Exploring barriers to influenza vaccine uptake and recommendation among healthcare providers in the community in China: A qualitative study

ABSTRACT

Healthcare providers (HCPs) are recommended for priority influenza vaccination due to their high risk of contracting influenza. HCPs greatly aid in targeted population immunization campaigns. Therefore, understanding the factors that influence HCPs’ decisions to get vaccinated and to recommend influenza vaccination is essential. However, there currently needs to be more evidence on this topic in China. Qualitative interviews using a semi-structured interview method were conducted with 180 HCPs from urban community hospitals and town hospitals in four cities in Shandong Province during August 2023. The interview content was analyzed using thematic analysis to identify the variables impacting the vaccination and recommendation practices of HCPs, as well as their suggestions for improving vaccination services. The results will help support the future development of precise intervention measures as well as focused education and training.

KEYWORDS:

• Influenza
• vaccine hesitancy
• healthcare providers

1. Introduction

The influenza virus is the cause of influenza, an acute respiratory infection. It is a seasonal illness with a quick rapid onset, a high rate of spread, and general susceptibility to infection. It is estimated by the World Health Organization (WHO) that influenza has the potential to cause 3 to 5 million severe cases and 290,000 to 650,000 deaths related to respiratory disease worldwide each year,^1–3 Due to occupational factors and daily influenza virus exposure during disease prevention and control, healthcare providers are particularly vulnerable to influenza infections.⁴ The WHO designates healthcare providers as a priority target group for seasonal influenza vaccination.⁵ According to the Technical Guidelines for Seasonal Influenza Vaccination in China (2022–2023), medical personnel (including clinical, public health, and health quarantine personnel) constitute a high-risk group for influenza and are strongly recommended for priority vaccination.⁶ Nonetheless, influenza vaccination coverage among healthcare providers in China is still low, marked by evident regional and workplace disparities.⁷ Vaccination coverage among healthcare providers in the United States is more than 75%,⁸ and there is still a large gap compared to the influenza vaccination rate of 30% in European countries.⁹ The low influenza vaccination rate among health care professionals (HCPs) in China is mostly explained by the common problem of vaccine hesitancy. However, a lack of evidence supports this theory. Through qualitative interviews, this study investigated the variables influencing HCP influenza vaccination.

Furthermore, we are aware that China still uses the current flu vaccine as a nonvaccination program. In most areas, people need to be vaccinated voluntarily and at their own expense. Health authorities encourage and urge people to get vaccinated, but the national flu vaccination rate is still very low, and it is estimated that the flu vaccination rate in China will still be below 4% in 2021.^10,11 Primary healthcare professionals are the gatekeepers of community health in China. They offer community members public health and basic healthcare services, are dependable counselors and influence community immunization decisions.¹² In Beijing, a study revealed that one major factor causing the elderly living in the community to have fewer vaccinations than they should be is the lack of professional recommendations.¹³ A 2017 study revealed that nearly one-third of pregnant women and 78% of people aged 60 and over say that they would receive a flu shot if recommended by their local healthcare provider.¹⁴ A study of HCPs’ motivations and recommendations for influenza vaccination in six European countries showed that segmentation of attitudes toward vaccine recommendation can help tailor interventions to the underlying motivation and current behavior of HCPs.¹⁵ However, national research evidence on this topic needs to be more comprehensive, and few studies have used in-depth interviews to investigate the factors that influence medical recommendations.

By creating interview questions, this study used a qualitative interview method to gather comprehensive data on the following three topics: (1) Influencing factors of influenza vaccination among HCPs in China; (2) Willingness of HCPs to recommend influenza vaccine and its influencing factors; (3) Suggestions for improving the vaccination services of HCPs.

2. Methods

2.1. Study design

This study used a semi-structured interview method to conduct face-to-face, in-depth interviews with selected respondents. Once the plan was formulated, the experts discussed and conducted the interviews in the field, modified the issues in the earlier interviews, and then discussed with the experts to develop the final interview questionnaire.

2.2. Selection of participants

Purposive and convenience sampling was used to recruit 180 participants. Four cities (Jinan, Qingdao, Jining, and Weifang) were selected in Shandong Province. Finally, we selected six urban community hospitals and three town hospitals in four cities with five respondents. The respondents were screened according to the following criteria:

1. Recommended by the person in charge of the community health service agency or health center

2. Respondents who volunteered to participate.

3. Working in the selected communities during the study period (August 2023).

4. Managers of primary healthcare institutions, clinical diagnosis and treatment doctors, public health doctors, and other healthcare professionals involved in vaccination services.

