SLU – Research Ethics Committee: Protocol Format

COVID-19 Vaccine Acceptance and Hesitancy Questionnaire (COV-AHQ)

FOR ADULTS (with Tagalog translation)

Date:________

Dear Respondent

Greetings of Peace! 

We, the BSN III-D3 of Saint Louis University-School of Nursing, together with our research promoter,
Prof. Sahlee Florendo MN, RN, is conducting a study entitled “Factors that Influence Hesitancy
towards COVID-19 Vaccination among Residents in Baguio City,” in partial fulfillment of the
requirements for the course Introduction to Nursing Research I. This study aims to determine the factors
that influence hesitancy to participate in Covid-19 vaccination among residents in Baguio City.  In
particular, this study aims to answer the following research questions:

a. What are the factors that influence hesitancy to participate in COVID19 vaccination among
residents in Baguio City? and;
b. Is there a significant difference on the factors influencing vaccine hesitancy when
respondents are grouped according to a) gender – male and female b) occupation – allied
medical health profession and non-allied medical health profession?

In this regard, we humbly request your participation in answering our questionnaire. The questionnaire
contains two parts. The first part consists of personal information such as age, gender and profession. The
second part consists of factors that influence vaccine hesitancy according to: (A) Personal Situation, (B)
Effectiveness (C) Lack of Trust and (D) Anti-Vaccine. Kindly answer the following questions by putting
a check (/) mark on the appropriate answer you think is suitable. Your answers will help us determine the
factors that influence hesitancy to participate in COVID19 vaccination among residents in Baguio City.

Attached herewith is a copy of the Questionnaire and an Informed consent. We genuinely hope you can
spare some time to read the items carefully in the questionnaire and answer them. Your answer is
essential, and we sincerely appreciate your response regarding this matter. 

Thank you, and God bless!

Respectfully yours,

SHAIRA MARIE BENAVIDES,

BSN III-D4 Representative, School of Nursing 
Saint Louis University

SAHLEE FLORENDO, MN, RN

Faculty, School of Nursing 
Saint Louis University 
 SLU – Research Ethics Committee: Protocol Format

PART 1: DEMOGRAPHIC PROFILE (Demograpiko)

Age (edad): ______
Gender (kasarian):   ▢ Male (lalaki)     ▢ Female (Babae)
Occupation (Trabaho): ____________________

PART 2: FACTORS THAT INFLUENCE COVID19 VACCINE HESITANCY

Instruction: The items below are factors that influence COVID-19 vaccine hesitancy. Please
check (/) all the items that apply to you.
Panuto: Piliin ang mga dahilan ng hindi pagpapabakuna para sa sakit na COVID-19. Lagyan
ng tsek (/) ang kahon na sumasang-ayon sa iyong paniniwala o kalagayan.

I did not receive the COVID-19 vaccine because…

Hindi pa ako nagpapabakuna para sa sakit na COVID-19 dahil…

A. PERSONAL SITUATION (PERSONAL NA KALAGAYAN/ SITWASYON)

 I do not feel concerned, because of age or health condition.
Hindi ako nababahala, dahil sa edad o kondisyon ng aking kalusugan. 
 It is a useless vaccine, COVID-19 is not very dangerous.
Ito ay isang walang silbing bakuna, ang COVID-19 ay hindi masyadong
delikado.
 Because of my physical condition, my health does not allow vaccination.
Dahil sa aking pisikal na kondisyon, hindi ako maaaring bakunahan.
 I have been tested negative, I am not sick, I have been sick and am
immunized.
Ako ay negatibo sa COVID-19, wala akong sakit na COVID-19, nakaranas na
ako ng ibang sakit at hindi na ako tatablan ng COVID-19.

A. EFFECTIVENESS (PAGKAMABISA)
 Lack of knowledge, I prefer to wait longer and to study it over the long term
to see if it is really effective and safe.
Kakulangan ng kaalaman, mas gugustuhin kong maghintay nang mas matagal at
pag-aralan ito sa mahabang panahon upang makita kung ito ay talagang
epektibo at ligtas.
 I prefer to treat myself in other ways, there are other treatments
(hydroxychloroquine). Social distancing and other behavioral measures are
sufficient. I am careful. I prefer to develop my own immunity.
Mas gusto kong gamutin ang sarili ko sa ibang paraan, may mga iba pa namang
panglunas sa sakit (gaya ng hydroxychloroquine). Sapat na ang social distancing
at iba pang pag uugali na angkop sa aking kaligtasan. Maingat ako. Mas gusto
kong bumuo ng sariling proteksyon laban sa sakit.
 SLU – Research Ethics Committee: Protocol Format

 Because of the possibility of a mutation of the virus (so the vaccine would be
less effective or not effective at all).
Dahil sa posibilidad ng pagbabago ng virus (kaya ang bakuna ay hindi gaanong
epektibo o hindi talaga epektibo).

A. LACK OF TRUST (KAKULANGAN SA TIWALA)

 Because a vaccine developed in an emergency is potentially dangerous, side
effects are unknown, and people can get sick.
Dahil ang bakuna na agaran isinagawa ay may potensyal na panganib, ang mga
side effects nito ay lingid sa kaalaman, at ang mga tao ay maaaring magkasakit.
 Because of my distrust of the pharmaceutical industry/medical profession,
the laboratories are in a logic of profitability.
Dahil sa kawalan ng aking tiwala sa industriya ng parmasyutiko/medikal na
propesyon, ang mga laboratoryo ay nasa lohika lamang ng kagustuhang kumita.
 Because of a lack of information, divergent opinions, and no scientific
consensus.
Dahil sa kakulangan ng impormasyon, magkakaibang opinyon, at walang
siyentipikong consensus.
 Because there are secret relationships between the government and the
pharmaceutical industry (opinions/conspiracy theories).
Dahil may mga lihim na ugnayan sa pagitan ng gobyerno at industriya ng
parmasyutiko (mga opinyon/mga teorya ng pagsasabwatan).
 Because of the poor management of vaccines and/or masks by the
government (negative opinions/comments regarding the government and its
management of the epidemic).
Dahil sa mahinang pamamahala ng mga bakuna at/o maskara ng gobyerno (mga
negatibong opinyon/komento tungkol sa pamahalaan at sa pamamahala nito sa
epidemya).

A. ANTI-VACCINE (HINDI PABOR SA BAKUNA)

 I am against vaccination (in general), I don’t get vaccinated.
Tutol ako sa pagpapabakuna (sa pangkalahatan), ayaw kong mabakunahan.
 Because vaccines are (possibly) harmful and because of the impact of
vaccines on health.
Dahil ang mga bakuna ay (may posibilidad) na nakasasama at dahil sa epekto ng
mga ito sa ating kalusugan.