A cross-sectional study of vaccination behavior and willingness regarding respiratory disease-related vaccines among the elderly in Beijing, China

ABSTRACT

This study aimed to determine the coverage of the 23-valent pneumococcal polysaccharide vaccine (PPV23) and the influenza vaccine, along with related factors, among elderly individuals aged 60 y and above in the capital urban of China. In 2023, 14 out of 43 streets or townships in Chaoyang District were selected using a random sampling method. Elderly participants completed a questionnaire. Logistic regression analysis was employed to identify influencing factors. Among 1,422 respondents, 235 (16.53%) had received the PPV23 vaccine; 747 (52.53%) expressed willingness but had not yet been vaccinated; and 440 (30.94%) indicated unwillingness. Influenza vaccine coverage was higher than that of PPV23: 437 respondents (30.73%) received annual influenza vaccination; 385 (27.07%) were willing but did not consistently receive the vaccine annually; 284 (19.97%) were willing but had not yet been vaccinated; and 316 (22.22%) explicitly refused influenza vaccination. The primary reason for refusal among unwilling participants for both vaccines was the perception that vaccination was unnecessary. For those willing but not ultimately vaccinated, the most frequent reason was lack of awareness regarding available vaccination services. Groups more likely to receive PPV23 and influenza vaccines included individuals who frequently experienced influenza and those recommended by medical staff. These groups also showed a greater inclination to continue influenza vaccination. It is imperative to strengthen community health education on these vaccines, encourage uptake among residents and healthcare professionals, and actively promote the benefits and convenience of PPV23 vaccination.

Introduction

China has officially entered a phase of moderate aging, with the level of aging continuing to intensify. By the end of 2024, the number of permanent residents aged 60 and above in Beijing reached 5.140 million, accounting for 23.5% of the total population,¹ Moreover, the elderly population in Beijing is steadily increasing, leading to a further intensification of population aging. As the urban district with the largest registered population in the capital of China, Chaoyang District exhibits a more pronounced aging trend. The number of registered residents aged 60 and above, as well as those aged 80 and above, both rank first citywide. Respiratory infectious diseases in elderly populations place a significant disease burden on families and individuals, while also exerting substantial pressure on healthcare resources in the capital. Due to the decline in immune function, older adults are at a substantially elevated risk of acquiring respiratory infectious diseases. Furthermore, many older adults have preexisting comorbidities, which exacerbate the severity of respiratory infections and increase the disease burden. Among individuals aged 65 y and above who have not received the influenza vaccine, the laboratory-confirmed incidence rate of influenza is 7.2%.² Significantly higher than other age groups, during the influenza epidemic season, the influenza-related excess mortality rate among individuals aged 60 and above accounts for 80% of the total excess mortality.³ Research indicates that the total economic burden associated with influenza-related outpatient and emergency visits for individuals aged 60 and above in China ranges from 111 to 141 US $ per person. Additionally, the total economic burden of hospitalization is approximately 1387 US $ per person.⁴ According to the China Health and Family Planning Statistical Yearbook, in 2018, the average medical expenditure per inpatient with pneumonia in hospitals amounted to 725 US $.⁵ It is projected that by 2035, the proportion of the elderly population will surpass 30%, signifying the transition into a severely aging society. During this period, the burden of disease is anticipated to increase significantly.

Vaccination serves as a critical strategy for preventing diseases such as influenza and pneumococcal pneumonia in the elderly population. It not only effectively reduces the incidence of these diseases but also diminishes the occurrence of associated complications, outpatient visits, hospitalizations, and mortality rates. Multiple studies have consistently demonstrated that the administration of the 23-valent pneumococcal polysaccharide vaccine (PPV23) to individuals aged 65 and above elicits specific antibody responses and significantly reduces the incidence of diseases caused by Streptococcus pneumoniae.⁶ Since 2007, Beijing has provided free influenza vaccination for local residents aged 60 and above with household registration,⁷ And since 2018, the local government has provided free vaccination with the 23-valent pneumococcal polysaccharide vaccine for residents aged 65 and above.⁸ However, over the past three years, the vaccination coverage for influenza and 23-valent pneumococcal polysaccharide vaccines among individuals aged 60 and above in Chaoyang District has remained approximately 20%. At the national level, the vaccination rate among the elderly is even lower. Specifically, the influenza vaccination rates for individuals aged 60 and above in China from 2019 to 2023 were 1.57%, 3.03%, 3.75%, and 4.16%, respectively.⁹ In 2022, the vaccination coverage of PPV23 in China was 2.35%, increasing to 3.2% in 2023. -Hence, the vaccination rate was substantially lower than that of the United States, where the pneumococcal vaccination rate among adults aged 65 and older was 64.0% in 2022.¹⁰ As of April 2025, the influenza vaccination coverage rate among individuals aged 65 and above in the United States had reached 71.1%.¹¹

To comprehensively understand the current status of PPV23 vaccination among individuals aged 65 and above in Chaoyang District, Beijing, and to identify the factors influencing their vaccination behavior and willingness, this study was undertaken. The findings aim to provide a robust scientific foundation for the development of targeted intervention strategies and policies.