2.3. Data collection and analysis

The interviews lasted 25–30 min. Informed consent was obtained from the respondent prior to the interview, and the interviews were audio-recorded and recorded. The audio recordings and notes were compiled by the researcher on the day of the interview. The above interview recordings will be numbered. Each respondent had only one unique interview code, consisting of 6 digits of district and county code, 2 digits of township (street) code, and 2 digits of individual code, for a total of 10 digits. During the interview, the respondents were free to express their thoughts, regardless of whether they agreed or disagreed with vaccination or recommended vaccination, and the interviewer recorded them truthfully. All those who refused to be interviewed were asked to record their basic characteristics and the reasons why they refused to be interviewed.

With the participant’s consent, the interview process was recorded, and the interviews were transcribed. The transcribed content was analyzed using NVivo 11 Thematic analysis was used to analyze the content. The focus of thematic analysis is to identify, analyze, and interpret meaningful patterns in qualitative data and to summarize the thematic framework. The analysis involved careful and repeated reading of the transcripts and then coding the text. An iterative process was followed for the thematic analysis to develop a narrative capturing the enablers and barriers for HCP’s influenza vaccine uptake and recommendation. To ensure credibility, the transcripts were identified and coded independently by two researchers, and their annotations were compared and discussed to reach a consensus. Detailed analysis steps include reading the text to capture overall meaning, identifying key phrases and coding them in the software, confirming meaning through peer discussion, categorizing sub themes into different categories, and summarizing major themes. Themes were then developed from sub-themes following the inductive thematic analysis used to analyze the textual data.¹⁶ After discussion and consensus among all researchers (all authors), the theme framework is summarized in Table 1. Demographic characteristics, awareness of key vaccine information, and the vaccine recommendation motivation scale were recorded using EpiData 4.6, and the data were analyzed using SPSS 26.0. A descriptive analysis of the calculation rate and component ratio was used to analyze demographic characteristics and awareness levels of essential vaccine information.

Table 1. Thematic framework.

Theme	Sub-theme
Motivators and Barriers for Healthcare Workers to Receive Influenza Vaccine.	Influenza risk perception Vaccine confidence Accessibility of influenza vaccine
Influence factors on influenza vaccine recommendation by HCPs.	Knowledge. Job responsibilities and division of work. Costs of Doctor-patient communication. Self-vaccination behavior.
Need and proposal.	Strengthen public outreach and education and encourage community participation. Guide and regulate media communication. Improve the mode of vaccination service and enhance the convenience of vaccination.

2.4. Quality control

1. The interview questionnaire was standardized by the Shandong Centre for Disease Control and Prevention. It was discussed and revised by experts until an agreement was reached.

2. The interviewers received comprehensive training on interview content and techniques before conducting the interviews.

3. Local publicity and mobilization were conducted prior to the interviews, support from the local CDC and leaders of grassroots organizations was obtained, and participation and cooperation in the interviews were improved. For those who refused to be interviewed, their basic characteristics and reasons for refusing to be interviewed were recorded.

4. All the interviews were audio-recorded and transcribed. On the day after the interview, the transcript were sorted out by double-entry method, and the records were coded uniformly to ensure the accuracy of data entry. The data were analyzed using the two-person double analysis method to ensure the accuracy of the final result. We stopped gathering data when interviewees could not generate any new themes or points in three sequential interviews (when thematic saturation was achieved).

3. Results

3.1. Participant characteristics

The study comprised a sample size of 180 individuals, sourced from 24 urban community hospitals and 12 town hospitals spanning four cities. A total of 66.7% and 33.3% of the participants were from community hospitals and town hospitals, respectively. The mean age of the HCPs was 36.9 years, and most participants were female (75.0%).According to occupational categorization, 49.4% of the respondents were vaccinated nurses, and 38.3% of the respondents had ≤10 years of work experience. A significant proportion, 68.3%, possessed a bachelor’s degree, and 87.8% reported direct patient interaction in their daily duties. Demographics and other characteristics are illustrated in Table 2.

Table 2. Demographic characteristics.

