COVID-19 Vaccine Brand Hesitancy and Other Challenges To Vaccination in The Philippines - PLOS Global Public Health

COVID-19 vaccine brand hesitancy and other challenges to vaccination in the Philippines | PLOS Global Public Health 10/20/23,
0/20/23, 2:31 PM
COVID-19 vaccine brand hesitancy and other challenges to

vaccination in the Philippines
Arianna Maever L. Amit , Veincent Christian F. Pepito, Lourdes Sumpaico-Tanchanco, Manuel M. Dayrit
Published: January 13, 2022 https://doi.org/10.1371/journal.pgph.0000165 See the preprint
Abstract
Effective and safe COVID-19 vaccines have been developed at a rapid and unprecedented pace to control the spread of the virus,
and prevent hospitalisations and deaths. However, COVID-19 vaccine uptake is challenged by vaccine hesitancy and anti-
vaccination sentiments, a global shortage of vaccine supply, and inequitable vaccine distribution especially among low- and middle-
income countries including the Philippines. In this paper, we explored vaccination narratives and challenges experienced and
observed by Filipinos during the early vaccination period. We interviewed 35 individuals from a subsample of 1,599 survey
respondents 18 years and older in the Philippines. The interviews were conducted in Filipino, Cebuano, and/or English via online
platforms such as Zoom or via phone call. All interviews were recorded, transcribed verbatim, translated, and analysed using
inductive content analysis. To highlight the complex reasons for delaying and/or refusing COVID-19 vaccines, we embedded our
findings within the social ecological model. Our analysis showed that individual perceptions play a major role in the decision to
vaccinate. Such perceptions are shaped by exposure to (mis)information amplified by the media, the community, and the health
system. Social networks may either positively or negatively impact vaccination uptake, depending on their views on vaccines.
Political issues contribute to vaccine brand hesitancy, resulting in vaccination delays and refusals. Perceptions about the
inefficiency and inflexibility of the system also create additional barriers to the vaccine rollout in the country, especially among
vulnerable and marginalised groups. Recognising and addressing concerns at all levels are needed to improve COVID-19
vaccination uptake and reach. Strengthening health literacy is a critical tool to combat misinformation that undermines vaccine
confidence. Vaccination systems must also consider the needs of marginalised and vulnerable groups to ensure their access to
vaccines. In all these efforts to improve vaccine uptake, governments will need to engage with communities to ‘co-create’ solutions.
Citation: Amit AML, Pepito VCF, Sumpaico-Tanchanco L, Dayrit MM (2022) COVID-19 vaccine brand hesitancy and other
challenges to vaccination in the Philippines. PLOS Glob Public Health 2(1): e0000165.
https://doi.org/10.1371/journal.pgph.0000165
Editor: Dione Benjumea-Bedoya, Corporacion Universitaria Remington, COLOMBIA
Received: October 27, 2021; Accepted: December 22, 2021; Published: January 13, 2022
Copyright: © 2022 Amit et al. This is an open access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Data Availability: All data relevant to the study are included in the article.
Funding: AMLA/VCFP/LST/MMD are funded by the Ateneo de Manila University Research Council COVID-19 Research
Grant (Grant No. COVID-URC 01 2021). The funder had no role in study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests: We have read the journal’s policy and the authors of this manuscript have the following competing
interests: VCFP owns shares of GMA Network, Inc., a Philippine Stock Exchange-listed company with interests in mass
media. AMLA, VCFP, and MMD receive funding from Sanofi to conduct research on self-care.
Introduction
The coronavirus disease 2019 (COVID-19) pandemic continues to burden health systems and communities globally, with millions of
cases and deaths [1]. Because of the significant and continued impact of COVID-19, vaccines have been developed at a rapid and
unprecedented pace to control the spread of the virus, and prevent hospitalisations and deaths [2]. Many vaccines have been
shown to be safe and effective with high-income countries having vaccinated more than half of their population [3]. Despite the
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COVID-19 vaccine brand hesitancy and other challenges to vaccination in the Philippines | PLOS Global Public Health 10/20/23, 2:31 PM
availability of these vaccines, countries are faced with various challenges including vaccine hesitancy and anti-vaccination
sentiments, limited global supply, and inefficient vaccine deployment [4, 5]. These issues in vaccine uptake, together with declining
community acceptance of other public health interventions, will mean a delayed recovery and prolonged pandemic [6].
The World Health Organization (WHO) in 2019 identified vaccine hesitancy or the reluctance to vaccinate as one of the top ten
threats to global health despite evidence of the important role of vaccines in improving population health outcomes [7]. Together
with weak primary health care and other health challenges, countries especially low- and middle-income countries (LMICs) will