Research subjects and methods

Respondents

From March to August 2023, a total of 14 communities were randomly selected from all sub-districts and towns in Chaoyang District, Beijing. The respondents comprised permanent residents aged 60 and above, and were selected through convenience sampling. Inclusion criteria included: being a permanent resident aged 60 y or older in Chaoyang District, Beijing; providing informed consent to participate in the survey; and possessing the ability to independently complete the questionnaire. Exclusion criteria encompassed: individuals under the age of 60; those unable to independently complete the questionnaire; and residents who had lost their capacity for self-care or suffered from mental illness, thereby rendering them incapable of accurately responding to the questionnaire. The required sample size was calculated according to the sample size formula for the cross-sectional study: $\mathit{n}=\frac{\mathit{p}(1-\mathit{p})}{{\left(\frac{\mathit{d}}{{\mathit{Z}}_{1-\mathit{\alpha }/2}}\right)}^2}=\frac{Z_{1-\alpha /2}^2\times \mathit{p}(1-\mathit{p})}{d^2}$. Sample size was determined based on the aim to estimate the vaccination rate with a relative precision of 10% of the point estimate. According to the PPV23 vaccination rate of the elderly in Chaoyang District of Beijing in 2017, with p = 28.8%,¹² α = 0.05, Z_1–α/2 = 1.96, and the allowable error d was 0.1p (corresponding to an error of ±~3%), n = 950 were calculated.

Investigation methods and contents

This study collected data via anonymous questionnaires developed using questionnaire star platform. Prior to the commencement of the survey, all staff members underwent unified and standardized training. Subsequently, the investigators distributed electronic questionnaires to eligible participants within each community. Participants voluntarily completed the questionnaires using their electronic devices. Before completing the questionnaires, the investigators informed the participants of the purpose and significance of the study, clarified that it was an anonymous and voluntary process, and obtained verbal informed consent from the participants. Participants completed the questionnaires by scanning a QR code. In cases where participants were unable or found it inconvenient to complete the questionnaires independently, the investigators assisted by reading each question aloud and recording the responses.

A structured questionnaire was employed, covering five domains: (1) sociodemographic characteristics; (2) health status, including medical history of influenza, pneumococcal pneumonia, and chronic diseases within the past five years; (3) cognitive and behavioral factors (vaccine knowledge, information channels, and provider recommendations); (4) vaccination behavior (uptake and reasons for non-vaccination); and (5) willingness to get vaccinated and the underlying reasons, including barriers to acceptance even when the vaccine is provided free of charge. Upon completion of the survey process, investigators collected and verified the questionnaires while screening out those containing missing information or apparent logical inconsistencies.

Quality control

(1) Anonymous surveys were implemented, and the principle of confidentiality was strictly upheld to minimize information bias; (2) Each account and device was restricted to submitting only one questionnaire to prevent duplicate entries; (3) The questionnaire was designed with mandatory fields to ensure completeness before submission; (4) Invalid questionnaires were manually reviewed and excluded to maintain survey quality. (5) Participants without electronic devices guided by the staff to complete the paper-based questionnaire. Upon completion of the survey, the access to the “one device, one questionnaire” system was revoked, and the staff input the questionnaire data on behalf of the participants.

Statistical methods

Data from the survey were entered and screened using SPSS 29.0 statistical software. This process involved the basic information of participants, their health status, vaccination rates for influenza and PPV23 vaccines, as well as their vaccination intentions. Univariate analysis was performed using chi-square tests to examine factors potentially influencing vaccination rates and intentions. Subsequently, variables that demonstrated statistically significant results in the univariate analysis were incorporated into a multivariate Logistic regression model for further analysis. The significance level was set at α = 0.05.

Results

Basic characteristics of the survey subjects

A total of 2,000 questionnaires were distributed. We received responses from 1,586 questionnaires and excluded 164 invalid ones. The primary reason for exclusion was the abnormal completion time of the questionnaires, which was either less than 2 minutes or more than 60 minutes. Finally, 1422 valid questionnaires were included in this study. The respondents included 555 men and 867 women; 464 were aged 60–64, 794 were aged 65–74, and 164 were aged 75 and above.

Analysis of the current status and determinants of vaccination coverage and willingness for PPV23

Among the 1,422 respondents, 235 (16.53%) had received the PPV23 vaccine; 747 (52.53%) expressed a willingness to be vaccinated but had not yet done so; and 440 (30.94%) indicated unwillingness to receive the vaccine.

