Portraying the stories behind vaccine hesitancy
Project SALUBONG (Shared Appraising, Life stories and Uncovering, Bridging and Optimizing, and Navigating and Gaining) is a mixed-method study aimed at co-developing a story-based vaccine confidence intervention together with its end-users.

The roll-out of recently developed vaccines against the novel pathogen SARS-COV-2 last March 2021 sparked polarizing debates surrounding the concept of vaccines or bakuna across all media platforms. Despite the longstanding triumph of vaccines in eradicating infectious diseases, you would still be surprised by the number of Filipinos unwilling to get vaccinated despite its availability.

Vaccines has been proven time and again that it is one of the most cost-effective measures against diseases. Not only does vaccination protect an individual from getting sick, it also prevents societal and economic burden as it reduces national spending on disease treatment and control.

Back in 2015, Philippines was once among the top ten countries worldwide for vaccine confidence. This changed dramatically after the onslaught of disinformation following the large-scale and highly politicized Dengvaxia controversy.

The national government had high hopes for French pharma giant Sanofi’s Dengvaxia – the world’s first vaccine approved for the prevention of dengue. In 2016, Dengvaxia was accessible in the Philippines and was launched in a school-based vaccination program inoculating over 800,000 children. A year later, Sanofi released a statement restricting the use of the vaccine only to those who had been previously infected with dengue.

After a few months following Sanofi’s announcement, the vaccination program became a national scandal, spotlighting the potential implications to the safety of the children who received the vaccine.

The Dengvaxia crisis fanned the public’s fear towards vaccination. Parents of inoculated children clamored for accountability and justice. Credibility of health officials and scientists were questioned, and the flurry of fake news obscured the science behind vaccination.

It wasn’t long until the rates of vaccine uptake in the country’s immunization programs plummeted with vaccine confidence dropping from 93% in 2015 to only 32% in 2018. This unwillingness to get vaccinated gave rise to the phenomenon and misinformed movement known as vaccine hesitancy (VH) – the delay in acceptance or refusal of vaccines despite availability of services.

According to the World Health Organization (WHO), VH is among the top 10 threats to global health. It reverses the progress made in managing vaccine-preventable and infectious diseases.

In low- and middle-income countries (LMIC) such as the Philippines, VH along with a feeble health system, and constrained hospital access results in outbreaks of previously controlled or eradicated diseases.

In fact, the decline in vaccination rates led to the declaration of a measles outbreak in 2019 and the poliovirus re-emergence in 2020 – breaking the country’s record of being polio-free for 19 years.

Understanding the phenomenon

Project SALUBONG team kick-off meeting last 2019

Narratives and perception on vaccination was drastically reshaped following the Dengvaxia scare. Vaccine Hesitancy (VH) is in an all-time high. However, little is studied nor documented in terms of understanding the experiences or concerns of caregivers (i.e. parents, head of households, and legal guardians) when it comes to the delay or refusal of childhood vaccination here in the Philippines.

With limited evidence to guide policy makers in considering VH interventions, Dr. Mark Donald Reñosa of the Research Institute for Tropical Medicine (RITM) together with Dr. Shannon McMahon of the University of Heidelberg explores and investigates the local narratives surrounding VH through Project SALUBONG, a mixed-method study aimed at developing a vaccine hesitancy intervention.

“Vaccine hesitancy is multi-dimensional and very complex. We wanted not to rely mainly on the blunt tool of scientific reason or evidence…but on a detailed understanding of the target population’s individual choices, in our case – families of small children,” explained Dr. Reñosa.

One of the published papers under Project SALUBONG purposively selected vaccine hesitant caregivers of under-five children from Dasmariñas and Silang, Cavite. Four (4) barriers of childhood vaccine uptake emerged from this study. These are individual, interpersonal and community, health system, and superstructural barriers.

RITM Senior Science Research Specialist Ms. Jhoys Guevarra performs online data collection. 

Among the four, individual and interpersonal and community barriers surfaced as primary factors affecting VH. Individual barriers reflect fears associated with vaccination such as side effects and in the light of novel vaccines.

According to Project SALUBONG coordinator Ms. Jhoys Guevarra, these fears are rooted on the caregivers actual experiences and were heightened by the misinformation following the Dengvaxia vaccination. Ms. Guevarra also noted that perceived lack of information is another component under individual barriers.

In terms of interpersonal and community barriers, it was reported that caregivers often defer to household heads or eldest members of the household who continuously oppose vaccination for its harmful effects – to avoid arguments and conflict.

Health system barriers include long waiting time, appointment rescheduling, and negative feelings towards school-based vaccination as caregivers have no idea who is to be held accountable for adverse reaction; while superstructural barriers includes natural calamities and the fear of getting COVID-19 and associated community lockdowns.

The results gathered from this study aimed to understand the present situation of VH in the CALABARZON region. However, it is only one of the several phases for data collection under Project SALUBONG. Aside from the caregivers, the study population included community leaders, policymakers, healthcare workers, and barangay health workers.

Human-centered VH intervention

One might ask, why gather multiple perspectives and narratives on VH? Dr. Reñosa expressed that this is because Project SALUBONG’s  methodology is grounded on human-centered design (HCD) where the process involves the active participation of the audiences targeted, which will in turn result into solutions tailor-fit to suit their needs.

“Using HCD is unique and unconventional because it creates a shared reflection, and captures situated cognition among those who are hesitant (families) and those who are on the frontlines of contending the epidemic of vaccine hesitancy. We are positive that since ‘we’ are with them along the way, then ‘they’ will help us find solutions to combat the health problem, somewhat a win-win situation,” said Dr. Reñosa.

RITM Senior Science Research Specialist Ms. Carol Malacad conducts an online intervention trial aiming to test the efficacy and adaptability of the SALUBONG intervention among 800 parents or caregivers of under-5 children

The Project SALUBONG team utilized the insights gathered and developed a story-based VH intervention to revive vaccine confidence in the country. The video is a 5-minute animated, locally-produced and empathic video co-created by families, healthcare workers, community leaders, and experts.

“The idea of the cartoon video came up during the conversations with the families, community members, and healthcare workers. They wanted something that they can watch and relate to: colorful and snappy, free of ‘political colors’, and a video that is easy to understand,” Dr. Reñosa explained.

The whole intention of the video is to portray salient real-life stories on vaccination. At the same time, the video can easily be incorporated into the many existing programs being managed by barangay health workers in the communities.

At present, the Project SALUBONG video intervention is being tested versus a control video in rural and urban barangays in province of Cavite targeting 800 caregivers. After which, the video will be launched on a large-scale experimental trial to assess the efficacy and acceptability of the intervention.

“It is our hope that as healthcare workers, researchers, and scholars, we continue to work together to build a contextual-based, a situational-specific, and human-centered intervention to address vaccine hesitancy and to bolster vaccine uptake,” ended Dr. Reñosa.


by Anel Azel Dimaano, Communication and Engagement Office

by Allenor Enciso, Communication and Engagement Office