Republic of the Philippines

Bulacan State University

City of Malolos , Bulacan
College of Nursing
Factors Influencing the COVID-19 Booster Hesitancy among Nursing Students of Bulacan State
University: An Assessment

Research Tool
Direction: Read the research survey tool carefully. Fill in or cross (X) the space provided for
your answer.
NOTE: This survey tool was made by the researcher from BSN 3A Group 8. Your responses
will be treated with utmost confidentiality and for education purposes only.

Name of the Respondent: ________________________________ Prefer not to say: _____

(optional) Surname First M.I.
Year Level & Section (e.g. BSN 3A): ________________ Age: _______ Sex: ___ M ____F

I. Vaccination Status

1. Are you vaccinated with COVID-19 Booster Shots? _____ Yes _____ No
2. Doses: _____ 1 Dose only _____ Full Dose _____ Did not received any doses
st

3. Brand (for those who received booster shots only):

_____ Astrazeneca _____ Gamaleya Sputnik _____ Janssen (J&J)
_____ Moderna _____ Pfizer _____ Sinovac
4. For those who received 1 or full doses of the COVID-19 booster shots, what are the
st

side effects have you experienced? (select all that apply)

____ Pain, Swollen Arm ____ Swollen Lymph Nodes
____ Chills ____ Fever
____ Body Aches ____ Headaches
____ Fatigue ____ Others: (please specify) ____________

II. Vaccinated Person Section

1. Did you choose your vaccination type, or did you just take what was available at the
time?
____ Choose my preferred vaccine _____ Took what is available
2. Was your choice of vaccination based on medical advice or your own research?
____ I did not choose _____ Personal Research ______Medical Advise
 Republic of the Philippines
Bulacan State University
City of Malolos , Bulacan
College of Nursing

3. Were you initially hesitant to take the vaccine? (Note here that a hesitant person was
eligible but previously unwilling)
____ Yes/To some extent _____ No

4. IF you were hesitant, please explain why you were initially hesitant (select all that apply)
____ Not relevant, I was never hesitant
____ I did not qualify to receive it before
____ I did not like any of the vaccine options available to me
____ I had religious grounds for not taking it
____ I had a medical condition that barred me from taking it
____ I did not trust the government
____ I did not trust medical authorities
____ I did not trust the vaccines (not safe, developed too quickly, do not know what is in it)
____ I was not sure about long-term side effects of the vaccine
____ Others: (specify) ___________________________________________

5. If you were hesitant, what changed your mind? (Select option that best applies)
____ Not relevant I was never hesitant
____ I was offered a vaccine
____ I was more comfortable with
____ I spoke to my doctor
____ I did more research
____ I consulted family and friends
____ My spiritual/religious leader advised me do it
____ I was persuaded by government/public health authorities
____ I noticed that a personality (public or otherwise) took it
____ I was forced by my employer/family members or felt like
____ I did not have a choice
____ I felt more comfortable because several people took it before me
____ I was frightened by the increased infections/deaths
____ My circumstances changed (such as being pregnant or any other medical or personal factor)
____ Others: (specify) ___________________________________________

6. What is your PRIMARY source of information on the COVID-19 booster shot situation?
____ Government/Official sources
____ Private/personal medical sources
____ Social media (Facebook/Instagram/WhatsApp/Twitter/TikTok/YouTube)
____ Personal internet research (via Google, Safari, Bing, Yahoo, Baidu, AOL, Ask.com, Excite)
____ Local radio/television/newspapers Information from family and friends
 Republic of the Philippines
Bulacan State University
City of Malolos , Bulacan
College of Nursing
7. What is the best way to communicate with you or the way that you generally prefer to
receive information?
____ Via newspapers (paper/electronic) ____ Via radio
____Via television (local or cable) ____Via Facebook
____ Via Instagram ____Via WhatsApp
____ Via Twitter ____Via TikTok
____ Via YouTube Social networks (family and friends)