Among individuals who were hesitant to receive the PPV23 vaccine, the most common reason for refusal was the perception that the vaccine was unnecessary, with 200 (45.45%) respondents selecting this option. The subsequent most frequent concerns pertained to vaccine safety and cost, with 125 (28.41%) and 103 (23.41%) respondents expressing worries about these aspects, respectively. Among the 23-valent pneumococcal vaccine recipients, 532 individuals (71.22%) expressed their willingness to get vaccinated but had not yet done so, the most common reason was a lack of awareness regarding the accessibility of vaccination services.

The chi-square test analysis identified statistically significant differences (p < .05) in the PPV23 vaccination status and willingness across 12 variables. The results are presented in Table 1.

Table 1.

Univariate analysis of responses about receipt of the pneumococcal polysaccharide vaccine.

Variable	Category	n (%)N = 1422	Willing and get vaccinated (%)	Willing, but not vaccinated (%)	Unwilling to get vaccinated (%)	χ2 value	P value
Gender	Male	555 (39.03)	110 (19.82)	268 (48.29)	177 (31.89)	9.361	.009
	Female	867 (60.97)	125 (14.42)	479 (55.25)	263 (30.33)
Age (years)	60–64	464 (32.63)	55 (11.85)	271 (58.41)	138 (29.74)	28.326	<.001
	65–74	794 (55.84)	133 (16.75)	408 (51.39)	253 (31.86)
	≥75	164 (11.53)	47 (28.66)	68 (41.46)	49 (29.88)
Community	Urban	442 (31.08)	60 (13.57)	272 (61.54)	110(24.89)	20.885	<.001
	Downtown	980 (68.92)	175 (17.86)	475 (48.47)	330 (33.67)
Degree	Below middle school	170 (11.95)	31 (18.24)	94 (55.29)	45 (26.47)	2.979	.561
	Middle school	328 (23.07)	58 (17.68)	173 (52.74)	97 (29.57)
	High school or upper	924 (64.98)	146 (15.80)	480 (51.95)	298 (32.25)
Jobs	Enterprise/public institution staff	773 (54.36)	131 (16.95)	401 (51.88)	241 (31.18)	8.954	.176
	Health professiol	95 (6.68)	22 (23.16)	49 (51.58)	24 (25.26)
	Farmers/private business	268 (18.85)	38 (14.18)	155 (57.84)	75 (27.99)
	Others	286 (20.11)	44 (15.38)	142 (49.65)	100 (34.97)
Marital status	Married	1232 (86.64)	195 (15.83)	680 (55.19)	357 (28.98)	32.292	<.001
	Unmarried/divorced	55 (3.87)	14 (25.45)	12 (21.82)	29 (52.73)
	Widowed/others	135 (9.49)	26 (19.26)	55 (40.74)	54 (40.00)
Spouse’s degree	High school or below/unmarried/divorced	1004 (70.60)	159 (15.84)	544 (54.18)	301 (29.98)	3.778	.151
	Bachlor or upper	418 (29.40)	76 (18.18)	203 (48.56)	139(33.25)
Child’s highest degree	High school or below/no child	167 (11.74)	25 (14.97)	85 (50.90)	57 (34.13)	0.995	.608
	Bachlor or upper	1255 (88.26)	210 (16.73)	662 (52.75)	383 (30.52)
Family size	≤3	974 (68.50)	159 (16.32)	482 (49.49)	333 (34.19)	16.064	<.001
	>3	448 (31.50)	76 (16.96)	265 (59.15)	107 (23.88)
Monthly income (CNY)	≤2000	188 (13.22)	27 (14.36)	115 (61.17)	46 (24.47)	16.607	.011
	2001–5000	719 (50.56)	103 (14.33)	388 (53.96)	228 (31.71)
	5001–10000	443 (31.15)	90 (20.32)	207 (46.73)	146 (32.96)
	≥10001	72 (5.06)	15 (20.83)	37 (51.39)	20 (27.78)
Chronic disease	Healthy	616 (43.32)	107 (17.37)	312 (50.65)	197 (31.98)	4.444	.617
	1 disease	322 (22.64)	45 (13.98)	182 (56.52)	95 (29.50)
	2–3 diseases	376 (26.44)	63 (16.76)	201 (53.46)	112 (29.79)
	≥4 diseases	108 (7.59)	20 (18.52)	52 (48.15)	36 (33.33)
Having suffered from flu	Hardly	775 (54.50)	124 (16.00)	371 (47.87)	280 (36.13)	22.137	<.001
	Often	647 (45.50)	111 (17.16)	376 (58.11)	160 (24.73)
Pneumonia history	Yes	118 (8.30)	34 (28.81)	56 (47.46)	28 (23.73)	14.551	<.001
	No	1304 (91.70)	201 (15.41)	691 (52.99)	412 (31.60)
Pneumonia history of family	Yes	223 (15.68)	47 (21.08)	125 (56.05)	51 (22.87)	9.508	.009
	No	1199 (84.32)	188 (15.68)	622 (51.88)	389 (32.44)
Heard of the disease	Yes	989 (69.55)	184 (18.60)	526 (53.19)	279 (28.21)	16.59	<.001
	No	433 (30.45)	51 (11.78)	221 (51.04)	161 (37.18)
Heard of the vaccine	Yes	736 (51.76)	197 (26.77)	422 (57.34)	117 (15.90)	215.128	<.001
	No	686 (48.24)	38 (5.54)	325 (47.38)	323 (47.08)
Recommendation	Yes	534 (37.55)	175 (32.77)	294 (55.06)	65 (12.17)	234.964	<.001
	No	888 (62.45)	60 (6.76)	453 (51.01)	375 (42.23)
Total			235 (16.53)	747 (52.53)	440 (30.94)