Group	Number of people	Constituent ratio (%)
gender
Male	45	25.0
Female	135	75.0
age
≤30	45	25.0
30–40	65	36.1
≥40	70	38.9
Work City
Jinan	45	25.0
Jining	45	25.0
Qingdao	45	25.0
Weifang	45	25.0
Type of medical institution
Community Hospital	120	66.7
Town Hospital	60	33.3
Job Category/Position Name
Primary doctor	52	28.4
Vaccination Nurse	89	49.4
Head of community hospital/vaccination clinic	14	7.8
Others	26	14.4
Years of working experience
≤10	69	38.3
10–20	52	28.9
≥20	59	32.8
Highest education level
Junior high school and below	2	1.1
Secondary school/high school and below	6	3.3
College	48	26.7
Undergraduate	123	68.3
Postgraduate and above	1	0.6

3.2. HCPs’ motivation and barriers to influenza vaccination

86% of HCPs were willing to be vaccinated against influenza, and 84% agreed that it should be a yearly vaccination. Through the survey, we found that factors influencing HCPs’ uptake of influenza vaccine included their perception of the risk of influenza, vaccine confidence, and accessibility of influenza vaccine:

3.2.1. Perception of influenza risk

The perception of the risk of influenza disease by HCPs was an influential factor in the decision to vaccinate. However, some unvaccinated HCPs believed that influenza was a common illness that did not pose a major threat to health and that even if they got the flu, they would recover quickly. Some healthcare workers even confused “flu” with “common cold.”

In addition, HCPs’’ subjective assessment of their own risk of influenza infection was an important factor influencing their willingness to vaccinate. Age and level of immunity were factors they considered. They adjusted their willingness to receive the flu vaccine according to the level of immunity at different ages. 65% of the unvaccinated individuals believed that being young and in good health was a sign of good resistance and that there was no need for vaccination.

They considered it “not a big threat” and thought they “recovered quickly and were fine once they were well.” (3707810303)

It does not have a big threat. The flu is not a very serious disease. It is just an infectious disease that happens more often. (3702121102)

Flu is just like a cold, and I do not think it is a big threat to the body. (3701140803)

I think the human body has some immune systems that it can repair itself. (3707810504)

3.2.2. Vaccine confidence

HCPs’ confidence in the influenza vaccine was an important factor influencing their willingness to vaccinate. Three sub-themes related to vaccine confidence were identified from the survey results: perceived benefits and risks of vaccination, influence of other HCPs, and previous vaccination experience.

3.2.2.1. Perceived benefits and risks of vaccination

The survey revealed that the majority of healthcare workers believed that influenza vaccination was useful in preventing influenza and that influenza vaccination was very important for protecting their health and the health of those around them. As a result, they were more likely to be vaccinated against influenza. There were mixed views about the benefits of flu vaccination among some unvaccinated respondents. Doubts about the efficacy of the vaccine and how long it lasts have deterred them. The recommended strains of the flu vaccine vary from year to year, and whether the predicted strain would be the one circulating this year was one of the concerns for HCPs. Some of them said that they wanted to see more data on the vaccine to confirm its effectiveness. Moreover, the survey found that Chinese medicine doctors had less confidence in vaccines, and they were more willing to believe that through traditional Chinese medicine care and strengthening their resistance to fight against “external evils,” they feared that vaccination would destroy their resistance.

“I think it is important and prevention.” (3702020204)

“Having the flu vaccine reduces the risk of infection and increases resistance to the flu.” (3708810201)

When we interviewed a Chinese doctor, he mentioned: “I still believe that Chinese medicine and traditional Chinese medicine are the best way to protect the body.” (3702020205)

“Every medicine has its side effects. Vaccines, too.” (3702121005). Another respondent said, “After receiving the vaccine, I will have a high fever for several days, and I do not think the effect is very good, and then I stopped taking it..” (3701140401)

“I still believe that Chinese medicine and traditional Chinese medicine are the best way to protect the body.” (3702020205)

“After vaccination, it would affect your resistance” (3702020801)

3.2.2.2. Previous vaccination experience

Vaccination confidence in HCPs is influenced by previous vaccination experience. A good vaccination experience is a motivating factor for HCPs to receive influenza vaccination. “I have been vaccinated every year, and it works” (3702020701). Conversely, poor vaccine experience reduces vaccine confidence, leading to vaccine hesitancy. One vaccinator said that she refused the flu vaccine because “I got it once before, and then I got a cold, and the bronchitis was worse than usual” (3707810306). “After you got the vaccine, you had a high fever for a few days, and then you stopped taking the vaccine” (3701140401).

3.2.2.3.Influence of other health providers

Studies have shown that there is a herd phenomenon in vaccination among HCPs and colleagues that can be established through experience exchange and personal influence. This phenomenon affects the confidence and willingness of surrounding people to vaccinate. Those who are just starting and exposed to the flu vaccine are more likely to be influenced by the vaccination experience and beliefs of their peers.