struggle to meet the demands of the communities within their health system capacity. With the pandemic, countries are further
burdened with many health systems overwhelmed throughout its course. The Philippines presently faces these challenges: vaccine
hesitancy and increasing anti-vaccination sentiments, a weak primary health care system with efforts to strengthen it through the
recently implemented Universal Health Care Law, and an overwhelmed health system because of the demands of COVID-19 and
other public health problems [8–13]. These challenges are further compounded by a global shortage of vaccine supply with
inequitable vaccine distributions [14].
Historically, the Philippines was one of the countries with generally high vaccine confidence rates [15]. Following the dengue
vaccine controversy in 2017 however, confidence levels have dramatically dropped and have impacted succeeding vaccination
efforts including the COVID-19 vaccination campaign [9, 12, 15–17]. Dengvaxia, the world’s first commercially available dengue
vaccine developed by Sanofi Pasteur, was introduced as part of a national school-based immunization programme despite the lack
of empirical data on the risks associated with administration of the vaccine among those not previously infected with dengue or
seronegative children [9, 12, 15–17]. By the time reports were released that the vaccine may cause more severe disease among
seronegatives, the Philippines had already inoculated more than 800,000 Filipino school-age children [9]. This was highly
politicised, and damaged trust in vaccines and the health sector [9, 12, 15–17]. As a result, immunisation rates dropped and the
country saw outbreaks of previously controlled vaccine-preventable diseases such as measles and polio [18, 19]. In addition to
vaccine hesitancy, the Philippine health system is not prepared for additional health care demands. As early as the first phase of
the pandemic, critical care capacity was overwhelmed with the influx of patients in hospitals [10, 11]. As of 16 September 2021, the
Philippines ranks third among countries with the highest number of newly confirmed cases per one million population [1, 20].
Globally, 42.9% of the world population have received one dose of a COVID-19 vaccine, with much lower rates in LMICs like the
Philippines [20, 21]. Only 55% of Filipinos have expressed willingness to be vaccinated against COVID-19, and as of 16 September
2021, only 30% of the population have been fully vaccinated[21, 22].
To end this pandemic, it is critical to implement all possible public health interventions and strategies from face masks, physical
distancing, to getting vaccinated [4, 23]. However, there is a need to recognise that the adoption of all these interventions is
influenced by individual risk perceptions, and these perceptions are shaped by various sources of information and experiences [24].
Additionally, there are interpersonal and structural factors that influence health decisions of individuals. Recognising the multiple
dimensions in which behaviours and decisions occur, theories and models have been proposed to explain how individuals make
decisions on their health based on factors that change over time and context [25, 26]. The social ecological model provides a useful
framework for investigating health behaviours and decisions by recognising that a multiplicity of factors interacts to influence health
of individuals [26]. These include individual factors representing biological or behavioural characteristics, interpersonal factors
representing networks and social capital operating within a defined boundary, and structural factors that include health systems and
are mediated through laws and policies [26]. Published studies on vaccination that utilised this model reported that vaccine
intentions and attitudes operate along multiple dimensions, with a series of events influencing decisions related to vaccination [17,
27, 28]. Improving adherence to interventions and vaccination rates therefore requires a better understanding of the different
reasons behind vaccine mistrust and not just determining their individual beliefs, knowledge, and levels of trust [17, 27, 28]. A
recently published scoping review supports the use of the social ecological model in understanding attitudes towards COVID-19
vaccination [29]. The review showed that influencing factors are embedded within the social ecological model and that multilevel
interventions are needed to improve uptake of vaccines [29]. This scoping review of 50 articles had representation from various
countries, but did not include data from the Philippines. We address this gap by exploring the vaccination narratives and challenges
experienced and observed by Filipinos during the early COVID-19 vaccination period. We used qualitative data from a mixed-
methods study conducted from June to August 2021 that aimed to understand how people in the Philippines view COVID-19 and
what influences their behaviours. With these findings, we hope to provide insights to possible avenues of future research and
directions for improving COVID-19 vaccine uptake and reach.
Material and methods

