https://orcid.org/0000-0002-2112-7292
ABSTRACT
The United Nations reported that the mortality risk of Corona Virus Disease 2019 (COVID-19) is five times higher in the elderly than the global average. Although the COVID-19 vaccine effectively prevents infections and reduce mortality among the elderly, vaccine hesitancy among the Chinese elderly poses a significant threat. This study, utilizing the “Confidence, Convenience and Complacency (3 Cs)” vaccine hesitancy model, aimed to explore factors contributing to vaccine hesitancy among the Chinese elderly and assess national countermeasures and potential improvement approaches. Thirteen elderly with vaccine hesitancy and eleven vaccine-related staff participated in semi-structured interviews. Thematic analysis revealed three key determinants of vaccine hesitancy among the elderly: perceived low threat of COVID-19, lack of confidence in COVID-19 vaccine, and poor accessibility to vaccination. China has implemented strategies, including advocacy through diverse channels, joint multi-sectoral promotion vaccination, and enhancing ongoing vaccination services. Recommendations from the vaccine-related staff emphasize improving vaccine awareness among the elderly, and prioritizing the vaccination environment and process. The study underscores the importance of targeted vaccination promotion programs addressing hesitation reasons to improve vaccination rates. Furthermore, existing countermeasures can serve as a foundation for enhancing vaccination strategies, including improved publicity, administration, and management approaches.
Introduction
Vaccines are a well-established and cost-effective tool in public health, especially in preventing infectious diseases such as Corona Virus Disease 2019 (COVID-19).Citation1 The threat of COVID-19 is severe to the elderly, with those aged 60 and above at significantly higher risk of severe illness and deathCitation2 – The United Nations reported that the mortality risk of COVID-19 is five times higher in the elderly than the global average.Citation3 Systematic vaccination against COVID-19 has demonstrated effective in reducing infections, morbidity, and mortalityCitation4 and contributing to an improved quality of life.Citation5 Despite Chinese authorities’ concerted efforts to vaccinate the elderly since April 2021, millions remain unvaccinated or incompletely vaccinated as of December 2022. This highlights a common problem of vaccine hesitancy among the elderly, characterized by delayed acceptance or outright refusal to be vaccinated despite the availability of vaccination services. This phenomenon is not limited to the Chinese elderly, but is also a global problem, as survey data reveal it exists across various populations.Citation6–11 This problem may impedes coverage of vaccination and the establishment of herd immunity, affecting the achievement of anti-pandemic efficacy.Citation12 Understanding the factors contributing to this hesitancy is essential for developing targeted public health intervention strategies.
The causes of COVID-19 vaccine hesitancy have been investigated, revealing that factors at the societal level, such as vaccine-related misinformation, complex political environments, and deeply ingrained cultural values, contribute to this phenomenon.Citation13 Additionally, age, gender, ethnicity, economic income, and physical health status play crucial roles in influencing vaccination acceptance.Citation14 Among the elderly, a particularly high-risk group, previous studies on vaccine hesitancy have revealed variations attributable to socioeconomic factors, cultural differences, policies, vaccination strategies, and promotion efforts. For instance, a study conducted in Switzerland found that vaccination decisions were influenced by disease prevalence, personal health knowledge, and past experiences.Citation15 In Australia, hesitancy among Aboriginal populations was associated to concerns about side effects, negative feedback on social media, and distrust in the government and healthcare workers.Citation16 In Hong Kong SAR, China, the elderly expressed concerns about infection risk from healthcare workers, skepticism about the government’s countermeasures to adverse vaccine events, and the influence of toxic cultural beliefs.Citation17 Applying the findings of these studies directly to the mainland Chinese context presents challenges due to differences in social systems, cultures, and the COVID-19 defense policies.Citation18 Despite studies in mainland China, most were conducted before the implementation of the free vaccination policy for the elderly. No studies have been found to investigate vaccine hesitancy and reasons for it among the elderly post-policy implementation. Changes in vaccination delivery policies can lead to shifts in attitudes.Citation19 Furthermore, previous studies have been primarily quantitative, limiting the in-depth exploration of various factor.Citation20 Therefore, conducting qualitative interviews with the elderly is essential to comprehend the reasons for vaccine hesitancy among the Chinese elderly.