3.2.3. Accessibility of influenza vaccine

Availability of influenza vaccine is an important factor influencing HCP vaccination intentions, including two aspects. One is the affordability of the vaccine, and the other is the timing of the vaccination.

In China, the influenza vaccine is still a non-immunization program vaccine and needs to be administered at one’s own expense. During the interviews, we found that community hospitals or health centers in some areas provided would provide free influenza vaccines for HCPs, and the vaccination rate in free areas (92%) was significantly greater than that in self-funded areas (77%). Respondents in self paying areas cited the cost of vaccines as a major barrier to vaccination. According to our survey, 44% of HCPs believed that vaccines are too expensive. One vaccination nurse also said that “the free or concessionary vaccination rate will be higher than the self-funded vaccination rate” (3707810403).

“Time accessibility is another aspect of influenza vaccine accessibility that influences HCP vaccination behavior. HCPs often miss vaccinations because they are busy and do not have enough time. “To the vaccination center at a fixed time and we missed it when we did not have time to go” (3707810605).

3.3. Motivators and barriers to vaccine recommendation

Of the 180 HCPs surveyed, most would be willing to recommend influenza vaccination. However, 32.2% of those surveyed indicated that they were not willing to take the initiative to make recommendations. The main factors influencing the willingness of HCPs to recommend vaccination are knowledge, job responsibilities and division of work, doctor-patient communication costs, and self-vaccination intention.

3.3.1. Knowledge

HCPs’ knowledge and beliefs about influenza and the influenza vaccine are the key factors that influence their recommended behaviors. Knowledge in this study primarily reflects whether HCPs are confident and able to answer visitors’ questions about vaccination.

However, in our study, we found that HCPs did not recommend influenza vaccination, in part because of a lack of relevant vaccine knowledge, which was mainly reflected in the following: On the one hand, HCPs were not the recommended population for influenza vaccination. According to the survey on awareness of key information about vaccination, such as “Who are the recommended priority groups for influenza vaccination,” only 23.9% answered correctly. In addition, there was a large difference in accuracy between those who recommended and those who did not recommend vaccines, with those who were unwilling to recommend vaccines (17.2%) being less accurate than those who were willing to recommend vaccines (27.0%) (Table 3). Some HCPs mistakenly believed that they would generally only take the initiative to recommend if the visitor was young and resistant. Only 55.0% and 28.3% considered family members and caregivers of infants under 6 months of age and pregnant women, respectively, as recommended priority groups. Some HCPs did not recommend vaccination for chronic diseases or egg allergies. Although the Chinese Center for Disease Control and Prevention published the “Technical Guidelines for Influenza Vaccination in China (2022–2023)” every year, which advised vaccination for high-risk groups, it remained unclear to HCPs, and often had strong subjective judgment. These findings further confirmed the importance of strengthening training and education to improve the HCP vaccine recommendation rate.

Table 3. Knowledge of key information on vaccines.

Question	Recommenders	Non-recommenders	Total accuracy rate	P-value
1. Do you know the Technical Guidelines for Influenza Vaccination in China (2022–2023)?				<.001
Very well understand	14.8%	6.9%
Understand	41.8%	31.0%
Roughly understand	27.0%	41.4%
Heard of it but not understood	18.9%	24.1%
Do not understand at all	0.8%	5.2%
2. The whole population is generally susceptible to influenza			87.2%	<.001
Yes	89.3%	82.8%
No	10.7%	17.2%
3. How does the flu spread?			67.8%	<.001
Droplet spread through sneezing and coughing	99.2%	96.6%
Direct or indirect contact with mucous membranes in the mouth and nose.	91.0%	77.6%
Aerosol transmission	77.0%	63.8%
Insect-borne	14.8%	17.2%
4. Influenza is not contagious during the incubation period			69.4%	<.001
Yes	29.5%	32.8%
No	70.5%	67.2%
5. There is no difference between influenza and the common cold.			79.4%	<.001
Yes	21.3%	19.0%
No	78.7%	81.0%
6. Which of the following are potential risks associated with contracting the flu?			55.6%	<.001
Fever and cough	97.5%	87.9%
Making a chronic underlying	98.4%	89.7%
Pneumonia	99.2%	89.7%
Encephalitis	93.4%	75.9%
Myocarditis	94.3%	77.6%
Cardiovascular events	77.0%	41.4%
Deaths	77.0%	46.6%
7. Who are the recommended priority groups for flu vaccination?			99.4%	<.001
Once a year	100.0%	96.6%
Once every 2–3 years	0.0%	3.4%
8. Who are the recommended priority groups for Flu vaccination?			23.9%	<.001
Healthcare workers	99.2%	84.5%
Home-bound seniors aged 60 years and older	98.4%	94.8%
Infants and children aged 6–23 months	77.0%	69.0%
Children aged 2–5 years	91.0%	77.6%
People with chronic health conditions	82.8%	67.2%
Family members and carers of babies under 6 months old	61.5%	41.4%
Pregnant women	32.8%	19.0%
9. Best time to get the flu vaccine in the North			96.7%	<.001
Any season	2.5%	5.2%
Usually, in autumn and winter	97.5%	94.8%
10. How long does the flu vaccine last?			98.3%	<.001
6–8 months	99.2%	96.6%
At least 5 years	0.8%	3.4%

