Determinants of influenza vaccine preferences among community-dwelling older adults residents: a discrete choice experiment in Shihezi, China.

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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Geriatr . 2026 Apr 21;26:790. doi: 10.1186/s12877-026-07534-3 Determinants of influenza vaccine preferences among community-dwelling older adults residents: a discrete choice experiment in Shihezi, China Yiyao Li 1, # , Xinmeng Wang 1, # , Ruiying Peng 1 , Yuhan Zhang 1 , XiaoJu Li 1, ✉ Author information Article notes Copyright and License information 1 Department of Public Health, Shihezi University school of Medicine, Shihezi, Xinjiang 832000 China ✉ Corresponding author. # Contributed equally. Received 2025 Nov 23; Accepted 2026 Apr 16; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13227889  PMID: 42015019 Abstract Background Influenza vaccination among the older adults can effectively prevent influenza infection and reduce the outbreak of influenza and influenza-like diseases. This study examined the preferences and heterogeneity of preferences among community-dwelling older adults for influenza vaccines and key attributes of the vaccination process. We aimed to inform the development of demand-driven influenza vaccination strategies. Methods Using a multi-stage cluster sampling approach, 654 older residents of Shihezi City, China, were surveyed. Preferences for influenza vaccination attributes were assessed with a mixed logit model to estimate relative attribute importance, willingness to pay, and heterogeneity across sociodemographic and health-related characteristics. Results Respondents consistently favored vaccines characterized by a lower incidence of adverse events, high protection rates, and lower out-of-pocket costs. Acceptance was greater when perceived disease severity was high and when vaccination was delivered within the community. The relative importance of vaccine attributes was as follows: incidence of non-serious adverse events (32.38%), protection rate (32.28%), vaccination site (18.54%), disease severity (11.75%), and incidence of serious adverse events (5.06%). Participants were willing to pay and additional 176.50 yuan and 391.00 yuan to reduce the incidence of non-serious adverse events from 50% to 20% and 10%, respectively. Substantial preference heterogeneity was observed by sex, marital status, education attainment, and self-rated health status. Conclusion Vaccine safety and effectiveness are pivotal detriments of influenza vaccination decisions among community-dwelling older adults. Tailoring vaccination strategies to reflect these preferences, and to account for subgroup differences, may improve influenza vaccination rates in this population. Keywords: Discrete choice experiments, Older adults, Influenza vaccine, Preference Introduction Influenza remains a major global public health challenge. The emergence of new variants facilitate recurrent circulation [ 1 ], contributing to substantial morbidity, mortality, and economic burden worldwide. Older adults (≥ 65 years), young children (< 5 years), and immunocompromised individuals face the highest risks of severe disease, hospitalization, and death [ 2 ]. Notably, 70–80% of seasonal influenza-related deaths and 50–70% of hospitalizations occur among people aged ≥ 65 years, with hospitalization rates reaching 309 per 100,000 person-years in this group [ 3 ]. In China, influenza is estimated to cause approximately 300,000 excess deaths among older adults annually, with mortality increasing significantly with age [ 2 , 4 ]. According to relevant literature [ 5 ], the economic impact of influenza in China is considerable with per-capita costs for influenza outpatients range from 768 to 999.9 yuan, while inpatient costs average 9,832 yuan. Older adults are particularly vulnerable to influenza infection due to their weak immune response [ 6 ]. Vaccination is widely recognized as the most effective strategy for reducing influenza transmission. Both the World Health Organization (WHO) and China’s National Immunization Technical Advisory Group (NITAG) recommend prioritizing influenza vaccination for older adults and other high-risk groups. Evidence suggests vaccine effectiveness (VE) among adults ≥ 65 years can reach up to 80% in preventing influenza and its complications [ 7 , 8 ]. However, influenza vaccination coverage remains suboptimal worldwide. Reported vaccination rates include 24.96% in the general population (95% confidence interval [CI]: 23.45–26.50%), 41.65% among patients with chronic diseases (95% CI:40.08–43.23%), 36.57% among health care workers ( P < 0.05), and 25.92% among pregnant women (95% CI: 23.18%–28.75%) [ 9 ].In China, coverage among older adults remains below 10% overall [ 10 ], and as low as 1.10% in areas where vaccination requires out-of-pocket payment [ 11 ]. Therefore, increasing influenza vaccination coverage and reducing influenza-associated morbidity and mortality remain urgent public health priorities. Shihezi, Xinjiang, is