In response to the extensive demand for COVID-19 vaccine and efficiently cater to the elderly, China has reformed the traditional vaccination system, which included the establishment of temporary vaccination points, on-site and home-based vaccination services. Moreover, numerous healthcare workers from community health service centers and hospitals underwent extensive training and were subsequently assigned the responsibility of administering COVID-19 vaccine. Importantly, these added responsibilities have been newly integrated into their daily duties.Citation21 To comprehend the challenges and successes associated policy implementation so as to provide valuable insights for the efficient execution of similar large-scale policies in the future, it is necessary to explore the first-hand experiences of those involved in vaccination services.Citation22,Citation23 Previous studies have investigated the vaccination knowledge, attitudes, practices or factors affecting the implementation in healthcare workers. DumiCitation24 summarized findings from Croatian physicians, emphasizing that doctors’ communication with the public is influenced by their prior work experiences, potentially resulting in ineffective communication. Striking a balance between explanations and vaccination targets is crucial. Studies have primarily focused on vaccine-related staff, assessing their willingness to receive COVID-19 vaccine and identifying reasons for hesitancy.Citation25–27 However, owing to their professional knowledge, role as “opinion leaders”, and their crucial role in promoting vaccination for the elderlyCitation28 – as of 2023, the National Health Commission’s Bureau of Disease Control and Prevention of the People’s Republic of China reported that, with the coordinated efforts of the government, the coverage of the elderly receiving COVID-19 vaccine within three months had reached 96.1%Citation29 – this underscores the importance of investigating the experiences and perspectives of these staff to inform more precise and effective interventions aimed at further boosting vaccination rates.
The World Health Organization’s Strategic Advisory Group of Experts on Immunization (SAGE) established a working group on vaccine hesitancy in 2011, introducing the “3 Cs” model to evaluate attitudes toward vaccines.Citation30 This model provides a framework for research and analyses that facilitates the development of appropriate strategies, encompassing three dimensions: Confidence, reflecting the level of trust in vaccine safety, efficacy, and the overall vaccine delivery system, including health service district agencies and healthcare professionals; Convenience, relating to the ease of access to vaccines, including factors such as availability, affordability, willingness to pay, and geographic accessibility; and Complacency, pertaining to people’s perceptions of the necessity, importance, and risks associated with vaccination. This study based on the “3 Cs” model aims to conduct qualitative interviews with the elderly who have not completed COVID-19 vaccine to identify the factors contributing to vaccine hesitancy. Additionally, we will examine the perspectives and experiences of vaccine-related staff, focusing on their countermeasures and encounters with vaccine hesitancy among the elderly. The findings from this study will not only provide insights to enhance and promote vaccination among the elderly, but also valuable knowledge to prevent similar public health emergencies in the future, ultimately improving the efficiency of emergency responses and safeguarding public health during potential outbreaks.
Methods
Settings and participants
From May 2022 to June 2023, we employed purposive sampling in three districts of Changsha City and one district in Shaoyang City, Hunan Province, China. In 2022, Hunan Province ranked ninth in national GDP, with Changsha City ranked first and Shaoyang City ranked eighth out of fourteen cities in Hunan Province. Participants were purposefully selected for in-depth interviews based on the following criteria: (1) the elderly aged 60 years or above who exhibited hesitancy toward COVID-19 vaccine despite meeting the eligibility criteria, or delayed vaccination for over a year; (2) staff involved in activities related to COVID-19 vaccine, such as vaccine promoters, vaccinators or administrators. Participants selection was guided by factors such as age, education, and economic level of the elderly, as well as the work position, years of experience and role of the staff. The strength of qualitative research is the quality of data, which compensates for the small number of participants.Citation31 According to Morse,Citation32 through data saturation, comprehensive theories can be developed.
Data collection
Between May and October 2022, we designed an interview outline based on the “3 Cs” model to investigate reasons for COVID-19 vaccine hesitancy among the elderly. The interview outline was refined through expert consultation and a pre-surveys. The final interview outline is shown in Appendix-A. Participant were recruited in townships and villages, or through recommendations from previously interviewed individuals.
To present a comprehensive overview of Chinese countermeasures against vaccine hesitancy and suggest potential improvements, we developed an interview outline for vaccine-related staff. This was based on literature review and expert consultation (see Appendix-B). Between November 2022 and June 2023, the researchers invited individuals including township healthcare workers, vaccinators at community health service centers and township health hospitals, and administrators at the Centers for Disease Control and Prevention.