On the other hand, some respondents indicated that their current knowledge of vaccines was not sufficient to enable them to make vaccination recommendations for some groups with special health conditions. Some health professionals say that patients who have heart stents are generally not recommended if they have serious medical conditions such as cancer, tumors, immune system disorders, blood clots, or kidney failure. One vaccination nurse said: “Their immune system is not as good as normal people and only knows their health status, so I am not sure if they can have the vaccine or I hope there will be more training in this area” (3708810205). One pregnant woman and one woman preparing to become pregnant also refused to receive and recommend the flu vaccine because they had questions about the indications for the flu vaccine and its clinical data. “I am not sure if the vaccine will affect my baby, and there is too little clinical data to know” (3702020204). The respondent mentioned, “I feel that my knowledge is not complete, so I should get more education” (3701140703).

In addition, our survey on awareness of key information about HCP vaccines showed that there are significant differences between recommenders and non-recommenders in understanding the Technical Guidelines for Influenza Vaccination in China (2022–2023), influenza susceptibility, infectiousness, influenza hazards, influenza vaccination information, and durability of protection. The dissemination and training of important information on influenza and influenza vaccines was a key measure to improve the HCP vaccine recommendation rate. According to our survey of HCP information sources, 72% of respondents still trusted the professional training provided by the Health Commission and the CDC the most when seeking information about vaccines. 20% trusted the Internet and the official WeChat public account the most.

3.3.2. Responsibilities and division of work

In China, healthcare providers in primary healthcare units are divided into clinical doctors, who are responsible for basic medical and healthcare services, and public health doctors, who are responsible for public health services such as vaccination. In the survey, we found that most HCPs chose to recommend vaccines based on responsibility and obligation rather than an active recommendation based on recognition of the protective value of vaccines, and they tended to have a more conservative recommendation attitude. One immunization nurse said: “I do not actively recommend vaccines, but if asked, I will take part in the discussion or refer to the relevant doctor” (3708810205).

An important factor that hinders the recommendation of medical personnel is the division of work. HCPs involved in clinical diagnosis and treatment believe that vaccine recommendation should be the responsibility of the vaccinating doctor or nurse, which is not part of their responsibilities, and they are unwilling to become involved in vaccine recommendation. “We are the front-line patients,” said one family physician. “The patients we deal with do not ask us about the flu vaccine.” (3708810605)

3.3.3. Costs of doctor – patient communication

We found that the cost of doctor – patient communication is a factor that discourages HCPs from recommending influenza vaccines. The cost of communication in this study is mainly manifested in two aspects. On the one hand, they are worried about the negative consequences after the recommendation, and they are afraid of causing conflicts between doctors and patients. Some respondents said that patients tend to misinterpret “recommendation” as “marketing” and believe that there are commissions for recommending vaccines. ”Some people will be skeptical and think that they(HCPs) are selling vaccines, so they cannot be too proactive in recommending them” (3702020401). There are too many people in the outpatient vaccination season, and the environment is noisy. When older adult visitors speak in a low voice, they cannot hear them, and when the voice is loud, they think that the service attitude is not good ” (3707810606).

Another aspect of communication costs is the time cost of communication. We found that in some outpatient clinics, there were not enough staff, fewer nurses responsible for vaccination, and not enough time to encourage those who came to visit to get vaccinated. One outpatient clinic manager said, “During the vaccination season, our vaccination clinic is under too much pressure, 200 people per day for two months, and it is simply too busy” (3707810606).

Therefore, when HCPs perceive that their communication skills are inadequate or the time cost of recommendation is too high, they are often reluctant to recommend vaccines to visitors. Strengthening communication training for HCPs, improving their communication skills, and organizing vaccine education activities for community residents are important measures to promote HCP recommendations.

