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Background: Despite the effort to eradicate rabies in the Philippines, human rabies cases have not decreased in the past decade. Rabid dogs pose the most significant hazard in the countries with the highest burden of rabies, and 70% rabies vaccine coverage is recommended for dogs in high-risk areas. Ascertaining the owned dog population and community knowledge on rabies can help improve vaccine coverage and information campaigns. Methodology/Principal findings: We conducted a cross-sectional survey in six randomly selected communities (five urban, one rural) in Central Luzon, Philippines. We first conducted the complete mapping of 9,173 households and then randomly selected 727 households. More than half (54.1%) of the households owned dogs (1.21 dogs/household). In the 727 households, we identified 878 owned dogs and 3256 humans. According to these results, the dog-to-human ratio was approximately 1:3.7. Only 8.8% of households reported a history of dog bite in 2019. Among dog-owning households, 31% reported that they allow their dogs to roam freely. Of the recorded dogs, 35.9% have never been vaccinated, and only 3.5% were spayed or castrated. Factors associated with lower rabies knowledge include (1) no education aOR: 0.30 (0.16–0.59), and (2) only primary school education aOR: 0.33 (0.22–0.49). In contrast, factors associated with higher knowledge include (1) owning a dog and not allowing them to roam freely aOR: 2.01 (1.41–2.87) and (2) owning a dog and allowing them to roam freely aOR: 1.84 (1.17–2.92), when compared to those with no dogs. Conclusions/Significance: We identified a larger dog population in the community than the usual estimates (1:10), suggesting that annual vaccine needs in the Philippines must be reassessed. Our survey shows a relatively good understanding of rabies; however, awareness of the concept of rabies as a disease, and how animals and humans can acquire it, is lacking. Author summary: Rabies is a fatal disease primarily transmitted by rabid dogs. It is estimated that 59 000 human deaths occur worldwide annually because of rabies. Prevention is possible using pre-exposure prophylaxis or post-exposure prophylaxis (PEP). Despite this, rabies remains a neglected disease and a burden, particularly in developing countries. In this study, we found that the current estimated dog to human ratio of 1:10 may be incorrect. Our data show that the ratio of 1:3.7 may more closely reflect real-world figures. This finding is supported by previous studies on dog populations. We provide compelling evidence that there is a need to revise the current guidelines for estimating the dog population to provide adequate vaccine coverage. Our findings on community knowledge about rabies show that there is relatively good understanding regarding rabies; however, awareness of the concept of rabies as a disease and how animals and humans can acquire it is lacking. This should be a point of focus for future education campaigns. [ABSTRACT FROM AUTHOR]

Vaccine scares undermine longstanding global health achievements. Remarkably little data has documented the lived experiences of policymakers working amidst vaccine scares and navigating their fallout. As a result, chances and challenges of large-scale national recuperation efforts are poorly understood. This study aims to explore the perspectives of policymakers involved in ongoing efforts to boost vaccine confidence in the Philippines following a 2017 Dengvaxia scare and the current COVID-19 pandemic. Between August and November 2020, we conducted 19 semi-structured narrative interviews with purposively selected policymakers from governmental agencies and non-governmental organizations in the Philippines. Interviews were conducted online, transcribed, and analyzed following the tenets of reflexive thematic analysis. We present results as an emerging model that draws on a chronology conveyed by policymakers in their own words. The Dengvaxia scare proved 'a decisive wedge' that splintered Filipino society and pitted governmental agencies against one another. The scare stoked distorted vaccination narratives, which were 'accelerated rapidly' via social media, and ignited feelings of uncertainty among policymakers of how to convey clear, accurate health messaging and how to prevent drops in care-seeking more broadly. Efforts to regain trust placed exceptional burdens on an already-strained health system. Respondent-driven recommendations on how to reinforce vaccine confidence and improve vaccination rollout include: developing clear vaccine messages, fostering healthcare providers' and policymakers' communication skills, and rebuilding trust within, toward and across governmental agencies. Further research on how to build enabling environments and rebuild trust in and across institutions remains paramount. [ABSTRACT FROM AUTHOR]