a high-latitude city in northwest China, with long and cold winters and a high incidence of influenza. The population aged ≥ 60 years in this city accounts for 21.4%, which indicates a high degree of aging. According to the influenza vaccination data of Shihezi Center for Disease Control and Prevention from January 1, 2020 to April 30, 2023, the influenza vaccination rate of the local elderly aged ≥ 60 years was 8.33%. All patients were purchased at their own expense. In addition, Shihezi city faces unique challenges and opportunities in terms of the distribution of medical and health resources and the accessibility of vaccination services, which makes it a representative case to study the implementation of immunization program in a specific region of China. This rate is substantially lower than the influenza vaccination coverage rates among the elderly populations in the United States [ 12 ], Japan [ 13 ], Denmark [ 14 ], Portugal, Spain, and the Netherlands [ 15 ] during the same period, and is also lower than that reported in several other Chinese provinces [ 11 ]. Meeting the WHO’s recommended coverage target of 80% will require more effective and targeted vaccination strategies [ 16 ]. Developing such strategies begins with a thorough understanding of both the supply-side characteristics of vaccination programs and the demand-side characteristics of target populations [ 17 ]. Quantifying vaccination characteristics and target population characteristics affecting influenza vaccination rates among older adults is an important research topic. In China, most research on older adults’ influenza vaccination intentions has relied on self-designed, structured questionnaires focusing on demographic characteristics, knowledge, and information channels [ 18 – 20 ]. However, Most of Existing studies on influenza vaccination willingness among older adults have predominantly employed cross-sectional surveys. These studies have consistently identified several key influencing factors, primarily including awareness of the influenza peak season [ 21 ], knowledge about influenza and influenza vaccines, acceptable vaccine prices [ 22 ], as well as objective barriers such as inconvenient access to vaccination and lack of or limited healthcare services, little is known about older adults’ preferences for specific vaccine-related attributes, such as safety, effectiveness, cost, and delivery settings [ 23 ]. Discrete choice experiment (DCE), as an effective tool that can quantify individual trade-offs between different attributes of products or services, has been widely used in vaccine preference research. However, studies applying DCE to the community elderly population in underdeveloped western China are still limited, and there is still room for exploration of refined measurement of influenza vaccine preference for community elderly residents. In view of this, this study applied DCE method to this specific population, aiming to provide a new empirical reference for the optimization of regional immunization strategy, so as to supplement and improve the existing evidence chain. Methods Participants Participants were community-dwelling adults aged ≥ 60 years residing in five communities of Shihezi City. Inclusion Criteria: (1) Age ≥ 60 years; (2) Resided in Shihezi City for more than 6 months; (3) Volunteered to participate and signed an informed consent form, and possessed the communication and comprehension abilities necessary to complete the questionnaire survey. Exclusion Criteria: (1) Suffering from acute febrile illness or being in the acute exacerbation phase of a chronic disease; (2) Unable to cooperate in completing the questionnaire due to severe fatigue, pain, or other physical discomfort at the time of the survey. All respondents provided written informed consent. Ethical approval was obtained from the Ethics Committee of the First Affiliated Hospital of Shihezi University School of Medicine (Ethics Approval Number: KJ2021-135-01). Data were collected in July 2023 using a multi-stage cluster random sampling approach. Five street offices in Shihezi were selected, and within different communities were randomly chosen based on registries provided by community health service stations (Xincheng [community No.20], Xiangyang [community No.7], Hongshan [community No.22], Laojie [community No.5], and Dongcheng [community No.50]). Eligible older adults were randomly selected from the community lists. Sample size was determined using Orme’s rule of thumb [ 24 ]: N > 500c/(t*a). Where c is the maximum number of attributable levels (3), t is the number of choice sets per questionnaire version (2), and a is the number of alternatives per choice set (2, with no “opt-out” option). It yielded a minimum required sample of 75. To ensure sufficient power and representation, at least 100 respondents were recruited per community (total minimum sample = 500). Research tools The questionnaire comprised two parts. The first part collected basic demographic and background information, including