3.3.4. Self-vaccination behavior

Because respondents’ job category may influence their willingness to recommend, we decided to use job category as a stratified factor and use stratified Cochran-Mantel-Haenszel (CMH) test to analyze the effect of self-vaccination on whether or not to recommend among different job categories. Our results showed that HCPs who were self-vaccinated were more likely to recommend influenza vaccine across job categories (p = .001) and that self-vaccination may facilitate willingness to recommend the influenza vaccine (Table 4). “I have been vaccinated every year, and I think the protective effect of the influenza vaccine is better, so I would like to recommend it to others in the hope that they can also be vaccinated” (3702020101).

Table 4. Univariate analysis of the influenza vaccine recommendation intentions of medical staff.

Item	Number of people	Willing to vaccinate	CMH P value
Whether to recommend			.001
Yes	122 (67.8%)	113 (62.8%)
No	58 (32.2%)	43 (23.9%)

4. Suggestions for improving vaccination services by HCPs

Recommendation by community HCPs plays an important role in reducing influenza vaccine hesitancy and improving community vaccination coverage. However, no single strategy can address all aspects of vaccine hesitancy. The study examined the needs and recommendations of HCPs for vaccination services and identified three recommendations for improvement from their perspective:

4.1. Strengthen publicity and education and call for community participation

The majority of respondents said that their organizations provide adequate information and training to residents about influenza or influenza vaccines. “I feel that my knowledge is not too comprehensive, and there should be more training” (3701140703). “We usually distribute leaflets, hold health talks …, but I feel that just ‘the tip of the iceberg.’ ” (3708810803). Some respondents mentioned that the community, as a grassroots organization, is at the forefront of service to people and can be more helpful in advocacy. “Sometimes it is not convenient for us to advocate better for the residents in the clinic. The community should be more convenient” (3702120903).

4.2.Guide and regulate media communication

The formation of cognition through information source channels is bidirectional. As the guardians of society, the media guide the focus of the attention of the public. Vaccine information can be more accurately conveyed, and social misconceptions about vaccines can be reduced through adequate communication. “There are too many different voices in the media,” said one clinic manager. “Reading too much negative information can lead to different perceptions of the vaccine because there are too many different voices in the self-published media.” (3702020205). In the current era of rapid dissemination of information on the Internet, a misconception will be exaggerated and taken as a fact by everyone. Officials should ensure that information about influenza and flu vaccines is correct and that mainstream media are properly guided.

4.3. Improving vaccination service patterns and increasing access to vaccines for high-risk groups

Because of their low immunity, most older people suffer from common diseases. They are an important group for health professionals to recommend for vaccination. Some older adults who live alone usually have little knowledge about the influenza vaccine due to incomplete information. “Still need more paper propaganda, the content close to life, to let the older adults and children see and understand” (3708810502). “Especially in the voluntary clinics, can be issued posters to publicize” (3701140802). Some older adults are bedridden due to mobility difficulties, their children are not around, there are too few door-to-door vaccination services, and they cannot be vaccinated against influenza. “It would be better if there were enough support to increase door-to-door vaccination services” (3702020304)

In addition, students are also a priority group recommended by the guidelines for vaccination. School-age children play an important role in the spread of influenza in schools, homes, and communities. Campus-based immunization is an important way to prevent and control influenza. One community clinic manager said, “Students only have time to go to school on weekends, and schools should adjust the time for universal vaccination”. (3707810606)

5. Discussion

This study used qualitative techniques to investigate the variables influencing HCPs’ recommendations for influenza vaccination. Our study showed that HCP perceptions of influenza risk, vaccine confidence, and access to vaccination services were important factors influencing HCP self-vaccination. At the same time, HCPs who get the flu vaccine themselves are more likely to recommend that patients get vaccinated. Furthermore, medical professionals’ knowledge of influenza and the influenza vaccine presents a dilemma when advising patients to get vaccinated against influenza. The expense of doctor-patient communication is a concern that prevents HCPs from making recommendations. Our findings also suggest that the current national policy environment of separation between healthcare and prevention is more conducive to vaccination. As a result, public health physicians and primary care physicians who perform primary prevention and treatment tasks have a completely different division of work, and this division of responsibility and work also encourages them to have different attitudes toward influenza vaccine recommendations. The information gathered from our interviews will help us understanding of the factors that encourage and hinder influenza vaccination among healthcare professionals and will assist in creating effective interventions.