As the investigators had opportunities to approach every eligible participant, they purposely selected and explained the background, content, benefits and risks of our study to eligible interviewees. Qualitative data were collected through face-to-face, semi-structured, one-to-one in-depth interviews conducted by researchers who were postgraduate student with professional training. After obtaining informed consent from participants, the interviews took place at agreed times and places, usually choosing the office of a community senior center or the participants’ homes. The design was intended to ensure that the participants were able to express themselves fully without pressure or distraction. Before the interviews, formal written consent was obtained from all participants and demographic data were collected. Rigorous measures were taken to minimize interview bias. Firstly, the interviewers maintained neutral and objective and avoided any influence on the participants to minimize the interviewer effect. Secondly, prior to the interviews, the purpose and methodology of the research were clearly communicated to participants, emphasizing confidentiality and encouraging truthful responses to reduce social desirability bias. Finally, the interviews followed a pre-determined outline that prevented leading and purposeful questions to reduce confirmation bias. The interviews lasted between 30 and 50 minutes per person and were recorded. Participants received a subsidy of 7.80 USD as a token of appreciation. Transcriptions were completed within 24 hours and shared with participants within 3 days to verify content accuracy. This study was approved by the Medical Ethics Committee.
Data analyses
The qualitative data was analyzed using the thematic analysis method outlined by Braun and Clarke.Citation33 Initially, the interviews were transcribed verbatim into a Word document. Additionally, all transcripts were read through at least three times to allow the researcher to familiarize with the data. Subsequently, preliminary codes were generated by segmenting and coding the data verbatim. The results of the preliminary coding were then analyzed and the codes were synthesized into themes. These themes were then reviewed and refined to align with the codes that comprised them. Each theme was named based on the clearest aspect of the data. For data analysis, the qualitative data were processed using NVivo2.0.
In conducting the qualitative interviews and thematic analysis, we used a series of strategies to ensure theoretical saturation of the data. As the interviews progressed, we iteratively analyzed the data collected in depth. When it was apparent that new data failed to contribute additional insights or perspectives, this indicate that the data saturation had been reached. Given the limited number of participants, we prioritized extracting diverse and in-depth information from each participant. Considering the intricate conceptual background of the interviews, we used a semi-structured interview method with an interview outline to guide the interview process. However, this outline was adapted for each interview to incorporate the phenomena mentioned by the preceding interviewee and to design questions for the subsequent participant. This iterative process, combined with repeated data analysis, ensured a comprehensive and accurate understanding of each main themes and sub-themes. Two researchers independently reviewed the data and conducted methodological testing throughout the analysis process. One researcher initially analyzed approximately two-thirds of the data and the other analyzed the remaining one-third. Both researchers reached a consensus that theoretical saturation had been reached.
This article adheres to the Standards for Reporting Qualitative Research Checklist (see Appendix 2).
Results
We conducted interviews with3 elderly individuals who expressed vaccine hesitancy about the COVID-19 and1 vaccine-related staff (see Appendix 3 for more details about the participants). The interview ranged from8 to 50 minutes. The results were mainly categorized into three aspects: the reasons behind the reluctance of the elderly to vaccinate against COVID-19; strategies to address vaccine hesitancy of the elderly; and potential measures for improvement in the future. shows the themes identified through the qualitative analysis in this study.
Table 1. Summary of the qualitative framework analysis.
The reasons behind the reluctance of the elderly to vaccinate against COVID-19
Perceived low threat of COVID-19 (Complacency)
It is very unlikely to be infected
Some elderly individuals expressed a low threat of COVID-19 due to their limited exposure to infected individuals in their neighborhood. Consequently, they considered their risk of COVID-19 infection to be very low, leading them to forgo vaccination. On the contrary, others with high concern about the global and domestic pandemic situation choose to get vaccinated as the outbreak escalated, especially when mortality was reported in Shanghai. Additionally, learning about the correlation between age and infection and severity, they emphasized the importance of considering vaccination.
