Understanding the practices and perceptions of Chinese older adults towards vaccination in the context of COVID-19: A qualitative study in Anhui Province

ABSTRACT

This study examines vaccination perceptions and practices among rural older adults in China during the COVID-19 pandemic to inform strategies for promoting vaccination among older adults. Qualitative research was employed, involving 13 rural older adults aged 60 and above in Anhui Province. Two rounds of in-depth interviews were conducted in May 2022 (during the severe pandemic period) and May 2024 (post-pandemic era), with data analyzed using grounded theory. Rural older adults exhibited dual perceptions of COVID-19 characterized by “seriousness” and “relative reassurance,” maintaining trust, understanding, and acknowledgment of government prevention policies. They generally recognized the necessity of COVID-19 vaccination as a key means to alleviate infection fears and reduce risk exposure. However, they exhibited self-marginalization, believing vaccine resources should be prioritized for younger individuals and those deemed more deserving. And, collectivist values motivated active compliance with epidemic control policies but also led to attention bias, causing them to overlook routine vaccines such as influenza and pneumonia vaccines that received less government promotion. As the pandemic progressed, individual awareness gradually awakened. Professional authority and family opinions emerged as new drivers for vaccination, though health belief biases also surfaced, with some seniors refusing shots citing “good physical constitution.” The government should intensify vaccination outreach, optimize community services, guide seniors toward accurate self-perception, and leverage the roles of family members and medical professionals in vaccination efforts. These measures will enhance vaccination rates among rural seniors and safeguard the health of the population.

Introduction

Globally, the COVID-19 pandemic has posed severe challenges to public health systems. Vaccination, as a key tool for preventing and controlling infectious diseases, plays a vital role in reducing the risk of disease transmission and protecting susceptible populations.¹ With global life expectancy increasing, the global population aged 60 and above will more than double, reaching 2.1 billion people by 2050.² The 2023 National Development Bulletin on Aging indicates that by the end of 2023,³ China’s population aged 60 and above reached 296.97 million, accounting for 21.1% of the total population; those aged 65 and above numbered 216.76 million, representing 15.4% of the total population. Population aging has become a major trend in China’s social development.⁴ As older adults age and their immune systems weaken, chronic diseases such as diabetes, cancer, and chronic obstructive pulmonary disease (COPD) heighten their risk of contracting infectious diseases and related complications.⁵ Over 70% of infectious disease deaths occur among those aged 65 and above.⁶ From December 8, 2022, to January 12, 2023, among the 59,938 COVID-19-related deaths reported by Chinese hospitals, 90.1% occurred in individuals aged 65 and older.⁷ Compared to urban areas in China, rural regions have a higher proportion of older residents and relatively scarce medical resources, resulting in higher incidence and mortality rates for infectious diseases.⁸ This not only severely impacts the quality of life for older adults but also exacerbates the economic burden caused by illness. In the United States, the economic burden associated with pneumococcal disease among the elderly exceeds that of other conditions such as myocardial infarction and stroke.⁹ The economic burden of influenza among rural older adults in China accounts for 113% of the average annual income of hospitalized patients, far exceeding that in urban areas (31%), with personal financial burdens significantly higher than the average.¹⁰ However, daily care for China’s rural older adults primarily relies on family members. Yet declining birth rates, increased life expectancy, and the outflow of younger populations due to urbanization mean family care becomes less accessible when rural older adults fall ill.⁸ In this context, vaccination for rural older adults becomes particularly crucial.

Vaccination is recognized as one of the most successful and cost-effective public health interventions in the world, making significant contributions to improving global health.¹¹ According to World Health Organization (WHO) estimates, vaccination prevents 2–3 million deaths annually, with an additional 1.5 million lives potentially saved by increasing coverage rates.¹² Furthermore, vaccines that prevent infections also play a vital role in chronic disease prevention and control,¹³ for instance, the hepatitis B vaccine reduces the risk of liver cancer.¹⁴ Despite the well-established efficacy and safety of vaccines, vaccine hesitancy among older adults remains a significant issue. The influenza vaccination rate among individuals aged 60 and above in China ranges from approximately 4% to 13%,¹⁵ significantly lower than the vaccination rates observed in Western countries during the flu season for those aged 65 and above.⁵ For instance, England reports a rate of 82.3%, Scotland 90.2%, and the United States 75.2%. The latest data from the Anhui Provincial Center for Disease Control and Prevention shows that the influenza vaccination rates among adults aged 60 and above in 2021–2023 were 0.99%, 1.34%, and 1.84%, respectively.¹⁶ The pneumococcal vaccination rate was 8.38% (based on the AHLS¹⁷ survey of 1566 rural older adults in Anhui Province conducted in July 2021, prior to the qualitative study). Influenza vaccination rates in urban and rural areas from 2021 to 2023 were 1.15%/0.9%, 1.52%/1.23%, and 2.26%/1.6%, respectively, with rural vaccination rates consistently lower than urban areas.¹⁶ These data underscore the urgency of addressing vaccination hesitancy among rural older adults.

Despite extensive research on vaccination and vaccine hesitancy, existing studies still have certain limitations. Most current research adopts a public health perspective and uses quantitative methods to explore factors influencing vaccination among older adults, such as disease prevalence, perceived health risks, and vaccine side effects.^18,19 However, it fails to adequately consider social and cultural environments, individual psychological experiences, social support systems, and self-identity. This makes it difficult to deeply uncover the underlying emotional motivations and complex factors driving vaccination decisions among older adults – such as concerns about personal health, considerations of family responsibilities, and altruistic attitudes toward the distribution of social resources. These factors may precisely be crucial determinants of vaccination willingness and behavior among older adults. Previous qualitative research has predominantly focused on younger adults,^20,21 with insufficient attention directed toward older adults, particularly those in rural areas. Among the limited qualitative research targeting older adults, identified factors include subtle individual-level elements (e.g., low perceived threat, weak vaccine confidence, peer pressure, and distrust in governments)^22–24 as well as macro-policy factors (e.g., shifts in media messaging and inadequate adaptation of digital technologies).²⁵ Most of these studies are cross-sectional, conducted at a single time point, and lack comparative explorations in the broader post-pandemic context or before and after the COVID-19 outbreak. The emergence of COVID-19, along with initial public concerns about vaccine availability, then potential side effects, and the impact of negative information during the pandemic, has exerted a systemic effect on vaccine trust and vaccine hesitancy. It was indicated that the pandemic further exacerbated vaccine hesitancy through misinformation, conspiracy theories, and political polarization stemming from vaccine-related policies.^26,27 This interplay has spawned new forms of hesitancy, such as reluctance toward booster shots and skepticism about mRNA technology.^28,29 Thus, the COVID-19 pandemic serves as a “natural experiment” and a valuable lens to observe public attitudes toward vaccines, offering a rare window into the evolution of such attitudes.