The influenza vaccination rate among healthcare professionals in this study was 86.6%, indicating that COVID-19 (coronavirus disease 2019) may be connected to this population’s comparatively high vaccination rate.¹⁷ We further explored barriers to vaccination and found that low influenza risk perception and perceived vaccine value were among the barriers to HCP vaccination. It has been reported that risk perceptions of influenza, such as a low level of concern about the disease, a perceived risk of adverse events, and a cognitive or emotional perception of the vaccine, are barriers.^18,19 Many participants thought they would “get well soon” or that their health prevented them from being at high risk of contracting influenza. In addition, some young HCPs believe that timely treatment after infection will not put their health at risk. Several studies have reported the same perception, namely that high-risk groups include older adults and people with chronic diseases rather than healthy adults.^20–23 However, HCPs are a special group; compared to the general population, they are exposed to a greater risk of influenza in the workplace and are 3.4 times at risk compared to healthy adults.²⁴ Even young physicians are at risk for influenza. The results from a study in Arabia showed that 526 medical workers with an average age of 34.5 ± 9.5 years were diagnosed with influenza.²⁵ Healthcare workers with influenza also increase the risk of nosocomial transmission. Consequently, immunization against influenza is highly advised for all healthcare personnel, particularly for those who frequently interact with high-risk populations.

One main obstacle to vaccination, according to one study, is people’s ignorance of influenza vaccines and lack of common sense.¹⁸ A European study found that HCPs working in primary healthcare settings needed to have adequate knowledge and were, therefore, reluctant to provide vaccination,²⁶ similar to that the findings of in the present study. Properly understanding the efficacy and side effects of vaccines and building confidence in vaccines is an important way to increase vaccination rates among HCPSs. Since HCPs are relatively new to the medical field, they are particularly vulnerable to the influence of their colleagues.

In terms of vaccine accessibility, vaccination intentions are significantly influenced by the cost of vaccination. HCPs in free vaccination areas (92%) were more willing to receive influenza vaccines than those in self-funded vaccination areas (77%). A survey also showed that the availability of free vaccination in healthcare facilities has a strong influence on healthcare workers’ willingness to receive the influenza vaccine.⁸ When administering influenza vaccines, “time availability” is an important consideration for HCPs, consistent with the results of the 2018–2019 online survey on influenza vaccination among healthcare workers in China, where 51.4% of respondents reported that “too busy” was the main barrier to influenza vaccination.²⁷ The influenza vaccination rate among HCPs can be raised by combining the free vaccination policy with the planning of multiple centralized vaccination programs to promote accessibility.

According to our research, one of the main reasons why HCPs are reluctant to recommend is a lack of understanding regarding influenza and influenza vaccinations. The accuracy rate of HCP knowledge of key information about influenza and influenza vaccine was only 6.1%, and their knowledge needs to be improved. Only 47.9% of respondents to our study said they understood the “Technical Guidelines for Influenza Vaccination in China,” despite the Chinese Center for Disease Control and Prevention publishing them annually since 2018 to direct community efforts. Therefore, relevant departments should organize HCPs to conduct professional training and evaluation on influenza vaccination technical guidelines and other documents, strengthen the dissemination of knowledge related to influenza and vaccination, and improve awareness among them, which coincides with the training needs of HCPs in our interview. When HCPs are faced with more complex vaccine counseling for individuals with medical issues, it becomes more difficult for them to offer professional immunization counseling as public knowledge of vaccination increases.

The main groups recommended for priority vaccination are older adults aged 60 years and over living at home (97.2%), HCPs (94.4%), and children aged 2–5 years (86.7%). The groups with the lowest recommendation rates included individuals with chronic conditions (77.8%) and infants aged 6–23 months (74.4%). Family members and caregivers of babies under 6 months of age (55%) and pregnant women (28.3%). In addition, 82% of HCPs said they would not voluntarily recommend influenza vaccination to healthy young adults. HCPs are also reluctant to administer the vaccine to pregnant women because of concerns about adverse effects on the fetus. During the 2017–2018 influenza epidemic, the influenza vaccination rate among pregnant women in China was less than 2%.²⁸ Pregnancy is still mentioned as a contraindication in certain influenza vaccine formulations offered in China, which may be the cause of the low recommendation rate for expectant mothers.

Additionally, there may not have been sufficient safety evaluation data on influenza vaccination in pregnant women in the past. However, foreign research data on inactivated influenza vaccines show that influenza vaccination is safe for pregnant women and can reduce the preterm birth rate.^29,30 Thus, it is imperative that the safety and protective effects of the influenza vaccine for expectant mothers be further investigated and that the safety monitoring system be further improved once the vaccine is available for sale. In the context of the influenza epidemic situation and the strategy to prevent and control comorbidities, HCPs should increase their understanding of family members and carers of infants under 6 months of age and those at higher risk of complications from influenza, according to the guidelines. To raise HCPs’’ awareness of immunization by key and taboo groups, the training of relevant population units with the low recommendation rates listed above should also intensify their training. Since influenza affects the entire community, it is advised that young people be protected against the illness to the greatest extent possible.