Analysis of the current status and determinants of vaccination coverage and willingness for influenza vaccine

437 respondents (30.73%) received the influenza vaccine annually; 385 (27.07%) were willing but did not consistently receive it every year; 284 (19.97%) were willing but had not yet been vaccinated; and 316 (22.22%) expressed unwillingness to receive the influenza vaccine.

Among individuals who declined the influenza vaccine, similar to pneumonia vaccination, the predominant reason for refusal was the perception that vaccination was unnecessary. Specifically, 137 (43.35%) individuals held this belief. Other common reason for refusal included concerns about safety, with 83 (26.27%).

Among the influenza vaccine recipients, 151 individuals (53.17%) who expressed their willingness to get vaccinated but had not yet done so, the most common reason was a lack of awareness regarding the accessibility of vaccination services, which was the same as the PPV23.

For the influenza vaccine, significant differences (p < .05) were observed in vaccination status and willingness across 11 variables, with the results presented in Table 2.

Table 2.

Univariate analysis of responses about receipt of the influenza vaccine.

Variable	Category	n (%)N = 1422	Willing and get vaccinated every year (%)	Willing, but not vaccinated every year (%)	Willing, but have not been vaccinated yet (%)	Unwilling to get vaccinated (%)	χ2 value	P value
Gender	Male	555 (39.03)	173 (31.17)	160 (28.83)	105 (18.92)	117 (21.08)	2.131	.546
	Female	867 (60.97)	264 (30.45)	225 (25.95)	179 (20.65)	199 (22.95)
Age (years)	60–64	464 (32.63)	118 (25.43)	128 (27.59)	117 (25.22)	101 (21.77)	29.493	<.001
	65–74	794 (55.84)	247 (31.11)	214 (26.95)	151 (19.02)	182 (22.92)
	≥75	164 (11.53)	72 (43.90)	43 (26.22)	16 (9.76)	33 (20.12)
Community	Urban	442 (31.08)	143 (32.35)	153 (34.62)	80 (18.10)	66 (14.93)	30.483	<.001
	Downtown	980 (68.92)	294 (30.00)	232 (23.67)	204 (20.82)	250 (25.51)
Degree	Below middle school	170 (11.95)	53 (31.18)	66 (38.82)	24 (14.12)	27 (15.88)	18.365	.005
	Middle school	328 (23.07)	106 (32.32)	87 (26.52)	67 (20.43)	68 (20.73)
	High school or upper	924 (64.98)	278 (30.09)	232 (25.11)	193 (20.89)	221 (23.92)
Jobs	Enterprise/public institution staff	773 (54.36)	243 (31.44)	205 (26.52)	158 (20.44)	167 (21.60)	16.801	.052
	Health professional	95 (6.68)	32 (33.68)	34 (35.79)	10 (10.53)	19 (20.00)
	Farmers/private business	268 (18.85)	89 (33.21)	76 (28.36)	49 (18.28)	54 (20.15)
	Others	286 (20.11)	73 (25.52)	70 (24.48)	67 (23.43)	76 (26.57)
Marital status	Married	1232 (86.64)	374 (30.36)	344 (27.92)	254 (20.62)	260 (21.10)	13.825	.032
	Unmarried/divorced	55 (3.87)	16 (29.09)	9 (16.36)	9 (16.36)	21 (38.18)
	Widowed/others	135 (9.49)	47 (34.81)	32 (23.70)	21 (15.56)	35 (25.93)
Spouse’s degree	High school or below/unmarried/divorced	1004 (70.60)	295 (29.38)	281 (27.99)	208 (20.72)	220 (21.91)	4.172	.243
	Bachlor or upper	418 (29.40)	142 (33.97)	104 (24.88)	76 (18.18)	96 (22.97)
Child’s highest degree	High school or below/no child	167 (11.74)	39 (23.35)	49 (29.34)	35 (20.96)	44 (26.35)	5.252	.154
	Bachlor or upper	1255 (88.26)	398 (31.71)	336 (26.77)	249 (19.84)	272 (21.67)
Family size	≤3	974 (68.50)	305 (31.31)	240 (24.64)	184 (18.89)	245 (25.15)	20.872	<.001
	>3	448 (31.50)	132 (29.46)	145 (32.37)	100 (22.32)	71 (15.85)
Monthly income (CNY)	≤2000	188 (13.22)	52 (27.66)	73 (38.83)	38 (20.21)	25 (13.30)	28.482	<.001
	2001–5000	719 (50.56)	211 (29.35)	178 (24.76)	163 (22.67)	167 (23.23)
	5001–10000	443 (31.15)	149 (33.63)	114 (25.73)	73 (16.48)	107 (24.15)
	≥10001	72 (5.06)	25 (34.72)	20 (27.78)	10 (13.89)	17 (23.61)
Chronic disease	Healthy	616 (43.32)	178 (28.90)	172 (27.92)	117 (18.99)	149 (24.19)	14.789	.097
	1 disease	322 (22.64)	90 (27.95)	102 (31.68)	62 (19.25)	68 (21.12)
	2 ~ 3 diseases	376 (26.44)	127 (33.78)	91 (24.20)	82 (21.81)	76 (20.21)
	≥4 diseases	108 (7.59)	42 (38.89)	20 (18.52)	23 (21.30)	23 (21.30)
Having suffered from flu	Hardly	775 (54.50)	224 (28.90)	175 (22.58)	166 (21.42)	210 (27.10)	34.557	<.001
	Often	647 (45.50)	213 (32.92)	210 (32.46)	118 (18.24)	106 (16.38)
Flu history	Yes	781 (54.92)	264 (33.80)	243 (31.11)	143 (18.31)	131 (16.77)	41.305	<.001
	No	641 (45.08)	173 (26.99)	142 (22.15)	141 (22.00)	185 (28.86)
Flu history of family	Yes	871 (61.25)	270 (31.00)	271 (31.11)	174 (19.98)	156 (17.91)	32.403	<.001
	No	551 (38.75)	167 (30.31)	114 (20.69)	110 (19.96)	160 (29.04)
Heard of the disease	Yes	1300 (91.42)	396 (30.46)	357 (27.46)	259 (19.92)	288 (22.15)	1.247	.742
	No	122 (8.58)	41 (33.61)	28 (22.95)	25 (20.49)	28 (22.95)
Heard of the vaccine	Yes	1222 (85.94)	397 (32.49)	336 (27.50)	246 (20.13)	243 (19.89)	30.751	<.001
	No	200 (14.06)	40 (20.00)	49 (24.50)	38 (19.00)	73 (36.50)
Recommendation	Yes	914 (64.28)	362 (39.61)	287 (31.40)	148 (16.19)	117 (12.80)	203.745	<.001
	No	508 (35.72)	75 (14.76)	98 (19.29)	136 (26.77)	199 (39.17)
Total			437 (30.73)	385 (27.07)	284 (19.97)	316 (22.22)

