–11 participated. In some of the study sites, there were participants belonging to Indigenous Peoples communities. Table 3 Demographic profile of FGD participants (n = 143) Sex n % Female 140 97.9 Male 3 2.1 Educational attainment Elementary level 29 20.3 High school level 89 62.2 College level 22 15.4 No information 3 2.1 Occupation Housewife 89 62.2 Housekeeper 21 14.7 Barangay personnel/volunteer* 14 9.8 Farmer 6 4.2 None 8 5.6 Others ** 5 3.5 * BHW, Barangay Nutrition Scholar, etc. ** Vendors, miners, encoder, seamstress Behavioral and social drivers of routine childhood immunization The following sections detail the enablers and barriers to routine childhood immunization identified through both KIIs and FGDs, organized according to the domains of the BeSD framework and the SEM (Fig. 3). Table 4 below outlines the various domains of the BeSD and levels of SEM vis a vis themes from the study. Figure 3. Nested Socioecological model on BeSD framework 11 , 20 Table 4 Themes under the BeSD domains and Socioecological levels BeSD Domain Socioecological Level Themes Thinking and Feeling Intrapersonal Perceived benefits of the vaccines Fear of negative side effects of the vaccines Social Processes Interpersonal Influence of husbands, elders and other family members Influence of peers (Bakuna Champions) Institutional Barangay Health Workers as influencers Local provision of incentives Community Influence of government officials and messages Influence of community elders and religious leaders Policy Linking immunization to the Pantawid Pampamilyang Pilipino Program Practical Issues Intra / Interpersonal Transportation challenges and costs Concern about missing work due to child’s vaccine side effects Institutional Accessibility of vaccination Policy Vaccine transportation and cold chain Availability of vaccines – stock-outs Movement of population (trans-out) Thinking and Feeling The drivers of vaccination related to what people think and feel all operated at the interpersonal level. It was well recognized by participants of the study that vaccinations provide protection against diseases. However, the same research participants articulated fear of side effects as a major reason for not bringing their children to the health centers for vaccination. While the participants shared that they knew that it is common for children to have fever after immunization, first-time mothers found this worrisome. Fever was perceived as an illness rather than as a commonly occurring reaction to vaccination. Mothers would also not allow their children to get vaccinated when the children were sick, even if it was a mild viral illness. They feared that the vaccination would worsen the health condition of their children: “Others think that when their children are sick, giving them vaccines will make the sickness worse and that there will be complications.” (R8 FGD) Social Processes Influential social processes were identified at the interpersonal, institutional, and policy level. At the interpersonal level, in Regions V and VIII, fathers were cited as exerting a strong influence on their wives. This influence could be either an enabler, if the husband supported vaccination, or a barrier, if they did not. Participants in all study sites also mentioned the influence of the elders, more specifically, the grandmother whose advice was frequently sought in relation to health concerns of other household members. Elderly participants in the FGD shared that they did not have vaccination when they were young, which could be cited as reason not to vaccinate: “Even without vaccination, I am still alive today.” (Region IV-B FGD). KIs in all regions emphasized the importance of peer-to-peer vaccine advocacy from Bakuna Champions in increasing vaccination uptake. The Bakuna Champions campaign of the Department of Health involves BHWs in selected municipalities and volunteers from the community who advocate for vaccination as defined in the Bakuna Champions Playbook, the training material used 26 . Commonly recruited community volunteers are the mothers. As one KI explained, “One of the campaigns with good results is our Bakuna Champions . They are volunteers who are advocates of vaccines. Examples of champions are mothers and fathers called BakuNanay and PapaBakuna , respectively.” (DPCB KII) At the institutional level of the health facility, BHWs were named by the participants as a vital force in shaping the perception of vaccination. While they have a health promotional role, BHWs are a part of the community and highly trusted; hence, they are familiar with the community members and regularly visit mothers and caregivers in their homes to promote vaccination and other health programs. Participants felt BHWs could be easily approached for health advice. As one KI said, “Face-to-face communication done by BHWs adds a personal touch that helps convince mothers.” (Region VIII KII). However, interviews with the BHWs revealed that they felt they needed additional training to develop their knowledge and skills so they could carry out their tasks with confidence. In particular, the BHWs felt that they needed to be updated on facts about the vaccines for NIP and improve communication strategies so they could respond more accurately to the queries from community members, especially on concerns on side effects and how to address these. The KIs also shared the same sentiment, explaining that the Department of Health and non-governmental organizations implement training for the BHWs, but these trainings are often limited to the study sites of the organizations so BHWs in other areas were not included in the training. At the institutional level, KIs and FGD participants from the local government identified the provision of incentives as a key social process influencing people’s motivation to get vaccinated. In some municipalities in Region VIII, children who had their routine vaccinations were given candies and hygiene kits. KIs across all regions stated that without the incentives, the enthusiasm of the people to get vaccinated diminished, saying, “…when there are no incentives, people do not come.” (Region V KII). However, KIs also noted that while the provision of incentives was effective in motivating people to get routine childhood vaccinations, the practice was not sustainable for the local government units and so it was not considered as a main strategy to increase vaccine uptake. Influences at the community level included information from government officials and agencies. The Department of Health launched Chikiting Ligtas 2023: Join the Big Catch Up, Magpabakuna para sa Healthy Pilipinas , a national Supplemental Immunization Activity against measles, rubella, and polio in May 2023 27 . An intensive information campaign using a variety of media platforms was launched to encourage community members to bring their children to health centers for vaccination. KIs in all regions mentioned that the number of vaccinated children increased due to the campaign. “During the MR-OPV SIA, 80–90% of the actual population was vaccinated.” (Region IV-B KII) However, when asked to assess an example audio visual material, some FGD participants noted that the individuals on the image were not representative of the local Indigenous Peoples communities in their area. FGD participants across the different regions also mentioned that the local government officials like Mayors and Barangay Chairpersons were trusted sources of information on health. As one participant said, “If the information comes from the barangay [officials], I know that it’s reliable.” (Region V FGD). In regions with Indigenous Peoples communities, the community elders/leaders were also named as strong influencers. Community members in general would follow the advice of the elders and, prior to vaccination, health workers would ask for their permission. According to one KI, “We held a town hall meeting. We invited the leaders of the [IP] groups to explain to them the importance of vaccination. This helped in introducing vaccination to the IP [Indigenous Peoples] communities.” (Region IV-B KII). Religious leaders were also influential, though this could be either in favor of or against vaccination. In Region IV-B, a KI mentioned a religious group that was opposed to immunization. A participant in the FGD in the same region shared her religious views on vaccination and health, stating that part of the teachings in her religion was that the human body can heal itself and that unprocessed herbs from the environment are better compared with medicines manufactured artificially. Vaccines were not considered natural hence, these were bad for the health. However, not all members and leaders of the religious groups who oppose vaccination shared the same sentiment. For instance, in one study site, a Municipal Health Officer who belongs to such a group still advocates for vaccination. Finally, at the policy level, the Pantawid Pamilyang Pilipino Program (4Ps) implemented by the Department of Social Welfare and Development through its Conditional Cash Transfer was cited by KIs and FGD participants in Regions V and VIII as a vital driver of routine immunization in children. In this program, select families categorized as belonging to the poorest of the poor or indigent by the local government are provided with cash assistance. To receive this cash assistance, beneficiaries are required to comply with regular preventive health and nutrition services, including availing vaccines included in the NIP 28 . Failure to comply results in the conditional cash transfer being withheld. Essentially, as one FGD participant explained, “…[as] part of the 4Ps, vaccination is required to receive money.” (Region V FGD). Practical Issues Practical issues were identified at the intra/interpersonal level, the institutional health facility and local government level, and the broader policy level. Transportation and economic issues were cited as challenges for individuals and families. KIs in all regions mentioned that indigenous children, especially those residing in geographically isolated and disadvantaged areas, were often missed in routine immunization because traveling from these communities to the health facility would take hours and transportation costs are high. According to a KI, access to vaccination is dependent on the household budget. For daily earners, wages were most likely to be spent on daily necessities such as food and water rather than on immunization, wherein benefits may be realized during episodes of illness from vaccine preventable diseases at a future time. With a minimum daily wage of PHP 395–405 in the regions covered by the study, a trip to and from the health center would cost more than a day’s toil: “...it depends on the budget of the household. A round trip from … to the center costs around 500 pesos (PHP 500 = US $ 9).” (Region V KII). Travel becomes even more challenging during the monsoon season with roads becoming slippery and muddy, making it difficult and sometimes treacherous to walk on. Another reason for missing the scheduled vaccination of the children was the daily responsibilities of the caregivers including farming, work, and household chores. As one FGD participant said, “Those who missed their children's vaccination often reason out that they are busy with work …” (Region V FGD) Economic reasons were also mentioned as the primary reason for some husbands’ hesitancy in having their children immunized. When the child developed a fever due to immunization, some of the husbands had to miss work to be able to take care of their sick child. Missing work results in loss of income for the husband, particularly when he is a daily wage earner. This affected how husbands felt about vaccination, and therefore how they shaped the vaccination decisions of the household. Access to vaccination was a major challenge especially in difficult to access areas. To address this at the institutional level, KIs in all study sites shared that the RHUs employed strategies including the use of the target client list and the “ Reaching Every Purok ” or “ Reaching Every Barangay ” strategy to increase vaccine coverage. These strategies included spot-mapping target clients, tracking pregnant mothers, conducting outreach vaccination activities and house-to-house visits where needed. “We bring the vaccines or services closer to the people. We also vaccinate in common areas like basketball courts, it can also be house-to-house. The strategies…could differ depending on what works best...” (Region VIII KII) Practical issues at the policy level were identified by various KIs, such as challenges in the supply chain including vaccine procurement, transport, and cold chain equipment. In the central office, a KI attributed the inadequate supplies to budgetary limitations and failed bidding. At the regional level, a KI mentioned the concern regarding inadequate cold storage facilities resulting in the inability to accommodate the allocated vaccine supply. Transport of vaccines was also identified as a challenge to geographically isolated and disadvantaged areas with a small number of targets: “There are areas that are hard to reach and with only a small number of targets. Carrying the large vaccine carrier through rivers and in hikes adds additional burden.” (Region V KII). A KI at the municipal level mentioned that the amount of vaccines they received did not match the amount that they requested resulting in lack of supply. During the implementation of the recent measles, rubella, and polio Supplemental Immunization Activity, the intensive promotion for this activity had motivated people to get vaccinated. However, since the supply was limited, many of those who went to the health centers for vaccination had to be turned away. As the KI explained, “Some people were disappointed when they were turned away because of stock outs during the MR-OPV SIA vaccinations. Some parents even got mad at the Health Care Workers (HCWs) because of false promises and wasted time.” (Region IV-B KII) KIs in all regions noted that another major challenge they encountered in the implementation of the NIP was the “trans-outs.” Trans-out was a term used by the KIs to refer to families that moved residence and were therefore, no longer within the area of responsibility of the RHU. They were not sure if the children were able to continue with their immunization schedules in their new location. In the RHU, these children were counted as those who were not able to complete their immunization. In some areas, there were also “trans-ins” referring to children who were originally from other locations and were not