According to our research, the majority of HCPs only proactively advise against influenza vaccination only before the onset of the illness. Our survey was conducted in mid-August, which is close to the optimal time for vaccination, but some respondents still said they had yet to receive any publicity or training. The pressure on outpatient services has increased significantly since the start of the vaccination season, which also suggests that relevant health departments should plan for influenza vaccination publicity, prevention, and control, as well as training and education for grassroots health care providers, which will give HCPs more time to perform effective community mobilization and rotation.

GPs believed that the immunization nurse should be in charge of recommending the vaccine in terms of the division of labor. Patients were more likely to trust the GP’s recommendation than the immunization nurse, which is similar to the findings of several previous studies.³¹ The health intervention role of community outpatient clinics can only be realized by strengthening the interface between the work of GPs and immunization nurses and improving cooperation between them. Hence, we advise public health agencies to include primary care physicians in their campaigns for public awareness and education ahead of the flu season.

Students and older adults are the most important groups identified by HCPs for the prevention and control of influenza in the community. The high infectivity of the influenza virus, among other factors, makes it capable of causing a widespread epidemic in crowded settings such as schools. As the key to preventing influenza on campuses, relevant departments should arrange for uniform vaccination of students to avoid the problem of needing more time to vaccinate on weekends due to curriculum pressure. Studies have shown that vaccination is 58% effective in preventing influenza in older adults.³² As a priority group for vaccination, older adults are also the main target of recommendations by HCPs. However, due to the aging population, the number of empty nesters in China is increasing rapidly, and most older adults have little understanding of influenza and the influenza vaccine due to limited information, physical reasons and inconvenient activities. The government can appropriately increase the number of outpatient clinics or institutions in the area that can provide door-to-door services and further improve vaccination services for older adults by further optimizing educational materials and educational forms.

Serving people as the smallest unit of social governance in China is the responsibility of the community. In terms of vaccine promotion, health service centers should strengthen the joint popularization and promotion of the flu vaccine in the community. Through banners, posters, leaflet distribution, questionnaires, and on-site consultations, they can answer community members’ questions about influenza. They can also actively support community-wide influenza vaccination participation at the same time. The media is one of the most important places for people to become informed. However, those who oppose vaccination are more likely to post anti-vaccination information on social media.³³ Conversely, exposure to an excessive amount of unfavorable information regarding vaccines might also lead to vaccine reluctance. For there to be a beneficial effect, officials ought to give pertinent media the right kind of direction.

This study has some limitations. First, selection bias may have been introduced by purposeful sampling,³⁴ which prevents the findings from being generalized to the whole population. However, the selection of a specific population may help us to understand better health workers’ vaccine hesitancy and motives for recommendation. In addition, the choice of data collection in community health centers versus HCWs in township health centers was limited. We will extend an invitation to CDC officials and vaccine policymakers to participate in additional research aimed at enhancing primary healthcare providers’ willingness to promote influenza vaccines, as well as their capacity to administer vaccination services and attain the objective of high vaccination coverage.

6. Conclusions

In this study, the immunization rate against influenza among healthcare professionals was 86.6%, while the recommended rate was 67.7%. Our study explored the factors that influence healthcare providers’ flu vaccination and recommendations, providing evidence to support the creation of targeted interventions in the future. To facilitate targeted education and training by relevant departments, this study presents the current understanding of influenza and influenza vaccination among HCPs at the local level. It also emphasizes the need for HCP education and training. The current vaccine service system should change from a clear division of labor, emphasize the significance of vaccine recommendations by clinical doctors, and incorporate them into the education and training of vaccination services. By supporting HCPs’ vaccination demonstrations and recommendations, fostering community-media collaboration, and effectively disseminating knowledge about influenza and vaccines, we can improve vaccination services for high-risk groups and increase the overall vaccination rate.

Author contributions

Yuwei Liu were responsible for analysis and interpretation of data, statistical analysis and writing the article. Ti Liu and Mingxiao Yao were responsible for analysis and collection of data. Zengqiang Kou and Renpeng Li were responsible for providing concept and design, study supervision and obtaining funding.

Informed consent statement

Informed consent was obtained from all subjects involved in the study.

Disclosure statement

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

Additional information

Funding

This work has been supported by Shandong Provincial Natural Science Foundation, [ZR2020MH338 and ZR2021MH372].