Our study employs a qualitative research approach, conducting two rounds of in-depth interviews before and after the pandemic. Integrating public health and sociological perspectives, it focuses not only on objective public health factors (e.g., vaccine efficacy and accessibility of vaccination services) but also on subjective sociological factors (e.g., collectivist culture, intergenerational relationships, and self-identity). Through longitudinal comparison, it captures shifts in rural older adults’ perceptions and practices regarding vaccination before and after the pandemic. The study aims to reveal, in a multidimensional and layered manner, the various factors influencing rural older adults’ vaccination cognition and behavior. This provides theoretical foundations and practical guidance for developing feasible policies and interventions to promote active participation in vaccination among rural older adults, thereby increasing overall vaccination rates and safeguarding the health of this demographic.

Methods

Participants and setting

In May 2022 (during the severe period of the pandemic) and May 2024 (post-pandemic era), four graduate students from a medical university in Anhui Province recruited 13 older adults aged 60 and above from their hometown villages using purposive sampling. Two rounds of in-depth interviews were conducted, with the number of participants determined by information saturation.³⁰ The 13 older adults are designated as A–M. The interview outlines focused on rural older adults’ vaccination behaviors, relevant experiences, psychological perceptions, and motivations regarding vaccines against COVID-19, influenza, and pneumonia during the COVID-19 pandemic. The first round of interviews occurred during the pandemic (May 2022), a period marked by severe outbreak conditions and early vaccination rollout, when older adults’ understanding of the pandemic and vaccines was still developing. The second round of interviews was conducted in the post-pandemic era (May 2024). By this time, epidemic prevention policies had been adjusted. According to the plan issued by the National Health Commission on December 27, 2022, COVID-19 was reclassified from a “Category B infectious disease managed with Category A measures” to a “Category B infectious disease managed with Category B measures” effective January 8, 2023.³¹ As social life gradually returns to normal, older adults’ vaccination practices and perceptions may also evolve. A comparative analysis of the two rounds of interviews provides a more comprehensive understanding of the interviewees’ vaccination practices and perceptions at different stages.

Data collection

This study employed a semi-structured interview guide designed by researchers trained in qualitative research. Considering the cognitive characteristics and communication habits of elderly participants, the guide focused on core questions while minimizing complex phrasing. Although concise, the interview guide comprehensively covers sociological and the public health perspectives, seeking to meet the exploratory needs of this research. The sociological perspective includes dimensions such as perceptions of the relationship between the government and the public, social group classification and self-identity, social support, and the influence of others’ opinions. The public health perspective encompasses dimensions including perceived pandemic risk, vaccine-related cognition, vaccination willingness and concerns, and responses to public health policies (see the detailed guide below).

To facilitate participant engagement, all interviews were conducted in their homes. The home environment not only reduces participants’ sense of unfamiliarity and restraint but also encourages them to relax and express themselves freely, thereby enabling the collection of more authentic and rich thoughts. Each interview lasted approximately 40 minutes. Interviewers maintained neutrality throughout and used probing questions (e.g., “Why do you think vaccines should be prioritized for younger people?”) to elicit detailed responses while fostering a supportive, non-judgmental atmosphere. Written informed consent for participation and audio recording was obtained from the respondent prior to each interview. Interviewers also assured participants that neither the content of their discussions nor their identities would be disclosed.

The outline of the interview is as follows:

1. What is the level of the COVID-19 epidemic compared with other epidemics you have experienced before? (Note: this question aims to understand the criteria for older adults to judge the risk of the epidemic. Compared with past experiences such as war, political movement, natural disasters, the significance of COVID-19 ranges from “the most terrible” to “not worth mentioning at all.”)

2. If the number of COVID-19 vaccines is not enough, how do you think the vaccine should be distributed? (Note: this question aims to understand the older population’s classification of social groups, their own classification, and the nature of the COVID-19 vaccine.)

3. What kind of relationship do you think the government and the people should have? What should the government do when the epidemic is coming? And what should people do? Is the current situation ideal and reasonable? Why? (Note: these questions aim to understand their perception about the country or government.)

4. How old were you the first time you received any vaccination? Have you had any other vaccines in recent years? What impressed you? What is your experience of vaccinating your children/grandchildren? (Note: these questions aim to understand the overall memories, perceptions, and familiarity of older adults with vaccines.)

5. Whose opinion is more important to you about your vaccination (spouse/children/grandchildren, colleagues/friends/neighbors/communities, media/experts/national announcements, etc.), and why? (Specific events/stories are better.)

6. Now, some people, although their physical condition allows them to be vaccinated, are unwilling to do so. What kind of people do you think they are? What do you think of them?

7. Is it necessary for you to get the COVID-19 vaccine? Is it important? What impact will your vaccination or non-vaccination have on your family and society? How much do you think you know about the COVID-19 vaccine? Are you worried? (Note: understanding their relationship with the vaccine. If there are specific events/stories, it is better.)

Data analysis

Conducting data analysis concurrently with data collection facilitates timely corrections and further investigation. Recorded conversations were fully and automatically transcribed verbatim. Transcriptions were reviewed by interviewers within two weeks after each in-depth interview to prevent transcription errors or information omissions. After verbatim transcription of the interview recordings, NVivo 14 was used to assist with coding. Subsequently, two researchers conducted independent manual coding. Prior to coding, both researchers jointly reviewed the interview transcripts and developed a preliminary coding manual based on the research objectives and theoretical framework, clearly defining the core coding dimensions. During the coding process, cross-checking was performed after every three transcripts were completed. Discrepancies were resolved through discussion to reach consensus, with the coding manual revised accordingly. The coding process followed grounded theory’s stages of open coding, axial coding, and selective coding. Through in-depth data analysis, consistent themes gradually emerged. Some analysis results are presented using the participants’ own words to ensure that the research findings truly reflect the participants’ perspectives and experiences.