Design and setting
We conducted an online survey among adults ages 18 and older in the Philippines (n = 1,599) from June to August 2021. A
subsample participated in the semi-structured interviews (n = 35) with representation from the general population and health
workforce from July to August 2021. Data from the interviews informed the findings of this paper.
Participants and recruitment
We aimed to interview participants from different regions in the Philippines, various age groups, socio-economic classes, and
vaccination status and attitudes. This allowed us to ensure maximum variation sampling, which aims to capture as many population
contexts as possible. We contacted a total of 115 individuals through the information they provided (i.e., mobile number, phone
number, e-mail). Out of the 115, 35 participants completed the interviews. The remaining 80 either refused or could not be
contacted after a maximum of three attempts. We classified participants according to their vaccination priority group based on the
COVID-19 Vaccination Program’s prioritisation framework [30]. Those in the first priority group (A1) were frontline workers in health
facilities; other priority groups (A2 to C) comprised and represented the general population (Table 1).
Table 1. Vaccine prioritisation framework (2020).

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Data collection
We conducted the interviews in Filipino, Cebuano, and/or English via online platforms such as Zoom or via phone call. The
interview guide included questions about their views on COVID-19, vaccines, and their risk perceptions and behaviours. We
recruited interview participants until saturation was reached (i.e., no new information was being obtained from the interviews) [31].
The interviews lasted between 60 to 90 minutes with a token amounting to USD 6 provided to each participant. All participants
consented to the interview being recorded.
Data analysis
The interviews were digitally recorded, transcribed verbatim, and translated from Filipino or Cebuano to English. The research team
are native and/or fluent speakers of the three languages, and checked for linguistic and conceptual equivalence in the translated
documents. We de-identified all participants and assigned pseudonyms. We analysed the data using inductive content analysis
focusing on the experiences and views towards vaccination [32]. Our analysis was guided by principles of grounded theory.
Transcripts of the interviews were read to identify themes and two investigators (AMLA, VCFP) independently coded the interviews
according to emergent themes in Microsoft Excel [33]. We used coding language that was close to the participants’ terms and
phrases to ensure that we were co-constructing accurate categories reflective of their responses [34]. The codes were reviewed,
and areas of disagreement were resolved between the two investigators. Themes from the interviews were further explored through
discussions with the other members of the team. We considered reflexivity throughout data collection and analysis, acknowledging
that our preconceptions and experiences about vaccination as public health practitioners and health professionals may influence
the way we analyse and interpret data. Our use of the grounded theory allowed us to explore the experiences of our participants
and our own shared experiences, and avoided being limited by how we view COVID-19 vaccination [35]. To highlight the complex
reasons for delaying and/or refusing COVID-19 vaccination, we embedded our findings within the social ecological model with three
broad themes: individual factors (attitudes, beliefs, knowledge, behaviours), interpersonal factors (relationships and social
networks), and structural factors (health systems and service delivery; media; and policies, regulations, and laws at the local,
national, and global level) [26] (Fig 1). The quotes presented in this paper are either in the original English or translated from
Filipino or Cebuano.
Fig 1. Social ecological model applied to COVID-19 vaccination.

This figure shows the three main tiers of factors influencing vaccination intention and uptake: individual (beliefs, attitudes,
knowledge, health literacy), interpersonal (relationships, networks), and structural (health systems and service delivery,
media, policies). These three dimensions are jointly or individually impacted by misinformation (white circles).
https://doi.org/10.1371/journal.pgph.0000165.g001
Patients and public involvement
The public were not directly involved in the design, recruitment, conduct, reporting, or dissemination plans of this research. Their
only involvement was as research participants.
Ethics statement
This study was approved by the University Research Ethics Office of Ateneo de Manila University (Study No. SMPH CORISK
2021). All participants were informed about the aims and objectives of the study by including the written consent form in the email
correspondence. Prior the interview, the research team thoroughly explained the study to them and provided them the opportunity
to ask questions they may have. Written digital consent was taken from study participants before the interview.
Results
We interviewed 35 participants with representation from different vaccination priority groups working in various parts of the country.
Our participants also had different educational backgrounds, employment status, and vaccination attitude (Table 2). There was an
almost equal proportion of females and males (females: 19; males: 16) with a median age of 38 years old (range: 21 to 74 years
old) in the overall study population.
Table 2. Characteristics of interview participants.

