Influenza Vaccination Willingness, Uptake, and Behavioral Drivers Among Adults Aged ≥60 Years in Henan Province: A BeSD-Based Survey with Registry Follow-Up.

objectivesTo identify factors influencing influenza vaccination willingness and uptake among adults aged ≥60 years in Henan Province and to evaluate the effect of a brief educational intervention on vaccination willingness and behavior.

methodsIn September 2024, a cross-sectional survey based on the Behavioral and Social Drivers (BeSD) framework was conducted among adults aged ≥60 years across five counties in Henan. For participants without baseline willingness, a 3 min one-on-one educational intervention was delivered. In May 2025, following the end of the 2024-2025 influenza vaccination season (which runs from 1 October to 31 March in Henan Province), we retrieved vaccination records for all participants from the Henan Provincial Immunization Information System. This system captures all influenza vaccinations administered at designated vaccination clinics across the province. To ensure completeness for doses administered outside the provincial system (e.g., in other provinces or at private healthcare facilities), we conducted telephone follow-up interviews with all participants whose baseline vaccination intention was inconsistent with their actual vaccination behavior (i.e., willing but unvaccinated or unwilling but vaccinated). During these interviews, for those who reported receiving the vaccine outside Henan Province or at private facilities, we inquired about the specific date and location of vaccination to supplement the registry data. We also explored the reasons behind the intention-behavior discrepancy. For these participants, we requested vaccination certificates or other supporting documentation to confirm their vaccination status.

resultsBaseline vaccination willingness was 68.20% (1630/2390), whereas the actual vaccination rate was only 6.95% (166/2390), yielding a willingness-to-behavior conversion rate of 9.51% (155/1630) among those with baseline willingness. Of the 760 participants without baseline willingness, 543 (71.45%) completed the 3 min one-on-one instant educational intervention and the follow-up assessment; the remaining 217 were excluded due to refusal or loss to follow-up. Among these 543 completers, 46 (8.47%) became willing to vaccinate, and eight (1.47%) were subsequently vaccinated. Multivariate analysis identified the social processes dimension as the strongest correlate of both willingness (OR = 1.38 per 1-point increase, 95% CI: 1.33-1.44) and uptake (OR = 1.12, 95% CI: 1.03-1.22). Urban residence was associated with higher willingness (OR = 1.41, 95% CI: 1.12-1.78) and higher uptake (OR = 1.64, 95% CI: 1.11-2.42). Current smokers had a significantly lower uptake than never smokers (OR = 0.43, 95% CI: 0.22-0.85). Among the 11 participants without baseline willingness who were eventually vaccinated (eight from the intervention group and three from the non-intervention group), family/friend influence (63.64%, 7/11) and physician recommendation (36.36%, 4/11) were the primary drivers. For those with willingness but no action (

conclusionsInfluenza vaccination among older adults in Henan exhibits a "high willingness, low conversion" pattern, with social processes as the strongest driver bridging the intention-behavior gap. A brief educational intervention improved willingness but failed to translate into meaningful uptake, underscoring that knowledge transfer alone is insufficient. We recommend a multi-component strategy that (1) mobilizes family members and community doctors as trusted vaccine advocates; (2) leverages family and village doctor networks to reduce urban-rural disparities; (3) counters the "perceived good health" barrier with age-specific risk communication; and (4) integrates vaccine recommendations into routine care for high-risk groups, particularly frequent outpatient attendees and smokers.