Results

Participant demographics

This study included 13 participants, 7 females and 6 males, aged 60–88 y (M = 66.5). Regional distribution: Bozhou City (n = 3), Bengbu City (n = 3), Lu’an City (n = 3), and Xuancheng City (n = 4) in Anhui Province. Participants exhibited varying physical conditions, with some suffering from chronic diseases such as cardiovascular disease, hypertension, and malignant tumors. Regarding vaccinations, over the past three years, 12 of the 13 older adults received three doses of the COVID-19 vaccine, two received the influenza vaccine, and one received the rabies vaccine following an animal bite. However, one participant had not received any vaccinations in the past three years, including the COVID-19 vaccine. Detailed information is presented in Table 1.

Table 1.

General information and vaccination practices.

Participant identifier	Gender	Age	Physical condition	Vaccination practices in recent three years
A	male	84	Have chronic cardiovascular disease and hemiplegia	Three doses of COVID-19 vaccine
B	female	60	Good	Three doses of COVID-19 vaccine
C	female	60	Good	Three doses of COVID-19 vaccine
D	male	60	Good	Three doses of COVID-19 vaccine
E	female	69	Able to care for oneself in daily life, with chronic conditions and other illnesses (heart disease, malignant tumors)	NO vaccination
F	male	60	Hypertension	Three doses of COVID-19 vaccine
G	male	62	Good	Three doses of COVID-19 vaccine
H	female	88	Good	Three doses of COVID-19 vaccine
I	female	60	Good	Three doses of COVID-19 vaccine
J	male	78	Chronic cardiovascular and cerebrovascular diseases, hypertension, emphysema	Three doses of COVID-19 vaccine
K	female	60	Good	Three doses of COVID-19 vaccine, one dose of flu vaccine
L	male	62	Good	Three doses of COVID-19 vaccine
M	female	61	Good	Three doses of COVID-19 vaccine, one dose of flu vaccine, four doses of rabies vaccine (for cat bites)

Results from the first round of interviews

Perceptions of the COVID-19 pandemic

During the peak of the pandemic, most participants believed COVID-19 was severe but not entirely hopeless. Some expressed fear over the pandemic’s widespread impact and prolonged duration. “None of us had experienced anything like this before (referring to events like SARS mentioned by the interviewer) … COVID-19 was by far the most severe… Yes, it’s been three years now – no previous events lasted as long as this one (referring to COVID-19).” (B) “…This pandemic is truly terrifying. Why? Because it has spread so widely – it’s truly global in scope.” (C) Some participants contrasted COVID-19 with past famines, noting that during the pandemic, food supplies remained available and government support was provided, making the situation less dire. “Compared to the famines of the 1960s, the COVID-19 pandemic is much better. At least people aren’t starving to death; there’s food to eat. And the country is helping through military force, manpower, and medical resources. No matter what, someone is here to treat us.” (E)

Perceptions of government actions during the pandemic: trust, recognition, comprehension and expectation

In the context of COVID-19, nearly all participants expressed high trust and recognition in the Chinese government’s epidemic prevention efforts. They believed the government can effectively manage the pandemic while safeguarding people’s rights and interests. “China has handled things well – cherishing life, putting people first… When the outbreak first emerged, the government urged everyone to stay calm and respond promptly to the call… Let’s move forward together.” (C) They also generally understood and supported the vaccination control measures implemented during the pandemic, viewing them as an important means of safeguarding public safety. “This is reasonable and justified. It’s right that you can’t travel without vaccination. What if no one follows the rules? (Vaccination) It is handled quite well in our country. In other nations, you might not even get a shot – that’s a big advantage.” (F) Furthermore, they affirmed the government’s scientific and precise epidemic prevention strategy and its effectiveness. “(The government’s epidemic control measures) are a very scientific and precise epidemic prevention policy, implemented very effectively.” (D) Moreover, they also expressed their expectations for government actions. “The government should further intensify public education and address certain misunderstandings among the public that perceive the measures as overly strict or excessive.” (D)

Perceptions of civic responsibility during the pandemic: collectivism

Against the backdrop of the COVID-19 pandemic, rural older adults exhibited distinct collectivist traits in their understanding of civic responsibility. They emphasized the importance of obedience and cooperation in epidemic prevention and control, supported these efforts through personal actions and integrated the fulfillment of civic duties into their daily lives. “We should cooperate with each other and respond to the Party’s call. Only when people are healthy can the country be stable.” (C) “The public must do a good job in prevention, publicity, education, and cooperation. For example, cooperating with medical personnel for nucleic acid testing, isolation, and other epidemic prevention policies and measures.” (D)

Perceptions of COVID-19 vaccination: necessity and reducing opportunity costs

In this survey, older adults generally agreed on the necessity of receiving the COVID-19 vaccine, with vaccination becoming a way for some to alleviate pandemic-related fears. “It’s necessary! Not getting vaccinated has disadvantages.” (A) “It’s necessary. At first, I thought vaccines would be hard to get, but now everyone can get vaccinated. Thanks to the government.” (C) Additionally, some participants exhibited a psychological tendency to avoid regret, worrying about bearing the risk of infection due to not getting vaccinated. “The virus is spreading throughout society, and the situation is so severe abroad. Not getting vaccinated would be detrimental.” (A) “In relative terms, getting vaccinated is better than not getting vaccinated. I don’t know exactly how much better, but not getting vaccinated seems to increase the likelihood of getting infected.” (G) This perception essentially reflects an implicit consideration of opportunity costs, where vaccination reduces the subsequent regret and losses from “potential infection due to not being vaccinated.”