Approaches to acquiring knowledge about vaccines

Regarding the PPCV23 vaccine, the primary sources of information were mobile phones/Internet (328 respondents, 23.07%), medical workers (257 respondents, 18.07%), family/friends (224 respondents, 15.75%), and community public welfare publicity (171 respondents, 12.03%).

For the flu vaccine, the main sources of information were family/friends (317 respondents, 22.29%), mobile phones/Internet (309 respondents, 21.73%), community public welfare publicity (302 respondents, 21.24%), and medical workers (282 respondents, 19.83%).

The logistic regression analysis for the vaccines

Figure 1 presents the results of the logistic regression analysis for the PPV23 vaccine. With unwillingness to receive the PPV23 vaccine as the reference category, the variables affecting willingness to receive the vaccine include gender, place of residence, marital status, and household size. The variables influencing both vaccination willingness and behavior encompass age group, frequency of influenza, awareness of the PPV23 vaccine, and whether medical staff have recommended it.

Figure 1.

Multivariate logistic regression analysis of 23-valent pneumococcal polysaccharide vaccine uptake among adults aged 60 y and older in Chaoyang District, Beijing.

Figure 2 illustrates the results of the logistic regression analysis for influenza vaccine acceptance. Using unwillingness to receive the vaccine as the reference category, the number of family members, monthly income, age group, and medical staff recommendation were identified as significant influencing factors on vaccine acceptance. We found that occupation and number of family members were the influencing factors of influenza vaccination behavior, while residence, influenza frequency and health care provider recommendation were the joint influencing factors of vaccination behavior and long-term vaccination behavior. The vaccination behavior of people living in urban-rural fringe (OR = 2.09, 95%CI: 1.42–3.07) and long-term vaccination behavior (OR = 2.09, 95%CI: 1.42–3.07) were better than those living in the central urban area. Compared with people with less influenza virus infection, people with frequent influenza virus infection were more willing to be vaccinated (OR = 1.80, 95%CI: 1.26–2.55) and more willing to be continuously vaccinated (OR = 1.71, 95%CI: 1.21–2.40). The vaccination behavior (OR = 4.32, 95%CI: 3.05–6.11) and continuous vaccination behavior (OR = 7.52, 95%CI: 5.26–10.75) recommended by medical staff were higher than those not recommended by medical staff.