Participant views on the barriers to COVID-19 vaccination are presented below, organised using the three tiers of the social
ecological model. Individual barriers include perceptions; attitudes; and beliefs about the science, about vaccines, about the health
system and government. Interpersonal barriers are the networks and social capital that influence health beliefs and decisions.
Vaccine procurement, supply, and logistics, together with media- and policy-related issues, comprise the structural barriers. Where
there are differences between the general population and health workers, these are highlighted in the text.
Individual barriers
Vaccine brand hesitancy and brand preferences.
Vaccine brand hesitancy or delay in getting the vaccine due to brand preferences was a common theme among the participants.
The country’s first administered vaccine was Sinovac-CoronaVac, which is manufactured by a Chinese biopharmaceutical
company. This was given to health workers despite lack of published data on effectiveness at the time and initial announcements
that these were not recommended for high-risk individuals (Quote I1, Table 3). In addition to concerns about the effectiveness of
the vaccine, participants also read and heard information on how this vaccine was made. They believed this specific vaccine was
using the same virus to ‘immunise’ an individual’s system, which may have unintended effects (Quote I2, Table 3). Other
participants cited that this specific brand was not recognised by other countries, and therefore wanted and waited for other
vaccines. Meanwhile, others refused to receive mRNA vaccines due to beliefs about its safety and effectiveness.
Table 3. Illustrative quotes for individual barriers.

Negative experiences with the health system as source of vaccine hesitancy and anti-vaccination sentiments.
The participants cited negative experiences in the past, whether these happened recently or decades ago, as causes of their
negative attitude towards vaccines. Three participants who identified themselves as COVID-19 ‘anti-vaxxers’ or those opposed to
vaccines, had different sources of anti-vaccination sentiments. These three participants belong to different priority groups. One
belongs to the A1 or frontliner group and is working as a Barangay Health/Emergency Response Team (BHERT) member who
responds to COVID-19 related health care needs in the community. The second is a retired professional (A2 or senior citizen group)
while the third is an environmental protection officer who oversees implementation of public health standards in the community (B2
or other government workers). These participants experienced an undesired event related to vaccines and/or medical care from
four years to more than three decades prior the pandemic (Quotes I3-I5, Table 3). Except for one anti-vaxxer, no other health
worker reported negative experiences that caused mistrust in the COVID-19 vaccines and vaccination campaign.
Vaccines are viewed as unsafe and deadly.
Perceptions on risk of getting infection with and dying from the virus varied among the participants. However, for those who were
opposed to the vaccines, their fear of the COVID-19 vaccine and its effects was greater than their fear of the virus and outcomes
(Quote I6, Table 3). This fear and their view of vaccines being unsafe and deadly resulted to vaccine refusals or delays. According
to them, the deaths observed after administration of the vaccine are caused by the vaccine; however, medical doctors and hospitals
report the death as being caused by underlying conditions such as comorbidities (Quotes I7-I8, Table 3). Some participants also
believed the circulating theory that the life span of those who are vaccinated is shortened and they only have two to three years to
live: “you are healthy but because of the vaccine, you suddenly die”. In addition to the belief that vaccines cause death or shorten
an individual’s life span, participants also had doubts about the COVID-19 vaccines particularly the mRNA vaccines that use a
relatively new technology (Quote I9, Table 3). These concerns about the safety profile of vaccines either caused delays in vaccine
acceptance and uptake or refusals. The reverse was reported among most of the health workers and other participants who viewed
vaccines positively. They believed that the vaccine protects them from severe illness, hospitalisation, and death, and that vaccines
only have minimal risk.
Vaccines are viewed as unnecessary and insufficient to prevent disease.
Vaccines were viewed as unnecessary by some participants, especially those in older age groups who are not allowed to go out
(Quote I10, Table 3). Those in lower priority groups felt that others needed the vaccine more than them. Younger participants
shared that they were COVID-19 survivors even without the vaccine; but those at high risk especially the elderly and persons with
comorbidities will need the vaccine to protect them (Quote I11, Table 3). The participants also viewed vaccines as insufficient–they
expected that getting vaccinated means no longer needing other public health interventions but were disappointed to learn that
vaccines are only one part of the solution. Participants therefore questioned the need for the vaccines given the information they
have read and/or watched about still being at risk of getting infected despite being vaccinated (Quote I12, Table 3). The lack of
clarity in the role of the vaccines has negatively influenced people’s decisions on getting the vaccine.
Skepticism towards vaccine incentives.
Vaccine incentives in the country, such as promotions and offers for those vaccinated, created skepticism among some of the
participants. These incentives ‘bothered’ participants and raised questions about the role of vaccines and the intentions of the
government. As a result, these incentives ‘disincentivised’ participants from getting the vaccine as participants felt being forced to
take it (Quote I13, Table 3).
Use of vaccines not fully approved by the Food and Drug Administration (FDA).
Participants viewed decisions to vaccinate individuals as ‘rash’ and expressed concerns about vaccines not yet being fully
approved by the Food and Drug Administration (FDA). Some also shared concerns about the rapid development of vaccines
compared to other vaccines that took decades to develop (Quote I14, Table 3). Participants felt that they were being experimented
on using an unproven vaccine, relating this with the dengue vaccine controversy (Quote I15, Table 3). This caused delay or refusal
in getting the vaccines when it was offered to them.
Low health literacy and lack of critical skills to evaluate health information.
Health literacy or how people acquire, evaluate, and apply health information to inform their decisions, including getting the vaccine,
is an important but underestimated tool to combat misinformation. Participants shared that Filipinos seemed to know a lot about
vaccines, but only superficially. They shared that those among low-resource communities and older population groups were
especially vulnerable to misinformation (Quote I16, Table 3). This lack of awareness and critical skills to evaluate information,
together with the rapid spread of misinformation, influences people’s decisions to get their first dose, to return to their second and
get fully vaccinated (Quote I17, Table 3). There were also several participants who shared that they were confused with the
contradictory information they were reading and hearing (Quotes I18, Table 3).
Religious beliefs do not support vaccines.
‘Antichrist’–this was how one participant described the vaccines against COVID-19. Another participant shared concerns about the
vaccines and how they would replace antibodies created by God (Quote I19, Table 3). She mentioned that these vaccines have
active chemicals that are causing unintended side effects and deaths.
Interpersonal barriers
Family influence and opposition to vaccines.
Participants recognised the influence of their family on their health decisions including getting vaccinated. One participant who was
opposed to COVID-19 vaccines shared that everyone in their family was unvaccinated because they believed her (A1, 51–60 years
old, female, Misamis Oriental). Similarly, a mother who had a negative experience related to the dengue vaccine that was
administered to her child, refused to have herself and her family vaccinated against COVID-19 (B2, 41–50 years old, female,
National Capital Region).
Misinformation spread by networks.
Rumours and misinformation about COVID-19 vaccines are easily spread by networks, whether by word of mouth or through social
media. A participant said her “eyes have been opened only now because of YouTube” (A2, 61–70 years old, female, Camarines
Norte). Participants believed that this affected vaccine uptake, especially among individuals who do not have the opportunity to
receive accurate information from official sources including the Department of Health (Quote IC1, Table 4).
Table 4. Illustrative quotes for interpersonal and community barriers.