Impact of the COVID-19 pandemic or COVID-19 vaccination on attitudes toward other vaccines: interaction effects and attention bias

The COVID-19 pandemic and vaccination efforts have had a dual impact on older adults’ attitudes toward other vaccines. On one hand, the widespread reach of the COVID-19 outbreak and the nationwide vaccination campaigns have heightened public awareness of vaccines. This has, to some extent, improved older adults’ perceptions of vaccines, leading some to become more conscious about receiving other vaccines – such as influenza vaccine – due to the pandemic. “If not for the COVID-19 pandemic, I wouldn’t even know older adults need vaccines like the flu or pneumonia shots.” (C) “It was because of the COVID-19 pandemic that my daughter took me to get the flu vaccine.” (G)

On the other hand, some participants’ level of concern about vaccines was overly dependent on whether the government mandated vaccination, which led to a cognitive bias. They assumed vaccines not explicitly required by the government could be skipped. “The government only mandates COVID-19 vaccination without emphasizing others, suggesting they’re less important. Otherwise, they’d surely require those too.” (D)

Perceptions of relationships with other groups: self-marginalization and sense of unworthiness

Some older adults exhibited self-identity biases, characterized by self-marginalization and a sense of unworthiness. They perceived their limited value and contribution to society, believing that vaccine distribution should prioritize younger people and healthcare workers. Participant E suffers from malignant ovarian cancer and coronary heart disease, and has a history of leg surgery. Although she was willing to get tested for nucleic acid and vaccinated, she claims that as a patient, she does not need vaccination and that it would be better to save vaccines for people who are useful to the country. She also said, “Let the young people get vaccinated first. People like us, who are already old, don’t contribute much to the country anymore – if we can tough it out, we will. Those young people are the pillars of the nation.” (E) “Of course, children should get vaccinated first, followed by young people. Logically, they (researchers, doctors, military personnel, or essential workers) should be prioritized, and we should wait.” (F) This reflects how some older adults, when weighing collective values, perceive their own roles as less significant and exhibit a tendency to “yield” in resource allocation.

Factors influencing vaccination decisions: organizational promotion and subjective perception

During the pandemic, vaccination decisions among older adults were influenced by multiple factors. First, calls from the government and the Communist Party of China exerted a significant impact on them. “We still heed the government’s recommendations and advocacy.” (B) Meanwhile, communities actively organized vaccination events and provided personalized services – such as timely notifications from community workers and door-to-door vaccination services for those unable to visit vaccination sites – ensuring older adults felt the vaccination process was convenient. “The community notified us very early in the WeChat group. There were also two mass nucleic acid testing rounds in between. If you couldn’t go, someone would come to your home specifically to do it… They really took care of us.” (B) During the pandemic, the requirement to present proof of vaccination for entry into certain public venues or transportation has also motivated older adults to get vaccinated. “Nowadays, you can’t go anywhere without getting vaccinated.” (G) Additionally, some older adults worried about potential side effects on their health. “They all mentioned side effects, so I was definitely a bit worried at that time.” (F) They also worried that vaccination may conflict with their underlying medical conditions. “They fear adverse reactions or conflicts between the vaccine and their existing illnesses.” (A) And, older adults have expressed that whether to receive the vaccine is a personal choice or preference. “Whoever wants to get vaccinated should go ahead; those who don’t shouldn’t be forced. We shouldn’t judge someone as good or bad based on this.” (H)

Findings from the second round of interviews

Perceptions of government actions: trust, comprehension, and expectation

After COVID-19 entered a phase of normalized management, participants still expressed understanding and trust in the government. “The government should look after the people, and the people should show mutual understanding toward the government.” (K) “Yes, the policy has changed, but no matter what, we should have confidence in the government.” (M) Others hoped the government would effectively implement established policies to safeguard public interests. “The government should implement the series of policies it has formulated, govern in accordance with regulations and laws, so that the people can fairly benefit from the nation’s policies.” (L)

Complex feelings toward COVID-19 vaccination

Older adults expressed mixed feelings about COVID-19 vaccination, acknowledging its value while harboring doubts about side effects and efficacy. “The vaccine does have some effectiveness… After getting vaccinated… I found it didn’t harm my body… People feel reassured.” (J) However, some older adults have been influenced by rumors regarding COVID-19 vaccines being ineffective or harmful. “This whole situation feels chaotic… I don’t know if the vaccine actually works, or if it’s real or fake… There are rumors like that.” (I) Someone also felt conflicted, worried that vaccination might affect their health, yet fearful that not getting vaccinated would cause inconvenience. “At that time, I was really concerned that getting vaccinated might negatively impact my health, but I was also worried about the inconvenience of not getting vaccinated. Either way, I had no choice, so I was extremely conflicted.” (M)

Attitudes toward future vaccination: differentiation

Currently, COVID-19 has entered a phase of routine management, and older adults have shown a clear differentiation in attitudes toward future COVID-19 vaccination or other vaccines. Some older adults explicitly refused to receive any vaccines. “I won’t get vaccinated, I really won’t. My health is fine, and it would be bad luck if something goes wrong after vaccination.” (H) “I don’t want to come into contact with this stuff (referring to vaccines). I’m afraid of it… I’m actually afraid of side effects on my body, afraid it might affect my health further.” (I) Someone maintained a wait-and-see attitude toward vaccination, which was influenced by their perceptions of vaccine effectiveness. “(Referring to the interviewer’s question about whether they would get vaccinated in the future) I haven’t thought about it…If it benefits the body, I’ll get it; if not, I won’t.” (K) However, others expressed a positive willingness to vaccinate. “(Referring to the interviewer’s question about whether they would still get vaccinated if it were self-funded) I would still get vaccinated because health is of great importance, and (getting vaccinated) mainly works as a preventive measure.” (L)

Impact of the COVID-19 pandemic or COVID-19 vaccination on attitudes toward other vaccines: negative outcome association, attention bias, and vaccination service differences