The outbreak situation in Hunan province appears to be well-managed. As long as there are no confirmed positive cases within our household, there is no need to be concerned. (#7)
However, in Shanghai, numerous severe cases and deaths have been reported among elderly individuals who have not received the vaccine. This unfortunate situation has instilled fear in us, prompting us to seek assistance from the local community health center. Subsequently, they kindly offered to come to my house-door and administer the vaccination for me. (#4)
People who believe they do not need vaccination
Some participants believed that, given their age, COVID-19 vaccine was unnecessary for preventing infection. Some even expressed the notion that regular alcohol consumption could act as a disinfectant and provide sufficient protection, thus making an additional COVID-19 vaccine unnecessary.
I am already 90 years old, what is the point of me getting vaccinated. (#7)
We, who drink regularly, are not afraid of the virus; drinking can disinfect. I do not have any desire to get vaccinated.(#8)
Lack of confidence in COVID-19 vaccine (Confidence)
Questioning the protective effectiveness of COVID-19 vaccine
Certain participants expressed reservations about the protective effectiveness of domestically provided vaccines, particularly those offered for free. Some questioned the ability of these vaccines to provide adequate protection when compared to their foreign counterparts. Instances of vaccinated individuals still contracting the virus raised doubts about the overall effectiveness of the vaccine. Moreover, confusion regarding the vaccination process and the distinction between booster shots and regular vaccinations emerged as additional concerns. They raised concerns about whether booster shots merely compensated for the perceived ineffectiveness of regular vaccinations.
Do vaccines actually work, huh? We are a bit skeptical. There is a six-month gap between booster shots, will it always be six months? Is the vaccine really effective? Does it actually enhance our immune system and cellular countermeasures? I am a bit hesitant about getting vaccinated, just to avoid any potential risks of getting the wrong one. (#1)
Questioning the safety of COVID-19 vaccine
Some participants expressed concerns about the safety of COVID-19 vaccine, citing the rapid development, small test populations, and varying dosing intervals as indicators of immaturity. While they could not definitively attribute symptoms to vaccine adverse reactions, reports of individuals experiencing coughing, muscle aches, and blood in the stool made them apprehensive. Participants, particularly those with medical backgrounds, acknowledged the low incidence of adverse reactions but emphasized that “low” does not equate to “none.” Some speculated that the vaccine was introduced to younger age groups due to its potential unsuitability for the elderly.
I live by myself, and I am concerned about possible side effects after getting vaccinated. It is a bit scary to be all alone if I have a rough night. My main worry is feeling uncomfortable right after getting the shot. If I skip getting vaccinated, I will likely be okay since I do not go out much anyway. (#11)
Poor accessibility to vaccination (Convenience)
Challenges arising from location and electronic devices
Nearly all participants faced difficulties related to the distance of vaccination centers and the intricacies of using electronic devices in the COVID-19 Vaccine Service. These challenges, including mobility issues, navigating subway lines, and the requirement to scan health codes and trip codes when entering public spaces, acted as significant barriers. Furthermore, their hesitance to disrupt their children’s routines or inconvenience others posed it challenging in independently visiting vaccination centers for inquiries.
It can be challenging to navigate all these digital devices, especially when everything seems to revolve around WeChat. They keep asking me to scan this code and that code, and honestly, I can not make sense of it all. It is really frustrating for me, but I understand it is not their fault. It is just the way things are, and they have their own responsibilities to fulfill. (#7)
Challenges stemming from limited information access
Participants expressed reservations about accepting new types of vaccines, citing factors such as slower reading speeds, vision limitations, and restricted access to information. These challenges hindered their ability to gather relevant information about COVID-19 vaccine.
If you want me to get the shot, just tell me when and where. Does the vaccine actually work? How long will it protect me? Right now, there are so many unknowns. We see snippets of information on TV, but they never really give us the full picture. (#1)
Strategies to address vaccine hesitancy of the elderly
Advocacy through diverse channels
Utilization of advertisements, radio or telephone for publicity
In an effort to enhance awareness of COVID-19 vaccine among the elderly, the health sector employed a range of strategies, including advertising campaigns, mobile broadcasting, and direct phone outreach targeted at individuals expressing hesitancy. These efforts aimed to address concerns and provide necessary information about the vaccine.
