Elderly vaccination in post-pandemic China : challenges and opportunities

Abstract

The COVID-19 pandemic exposed longstanding challenges in vaccination uptake among older adults in China. This thesis investigates the dynamics and determinants of elderly vaccination, focusing on the interplay between macro-level policies and proximal behavioural and social drivers. Using a mixed-methods design, the thesis explores critical policy, social, behavioural, and structural factors influencing vaccine uptake for COVID-19, seasonal influenza (SIV), pneumococcal (PV), and herpes zoster (HZV) vaccines. It aims to propose evidence-based strategies to promote life-course immunisation among ageing populations across different policy and cultural contexts in China.

Chapter 3 presents a policy analysis using the Multiple Streams Framework to examine how delayed prioritisation, ideological complacency, and inconsistent implementation contributed to systemic vulnerabilities in elderly vaccination. Drawing on 95 press conference transcripts, the chapter demonstrates that the weak convergence of the problem, political, and policy streams ultimately rendered older adults the Achilles’ heel of China’s COVID-19 containment strategy. Chapter 4 reports findings from a cross-sectional survey of 2,107 older adults in Shenzhen. The study identifies several key predictors of willingness to receive SIV and PV, including having a contracted family doctor, undergoing regular physical check-ups, and awareness of local free vaccination policies. Notably, 70% of respondents indicated that their experience during the pandemic had increased their willingness to receive future vaccinations. Chapters 5 and 6 explore the behavioural and social drivers of elderly vaccination through 56 in-depth interviews conducted in Shenzhen and Hong Kong. Guided by the Integrative Model of Behavioural Prediction (IMBP) and Critical Medical Anthropology (CMA), these chapters identify both shared and context-specific factors. In Shenzhen, motivations included perceived vulnerability, family influence, and trust in healthcare providers (HCPs). Barriers included vaccine fatigue, misinformation, and confusion about eligibility. Conversely, older adults in Hong Kong displayed greater vaccine knowledge and autonomy, supported by community outreach and cultural practices such as tea gatherings. Although both sites reported challenges such as digital exclusion and fragmented policies, the nature of trust differed. In Hong Kong, socio-political tensions affected institutional trust, while in Shenzhen, misinformation on social media played a greater role. Chapter 7 presents a mixed-methods study that examined the factors shaping HZV uptake among older adults in Shenzhen. Facilitators included prior awareness of shingles, history of influenza vaccination, fear of pain, HCP recommendations, encouragement from family members, and knowledge of life-course immunisation. Barriers included high cost, low perceived risk, reliance on traditional remedies, concerns about side effects and efficacy among the oldest age groups, and limited institutional support.

By integrating policy analyses, empirical field investigations, and comparative regional insights, this thesis contributes evidence-based recommendations to optimise elderly vaccination in post-pandemic China. Key findings underscore three paradoxes: heightened vaccine awareness amid growing hesitancy; policy incentives improving access while complicating eligibility; and social networks that both enable and constrain decision-making. The findings underscore the need for national guidelines tailored to the specific needs of older adults, transparent risk communication, expanded financial support, culturally responsive interventions, and the strategic use of pandemic-driven initiatives to promote sustainable life-course immunisation.