Influenced by their COVID-19 vaccination experiences, older adults have shown a noticeable shift in attitudes toward other vaccines. In the second round of interviews, negative outcomes led them to extend their doubts about vaccine efficacy to other vaccines. “I haven’t heard of them (referring to the influenza and pneumococcal vaccines) … Mainly, I’m concerned about vaccine side effects and safety issues. There must be no counterfeit or substandard products, as receiving fake vaccines will have the opposite effect. This mainly depends on local governments to keep in check.” (L) Attention bias persisted in the second round, but unlike the first round, older adults perceived that the necessity of vaccination had diminished following the normalization of pandemic management, which consequently weakened their focus on other vaccines. “I don’t feel it’s necessary to get other vaccines… It doesn’t matter whether I get them or not.” (I) “Since there hasn’t been a seasonal flu outbreak prompting vaccination, I don’t think it’s necessary for everyone to get vaccinated.” (L) Moreover, differences in vaccination services also influenced their attitudes. In contrast to the notification mechanisms and services for COVID-19 vaccinations, flu and pneumonia vaccination services were perceived as inadequate. “For the COVID-19 vaccine, someone notified you and even took you there. But for these vaccines (referring to flu and pneumococcal vaccines), no one notifies you. You have to find a vaccination site yourself.” (M)

Perceptions of relationships with other groups: self-marginalization and sense of unworthiness

The second round of interviews similarly revealed older adults’ self-marginalization cognition in their social positioning. “The younger ones get vaccinated first, then the elderly move back a bit. Priority will be given to those with essential roles… These individuals who are actively contributing to society and serving the nation will be vaccinated first.” (K)

New factors influencing vaccination decisions

Beyond factors identified in the first round of interviews, professional and knowledge-based authority recommendations significantly influenced vaccination decisions among older adults. For instance, Participant I followed their doctor’s advice, while H trusted and heeded her daughter’s (a college student) opinion. “When someone knowledgeable in medicine recommends it… I’d be more willing to get vaccinated.” (L) “My daughter says to get vaccinated…. I listen to my daughter.” (H) And, intergenerational responsibility – specifically the sense of obligation to protect family members – motivated some older adults to choose COVID-19 vaccination, primarily out of concern that they might infect young children. “It’s that instinct to protect children.” (I) “Because children are still growing, getting vaccinated helps their future health. (K) The emergence of health belief bias in the second round of interviews led some older adults to believe they had a lower risk of contracting the disease and therefore did not need to be vaccinated. “I’m healthy – I can fight off this virus. I don’t need it.” (I) “If you’re in good health, there’s no need to get vaccinated.” (L)

The unique value of integrating sociological and public health perspectives

Perception of epidemic risk

From a public health perspective, respondents’ perception of the severity of the COVID-19 pandemic stems from its objective characteristics, such as extensive transmission and prolonged duration (B: Never experienced such a persistent pandemic. C: The terrifying global spread of the pandemic). From a sociological perspective, this perception is not isolated but embedded within respondents’ historical experiences and collectivist cultural frameworks. By comparing the pandemic to the famine of the 1960s (E: At least we have food to eat and state support), respondents formed a judgment of severe but not hopeless risk. simultaneously, collectivist values define epidemic prevention as a civic duty (C: Only with the people’s health can the nation remain stable), further reinforcing perceptions of pandemic risk.

Perceptions and practices regarding vaccination

From a public health perspective, convenient services such as community door-to-door vaccination and WeChat notifications (B: Community-based door-to-door nucleic acid testing and vaccination), along with vaccine certificate verification policies (G: Impossible to move without proof of vaccination), were key objective factors driving vaccination during the severe phase of the pandemic. From a sociological perspective, respondents’ self-marginalization perceptions (E: Young people are the nation’s pillars and should be prioritized for vaccination) inhibited vaccination. However, intergenerational responsibility (I: Instinctively wanting to protect children) and trust in professional authority (L: Following doctors’ advice) emerged as new subjective drivers in the post pandemic era.

The low uptake of routine vaccines – such as influenza and pneumococcal vaccines – can be attributed to two factors: their relatively low priority, as the government focused exclusively on COVID-19 vaccination (D: Government emphasizes only COVID-19 vaccination), and inadequate service accessibility, since routine vaccines required self-arranged visits to clinics whereas COVID-19 vaccines were delivered door-to-door (M: COVID-19 vaccines delivered door-to-door, while routine vaccines require self-arranged visits to vaccination sites). From a sociological perspective, collectivist values have led respondents to align their attention closely with government priorities. (D: If the government doesn’t emphasize it, it must not be important), creating a significant attention bias.”

Conceptual framework development

Based on the results of two rounds of in-depth interviews, the conceptual frameworks were constructed to observe changes in the perceptions and practices of participants across both rounds.

The left framework was constructed from the first-round interviews and the right framework from the second round. In each framework, on the left is about the individual’s self-perceptions, the upper right corner is about the perceptions regarding government actions, and the lower right corner is about the perceptions of societal factors. The green arrows represent factors promoting vaccination, while the red arrows represent barriers for older adults to get vaccinated.

Framework 1 illustrated the interplay of factors influencing rural older adults’ vaccine-related perceptions and practices during the first round of interviews. Trust, recognition, comprehension and expectation of government epidemic prevention policies were observed. Their collectivist mind-set drives active compliance with these measures, yet also leads to attention bias that neglects routine vaccinations. Concurrently, self-identity bias influences their vaccination decisions, and COVID-19 vaccination to some extent impacts perceptions of other vaccines. Moreover, vaccination status verification policy and actively organized vaccination by community were also important factors in promoting older adults to get vaccinated (Figure1).

Figure 1.

Conceptual framework construction (1).

Framework 2 displayed findings from the second round of interviews, revealing shifts in factors and their relationships compared to the first round. As the pandemic progressed, individual awareness among older adults gradually increased. Professional authority (doctors) and the informed family members (an undergraduate in a university) became new motivators for vaccination. However, health belief biases emerged, with some older adults refusing vaccination citing “good physical constitution.” While trust in the government persists, expectations now focus more on policy implementation and vaccine quality oversight. Reduced government vaccination promotion efforts have diminished vaccine priority, extending COVID-19 vaccine skepticism to other vaccines. Combined with the lack of convenient services for routine vaccines, this has further deepened neglect toward them (Figure 2).

Figure 2.

Conceptual framework construction (2).

Compared with framework 1, framework 2 contained more red arrows, suggesting that vaccine-hesitancy factors among rural-dwelling older adults in China have become more salient.

