Jireh Ann P.

Mejino
TMTCS-SOM

I. Research Question: What are the factors influencing COVID-19 booster vaccination
hesitancy of Olongapo City residents?

II. Introduction
The reluctance of people to receive safe and recommended available vaccines is known
as ‘vaccine hesitancy’. According to Lin et al. (2020), the “intention to be vaccinated against an
infectious disease is recognized as a foremost issue affecting the success of vaccination
programs.” It is considered a complex public health issue. For the past two years in the
Philippines, vaccine scandals and reports about the serious side-effects of vaccination have
increased vaccination hesitancy among the public.
The intention for an individual to receive vaccination has multiple factors. The health
belief model (HBM) is one of the most commonly used models to determine vaccination
intention [2]. In previous studies, the HBM constructs have been recognized as an important
predictor of influenza vaccination uptake. The HBM comprises several main constructs:
perceived susceptibility, severity, benefits, barriers, self-efficacy to engage in a behaviour and
cues to action [3].
Willingness-to-pay (WTP) is the maximum amount in monetary terms wherein an
individual would be willing to sacrifice to obtain the benefits of a program, service of health
technology [4]. According to Ess and Szucs (2002), in vaccination decisions, the decision to get
vaccinated depends on the WTP of an individual for a vaccination to obtain increased health
benefits.
Evidence about the public’s acceptance and the willingness-to-pay for the COVID-19
booster vaccine is essential for the effectivity of the vaccination program in Olongapo City.

III. Background/Review of the Literature

By May 2022, worldwide, there were more than 500 million cases of COVID-19
infection and more than six million deaths due to it. In the Philippines, more than three
million were infected and more than 60,000 people died due to COVID-19. The ongoing
COVID-19 pandemic remains concerning as the virus that caused it has changed over time,
along with the documentation of its reinfection among individuals. As the COVID-19 variant
emerges and the pandemic continues, vaccination remains one of the most effective strategies
in disease prevention and public health promotion as vaccines reduce the severity and death
from COVID-19.
Furthermore, findings from several studies indicate that full vaccination and booster
doses provide additional protection against reinfection. This is of utmost importance as the
reinfection of the virus is not uncommon. According to Cavanaugh et al. (2021), among
previously infected individuals, those who were not vaccinated were twice as likely to be re-
infected compared to those who were fully vaccinated. Moreover, according to Levine-
Tiefenbrun et al. (2021), the COVID-19 viral load was significantly lower among vaccinated
people compared with unvaccinated people.
Despite the availability of COVID-19 vaccines and the proven benefits of vaccinations
outweighing the potential risks, vaccine hesitancy remains a persistent global problem.
According to the World Health Organization Strategic Advisory Group on Experts (SAGE)
on Immunization, the following definition of vaccine hesitance was developed: “Vaccine
hesitancy refers to a delay in acceptance or refusal of vaccination despite availability of
vaccination services. Vaccine hesitancy is complex and context specific, varying across time,
place, and vaccines.” Individuals choose not to receive vaccines due to a variety of reasons
and Volpp and colleagues (2021) stated that strategies with a focus on addressing facts and
evidence about COVID-19 vaccines and establishing vaccine confidence and acceptance in
all populations are key to increasing vaccine rates.
Also, according to Volpp and colleagues (2021), theory-based interventions in promoting
behavioral health provide information regarding what factors contribute to targeted
preventive health behaviors. The health belief model (HBM) is a useful theoretical
behavioral change model in understanding intentions to vaccinate against COVID-19 [9].
According to the HBM framework, people’s specific beliefs, namely perceived severity and
susceptibility of the disease and the perceived benefits and risks of the vaccine, relate to
health behaviors [10].
 Figure 1. Health Belief Model Components and Linkages [11].

