Vaccine 38 (2020) 54–62

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Factors associated with the willingness of primary caregivers to avail of a

dengue vaccine for their 9 to 14-year-olds in an urban community in the
Philippines
Ma. Sophia Graciela L. Reyes a,1,⇑, Karen Mae G. Lee a,1, Adrianna Michelle L. Pedron a,1,
Jennel Mae T. Pimentel a,1, Paul Adrian V. Pinlac b
a
College of Public Health, University of the Philippines Manila, 625 Pedro Gil Street, Ermita, Manila 1000, Philippines
b
Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines Manila, 625 Pedro Gil Street, Ermita, Manila 1000, Philippines

a r t i c l e i n f o a b s t r a c t

Article history: To help address the need for preventive measures against dengue fever, a leading cause of child mortality
Received 4 September 2018 in the Philippines, vaccine trials are ongoing and a tetravalent vaccine (DengvaxiaTM, Sanofi Pasteur) has
Received in revised form 14 September been developed. It is hypothesized that while acceptability would be high among primary caregivers (i.e.,
2019
parents/guardians), the willingness to have one’s child immunized against dengue would be associated
Accepted 1 October 2019
Available online 24 October 2019
with socio-demographic variables, attitudes and knowledge regarding dengue and vaccination, and past
experience with dengue. This study aimed to assess the aforementioned factors’ association with primary
caregivers’ willingness to avail of a dengue vaccine for their 9 to 14-year-old children in an urban com-
Keywords:
Dengue fever
munity in the Philippines.
Dengue vaccine A cross-sectional study utilizing interviews was conducted to determine which factors were associated
Vaccine acceptance with willingness-to-avail assuming a free vaccine, and a case study utilizing a focus group discussion was
Health belief model employed to capture some underlying reasons for their willingness. Data were analyzed using multiple
logistic regression and thematic analysis.
Among the 202 study participants, 193 (95.54%) were willing to avail of the vaccine. There was a high
probability of vaccine acceptance by primary caregivers (95.54%), with good attitude towards vaccination
(12/15 points) [aOR 10.62, 90% CI (1.73–26.28)] and large household size (>5) [aOR 9.63, 90% CI (2.04–
45.58)] being positively associated with willingness-to-avail, and good knowledge regarding dengue
fever [aOR 0.10, 90% CI (0.03–0.74)] and older age (>44 years) [aOR 0.14, 90% CI (0.03–0.61)] being neg-
atively associated.
Crude analysis showed that household size, knowledge regarding dengue, and attitude towards vacci-
nation were significantly associated with willingness. Multivariate analysis revealed that these factors
and the primary caregiver’s age were associated with willingness. Thematic analysis showed various per-
ceptions regarding dengue and vaccination. Knowing these factors are associated with willingness-to-
avail of the vaccine may help in understanding the audience of health promotion projects aimed at
increasing immunization coverage.
Ó 2019 Elsevier Ltd. All rights reserved.

1. Introduction
Abbreviations: DEBS, Department of Epidemiology and Biostatistics; DF, dengue
fever; DHPE, Department of Health Promotion and Education; DMM, Department of
Medical Microbiology; DOH, Department of Health; FGD, focus group discussion;
Dengue fever is one of the leading causes of child mortality in
HBM, health belief model; IEC, information, education, and communication; IVR, the Philippines, being the 2nd leading cause in the 5–9 year old
Initiative for Vaccine Research; KAP, Knowledge, Attitude and Practice; UPMREB, age group, and 6th in the 10–14 year old age group [1]. Both glob-
University of the Philippines Manila Research Ethics Board; UPM-CPH, University of ally and nationally, there is a significant public health and eco-
the Philippines Manila – College of Public Health.
⇑ Corresponding author. nomic burden imposed by dengue fever [2]. Despite already
E-mail addresses: mlreyes8@up.edu.ph (Ma. Sophia Graciela L. Reyes), alpe-
existing preventive measures such as vector control and individual
dron@up.edu.ph (A.M.L. Pedron), pvpinlac@up.edu.ph (P.A.V. Pinlac). protective measures such as insect repellents, the cases of dengue
1
These authors contributed equally to this work.

https://doi.org/10.1016/j.vaccine.2019.10.001
0264-410X/Ó 2019 Elsevier Ltd. All rights reserved.