Discussion

The dual impact of government actions on vaccination

The first round of interviews revealed that rural older adults’ high level of trust and recognition in government actions directly translated into their willingness to cooperate with vaccination efforts. During the peak of the pandemic, the government incentivized older adults to get COVID-19 vaccinated by linking vaccination status to entry into specific public settings, and communities served as the key vehicle for rolling out this measure. From a public health perspective, this demonstrates the effectiveness of policy-driven service provision. From a sociological perspective, the public’s strong response to government appeals stems from collectivist values emphasizing “subordination to the public interest” and psychological identification with governmental authority. In promoting COVID-19 vaccination, communities have implemented measures such as “sending notifications via WeChat groups” and “providing door-to-door vaccination services for older adults who face difficulties in traveling to vaccination sites.” These efforts have alleviated, to a certain extent, the issues of limited mobility among older adults and delays in their access to vaccination-related information, thereby facilitating the advancement of vaccination efforts. This top-down administrative approach has been crucial to the rollout of COVID-19 vaccinations,³² aligning with the realities of China as a vast nation. The role of communities in this public health emergency management also aligns with prior research, demonstrating that community advocacy and mobilization can serve as effective strategies to reduce vaccine hesitancy and promote vaccination.³³

However, shifts in the government’s emphasis on vaccination may influence public attitudes. International research indicates that political factors, such as government actions, are closely linked to public willingness to receive vaccinations.^34,35 In China, when higher-level governments reduced their emphasis on COVID-19 vaccination – specifically during the second interview conducted in the post-pandemic period – the necessity of “maintaining trust” became even more critical. The entire implementation system, accustomed to top-down directives and control, may inevitably lead to weakened efforts from relevant departments. It could even swing to the opposite extreme of over-promoting vaccination, leaving virtually no one concerned about this vital public health strategy. Ultimately, this will shape public perception, leading people to believe that matters not prioritized by the government are unimportant – a cognition shaped by collectivist ideology. When reviewing relevant official policies, we found that after nearly 21 months of daily updates since the onset of the COVID-19 pandemic, the National Health Commission’s website had ceased updating COVID-19 vaccination data in late December 2022. This may lead the public to perceive COVID-19 vaccination as unnecessary, resulting in diminished attention toward vaccination efforts. However, the situation in Hong Kong, China, differs significantly from mainland China, where official websites continue to update COVID-19 information and strategies, and the public can schedule vaccinations through official channels. Internationally, high-income countries such as the United States, the United Kingdom, and Canada have consistently maintained a proactive stance toward COVID-19 vaccination, with a particular focus on the elderly as a high-risk group. They not only continue to recommend vaccination for older adults but also advise them to voluntarily shorten the interval between doses and maintain a schedule of booster shots every 6 to 12 months.³⁶ Data on COVID-19 vaccination rates for the 2023–2024 series show that the United States stands at 42.6%, England (United Kingdom) at 62.3%, Sweden at 68.81%, and Denmark at 78%—all significantly higher than the median rate of 23.6%. China currently has no publicly available data on this matter.³⁷

Both rounds of interviews revealed attention bias among older adults. Whether it was the insufficient attention paid to other vaccines during the pandemic when COVID-19 vaccination services were more readily available, or the diminished emphasis on COVID-19 vaccination in the post-pandemic period of routine management, these findings resonate with Zhao’s observation that China’s emergency policies prioritize disease control over prevention.³⁸ Moreover, concerns about the safety and side effects of COVID-19 vaccines are widespread across many different regions of the world.³⁹ Our research shows that older adults, influenced by rumors about COVID-19 vaccines, have doubts about safety and quality of vaccines, and expect the governments to oversee vaccine production and quality control. This indicates that if the government fails to sustain trust through consistent service delivery and reliable information, public cooperation with public health measures may decline as policy attention wanes. Therefore, governments play a crucial role during public health pandemics, making it essential for many global governments to strategically build and maintain levels of health trust among their populations.⁴⁰

Collectivism is a double-edged sword when it comes to improving compliance with public health measures

Collectivism, which prioritizes group interests over individual ones and emphasizes the role of mutual dependence and social norms in combating COVID-19 risks.^41,42 Both rounds of interviews revealed the dual impact of collectivist beliefs on rural older adults’ vaccination.

On the one hand, our research suggests that collectivism, as a sociocultural factor, motivates older adults to actively cooperate with government public health measures during epidemics. Older adults generally perceive vaccination as a civic duty – responding to the nation’s call and safeguarding collective interests – which represents a unique and crucial mechanism within the Chinese context. This aligns with findings from Mo,⁴³ indicating that collectivism as a sociocultural factor significantly influences COVID-19 vaccination. A study of the Turkish population also revealed that individuals with higher levels of collectivism demonstrated greater willingness to receive vaccinations.⁴⁴ Compared to the individualism pursued by Western nations, the collectivism emphasized in traditional Chinese culture leads individuals to prioritize the interests of others,⁴⁵ and cooperating with the government or community vaccination efforts is seen as fulfilling a collective responsibility. Especially when considering the health of family members, the desire to protect their families often serves as a key motivator for vaccination.⁴⁶

On the other hand, collectivism may also lead to attention bias, causing older adults to overly rely on government signals to determine the importance of public health strategies, thereby neglecting vaccines without mandatory vaccination requirements. This bias not only hinders the widespread adoption of routine vaccines and leads to low coverage rates, but also fuels misunderstandings among the elderly regarding overall epidemic prevention strategies. It reflects a “policy-driven perception” shaped by collectivism. Deng’s research²⁵ also revealed that China’s older adults vaccination issues initially received insufficient attention because policy priorities focused on curbing epidemic spread and reducing mortality rates rather than advancing COVID-19 vaccination efforts. Therefore, when addressing public health emergencies, relying solely on public health interventions to boost vaccination rates among older adults is insufficient. It is also essential to focus on attention bias stemming from collectivist orientations and leverage the role of this underlying belief in promoting vaccination among China’s elderly population.