Figure 2.

Multivariate logistic regression analysis of influenza vaccine uptake among adults aged 60 y and older in Chaoyang District, Beijing.

Disscussion

Exploring the current vaccination rate and the status of vaccination willingness under the existing policy holds substantial significance. This study further investigates multiple dimensions, including demographic influencing factors among vaccinated individuals, channels for obtaining information, reasons for unwillingness to be vaccinated, and reasons for not yet being vaccinated. The objective is to provide actionable and effective recommendations to promote vaccination coverage.

Although Beijing has implemented a free vaccination program for the PPV23 vaccine, both the current vaccination rate and willingness to be vaccinated remain relatively low. According to the survey results, only 16.53% (235 individuals) of respondents have been vaccinated with the PPV23 vaccine; 52.53% (747 individuals) express willingness to be vaccinated but have not yet done so; and 30.94% (440 individuals) are unwilling to receive the vaccine. The vaccination coverage rate in Beijing is lower than that observed in certain international and domestic regions. For instance, it lags significantly behind developed countries such as the United Kingdom, where the vaccination rate is 69.2%.¹³ Furthermore, compared to other regions within China that offer free PPV23 vaccinations for the elderly, the vaccination rate among individuals aged 60 and above is higher in several areas: 26.28% in Taizhou City, Zhejiang Province,¹⁴ 40.39% in Changshu City, Suzhou,¹⁵ and 27.74% in Shanghai,¹⁶ all surpassing the PPV23 vaccination rate in Chaoyang District, Beijing. Additionally, the vaccination willingness among the elderly in Chaoyang District is relatively low, with 69.06% (982 individuals) expressing interest in vaccination. This figure aligns closely with the 68.99% reported in Dongcheng District, Beijing,¹⁷ but falls below the 87.92% recorded in Guangzhou.¹⁸

The current status of influenza vaccination is more favorable compared to that of PPV23. Specifically, 30.73% (437 individuals) receive the influenza vaccine annually; 27.07% (385 individuals) express willingness but do not receive it every year; 19.97% (284 individuals) are willing but have yet to be vaccinated; and 22.22% (316 individuals) are unwilling to receive the vaccine. Prior research has demonstrated that Beijing’s influenza vaccination rate ranks among the highest nationwide,⁹ a conclusion corroborated by this study, with vaccination levels significantly surpassing those of Henan Province (2.77%) and Jiangsu Province (16.55%). Despite over 50% of the elderly population having received the influenza vaccine, only a small proportion adhere to regular and timely vaccination. Given that influenza virus strains evolve annually and the vaccine is updated accordingly, receiving the vaccine annually is essential for optimal protection.¹⁹ A considerable number of elderly individuals fail to maintain regular vaccination schedules, underscoring the need to enhance their awareness of its importance. Notably, 77.78% (1,106 individuals) of the elderly population express a willingness to receive the influenza vaccine, a figure higher than the 53.66% in Kaifu District, Changsha City, and 31.78% in Jiaozuo City, Henan Province,²⁰ placing it among the leading rates nationwide.

There are numerous factors that can influence the public’s willingness and behavior regarding influenza and pneumonia vaccination. These factors encompass the public’s comprehension of the diseases and vaccines, the efficient communication of vaccine service information, and concerns about vaccine safety. Additionally, demographic and family-related factors, such as age, family size, marital status, and monthly income, may also play a significant role.

Both the PPV23 vaccine and the influenza vaccine exhibit certain similarities in terms of the reasons for vaccine hesitancy among the elderly and the barriers faced by those willing but not yet vaccinated. Among the hesitant elderly, the predominant reasons include perceiving vaccination as unnecessary and expressing safety concerns. These factors remain the primary contributors to vaccine hesitancy in contemporary society.²¹ Consequently, it is imperative to enhance the elderly population’s awareness of vaccine importance through targeted educational interventions. Efforts should focus on reinforcing their understanding of disease severity and the efficacy of vaccines. Despite extensive research validating vaccine safety and reliability, apprehensions persist within the elderly demographic. To address this, governmental and medical entities must intensify efforts in disseminating accurate vaccine safety information and fostering open communication channels to mitigate cognitive biases within this population.²²

For elderly individuals who are willing but have not undergone vaccination, the primary reason is a lack of awareness regarding vaccination services and costs. This suggests that inadequate information dissemination and communication significantly influence vaccination behavior. Details about PPV23 and influenza vaccine services have not been effectively communicated to the public. Many elderly residents remain unaware of where to access vaccination services. Furthermore, despite the vaccines being provided free of charge, many elderly individuals still perceive them as too costly and thus choose not to vaccinate. These findings indicate that prior outreach efforts were insufficient and critical information was not adequately conveyed to the elderly population.