considered part of the target client list of children to be vaccinated. In some RHUs, the practice is to vaccinate all eligible children regardless of their residence while in other areas, trans-ins are not included in the target client list. Discussion This study identified a range of social and behavioral drivers to routine childhood vaccine uptake across the levels of the SEM and BeSD domains, as well as strategies and factors that enhance and encourage uptake. Some recommendations are also provided. Address vaccine concerns and misperceptions The study emphasizes the importance of perceptions of benefits and negative side effects of vaccines in influencing vaccination decisions. While perceptions of benefits may have resulted in vaccine uptake, experience of negative side effects has contributed to vaccine hesitancy. Additionally, the perception that the child is sick and cannot be vaccinated was identified as an important barrier to vaccination. Similar findings were found in studies conducted in other countries 29 – 30 . Capacity development of HCWs as well as enhanced implementation of health promotion strategies may help address existing misconceptions related to vaccination during a child’s mild intercurrent illness 30 , 31 and perceived negative side effects, as proper health education was reported to exert a positive impact on the vaccine coverage 32 . Development of health promotion materials should consider cultural inclusivity, as materials that are not culturally inclusive may serve as a barrier to health seeking behavior 33 . In this study, some caregivers lacked confidence in the NIP, still citing the Dengvaxia controversy as the reason behind their lack of enthusiasm to participate in the NIP. The Dengvaxia controversy that began in 2017 has continued to shape peoples’ perceptions of vaccines leading to continuing vaccine hesitancy. The controversy led to the “crisis of confidence” that damaged not only public trust and confidence in the dengue vaccine but also the other programs of the Department of Health including the NIP 34 . The Department of Health in collaboration with the WHO, UNICEF and expert groups may indicate its clear position on the controversy using available scientific evidence to restore trust in the government, thus addressing the decrease in vaccine confidence. Recognize family and community influencers and build their capacity to reinforce motivation to vaccinate The NIP is an integral component of primary health care, closely linked to community engagement for the delivery of health-related activities, including vaccination services. This study highlights that other family members including fathers and grandmothers may exert a strong influence on acceptance of NIP vaccination. Other community influencers such as the local government leaders, religious leaders and tribal elders in the case of indigenous cultural communities, are also strong social drivers for immunization. The Bakuna champions campaign aims to engage community members, such as parents and caregivers, to actively participate in the immunization programs against vaccine preventable diseases. The champions serve as role models who may be able to instill positive attitudes towards immunization. There is a growing body of evidence indicating that vaccine champions can improve vaccine uptake 35 – 39 , though more evaluation in low- and middle-income country settings is needed. Champions have been successfully engaged in other health programs such as in the urban sanitation champions for water, sanitation and hygiene 40 . The Bakuna champions campaign may need to be expanded and sustained to encourage participation of more community members and for them to be involved in other major health programs. Train BHWs and technical support for the strengthening of health promotion units in the provincial level The BHWs serve as Health Education and Promotion Officers in their respective barangays to advocate for vaccination 41 . The BHW participants in this study expressed the need for training to update their knowledge on vaccines and enhance their skills in community engagement. Continuing training of BHWs aligned with the principles of continuing education that is required for health professionals may help them in performing their roles more effectively. Additionally, the trained BHWs can later be trainers themselves for new BHWs. In the Universal Health Care Act, Provincial Health Offices are mandated to establish fully functional and funded health promotion units for the implementation of proactive and effective health promotion programs 42 . The Provincial Health Officer and staff may benefit from capacity building activities on health promotion and education including immunization. Provision of technical support to ensure a dedicated and proactive health promotion unit at the provincial level may support the creation of health promotion programs tailored to the needs of the province. Similar capacity building activities may be implemented at the municipal level for a more comprehensive approach. Ensure availability of vaccines for a successful vaccination program Mothers spend time and resources to reach the RHU on days when their children are supposed to be vaccinated. There were instances wherein there was a lack of available vaccines which deterred some mothers from returning to the RHUs. KIs at all administrative levels identified vaccine availability as a major challenge that could be explained by concerns related to vaccine procurement, transport, and storage including cold chain equipment. At the national level, identified challenges included financing and failed biddings. While KIs in this study highlighted the lack of financing in the procurement of vaccines, the budget allocation for the NIP increased from 2012-2020 17 . In terms of financing, the main challenge remains to be the low immunization coverage performance, which is related to underutilization of existing resources, thus there is difficulty in lobbying for further increase in the budget allocated for vaccines 43 . Vaccine stock-out in the country in recent years was affected by the transition in vaccine procurement from UNICEF to self-procurement by the Department of Health. There were also delays in the release of funding by the government affecting vaccine delivery 44 . In a local study, failed biddings were highlighted to contribute to the delay of up to 100 days in the overall vaccine delivery timeline 17 . Limited vaccine storage capacity was mentioned as another challenge by KIs. Ideally, procurement of vaccines is done annually with a three-month stock buffer intended for potential outbreaks and to prevent stock-outs 45 . However, because vaccine storage capacity at the Research Institute for Tropical Medicine can only accommodate 3 months of the annual supply, procurement of vaccines is done in 4 tranches 43 . When delays in vaccine procurement and delivery occur, this may lead to significant stock-outs in the country. Challenges in the determination of the vaccine demand may also affect the vaccine supply. Vaccine demand is determined by the requests submitted to the Department of Health central office by the regions and the provinces 44 . However, in an assessment of the NIP, concerns on the exchange of information due to weak feedback mechanisms between the central and the local governments may negatively impact the coordination, particularly, in the planning and distribution of vaccine supplies 43 . Enhancing the monitoring of the vaccine stock levels, the number of eligible children for vaccination, and coverage rates may facilitate effective forecasting and timely procurement. Make vaccination services accessible to reach the unreached Long distances, challenging road conditions, high transportation costs, and conflicting vaccination and work schedules serve as impediments to accessibility of NIP services. Health center staff conducted innovative strategies and activities such as outreach vaccination and use of satellite vaccination sites to reach people in geographically isolated and disadvantaged areas. Continuing support for and recognition of these extraordinary efforts would help ensure timely delivery of vaccination services especially to disadvantaged populations 46 . This study has shown that gaps in immunization records were partly due to “trans-outs”. While there were some areas where “trans-out” children received vaccination, there were areas where administering vaccines proved challenging due to the unclear immunization status of children and their non-inclusion in the initial target list of eligible children. Consequently, transfer of residence may lead to delays or missed immunization schedules. In such cases, children were reported as having incomplete immunization in their original locality. The value of updated records becomes evident in the case of “trans-outs” where the HCWs will have a basis in determining the immunization status of a patient. Public health authorities emphasized the importance of keeping accurate immunization records 47 . Partner and collaborate to enhance NIP implementation Effective partnerships with collaborators, whether from the government or non-government sectors, contribute to the achievement of vaccination goals. Global health partners of the Department of Health, namely, UNICEF and the WHO have also been long time partners and supporters of the NIP. In April 2023, the Department of Health, UNICEF and the WHO launched Chikiting Ligtas 2023: Join the Big Catch Up, Magpabakuna para sa Healthy Pilipinas! 27 . The WHO and UNICEF provided assistance in procuring vaccines, deploying additional health staff for social mobilization and building cold chain capacities, among others 27 . Additionally, in the conduct of vaccine related public health initiatives particularly the World Immunization Week, the Department of Health urged its partners in the medical community and the private sector to intensify collaborative efforts to build strong and resilient immunization programs 48 . Professional organizations such as the Philippine Medical Association, the Pediatric Infectious Disease Society of the Philippines, the Philippine Pediatric Society, the Philippine Foundation for Vaccination and the Pharmaceutical and Hospital Association of the Philippines were notable private sector partners of the NIP. Private sector partners such as SM Supermalls and Megaworld Corporation provided additional vaccination venues for greater accessibility to the public. Partnerships with higher education institutions may be explored to provide the technical support needed for the continuing capacity building of HCWs in communication, health leadership, and other essential skills related to vaccination. Local government units at the frontlines will need to demonstrate leadership in service delivery related to population-based health programs. Opportunities for integration with other major public health programs As these services are to be delivered by the same HCWs, commodities like vaccines and drugs can be simultaneously distributed to the same target groups in the community setting. As such, there may be an opportunity to integrate policy, advocacy, training, and service delivery of vaccines and drugs on a mass scale including health promotion and education. For example, in Region VIII where schistosomiasis is endemic and Mass Drug Administration is being implemented, vaccination schedules may coincide with Mass Drug Administration schedules, so that caregivers with children eligible for both programs will only take a single trip to the health center. This combined approach may help reduce cost and increase efficiency, as this would lessen the time entailed to conduct separate programs on the part of the HCWs and on the mothers who do not have to go on separate days for Mass Drug Administration and vaccination. Strengths and limitations of the study By covering three regions with low routine childhood vaccine coverage in the Philippines, this study is able to provide a broader view of different contexts that shape the factors affecting vaccine uptake from both the vaccinators’ and caregivers’ perspective. The responses obtained from the KIIs and FGDs cover all the administrative levels of the Department of Health from the central office, regional, provincial, municipal levels down to the community level. This overall design provided a general understanding of program implementation, good practices, and challenges that may contribute to enhancement of service delivery. The study also had its limitations including the selection of the study sites. Some areas with low FIC coverage rates were not included due to logistical limitations. Recruitment of FGD participants may also be biased towards those who were vaccinated or had vaccinated children due to recruitment being conducted near health facilities. While efforts were made to enlist unvaccinated individuals and those with unvaccinated children, most of the participants were those who were vaccinated. Lastly, the timing of the study may have affected the data gathered. Field data collection began in July 2023, one month after the MR-OPV SIA campaign concluded. The campaign, which was intensive with the goal of reaching every unvaccinated child, may have shaped perspectives on the NIP in the study sites. Summary and Conclusions Perceptions of benefits and negative side effects remain the major drivers of vaccination. These perceptions were also influenced by family and community relationships. To improve vaccine uptake, continuing capacity building activities for the HCWs and BHWs will enhance the conduct of health promotion and education campaigns. Key messages that highlight the benefits of vaccination while at the same time address the misconceptions and negative side effects must be tailored to the community context. Empowering non-health professionals in the community who will act as vaccination champions may also contribute to higher vaccine uptake. There is also a need for continuing capacity building and the delivery of health promotion with the use of culturally inclusive information and education materials. Practical issues affecting the different administrative levels such as supply chain, vaccination policies, and health leadership were also found to contribute to vaccine uptake. There were challenges in procurement, transport and cold chain facilities affecting vaccine supply found in all administrative levels. Identifying and addressing these challenges is essential to ensuring adequate vaccine supply. Vaccination policies must also be harmonized across different agencies to ensure the smooth