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 Ma. Sophia Graciela L. Reyes et al. / Vaccine 38 (2020) 54–62
had been continually increasing [3]. In response to this dilemma, a
dengue vaccine was developed. Almost two dozen candidates
underwent preclinical evaluation, but seven of them made it to
clinical development [4].
The first registered dengue vaccine, CYD-TDV (Chimeric yellow
fever dengue - tetravalent dengue vaccine) or Dengvaxia, had been
evaluated in 2 parallel Phase III randomized clinical trials (CYD14
and CYD15) conducted in 2014 as a 3-dose series of 0.5 mL per
dose in 6-month intervals over a period of one year. The parallel
clinical trials were conducted in 5 countries in Latin America
(CYD15) and 5 countries in Asia (CYD14), including the Philippines,
with 20,869 participants aged 9–16 years for the former and
10,275 participants aged 2–14 years for the latter at first vaccina-
tion [4]. The vaccine was licensed in the Philippines for the use
of 9 to 45-year-olds in endemic areas in December 22, 2015 [5].
One of the goals of the World Health Organization and the
Department of Health (DOH) is to reduce the burden of dengue
through different dengue control interventions. The WHO Initiative
for Vaccine Research (IVR) has as one of its main objectives the
identification of knowledge gaps related to the development, eval-
uation and implementation of dengue vaccines [6]. In 2016, the
Philippine government implemented a school-based dengue vacci-
nation program in selected public schools in areas with high inci-
dence of dengue fever as their priority target areas, specifically
regions IV-A (CALABARZON), III, and NCR [7]. The success of any
vaccination program may be greatly dependent on the presence
of several factors associated with the willingness to avail of the
vaccine. Determining and understanding these factors could help
government agencies understand and address concerns regarding
the dengue vaccine. Identifying and understanding the perceptions
of primary caregivers regarding dengue vaccination could also help
the government develop interventions and address them using
public health education programs, improve current and future
immunization programs, and maximize resources, especially given
the controversies surrounding the vaccine’s efficacy that have been
surfacing since its initial roll out to the public. It should be noted
that this research was conducted and completed prior to the pub-
lication of a study by Larson, Hartigan-Go, and de Figueiredo
(2019) which found that there was a significant drop in vaccine
confidence in the Philippines from the year 2015 to the year
2018, attributed to the dengue vaccine controversy [8].
This study aimed to determine the factors associated with the
willingness of primary caregivers to avail of a dengue vaccine for
their 9 to 14-year-old children in a local barangay - the smallest
administrative unit in the Philippines. Specifically, this study
determined the distribution of several factors among the study
population, assessed the willingness of primary caregivers to avail
of the vaccine, determined if the aforementioned factors are asso-
ciated with the willingness to avail of the vaccine, and determined
the reasons behind the willingness to avail.
2. Methods
An analytic cross-sectional study design was employed to
determine whether or not primary caregivers were willing to avail
of a free dengue vaccine for their children, as well as the factors
associated with willingness. A case study design was employed
to identify the reasons behind their willingness or hesitation.
The study was conducted between January and March 2017 as
part of the baccalaureate special studies course in the University
of the Philippines Manila – College of Public Health (UPM-CPH).
This was done in a highly urbanized barangay in the Philippines,
selected due to high incidence of dengue in the area, but was not
a recipient of the then ongoing national dengue immunization
program by the government. Furthermore, a barangay in the city
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55
without an elementary school was selected in order to avoid pos-
sible instances wherein respondents would have already had their
children vaccinated against dengue, as barangays with schools that
accommodated the 4th grade were targeted by the Department of
Health for their dengue immunization program [9,10].
The study population consisted of primary caregivers who were
at least 18 years of age with child/ren or ward/s aged 9–14 years
old, and who were current residents of the selected barangay at
the time of data collection. This age range was set because of three
primary reasons: (a) majority of the dengue cases at the time
belonged to the 5-to-14 year-old age group; (b) dengue was the
2nd leading cause of child mortality in children aged 5–9 years
and was the 6th leading cause in children aged 10–14; and (c)
according to the WHO, the vaccine had been registered for the
use of individuals aged 9–45 years, as of August 2016 [1,4,11]. Pri-
mary caregivers whose children had already been vaccinated for
dengue, as well as those who lived in certain areas of the barangay
where entry was not granted for privacy or administrative reasons
were excluded.
The study was approved by the University of the Philippines
Manila Research Ethics Board (UPMREB). Permission to conduct
the study was obtained from the chairman of the barangay, and
informed consent was secured from each study participant.
2.1. Conceptual framework
To better understand the factors and reasons behind the will-
ingness to avail of a dengue vaccine, the health belief model was
used as a basis for the framework of this study (Fig. 1) [12].
Based on literature, six major factors were statistically signifi-
cant in their corresponding studies related to the acceptance of
vaccination, attitudes towards vaccination, and the like. These
are the following: attitude towards dengue fever, attitude towards
vaccination practice, level of knowledge regarding applicable vac-
cine, socioeconomic status, demographics, and past experience
with dengue [13,14]. In this study, the relationship of interest is
between attitudes towards vaccination and dengue fever and the
willingness to avail of the dengue vaccine. Attitudes include the
perceived threats, benefits, and barriers. According to the health
belief model, the likelihood of a behavior, in this case, the willing-
ness to avail of dengue vaccine, is affected by the perceived threat
of disease and the perceived barriers weighed against the per-
ceived benefits.
Fig. 1. Conceptual Framework of Study – Modified Health Belief Model. In this
modified health belief model (HBM), perceptions on dengue fever (DF) and
vaccination are hypothesized to be associated with a parent/caregiver’s willingness
to avail of the dengue vaccine for one’s child or ward (A). This relationship is
thought be confounded by the parent/caregiver’s knowledge and past experience
with dengue, as well various sociodemographic variables (B). Reasons that have
brought about the attitude towards DF and vaccination (C) would also be
qualitatively determined. On the other hand, while extant government programs
may serve as cues to action, and reasons may be linked to other variables in the
model, addressing these are outside the scope of this study.