Perceived conflicts of interest of health professionals.
Participants viewed key figures in the response to the pandemic as having conflicts of interests. This perception of having ‘hidden
agenda’ created mistrust in the information provided health professionals, health organisations, and other figures and institutions.
These conflicts of interest, whether financial or non-financial, subject evidence and data to bias especially if there are undesired
adverse effects to the treatment or vaccine (Quote IC2, Table 4).
Structural barriers: Health systems and service delivery
Inadequate supply of vaccines.
Observations of participants regarding supply of vaccines varied according to location and membership to the vaccine priority
groups. Participants, especially those from cities and provinces outside of metropolitan areas, reported that the supply of vaccines
was insufficient to meet the demands and needs of the communities (Quote S-HS1, Table 5). However, even within highly
urbanised areas, participants shared that there were those who did not get their second doses on time because no vaccines arrived
(Quote S-HS2, Table 5). Health workers found that vaccines for them were easily accessible, however those in other groups had to
wait longer before getting the vaccine (Quote S-HS3, Table 5).
Table 5. Illustrative quotes for structural barriers relating to health systems and service delivery.
Perceived inefficiencies of the vaccination system.
Participants highlighted issues with the system including the slow rollout of vaccines, long waiting time, inefficient registration
systems, and lack of a centralised system. Participants mentioned getting frustrated with the speed at which vaccines are being
distributed and administered in the country (Quote S-HS4, Table 5). Participants also mentioned issues with the waiting process to
get a slot after registration and the waiting time at the day of the vaccination, with some being asked to stay at vaccination sites for
two hours to watch a seminar on COVID-19 and vaccines (Quotes S-HS5-6, Table 5). There was perceived risk of exposure, which
could be lessened if the process was faster and more efficient. There were also glitches in the online registration systems used by
local governments that caused additional delays in getting people vaccinated (Quote S-HS7, Table 5). Local governments are
responsible for the distribution and administration of vaccines among their constituents, and individuals may register with various
local governments depending on their place of residence or work. This lack of a centralised system makes it difficult to track who
have already been vaccinated and where they have been vaccinated such that those who are still waiting for a slot are unable to
secure one (Quote S-HS8, Table 5).
View that the vaccination system is inflexible and excludes vulnerable and marginalised populations.
The current vaccination system of some local governments is viewed as inflexible that excludes vulnerable and marginalised
populations. There are individuals who lack access to technology and digital platforms. Especially in rural areas and among the
elderly, their exclusion due to access issues is further compounded by their low digital health literacy. These individuals are then
unable to register online and get the vaccine (Quote S-HS9, Table 5). While registration is online, even those in older age groups
who are part of highly prioritised groups because of their susceptibility to the virus are required to go to the vaccination centre
(Quote S-HS10, Table 5). Similarly, those belonging to marginalised groups and communities also encounter considerable
challenges to getting the vaccine (Quote S-HS11, Table 5).
Logistical challenges.
A participant recognised that there are also logistical constraints in the distribution of vaccines, in addition to problems with supply.
The COVID-19 vaccines have different temperature requirements with some requiring special distribution systems (S-HS12, Table
5). These logistical challenges influence the distribution of vaccine brands to areas that have the capability to store them and affect
decisions to delay getting the vaccine especially among those who prefer other brands (S-HS13, Table 5).
Health professionals seen as amplifiers of misinformation.
Misinformation on vaccines and treatment were not only observed within families and social networks, but also within the medical
community reported by participants who are health professionals themselves. There have been debates about Ivermectin as
treatment for COVID-19, as well as vaccines, which have created factions within the group (S-HS14, Table 5). Some of these
health professionals who are anti-vaxxers or opposed to vaccines publicly share their views in media and in their practice (S-HS15,
Table 5). Because of the stature and credibility of health professionals, their views, whether backed by science or not, get amplified
in the media and communities.
Pandemic response deemed as ineffective affects trust in health institutions.
The response and messaging of health organisations, together with other key figures and institutions in the country, were viewed by
participants as ineffective (S-HS16, Table 5). As a result, there is declining trust in these organisations with participants doubting
information provided, such that Filipinos no longer take the pandemic seriously (S-HS17, S-HS18, Table 5). In turn, participants
turn to other sources of information that they think are more credible and trustworthy.
Structural barriers: Media and policies
Traditional and digital media accelerating the infodemic.
Information on the virus and vaccines are easily and effectively amplified by the media. With the infodemic (portmanteau of
information and epidemic) or the exponential production of information whether scientifically accurate or not, traditional media and
digital media become drivers of (mis)information or fear towards vaccines (Quotes S-MP1-S-MP2, Table 6). Information that
participants were receiving from these sources influenced their health beliefs and vaccine decisions (Quote S-MP3, Table 6).
Table 6. Illustrative quotes for structural barriers relating to the media and policies.
