Association of modified 5C scale and influenza vaccine hesitancy among the elderly population in Ningbo, China: a cross-sectional study

Seasonal influenza imposes disproportionate morbidity and mortality burdens on elderly populations globally, with suboptimal vaccination coverage persisting as a critical public health challenge. Despite policy advancements including China’s 2025 elderly influenza vaccination target, persistent gaps necessitate deeper understanding of influenza vaccine hesitancy determinants in high-risk cohorts. This cross-sectional study assessed influenza vaccine hesitancy among 2,288 community-dwelling adults aged ≥ 60 years in Ningbo, China (February–March 2025). Validated 5C psychological antecedent scales (Confidence, Complacency, Convenience, Calculation, Collective Responsibility) were administered alongside sociodemographic and cognitive assessments. Multivariable logistic regression identified determinants of hesitancy (defined as vaccine refusal/delay), reporting adjusted Odds Ratios (ORs) with 95% Confidence Intervals (CIs). We calculated the proportion of hesitant respondents indicating a potential change in vaccination intention for each motivator. The prevalence of influenza vaccine hesitancy among the elderly population in Ningbo was 32.4% (741/2288). We found that female (OR = 1.30, 95%CI: 1.00–1.70) was significantly associated with higher odds of hesitancy and urban residence (OR = 0.74, 95%CI: 0.56–0.98) and influenza-vaccine-related cognition (OR = 0.66, 95%CI: 0.50–0.86) were significantly associated with lower odds of hesitancy. The results showed that having no history of influenza vaccination (OR = 12.01, 95% CI:9.36–15.50) was most strongly associated with higher odds of influenza vaccine hesitancy. Lower confidence (OR = 0.82, 95%CI: 0.79–0.85) and higher complacency (OR = 1.14, 95%CI: 1.11–1.17) was associated with higher odds of influenza vaccine hesitancy. Among influenza vaccine hesitators, a relative/decedent’s recommendation would convince 26.7% to be vaccinated, far exceeding a physician’s advice (18.9%). Personal infection fear and perceived high exposure persuaded 22.4% and 19.6%, respectively. Nearly one-third of elderly exhibit influenza influenza vaccine hesitancy, driven by intersecting demographic, cultural, and policy factors. The counterintuitive role of collective responsibility highlights the need for culturally adapted interventions. We propose family-inclusive education, age-targeted digital outreach, and health system integration to overcome barriers.