56 Ma. Sophia Graciela L. Reyes et al. / Vaccine 38 (2020) 54–62
The modifying variables are composed of the sociodemographic
characteristics of the respondents, their knowledge regarding vac-
cination and dengue fever, and their past experiences with dengue
fever. These modifying variables served as co-variates in the study
and have a direct link to attitudes towards vaccination and dengue
fever, as well as the willingness to avail of the dengue vaccine. The
definitions of the major study variables may be found in Supple-
mentary File 1.
The study also examined the reasons behind the willingness-to-
avail. These include those behind vaccination, dengue fever, and
dengue vaccination. The study did not assess how the modifying
variables affect the reasons behind the willingness of the primary
caregivers to avail of the dengue vaccine, nor did it examine the
cues to action (e.g. school-based vaccination programs).
2.2. Quantitative methods
Information regarding the knowledge and attitudes of the resi-
dents regarding dengue fever and vaccination, their demographics,
as well as their past experiences with dengue were gathered
through interviews. Out of 221 primary caregivers in the barangay,
218 were eligible to participate in the study while 16 refused par-
ticipation, leaving 202 (93%) study participants. A waiver of
informed consent documentation was requested from the
UPMREB. The participants were interviewed using a pretested,
standardized, and validated interview schedule [see Supplemen-
tary File 2]. This tool was based on existing standardized tools used
in similar studies on immunization from open-source journals [15–
18] further developed by the proponents in consultation with
experts from the UPM-CPH Department of Medical Microbiology
(DMM) and Department of Health Promotion and Education
(DHPE), and pretested [19] with residents of the selected barangay
whose children did not fall under the age range of 9–14 years. Each
interview lasted between 5 and 10 min. Control numbers were
assigned to the interview schedules in place of the respondents’
names to protect the identity of the participants.
Data were encoded and checked for legibility, response incon-
sistencies, and completeness. Data were subsequently analyzed
using Microsoft Excel for proportions and Stata Statistical Software
(Release 12; StataCorp LP, 2011) for multiple logistic regression to
determine association. The level of significance was set at 10% due
to the small sample size. The power calculations may be found in
Supplementary File 3.
2.3. Qualitative methods
The perceived benefits of the dengue vaccine, barriers to access,
threats of the disease, and the reasons behind the willingness to
avail of the vaccine were gathered through an FGD in order to fur-
ther explore the results obtained from the interviews.
A topic outline was used as a data collection tool for the FGD
[see Supplementary File 4]. Like the interview schedule, this tool
was adapted and modified from existing tools [15–17] and devel-
oped in consultation with experts from the UPM-CPH’s DMM and
DHPE. A pretest was conducted with a group of 13 residents whose
children did not fall under the age range of 9–14 years [19], and
was facilitated by a trained faculty member of the UPM-CPH
Department of Epidemiology and Biostatistics (DEBS). All questions
were understood and addressed by the participants of the pretest,
and no changes were made to the topic outline. Each survey inter-
viewee was invited at the completion of their respective interviews
to attend the FGD on the specified date and time, but the non-
mandatory nature of the FGD was highlighted. The actual FGD
was conducted in the barangay health center on March 1, 2017,
which succeeded the completion of the survey, with 10 partici-
pants, all but one of whom are female.
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The FGD participants were composed of barangay health work-
ers and home-makers, all of whom were either current or former
employees of the barangay. One of them is the parent of a special
child and the rest have children attending public schools, all within
the 9 to 14-year-old age bracket, but had not been administered
the dengue vaccine at the time of data collection. The FGD was
facilitated by a faculty member of UPM-CPH and had a duration
of approximately 1 hour and 10 minutes. Informed consent was
taken from each of the participants individually before the start
of the FGD.
The proceedings of the FGD were transcribed, cleaned, and
paraphrased. Thematic analysis was used to analyze qualitative
data yielded from the FGD, enabling the researchers to detect pat-
terns among the concerns and perceptions of the primary care-
givers about availing of the dengue vaccine.
3. Results and discussion
3.1. Sociodemographic information
The study gathered a total of 221 participants based on the
inclusion criteria. Three participants were dropped from the study
because their children had already been vaccinated. Sixteen resi-
dents of the barangay refused to participate in the study. A sum-
mary of the sociodemographic characteristics of the respondents
included in the study (n = 202) are provided in Table 1.
3.2. Knowledge regarding dengue fever
Among the possible methods of dengue prevention, the respon-
dents were most knowledgeable on environmental sanitation, the
covering, emptying, and cleaning of domestic water storage con-
tainers, and removal of artificial man-made mosquito habitats such
as stagnant water in flower vases and spare tires. Only 3 (1.48%)
respondents knew about dengue vaccine as a method of dengue
prevention. Table 2 shows the distribution of participants among
knowledge items.
The categorization of the respondents into having poor or good
knowledge regarding dengue fever was dependent on their knowl-
edge scores on three important properties of the disease: its symp-
toms, transmission, and prevention methods. A respondent was
considered to have good knowledge if they had reached the cut-
off scores of all three sections on the properties of dengue fever
[see Supplementary File 1]. The distribution of participants accord-
ing to their score range per section may be found in Supplementary
File 5. Table 3 shows that out of the 202 respondents, 193 (95.54%)
were considered as having poor knowledge regarding dengue
fever, having failed to reach the cut-off point/s for one or more sec-
tions on dengue fever knowledge.
3.3. Knowledge regarding vaccination
Participants received a mean score for vaccination knowledge of
4.68 with a standard deviation of 0.71. Out of the 202 participants,
198 (98.02%) had total scores for knowledge regarding vaccination
within the range of 3–5 points. This reflects that the respondents
generally had good knowledge regarding vaccination. It was found
that the three statements that the participants responded posi-
tively to were those relating to vaccine safety, the ability to
strengthen a child’s immune system, and how a vaccine’s benefits
outweigh its risks. The statement regarding vaccines being well
tested for safety yielded the greatest number of positive responses.
These are reflective of the beliefs of the respondents in the benefits
of vaccination, possibly due to their own experiences; the remain-
ing two statements that received more varied responses are those
 Ma. Sophia Graciela L. Reyes et al. / Vaccine 38 (2020) 54–62 57