implementation of the NIP. Lastly, health leadership at the provincial level is found to contribute to the performance of the RHUs through provision of support for further enhancement of capacity of Provincial Health Offices for oversight of health service delivery and provision of health system support is recommended. Abbreviations 4Ps Pantawid Pamilyang Pilipino Program BeSD Behavioural and Social Drivers of Vaccination (BeSD) BHW Barangay Health Worker COREQ Consolidated Criteria for Reporting Qualitative Research FGD Focus Group Discussion HCW Healthcare Workers KI Key Informant KII Key Informant Interview NIP National Immunization Program RHUs Rural Health Units SEM Socioecological Model WHO World Health Organization Declarations Ethics approval and consent to participate The study protocol and questionnaires were reviewed and approved by the UP-Manila Ethics Review Board [UPMREB 2023-0321-01]. Informed consent of all participants was sought prior to data collection. The anonymity of the participants was ensured by not including names in the report. Consent for publication Consent for publication has been obtained through the informed consent forms signed by research participants prior to data collection. Availability of data and materials The data that support the findings of this study are available on request from the corresponding author, SND. The data are not publicly available due to some pieces of information which may compromise the anonymity of the participants. Competing interests The authors declare that there are no financial and non-financial competing interests during the conduct of the study. Funding The study is funded by the DFAT Australian Expert Technical Assistance Program (AETAP), in collaboration with the Australian Regional Immunisation Alliance (ARIA) Authors' contributions SND, ML, MML, ER, SND, JK, FV, VBJ and MDanchin designed this study; PJA, MML, ER, AA, PJA, YF, JZR and MDato collected and verified the data; SND and ML analyzed the data; SND and YF wrote the original draft. All authors were involved in interpretation of the study results, review and revision of drafts, and approval of the article prior to submission. Acknowledgements The authors would like to thank the DOH and their key officials in the central office and regional offices in Regions IV-B (MIMAROPA), V, and VIII (Eastern Visayas) and the local health offices in the provincial and municipal levels of the regions for their support and cooperation in the conduct of the data collection. The authors also acknowledge the valuable administrative and data collection support of Ms. Anna Marie Demeterio. References Nandi A, Shet A. Why vaccines matter: Understanding the broader health, economic, and Child Development Benefits of routine vaccination. Human Vaccines & Immunotherapeutics. 2020 Jan 24;16(8):1900–4. doi:10.1080/21645515.2019.1708669 Hirabayashi K. The impact of covid-19 on routine vaccinations [Internet]. 2020 [cited 2024 Jul 17]. Available from: https://www.unicef.org/eap/stories/impact-covid-19-routine-vaccinations World Health Organization. Immunization coverage [Internet]. World Health Organization; 2024 [cited 2024 Jul 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/immunization-coverage UNICEF [Internet]. 2023 [cited 2024 Jul 17]. Available from: https://data.unicef.org/data-for-action/zero-dose-children-the-alarming-reality-of-missed-vaccinations-highlighted-in-unicefs-2023-world-immunization-week-dashboard/ WHO/UNICEF estimates of National Immunization Coverage [Internet]. World Health Organization; [cited 2024 Jul 15]. Available from: https://www.who.int/teams/immunization-vaccines-and-biologicals/immunization-analysis-and-insights/global-monitoring/immunization-coverage/who-unicef-estimates-of-national-immunization-coverage UNICEF [Internet]. 2019 [cited 2024 Jul 17]. Available from: https://data.unicef.org/resources/all-children-immunized-and-healthy/ Meyer E, Sikka N, Durry E, Datta D. Notes from the Field: CDC Polio Surge Response to Expanding Outbreaks of Type 2 Circulating Vaccine-Derived Poliovirus — Africa and Philippines, September 2019–March 2020. MMWR Morb Mortal Wkly Rep 2020;69:1182–1183. DOI: http://dx.doi.org/10.15585/mmwr.mm6934a6. Domai FM, Agrupis KA, Han SM, Sayo AR, Ramirez JS, Nepomuceno R, Suzuki S, Villanueva AMG, Salva EP, Villarama JB, Ariyoshi K, Mulholland K, Palla L, Takahashi K, Smith C, Miranda E. Measles outbreak in the Philippines: epidemiological and clinical characteristics of hospitalized children, 2016-2019. Lancet Reg Health West Pac. 2021 Dec 15;19:100334. doi: 10.1016/j.lanwpc.2021.100334. PMID: 34977832; PMCID: PMC8686022. UNICEF [Internet]. 2024 [cited 2024 Jul 17]. Available from: https://www.unicef.org/philippines/press-releases/measles-and-pertussis-outbreaks-wake-call-philippines UNICEF. DOH, WHO, UNICEF to boost child immunization rate in the Philippines [Internet]. 2023 [cited 2024 Jul 17]. Available from: https://www.unicef.org/philippines/press-releases/doh-who-unicef-boost-child-immunization-rate-philippines WHO. Understanding the Behavioural and Social Drivers of Vaccine Uptake. WHO position paper. 2022 May 20; 97(20):209-224. Available from: https://iris.who.int/bitstream/handle/10665/354458/WER9720-eng-fre.pdf Dayrit MM, Mendoza RU, Valenzuela SA. The importance of effective risk communication and transparency: lessons from the dengue vaccine controversy in the Philippines. J Public Health Policy. 2020 Sep;41(3):252-267. doi: 10.1057/s41271-020-00232-3. PMID: 32518285. Larson HJ, Hartigan-Go K, de Figueiredo A. Vaccine confidence plummets in the Philippines following dengue vaccine scare: why it matters to pandemic preparedness. Hum Vaccin Immunother. 2019;15(3):625-627. doi: 10.1080/21645515.2018.1522468. Epub 2018 Oct 12. Erratum in: Hum Vaccin Immunother. 2020 Oct 2;16(10):2577. doi: 10.1080/21645515.2019.1628510. PMID: 30309284; PMCID: PMC6605722. UNICEF [Internet]. 2023 [cited 2024 Jul 17]. Available from: https://www.unicef.org/philippines/press-releases/new-data-indicates-declining-confidence-childhood-vaccines-25-percentage-points Hamson E, Forbes C, Wittkopf P, Pandey A, Mendes D, Kowalik J, Czudek C, Mugwagwa T. Impact of pandemics and disruptions to vaccination on infectious diseases epidemiology past and present. Hum Vaccin Immunother. 2023 Aug 1;19(2):2219577. doi: 10.1080/21645515.2023.2219577. Epub 2023 Jun 8. PMID: 37291691; PMCID: PMC10332206. Maravilla J, Catiwa J, Guariño R, Yap JF, Pagatpatan C, Orolfo DD, de Silos J, Leigh MC, Babate J, Lopez V. Exploring indirect impacts of COVID-19 on local health systems from the perspectives of health workers and higher education stakeholders in the Philippines using a phenomenological approach. Lancet Reg Health West Pac. 2023 Jan;30:100585. doi: 10.1016/j.lanwpc.2022.100585. Epub 2022 Sep 16. PMID: 36128337; PMCID: PMC9477542. Ulep VG, Uy J. An Assessment of the Expanded Program on Immunization (EPI) in the Philippines: Challenges and Ways Forward. Philippine Institute for Development Studies. 2021. Available from: https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidsdps2104.pdf Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007 Dec;19(6):349-357. https://doi.org/10.1093/intqhc/mzm042 Department of Health. Field Health Services Information System Manual. 2018. Olaniyan A, Isiguzo C, Hawk M. The Socioecological Model as a framework for exploring factors influencing childhood immunization uptake in Lagos state, Nigeria. BMC Public Health. 2021 May 5;21(1):867. doi: 10.1186/s12889-021-10922-6. PMID: 33952252; PMCID: PMC8098781. Attwell K, Turvey J, Wood L. Covid-19 vaccination of at-risk and marginalised groups: Recentering the state in vaccine uptake. Social Science & Medicine. 2024 May;348:116812. doi:10.1016/j.socscimed.2024.116812 Ingram M, Wolf AMA, López-Gálvez NI, Griffin SC, Beamer PI. Proposing a social ecological approach to address disparities in occupational exposures and health for low-wage and minority workers employed in small businesses. J Expo Sci Environ Epidemiol. 2021 May;31(3):404-411. doi: 10.1038/s41370-021-00317-5. Kennedy W, Fruin R, Lue A, Logan SW. Using ecological models of health behavior to promote health care access and physical activity engagement for persons with disabilities. J Patient Exp. 2021;8:237437352110340. https://doi.org/10.1177/23743735211034031 Baral S, Logie CH, Grosso A, Wirtz AL, Beyrer C. Modified social ecological model: A tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health. 2013;13(1). https://doi.org/10.1186/1471-2458-13-482 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. https://doi.org/10.1191/1478088706qp063oa Department of Health Health Promotion Bureau [HPB]. Health Promotion Playbook for Immunization: Bakuna Champions. 2023. Available from: https://doh.gov.ph/healthypilipinas/get-vaccinated/ World Health Organization. DOH, WHO, UNICEF launch “Chikiting Ligtas” – measles, rubella, and polio national supplemental immunization campaign [Internet]. World Health Organization; 2023 [cited 2024 Jul 17]. Available from: https://www.who.int/philippines/news/detail/27-04-2023-doh--who--unicef-launch--chikiting-ligtas----measles--rubella--and-polio-national-supplemental-immunization-campaign Republic Act No. 11310. An Act Institutionalizing the Pantawid Pamilyang Pilipino Program (4Ps). 2019 Jun 17. Farajzadeh N, Hosseini H, Keshvari M, Maracy MR. A cross-sectional study on the reasons for vaccine hesitancy in children under seven years of age in Isfahan, Iran. Vaccine X. 2023;15:100396. https://doi.org/10.1016/j.jvacx.2023.100396 Hussin HB, Marzo RR, Mamat NB, Safee NFB, Omar NB, Yin TS. The Barriers of Child Immunization Completion among Parents in the Community Health Centre, Johor Bahru. J Pharm Res Int. 2020;32(4):48-58. Francis MR, Nohynek H, Larson H, Balraj V, Mohan VR, Kang G, Nuorti JP. Factors associated with routine childhood vaccine uptake and reasons for non-vaccination in India: 1998-2008. Vaccine. 2018 Oct 22;36(44):6559-6566. doi: 10.1016/j.vaccine.2017.08.026. Epub 2017 Aug 24. PMID: 28844636. Siddiqui A, Priya, Adnan A, Abbas S, Qamar K, Islam Z, Rahmat ZS, Essar MY, Farahat RA. Covid-19 vaccine hesitancy in conflict zones: A review of current literature. Front Public Health. 2022. doi: 10.3389/fpubh.2022.1006271 Gamlin JB. Shame as a barrier to health seeking among indigenous Huichol migrant labourers: An interpretive approach of the 'Violence Continuum' and 'authoritative knowledge'. Soc Sci Med. 2013;97:75-81. https://doi.org/10.1016/j.socscimed.2013.08.012 Mendoza RU, Valenzuela S, Dayrit M. A crisis of confidence: The case of dengvaxia in the Philippines. SSRN Electronic Journal. 2020. https://doi.org/10.2139/ssrn.3519736 Malik AA, Ahmed N, Shafiq M, et al. Behavioral interventions for vaccination uptake: A systematic review and meta-analysis. Health Policy 2023;137:104894. doi: 10.1016/j.healthpol.2023.104894 Kiiza D, Semanda JN, Kawere BB, et al. Strategies to Enhance COVID-19 Vaccine Uptake among Prioritized Groups, Uganda-Lessons Learned and Recommendations for Future Pandemics. Emerg Infect Dis 2024;30(7):1326-34. doi: 10.3201/eid3007.231001 Dhaliwal BK, Seth R, Thankachen B, et al. Leading from the frontlines: community-oriented approaches for strengthening vaccine delivery and acceptance. BMC Proc 2023;17(Suppl 7):5. doi: 10.1186/s12919-023-00259-w Sabin Vaccine Institute and United Nations Children’s Fund. Vaccination Acceptance Research Network 2023 Conference: When Communities Lead, Global Immunization Succeeds. Conference Report, 2024. Kaufman J, Overmars I, Fong J, Tudravu J, Devi R, Volavola L, Vodonaivalu L, Jenkins K, Leask J, Seale H, Mohamed Y, Joshi K, Datt H, Sagan S, Dynes M, Hoq M, Danchin M. Training health workers and community influencers to be Vaccine Champions: a mixed methods RE-AIM evaluation. BMJ Global Health (in press) International Water Association [Internet]. 2023 [cited 2024 Jul 17]. Available from: https://iwa-network.org/projects/inclusive-sanitation-champions/ Department of Health. Barangay Health Worker Reference Manual. Department of Health. 2021. Available from: https://doh.gov.ph/sites/default/files/basic-page/BHW%20REFERENCE%20MANUAL%20-%20TAGALOG.pdf Department of Health. Implementing Rules and Regulations of R.A. 11223. Department of Health. 2019. Available from: https://www.philhealth.gov.ph/about_us/UHC-IRR_Signed.pdf Asian Development Bank. Second Health System Enhancement to Address and Limit COVID-19 under the Asia Pacific Vaccine Access Facility: Report and Recommendation of the President. Asian Development Bank. 2021. Available from: https://www.adb.org/projects/documents/phi-54171-003-rrp Department of Health. National Immunization Program Manual of Operations. Department of Health. 2023. Nfor E, Agaceta C, Linatoc I, Desano C. Strengthening the Department of Health’s Warehouse Management System in the Philippines. US Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. 2017. Available from: https://siapsprogram.org/wp-content/uploads/2018/01/17-216_Philippines_DOH-WMS-Assessment_report_FINAL.pdf World Health Organization Regional Office for the Western Pacific. Regional Framework for Reaching the Unreached in the Western Pacific (2022-2030). Manila: World Health Organization Regional Office for the Western Pacific; 2023. National Center for Immunization and Respiratory Diseases. Documenting vaccinations. Centers for Disease Control and Prevention. Atlanta: Centers for Disease Control and Prevention; 2019 May 7. Available from: https://www.cdc.gov/vaccines/hcp/admin/document-vaccines.html Department of Health. The Philippine National Deployment and Vaccination Plan for COVID-19. Department of Health. 2021. 