As seen in Figure 1, the major constructs of the HBM are perceived susceptibility,
benefits, severity, barriers, and self-efficacy (under individual beliefs). The modifying factors
affect these perceptions, as do cues to actions. The combined beliefs and cues to action leads
to an individual’s health behavior [11]. Perceived severity refers to the belief that the
consequences resulting from getting the disease are serious for the self and others. Perceived
susceptibility refers to the belief that there is high risk of getting the disease. Perceived
benefits refer to the belief that the COVID-19 vaccine uptake will reduce the risk or
seriousness of the disease threat.
This has been investigated in the Philippines in a study conducted by Caple et al. (2021).
Multivariable analysis in the study revealed that HBM constructs were associated with
vaccination intention in the country. Additionally, the perceptions of high susceptibility, high
severity, and significant benefits; and external cues to action were found out to be good
predictors for vaccination intent.
As the virus continues to mutate and evolve, it is of utmost importance to investigate the
public’s perceptions toward the COVID-19 vaccine booster shots. To date, there are limited
theory-based studies conducted to understand the COVID-19 booster vaccination hesitancy.
Hence the need for this study in order to determine the factors affecting the booster
vaccination hesitancy in the local community of Olongapo City and to address them by the
local implementors of the vaccination program to ensure that the goals of the said program
are met. The goals are as follows: reduce COVID-19 related morbidity and mortality,
maintain essential services, control transmission and minimize social and economic
disruptions [13].
 IV. Objectives
The objective of the current study is to determine the factors influencing COVID-19
booster vaccination hesitancy of Olongapo City residents by assessing their vaccination intent
and willingness-to-pay (WTP). Particularly, the study has the following sub-objectives:
1. To determine the acceptability of a COVID-19 booster vaccine depending upon:
a. Demographic factors and psychological characteristics (participants’ health
perception, presence of chronic diseases, knowing someone in the community
who has had COVID-19)
b. Belief about susceptibility and severity of COVID-19
c. Belief about perceived benefits of the vaccine
d. Willingness-to-pay (WTP) for COVID-19 booster vaccine
2. To assess the possible cues to vaccination of our respondents.

V. Methodology
Study Design: Cross sectional study design, web-based anonymous survey using paper-
and-pencil face-to-face and online questionnaires. The questionnaires will be written in
English. The participants will be informed that their participation is voluntary and consent
will be acquired prior to completion of the questionnaire. The health belief model (HBM)
will be used as a theoretical framework for understanding COVID-19 booster vaccination
intent and WTP.

Setting: Local community of Olongapo City.

Study Subjects: Responses to be used for data collection will be limited to respondents
who are at least 18 years old, residents of Olongapo City.

Population, Sample Size and Selection of Sample: The target population of this study
consists of 260,317 residents of Olongapo City. Due to time and accessibility constraints, the
researcher used the Slovin’s formula in determining the appropriate sample size. From a
population of 260,317, a sample size of 399 residents will be chosen to represent the
population with 5% margin of error.

N
n= 2
(1+ N e )
260,317
n=
(1+260,317 ( 0.05 )2)
 n=399
A sample of 200 residents will be allocated to online questionnaires while a sample of 199
residents will be allocated to paper-and-pencil face-to-face distribution of questionnaires. The
method of random sampling was used to develop the sample of the study. According to this
method, sample members are selected on the basis of their convenience. A convenient sample
consists of subjects included in the study due to being in the right place at the right time. Using
this technique, each sample has the same probability as other samples to be selected to serve as a
representation of an entire population, leading to an unbiased data collection and an unbiased
conclusion.