Table 1 Table 3
Socio-demographic characteristics of study participants (n = 202). Classification of study participants according to level of knowledge regarding dengue
fever. A summary of the classification of respondents into having good or poor
Socio-demographic factor Number Percent (%) knowledge stratified into the three properties of dengue fever considered in the study
Age in years, x̅ = 43.74 ± 9.87 (symptoms, transmission, and prevention methods).
44 years old 120 59.40
Knowledge classification Number Percent (%)
45 years olda 82 40.60
Dengue Fever Symptoms (n = 202)
Sex of Respondent
Poor 41 20.30
Male 22 10.89
Good 161 79.70
Female 180 89.11
Dengue Fever Transmission (n = 202)
Household Size
Poor 55 27.23
Small (5)b 88 43.56
Good 147 72.77
Large (>5) 114 56.44
Dengue Fever Prevention (n = 202)
Marital Status
Poor 192 95.05
Single/Widowed 32 15.84
Good 10 4.95
Married/Cohabiting 170 84.16
Overall knowledge re: dengue fever (n = 202)
Monthly Household Income
Poora 193 95.54
Below Poverty Thresholdc 88 43.56
Goodb 9 4.46
Above Poverty Threshold 114 56.44
Total 202 100
Level of Educationd
None 7 3.46 a
90% CI: 92.35–97.66%.
Primary/Secondary 150 74.26 b
90% CI: 2.34–7.65%.
Tertiary 45 22.28
Employment Status
Unemployed 122 60.39 frequencies of agreement to the statements on vaccination can
Self-employed 23 11.39
be seen in Table 4.
Private/Government Employee 57 28.22
In order to be classified as having good knowledge regarding
a
The selection of the cutoff was arbitrary; the authors opted for a binary variable vaccination, a respondent must have agreed to at least 3 out of
for age, and the age of 45 is usually considered the start of the middle-aged adult the 5 statements listed above. Among the 202 respondents, 198
stage.
b
At the time of data collection, the national average household size was 5 people
(98.02%, 90%CI 95.53–99.32%) achieved the knowledge cut-off,
per household. and were therefore considered to have good knowledge regarding
c
Cutoff set at Php 9064.00, which at the time of data collection was the poverty vaccination.
threshold in Manila [20].
d
Completed levels of education.
3.4. Attitude towards dengue fever
Table 2
Distribution of participants’ answers to items on dengue fever knowledge. The items Table 5 shows that majority of the participants (91.50%) agreed
below were translated into the local vernacular in the actual questionnaire to ensure that dengue is a serious illness, while more than half of the partic-
understanding. ipants (64.80%) believed that their child is at risk of getting dengue
Knowledge items Number Percent fever. Majority of the respondents (85.10%) agreed that dengue
(%) fever can be prevented.
Dengue Symptoms Each respondent’s score was a summation of their levels of
Fever 173 85.64 agreement to the statements listed above. Because no respondent
Rashes 152 75.25 received a score less than 8, the distribution of responses according
Bleeding 78 38.61 to level of agreement reflects that responses were generally not on
Nausea/Vomiting 58 28.71
Body aches/pains 15 7.43
the extreme negative end of the scale (i.e. not leaning towards
Abdominal pain or tenderness 9 4.46 ‘‘strongly disagree”). The study respondents got a mean score of
Weakness 8 3.96 11.88 with a standard deviation of 1.56, which is more or less near
Pain behind the eyes 4 1.98 the cutoff point of 12 for having a good attitude towards dengue
Restlessness 1 0.50
fever. Of the 202 respondents, 131 (64.85%; 90%CI 58.94–70.43%)
Fluid accumulation 0 0
were considered to have a good attitude towards dengue fever –
Method of Dengue Transmission
a less polarized but inverse result compared with the overall result
Mosquito bite 147 72.77
Dirty water and environment 45 22.28 for knowledge on dengue fever [see Supplementary File 6].
I don’t know 10 4.95
Preventive measures against dengue fever 3.5. Attitude towards vaccination
Environmental sanitation 173 85.64
Covering, emptying, and cleaning of domestic water 85 42.01 Among the three statements used to assess the respondents’
storage containers attitude towards vaccination, the statement on vaccination’s
Removing artificial man-made habitats 69 34.16
Using insecticide sprays 22 10.89
importance for disease prevention received the greatest number
Using household protection (e.g. window screens, 18 8.91 of positive responses (98%). The proportion of answers per level
insecticide or repellent-treated materials, coils, of agreement for each statement is shown in Table 6. Majority of
vaporizers) the participants agreed that vaccines are safe (89.1%), and even
Proper solid waste disposal 4 1.98
more (95.5%) agreed that meeting their child’s vaccination sched-
Using personal protection 3 1.48
Dengue vaccine 3 1.48 ule is important.
The median of the scores for all three statements is 4, and the
respondents yielded a mean score of 12.63 with a standard devia-
concerning vaccines preventing deadly diseases and the prevalence tion of 1.41 for attitude towards vaccination, slightly above the
of vaccine-preventable diseases in the Philippines – items which cutoff point of 12 [see Supplementary File 6]. This reflects that
may not be as familiar to the respondents as the first three. The although the respondents did not wholly agree with the state-