Similar to the findings in our team’s prior research on herpes zoster vaccination rates,²³ individuals who were aware of the PPV23 vaccine demonstrated a significantly higher willingness to vaccinate. Furthermore, those who received recommendations from healthcare professionals exhibited markedly enhanced vaccination intentions and behaviors. These results underscore the critical importance of accessible vaccine information and the pivotal role played by medical personnel. It is imperative to broaden the dissemination channels for vaccine-related information through the strategic use of digital media and interpersonal communication.²⁴ This ensures that older adults can accurately comprehend vaccine-related information and mitigate the risk of misinformation. A primary source of vaccine information for the elderly remains the recommendation of healthcare professionals. Within the framework of the Theory of Planned Behavior (TPB), such recommendations influence subjective norms and perceived behavioral control. Subjective norms reflect the impact of influential others within one’s social environment on individual behavior, whereas perceived behavioral control pertains to an elderly person’s confidence in their ability to successfully complete the vaccination process.²⁵ For older adults, healthcare providers are typically the most authoritative and reliable source of health information. When physicians exhibit a positive attitude toward vaccines and actively recommend them, this can effectively reduce vaccine hesitancy among the elderly,²⁶ enhance their trust in vaccines, and reinforce their belief in the efficacy of vaccines to reduce infection risks and disease severity, thereby promoting increased vaccination uptake.²⁷

In addition to physician promotion, an analysis of information sources reveals that for the PPV23 and influenza vaccines, the primary channels for obtaining information are mobile phones/Internet, healthcare professionals, family and friends, and community public welfare campaigns. With the proliferation of information, the volume of online content has surged; however, it is concerning that a significant amount of false vaccine-related misinformation exists on the Internet.^28,29 Therefore, older adults must enhance their capacity to discern credible information. Furthermore, this finding underscores the critical role of interpersonal communication in the dissemination of vaccine-related knowledge. Consistent with prior research, communication-based interventions have proven effective in mitigating vaccine hesitancy,^30,31 and reducing vaccine mistrust. Some studies have introduced the Popular Opinion Leader (POL) model, a community-based intervention strategy that trains trusted community leaders to disseminate health information within their social networks (e.g., friends, family, and neighbors). This approach has been shown to reduce stigma and improve help-seeking behaviors.³² Additionally, the POL model has demonstrated efficacy in vaccine promotion,³³ enhancing vaccine comprehension and thereby alleviating vaccine hesitancy.

Different living environments and conditions can exert complex influences on elderly residents’ attitudes toward vaccines. Consistent with prior research,³⁴ family support positively impacts vaccine attitudes and vaccination behaviors. Research indicates that family support facilitates proactive engagement in health-promoting behaviors among the elderly.^35,36 Relatives of the elderly, such as spouses and children, may prioritize their physical well-being by encouraging vaccination,³⁷ to mitigate infection risks. Furthermore, family members often assist in acquiring pertinent vaccine information, enhancing the elderly’s comprehension of vaccine safety and necessity, thereby increasing their vaccination intent. Additionally, during the decision-making process, the elderly may align their choices with the collective health preferences of their families due to familial influence. The presence of family members also improves vaccination accessibility for the elderly by aiding in appointment scheduling and providing accompaniment during vaccination, thus promoting adherence to vaccination protocols.

Contrary to prior research,³⁸ elderly individuals residing in urban areas or with higher incomes are more susceptible to vaccine hesitancy. Elderly individuals residing in the urban-rural fringe and with limited income have restricted access to relevant information but may place greater trust in government-led public health campaigns and respond more positively to governmental vaccination initiatives. Furthermore, due to insufficient medical security from large hospitals and higher medical expenses, these individuals may prioritize preventive healthcare measures and demonstrate a stronger willingness to vaccinate as a means of disease prevention and cost avoidance. Additionally, given their lower income, they are more sensitive to free vaccination programs and thus more likely to accept such opportunities. Finally, elderly residents in the urban-rural fringe, being geographically distant from large hospitals, rely more heavily on community health service stations,³⁹ than their urban counterparts.

The study sample consisted of permanent residents aged 60 y and older in Chaoyang District, Beijing. Currently, publicly funded influenza and 23-valent pneumococcal vaccines are exclusively available to eligible individuals aged 65 and above. Consequently, adults aged 60 to 64 y must bear the full cost of these vaccines out-of-pocket. This financial responsibility renders them particularly sensitive to both the direct costs of the vaccines and indirect costs, such as potential lost wages from time taken off work for vaccination. In contrast, while individuals aged 65 and above were less affected by direct costs, their uptake was hindered by other barriers, most notably misinformation regarding their eligibility for the free vaccination program.

In Chaoyang District of Beijing, the average income of elderly residents aged 60 y and older is less than 5000 RMB.¹ Against this backdrop, the costs of seasonal influenza vaccine (around 100 yuan) and 23-valent pneumococcal polysaccharide vaccine (approximately 180 yuan) could potentially affect vaccination uptake among the elderly population While the influenza vaccine is comparatively affordable, its required annual administration presents a recurring expense. The higher cost of the pneumococcal vaccine, despite its longer duration of protection, represents a significant one-time financial outlay. Consequently, the direct costs associated with both vaccines raise considerable concern for the elderly population, potentially acting as a barrier to uptake.