age, sex, ethnicity, occupation, education level, marital status, monthly personal income, health status, and behavioral habits of the respondents. The second part assessed the respondents’ preferences. In addition to the discrete choice questionnaire, the survey included self-rated importance scores for the attributes used in the DCE to allow for comparative analysis. A five-point Likert scale was used to rate the importance of each attribute (“not at all important” “not important” “average” “important” and “very important”, corresponding to scores of 1 to 5, respectively. The discrete choice questionnaire was designed in accordance with the practice guidelines of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) [ 25 ]. The main design steps were as follows: During the determination of attributes and levels, a literature review was conducted to identify potential attributes of influenza vaccination relevant to older adults [ 26 ], Commonly studies attributes include vaccine price, protection rate (VE), duration of protection, incidence of adverse events (divided into serious and non-serious adverse effect risks), and the number of required vaccinations [ 27 , 28 ]. Additionally, costs such as travel and time are often considered. de Bekker-Grob [ 17 ]suggested that the vaccination site and service delivery method are also important attributes. Based on this, as well as expert recommendations and group discussions, six key attributes were selected: disease severity, protection rate, vaccination site, incidence of non-serious adverse events, incidence of serious adverse events, and out-of-pocket costs. Four attributes had three levels each, while two attributes had two levels each (Table 1 ). Table 1. Attributes and levels of the discrete choice experiment Attribute Levels Description Severity of illness [ 29 ] Low: 1 in 100,000 High: 30in 100,000 The severity of illness is described as influenza-associated respiratory excess mortality, which is the excess of influenza and pneumonia mortality observed during the influenza season over the portion of the nonepidemic season. Higher rates indicate more severe influenza in the current season. Rates of non-serious adverse events [ 28 ] Low: <10% Medium: 10%-30% High: >30% Incidence of non-serious (mild to moderate) adverse events, including pain at the injection site, fatigue, nausea, etc., which are generally mild and transient. Serious adverse events Incidence rate [ 28 ] Low: 1 in 1,000,000 Medium: 101,000,000 Hight: 100in 1,000,000 Refers to events that result in hospitalization, disability, life-threatening or death, or birth defects after vaccination. Protection rate [ 28 ] Low: <40% Medium: 40%-60% High: >60% The degree to which the risk of getting sick is reduced compared to not getting the vaccine, (e.g. 60%: Of the 100 people who would normally get the flu, 60 no longer get the flu because they got the vaccine, while 40 will still get the flu). Out-of-pocket cost [ 29 ] Free: ¥ 0 currunt price: ¥ 148 High: ¥ 200 Out-of-pocket cost refers to the cost that an individual needs to bear when getting vaccinated, that is, the price of the vaccine. Vaccination site [ 29 ] Community health service stations, community health service centers Vaccination sites refer to locations where influenza vaccine is available and administered. Open in a new tab Using the attributes and levels identified in Table 1 , Ngene software was employed to generate a D-efficient design comprising 60 choice sets, each containing two vaccine options. To reduce respondent burden, these were divided into six versions with 10 choice sets each. A repeated choice set was included to assess internal consistency, specifically the second choice set was repeated as the ninth question, which was excluded from regression analysis but used to check data quality. The final questionnaire included 11 DCE questions. To maximize information on older adults’ preferences, no opt-out option was provided [ 30 ]. Variables and measurements Outcome variables The outcome measure for this study was “influenza vaccination preference”. By asking, “Are you willing to receive one of the following influenza vaccine regimens?” Take the measure to define a response of “yes” as a willingness to choose one of the vaccine options and “no” as no willingness to choose the following vaccination options. Vaccination attributes: including disease severity, incidence of non-serious adverse events, incidence of serious adverse events, protection rate, cost to be paid, location of vaccination. Covariates When exploring the heterogeneity analysis of preferences based on the literature review, the following covariates were included in the mixed logit model: age, gender, education level, marital status, personal monthly income, and health status. Statistical analysis Out-of-pocket costs were treated as a continuous variable, while disease severity, protection rate, vaccination site, and the incidences of non-serious and serious adverse events were treated as categorical variables. For categorical attributes, dummy