8. Do you find the information conveyed by popular personalities (local and international)
on social media helpful in terms of forming your own opinions on COVID-19 related
matters?
____ Yes, very helpful _____Somewhat helpful
____ Not helpful/Distracting/Misleading _____ Unsure/won’t say

9. Would you support the imposition of COVID-19 booster shots mandates in respect of:

a. Arriving visitors ____ Yes ____ No ____ Unsure/Won’t Say

b. Frontline ____ Yes ____ No ____ Unsure/Won’t Say
medical/Elder care
workers
c. Public servants ____ Yes ____ No ____ Unsure/Won’t Say
d. Workers in the ____ Yes ____ No ____ Unsure/Won’t Say
Hotel/Tourism sector
e. Taxi/Minibus drivers ____ Yes ____ No ____ Unsure/Won’t Say
and conductors
f. Secondary/Tertiary ____ Yes ____ No ____ Unsure/Won’t Say
school children
g. Primary school ____ Yes ____ No ____ Unsure/Won’t Say
children

III. Unvaccinated Person Section

1. Which of the reasons best explains why you are unvaccinated this time? (Select all apply)
_____ I did not qualify to receive it before
_____ Cannot find the time to go/lines are too long
_____ I do not like any of the vaccine options available to me
_____ I will not take it on a religious ground
 Republic of the Philippines
Bulacan State University
City of Malolos , Bulacan
College of Nursing
_____ I believe that I have a medical condition that bars me from taking it
_____ I do not trust the government/medical authorities here in my barangay
_____ I do not trust the vaccine (not safe, developed too quickly, do not know what is in it)
_____ I believe it is a choice and I chose not to
_____ No reason really, I just do not want to take it
_____ I am not sure about long-term side effects of the vaccine
_____ It is not mandatory for school
_____ Side effects from the previous vaccination
_____ Others: (specify) ___________________________

2. Has your view on the COVID-19 booster shots always has been the same or has it
changed over time?
_____ No change, I still am not going to take it
_____ I am now more inclined towards taking it
_____ I am now less inclined towards taking it

3. Which of these sources of information has been the most helpful to you in terms of
deciding NOT to take the booster shots (Select all apply)
_____ Government/Official sources
_____ Private/Personal medical sources
_____ Social Media (Facebook, Instagram, Twitter, WhatsApp, Tiktok, Youtube)
_____ Personal Internet Research (via Google, Safari, Bing, Yahoo, Baidu, AOL, Ask.com, Excite)
_____ Local Radio/Television/Newspaper
_____ Information from family and friends

4. Specifically, what type of information on the COVID-19 booster shots would help you be
more inclined to take it?
 Republic of the Philippines
Bulacan State University
City of Malolos , Bulacan
College of Nursing
a. The side effects of the ____ Yes, useful ____ Not particularly useful
vaccine
5.
b. How effective the ____ Yes, useful ____ Not particularly useful
vaccine

c. The numbers of people ____ Yes, useful ____ Not particularly useful
who got sicked/died and
their vaccination status

d. The different types of ____ Yes, useful ____ Not particularly useful
vaccines available

e. Location of vaccination ____ Yes, useful ____ Not particularly useful

sites

f. The position of my ____ Yes, useful ____ Not particularly useful

church or religious
leader

g. The impact of the ____ Yes, useful ____ Not particularly useful
vaccine on my health
status

Was your decision not to vaccinate based on the advice of a medical practitioner that is
familiar with your case?
____ Yes, I consulted
____ No, I did not consult
____ Medical advice was irrelevant in my case

6. Was your decision not to vaccinate based on:

a. The advice of a ____ Yes ____ No, nothing to do

religious leader? with religion
b. The advice of ____ Yes ____ No, nothing to do
family/friends? with family/friends

c. What you saw/heard on ____ Yes ____ No, nothing to do

social media? with social media

d. Personal choice? ____ Yes ____ No

 Republic of the Philippines
Bulacan State University
City of Malolos , Bulacan
College of Nursing