The influenza vaccination behavior among individuals who were farmers or engaged in private business prior to retirement was relatively low. This may be attributed to several factors, including weaker health awareness, insufficient understanding of vaccine-related disease prevention behaviors, and limited access to relevant information,⁴⁰ which hinder their ability to make informed decisions regarding vaccination. Furthermore, the income of private business owners and farmers tends to fluctuate significantly. Compared with other professions (e.g., public servants), they are more sensitive to both direct and indirect costs associated with vaccines (e.g., potential work disruptions due to vaccination). Due to the lack of fixed rest periods and unstable schedules, the time cost of vaccination is further exacerbated, leading them to prioritize seeking medical care only when illness occurs rather than proactively engaging in preventive measures such as vaccination.

Those who frequently experience influenza exhibit a significantly higher likelihood of both intending to and actually receiving vaccinations, thereby underscoring the importance of disease risk perception. As outlined in the Theory of Planned Behavior (TPB), behavioral intention serves as a critical determinant of actual behavior, which is shaped by attitudes, subjective norms, and perceived behavioral control.⁴¹ The perception of disease risk can influence the attitudes of older adults. When older adults perceive themselves to be at high risk of contracting pneumonia or influenza and recognize the severity of these diseases, their attitudes toward vaccines tend to become more favorable, leading them to view vaccination as beneficial.

This study has certain limitations that warrant acknowledgment. For example, the samples for this survey were exclusively collected from selected sub-districts and towns within Chaoyang District, Beijing, which may compromise the representativeness of the findings. The self-administered nature of the questionnaire necessitated a certain level of cognitive ability. Consequently, individuals who were very elderly, had very low educational attainment, or had sub-optimal cognitive function may have been under-represented or inadvertently excluded. Furthermore, in future research, we plan to continue monitoring the vaccination status of the elderly population, appropriately broaden the scope of the survey, and provide a robust scientific foundation for the development of relevant policies and measures.

In conclusion, the low willingness to receive pneumonia and influenza vaccinations in our country represents a complex social phenomenon that encompasses various dimensions, including health awareness, information dissemination, vaccine trust, economic considerations, and cultural as well as social psychological factors. Enhancing vaccination willingness necessitates collaborative efforts from the government, media, healthcare institutions, and all societal sectors. By implementing measures such as reinforcing health education, refining information dissemination strategies, ensuring vaccine safety, alleviating economic burdens, and enhancing vaccination accessibility, public trust and acceptance of vaccines can be gradually cultivated.

Biographies

Zhen Li, is a Deputy Chief Physician of Preventive Medicine and serves as the deputy Director of the Department of Immunization and Prevention at the Beijing Chaoyang District Center for Disease Control and Prevention (Chaoyang District Health Supervision Institute). She received her Master’s degree from Peking Union Medical College. With over a decade of professional experience, her research focuses on immunization program implementation and surveillance of vaccine-preventable diseases. Li has led multiple significant research initiatives funded by the Beijing Natural Science Foundation, the Chinese National Center for Disease Control and Prevention, and the Beijing Center for Disease Control and Prevention. She has authored over 10 scientific papers, contributing substantially to the advancement of preventive medicine.

Yunhua Bai, is a Chief Physician specializing in disease control. A graduate of Peking University, he has accumulated over three decades of experience in immunization programs and vaccine management. His extensive publication record includes two translated works, five scholarly treatises, more than 10 SCI-indexed papers, and over 50 articles in Chinese academic journals. Bai has led and successfully completed four major national special projects and one research initiative funded by the Science and Technology Commission, making substantial contributions to the field of disease prevention and control.

Bin Jia, Master of Public Health from Peking University, is the Chief Physician of Preventive Medicine. Jia leads the Department of Immunization and Prevention of the Beijing Chaoyang District Center for Disease Control and Prevention (Chaoyang District Health Supervision Institute). With over two decades of experience, Jia specia lizes in immunization planning and the surveillance of vaccine- preventable diseases. Jia has been a principal investigator in numerous significant research initiatives, including projects funded by the Beijing Natural Science Foundation, the National Center for Disease Control and Prevention, the Beijing Municipal Center for Disease Control and Prevention, and the Science and Technology Commission of Beijing Chaoyang District. He has authored more than 20 scientific papers, contributing extensively to this field.

Funding Statement

This research received funding by National Science and Technology Major project [2021ZD0111000].

Disclosure statement

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

Ethical approval

The Medical Ethics Committee of the Chaoyang District Center for Disease Control and Prevention (Chaoyang District Health Supervision Institute) in Beijing believes that: since this study uses an anonymous questionnaire survey method, and it has been stated before the survey that participation is voluntary and personal identity information will not be disclosed, ethical review can be exempted.