variables were created for each level, with one level serving as the reference category. Descriptive analyses of demographic characteristics were conducted using Stata 17.0. A mixed logit model was then used to estimate preferences for influenza vaccines and vaccination programs among older adults. Preference weights ( β coefficients) were calculated for each attribute and level, with statistical significance set at P < 0.05. The Relative Importance (RI) of each attribute was calculated as the ratio of the utility difference between the maximum and minimum regression coefficients within an attribute to the total utility difference across all attributes [ 31 ]. These results were compared with respondents’ self-rated importance scores. Heterogeneity in preferences was explored by interacting age, sex, marital status, education level, personal monthly income, chronic disease and self-rated health status with the attribute dummy variables. Finally, willingness-to-pay (WTP) was estimate by calculating the ratio of the coefficients of non-cost attributes to the out-of-pocket cost coefficient, allowing for assessment of the trade-offs respondents were willing to make between attributes [ 32 ]. Results Participant characteristics A total of 654 older adults were surveyed, with an average age of 73.94 ± 7.70 years. After excluding incomplete questionnaires and those failing the consistency test, 591 valid responses were analyzed, with an average age of 73.73 ± 7.76 years (effective response rate: 90.37%). Of these, 210 respondents were men (35.53%) and 381 were women (64.47%). Respondents aged 60–70 years accounted for 40.9% ( n = 242). Nearly half (49.92%) had a primary school education or less ( n = 295), and 70.05% ( n = 441) were married. Most participants (85.45%; n = 505) reported an individual monthly income between 1,500 and 5,999 yuan, with a mean income of 3,807.02 yuan. One-third (34.69%; n = 205) of respondents rated their health as “good” (Table 2 ). Table 2. Basic characteristics of the respondents Variables Samples that passed the consistency check ( n = 591) Number/person Proportion /% Gender male 210 35.53 female 381 64.47 Age 60–70 years old 242 40.95 71–80 205 34.69 81 and older 144 24.37 Education level Primary school and below 295 49.92 Junior high school, technical secondary school, technical secondary school 244 41.29 College and above 52 8.80 Marital status unmarried 3 0.51 Married 414 70.05 Divorced 161 27.24 Widowed 13 2.20 Personal monthly income 1,499 yuan and below 35 5.92 1,500-5,999 yuan 505 85.45 6,000 yuan and above 51 8.63 Self-rated health status Very poor 17 2.88 Poor 133 22.50 Average 187 31.64 Better 205 34.69 Very good 49 8.29 Open in a new tab Preference estimation The regression results indicated that at least one level of each attribute was statistically significant ( P < 0.05), demonstrating that all attributes included in the study influenced preferences for influenza vaccination. Specifically, community-dwelling older adults showed a preference for vaccines under the following conditions: higher disease severity (i.e., influenza poses greater health risks), lower incidences of serious adverse events and non-serious adverse events, higher protection rates, lower out-of-pocket costs, and administration at community health service stations. Older adults were more likely to receive vaccination when influenza severity was high ( β = 0.467). Regarding adverse events, they preferred vaccines with a non-serious adverse event rate of approximately 10% ( β = 2.346) and a low incidence of serious adverse events ( β = 0.567). Vaccines with an probably around 80% protection rate were most preferred ( β = 1.327). Compared with vaccination at community health service stations, vaccination at community health service centers was less preferred ( β = -0.737). Out-of-pocket costs also played a significant role; older adults most likely preferred vaccines with low treatment cost. Higher costs reduced the likelihood of vaccine selection ( β = -0.006). Details are presented in Table 3 . Table 3. Influenza vaccination preferences of community-dwelling older adults based on mixed logit model ( n = 591) Attributes and levels Beta. SE P -value 95%CI Severity of illness (reference level: low) high 0.467 0.068 < 0.001 0.334 0.600 Incidence of non-serious adverse events (reference level: high) medium 1.059 0.047 < 0.001 0.966 1.153 low 2.346 0.092 < 0.001 2.166 2.527 Rate of serious adverse events (reference level: high) medium 0.366 0.055 < 0.001 0.258 0.474 low 0.567 0.053 < 0.001 0.463 0.672 Protection rate (reference level: low) medium 0.044 0.042 0.290 -0.037 0.125 high 1.327 0.063 < 0.001 1.204 1.450 Location of vaccination (reference level: community health service station) Community health service centers -0.737 0.068 < 0.001 -0.870 -0.604 Out-of-pocket expenses -0.006 0.001 < 0.001 -0.007 -0.005 Log likelihood -5146.81 Akaike Information quasi-test (AIC) 10413.62 Bayesian information quasimeasure (BIC) 10856.27 Sample size 591 Observed values 11,820 Open in a new tab