If the elderly can understand, we will just give them a call to communicate instead of going to their home. If we call them and they still refuse to get vaccinated, then we will have to visit them in person and handle the situation, or something like that kind of thing. (#16)
Face-to-face publicity, vaccination sites and door-to-door campaigns
Aligned with the National Basic Public Health Service, township health hospitals and community health service centers were mandated to provide free medical checkups for individuals aged 60 and above. To leverage this existing infrastructure, primary healthcare workers proposed the establishment of information booths near these medical checkup points. The aim was to raise awareness about COVID-19 vaccine among the elderly and provide them with vaccine-related information. Moreover, to mobilize public engagement, staff members at vaccination centers actively encouraged those elderly individuals who had already been vaccinated to become advocates themselves. In cases where the elderly were not actively seeking vaccine-related information and were unwilling to engage in phone communication, public sector staff in townships, with the consent of the individual or their children, conducted home visit to provide vaccine education and address any concerns.
We conducted medical check-ups for the elderly in the community and implemented visual aids, such as electronic screens and banners, in prominent areas of each community to enhance visibility and promote awareness. Our staff members stationed at these locations provided consultations for the elderly. (#22)
Joint multi-sectoral promotion vaccination
Collaboration between township or community offices and health-care institutions
Various government departments collaborated to promote vaccination. Township governments, neighborhood offices, and healthcare institutions formed partnerships to disseminate vaccine information, establish temporary vaccination sites, and organize door-to-door medical teams. The CDC played a pivotal role in training staff, reporting vaccination data, and distributing vaccines.
Our work involves the entire community working together, including us at the CDC. We collaborate and coordinate to carry out vaccination campaigns and provide public education. Each of us has specific roles and responsibilities that contribute to the overall effort. (#21)
Proper handling of negative vaccine-related incidents
In cases of suspected abnormal vaccine reactions, healthcare professionals gathered relevant information and reported it to the CDC. A municipal medical expert group thoroughly examined the situation to determine whether it could be attributed to an adverse reaction from the vaccine. The township government or neighborhood office is responsible for managing any necessary follow-up actions.
We are not qualified to decide whether this is an abnormal reaction or not, but we need experts, and we have a team of experts in the city. (#21)
The health centers are dedicated to carrying out the vaccination work, and we aim to alleviate any concerns they may have. We take on the responsibility of handling any conflicts that arise. (#24)
Enhancing ongoing vaccination services
Implementation of elderly-friendly measures: streamlining the process
To minimize waiting times for the elderly, both township health hospitals and community health service centers have implemented various measures. Firstly, they have established a dedicated “green vaccination channel” specifically designed to cater to the needs of the elderly. This channel simplifies the vaccination process by conducting a comprehensive assessment of the elderly’s physical condition, administering the vaccine, and providing post-vaccination observation. For the elderly facing mobility challenges or those who prefer not to visit vaccination centers, medical staff have established centralized vaccination points within township or community senior activity centers. In cases where the elderly exhibit reluctance to receive the vaccine, a specialized medical team, consisting of public sector staff, vaccinators, and doctors from tertiary care hospitals, will visit their homes with the elderly’s or their children’s consent. The team educates them about the benefits of vaccination, and a doctor from the tertiary care hospital assesses their health condition. If deemed eligible and willing, the vaccinator administers the vaccine on-site, ensuring their well-being during a 30-minute post-vaccination period.
In some instances, the vaccination process is centralized within the community, often within an activity center. For elderly individuals who are unable to move, we provide vaccination services directly at their homes. (#23)
Potential measures for improvement in the future
Improving vaccine awareness among the elderly
Enhancing the effectiveness and safety promotion of vaccine
The participants underscored the significance role of bolstering awareness regarding the effectiveness and safety of new vaccines to elevate acceptance levels. Furthermore, they stressed the importance of educating the public about the significance and advantages of receiving vaccinations.
There is still a need to promote vaccination mainly for the elderly with basic diseases, and there is still a need to consistently explain the benefits of the vaccine. (#20)
Timely resolution of adverse vaccine-related incidents
The participants highlighted the importance of swift and transparent communication from relevant authorities when addressing adverse events associated with vaccines. This is indispensable for mitigating the spread of concerns related to adverse effects among the elderly. Furthermore, healthcare professionals must approach the interpretation and discussion of vaccine-related adverse reactions with care when engaging with the elderly.