Background: Soil-transmitted helminth (STH) infections are still prevalent among schoolchildren in the Philippines. We evaluated the risk factors associated with STH and the relationship between STH and nutritional indices among schoolchildren aged 9–10 years in Laguna province, the Philippines. Methods: We used the baseline data from 40 schools enrolled in a randomised controlled trial of the Magic Glasses Philippines health education package. Data on demographic and socio-economic variables, and STH related knowledge, attitudes and practices, were obtained through a questionnaire. Stool samples were collected and assessed for STH egg presence using the Kato-Katz technique. Haemoglobin levels and height and weight of study participants were also determined. The generalized estimating equations approach was used to construct logistic regression models to assess STH-associated risk factors, and the association between any STH infection and anaemia, child stunting, wasting and being underweight. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000508471). Findings: Among 1,689 schoolchildren, the prevalence of any STH was 23%. The prevalence of anaemia, stunting, being underweight and wasting was 13%, 20.2%, 19% and 9.5%, respectively. Age, socio-economic status, rural/urban classification of schools and knowledge of STH were significant risk factors for acquiring a STH infection. Moreover, infections with any STH were significantly associated with stunting (P = <0.001) and being underweight (P = <0.003), but not wasting (P = 0.375) or anaemia (P = 0.462) after controlling for confounding covariates. Conclusion: The study findings emphasise the need for sustainable deworming in tandem with other measures such as the provision of health education, improvements in sanitation and hygiene, and nutritional programs in order to control STH infections and improve morbidity outcomes in schoolchildren. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12616000508471). Author summary: Soil-transmitted helminth (STH) infections continue to be high among schoolchildren in the Philippines despite the conduct of semi-annual nationwide school-based mass drug administration (MDA) program more than a decade ago. In this cross-sectional survey, we assess the prevalence of STH, the risk factors associated with infection, and the impact of STH on nutritional indices among schoolchildren in Laguna province, the Philippines. Our results show that STH prevalence (23%) remains above the World Health Organization (WHO) target of < 20% for morbidity control. The prevalences of stunting (20.2%), being underweight (19%) or wasting (9.5%) are high and are still regarded as public health problems according to WHO criteria, but low anaemia prevalence (13%) was observed. Age, socio-economic status, rural/urban classification of schools and knowledge of STH were significant risk factors for STH infections. Moreover, infections with STH were significantly associated with stunting and being underweight but not wasting or anaemia after controlling for key confounders. Sustainable deworming in tandem with other measures such as the provision of health education, improvements in sanitation and hygiene, and nutritional programs, are needed to control intestinal worm infections and improve morbidity outcomes in schoolchildren. [ABSTRACT FROM AUTHOR]

The ongoing COVID-19 pandemic has required tremendous shifts in data collection techniques. While an emerging body of research has described experiences conducting remote interviews, less attention has been paid to focus group discussions (FGDs). Herein, we present experiences conducting remote FGDs (n=9) with healthcare workers and caretakers of small children in the Philippines. We used 'Facebook Messenger Room' (FBMR), the preferred platform of participants. Despite some success, we generally encountered considerable challenges in terms of recruiting, retaining and moderating remote FGDs, particularly among caretakers of small children. Finding a quiet, private place proved unfeasible for many participants, who were juggling family demands in tight, locked down quarters. Connectivity issues and technological missteps compromised the flow of FGDs and minimised the ability to share and compare opinions. For the research team, remote FGDs resulted in a dramatic role shift for notetakers--from being passive observers to active tech supporters, chatbox referees and co-moderators (when audio disruptions occurred). Finally, we note that remote FGDs via FBMR are associated with ethical complexities, particularly as participants often chose to use their personal Facebook accounts, which can compromise anonymity. We developed and continuously refined strategies to mitigate challenges, but ultimately decided to forgo FGDs. We urge fellow researchers with more successful experiences to guide the field in terms of capturing high-quality data that respond to research questions, while also contending with privacy concerns, both in online spaces, as well as physical privacy despite lockdowns in tight quarters. [ABSTRACT FROM AUTHOR]