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58 Ma. Sophia Graciela L. Reyes et al. / Vaccine 38 (2020) 54–62
Table 4
Frequency of positive responses on knowledge regarding vaccination.
Knowledge regarding vaccination items Number Proportion
(%)
Vaccines are well tested for safety 196 97.03
Vaccines help strengthen a child’s immune system 190 94.06
The benefits from vaccines outweigh the risks 188 93.07
Some vaccine-preventable diseases remain common 186 92.08
in the Philippines like tuberculosis, poliomyelitis,
measles, etc.
Vaccines prevent potentially deadly diseases or 185 91.58
infections
ments, they generally had good attitudes towards vaccination. One
hundred and eighty-two (90.10%; 90%CI 85.94–93.34%) of the 202
respondents were considered as having a good attitude regarding
vaccination.
3.6. Past experience with dengue fever
Of the 202 participants, 152 (75.25%; 90%CI 69.74–80.19%) had
either a personal or a secondhand experience with dengue. The
experiences of the respondents may have had an influence on their
answers in the sections on knowledge and attitude towards den-
gue fever and vaccination.
3.7. Willingness to avail of the dengue vaccine
After having answered the sections above, the respondents
were asked if they would be willing to avail of a free dengue vac-
cine for their child/ren should the government offer one. Answers
were classified into ‘‘willing” or ‘‘not willing”. Some respondents
answered with uncertainty, i.e. ‘‘it depends”, after which they were
asked to expound and state whether they lean towards ‘‘willing” or
‘‘not willing”. Among the 202 respondents who participated in the
study, 193 (95.54%; 90%CI 92.35%-97.66%) were willing to avail of a
dengue vaccine for their children or wards aged 9–14 years old if
the government were to offer it to them for free. This rate is high,
in comparison with results of similar studies conducted in Indone-
sia [13,14].
3.8. Crude analysis
Among the predetermined factors analyzed, the following fac-
tors were found to be significantly associated with willingness-
to-avail: household size, knowledge regarding dengue fever, and
attitude towards vaccination. Conversely, there was no sufficient
evidence for the association of the following factors to the outcome
variable: age, marital status, employment status, attitude towards
dengue fever, and past experience with dengue fever. Factors such
as monthly household income, level of education, and knowledge
regarding vaccination yielded data that are perfectly predicted
(100% willing to avail of the vaccine), and therefore could not be
analyzed further to explore the possibility of a significant associa-
tion [see Supplementary File 7]. This is likely due to the small study
population size.
Table 5
Attitude towards dengue fever, according to level of agreement of study participants. Distribution of the responses according to level of agreement to each statement.
Statement Strongly Agree
Freq (%)
Dengue is a serious illness. (n = 202) 86 (42.5)
My child is at risk of getting dengue fever. (n = 202) 29 (14.3)
Dengue fever can be prevented. (n = 202) 54 (26.7)
*
Numerical values for Likert scale levels: Strongly Agree: 5; Agree: 4; Neutral: 3; Disagree: 2; Strongly Disagree: 1.
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Among the statistically significant factors, household size (OR:
4.84; 90%CI 1.27–18.49) and attitude towards vaccination (OR:
5.53; 90%CI 1.60–19.11) were found to be positively associated
with the willingness to avail of a dengue vaccine, while knowledge
regarding dengue fever (OR: 0.13; 90%CI 0.30–0.57) was found to
be negatively associated.
3.9. Multiple logistic regression analysis
In order to model the outcome variable and the factors associ-
ated with it, multiple logistic regression was performed as part
of the analysis. Variable selection based on the p-values obtained
by the factors was performed to determine which of the factors
would be included in the full model. Those factors which yielded
a p-value of less than 0.25 (Wald’s Test) were included in the full
model of the multiple logistic regression analysis, and those factors
were found to be the following: age, household size, knowledge
regarding dengue fever, attitude towards dengue fever, and atti-
tude towards vaccination. The employment status of being self-
employed was also included in the full model, as it yielded a p-
value of exactly 0.25 in the crude analysis. For the final model, only
four factors were found to be significantly associated with the out-
come, as shown in Table 8. These are the following: age, household
size, knowledge regarding dengue fever, and attitude towards
vaccination.
3.10. Thematic analysis
Thematic analysis was conducted to analyze the data from the
FGD. Most primary caregivers reported that if the dengue vaccine
were safe, they would be willing to have their child vaccinated.
Several themes emerged from the analysis which encompass or
are linked to reasons behind the willingness of these primary care-
givers to vaccinate, and are as follows:
3.10.1. Perceived threats of dengue fever
Emergent themes identified as perceived threats were further
subdivided into perceived susceptibility and perceived severity.
Susceptibility to dengue was perceived to be universal in that
everyone can get bitten by mosquitoes and therefore anyone
may be infected. This was agreed upon by all other participants
in a consensus.
The participants perceived the severity of dengue to be fatal and
complex. A mother experienced losing her otherwise healthy child
to dengue, which presented with nonspecific symptoms like fever
and chills, and whose prognosis rapidly deteriorated. Another par-
ent expressed their belief that dengue is hard to detect because of
how young children have difficulty in articulating whether or not
they feel sick. They also shared their beliefs about the difficulty
to control dengue and detect its symptoms – that it is prone to
escalating into an epidemic; that aside from rashes, the symptoms
are nonspecific and therefore difficult to detect immediately; and
that re-infection with dengue is indicative of a stronger strain
and more severe outcomes.
Agree Neutral Disagree Strongly Disagree Mean* Median*
Freq (%) Freq (%) Freq (%) Freq (%)
99 (49.0) 7 (3.5) 10 (5.0) 0 4.29 4
102 (50.5) 28 (13.9) 38 (18.8) 5 (2.5) 3.54 4
118 (58.4) 16 (7.9) 11 (5.5) 3 (1.5) 4.03 4
 Ma. Sophia Graciela L. Reyes et al. / Vaccine 38 (2020) 54–62
Table 6
Attitude towards vaccination according to level of agreement of study participants. The frequency and proportion of answers in the statements for the assessment of attitude
towards vaccination.
Statement
Vaccination is important for disease prevention. (n = 202)
