Understanding drivers of influenza vaccine hesitancy among pregnant women in China: evidence from an extended theory of planned behavior

Background Pregnant women's influenza vaccination uptake was low, although being recommended as a priority. Research design and methods We conducted a cross-sectional questionnaire survey in China from June to July 2021. Hierarchical regression analysis and structural equation modeling were performed based on the extended theory of planned behavior, in which attitudes, subjective norms, perceived behavioral control, and intention each affect vaccine hesitancy; response efficacy, knowledge, vulnerability, and severity were added as extended dimensions; vaccination history played as a moderator. Results Totally, 1283 pregnant women participated in this study. The intention existed as a mediator between attitude [beta(indirect) = 0.142 (95% confidence interval (CI): 0.084, 0.206), P < 0.001], subjective norms [beta(indirect) = 0.568 (95%CI: 0.424, 0.754), P < 0.001], perceived behavioral control [beta(indirect) = 0.070 (95%CI: 0.025, 0.118), P = 0.004] and vaccine hesitancy. Further, indirect effect differences between the two dimensions of attitude (P < 0.001), perceived behavioral control (P < 0.001), and subjective norms were each statistically significant. Vaccination history did not moderate the association between attitude (P = 0.679), subjective norms (P = 0.645), and hesitancy. Conclusions The subjective norms dimension has a strong association with influenza vaccine hesitancy. Vaccination history was limited to reduce hesitancy.