Background: Studies focusing on the Integrated Management of Childhood Illness (IMCI) program in the Philippines are limited, and perspectives of frontline health care workers (HCWs) are largely absent in relation to the introduction and current implementation of the program. Here, we describe the operational challenges and opportunities described by HCWs implementing IMCI in five regions of the Philippines. These perspectives can provide insights into how IMCI can be strengthened as the program matures, in the Philippines and beyond.Methods: In-depth interviews (IDIs) were conducted with HCWs (n = 46) in five provinces (Ilocos Sur, Quezon, National Capital Region, Bohol and Davao), with full transcription and translation as necessary. In parallel, data collectors observed the status (availability and placement) of IMCI-related materials in facilities. All data were coded using NVivo 12 software and arranged along a Social Ecological Model.Results: HCWs spoke of the benefits of IMCI and discussed how they developed workarounds to ensure that integral components of the program could be delivered in frontline facilities. Five key challenges emerged in relation to IMCI implementation in primary health care (PHC) facilities: 1) insufficient financial resources to fund program activities, 2) inadequate training, mentoring and supervision among and for providers, 3) fragmented leadership and governance, 4) substandard access to IMCI relevant written documents, and 5) professional hierarchies that challenge fidelity to IMCI protocols.Conclusion: Although the IMCI program was viewed by HCWs as holistic and as providing substantial benefits to the community, more viable implementation processes are needed to bolster acceptability in PHC facilities. [ABSTRACT FROM AUTHOR]

Human-centred design (HCD) is an approach to problem-solving that prioritises understanding and meeting the needs of the end-users. Researchers and designers practice empathic listening as users share their perspectives, thereby enabling a variety of stakeholders to cocreate effective solutions. While a valuable and, in theory, straightforward process, HCD in practice can be chaotic: Practitioners often struggle to navigate an excess of (often conflicting) ideas and to strike a balance between problem-understanding and problem-solving. In this practice paper, we outline our own experiences with HCD, which ultimately resulted in the development of a successful video-based intervention to bolster vaccine confidence in the Philippines. We highlight the use of 'radical circles' to overcome roadblocks and navigate tensions. Radical circles entail groups of individuals with divergent opinions and identities engaging in critical analysis of a given idea, actively challenging standard ways of thinking, and ultimately, generating solutions. Employing radical circles enabled us to innovate and adapt to new perspectives that emerged along the non-linear HCD pathway. Our incorporation of radical circles into HCD methodology demonstrates its potential as a powerful complementary step in the meaning-making process. In our view, radical circles could enrich HCD processes and provide a solution to design overcrowding, leading to meaningful, transformative and successful interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Vaccine hesitancy (VH) continues to pose a public health threat globally. Understanding the attitudes and perceptions about vaccination of key stakeholders in vaccine decision-making (such as health care workers (HCWs) and caregivers) about vaccination can pave the way toward novel approaches to bolster vaccine confidence. In this study, we explored the role of notions of responsibilities among HCWs and caregivers in shaping vaccination interactions and decision-making in the Philippines., Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with 44 vaccine-hesitant caregivers, seven HCWs, and 20 community health workers (barangay health workers) in the Philippines between August 2020 and March 2021. The interviews and focus groups were conducted online, transcribed verbatim, and analysed through the reflexive thematic analysis approach., Results: Caregivers highlighted responsibility in terms of being a good caregiver, managing risk to one's own child, and seeking and validating information. Meanwhile, HCWs highlighted responsibility as: being a good HCW, managing risk to children and to the community, and providing and transforming information. Our findings suggest that responsibility manifests differently in HCWs' and caregivers' narratives, and that these notions can be both conflicting and complementary, shaping the interaction between stakeholders and, ultimately, their vaccine decision-making. We also found that fostering a good relationship between HCWs and caregivers through communication techniques such as motivational interviewing could help bridge the gap created by mistrust in vaccinations. HCWs sharing their own experiences as parents who vaccinate their own children also resonate with caregivers., Conclusions: Notions of responsibility can underpin collaborative and divisive interactions between HCWs and caregivers. Public health messaging and interventions related to vaccination must consider strategies that align with these notions to address VH., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