Vaccines are safe. (n = 202)
It is important to meet your child’s vaccination schedule. (n = 202)
*
Numerical values for Likert scale levels: Strongly Agree: 5; Agree: 4; Neutral: 3; Disagree: 2; Strongly Disagree: 1.
3.10.2. Perceived benefits of the dengue vaccine
The participants believed in the protective effects of vaccines
against diseases. The general sentiment was that a child could still
get the dengue after vaccination, but the illness would not become
severe. Participants’ willingness to avail of the vaccine was affected
by their past experience with dengue fever. They did not want their
children to experience dengue fever after seeing how it affected
others, and would therefore have their children vaccinated against
dengue if given the chance.
The respondents believed in wide vaccine coverage and won-
dered why the vaccine only targeted 9 to 14- year-old children
(an assumption presumably derived from the study’s target popu-
lation), when a lot of children below the age of 9 and above 14 are
at risk of dengue infection. The duration of conferred immunity of
the dengue vaccine was also perceived as a benefit. The respon-
dents asked for information on the length of the vaccine’s effects,
and whether or not it would confer lifetime protection.
3.10.3. Perceived barriers to dengue vaccine acceptability
Inadequate background knowledge, vaccine affordability, and a
perceived ineffectiveness of the vaccine were identified as barriers
by the participants. One participant expressed that primary care-
givers from other areas may possibly have low confidence in the
vaccine because of a lack of specific information regarding the
side-effects and exact constituents of the vaccine. Most partici-
pants were willing to have their children vaccinated for free or at
low cost relative to ‘‘ordinary employees”. When presented with
a situation wherein the vaccine would be too expensive for their
means, they expressed their willingness to save up for it should
safety and effectiveness be proven.
One of the participants stated that if they received news about
deaths due to dengue despite immunization against the disease,
they would hesitate to avail of the vaccine. According to them, it
would defeat the purpose of immunization and would make the
parent question the need to have their children vaccinated against
dengue since they would die either way.
A perceived threat from vaccination was adverse effects. One of
the participants, a barangay health worker, recounted their interac-
tion with a person-with-disability who attributed his weakness
and loss of hearing to an injection hitting a vein in his neck. Others
shared that they overheard claims of dengue vaccine side effects
such as intense nausea and the ability to lower one’s intellect from
their acquaintances, citing that they would hesitate to have their
children vaccinated should these claims be proven true.
3.11. Attitude towards vaccination
The researchers found that those with a good attitude towards
vaccination were approximately 10.62 times (90%CI: 1.73–26.28)
more likely to be willing to avail of a dengue vaccine than those
with a poor attitude. This was supported by the FGD, wherein
the respondents all agreed to avail of a dengue vaccine, and
expressed their belief in the protective benefits of the vaccine for
their children’s immune system. This finding is supported by two
similar studies conducted in Indonesia, which stated that an indi-
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Strongly Agree Agree Neutral Disagree Strongly Disagree Mean* Median*
Freq (%) Freq (%) Freq (%) Freq (%) Freq (%)
65 (32.2) 133 (65.8) 3 (1.5) 1 (0.05) 0 4.30 4
45 (22.3) 135 (66.8) 17 (8.4) 3 (1.5) 2 (1.0) 4.08 4
67 (33.1) 126 (62.4) 5 (2.5) 2 (1.0) 2 (1.0) 4.26 4
vidual’s attitude towards vaccination is one of the factors most
associated with dengue vaccine acceptance [13,14].
3.12. Household size
In a developing country such as the Philippines with densely
populated urban areas, household size implies economic con-
straints. Households with monthly incomes below the poverty line
would find difficulty in providing for an increasing number of chil-
dren with an increasing cost of healthcare. In this study, it was
found that having a large household size, which is greater than
the national average of five people per household, increased the
willingness of primary caregivers to avail of a dengue vaccine by
9.63 times (90%CI: 2.04–45.38) given the assumption that the vac-
cine is free.
Cost appears to be a consideration among primary caregivers,
which, as mentioned, is tied up with household size. However, it
must be noted that all of those who were not willing to participate
belonged to the group of respondents with monthly household
incomes above the poverty threshold (Table 7); hence the implied
link between household size and economic constraints may not be
adequate, after all, to explain the direct association between
household size and willingness to avail of the vaccine.
3.13. Parental age
Previous studies [13,21] have found that age of parents was not
significantly associated with willingness to vaccinate their chil-
dren. However, multivariate logistic regression analysis in this
study revealed that primary caregivers older than 44 years of age
are approximately 86% less likely (90%CI: 0.03–0.61) to be willing
to avail of a dengue vaccine than those who are 44 years of age
and younger. This could be intuitively explained by a generation
gap, as supported by one sentiment shared in the FGD –one parent
explained that though they are aware of the positive effects of vac-
cines on the immune system, there are still older primary care-
givers who remain skeptical about vaccination due to its
unavailability during their youth.
3.14. Knowledge regarding dengue fever
This study found that primary caregivers who have good knowl-
edge on dengue fever were 90% less likely (90%CI: 0.03–0.74) to be
willing to avail of a free dengue vaccine than those who have poor
knowledge. This inverse relationship is interesting to note, as sim-
ilar studies found no significant association [13] or a positive asso-
ciation between good disease knowledge and vaccine acceptance
[21]. It may also be worthwhile to note that this study also found
that the primary caregivers who were unwilling to avail of a free
dengue vaccine all had completed tertiary level education, and
had good knowledge regarding vaccination, suggesting that good
knowledge does not necessarily translate to willingness to
vaccination.
One emergent theme that could intuitively explain this associ-
ation would be the knowledge monopoly in healthcare. This occurs
60 Ma. Sophia Graciela L. Reyes et al. / Vaccine 38 (2020) 54–62