Relative importance of attributes Figure 1 illustrates the relative importance of influenza vaccine attributes estimated by the mixed logit regression model, focusing on non-monetary attributes. Among the attributes, the incidence of non-serious adverse events was rated as most important (32.38%), closely followed by the protection rate (32.28%). Fig. 1. Open in a new tab Relative importance of attributes (mixed logit model) Figure 2 presents the self-rated importance scores of the vaccine attributes. Older adults rated the protection rate as the most important (mean score = 4.18), followed by disease severity (mean score = 4.03). Vaccination site (mean score = 2.60) and out-of-pocket cost (mean score = 2.34) were considered less important. Fig. 2. Open in a new tab Relative importance of attributes (self-rated by respondents) Preference heterogeneity across subgroups To further analyze sources of preference heterogeneity among older adults, 9 mixed logit models were established in addition to the base model (Model 1). Interaction terms were introduced between each random parameter and respondents’ age, marital status, personal monthly income, education level, chronic disease, self-rated health status. Model 2 showed that older adults aged ≥ 81 years were more likely to prefer vaccines with an 80% protection rate compared with those aged < 80 years. Model 5 indicated that respondents without a spouse were more likely to prefer vaccines with a 10% non-serious adverse event rate than those with a spouse. Model 6 demonstrated that respondents with a junior high school education or higher were more likely to choose vaccines with low rates of both non-serious and serious adverse events compared with those with a primary school education or less. Model 7 revealed that respondents with poorer self-rated health were more likely to prefer vaccines with lower incidences of non-serious adverse events and were more accepting of higher out-of-pocket costs than those with better self-rated health. Finally, Model 9 revealed that, compared to elderly individuals with diabetes, those without diabetes showed a stronger preference for vaccines with a protection rate of 80% and a low incidence of serious adverse events. Model 3, 4, 8, 10 showed that there is no preference heterogeneity for influenza vaccine among elderly people of different genders, personal monthly income and whether they have coronary heart disease or hypertension. The detailed results of these models are presented in Table 4 . Table 4. Heterogeneity analysis of elderly residents' demographic characteristics on preferences for influenza vaccine selection ( n =591) Interaction terms Age (≥ 81 years old) Gender (female) Personal monthly income (≥ 5,000 yuan) Marital status (no spouse) Education level (Junior high school and above) Self-rated health status (poor) Coronary heart disease (Yes) Diabetes (Yes) Hypertension (Yes) Beta (SE) Beta (SE) Beta (SE) Beta (SE) Beta (SE) Beta (SE) Beta (SE) Beta (SE) Beta (SE) The severity of the disease is high 0.067 (0.159) -0.082 (0.155) 0.290 (0.181) 0. 021 (0.129) 0.087 (0.131) 0.188 (0.118) 0.087 (0.152) 0.274 (0.159) 0.011 (0.148) The protection rate was around 80% *0.111 (0.055) -0.026 (0.091) -0.097 (0.113) 0.062 (0.048) 0.022 (0.052) 0.004 (0.047) -0.076 (0.158) *-0.366 (0.170) -0.035 (0.156) The rate of nonserious adverse events was around 10% 0.016 (0.073) 0.125 (0.110) 0.138 (0.164) *0.119 (0.058) *0.146 (0.068) *0.116 (0.046) -0.043 (0.117) -0.088 (0.169) 0.065 (0.150) The incidence of serious adverse events was low 0.072 (0.066) 0.054 (0.112) -0.175 (0.143) 0.010 (0.053) *0.347 (0.040) 0.025 (0.044) 0.056 (0.112) *-0.287 (0.144) 0.009 (0.133) The vaccination place was community health service center 0.122 (0.131) -0.059 (0.143) 0.366 (0.158) 0.133 (0.106) 0.076 (0.121) 0.026 (0.091) -0.021 (0.148) -0.150 (0.148) 0.042 (0.144) Out-of-pocket expenses 0.091 (0.279) -0.001 (0.001) 0.253 (0.125) 0.090 (0.077) 0.029 (0.088) **-0.190 (0.072) -0.091 (0.103) -0.162 (0.103) 0.017 (0.100) Open in a new tab Age < 80 years old, male, personal monthly income < 5,000 yuan, marital status as spouse, education level of primary school or below, self-rated health status as better, not suffering from coronary heart disease, diabetes or hypertension were used as reference * P < 0.05, ** P < 0.01 Willingness-to-Pay analysis WTP values for each attribute were estimated using the mixed logit model. When disease severity increased from low to high (from 10/100,000 to 30/100,000 influenza-associated respiratory excess mortality), older adults were willing to pay an additional 77.83 yuan for vaccination. To reduce the incidence of non-serious adverse events from about high to medium and low, respondents were willing to pay an additional 176.50 and 391.00 yuan, respectively. To decrease the incidence of serious adverse events from high to medium, they were willing to pay 61.00 and 94.50 yuan more. For increases in protection rate, respondents were willing to pay 7.33 yuan more for an increase from low to medium