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1","display":"","copyAsset":false,"role":"figure","size":546570,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBehavioural and Social Drivers for vaccination framework­­\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4819793/v1/3ad52f19f112e83f0a1354bd.png"},{"id":64144541,"identity":"59da35b6-e55c-489e-a042-c750e5f021c0","added_by":"auto","created_at":"2024-09-08 19:40:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":597570,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSocioecological Model\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4819793/v1/043092d9933f6cde381b1c72.png"},{"id":64144539,"identity":"e3a8550f-e4a8-4205-a77f-b2e57705815f","added_by":"auto","created_at":"2024-09-08 19:40:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":429027,"visible":true,"origin":"","legend":"\u003cp\u003eNested Socioecological model on BeSD framework\u003csup\u003e11,20\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4819793/v1/8f5f4373b99018e738eb95b4.png"},{"id":92883705,"identity":"77f11942-2d55-457f-aec6-cd03ae5c41c8","added_by":"auto","created_at":"2025-10-06 16:08:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3137011,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4819793/v1/618a31d2-aaae-4995-ae65-2731c8e146e1.pdf"}],"financialInterests":"","formattedTitle":"Behavioral and Social Drivers of Routine Childhood Immunization in Selected Low Coverage Areas in the Philippines","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRoutine childhood vaccination is a vital public health strategy that reduces the burden of life-threatening vaccine preventable diseases. Additionally, growth, cognition, and schooling benefits have been observed among fully vaccinated children\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. However, global immunization rates declined in 2020 and 2021, due to the multifactorial impacts of the COVID-19 pandemic\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In 2021, there were 18.2\u0026nbsp;million \u0026ldquo;zero-dose\u0026rdquo; children, or children who have received no vaccines \u0026ndash; an increase of 5\u0026nbsp;million annually since 2019\u003csup\u003e4\u003c/sup\u003e. While some recovery has been noted in 2022 and 2023\u003csup\u003e5\u003c/sup\u003e, millions of children are still being left behind, particularly in low- and middle-income countries like the Philippines\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the Philippines, vaccines for children under the age of 5 years are provided free of charge through the National Immunization Program (NIP), formerly known as the Expanded Programme on Immunization. The country comprises 17 regions, which are subdivided into provinces, highly urbanized cities and municipalities, and barangays or villages. Immunization service delivery is managed by the central office of the Department of Health Disease Prevention and Control Bureau with program managers at regional levels that provide technical and logistic support. Program coordinators at the provincial and municipal levels oversee the implementation of the program at the \u003cem\u003ebarangay\u003c/em\u003e levels. Coverage for routine childhood immunization in the Philippines has been well below the target 95% vaccination rate since 2014\u003csup\u003e5\u003c/sup\u003e. Low coverage has led to outbreaks of vaccine preventable diseases such as polio in 2019\u0026ndash;2020, measles in 2016\u0026ndash;2019, and pertussis in 2024\u003csup\u003e7\u0026ndash;9\u003c/sup\u003e. The Philippines has a high number of zero-dose children, placed fifth in terms of numbers globally in 2022\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAccording to the World Health Organization\u0026rsquo;s (WHO) Behavioural and Social Drivers (BeSD) of Vaccination framework, the factors affecting vaccine uptake includes what people think and feel about vaccines, social influences and processes, motivation, or hesitancy to vaccinate, and practical or logistical issues\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In the Philippines, one potential factor contributing to low coverage is distrust in vaccines due to the \u003cem\u003eDengvaxia\u003c/em\u003e controversy in 2017, when the new dengue vaccine allegedly caused fourteen deaths in vaccinated children before the vaccine program was stopped\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The controversy fueled the distrust not only in \u003cem\u003eDengvaxia\u003c/em\u003e but in vaccines in general\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Vaccine confidence was also affected by the COVID-19 pandemic, with UNICEF reporting in 2023 that vaccine confidence in the Philippines dropped by 25% from 2020-2022\u003csup\u003e14\u003c/sup\u003e. Aside from this, the COVID-19 pandemic also hindered the implementation of many healthcare services and programs including the NIP\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. People were hesitant to avail of public health services in their local health centers due to fear of exposure to the COVID-19 virus and infection\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Moreover, health resources, which were already limited to start with, were diverted to COVID-19 response measures, exacerbating existing accessibility and availability issues\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSpecific data on the drivers of vaccine uptake in low coverage areas from the perspective of both those seeking and those facilitating vaccination is needed to inform tailored interventions. Therefore, this study aimed to identify the social and behavioral drivers of routine childhood immunization according to caregivers and health officials to identify targeted strategies to improve uptake.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eIn this qualitative study, we applied a constructivist approach, conducting focus group discussions (FGDs) with primary caregivers and key informant interviews (KIIs) with immunization program managers and coordinators to gather data on their experiences and perspectives on routine childhood vaccination. This study is presented using the Consolidated Criteria for Reporting Qualitative (COREQ) research\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Sites\u003c/h2\u003e \u003cp\u003eIn consultation with the Department of Health Public Health Operations Center, Regions IV-B, V, and VIII were identified as study sites with low routine vaccination coverage. The main sources of livelihood in these regions are agriculture, gold mining, tourism, livestock, and fisheries. The languages spoken include Tagalog (all), Bicolano (parts of Region V), and Waray (Region VIII), and there are Indigenous Peoples communities in Regions IV-B and VIII. Under these Regions, the provinces, municipalities, and barangays with low NIP coverage were selected in consultation with the Department of Health Centers for Health Development of the Region and the respective local health authorities. The vaccination coverage rates of the selected municipalities are described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImmunization coverage in selected study sites in 2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTUDY REGIONS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSTUDY PROVINCES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSTUDY MUNICIPALITIES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFully immunized coverage (FIC)* %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eIV-B\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePalawan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAborlan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNarra\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOriental Mindoro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNaujan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVictoria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCamarines Norte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParacale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVinzons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCamarines Sur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCaramoan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGainza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eVIII\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLeyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePalo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanuan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSamar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBasey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSta. Rita\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003eSource: FIC data of municipalities were obtained from PHO/RHU, while FIC data of the provinces, regions, and the whole country were retrieved from the FHSIS.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e*Defined as children who completed their 1 dose of BCG, 3 doses of DPT-Hib-HepB vaccine, 3 doses of OPV, and 2 doses of MCV on or before 1 year of age. The projected under-1 year old population was used as the denominator to calculate the FIC coverage\u003c/em\u003e \u003csup\u003e \u003cem\u003e \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e \u003c/em\u003e \u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eConceptual Framework\u003c/h2\u003e \u003cp\u003eThe study was guided by the WHO BeSD framework\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e and the Socioecological Model (SEM) as outlined by Olaniyan and colleagues\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The BeSD framework identifies four domains of behavioural drivers, or factors that may be either barriers or facilitators to vaccine uptake. These are thinking and feeling about vaccines, social processes, motivational factors, and practical issues involved in seeking and receiving vaccination. The BeSD model, though, is primarily focused on the individual and does not cover broader influences such as political and other socio-economic factors\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo capture the broader contextual and multi-leveled factors affecting vaccine uptake, we also applied the SEM. This model has been used in various studies looking into factors that shape health behavior\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Using this model, the factors that affect the uptake of vaccination can be categorized into five socioecological levels. The intrapersonal level includes factors that are intrinsic to the individual such as perceptions, knowledge, and beliefs regarding vaccination. The interpersonal level constitutes factors associated with the relationships between an individual and significant individuals and social groups that can influence an individual\u0026rsquo;s vaccination decisions. The institutional level pertains to factors referring to the health facility and local health service delivery. The community level refers to factors found within the environment where the individual lives. Lastly, the policy level factors include vaccination policies, programs and activities on immunization that are implemented by the state.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Recruitment\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eKey informant interviews (KIIs)\u003c/h2\u003e \u003cp\u003eKIIs were conducted to get the perspective of program managers from the different levels of the Department of Health and coordinators from local government units at the provincial and municipal levels about NIP vaccination. Key informants (KIs) were identified through purposive methods and were invited by a member of the study team to take part in an individual or group interview. Participants provided written informed consent prior to participation. Approximately 14 KIs were invited from each region/province.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFocus group discussions (FGDs)\u003c/h2\u003e \u003cp\u003eFGDs were conducted to gather community perspectives on vaccination, particularly on factors relevant to vaccine uptake and hesitancy. We recruited primary caregivers of children aged 0\u0026ndash;11 years from each study site through the cooperation of Barangay Health Workers (BHWs). Caregivers of children that were vaccinated and unvaccinated were purposively selected to capture a range of perspectives and experiences. Caregivers included BHWs in some locations as well. Interested participants were invited to attend a meeting in a central location in the barangay during the day, where they could take part in a survey (described elsewhere) and/or an FGD. When people arrived, the study team greeted them, described the study, assessed their eligibility, and provided information and consent materials. FGD participants provided written informed consent. We recruited approximately 8\u0026ndash;15 participants for each FGD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eBoth KIIs and FGDs were facilitated by a member of the research team with qualitative research expertise (SND, female, PhD, medical anthropology; ML, female, MA, anthropology), with other members of the research team present to take notes and occasionally probe responses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eKey informant interviews (KIIs)\u003c/h2\u003e \u003cp\u003eThe respondents were asked about their duties and responsibilities, vaccine uptake and hesitancy within the communities, training, coordination mechanism, and recommendations were asked. Some respondents were interviewed individually, while others were interviewed in a group setting with other relevant people from the same office. KIIs were conducted in Filipino and/or English. The interviews lasted approximately 60 minutes and were audio recorded and transcribed by a member of the research team. Field notes were also taken during the interview. Participants did not receive reimbursement for their participation, as it was conducted during their workday with management approval. A non-monetary token of gratitude for participating in the study was given.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFocus group discussion (FGD)\u003c/h2\u003e \u003cp\u003eFGDs were conducted in a room in the local health center or in the \u003cem\u003ebarangay hall\u003c/em\u003e. Participants were asked about their knowledge of the process of vaccination, reasons for vaccination and non-vaccination. A sample promotional audio-visual material used during the Department of Health's Supplemental Immunization Activity was also shown to the FGD participants for their assessment. The language used during the FGDs was Filipino, a major language in the country. A staff member from the Rural Health Unit (RHU) was present to translate the questions and responses from the participants to the local language, whenever necessary. The FGD guide was pretested and edited accordingly. FGDs lasted 60\u0026ndash;90 minutes. These were audio recorded and transcribed by a member of the research team, supplemented by contemporaneous notes. Participants were given non-monetary tokens of gratitude for their participation in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eTranscripts were analyzed by SND and ML, using both inductive and deductive thematic analysis\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. First, themes were inductively identified. SND, ML and JK (female, PhD, public health) then performed deductive axial coding to categorize the themes according to the domains of the BeSD model and the levels under the SEM.