Many individuals hear stories about others experiencing adverse reactions, such as fainting or having a stroke after receiving the new vaccine. However, these are often isolated incidents. This underscores the importance of raising awareness and providing accurate explanations. Healthcare workers like us should also understand this and convey during our conversations that these instances may not be directly connected to vaccines. (#18)
Optimizing the vaccination environment and process
Enhancing clarify and simplify in the vaccination process
The participants underscored the importance of empathizing with the elderly and actively addressing the challenges they encounter during the vaccination process, including long queues, complex vaccination procedures, and post-vaccination discomfort. By adopting a perspective that, errors the experiences of the elderly, improvements in vaccination services can be realized, ultimately alleviating the concerns of the elderly.
It is akin to treating them as if they were our own parents, helping them with various tasks and scheduling their health check-ups. These measures would undoubtedly be beneficial. (#17)
Discussion
To our knowledge, this study is the first attempt to investigate the reasons for vaccine hesitancy among the elderly who have not yet completed a full or booster COVID-19 vaccine, following the implementation of China’s free vaccination policy for them. Furthermore, we also conducted an innovative examination vaccine-related staffs after a significant increase in vaccination rates among the elderly, in order to identify effective strategies for reducing vaccine hesitancy in the elderly. Our data analysis revealed key factors contributing to vaccine hesitancy among the elderly within the 3 Cs model: Complacency – perceived low threat of COVID-19 and believe in not needing vaccination; Confidence – lack of confidence in the vaccine’s efficacy and safety; and Convenience – accessibility challenges due to distance, reliance on electronic devices, and insufficient vaccine information. In response, vaccination-related staff emphasize government actions such as comprehensive public awareness campaigns, collaborative efforts, and continuous improvements in vaccination services. Moreover, the staff has concluded that government and societal efforts should focus on enhancing the elderly’s understanding of vaccines, optimizing the vaccination environment, and refining the overall vaccination process to improve their preparedness and response to future public health emergencies. This study not only offers targeted recommendations for promoting COVID-19 vaccine among the elderly but also provides a guiding direction for policymakers, health administrators, and the public in facing similar outbreaks in the future. By empowering the elderly to actively participate in preventing and controlling public health emergencies, this research contributes to the broader goal of safeguarding public health and safety.
The elderly exhibits a diverse range of perspectives regarding the necessity of COVID-19 vaccine. Some participants perceive a low threat of contracting the virus, while others have underlying medical conditions that raise concerns about their suitability for vaccination. These findings are consistent with previous research,Citation15,Citation34 which emphasized the influence of risk perception, threat level, and adaptive coping styles on adherence to preventive measures.Citation35–37Notably, individuals in good health may not perceive the need for vaccination.Citation8 Interestingly, public sector workers did not acknowledge that the elderly might not perceive the need for COVID-19 vaccine due to a perceived lower threat level. This discrepancy may stem from a lack of effective communication between the staff and the the elderly, leading to a misinterpretation of the reasons behind vaccine hesitancy.
A prevalent issue among many the elderly is skepticism regarding the safety and efficacy of COVID-19 vaccine, a sentiment that resonates with previous studies.Citation7,Citation20 The shortage of time from development to production of vaccinesCitation10 and the lack of transparency in the vaccine evaluation process lead to doubts about the introduction of new vaccines and vaccination procedures. Furthermore, media coverage of adverse vaccine events blurs the lines between scientific evidence and misinformation, thus amplifying skepticism toward official reports.Citation19 The internet also plays a significant role in rapidly disseminating negative vaccine-related events and anti-vaccine rhetoric, contributing to the proliferation of vaccine hesitancy.Citation38 Studies have shown that problematic social media use can seriously affect vaccine acceptance.Citation39 Previous findings have shown that both perceptions of COVID-19 and beliefs about vaccination may influence vaccination behavior.Citation40 To improve awareness of COVID-19 among the elderly, China has implemented a range of strategies, including extensive advertising campaigns, outreach through radio and telephone, and informative presentations at various outreach points or through door-to-door approaches. Notably, vaccination staff have observed that the elderly are more likely to trust recommendations from medical experts and local community staff, highlighting the importance of endorsements from trusted individuals when encouraging vaccination.Citation38,Citation41,Citation42 In addressing public health emergencies, the public sector can serve as a critical bridge by facilitating transparent dialogue between the public and experts. This can be achieved through the utilization of cyberspace analytic, social media, and reliable information dissemination channels.