Table 7
Univariate logistic regression analysis models showing factors associated with the willingness to avail of a dengue vaccine (n = 202). The odds ratios (OR), and their corresponding
90% confidence intervals and p-values of the association between the predetermined independent variables/factors to the willingness to avail of a dengue vaccine.

Variable/Factor n (%) % Willing Crude OR (90% CI) p-value

Age
44 years old (R)a 120 (59.40%) 97.5%
>44 years old 82 (40.60%) 92.68% 0.32 (0.99–1.06) 0.199
Household Size
Small (R) 88 (43.56%) 92.05%
Large 114 (56.44%) 98.25% 4.84 (1.27–18.49) 0.053
Marital Status
Single/Widowed (R) 32 (15.84%) 96.87%
Married/Cohabiting 170 (84.16%) 95.29% 0.65 (0.11–3.85) 0.693
Monthly Household Income
Below Poverty Threshold (R) 88 (43.56%) 100%
Above Poverty Threshold 114 (56.44%) 92.11% N/A
Level of Education
None (R) 7 (3.46%) 100%
Primary/Secondary 150 (74.26%) 100%
Tertiary 45 (22.28%) 80% N/A
Employment Status
Unemployed (R) 122 (60.39%) 96.72%
Self-Employed 23 (11.39%) 91.3% 0.35 (0.81–1.56) 0.250
Private/Government Employee 57 (28.22%) 94.74% 0.61 (0.17–2.20) 0.527
Knowledge re: dengue fever
Poor (R) 193 (95.54%) 96.37%
Good 9 (4.46%) 77.78% 0.13 (0.30–0.57) 0.023
Knowledge re: vaccination
Poor (R) 4 (1.98%) 100%
Good 198 (98.02%) 95.45% N/A
Attitude towards dengue fever
Poor (R) 70 (34.65%) 98.57%
Good 132 (65.35%) 93.94% 0.22 (0.038–1.31) 0.163
Attitude towards vaccination
Poor (R) 19 (9.41%) 84.21%
Good 183 (90.59%) 96.72% 5.53 (1.60–19.11) 0.023
Past experience with dengue fever
Without (R) 50 (24.75%) 98.04%
With 152 (75.25%) 94.70% 0.36 (0.06–2.09) 0.338
a
(R) = Referent Value.

Table 8
Multiple Logistic Regression: Final Model.

Factor n (%) % Willing Crude OR (90% CI) p-value aOR (90% CI) p-value
Age
44 years old (R) 120 (59.40%) 97.50% 0.32 (0.99–1.07) 0.199 0.14 (0.03–0.61) 0.027
>44 years old 82 (40.60%) 92.68%
Household size
Small (R) 88 (43.56%) 92.05% 4.84 (1.27–18.49) 0.053 9.63 (2.04–45.38) 0.016
Large 114 (56.44%) 98.25%
Knowledge re: dengue fever
Poor (R) 193 (95.54%) 96.37% 0.13 (0.30–0.57) 0.023 0.10 (0.03–0.74) 0.032
Good 9 (4.46%) 77.78%
Attitude towards vaccination
Poor (R) 19 (9.41%) 84.21% 5.53 (1.60–19.11) 0.023 10. 62 (1.73–26.28) 0.010
Good 183 (90.59%) 96.72%

when there is an imbalance in decision making power or a large 3.15. Limitations

knowledge gap between the physician and the patient, biased
towards the physician [22]. In this study, a large knowledge gap
present due to the novelty of the dengue vaccine is a possible rea-
son for the willingness to avail of the vaccine. It was evident in
some answers that despite vaccine hesitancy, the participants
would be willing to avail of the vaccine if their own doctors or
the DOH would assure safety. They believed that as long as the
DOH would roll the vaccine out, it would be safe to use.
3.15.1. Selection bias
In the study, selection bias may have occurred as a result of
refusal to participate in the interview. Majority of those who
refused to participate in the interview appeared to have come
from higher socioeconomic classes and may have had different
characteristics from actual study participants. The researchers
were also refused entry by a private homeowners’ association