Survey Instrument: The survey will consist of questions and statements that will assess
the following: 1) demographics, health status, and COVID-19 experience, 2) intent to receive
a COVID-19 booster vaccine; 3) perceived susceptibility to and severity of COVID-19; 4)
perceived benefits of a COVID-19 booster vaccine; 5) willingness to pay (WTP) for a
COVID-19 booster vaccine. The questions and statements were adapted from a study
conducted by Caple et al. (2021).
1. Demographics, health status, and COVID-19 experience: Demographic
information including age, gender, marital status, education, occupation, monthly income
will be collected. Participants will be also asked if they have an existing chronic
condition, if they ever tested positive for COVID-19 before and after receiving
vaccination, received previous doses of vaccine due to mandate from employers,
experienced side effects from previous doses of the vaccine, and to indicate if they know
someone who has tested positive for COVID-19 after receiving vaccination, know
anyone who died from COVID-19 before and after received vaccination.
2. Intent to receive a COVID-19 booster vaccine: Intention to receive a COVID-
19 booster vaccine will be assessed using a one-item question (“Since a booster vaccine
for COVID-19 is available in the Philippines, would you use it?”) on a five-point scale
ranging from 1 = ‘definitely no’ to 5 = ‘definitely yes’. Responses will be additionally
recorded into two distinct categories: vaccine hesitant (responses included: ‘definitely
no’, ‘probably no’, and ‘unsure’) and not vaccine hesitant (responses included: ‘probably
yes’ and ‘definitely yes’).
3. Perceived susceptibility to and severity of COVID-19: HBM-derived items will
be used to assess individual beliefs about a COVID-19 booster vaccine. Questions posed
to participants will assess perceived susceptibility of COVID-19 (two items), perceived
severity of COVID-19 (three items), and cues to action (two items). All response items
will be on a four-point scale ranging from ‘strongly agree’ to ‘strongly disagree’. For
analysis purposes, all responses will be coded as either ‘agree’ (responses included:
‘strongly agree’ and ‘agree’) or ‘disagree’ (responses included: ‘strongly disagree’ and
‘disagree’).
4. Perceived benefits of a COVID-19 vaccine: Perceived benefits will be queried
using two items. All response items will be rated on a four-point scale ranging from
‘strongly agree’ to ‘strongly disagree’. Similar to perceived susceptibility to and severity
of COVID-19, all responses will be coded as either ‘agree’ or ‘disagree’. In addition to
 perceived benefits of a COVID-19 vaccine, respondents will be also asked to rate–on a
four-point scale ranging from ‘strongly agree’ to ‘strongly disagree’–perceived barriers
surrounding a COVID-19 vaccine (e.g., ‘I worry about the possible side-effects of the
COVID-19 vaccine.’; ‘I worry about fake COVID-19 vaccines.’). For analysis purposes,
all responses will be coded as either ‘agree’ or ‘disagree’.
5. Willingness to pay for COVID-19 vaccine: Willingness to pay (WTP) will be
measured using a one-item question (“What is the maximum amount you are willing to
pay for two doses of the COVID-19 vaccine?”) on an eight-point scale (‘PHP500’,
‘PHP1,000’, ‘PHP1,500’, ‘PHP2,000’, ‘PHP2,500’, ‘PHP3,000’, ‘PHP3,500’, and
‘PHP4,000’). The price range options are based on the approximate minimum-maximum
price range of current vaccines in the Philippines.

Analyses: All statistical analyses will be conducted using Statistical Package for the
Social Sciences (SPSS) version 27. A p-value of less than .05 will be considered statistically
significant. The researcher will utilize frequency tables, charts and proportions for data
summarization – the proportions and their respective 95% confidence intervals (CI) will be
calculated for each predictor variable. The model fit of binary logistic regression analysis
will be calculated using the Hosmer-Lemeshow goodness-of-fit test [14]. The participant
responses to the one-item intent to receive COVID-19 booster vaccine (“Since a booster
vaccine for COVID-19 is available in the Philippines, would you use it?”) will be coded into
two categories: vaccine hesitant (responses included are “definitely no”, “probably no”,
“unsure”) and not vaccine hesitant (responses included are “probably yes”, “definitely yes”).
The eight options of WTP for a COVID-19 vaccine were categorized into three categories
(PHP500–1,000, PHP1,500–2,500, PHP3,000–4,000). A multinomial logistic regression will
be employed to model factors associated with WTP for a COVID-19 vaccine with the lowest
(PHP500–1,000) as the reference. The researcher will run univariate analyses followed by a
binary logistic regression analysis, including all factors showing significance (p < .05), to
determine which factors predicted individual intention to receive a COVID-19 vaccine. Only
significant factors in the univariate analyses will be included in the binary logistic regression
analysis.
VI. Dummy Tables
1. Demographics and COVID-19 Booster Vaccine Intent
2. Respondents’ Health Beliefs Regarding COVID-19 and its Vaccines

3. COVID-19 Booster Vaccination Intent

COVID-19 Booster Vaccination Intent

10
40
80

50

70

Definitely No Probably No Unsure Probably Yes Definitely Yes

4. Willingness-to-pay for a COVID-19 Booster Vaccine

Maximum amount willing to pay
% of Respondents
(in PHP: Philippine Peso)
500
1,000
1,500
2,000
2,500
3,000
3,500
 4,000

VII. References
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