COVID-19 Vaccine Brand Hesitancy and Other Challenges to Vaccination in the Philippines

"Improving adherence to interventions and vaccination rates...requires a better understanding of the different reasons behind vaccine mistrust..."

The highly politicised dengue vaccine controversy in the Philippines in 2017 damaged trust in vaccines and the health sector, leading confidence levels to dramatically drop and impacting subsequent vaccination efforts, including the COVID-19 vaccination campaign. In low- and middle-income countries (LMICs) like this one, COVID-19 vaccine uptake is challenged not only by vaccine hesitancy and anti-vaccination sentiments but by an already-weak health system and inequitable global vaccine distribution. This paper explores vaccination narratives and challenges experienced and observed by Filipinos during the early vaccination period of the pandemic.

The researchers 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. (As of September 16 2021, only 3 in 10 Filipinos had received one dose, with significant differences between population groups: Almost all frontline and health workers had been vaccinated, while only 2 in 5 elderly Filipinos had received their first dose.)

Data from the interviews informed the findings of this paper. To highlight the complex reasons for delaying and/or refusing COVID-19 vaccination, the researchers embed the findings within the social ecological model (SEM), 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). Interviewees' views on the barriers to COVID-19 vaccination are presented, organised using the three tiers of the SEM, and illustrated by direct quotations - either in the original English or translated from Filipino or Cebuano.

The analysis showed that individual perceptions play a major role in the decision to vaccinate. For example, vaccine brand hesitancy was a common theme among the participants, with past and current political issues contributing to refusals to specific vaccine brands. The country's first administered vaccine was Sinovac-CoronaVac, which is manufactured by a Chinese biopharmaceutical company. Reports that the virus emerged from Wuhan, China triggered skepticism towards vaccines manufactured in that country. The vaccine 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. In addition to concerns about the effectiveness of the vaccine, participants had read and heard information indicating that this specific vaccine was using the same virus to "immunise" an individual's system, which may have unintended effects. Other participants noted that this specific brand was not recognised by other countries and therefore wanted and waited for other vaccines. Meanwhile, still others refused to receive mRNA vaccines due to beliefs about its safety and effectiveness.

Connected to the theme of brand hesitancy is the perception that the COVID-19 vaccines are unsafe or even deadly. Some participants felt they were being experimented on with an unproven vaccine (not yet being fully approved by the Food and Drug Administration due to the emergency nature of the vaccination), relating this case to the dengue vaccine controversy. Vaccine incentives in the country, such as promotions and offers for those vaccinated, created skepticism among some of the participants. Other mistrustful feelings could be traced to negative experiences - either one's own (individual level of the SEM) or among family and friends (interpersonal level of the SEM) - with vaccination (e.g., the dengue vaccine) and/or the medical system in the past.

Some questioned the need for the COVID-19 vaccine, with younger participants sharing they were COVID-19 survivors even without the vaccine, and others feeling disappointed, given the information they had read and/or watched about still being at risk of getting infected despite being vaccinated. The lack of clarity about the role of the vaccines has negatively influenced people's decisions to get it.

The research revealed that such perceptions are shaped by exposure to (mis)information amplified by the media, the community, and the health system. Some participants viewed key figures in the response to the pandemic as having conflicts of interests. This perception of having a "hidden agenda" created mistrust in the information provided health professionals, health organisations, and other figures and institutions.

Misinformation is often spread through networks, whether by word of mouth or through social media. A participant said her "eyes have been opened only now because of YouTube". Participants shared that Filipinos in low-resource communities and older population groups are especially vulnerable to misinformation. "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."

At the structural level, perceptions about the inefficiency and inflexibility of the health system also create additional barriers to the vaccine rollout in the country, especially among vulnerable and marginalised groups. In rural areas and among the elderly, their exclusion due to access issues is further compounded by their low digital health literacy.

Furthermore, the response and messaging of health organisations, together with other key figures and institutions in the country, were viewed by participants as ineffective. Perceived poor policy implementation and lack of evidence-based policies contribute to loss of confidence in vaccines and health institutions. As a result, there is declining trust in these organisations with participants, such that some Filipinos no longer take the pandemic seriously and/or turn to other sources of information they think are more credible and trustworthy. Traditional and digital media accelerate the infodemic.

Reflecting on the findings, the researchers urge that addressing the ongoing infodemic and anti-vaccination sentiments operating at all three SEM levels (individual, interpersonal, structural) in the Philippines requires strategies such as:

• Empowering individuals to evaluate health information through health literacy initiatives;
• Expanding discussions to involve those who influence uptake: families and peers;
• Retraining individuals engaged in vaccine promotion activities on how to engage with vocal vaccine deniers in public;
• Building the capacity of journalists who report vaccination-related news in public health and science communication;
• Requiring public figures to disclose conflicts of interests and be transparent to the public, laying out the risks and benefits of vaccines;
• Ensuring laws should are well implemented and equally implemented regardless of socioeconomic class or social position to encourage trust in the healthcare system and in vaccination initiatives;
• Studying best practices in vaccine rollout to implement systems that are efficient and inclusive;
• Providing technological support (particularly among older populations), allowing flexible options for receiving the vaccine (such as at-home vaccination), and increasing the role of the private sector in the rollout and administration of the vaccine; and
• Connecting with individuals, communities, and other institutions, including those who are against vaccines or hesitant towards vaccines, to co-create effective and sustainable solutions.

In conclusion: "Recognising and addressing concerns at all levels are needed to improve COVID-19 vaccination uptake and reach."