Characteristics of included participants
A total of 57 KIIs were conducted in the study sites, namely, Regions IV-B, V and VIII covering six provinces, and 12 municipalities. Program managers, coordinators and implementers at the national, regional, provincial and municipal levels were interviewed. From the six study sites in the three different regions, a total of 143 participants engaged in 12 FGDs (see Table 1). Most (97.9%) were female primary caregivers with a few BHWs with children aged 0–11. The age range of the participants was 19 to 76 years old, and the number of their children ranged from 1 to 10. Three quarters of participants had at least a high school education, and most were housewives (62.1%). In some of the study sites, there were participants belonging to Indigenous Peoples communities.
Behavioural 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 (See Additional file 3). Table 2 below outlines the various domains of the BeSD and levels of SEM vis a vis themes from the study.
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 centres for vaccination. First-time mothers found this worrisome as 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 with even a mild viral illness:
“Others think that when their children are sick, giving them vaccines will make the sickness worse and that there will be complications.” (Region VIII FGD)
Social processes. Influential social processes were identified at the interpersonal, institutional, community, 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 elders, particularly grandmothers. Some elderly FGD participants didn’t see the value of vaccination:
“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 campaign of the DOH in increasing vaccination uptake [29]. The campaign involves BHWs in selected municipalities and volunteers from the community:
“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.” (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. BHWs are a part of the community and highly trusted. Participants felt BHWs could be easily approached for health advice:
“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 supported the sentiment of the BHWs.
At the institutional level, KIs and FGD participants 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 emphasized the importance of incentives, however, KIs noted that this practice was not sustainable for the local government units and so it was not considered as a main strategy to increase vaccine uptake,
“…when there are no incentives, people do not come.” (Region V KII)
Influences at the community level included information from government officials and agencies. FGD participants across the different regions mentioned that the local government officials like Mayors and Barangay Chairpersons were trusted sources of information on health. They mentioned that,
“If the information comes from the barangay [officials], I know that it’s reliable.” (Region V FGD).
KIs in all regions also mentioned that the number of vaccinated children increased due to a recent national Supplemental Immunization Activity against measles, rubella, and polio in May 2023. However, when asked to assess an example audio visual material from this campaign, some FGD participants noted that the individuals on the image were not representative of the local Indigenous Peoples communities in their area.
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 invited the leaders of the [Indigenous Peoples] 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 favour 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 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.
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 social driver of routine immunization in children. In this program, the poorest families are provided with cash assistance if they comply with regular preventive health and nutrition services, including availing vaccines included in the NIP [30].
Practical issues. Individuals and families cited transportation and economic issues as barriers to vaccination. KIs in all regions mentioned that those residing in geographically isolated and disadvantaged areas, were often missed in routine immunization. According to a KI, daily wage earners were most likely to spend on daily necessities rather than on immunization, particularly when a trip to and from the health centre would cost more than a day’s toil:
“…it depends on the budget of the household. A round trip … to the centre costs around 500 pesos (PHP 500 = US $9).” (Region V KII)
Another reason for missing the scheduled vaccination of the children was 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)
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, thus, resulting in loss of income for the husband. 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, spot-mapping target clients, tracking pregnant mothers, conducting outreach vaccination activities and house-to-house visits.
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 number of vaccines they received did not match what that they requested, resulting in lack of supply. Recent intensive promotion during the Supplemental Immunization Activity motivated people to get vaccinated, but limited supply meant many people 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 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, trans-ins are not included in the target client list.