The motivation of the elderly to vaccinate is influenced by the convenience of vaccination services. SiuCitation17 also found that the elderly’ perceptions of the accessibility of community health services and the adequacy of information provided by healthcare providers have a significant impact on their attitudes and behaviors toward vaccination. In China, the promotion of vaccination has been achieved through collaborative efforts across multiple sectors. Measures such as establishing green lanes, setting up centralized vaccination points in villages/communities, and providing door-to-door assessment and vaccination services have effectively enhanced the accessibility of vaccination services. Moving forward, it is advisable to address the multifaceted needs of the elderly and establish age-friendly vaccination processes as early as possible. Additionally, strategies to enhance vaccine providers can be implemented, such as allocating sufficient government funding, prioritizing vaccination for the elderly in political agendas, and coordinated efforts to improve vaccination planning. Furthermore, public sector workers have observed that promoting vaccination is less challenging in rural areas compared to urban settings. It would be beneficial to gain insights into different contexts and identify the factors contributing to these differences.
During public health emergencies, the prioritization of vaccination for vulnerable individuals, particularly the elderly with underlying health conditions, becomes paramount. Considering that trust in the healthcare system mediates widespread trust and willingness to receive COVID-19 vaccine,Citation41 administrators should recognize the importance of establishing a trust relationship between the general population and the healthcare system. This can be achieved through more transparent and professional communication, health education, and addressing vaccine-related stigmas. Strengthening trust in the healthcare system will help enhance digital monitoring and regulation, preventing the public from making uninformed vaccine decisions and facilitating the uptake of new vaccines.Citation43 Healthcare providers and physicians remain the most trustworthy sources for vaccine recommendations. Relevant professionals should support and encourage the elderly, addressing their concerns to promote vaccine acceptance.Citation19
There are several limitations to this study. Firstly, while we made efforts to approach all eligible participants, not all of them accepted our interview invitations. Additionally, we did not collect demographic information from those who refused to participate, nor did we gather data on the reasons for their refusal. However, it is important to note that qualitative studies prioritize information richness rather than sample size, and data saturation is a key factor in obtaining meaningful results. Despite these limitations, we believe that our study still provides comprehensive insights and meaningful explanations regarding vaccine hesitancy among the elderly, drawing from the Chinese experience and offering directions for future improvement. It is important to mention that this study was conducted solely in Changsha and Shaoyang, China, and relied on a purposive sample. However, given the commonality in epidemic prevention, control policies, and vaccination strategies across the country, we consider our findings to be representative at a broader scale.
This study is a pioneering exploration into factors influencing vaccine hesitancy among the elderly in the context of China’s free COVID-19 vaccination policy. Significant barriers, including low awareness of the pandemic threat, skepticism about vaccine efficacy, and concerns about vaccination convenience, have been identified. Valuable insights from actively engaged professionals suggest promising measures to enhance vaccination rates. Moving forward, rigorous testing of these strategies is crucial to inform effective interventions, ensuring successful vaccine uptake among the elderly and contributing to the optimization of vaccination strategies in China.
Author contributions
Wenjie Gong conceived the study. Xiaoyu Li and Yanping Bai were responsible for the textual analysis and writing of the articles under the guidance of Wenjie Gong, while Xiaoyu Li and Yunshan Bai was responsible for conducting the interviews and transcribing the audio recordings of the interviews. Xiaoyu Li and Yanping Bai helped with the revision of the interview outlines and questionnaires, and were responsible for contacting the respondents to collaborate with the data collection. Lijun Weng was responsible for literature searching, data quality supervision and manuscript preparation. All authors approved the final draft. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. Wenjie Gong is the guarantor of the study.
Appendix 3 participants details.docx
Download MS Word (20.8 KB)Appendix 2 Reporting Qualitative Research Checklist.docx
Download MS Word (20.1 KB)Appendix 1 interview outline.docx
Download MS Word (15.4 KB)Acknowledgments
We would like to thank the HER Team from Xiangya school of public health in Central South University including Jiale Peng and Yuhua Qin for contacting the respondents to collaborate with the data collection.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplementary material
Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2315663
Additional information
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References
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