Perceived poor policy implementation and lack of evidence-based policies contributing to loss of confidence in vaccines and health institutions.
The government developed the Philippine “National Deployment and Vaccination Plan for COVID-19 Vaccines” that identifies
population groups to be prioritised ensure vaccine equity accounting for different risks and needs [36]. This plan also stated that
only vaccines granted with emergency use authorisation (EUA) or certificate of product registration (CPR) by the Philippine FDA will
be purchased by the government. However, this was reported by participants to be poorly implemented with others using
connections also known as ‘palakasan’ system to get the vaccine ahead of those in the priority list (Quote S-MP4, Table 6). Even
within the government, the Presidential Security Group were given vaccines even without EUA and/or CPR registration from the
FDA (Quote S-MP5, Table 6). In addition, the government purchased vaccines that did not publish their results, and reportedly had
lower efficacy rates but more expensive (Quote S-MP6, Table 6). As a result, participants felt that the government was ‘settling for
less’ and that Filipinos deserved better (A4, 21–30 years old, female, National Capital Region). These issues contributed to
declining confidence in vaccines and health institutions, with Filipinos questioning the safety of such vaccines and the
implementation of these prioritisation frameworks.
National and local political issues.
Past and current political issues contributed to refusals to specific vaccine brands. Together with reports of how the virus emerged
from Wuhan, China, these triggered skepticism towards vaccines manufactured in their country. Participants mentioned the dispute
of the Philippines and China regarding contested territory at the West Philippine Sea (South China Sea) as a reason for not
preferring and/or refusing vaccines from their country, even when donations of Sinovac from China were the first vaccines to be
available (Quote S-MP7, Table 6). This dispute also influenced how participants thought about the origins of the virus and why
other countries developed their own vaccines (Quote S-MP8, Table 6). Locally, participants viewed politics to have influence on
which cities or provinces receive preferred vaccine brands. They mentioned that these ‘favored hospitals and provinces’ were
prioritised, which was perceived as unfair and causing further delays in the vaccination rollout (Quote S-MP9, Table 6).
Discussion
One of the most effective public health strategies, vaccination, has been the focus of false and inaccurate information with rapidly
declining rates of acceptance. [37]. In the Philippines, vaccine confidence plummeted after the Dengue vaccine controversy [9, 12,
15–17]. While anti-vaccination views and vaccine hesitancy are not yet the main barrier to vaccination in the Philippines which still
struggles with vaccine access and distribution, lessons from other countries indicate that these equally and urgently need to be
addressed in addition to other challenges [38]. Our study supports the findings of other published research that report a host of
individual, interpersonal, and structural barriers that work individually or collectively against vaccination uptake and reach [29].
Therefore, there is a need for a holistic approach to promote COVID-19 vaccination that not only addresses barriers at the
individual level, but also at the interpersonal and structural levels [38, 39].
Individual perceptions, beliefs, and experiences play a major role on the decision to vaccinate. These are shaped by exposure to
(mis)information spread by networks, by key health figures and institutions, and through the media [40–43]. Misinformation
regarding vaccines have been present since vaccines were first developed [44–46], but the advent of social media made its
propagation much easier [43, 45, 47]. Unique to the Philippine context is vaccine brand hesitancy, specifically towards Chinese
manufactured vaccines and mRNA vaccines. This is caused in part by lack of transparency and scientific information, and spread
through networks and the media. Further aggravating the issue is how some people attempt to correct misconceptions in a way that
alienates people instead of addressing misinformation. People involved in vaccine promotion activities, especially primary care
providers, may need to be trained on how to engage with vocal vaccine deniers and promote vaccination. The World Health
Organization document outlining how to respond to vaccine misinformation would be an important resource in such an endeavour
[48]. Celebrities and social media influencers may also play a role in promoting vaccination [41], but it is essential that they disclose
conflicts of interest to develop trust with their audience. The media also needs to be trained on how to present news regarding
adverse effects following immunsation, and regarding COVID-19 in general, so as not to create unnecessary panic and dissuade
people from getting vaccinated. A study reported that there may be a need to use first-person, people-centred narratives to prevent
‘psychic numbing’ and give faces to numbers [49]. In all these, it is vital to engage with the public, especially those who are vaccine
hesitant, in order to promote vaccination using language that is inclusive and applicable to their context [48].
The health system and one’s interactions with it also contribute to one’s decision to get vaccinated. As in this study, trust in the
health system has been found to be a major factor in getting COVID-19 vaccine [41, 50]. The Philippine government has instituted
several health system confidence-building policies. The recent COVID-19 Vaccination Program Act stipulates the provision of free
COVID-19 vaccines to all Filipinos and the establishment of an indemnification fund for people who could possibly develop adverse
effects following immunisation [51]. Perceptions of ‘palakasan’ (i.e., use of political connections), stemming from instances during
the course of the pandemic where powerful individuals seem to be above the law [52], contribute to vaccine hesitancy and poor
uptake of vaccines. These negative impacts are further compounded by the highly politicised Dengvaxia controversy where