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eA total of 57 KIIs were conducted in Regions IV-B, V and VIII covering six provinces, and 12 municipalities. At the national level, eight program managers from the Department of Health Public Health Operations Center, Disease Prevention and Control Bureau, Epidemiology Bureau and Health Promotion Bureau were interviewed. At the regional level, the KIs were the NIP program managers and health education and promotion officers. At the provincial level, Provincial Health Officers and NIP coordinators were interviewed. All Provincial Health Officers except one were represented in the KIIs. At the municipal level, 12 Municipal Health Officers, 12 NIP coordinators, two midwives and two nurses from the Department of Health were interviewed. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the number of KIIs conducted per administrative level.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of KIIs conducted per administrative level\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministrative level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of KIIs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvincial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMunicipal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e57\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFrom the six study sites in the three different regions, a total of 143 participants engaged in the FGDs (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Most (97.9%) were female primary caregivers. The age range of the participants was 19 to 76 years old, and the number of their children ranged from 1 to 10. In terms of educational attainment, 29 (20.3%) attained elementary level education, 89 (62.2%) participants reached high school level education, and 22 (15.4%) attained college level education. Most of the participants were housewives (62.1%), and only a few were employed. In most FGDs, a few BHWs with children aged 0\u0026ndash;11 participated. In some of the study sites, there were participants belonging to Indigenous Peoples communities.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic profile of FGD participants (n\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e97.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational attainment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e62.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e62.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousekeeper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBarangay\u003c/em\u003e personnel/volunteer*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e*\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eBHW, Barangay Nutrition Scholar, etc.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e**\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eVendors, miners, encoder, seamstress\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBehavioral and social drivers of routine childhood immunization\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe following sections detail the enablers and barriers to routine childhood immunization identified through both KIIs and FGDs, organized according to the domains of the BeSD framework and the SEM (Fig.\u0026nbsp;3). Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e below outlines the various domains of the BeSD and levels of SEM vis a vis themes from the study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3.\u003c/b\u003e Nested Socioecological model on BeSD framework\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes under the BeSD domains and Socioecological levels\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeSD Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocioecological Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThinking and Feeling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntrapersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerceived benefits of the vaccines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFear of negative side effects of the vaccines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial Processes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterpersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInfluence of husbands, elders and other family members\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInfluence of peers (Bakuna Champions)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitutional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarangay Health Workers as influencers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLocal provision of incentives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInfluence of government officials and messages\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInfluence of community elders and religious leaders\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLinking immunization to the Pantawid Pampamilyang Pilipino Program\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePractical Issues\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntra / Interpersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTransportation challenges and costs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConcern about missing work due to child\u0026rsquo;s vaccine side effects\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitutional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccessibility of vaccination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVaccine transportation and cold chain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailability of vaccines \u0026ndash; stock-outs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMovement of population (trans-out)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eThinking and Feeling\u003c/h2\u003e \u003cp\u003eThe drivers of vaccination related to what people think and feel all operated at the interpersonal level. It was well recognized by participants of the study that vaccinations provide protection against diseases. However, the same research participants articulated fear of side effects as a major reason for not bringing their children to the health centers for vaccination. While the participants shared that they knew that it is common for children to have fever after immunization, first-time mothers found this worrisome. Fever was perceived as an illness rather than as a commonly occurring reaction to vaccination. Mothers would also not allow their children to get vaccinated when the children were sick, even if it was a mild viral illness. They feared that the vaccination would worsen the health condition of their children: \u0026ldquo;Others think that when their children are sick, giving them vaccines will make the sickness worse and that there will be complications.\u0026rdquo; (R8 FGD)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSocial Processes\u003c/h2\u003e \u003cp\u003eInfluential social processes were identified at the interpersonal, institutional, and policy level.\u003c/p\u003e \u003cp\u003eAt the interpersonal level, in Regions V and VIII, fathers were cited as exerting a strong influence on their wives. This influence could be either an enabler, if the husband supported vaccination, or a barrier, if they did not. Participants in all study sites also mentioned the influence of the elders, more specifically, the grandmother whose advice was frequently sought in relation to health concerns of other household members. Elderly participants in the FGD shared that they did not have vaccination when they were young, which could be cited as reason not to vaccinate: \u0026ldquo;Even without vaccination, I am still alive today.\u0026rdquo; (Region IV-B FGD).\u003c/p\u003e \u003cp\u003eKIs in all regions emphasized the importance of peer-to-peer vaccine advocacy from \u003cem\u003eBakuna Champions\u003c/em\u003e in increasing vaccination uptake. The \u003cem\u003eBakuna Champions\u003c/em\u003e campaign of the Department of Health involves BHWs in selected municipalities and volunteers from the community who advocate for vaccination as defined in the \u003cem\u003eBakuna Champions\u003c/em\u003e Playbook, the training material used\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Commonly recruited community volunteers are the mothers. As one KI explained, \u0026ldquo;One of the campaigns with good results is our \u003cem\u003eBakuna Champions\u003c/em\u003e. They are volunteers who are advocates of vaccines. Examples of champions are mothers and fathers called \u003cem\u003eBakuNanay and PapaBakuna\u003c/em\u003e, respectively.\u0026rdquo; (DPCB KII)\u003c/p\u003e \u003cp\u003eAt the institutional level of the health facility, BHWs were named by the participants as a vital force in shaping the perception of vaccination. While they have a health promotional role, BHWs are a part of the community and highly trusted; hence, they are familiar with the community members and regularly visit mothers and caregivers in their homes to promote vaccination and other health programs. Participants felt BHWs could be easily approached for health advice. As one KI said, \u0026ldquo;Face-to-face communication done by BHWs adds a personal touch that helps convince mothers.\u0026rdquo; (Region VIII KII). However, interviews with the BHWs revealed that they felt they needed additional training to develop their knowledge and skills so they could carry out their tasks with confidence. In particular, the BHWs felt that they needed to be updated on facts about the vaccines for NIP and improve communication strategies so they could respond more accurately to the queries from community members, especially on concerns on side effects and how to address these. The KIs also shared the same sentiment, explaining that the Department of Health and non-governmental organizations implement training for the BHWs, but these trainings are often limited to the study sites of the organizations so BHWs in other areas were not included in the training.\u003c/p\u003e \u003cp\u003eAt the institutional level, KIs and FGD participants from the local government identified the provision of incentives as a key social process influencing people\u0026rsquo;s motivation to get vaccinated. In some municipalities in Region VIII, children who had their routine vaccinations were given candies and hygiene kits. KIs across all regions stated that without the incentives, the enthusiasm of the people to get vaccinated diminished, saying, \u0026ldquo;\u0026hellip;when there are no incentives, people do not come.\u0026rdquo; (Region V KII). However, KIs also noted that while the provision of incentives was effective in motivating people to get routine childhood vaccinations, the practice was not sustainable for the local government units and so it was not considered as a main strategy to increase vaccine uptake.\u003c/p\u003e \u003cp\u003eInfluences at the community level included information from government officials and agencies. The Department of Health launched \u003cem\u003eChikiting Ligtas\u003c/em\u003e 2023: \u003cem\u003eJoin the Big Catch Up, Magpabakuna para sa Healthy Pilipinas\u003c/em\u003e, a national Supplemental Immunization Activity against measles, rubella, and polio in May 2023\u003csup\u003e27\u003c/sup\u003e. An intensive information campaign using a variety of media platforms was launched to encourage community members to bring their children to health centers for vaccination. KIs in all regions mentioned that the number of vaccinated children increased due to the campaign. \u0026ldquo;During the MR-OPV SIA, 80\u0026ndash;90% of the actual population was vaccinated.\u0026rdquo; (Region IV-B KII) However, when asked to assess an example audio visual material, some FGD participants noted that the individuals on the image were not representative of the local Indigenous Peoples communities in their area. FGD participants across the different regions also mentioned that the local government officials like Mayors and Barangay Chairpersons were trusted sources of information on health. As one participant said, \u0026ldquo;If the information comes from the barangay [officials], I know that it\u0026rsquo;s reliable.\u0026rdquo; (Region V FGD).\u003c/p\u003e \u003cp\u003eIn regions with Indigenous Peoples communities, the community elders/leaders were also named as strong influencers. Community members in general would follow the advice of the elders and, prior to vaccination, health workers would ask for their permission. According to one KI, \u0026ldquo;We held a town hall meeting. We invited the leaders of the [IP] groups to explain to them the importance of vaccination. This helped in introducing vaccination to the IP [Indigenous Peoples] communities.\u0026rdquo; (Region IV-B KII). Religious leaders were also influential, though this could be either in favor of or against vaccination. In Region IV-B, a KI mentioned a religious group that was opposed to immunization. A participant in the FGD in the same region shared her religious views on vaccination and health, stating that part of the teachings in her religion was that the human body can heal itself and that unprocessed herbs from the environment are better compared with medicines manufactured artificially. Vaccines were not considered natural hence, these were bad for the health. However, not all members and leaders of the religious groups who oppose vaccination shared the same sentiment. For instance, in one study site, a Municipal Health Officer who belongs to such a group still advocates for vaccination.\u003c/p\u003e \u003cp\u003eFinally, at the policy level, the \u003cem\u003ePantawid Pamilyang Pilipino Program\u003c/em\u003e (4Ps) implemented by the Department of Social Welfare and Development through its Conditional Cash Transfer was cited by KIs and FGD participants in Regions V and VIII as a vital driver of routine immunization in children. In this program, select families categorized as belonging to the poorest of the poor or indigent by the local government are provided with cash assistance. To receive this cash assistance, beneficiaries are required to comply with regular preventive health and nutrition services, including availing vaccines included in the NIP\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Failure to comply results in the conditional cash transfer being withheld. Essentially, as one FGD participant explained, \u0026ldquo;\u0026hellip;[as] part of the 4Ps, vaccination is required to receive money.\u0026rdquo; (Region V FGD).