The awakening of individual consciousness has a dual impact on vaccination

The findings indicate that as the pandemic progressed and access to information expanded, rural older adults gradually developed greater self-awareness, shifting their vaccination decisions from “collectively driven” to “individually chosen,” with individuals beginning to weigh professional advice alongside personal perceptions and family responsibilities when making decisions – rather than simply adhering to collective norms. This awakening is primarily reflected in two aspects. On the one hand, older adults are more inclined to rely on professional authorities (such as doctors’ advice) and knowledgeable sources (such as informed family members) when making decisions. This can be seen as an awakening of individual consciousness, and such an awakening help promote voluntary vaccination behavior – provided that professional advice and information dissemination are accurate and effective. Numerous studies have also confirmed that healthcare providers are the most trusted source for vaccine recommendations. Advice from doctors or family members can help increase individuals’ willingness to get vaccinated.⁴⁷ So, relevant personnel should support and encourage older adults to prevent diseases through vaccination.⁴⁸

On the other hand, we also found emerging individual awareness of making vaccination decisions based on personal health status. Some older adults refused vaccination on the grounds of being in good physical condition, believing their health could resist the viruses. While this reflects personal initiative, it also exposes a health belief bias, which is consistent with findings from a Canadian study⁴⁹ showing that older adults refuse vaccinations due to overestimating their own immunity. This health belief bias stems both from insufficient professional health information and from overreliance on personal experience and subjective perceptions. Additionally, caution is needed regarding older adults questioning vaccine efficacy due to vaccine-related rumors, as well as their lack of understanding about influenza and pneumococcal vaccines stemming from insufficient access to health information. This reflects that older adults are prone to being influenced by subjectively perceived information when making decisions, yet the information is often incomplete or lacking in authority. In China, the primary source of health information for older adults is the internet, with more than 100 million older netizens.⁵⁰ And the transmission of information among family members and friends is also widespread.⁵¹ Meanwhile, they are the most vulnerable group to health misinformation,⁵² as they often struggle to verify the information they receive, which leaves them prone to being influenced by one-sided information.Therefore, it is particularly important to strengthen the promotion of preventive healthcare and vaccine-related knowledge. Delivering accurate information to older adults through authoritative channels, guiding them to develop scientifically sound health knowledge, and helping them make vaccination decisions based on scientific information, remains a vital measure to improve vaccination rates among this demographic.

Perceived psychological benefits are a key factor in promoting vaccination intent, while perceived practical benefits influence people’s long-term confidence in vaccination

Perceived psychological benefits refer to an individual’s subjective assessment and belief that certain behaviors or interventions may yield positive psychological outcomes by reducing the threat of disease.⁵³ This serves as a key motivation for older adults to receive vaccinations. In our study, older adults chose to get vaccinated against COVID-19 to alleviate their infection concerns and stress, driven by a psychological desire to avoid regret. During the COVID-19 pandemic, Wang’s⁵⁴ research revealed that vaccine hesitancy among older adults primarily stemmed from misunderstandings about COVID-19 vaccine contraindications and excessive concerns about vaccine side effects, leading to negative emotions such as anxiety and depression. Vaccination against COVID-19 alleviates fear of the pandemic and psychological concerns about contracting the virus.³² However, when the actual effectiveness of vaccination falls short of expectations – such as individuals contracting COVID-19 despite receiving the vaccine – it not only significantly impacts older adults’ trust in COVID-19 vaccines but also extends to others like influenza and pneumococcal vaccines.⁵⁵ This underscores the critical importance of ensuring the actual efficacy and safety of vaccines during promotion and administration. Concurrently, it is essential to strengthen scientific explanations regarding vaccine effectiveness and side effects to alleviate the concerns and anxieties of older adults.

Compared with other social groups, self-identity and generational responsibilities among China’s rural older adults influence vaccination rates

Both rounds of interviews revealed that perceptions of self-marginalization constitute a unique barrier to vaccination among rural older adults in China. Due to environmental factors such as scarce resources, older adults in rural China often place themselves at the margins of social resource distribution. They perceive themselves as advanced in age and of limited contribution to the nation, viewing vaccination as a waste of social resources. This type of cognition reflects older adults’ simple altruism and their neglect of personal health, which is consistent with the traditional family value in rural China of prioritizing children over self. This sociological phenomenon, shaped by rural social norms and resource allocation patterns, substantially influences the acceptance of public health interventions like vaccination. Should this social factor be overlooked, public health authorities will encounter cognitive resistance from the elderly when promoting vaccination.

During the second round of interviews, the emergence of intergenerational responsibility strengthened older adults’ willingness to get vaccinated. On the one hand, older adults chose vaccination out of a sense of duty to protect their children’s health. On the other hand, they began actively accepting their children’s care, with parental advice becoming a key driver of vaccination behavior. A Chinese controlled experiment involving grandchildren showed that grandparents in the intervention group were more likely to receive COVID-19 booster shots compared to the control group.⁵⁶ So, in vaccination practice, this two-way care dynamic – where elders protect the young and the young care for the elders – offers a novel intervention pathway. It not only transforms older adults’ intergenerational responsibility into personal motivation for vaccination but also corrects their cognition that “old people are useless” by conveying authoritative health knowledge and education to their children.

Through an integrated public health and sociological lens, we found that improving vaccination rates among rural older adults cannot rely solely on optimizing public health services (e.g., enhancing vaccination delivery) or merely correcting cognitive (e.g., conducting public education campaigns). A comprehensive intervention strategy is required. At the public health level, maintaining stable vaccine supply and optimizing vaccination services to enhance accessibility for older adults, while strengthening authoritative dissemination of health information including vaccine knowledge. At the sociological level, leveraging collectivist values to promote “vaccination as a family and social responsibility,” correcting the self-marginalization perceptions of older adults, and harnessing intergenerational relationships as bridges for health information transmission. By integrating these two approaches, we aim to break the vicious cycle between objective service gaps and subjective cognitive, thereby achieving a sustainable increase in vaccination coverage among the elderly.