individuals, especially parents of school-age children, felt that health institutions and governments were experimenting on them [9,
12] with our participants relating the COVID-19 vaccine ‘experiment’ with the dengue vaccine. In addition, inadequate supply,
logistical challenges, and perceptions about the inefficiency and inflexibility of the system negatively impact vaccination rates in the
country. As of 16 September 2021, only 3 in 10 Filipinos received one dose with significant differences between population groups:
almost all frontline and health workers have been vaccinated while only 2 in 5 elderly Filipinos received their first dose [21]. Those
in the third priority group have higher rates than the elderly population group, which were offered the vaccines earlier. Apart from
individual reasons, marginalised and vulnerable groups such as the elderly have reported not being able to get their vaccine due to
lack of home vaccination services and guidance in using online registration systems. The system will need to consider needs of all
population groups to improve vaccination uptake. In all these, trust in the health system needs to be maintained, while disregarding
regulations and policies in place can erode trust in the vaccination process.
In the Philippines, the national government has the responsibility to procure, allocate, and distribute the vaccines to the different
provinces and municipalities, but it is the local government that is responsible for last-mile transport and actual inoculation. This
results in wide variations in client registration and procedures between different localities. This underlines the need to identify best
practices in vaccine rollout systems to implement a system that is efficient and inclusive to ensure that access to technology and
mobility will not be barriers to vaccination.
There are a number of limitations that need to be considered when interpreting our findings. First, we were not able to have
representation from the A5 priority group (indigent population). While we initially were able to get a participant from this group
based on the survey response, we later found during the interview that this individual belonged to a different vaccination priority
classification. This may point to issues with online data collection where researchers are unable to reach individuals from low-
resource households. Second, there may be social desirability bias because we were unable to ensure if the respondent had other
people with them that may have caused a change in their responses. Additionally, we did not disclose any political affiliations and
interests, but participants may have been cautious in mentioning negative experiences related to vaccination. Participants may also
have chosen more positive responses considering our background as health researchers. However, we emphasised that they will
remain anonymous and their data treated with utmost confidentiality. Lastly, factors influencing COVID-19 vaccination uptake is
context-specific, and this paper does not aim to represent all situations and circumstances.
Conclusion
Challenges to COVID-19 vaccination may be individual, interpersonal, and/or structural, which interact to influence decisions.
Individual perceptions play a major role in the decision to vaccinate, and such perceptions are shaped by exposure to
(mis)information amplified by the media, the community, and the health system. In the Philippines, vaccine brand hesitancy and
misinformation are prevalent due to their rapid spread through social media and sensationalism in traditional media. Information on
the effectiveness of safety of vaccines regardless of brand needs to be communicated to the public to increase COVID-19 vaccine
confidence. At the interpersonal level, exposure to networks and health workers who are opposed to vaccines heightens public
skepticism of vaccination. Structural barriers including political issues and poor implementation further contribute to vaccine
refusals. The ongoing infodemic and anti-vaccination sentiments operating at all three levels (individual, interpersonal, structural)
require empowering individuals to evaluate health information, and therefore health literacy becomes a critical tool to combat
misinformation. Families and peers also need to be involved in these discussions as they influence vaccine uptake. Individuals
engaged in vaccine promotion activities may need to be retrained on how to engage with vocal vaccine deniers in public. Given the
involvement of traditional media, trainings on public health and science communication may be helpful in reporting vaccination-
related news. Public figures need to disclose conflicts of interests and be transparent to the public, laying out the risks and benefits
of vaccines. Laws should be well-implemented and equally implemented regardless of socioeconomic class or social position to
encourage trust in the health care system and in vaccination initiatives. There is also a need to study best practices in vaccine
rollout to implement systems that are efficient and inclusive so that we can vaccinate as many people against COVID-19 as quickly
and as inclusively as possible: provide technological support particularly among older populations and allow flexible options for
receiving the vaccine such as home vaccination. Given resource limitations, the vaccination rollout could also be improved by
increasing the role of the private sector in the rollout and administration of the vaccine. The government and health organisations
will need to connect with individuals, communities, and other institutions, including those who are against vaccines or hesitant
towards vaccines, to co-create effective and sustainable solutions.
Acknowledgments
We would like to thank Michelle Edillon, Kriselle Abcede, Ryan Molen, and Josef Bondoc for their invaluable support to this project.
We provide credit to BioRender.com for the figures illustrated in this paper. Finally, we are grateful to our participants who
generously shared their stories with us.
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COVID-19 vaccine brand hesitancy and other challenges to vaccination in the Philippines | PLOS Global Public Health 10/20/23,