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePractical Issues\u003c/h2\u003e \u003cp\u003ePractical issues were identified at the intra/interpersonal level, the institutional health facility and local government level, and the broader policy level.\u003c/p\u003e \u003cp\u003eTransportation and economic issues were cited as challenges for individuals and families. KIs in all regions mentioned that indigenous children, especially those residing in geographically isolated and disadvantaged areas, were often missed in routine immunization because traveling from these communities to the health facility would take hours and transportation costs are high. According to a KI, access to vaccination is dependent on the household budget. For daily earners, wages were most likely to be spent on daily necessities such as food and water rather than on immunization, wherein benefits may be realized during episodes of illness from vaccine preventable diseases at a future time. With a minimum daily wage of PHP 395\u0026ndash;405 in the regions covered by the study, a trip to and from the health center would cost more than a day\u0026rsquo;s toil: \u0026ldquo;...it depends on the budget of the household. A round trip from \u0026hellip; to the center costs around 500 pesos (PHP 500\u0026thinsp;=\u0026thinsp;US \u003cspan\u003e$\u003c/span\u003e9).\u0026rdquo; (Region V KII). Travel becomes even more challenging during the monsoon season with roads becoming slippery and muddy, making it difficult and sometimes treacherous to walk on. Another reason for missing the scheduled vaccination of the children was the daily responsibilities of the caregivers including farming, work, and household chores. As one FGD participant said, \u0026ldquo;Those who missed their children's vaccination often reason out that they are busy with work \u0026hellip;\u0026rdquo; (Region V FGD) Economic reasons were also mentioned as the primary reason for some husbands\u0026rsquo; hesitancy in having their children immunized. When the child developed a fever due to immunization, some of the husbands had to miss work to be able to take care of their sick child. Missing work results in loss of income for the husband, particularly when he is a daily wage earner. This affected how husbands felt about vaccination, and therefore how they shaped the vaccination decisions of the household.\u003c/p\u003e \u003cp\u003eAccess to vaccination was a major challenge especially in difficult to access areas. To address this at the institutional level, KIs in all study sites shared that the RHUs employed strategies including the use of the target client list and the \u0026ldquo;\u003cem\u003eReaching Every Purok\u003c/em\u003e\u0026rdquo; or \u0026ldquo;\u003cem\u003eReaching Every Barangay\u003c/em\u003e\u0026rdquo; strategy to increase vaccine coverage. These strategies included spot-mapping target clients, tracking pregnant mothers, conducting outreach vaccination activities and house-to-house visits where needed. \u0026ldquo;We bring the vaccines or services closer to the people. We also vaccinate in common areas like basketball courts, it can also be house-to-house. The strategies\u0026hellip;could differ depending on what works best...\u0026rdquo; (Region VIII KII)\u003c/p\u003e \u003cp\u003ePractical issues at the policy level were identified by various KIs, such as challenges in the supply chain including vaccine procurement, transport, and cold chain equipment. In the central office, a KI attributed the inadequate supplies to budgetary limitations and failed bidding. At the regional level, a KI mentioned the concern regarding inadequate cold storage facilities resulting in the inability to accommodate the allocated vaccine supply. Transport of vaccines was also identified as a challenge to geographically isolated and disadvantaged areas with a small number of targets: \u0026ldquo;There are areas that are hard to reach and with only a small number of targets. Carrying the large vaccine carrier through rivers and in hikes adds additional burden.\u0026rdquo; (Region V KII).\u003c/p\u003e \u003cp\u003eA KI at the municipal level mentioned that the amount of vaccines they received did not match the amount that they requested resulting in lack of supply. During the implementation of the recent measles, rubella, and polio Supplemental Immunization Activity, the intensive promotion for this activity had motivated people to get vaccinated. However, since the supply was limited, many of those who went to the health centers for vaccination had to be turned away. As the KI explained, \u0026ldquo;Some people were disappointed when they were turned away because of stock outs during the MR-OPV SIA vaccinations. Some parents even got mad at the Health Care Workers (HCWs) because of false promises and wasted time.\u0026rdquo; (Region IV-B KII)\u003c/p\u003e \u003cp\u003eKIs in all regions noted that another major challenge they encountered in the implementation of the NIP was the \u0026ldquo;trans-outs.\u0026rdquo; Trans-out was a term used by the KIs to refer to families that moved residence and were therefore, no longer within the area of responsibility of the RHU. They were not sure if the children were able to continue with their immunization schedules in their new location. In the RHU, these children were counted as those who were not able to complete their immunization. In some areas, there were also \u0026ldquo;trans-ins\u0026rdquo; referring to children who were originally from other locations and were not considered part of the target client list of children to be vaccinated. In some RHUs, the practice is to vaccinate all eligible children regardless of their residence while in other areas, trans-ins are not included in the target client list.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study identified a range of social and behavioral drivers to routine childhood vaccine uptake across the levels of the SEM and BeSD domains, as well as strategies and factors that enhance and encourage uptake. Some recommendations are also provided.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAddress vaccine concerns and misperceptions\u003c/h2\u003e \u003cp\u003eThe study emphasizes the importance of perceptions of benefits and negative side effects of vaccines in influencing vaccination decisions. While perceptions of benefits may have resulted in vaccine uptake, experience of negative side effects has contributed to vaccine hesitancy. Additionally, the perception that the child is sick and cannot be vaccinated was identified as an important barrier to vaccination. Similar findings were found in studies conducted in other countries\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e–\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Capacity development of HCWs as well as enhanced implementation of health promotion strategies may help address existing misconceptions related to vaccination during a child’s mild intercurrent illness\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e and perceived negative side effects, as proper health education was reported to exert a positive impact on the vaccine coverage\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Development of health promotion materials should consider cultural inclusivity, as materials that are not culturally inclusive may serve as a barrier to health seeking behavior\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, some caregivers lacked confidence in the NIP, still citing the \u003cem\u003eDengvaxia\u003c/em\u003e controversy as the reason behind their lack of enthusiasm to participate in the NIP. The \u003cem\u003eDengvaxia\u003c/em\u003e controversy that began in 2017 has continued to shape peoples’ perceptions of vaccines leading to continuing vaccine hesitancy. The controversy led to the “crisis of confidence” that damaged not only public trust and confidence in the dengue vaccine but also the other programs of the Department of Health including the NIP\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. The Department of Health in collaboration with the WHO, UNICEF and expert groups may indicate its clear position on the controversy using available scientific evidence to restore trust in the government, thus addressing the decrease in vaccine confidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eRecognize family and community influencers and build their capacity to reinforce motivation to vaccinate\u003c/h2\u003e \u003cp\u003eThe NIP is an integral component of primary health care, closely linked to community engagement for the delivery of health-related activities, including vaccination services. This study highlights that other family members including fathers and grandmothers may exert a strong influence on acceptance of NIP vaccination. Other community influencers such as the local government leaders, religious leaders and tribal elders in the case of indigenous cultural communities, are also strong social drivers for immunization.\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eBakuna champions\u003c/em\u003e campaign aims to engage community members, such as parents and caregivers, to actively participate in the immunization programs against vaccine preventable diseases. The champions serve as role models who may be able to instill positive attitudes towards immunization. There is a growing body of evidence indicating that vaccine champions can improve vaccine uptake\u003csup\u003e\u003cspan additionalcitationids=\"CR36 CR37 CR38\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e–\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e, though more evaluation in low- and middle-income country settings is needed. Champions have been successfully engaged in other health programs such as in the urban sanitation champions for water, sanitation and hygiene\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. The \u003cem\u003eBakuna champions\u003c/em\u003e campaign may need to be expanded and sustained to encourage participation of more community members and for them to be involved in other major health programs.\u003c/p\u003e \u003cp\u003e \u003cem\u003eTrain BHWs and technical support for the strengthening of health promotion units in the provincial level\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe BHWs serve as Health Education and Promotion Officers in their respective barangays to advocate for vaccination\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. The BHW participants in this study expressed the need for training to update their knowledge on vaccines and enhance their skills in community engagement. Continuing training of BHWs aligned with the principles of continuing education that is required for health professionals may help them in performing their roles more effectively. Additionally, the trained BHWs can later be trainers themselves for new BHWs.\u003c/p\u003e \u003cp\u003eIn the Universal Health Care Act, Provincial Health Offices are mandated to establish fully functional and funded health promotion units for the implementation of proactive and effective health promotion programs\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. The Provincial Health Officer and staff may benefit from capacity building activities on health promotion and education including immunization. Provision of technical support to ensure a dedicated and proactive health promotion unit at the provincial level may support the creation of health promotion programs tailored to the needs of the province. Similar capacity building activities may be implemented at the municipal level for a more comprehensive approach.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eEnsure availability of vaccines for a successful vaccination program\u003c/h2\u003e \u003cp\u003eMothers spend time and resources to reach the RHU on days when their children are supposed to be vaccinated. There were instances wherein there was a lack of available vaccines which deterred some mothers from returning to the RHUs.\u003c/p\u003e \u003cp\u003eKIs at all administrative levels identified vaccine availability as a major challenge that could be explained by concerns related to vaccine procurement, transport, and storage including cold chain equipment. At the national level, identified challenges included financing and failed biddings. While KIs in this study highlighted the lack of financing in the procurement of vaccines, the budget allocation for the NIP increased from 2012-2020\u003csup\u003e17\u003c/sup\u003e. In terms of financing, the main challenge remains to be the low immunization coverage performance, which is related to underutilization of existing resources, thus there is difficulty in lobbying for further increase in the budget allocated for vaccines\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Vaccine stock-out in the country in recent years was affected by the transition in vaccine procurement from UNICEF to self-procurement by the Department of Health. There were also delays in the release of funding by the government affecting vaccine delivery\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. In a local study, failed biddings were highlighted to contribute to the delay of up to 100 days in the overall vaccine delivery timeline\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLimited vaccine storage capacity was mentioned as another challenge by KIs. Ideally, procurement of vaccines is done annually with a three-month stock buffer intended for potential outbreaks and to prevent stock-outs\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. However, because vaccine storage capacity at the Research Institute for Tropical Medicine can only accommodate 3 months of the annual supply, procurement of vaccines is done in 4 tranches\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. When delays in vaccine procurement and delivery occur, this may lead to significant stock-outs in the country.\u003c/p\u003e \u003cp\u003eChallenges in the determination of the vaccine demand may also affect the vaccine supply. Vaccine demand is determined by the requests submitted to the Department of Health central office by the regions and the provinces\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. However, in an assessment of the NIP, concerns on the exchange of information due to weak feedback mechanisms between the central and the local governments may negatively impact the coordination, particularly, in the planning and distribution of vaccine supplies\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Enhancing the monitoring of the vaccine stock levels, the number of eligible children for vaccination, and coverage rates may facilitate effective forecasting and timely procurement.