Introduction: The success of global health interventions heavily relies on reaching populations in a way that aligns with their priorities and needs. This warrants novel approaches to determine the design of meaningful interventions and targeted delivery pathways. To date, global health scholarship and practice have largely underused approaches already established in fields that emphasize customer satisfaction, such as quality management or consumer psychology., Methods: In our study, we apply Kano methodology-originally designed to understand how product attributes nonlinearly influence customer satisfaction-to inform design decisions regarding a video-based vaccine intervention in the Philippines. Between September 2021 and April 2022, we administered a Kano questionnaire to 205 caregivers of small children. Data were analyzed following routine Kano approaches, supplemented by cultural consensus analysis (CCA), which is an approach used largely in anthropology to identify distinct cultural groups and competencies., Results: Applying Kano and CCA methodologies allowed us to make informed design decisions in terms of optimizing accessibility and credibility of an intervention that ultimately proved successful in bolstering vaccine intentions. Results guided us to include national and international logos, to appreciate the value of summarizing key messages, and to recognize the importance of fact- or story-based communication as attributes that influenced respondent satisfaction one-dimensionally. We found that involving trusted messengers and including text-based information were required to avoid dissatisfaction. Interacting with someone after viewing the product and creating opportunities to share the promotional material via social media were attractive attributes whose presence would increase satisfaction but would not spark severe dissatisfaction if omitted. Other attributes (short duration, video- or animation-based intervention, delivering the intervention at health centers or in group settings) played a limited role in respondent satisfaction., Conclusions: Global health research and practice can benefit from applying approaches established in other fields when making evidence-based prioritization decisions to tailor interventions., (© Wachinger et al.)

Background: The public's confidence in vaccinations has eroded, and anti-vaccination movements have gained traction around the world, including in the Philippines. 'Salubong', a Filipino term, refers to welcoming someone back into one's life and elicits ideas about friendship and family relationships. We extended this concept to vaccines in efforts to design an intervention that would re-welcome vaccines into homes., Methods: Using human-centred design, we developed and refined a story-based intervention that engages Filipino families, community leaders and community health workers. We conducted a randomised controlled trial among 719 caregivers of small children to test the developed intervention against a control video. We assessed the binary improvement (improvement vs no improvement) and the amount of improvement in vaccine attitudes and intentions after intervention exposure., Results: Although the intervention group began with marginally higher baseline vaccine attitude scores, we found that 62% of the intervention group improved their vaccine attitude scores versus 37% of the control group (Fisher's exact, p<0.001). Among individuals whose scores improved after watching the assigned video, the intervention group saw higher mean attitude score improvements on the 5-point scale (Cohen's d=0.32 with 95% CI 0.10 to 0.54, two-sided t-test, p<0.01). We observed similar patterns among participants who stated that they had previously delayed or refused a vaccine for their child: 67% of 74 in the intervention group improved their vaccine attitude scores versus 42% of 54 in the control group (Fisher's exact, p<0.001). Among the subset of these individuals whose scores improved after watching the assigned video, the intervention group saw higher mean attitude score improvements on the 5-point scale that were marginally significant (Cohen's d=0.35 with 95% CI -0.01 to 0.70, two-sided t-test, p=0.06)., Conclusions: Our results provide solid evidence for the potential of co-designed vaccine confidence campaigns and regulations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Targeted vaccination promotion efforts aimed at building vaccine confidence require an in-depth understanding of how and by whom decisions about vaccinating children are made. While several studies have highlighted how parents interact with other stakeholders when discussing childhood vaccination, less is known about the way in which vaccination uptake is negotiated within households., Methods: We conducted 44 in-depth interviews with caregivers of children under five in the Philippines who had delayed or refused vaccination. Interviews were conducted between August 2020 and March 2021 and were audio-recorded, transcribed verbatim and translated into English. Notions of intra-household vaccination bargaining emerged early during systematic debriefings and were probed more pointedly throughout data collection., Results: Parents as well as paternal and maternal families proved to be dominant stakeholders in intra-household bargaining for childhood vaccination. Although bargaining among these stakeholders was based on engrained, gender-based power imbalances, disadvantaged stakeholders could draw on a range of interrelated sources of bargaining power to nevertheless shape decision-making. Sources of bargaining power included, in descending order of their relevance for vaccination, (1) physical presence at the household (at the time of vaccination decision-making), (2) interest in the topic of vaccination and conviction of one's own position, (3) previous vaccination and caregiving experience, and (4) access to household resources (including finances). The degree to which each household member could draw on these sources of bargaining power varied considerably over time and across households., Conclusion: Our findings highlight how bargaining due to intra-household disagreement coins decisions regarding childhood vaccination. Considering the risks for public health associated with vaccine hesitancy globally, we advocate for acknowledging intra-household dynamics in research and practice, such as by purposefully targeting household members with decision-making capacity in vaccination promotion efforts, aligning promotion efforts with available bargaining capacity or further empowering those convinced of vaccination., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