COVID-19 vaccine brand hesitancy and other challenges to

Published: January 13, 2022 https://doi.org/10.1371/journal.pgph.0000165 See the preprint

Editor: Dione Benjumea-Bedoya, Corporacion Universitaria Remington, COLOMBIA

Material and methods

Participants and recruitment

Table 1. Vaccine prioritisation framework (2020).

Fig 1. Social ecological model applied to COVID-19 vaccination.

Patients and public involvement

Table 2. Characteristics of interview participants.

Vaccine brand hesitancy and brand preferences.

Table 3. Illustrative quotes for individual barriers.

Vaccines are viewed as unsafe and deadly.

Vaccines are viewed as unnecessary and insufficient to prevent disease.

Skepticism towards vaccine incentives.

Religious beliefs do not support vaccines.

Family influence and opposition to vaccines.

Misinformation spread by networks.

Table 4. Illustrative quotes for interpersonal and community barriers.

Perceived conflicts of interest of health professionals.

Structural barriers: Health systems and service delivery

Inadequate supply of vaccines.

Perceived inefficiencies of the vaccination system.

Health professionals seen as amplifiers of misinformation.

Pandemic response deemed as ineffective affects trust in health institutions.

Structural barriers: Media and policies

Traditional and digital media accelerating the infodemic.

National and local political issues.

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