Conflicting and Complementary Notions of Responsibility in Caregiver's and Health Care Workers' Vaccination Narratives in the Philippines

"[P]artnering and fostering good relationships between caregivers and HCWs through aligning with their notions of responsibility is needed to facilitate vaccination uptake and improve their vaccine interaction."

Since the 2016 Dengvaxia controversy, caregivers in the Philippines have remained ambivalent (and in many cases hesitant) about vaccination, and healthcare workers (HCWs) have been attempting to restore their trust in the longstanding childhood vaccination programme. For caregivers, social prescriptions subject them to expectations to construct themselves as "responsible citizens" by maintaining their children's health and protecting them against sickness and harm. HCWs also have responsibilities in line with vaccination stemming from duties and obligations delegated to them based on their role in society. This study explores the role of different notions of "responsibility" among HCWs and caregivers in shaping vaccination interactions and decision-making. It is part of a larger mixed-methods study set in the Philippines, to develop a vaccine-confidence intervention based on human-centred design.

Between August 2020 and March 2021, the researchers conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with 44 vaccine-hesitant caregivers, 7 HCWs, and 20 community health workers (barangay health workers) in areas of the Calabarzon region with the lowest vaccination rates among children under 5. The interviews and focus groups were conducted online, transcribed verbatim, and analysed through the reflexive thematic analysis approach.

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. The 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.

For example, seeking information and providing information were complementary notions of responsibility of caregivers and HCWs, respectively. Specifically, caregivers seek and validate information, while HCWs provide and transform information. HCWs showed awareness of the nature of information that caregivers need to help them in vaccine decision-making. However, caregivers still reported a perceived lack of information, noting that HCWs were prone to providing general information that could not fully address their concerns. In addition, insights from neighbours, friends, and online discourse were messages that contradicted HCW messaging.

Tensions exist, such as between the competing notions of responsibility in managing risk to one's own child and managing risk to children and to the community. Despite tensions, these notions of responsibility could also align. For example, a mother allowed polio vaccination for her child, as she shared that "I don't know of any way to prevent polio aside from the injection".

Notably, caregivers in the study who refused vaccination were seen as "careless" and "neglectful" by other caregivers for their vaccine choices, emphasising the social construct that a "good caregiver" vaccinates. The findings also highlight that vaccine decision-making is heavily influenced by caregivers' perceptions of vaccine risks, which discourages them from vaccinating their children despite societal pressure and public health messaging to do so. The spread of misinformation and rumours about vaccines also makes it difficult to settle on a course of action. However, personalised vaccine strategies, such as devising caregivers' own vaccination schedules, delaying consent, or selecting vaccination, may be seen as "irrational" from the public health perspective.

As highlighted in this study, the conflicting nature of caregivers' and HCWs' notions of responsibilities has the potential to instigate tensions and mistrust in their interactions. Suggestions outlined to help bridge this gap include:

• HCWs can reach out and partner with caregivers to enable good vaccination decisions despite the latter's hesitations and risk perceptions. For instance, by sharing their personal vaccine decisions, HCWs emphasise the safety and effectiveness of vaccines, removing professional barriers and acting as fellow parent who wants the best care for their child.
• Instead of resorting to verbal coercion to force caregivers to vaccinate, HCWs could listen respectfully to parental concerns, encourage questions, and provide accurate information about the risks and benefits of vaccines in a way that aligns with the notions of responsibilities of caregivers. Motivational interviewing techniques have been found to be effective in establishing trustful patient-provider interaction and facilitating vaccine acceptance in various settings.
• Besides trying to foster good relationships between HCWs and caregivers, policymakers should strive to address health system challenges, especially in low- and middle-income countries (LMICs), to motivate HCWs and to entice caregivers to seek care from public health facilities.

In conclusion: "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."