We used KoBo Collect and KoBo Toolbox as an electronic data capture platform for a dog population and rabies knowledge and practices community survey in the Philippines. It has allowed for easy design and deployment of an electronic form with minimal technical knowledge from the investigators. Using this platform allowed for shorter training for data collectors, minimal errors during data collection, and faster turn-around time for data cleaning and analysis.

Background: Several studies have highlighted that vaccine hesitancy (VH) is among the most important threats to global health, especially in low- and middle-income countries, including the Philippines. However, there is a dearth of literature exploring family experiences of-or concerns related to-childhood vaccinations that gives voice to vaccine hesitant caregivers (VHCs) of small children. Here, we present insights from VHCs from the Philippines., Methods: This research draws on in-depth interviews (IDIs) with 44 VHCs who had previously delayed or refused vaccination for their children in rural and urban communities in Cavite Province, the Philippines. Amid the COVID-19 pandemic, we conducted IDIs via an online platform of the respondents' choosing (ie, Facebook messenger call, Skype and Zoom). All interviews were recorded, transcribed, translated and analysed drawing from the tenets of constructivist grounded theory. We use the social ecological model to structure our results., Results: Among the reasons for delay or refusal of childhood vaccinations, a fear of side effects emerged as the most salient concern, exacerbated by previous negative experiences (including trauma) from a dengue vaccine controversy in 2017. Respondents cited the dengue vaccine controversy as they expressed reluctance (regarding any new vaccines) and suspicion (towards school-based vaccination, the distribution channel used for the dengue vaccine). Heads of households opposing vaccines, perceptions that vaccines are non-essential and influences from the social and traditional media or neighbours contributed to further refusal and delay. Upon probing, VHCs recounted health system concerns particularly with regards to healthcare workers who are sometimes unable to answer their questions and can be dismissive or disrespectful regarding caregivers' concerns., Conclusion: Understanding VH from the lens of VHCs highlights pathways for interventions to regain trust and bolster confidence towards vaccines. Our findings may serve as linchpins in the development of VH interventions aiming at changing behaviour on a population scale., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Since the onset of a dengue vaccine controversy in late 2017, vaccine confidence has plummeted in the Philippines, leading to measles and polio outbreaks in early 2019. This protocol outlines a human-centered design (HCD) approach to co-create and test an intervention that addresses vaccine hesitancy (VH) via narrative and empathy with and among families and healthcare workers. METHODS AND ANALYSIS: 'Salubong' is a Filipino term that means to welcome someone back into one's life, reinforcing notions of family ties and friendships. We apply this sentiment to vaccines. Following the phases of HCD, guided by a theoretical framework, and drawing from locally held understandings of faith and acceptance, we will conduct in-depth interviews (IDIs) and focus group discussions (FGDs) in rural and urban Filipino communities that witnessed dramatic increases in measles cases in recent years. During qualitative engagements with caretakers, providers, and policymakers, we will collect narratives about family and community perceptions of childhood vaccinations, public health systems and opportunities to restore faith. IDIs and FGDs will continuously inform the development of (and delivery mechanisms for) story-based interventions. Once developed, we will test our co-created interventions among 800 caretakers and administer a VH questionnaire prior to and immediately following the intervention encounter. We will use the feedback gained through the survey and Kano-style questionnaires to further refine the intervention. Considering the data collection challenges posed by the ongoing COVID-19 pandemic, we have developed workarounds to conduct data collection primarily online. We will use systematic online debriefings to facilitate comprehensive participation of the full research team., Ethics and Dissemination: Ethical approval has been granted by the Institutional Review Board of the Research Institute for Tropical Medicine (number 2019-44) and Ethical Commission of Heidelberg University, Faculty of Medicine (S-833/2019). Study findings will be disseminated in scientific conferences and published in peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)