Conclusion

This study explored the cognitive characteristics and vaccination practices among rural older adults in Anhui Province during the COVID-19 pandemic through two rounds of in-depth interviews with 13 participants, combined with grounded theory analysis. Results indicate that older adults’ perceptions and practices regarding vaccination are complex, influenced by government actions, sociocultural beliefs, individual cognition, and psychological experiences. Therefore, based on the findings of this study, the following targeted measures can be implemented to enhance vaccination rates among rural elderly populations:

1. Given older adults’ reliance on authoritative information and health belief biases, credible sources such as physicians and community workers should convey scientifically grounded information about vaccine safety and efficacy. This approach aims to correct misconceptions, including “vaccination is unnecessary for healthy individuals” or “vaccination is pointless for older adults.”

2. Recognizing the critical role of community services in vaccination promotion and the limited accessibility of routine vaccination services, optimize community vaccination services. Establish proactive notification mechanisms and home-visit vaccination services for routine vaccines (e.g., influenza, pneumococcal vaccines), building upon the efficient service models implemented during COVID-19 vaccine rollout.

3. Building on the influence of intergenerational relationships on vaccination decisions, leverage intergenerational responsibility in vaccination efforts. Encourage children to share scientific vaccination knowledge with their elderly parents or grandparents, while reinforcing vaccination willingness among the elderly through emotional appeals such as “grandchildren’s health requires protection from their elders.”

4. Addressing attention biases stemming from collectivist culture, integrate routine vaccination into government public health communication priorities. Prevent elderly individuals from neglecting non-mandatory vaccinations due to reduced policy visibility.

Limitations and future research

This study has certain limitations. (1) The sample is not sufficiently representative. A total of 13 older adults we recruited were from rural areas of Anhui Province, represent a small sample size with limited geographical diversity, making it difficult to account for variations across different rural regions. Consequently, the generalizability and extrapolation of the research findings are constrained. At the same time, due to differences in sociocultural and policy environments, the findings and recommendations of this study may be applicable to China or other countries with similar contexts, but may not be applicable to Western countries. Qualitative research is more concerned with achieving an interpretive understanding of the actors’ logic of action rather than with the representativeness of the sample.⁵⁷ Through two rounds of pre- and post-pandemic in-depth interviews with 13 participants, this study indicates that vaccine hesitancy is not a static individual attitude but a “contextual product” that evolves with pandemic dynamics, policy adjustments, and shifts in the information environment. It explores how the elderly balance health benefits against perceived risks and unpacks the complex logics of action in which rationality and emotion intersect across individuals, communities, and authoritative entities. Furthermore, the interviewees were drawn from an inland province with a large rural population. The province’s socioeconomic conditions, governance, and public sentiment closely resemble those in most other inland regions; accordingly, the findings can serve as a useful reference for understanding vaccination uptake and its determinants among older adults across inland China. (2) Some participants could only express their views in dialects. During text transcription, we converted some dialect terms into Mandarin expressions on the principle of not altering their original meaning. For example, the kinship term “Dajinzi” (大妗子, dà jīn zǐ, a dialect term used in some regions of China to refer to one’s uncle’s wife) mentioned by Respondent M was standardized to the general expression “jiuma” (舅妈, jiǔ mā, the standard Mandarin term for “aunt by marriage”). Nevertheless, there remains a risk of subtle semantic deviations. (3) During the research process, the researchers’ subjective interpretations may have influenced the results of coding and thematic analysis, leading to a certain degree of subjectivity. (4) The recall bias of participants may have affected the accuracy of the data. (5) The study did not examine how gender bias, cultural barriers among ethnic minorities, or religious beliefs shape rural older adults’ vaccination decisions. Most minority groups in China live in concentrated communities; the interview sites were not ethnic-minority areas, and religious adherence is uncommon there. None of the 13 participants raised these topics, leading us to assume they had little influence on local vaccine uptake.

Future studies could expand the research scope and sample structure, increase the sample size, and include groups from different regions, ethnic minorities, and religious backgrounds. It should conduct an in-depth analysis of the impacts of factors such as ethnic cultural practices and traditional health beliefs on vaccination-related cognitions and behaviors, thereby providing a basis for formulating targeted cross-cultural vaccination promotion strategies. In addition, future studies may further explore the influence of gender bias on rural older adults’ vaccination willingness. Methodologically, a combination of multiple research methods could be adopted for mutual validation to enhance the reliability and generalizability of the research findings.

Biographies

Li Wang is a Professor and Deputy Director of the Department of Health Management, at the School of Health Services Management, Anhui Medical University, China, and was a Visiting Professor at the Dalla Lana School of Public Health (DLSPH), University of Toronto. In recent years, Li Wang is mainly focusing on research about vaccine hesitancy, and has around 20 peer-reviewed publications in this field. Li Wang: wangli.0602@163.com.

Xiaolin Wei is a medical doctor, public health specialist, professor and the Dalla Lana Chair in Global Health Policy in the Dalla Lana School of Public Health (DLSPH), University of Toronto. He was elected as a Fellow of Canadian Academy of Health Sciences in 2022. Xiaolin is the faculty co-lead for implementation science. He has served as a board member and has served as the Secretary General and Vice President of the International Union of Lung Disease from 2012 to 2023. He holds adjunct/visiting professorship with the Johns Hopkins University, USA, the University of St. Andrews, and the University of Leeds, UK, Fudan University and Peking University, China. He regularly provides consultancy to the World Health Organization regarding tuberculosis, antimicrobial resistance and implementation science/clinical trials design. Xiaolin Wei: xiaolin.wei@utoronto.ca.

Funding Statement

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the Anhui Medical University Hospital Management Research Institute “National Medical Science and Technology” Open Project—Perception of Occupational Infection Risks, Protective Practices, and Optimized Prevention Strategies Among Healthcare Workers in Anhui Province [2023gykj06]; Canadian Institutes of Health Research (CIHR) [179238]; Anhui Province University Philosophy and Social Science Excellent Research and Innovation Team 2023—Research on Collaborative Governance of Primary Health [2023AH010036].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Consent statement

All participants gave informed consent prior to study participation. They were informed that data would be published anonymously and that they could terminate the questionnaire at any time to withdraw their consent.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

This study was ethically reviewed and approved by the Biomedical Ethics Committee at Anhui Medical University (IRB number: 20,210,614). Informed consent to utilize the collected information for research purposes was obtained from all participants.