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eMake vaccination services accessible to reach the unreached\u003c/h2\u003e \u003cp\u003eLong distances, challenging road conditions, high transportation costs, and conflicting vaccination and work schedules serve as impediments to accessibility of NIP services. Health center staff conducted innovative strategies and activities such as outreach vaccination and use of satellite vaccination sites to reach people in geographically isolated and disadvantaged areas. Continuing support for and recognition of these extraordinary efforts would help ensure timely delivery of vaccination services especially to disadvantaged populations\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has shown that gaps in immunization records were partly due to “trans-outs”. While there were some areas where “trans-out” children received vaccination, there were areas where administering vaccines proved challenging due to the unclear immunization status of children and their non-inclusion in the initial target list of eligible children. Consequently, transfer of residence may lead to delays or missed immunization schedules. In such cases, children were reported as having incomplete immunization in their original locality. The value of updated records becomes evident in the case of “trans-outs” where the HCWs will have a basis in determining the immunization status of a patient. Public health authorities emphasized the importance of keeping accurate immunization records\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003ePartner and collaborate to enhance NIP implementation\u003c/h2\u003e \u003cp\u003eEffective partnerships with collaborators, whether from the government or non-government sectors, contribute to the achievement of vaccination goals. Global health partners of the Department of Health, namely, UNICEF and the WHO have also been long time partners and supporters of the NIP. In April 2023, the Department of Health, UNICEF and the WHO launched \u003cem\u003eChikiting Ligtas 2023: Join the Big Catch Up, Magpabakuna para sa Healthy Pilipinas!\u003c/em\u003e\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. The WHO and UNICEF provided assistance in procuring vaccines, deploying additional health staff for social mobilization and building cold chain capacities, among others\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Additionally, in the conduct of vaccine related public health initiatives particularly the World Immunization Week, the Department of Health urged its partners in the medical community and the private sector to intensify collaborative efforts to build strong and resilient immunization programs\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. Professional organizations such as the Philippine Medical Association, the Pediatric Infectious Disease Society of the Philippines, the Philippine Pediatric Society, the Philippine Foundation for Vaccination and the Pharmaceutical and Hospital Association of the Philippines were notable private sector partners of the NIP. Private sector partners such as SM Supermalls and Megaworld Corporation provided additional vaccination venues for greater accessibility to the public. Partnerships with higher education institutions may be explored to provide the technical support needed for the continuing capacity building of HCWs in communication, health leadership, and other essential skills related to vaccination. Local government units at the frontlines will need to demonstrate leadership in service delivery related to population-based health programs.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eOpportunities for integration with other major public health programs\u003c/h2\u003e \u003cp\u003eAs these services are to be delivered by the same HCWs, commodities like vaccines and drugs can be simultaneously distributed to the same target groups in the community setting. As such, there may be an opportunity to integrate policy, advocacy, training, and service delivery of vaccines and drugs on a mass scale including health promotion and education. For example, in Region VIII where schistosomiasis is endemic and Mass Drug Administration is being implemented, vaccination schedules may coincide with Mass Drug Administration schedules, so that caregivers with children eligible for both programs will only take a single trip to the health center. This combined approach may help reduce cost and increase efficiency, as this would lessen the time entailed to conduct separate programs on the part of the HCWs and on the mothers who do not have to go on separate days for Mass Drug Administration and vaccination.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e \u003cp\u003eBy covering three regions with low routine childhood vaccine coverage in the Philippines, this study is able to provide a broader view of different contexts that shape the factors affecting vaccine uptake from both the vaccinators’ and caregivers’ perspective. The responses obtained from the KIIs and FGDs cover all the administrative levels of the Department of Health from the central office, regional, provincial, municipal levels down to the community level. This overall design provided a general understanding of program implementation, good practices, and challenges that may contribute to enhancement of service delivery.\u003c/p\u003e \u003cp\u003eThe study also had its limitations including the selection of the study sites. Some areas with low FIC coverage rates were not included due to logistical limitations. Recruitment of FGD participants may also be biased towards those who were vaccinated or had vaccinated children due to recruitment being conducted near health facilities. While efforts were made to enlist unvaccinated individuals and those with unvaccinated children, most of the participants were those who were vaccinated.\u003c/p\u003e \u003cp\u003eLastly, the timing of the study may have affected the data gathered. Field data collection began in July 2023, one month after the MR-OPV SIA campaign concluded. The campaign, which was intensive with the goal of reaching every unvaccinated child, may have shaped perspectives on the NIP in the study sites.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Summary and Conclusions","content":"\u003cp\u003ePerceptions of benefits and negative side effects remain the major drivers of vaccination. These perceptions were also influenced by family and community relationships. To improve vaccine uptake, continuing capacity building activities for the HCWs and BHWs will enhance the conduct of health promotion and education campaigns. Key messages that highlight the benefits of vaccination while at the same time address the misconceptions and negative side effects must be tailored to the community context. Empowering non-health professionals in the community who will act as vaccination champions may also contribute to higher vaccine uptake. There is also a need for continuing capacity building and the delivery of health promotion with the use of culturally inclusive information and education materials.\u003c/p\u003e\u003cp\u003ePractical issues affecting the different administrative levels such as supply chain, vaccination policies, and health leadership were also found to contribute to vaccine uptake. There were challenges in procurement, transport and cold chain facilities affecting vaccine supply found in all administrative levels. Identifying and addressing these challenges is essential to ensuring adequate vaccine supply. Vaccination policies must also be harmonized across different agencies to ensure the smooth implementation of the NIP. Lastly, health leadership at the provincial level is found to contribute to the performance of the RHUs through provision of support for further enhancement of capacity of Provincial Health Offices for oversight of health service delivery and provision of health system support is recommended.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e4Ps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePantawid Pamilyang Pilipino Program\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eBeSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eBehavioural and Social Drivers of Vaccination (BeSD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eBHW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eBarangay Health Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eCOREQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eConsolidated Criteria for Reporting Qualitative Research\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eFGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eFocus Group Discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHCW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHealthcare Workers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eKI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eKey Informant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eKII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eKey Informant Interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eNIP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eNational Immunization Program\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eRHUs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eRural Health Units\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eSEM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eSocioecological Model\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol and questionnaires were reviewed and approved by the UP-Manila Ethics Review Board [UPMREB 2023-0321-01]. Informed consent of all participants was sought prior to data collection. The anonymity of the participants was ensured by not including names in the report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication has been obtained through the informed consent forms signed by research participants prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author, SND. The data are not publicly available due to some pieces of information which may compromise the anonymity of the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no financial and non-financial competing interests during the conduct of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is funded by the DFAT Australian Expert Technical Assistance Program (AETAP), in collaboration with the Australian Regional Immunisation Alliance (ARIA)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSND, ML, MML, ER, SND, JK, FV, VBJ and MDanchin designed this study; PJA, MML, ER, AA, PJA, YF, JZR and MDato collected and verified the data; SND and ML analyzed the data; SND and YF wrote the original draft. All authors were involved in interpretation of the study results, review and revision of drafts, and approval of the article prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the DOH and their key officials in the central office and regional offices in Regions IV-B (MIMAROPA), V, and VIII (Eastern Visayas) and the local health offices in the provincial and municipal levels of the regions for their support and cooperation in the conduct of the data collection. The authors also acknowledge the valuable administrative and data collection support of Ms. Anna Marie Demeterio.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNandi A, Shet A. Why vaccines matter: Understanding the broader health, economic, and Child Development Benefits of routine vaccination. Human Vaccines \u0026amp;amp; Immunotherapeutics. 2020 Jan 24;16(8):1900\u0026ndash;4. doi:10.1080/21645515.2019.1708669\u003c/li\u003e\n\u003cli\u003eHirabayashi K. The impact of covid-19 on routine vaccinations [Internet]. 2020 [cited 2024 Jul 17]. Available from: https://www.unicef.org/eap/stories/impact-covid-19-routine-vaccinations\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Immunization coverage [Internet]. World Health Organization; 2024 [cited 2024 Jul 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/immunization-coverage\u003c/li\u003e\n\u003cli\u003eUNICEF [Internet]. 2023 [cited 2024 Jul 17]. Available from: https://data.unicef.org/data-for-action/zero-dose-children-the-alarming-reality-of-missed-vaccinations-highlighted-in-unicefs-2023-world-immunization-week-dashboard/\u003c/li\u003e\n\u003cli\u003eWHO/UNICEF estimates of National Immunization Coverage [Internet]. World Health Organization; [cited 2024 Jul 15]. Available from: https://www.who.int/teams/immunization-vaccines-and-biologicals/immunization-analysis-and-insights/global-monitoring/immunization-coverage/who-unicef-estimates-of-national-immunization-coverage\u003c/li\u003e\n\u003cli\u003eUNICEF [Internet]. 2019 [cited 2024 Jul 17]. Available from: https://data.unicef.org/resources/all-children-immunized-and-healthy/\u003c/li\u003e\n\u003cli\u003eMeyer E, Sikka N, Durry E, Datta D. Notes from the Field: CDC Polio Surge Response to Expanding Outbreaks of Type 2 Circulating Vaccine-Derived Poliovirus \u0026mdash; Africa and Philippines, September 2019\u0026ndash;March 2020. MMWR Morb Mortal Wkly Rep 2020;69:1182\u0026ndash;1183. DOI: http://dx.doi.org/10.15585/mmwr.mm6934a6.\u003c/li\u003e\n\u003cli\u003eDomai FM, Agrupis KA, Han SM, Sayo AR, Ramirez JS, Nepomuceno R, Suzuki S, Villanueva AMG, Salva EP, Villarama JB, Ariyoshi K, Mulholland K, Palla L, Takahashi K, Smith C, Miranda E. Measles outbreak in the Philippines: epidemiological and clinical characteristics of hospitalized children, 2016-2019. Lancet Reg Health West Pac. 2021 Dec 15;19:100334. doi: 10.1016/j.lanwpc.2021.100334. PMID: 34977832; PMCID: PMC8686022.\u003c/li\u003e\n\u003cli\u003eUNICEF [Internet]. 2024 [cited 2024 Jul 17]. Available from: https://www.unicef.org/philippines/press-releases/measles-and-pertussis-outbreaks-wake-call-philippines\u003c/li\u003e\n\u003cli\u003eUNICEF. DOH, WHO, UNICEF to boost child immunization rate in the Philippines [Internet]. 2023 [cited 2024 Jul 17]. Available from: https://www.unicef.org/philippines/press-releases/doh-who-unicef-boost-child-immunization-rate-philippines\u003c/li\u003e\n\u003cli\u003eWHO. Understanding the Behavioural and Social Drivers of Vaccine Uptake. WHO position paper. 2022 May 20; 97(20):209-224. Available from: https://iris.who.int/bitstream/handle/10665/354458/WER9720-eng-fre.pdf\u003c/li\u003e\n\u003cli\u003eDayrit MM, Mendoza RU, Valenzuela SA. The importance of effective risk communication and transparency: lessons from the dengue vaccine controversy in the Philippines. J Public Health Policy. 2020 Sep;41(3):252-267. doi: 10.1057/s41271-020-00232-3. PMID: 32518285.