and 221.17 yuan more for an increase to high When the vaccination site changed from a community health service station to a community health service center (urban traditional Chinese medicine hospital), a price reduction of 122.83 yuan would be required to offset the decrease in preference. Detailed results are provided in Table 5 . Table 5. Willingness to pay for influenza vaccination program for the older adults in the community ( n = 591) Attributes and Levels Willingness to pay (WTP, yuan) 95%CI for WTP Severity of illness Low → High 77.83 47.71 120.00 Nonserious adverse event rates High → medium 176.50 138.00 230.60 High → Low 391.00 309.43 505.40 Rate of serious adverse events High → medium 61.00 36.86 94.80 High → Low 94.50 66.14 134.40 Protection rate Low → medium 7.33 -5.29 25.00 Low → High 221.17 172.00 290.00 Location of vaccination Community health service Station → Community health service center -122.83 -124.29 -120.80 Open in a new tab Discussion A systematic review by Yang Yuzhen et al. [ 33 ] identified only three studies on influenza vaccination preferences between 2000 and 2022, with very few DCE studies specifically targeting older adults. Given that declarative and demonstrated preferences obtained through DCE experiments show high correspondence in over 80% of cases, DCE methods are well suited for quantitatively evaluating influenza vaccine preferences among the older adults [ 34 ]. Using data from 591 adults aged ≥ 60 years in five communities of Shihezi City, this study applied a DCE approach to identify both preferences and heterogeneity in influenza vaccination choices. The goal was to determine which vaccine attributes and programmatic interventions could improve influenza vaccination uptake in older populations [ 35 ]. All six attributes included in this study significantly influences vaccination preferences. Ranked from most to least influential, they were: (1) incidence of non-serious adverse events, (2) protection rate, (3) vaccination site, (4) disease severity, (5) incidence of serious adverse events, and (6) out-of-pocket payment. Vaccine safety (non-serious adverse event rate) and VE (protection rate) emerged as the two most important attributes, consistent with findings from earlier studies [ 36 ]. Previous cross-sectional surveys of influenza vaccination intention among older adults highlighted beliefs about vaccine effectiveness and safety as key determinants of uptake [ 37 – 40 ], but these surveys could not quantify the relative importance of each attribute. Our study demonstrates that vaccine safety exerts an even stronger influence than protection rate on influenza vaccination decisions among older adults. Specifically, a low incidence of non-serious adverse events (approximately 10%) and a very low incidence of serious adverse events (approximately 1 per 1,000,000) significantly increased the likelihood of vaccine acceptance. Increasing the protection rate from low (approximately 40%) to high (approximately 80%) also produced a substantial improvement in preference, aligning with findings from studies conducted in China [ 41 ] and Japan [ 42 ]. The elderly population in Shihezi City communities possesses relatively high educational attainment. When receiving influenza vaccine-related health education, they primarily rely on authoritative sources, chiefly official guidelines from health administrative departments and opinion leaders on social media. Consequently, their choice of influenza vaccines is more influenced by accurate information, which likely explains the local elderly population’s preference for vaccines with higher protection rates. Additionally, Our findings indicate that older adults are more likely to get vaccinated at community health stations, they prioritize proximity and convenience when getting vaccinated, rather than traveling to community health centers that may be farther from their neighborhoods in order to access better medical resources and services. Compared to conventional vaccination sites accessible within China, other countries are exploring more innovative locations such as retail pharmacies [ 12 ], However, due to national circumstances and other factors, the establishment of such sites cannot be directly replicated. While each vaccination location has its own merits, most research findings indicate that convenience remains the primary demand among target populations [ 43 , 44 ].This suggests that in immunization planning, the supply of influenza vaccines should be prioritized to a greater extent toward grassroots community health service stations, thereby alleviating their current shortage of influenza vaccines. Disease severity also influenced vaccination decisions, consistent with the findings of Eilers R et al. [ 27 ] regarding vaccination preferences among the older adults. These findings provide further insight into the role of behavioral and social drivers (BeSD) in influenza vaccination among older adults. According to the theory of Health Belief Model, vaccine efficacy can be categorized as