HBM theory provides a valuable framework for evaluating factors
associated with vaccination behavior. Using the HBM model,
we found that cues to action were the most important factors associated
with willingness to receive influenza vaccine. Prior studies
have identified healthcare providers’ recommendations as an
important cue to action for pregnant women to receive influenza
vaccine [22,23]. A study by Geraldine and colleagues demonstrated
that the factors associated with higher rate of vaccination during
the influenza A (H1N1) 2009 pandemic were vaccination occurring
toward the end of pregnancy, and confidence in advice offered by
health professionals [23]. In our study population, a recommendation
for vaccination from a family member or husband was also
an important cue to action suggesting that vaccination campaigns
could also target family members as well as pregnant women
themselves in order to increase vaccination coverage.
Surprisingly, after accounting for cues to action, potential barriers
to influenza vaccination, including safety concerns and lack of
confidence in the effectiveness of the vaccine, were not important
predictors of willingness to be vaccinated in our survey. Thisfinding
is in contrast with several previous studies of pregnant women conducted
inWestern countries [24–26]. In the Georgia Pregnancy Risk
Assessment and Monitoring System, unvaccinated respondents
cited a variety of reasons for not receiving the influenza vaccine
including worries that the vaccine might harm their babies (27%)
or themselves (26%) [27]. Similarly, in a cross-sectional survey of
pregnant women at an academic, tertiary care hospital in Pennsylvania,
61% of the women reported concern about vaccine safety
during pregnancy and 8% reported the belief that the influenza vaccine
caused influenza [28]. As perceived barriers were associated
with lower willingness to be vaccinated in univariate models, it is
likely that confidence in recommendations of healthcare providers
and family members overrides any personal concerns about safety
or effectiveness