The Mediating Role of Vaccine Hesitancy in Influenza Vaccination Uptake and Intention Among Older Adults in Urban China: Based on a Structural Equation Modeling Study.

Background: Influenza presents significant risks to older adults; however, vaccination coverage in China remains low despite robust recommendations. Factors such as vaccine hesitancy, physician recommendations, health status, and socioeconomic conditions influence vaccination rates. This study uses large-scale influenza vaccination data from urban older adults in six cities and applies structural equation modeling to investigate the determinants of both influenza vaccination uptake and future intention. Methods: A cross-sectional survey was conducted from December 2024 to January 2025 across six major Chinese cities, involving 13,363 community-dwelling adults aged ≥60 years. Vaccine hesitancy was measured using the validated 5C scale. Structural equation modeling with weighted least squares mean and variance adjusted estimation was employed to assess direct and indirect effects of physician recommendation, socioeconomic status, medical status, and subjective health on influenza vaccination uptake. Results: The vaccination uptake rate is 34.05%, while the intention rate is 32.20%. Vaccine hesitancy is the strongest negative predictor of vaccination (β = -0.488, p < 0.001). Physician recommendation has the largest total effect (β = 0.351), with 45.60% of this effect mediated through reduced vaccine hesitancy. Medical status is directly associated with lower uptake; it consistently promoted intention. Higher socioeconomic status also positively affected vaccination (total effect = 0.167), partly via lower hesitancy. Conclusions: Vaccine hesitancy serves as a pivotal mediator in influenza vaccination uptake and intention among Chinese older adults. Strengthening physician recommendations and addressing socioeconomic disparities are key strategies to reduce hesitancy and improve coverage.