\u003c/li\u003e\n\u003cli\u003eLarson HJ, Hartigan-Go K, de Figueiredo A. Vaccine confidence plummets in the Philippines following dengue vaccine scare: why it matters to pandemic preparedness. Hum Vaccin Immunother. 2019;15(3):625-627. doi: 10.1080/21645515.2018.1522468. Epub 2018 Oct 12. Erratum in: Hum Vaccin Immunother. 2020 Oct 2;16(10):2577. doi: 10.1080/21645515.2019.1628510. PMID: 30309284; PMCID: PMC6605722.\u003c/li\u003e\n\u003cli\u003eUNICEF [Internet]. 2023 [cited 2024 Jul 17]. Available from: https://www.unicef.org/philippines/press-releases/new-data-indicates-declining-confidence-childhood-vaccines-25-percentage-points\u003c/li\u003e\n\u003cli\u003eHamson E, Forbes C, Wittkopf P, Pandey A, Mendes D, Kowalik J, Czudek C, Mugwagwa T. Impact of pandemics and disruptions to vaccination on infectious diseases epidemiology past and present. Hum Vaccin Immunother. 2023 Aug 1;19(2):2219577. doi: 10.1080/21645515.2023.2219577. Epub 2023 Jun 8. PMID: 37291691; PMCID: PMC10332206.\u003c/li\u003e\n\u003cli\u003eMaravilla J, Catiwa J, Guari\u0026ntilde;o R, Yap JF, Pagatpatan C, Orolfo DD, de Silos J, Leigh MC, Babate J, Lopez V. Exploring indirect impacts of COVID-19 on local health systems from the perspectives of health workers and higher education stakeholders in the Philippines using a phenomenological approach. Lancet Reg Health West Pac. 2023 Jan;30:100585. doi: 10.1016/j.lanwpc.2022.100585. Epub 2022 Sep 16. PMID: 36128337; PMCID: PMC9477542.\u003c/li\u003e\n\u003cli\u003eUlep VG, Uy J. An Assessment of the Expanded Program on Immunization (EPI) in the Philippines: Challenges and Ways Forward. Philippine Institute for Development Studies. 2021. Available from: https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidsdps2104.pdf\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007 Dec;19(6):349-357. https://doi.org/10.1093/intqhc/mzm042\u003c/li\u003e\n\u003cli\u003eDepartment of Health. Field Health Services Information System Manual. 2018.\u003c/li\u003e\n\u003cli\u003eOlaniyan A, Isiguzo C, Hawk M. The Socioecological Model as a framework for exploring factors influencing childhood immunization uptake in Lagos state, Nigeria. BMC Public Health. 2021 May 5;21(1):867. doi: 10.1186/s12889-021-10922-6. PMID: 33952252; PMCID: PMC8098781.\u003c/li\u003e\n\u003cli\u003eAttwell K, Turvey J, Wood L. Covid-19 vaccination of at-risk and marginalised groups: Recentering the state in vaccine uptake. Social Science \u0026amp;amp; Medicine. 2024 May;348:116812. doi:10.1016/j.socscimed.2024.116812\u003c/li\u003e\n\u003cli\u003eIngram M, Wolf AMA, L\u0026oacute;pez-G\u0026aacute;lvez NI, Griffin SC, Beamer PI. Proposing a social ecological approach to address disparities in occupational exposures and health for low-wage and minority workers employed in small businesses. J Expo Sci Environ Epidemiol. 2021 May;31(3):404-411. doi: 10.1038/s41370-021-00317-5.\u003c/li\u003e\n\u003cli\u003eKennedy W, Fruin R, Lue A, Logan SW. Using ecological models of health behavior to promote health care access and physical activity engagement for persons with disabilities. J Patient Exp. 2021;8:237437352110340. https://doi.org/10.1177/23743735211034031\u003c/li\u003e\n\u003cli\u003eBaral S, Logie CH, Grosso A, Wirtz AL, Beyrer C. Modified social ecological model: A tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health. 2013;13(1). https://doi.org/10.1186/1471-2458-13-482\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. https://doi.org/10.1191/1478088706qp063oa\u003c/li\u003e\n\u003cli\u003eDepartment of Health Health Promotion Bureau [HPB]. Health Promotion Playbook for Immunization: Bakuna Champions. 2023. Available from: https://doh.gov.ph/healthypilipinas/get-vaccinated/\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. DOH, WHO, UNICEF launch \u0026ldquo;Chikiting Ligtas\u0026rdquo; \u0026ndash; measles, rubella, and polio national supplemental immunization campaign [Internet]. World Health Organization; 2023 [cited 2024 Jul 17]. Available from: https://www.who.int/philippines/news/detail/27-04-2023-doh--who--unicef-launch--chikiting-ligtas----measles--rubella--and-polio-national-supplemental-immunization-campaign\u003c/li\u003e\n\u003cli\u003eRepublic Act No. 11310. An Act Institutionalizing the Pantawid Pamilyang Pilipino Program (4Ps). 2019 Jun 17.\u003c/li\u003e\n\u003cli\u003eFarajzadeh N, Hosseini H, Keshvari M, Maracy MR. A cross-sectional study on the reasons for vaccine hesitancy in children under seven years of age in Isfahan, Iran. Vaccine X. 2023;15:100396. https://doi.org/10.1016/j.jvacx.2023.100396\u003c/li\u003e\n\u003cli\u003eHussin HB, Marzo RR, Mamat NB, Safee NFB, Omar NB, Yin TS. The Barriers of Child Immunization Completion among Parents in the Community Health Centre, Johor Bahru. J Pharm Res Int. 2020;32(4):48-58.\u003c/li\u003e\n\u003cli\u003eFrancis MR, Nohynek H, Larson H, Balraj V, Mohan VR, Kang G, Nuorti JP. Factors associated with routine childhood vaccine uptake and reasons for non-vaccination in India: 1998-2008. Vaccine. 2018 Oct 22;36(44):6559-6566. doi: 10.1016/j.vaccine.2017.08.026. Epub 2017 Aug 24. PMID: 28844636.\u003c/li\u003e\n\u003cli\u003eSiddiqui A, Priya, Adnan A, Abbas S, Qamar K, Islam Z, Rahmat ZS, Essar MY, Farahat RA. Covid-19 vaccine hesitancy in conflict zones: A review of current literature. Front Public Health. 2022. doi: 10.3389/fpubh.2022.1006271\u003c/li\u003e\n\u003cli\u003eGamlin JB. Shame as a barrier to health seeking among indigenous Huichol migrant labourers: An interpretive approach of the \u0026apos;Violence Continuum\u0026apos; and \u0026apos;authoritative knowledge\u0026apos;. Soc Sci Med. 2013;97:75-81. https://doi.org/10.1016/j.socscimed.2013.08.012\u003c/li\u003e\n\u003cli\u003eMendoza RU, Valenzuela S, Dayrit M. A crisis of confidence: The case of dengvaxia in the Philippines. SSRN Electronic Journal. 2020. https://doi.org/10.2139/ssrn.3519736\u003c/li\u003e\n\u003cli\u003eMalik AA, Ahmed N, Shafiq M, et al. Behavioral interventions for vaccination uptake: A systematic review and meta-analysis. Health Policy 2023;137:104894. doi: 10.1016/j.healthpol.2023.104894\u003c/li\u003e\n\u003cli\u003eKiiza D, Semanda JN, Kawere BB, et al. Strategies to Enhance COVID-19 Vaccine Uptake among Prioritized Groups, Uganda-Lessons Learned and Recommendations for Future Pandemics. Emerg Infect Dis 2024;30(7):1326-34. doi: 10.3201/eid3007.231001\u003c/li\u003e\n\u003cli\u003eDhaliwal BK, Seth R, Thankachen B, et al. Leading from the frontlines: community-oriented approaches for strengthening vaccine delivery and acceptance. BMC Proc 2023;17(Suppl 7):5. doi: 10.1186/s12919-023-00259-w\u003c/li\u003e\n\u003cli\u003eSabin Vaccine Institute and United Nations Children\u0026rsquo;s Fund. Vaccination Acceptance Research Network 2023 Conference: When Communities Lead, Global Immunization Succeeds. Conference Report, 2024.\u003c/li\u003e\n\u003cli\u003eKaufman J, Overmars I, Fong J, Tudravu J, Devi R, Volavola L, Vodonaivalu L, Jenkins K, Leask J, Seale H, Mohamed Y, Joshi K, Datt H, Sagan S, Dynes M, Hoq M, Danchin M. Training health workers and community influencers to be Vaccine Champions: a mixed methods RE-AIM evaluation. BMJ Global Health (in press)\u003c/li\u003e\n\u003cli\u003eInternational Water Association [Internet]. 2023 [cited 2024 Jul 17]. Available from: https://iwa-network.org/projects/inclusive-sanitation-champions/\u003c/li\u003e\n\u003cli\u003eDepartment of Health. Barangay Health Worker Reference Manual. Department of Health. 2021. Available from: https://doh.gov.ph/sites/default/files/basic-page/BHW%20REFERENCE%20MANUAL%20-%20TAGALOG.pdf\u003c/li\u003e\n\u003cli\u003eDepartment of Health. Implementing Rules and Regulations of R.A. 11223. Department of Health. 2019. Available from: https://www.philhealth.gov.ph/about_us/UHC-IRR_Signed.pdf\u003c/li\u003e\n\u003cli\u003eAsian Development Bank. Second Health System Enhancement to Address and Limit COVID-19 under the Asia Pacific Vaccine Access Facility: Report and Recommendation of the President. Asian Development Bank. 2021. Available from: https://www.adb.org/projects/documents/phi-54171-003-rrp\u003c/li\u003e\n\u003cli\u003eDepartment of Health. National Immunization Program Manual of Operations. Department of Health. 2023.\u003c/li\u003e\n\u003cli\u003eNfor E, Agaceta C, Linatoc I, Desano C. Strengthening the Department of Health\u0026rsquo;s Warehouse Management System in the Philippines. US Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. 2017. Available from: https://siapsprogram.org/wp-content/uploads/2018/01/17-216_Philippines_DOH-WMS-Assessment_report_FINAL.pdf\u003c/li\u003e\n\u003cli\u003eWorld Health Organization Regional Office for the Western Pacific. Regional Framework for Reaching the Unreached in the Western Pacific (2022-2030). Manila: World Health Organization Regional Office for the Western Pacific; 2023.\u003c/li\u003e\n\u003cli\u003eNational Center for Immunization and Respiratory Diseases. Documenting vaccinations. Centers for Disease Control and Prevention. Atlanta: Centers for Disease Control and Prevention; 2019 May 7. Available from: https://www.cdc.gov/vaccines/hcp/admin/document-vaccines.html\u003c/li\u003e\n\u003cli\u003eDepartment of Health. The Philippine National Deployment and Vaccination Plan for COVID-19. Department of Health. 2021. Available from: https://www.covidlawlab.org/wp-content/uploads/2021/02/Phillipines_2020.01_The-Philippine-National-COVID-19-Vaccination-Deployment-Plan_EN.pdf\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-health-research-and-policy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ghrp","sideBox":"Learn more about [Global Health Research and Policy](http://ghrp.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/GHRP/default.aspx","title":"Global Health Research and Policy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Routine childhood vaccination, behavioural and social drivers, vaccine hesitancy, Philippines","lastPublishedDoi":"10.21203/rs.3.rs-4819793/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4819793/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRoutine childhood vaccination coverage under the National Immunization Program of the Philippines is well below the target of 95% with a high number of zero-dose children. Declining immunization rates led to outbreaks of vaccine preventable diseases such as measles, polio, and pertussis. This study aimed to identify the factors affecting childhood vaccine uptake by exploring the perspectives of community members, program managers, and coordinators.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003eThree regions with low vaccine coverage in the Philippines were selected as study sites. We conducted focus groups with adult caregivers of vaccinated and unvaccinated children aged 0\u0026ndash;11 years recruited by \u003cem\u003ebarangay\u003c/em\u003e (community) health workers. Key informant interviews were also conducted with immunization program managers and coordinators from different administrative levels. Focus group and interview guides were informed by the World Health Organization\u0026rsquo;s Behavioural and Social Drivers (BeSD) of Vaccination framework, which include the following domains influencing vaccine uptake: \u0026ldquo;Thinking and feeling\u0026rdquo;, \u0026ldquo;Social processes'', \u0026ldquo;Motivation\u0026rdquo;, and \u0026ldquo;Practical issues''. Transcripts were analyzed by themes and deductive axial coding was used to categorize themes into BeSD domains and socioecological levels.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwelve focus groups (n\u0026thinsp;=\u0026thinsp;143) and 57 key informant interviews were done. Under the \u0026lsquo;Thinking and feeling\u0026rsquo; domain of the BeSD, at the intrapersonal level, the perception of benefits and negative side effects of routine vaccines were clear drivers of vaccination. In the \u0026lsquo;Social processes\u0026rsquo; domain, factors at multiple socioecological levels such as influence of family, barangay health workers, and community leaders were identified. Incentives such as candies and hygiene kits were also a driver to vaccination. Practical issues such as the availability of vaccines and accessibility of vaccination sites remain a barrier to vaccination despite implementation of strategies such as outreach vaccination activities and house-to-house visits by health center personnel.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAvailability of routine vaccines and accessibility to vaccination sites are major challenges in the Philippines. Acceptability of routine vaccines continue to be affected by previous controversies around the Dengue vaccine and the recent COVID-19 pandemic. Enhancing training for health care workers on health promotion education regarding vaccination may contribute to increased vaccine uptake. Integration of immunization with other population-based health programs could be explored.\u003c/p\u003e","manuscriptTitle":"Behavioral and Social Drivers of Routine Childhood Immunization in Selected Low Coverage Areas in the Philippines","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-08 19:40:18","doi":"10.21203/rs.3.rs-4819793/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2024-08-24T03:08:51+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-08-02T08:58:57+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-02T08:55:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-01T06:50:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Health Research and Policy","date":"2024-07-29T03:06:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-health-research-and-policy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ghrp","sideBox":"Learn more about [Global Health Research and Policy](http://ghrp.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/GHRP/default.aspx","title":"Global Health Research and Policy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6669466b-a822-41b4-a2cb-e991abc9f9af","owner":[],"postedDate":"September 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:00:09+00:00","versionOfRecord":{"articleIdentity":"rs-4819793","link":"https://doi.org/10.1186/s41256-025-00447-5","journal":{"identity":"global-health-research-and-policy","isVorOnly":false,"title":"Global Health Research and Policy"},"publishedOn":"2025-09-29 15:57:07","publishedOnDateReadable":"September 29th, 2025"},"versionCreatedAt":"2024-09-08 19:40:18","video":"","vorDoi":"10.1186/s41256-025-00447-5","vorDoiUrl":"https://doi.org/10.1186/s41256-025-00447-5","workflowStages":[]},"version":"v1","identity":"rs-4819793","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4819793","identity":"rs-4819793","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}