7. Consider these possibilities and tell me each instance if any of them would persuade you
to change your mind and take the COVID-19 Vaccine?

a. If it would allow me to access social activities more freely

_____ Possibly/Yes _____ No _____ Unsure
b. If I was given more scientific or medical information
_____ Possibly/Yes _____ No _____ Unsure
c. If I saw people, I care about getting sick/dying from COVID-19
_____ Possibly/Yes _____ No _____ Unsure
d. If I saw influential people who now oppose it switch their position
_____ Possibly/Yes _____ No _____ Unsure
e. If it was required for me to travel overseas
_____ Possibly/Yes _____ No _____ Unsure
8. Consider these individuals/entities and in each instance please tell me how much or how
little you respect their opinion on COVID-19. In each instance “1” means you have a
little or no respect in opinion and 10 means you have a very high regard for the views and
opinions
____ Local newspaper
____ Local radio stations
____ Local television
____ Government politicians
____ Opposition politicians
____ Trade Union Leaders
____ Private sector leaders
____ University leaders
____ Ministry of Health
____ Private doctor
____ Family members
____ Social Media influencers

9. What is the best way to communicate with you or the way that you generally prefer to
receive information?
____ Via newspapers (paper/electronic) ____ Via radio
____Via television (local or cable) ____Via Facebook
____ Via Instagram ____Via WhatsApp
____ Via Twitter ____Via TikTok
____ Via YouTube Social networks (family and friends)

10. Do you find the information conveyed by popular personalities (local and international)
on social media helpful in terms of forming your own opinions on COVID-19 related
matters?
 Republic of the Philippines
Bulacan State University
City of Malolos , Bulacan
College of Nursing
____ Yes, very helpful _____Somewhat helpful
____ Not helpful/Distracting/Misleading _____ Unsure/won’t say

11. If you were to choose between expanding the level of vaccination in the country and
prolonged restrictions, which would you prefer
____ Increase vaccination levels (however)
____ Continue restrictions
____ Unsure/won’t say

12. Apart from vaccination, what do you think of these other options for combating COVD-
19:
a. No need for any _____ Good option _____ Bad option ____ Unsure
options, COVID-19 is a
hoax
b. Natural immunity _____ Good option _____ Bad option ____ Unsure
(let the vulnerable get
sick and the rest of us
get on with life)
c. Comprehensive _____ Good option _____ Bad option ____ Unsure
lockdowns
d. More handwashing _____ Good option _____ Bad option ____ Unsure
e. Better social _____ Good option _____ Bad option ____ Unsure
distancing

13. Would you support the imposition of COVID-19 booster shots mandates in respect of:

a. Arriving visitors ____ Yes ____ No ____ Unsure/Won’t Say

b. Frontline ____ Yes ____ No ____ Unsure/Won’t Say
medical/Elder care
workers
c. Public servants ____ Yes ____ No ____ Unsure/Won’t Say
d. Workers in the ____ Yes ____ No ____ Unsure/Won’t Say
Hotel/Tourism sector
e. Taxi/Minibus drivers ____ Yes ____ No ____ Unsure/Won’t Say
 Republic of the Philippines
Bulacan State University
City of Malolos , Bulacan
College of Nursing
and conductors
f. Secondary/Tertiary ____ Yes ____ No ____ Unsure/Won’t Say
school children
g. Primary school ____ Yes ____ No ____ Unsure/Won’t Say
children

References:
Maragakis, L., & Kelen, G. (2022, September 26). Booster Shots and Additional Doses for
COVID-19 Vaccines — What You Need to Know. Johns Hopskin Medicine.
https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/booster-
shots-and-third-doses-for-covid19-vaccines-what-you-need-to-know 

UNICEF. (2022, January 20). COVID-19 Vaccine Hesitancy Survey Report 2021. UNICEF.
https://www.unicef.org/easterncaribbean/press-releases/covid-19-vaccine-hesitancy