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 Ma. Sophia Graciela L. Reyes et al. / Vaccine 38 (2020) 54–62
to conduct the study in one street despite endorsement from
the barangay.
3.15.2. Concerns with sample size and interpretability
The power of the study was affected by the small sample size
due to privacy concerns of one homeowner’s association that did
not permit entry despite barangay clearance, as well as several
individuals who chose to refuse participation. The possible utility
of the results for another, wider population, such as those outside
an urban setting, was also limited by the confinement of survey
respondents to a single urban barangay. This was done to adhere
to time and budgetary constraints.
3.15.3. Homogeneity of FGD participants
The lone FGD that was conducted included participants which
may not have adequately represented the same source population
as that of the interviews, since the majority of those in the former
were employees of the barangay hall.
3.15.4. Structure of survey tool
Overlap between items found in different parts of the data col-
lection tool, such as that of knowledge regarding and attitude
towards vaccination, might have affected the results. However,
for this particular study, the two factors mentioned were only
taken separately as factors to willingness, and not as factors to
one another.
4. Conclusions
Nineteen of every twenty primary caregivers with children aged
9–14 had poor knowledge regarding dengue fever. Conversely, a
higher proportion of participants (98%) had good knowledge on
vaccination. Despite the majority having poor knowledge regard-
ing dengue fever, 95% were still willing to have their children vac-
cinated against the disease.
The most important independent predictors of willingness to
avail of a dengue vaccine were attitude towards vaccination,
household size, age of the primary caregivers, and knowledge
regarding dengue fever. Knowledge regarding dengue fever being
negatively associated with willingness to avail of the vaccine, in
particular, was an interesting finding given the importance of
informed decision making in a person’s healthcare. This, along with
supporting statements from the FGD regarding knowledge mono-
poly in healthcare, may be explored in further studies. Other per-
ceptual drivers of vaccine attitude, such as trust in health care
providers or the government, method of vaccine delivery, and
how the specific disease or vaccine ranks in comparison to other
perceived needs, may be explored in future studies.
This study serves as a preliminary contribution to future studies
in understanding vaccine hesitancy and the factors affecting con-
sumers’ willingness to avail of a vaccine. Because the study’s quan-
titative results were significantly affected by a small sample size
and study area, the group recommends inflating the sample size
requirement by 15–20% to account for possible non-response,
and employing better recruitment strategies. This would allow
for expanded stratification of participants’ categories (i.e. in this
study, single and widowed primary caregivers had to be combined
into one sub-category in order for the data to be properly analyzed,
whereas a larger sample size may make it possible to analyze these
sub-categories separately). This is especially so because certain
observations obtained in data analysis were insufficient to estab-
lish statistical significance, such as how all respondents who were
not willing to have their children vaccinated against dengue had
completed at the very least a tertiary level of education. The small
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61
proportion of respondents that answered ‘‘not willing” limited the
scope and significance of data analysis; a larger study area and
sample size may allow a larger proportion of ‘‘unwilling” respon-
dents to be detected.
It is also recommended that future studies on this topic ensure
that a list of households of the target population is available for use
as a sampling frame. Majority of the respondents in the study were
female, and majority of the respondents were unemployed as well;
although the relationship between the two observations was not
the focus of the study, i.e. whether women make the healthcare
decisions if they are unemployed, this may possibly affect the
number of parents who are willing to avail of the vaccine. Thus,
this relationship along with other factors not included in this study
such as the sex of the children and of the primary caregivers could
be further explored in future research. The female majority reflects
the reality of Filipino communities in general, where mothers or
women are responsible for staying home to tend to their children
or wards. Further classification of the respondents’ answers is also
recommended: for example, ‘‘conditional” may be added as
another descriptor for the variable willingness. Dichotomizing
the answers of the respondents into ‘‘willing” and ‘‘unwilling”
may be problematic as it does not take those who would have
given conditional answers (i.e., ‘‘it depends”).
Dengue fever is a national public health concern with increasing
incidence rates, especially in the younger age brackets, and it is
therefore imperative that measures to improve knowledge and
attitudes towards both dengue fever and vaccination be imple-
mented. Efforts by the local government and their respective bar-
angay health centers to correct misconceptions through health
education should be made, especially in the area of dengue preven-
tion measures. This can be accomplished by conducting health
seminars and by sufficiently distributing information, education,
and communication (IEC) materials for the improvement of knowl-
edge and attitudes towards dengue fever and vaccination in coop-
eration with village associations, the DOH, and medical
associations.
Additionally, information regarding dosage, possible side
effects, and the administration procedure of the vaccine can be
provided to the participants, as it may affect the actual acceptance
rate of the vaccine, as compared to the computed result (95.54%).
This may aid the participants in making more informed choices,
given that poor knowledge was shown in this study to be signifi-
cantly associated with the increased likelihood of primary care-
givers to avail of a dengue vaccine.
Lastly, it is recommended that the Department of Health con-
sider the perceptions of primary caregivers in the development
of different vaccination programs. If data regarding willingness of
primary caregivers to accept a vaccine were to be used as a basis
of the development of a vaccination program, the program may
be more effective given that the target population’s reasons for
acceptance/non-acceptance will have been incorporated.
Ethics approval and consent to participate
This study was reviewed and granted approval for implementa-
tion by the University of the Philippines Manila Research Ethics
Board (UPMREB) Review Panel 5b (College of Public Health), and
was assigned the study protocol code UPMREB-2016-464-UND. A
waiver of informed consent documentation was requested from
the University of the Philippines Manila - Research Ethics Board
(UPM-REB) for the survey interview, and a cover letter was dis-
cussed with the participant to ensure understanding of its con-
tents. Informed consent was taken from the participants of the
FGD in the form of an informed consent form, which was approved
by the aforementioned Ethics Board.
62 Ma. Sophia Graciela L. Reyes et al. / Vaccine 38 (2020) 54–62
Consent for publication
Not applicable.
Data availability
The datasets generated and/or analyzed during the current
study are not publicly available due to a confidentiality clause
observed by the authors, but are available from the corresponding
author on reasonable request.
Authors’ contributions
All authors made substantial contributions to the conception
and design of the study, as well as the acquisition of data. PVP pro-
vided technical assistance to the research group in the design, con-
duct, and analysis of the study. MLR, KGL, ALP and JTP conducted
the survey/interviews. KGL and JTP performed statistical analyses
while MLR and ALP conducted the thematic analysis. All authors
drafted the work and gave final approval of the version to be pub-
lished. MLR facilitated critical revisions of the manuscript for sub-
mission in consultation with PVP. All authors agree to be
accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved. All authors attest they
meet the ICJME criteria for authorship.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
Acknowledgements
We would like to express our sincere appreciation to the follow-
ing for their invaluable inputs for the improvement of our study:
Prof. Maylin C. Palatino, Prof. Kim L. Cochon, Dr. Maria Margarita
M. Lota, Prof. Buenalyn Teresita Ramos-Mortel, and Dr. Carl Abe-
lardo T. Antonio of the University of the Philippines-Manila College
of Public Health, and Dr. Rhoel R. Dinglasan of the University of
Florida.
Appendix A. Supplementary material
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.vaccine.2019.10.001.
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