研究背景
接種流感疫苗為臺灣公共衛生上重要實務，孕婦接種流感疫苗能使孕婦自身與六個月以下新生兒減少罹患流感的風險，甚至可以降低六個月以下新生兒因流感而住院91.5%的機率。美國1957年即鼓勵孕婦接種流感疫苗，而且世界衛生組織及其他衛生主管機關皆建議孕婦接種，但大多調查結果皆顯示接種率少於50%。因此，自2008年來，已有許多文獻曾探討影響流感疫苗接種意圖或行為的相關因素，國內則僅一篇碩士論文。其中，運用健康行為科學理論之研究並不多，主要運用健康信念模式，亦有研究輔以預期情緒、主觀規範，以及社會規範。再者，上述研究中，只有少數文獻針對測量接種態度之各構面進行信效度檢驗。

研究目的
本研究驗證以健康信念模式為主之研究架構潛在影響因素與測量題項間之配適度，並利用此架構探討影響國內孕婦季節性接種流感疫苗接種意圖之相關因素。

研究方法
本研究為橫斷性研究，包含量表發展與建構，以及探討孕婦接種流感疫苗接種意圖之相關因素。研究對象為在2016年8至9月期間，於臺北市立聯合醫院婦幼院區婦產科候診的孕婦。本研究邀請514位孕婦參與，同意率為70.04%，排除不符合本研究之收案條件之樣本後，共315位有效樣本。本研究參考國內外相關文獻擬定問卷初稿，輔以深度訪談，以及流感疫苗與行為科學領域之專家審查修正問卷，再進行問卷試測後，遂進行正式施測及其信效度檢驗。信效度檢驗包含內部一致性檢驗，以及運用驗證性因素分析檢驗健康信念模式各構面之建構效度，本研究以SAS 9.4版及Amos 21版檢驗之。此外，本研究運用Stata 13版，並以階層式多元線性迴歸探討孕婦流感疫苗接種意圖之相關因素。

研究結果
本研究量表具高度之內部一致性，庫李信度及Cronbach’s α皆達0.7以上。健康信念模式之建構效度達可接受之範圍，χ2/df（即卡方/自由度）為2.269、配適度指標(Goodness of Fit Index, GFI)為0.863、近似誤差平方根(Root Mean Square Error of Approximation, RMSEA)為0.064、規範配適度指標(Normed Fit Index, NFI)為0.868、比較配適度指標(Comparative Fit Index, CFI)為0.921。此外，收斂效度及區別效度亦達可接受範圍。
根據多元線性迴歸分析結果，在控制主要自變項及其他變項後，接種流感疫苗的自覺利益愈大(β=0.38; p<0.01)、接種流感疫苗的自覺障礙愈小(β=-0.31; p<0.001)、獲得愈多的行動線索(β=1.18; p<0.001)、接種流感疫苗自我效能愈高(β=0.41; p<0.001)、主觀規範愈高(β=0.58; p<0.01)、擔心程度愈高(β=0.80; p<0.05)，以及社會規範愈低(β=-1.16; p<0.05)，流感疫苗接種意圖愈高。

結論與建議：
本研究已驗證健康信念模式為主之研究工具的信效度。影響孕婦流感疫苗接種意圖之主要相關因素包括自覺利益、自覺障礙、行動線索、自我效能、主觀規範、預期情緒，以及社會規範。本研究建議：為了提升孕婦流感疫苗接種率，應針對這些重要因素設計衛生教育計畫，發展相關單張、海報及影片；此外，應鼓勵醫護人員支持、倡議並參與此接種政策。建議未來研究方向，可進一步瞭解醫護人員對於孕婦流感疫苗的觀點，並透過疫苗接種監測系統評價公費流感疫苗接種計畫之成效。

Introduction
Influenza vaccination, as one of the most important practice of public health in Taiwan, can decrease the risk of contracting influenza for pregnant women or infants less than six months of age, and the effectiveness of preventing a baby from hospitalization due to flu was 91.5%. In the United States, it has been recommended that pregnant women receive the vaccine since 1957. In addition, the Guidelines from the World Health Organization (WHO) and some other health authorizes also have recommended influenza vaccination for pregnant women. However, the take-up rate was lower than 50% according to most studies. As a result, there have been many researches aimed at exploring the factors associated with the intentions towards receiving influenza vaccine or vaccination behaviors during pregnancy since 2008, whereas there was only one master thesis in Taiwan. Among these previous studies, not many were conducted based on behavioral science, if any, only the Health Belief Model (HBM), or others such as anticipated emotions, subjective norms, and social norms which were used as supplementary theories. Furthermore, only a very few studies conducted validity and reliability tests of the instruments regarding the attitudes towards influenza vaccination.

Objective
The objectives of this study are to examine the factor structure of the HBM model, and to investigate the factors associated with the behavioral intentions towards receiving influenza vaccine during pregnancy.

Methods
This is a cross-sectional study, which contains two parts, the development of the HBM-based instruments and analysis of associated factors toward pregnant women’s behavioral intentions of receiving influenza vaccine during pregnancy. The survey was conducted in OB/GYN clinics in Taipei City hospital, Fuyou Branch, from August to September in 2016. A total of 514 pregnant women were invited to paticipate and the e response rate was 70.04%. The total effective sample size was 315. Based on the previous literatures, results from in-depth interviews, and experts in vaccine and behavioral science fields, the instruments were pretested and validated, including internal consistency and construct validity throught confirmatory factor analysis, using SAS 9.4 and Amos 21. Furthermore, this study used hierarchical multiple linear regression analysis to investigate the factors associated with determinants of behavioral intentions towards receiving influenza vaccines among pregnant women using Stata 13.

Results
The survey instruments showed high internal consistency for all constructs (Kuder-Richardson reliability and Cronbach’s alpha (α≥0.7)). It also had an acceptable construct validity among the HBM constructs (χ2/df=2.269, Goodness of Fit Index (GFI)=0.863, Root Mean Square Error of Approximation (RMSEA)=0.064, Normed Fit Index (NFI)=0.868, Comparative Fit Index (CFI)=0.921). In addition, convergent validity and discriminant validity were also acceptable. Therefore, the instrument has demonstrated its good validity and reliability.
According to the results from the multiple linear regression model, after controlling for other variables, those who perceived more benefits from receiving the vaccines (β=0.38; p<0.01), perceived less barriers (β=-0.31; p<0.001), had more cues to action (β=1.18; p<0.001), with higher self-efficacy (β=0.41; p<0.001), with higher subjective norms (β=0.58; p<0.01), with more anticipated worry (β=0.80; p<0.05), with lower social norms (β=-1.16; p<0.05) were more willing to receive influenza vaccination.

Conclusions and Recommendations
This study has confirmed the reliability and validity of the HBM-based instruments. Factors associated with pregnant women’s behavioral intentions towards receiving the influenza vaccine included the perceived benefits, perceived barriers, cues to action, self-efficacy, subjective norms, anticipated worry, and social norms. In order to increase the take-up rate of influenza vaccines among pregnant women, the health education program needs to focus on these key factors when designing pamphlets, posters, and/or videos. In addition, it is suggested that we should encourage healthcare personnel to support, promote, and to be involved in this vaccination policy. In the future, it is suggested that more research can be prepared on subjects such as understanding the opinions regarding influenza vaccinations from healthcare personnel as well as to enhance the program evaluation of promoting vaccines among pregnant women through the establishment of immunization surveillance system.

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