perceived benefits, while the occurrence of adverse events and vaccination sites can be classified as perceived barriers [ 45 ]. Perceived threat encompasses factors such as not viewing influenza as a threat (i.e., the perceived severity of the disease among older adults in this study) [ 46 ]. Other findings indicate that perceived benefits of vaccination positively influence willingness to receive the influenza vaccine while perceived harms negatively affect this willingness [ 47 , 48 ]. The health behavior of elderly individuals participating in influenza vaccination in this study can also be explained by their beliefs regarding health issues. Although low out-of-pocket costs also fall under the perceived benefits dimension of influenza vaccination, our survey indicates that the elderly population residing in Shihezi’s communities primarily consists of retired workers. Their post-retirement income sources and security are stable. Based on the current average monthly income level of Shihezi’s elderly, the cost of the influenza vaccine accounts for only 3.83% of their income. This explains why price had the least influence on vaccination preference among all six attributes examined in this study, consistent with findings from Shan Zhu et al. [ 49 ]. Interestingly, the self-rated importance ranking of influenza vaccine attributes did not fully align with the simulated choice behavior observed in DCE. In our DCE analysis, the incidence of non-serious adverse events emerged as the most important attribute, followed by the protection rate. In contrast, self-rated rankings placed protection rate first, followed by disease severity. This discrepancy highlights that the impact of protection rate on vaccination choice was stronger than expected [ 50 ]. Overall, the top three considerations for community-dwelling older adults were protection rate, incidence of non-serious adverse events, and disease severity. Future studies should include in-depth interviews with older adults from diverse demographic backgrounds to capture their true perspectives on vaccine attributes [ 51 ]. Age, family structure, educational level, and health status significantly influence older adults’ preferences regarding influenza vaccination [ 52 ]. Older individuals tend to choose vaccines with high protection rates, suggesting that the quadrivalent influenza vaccine may be recommended [ 53 ]; those who are unmarried, have a lower educational level, or are in poorer health prefer vaccines with a lower rate of adverse reactions (approximately 10%), and targeted health education emphasizing safety is needed to build their confidence. Individuals with lower self-rated health are willing to bear higher out-of-pocket costs, reflecting that they prioritize vaccine efficacy over price sensitivity [ 54 ], highlighting the importance of expanding access to health information to support decision-making [ 55 ]. Efforts should be made to improve and optimize the influenza vaccination experience for older adults [ 56 ].vaccine development should focus on reducing adverse reactions and enhancing protective efficacy, while regulatory agencies need to strengthen safety monitoring [ 57 ]; service accessibility should be improved by establishing community-based vaccination sites [ 58 ]and health education campaigns should be conducted before the flu season to increase participation [ 59 ]. differentiated strategies should be implemented for groups with distinct characteristics, such as prioritizing high-protection-rate vaccines for the elderly, while addressing vaccination concerns among vulnerable groups through health promotion activities, thereby increasing overall vaccination rates [ 60 ]. Implications for practice In the formulation of public health policies, priority is given to ensuring the safety and accessibility of vaccines. Older adults slightly prioritize vaccine safety (non-serious adverse events) over efficacy (protection rate), so policymakers should focus on both factors in vaccine procurement and public communication. They strongly prefer vaccination at community health service stations and are highly cost-sensitive, supporting free or subsidized influenza vaccination for the elderly; improving vaccine literacy through community lectures and easy-to-understand materials is also essential. For clinical communication strategies, individualized communication with seniors is required due to preference differences, and healthcare workers should use plain language to explain vaccine safety and efficacy to enhance trust and vaccination uptake—for unmarried, low-education or poor-health seniors, the mild and temporary nature of adverse reactions should be highlighted and positive cases used to reduce vaccine hesitancy. Strengths and limitations This study pioneers the application of the discrete choice experiment method to investigate influenza vaccine preferences among community-dwelling older adults in Shihezi City. The selection of six key attributes, spanning vaccine characteristics, contextual factors, and economic considerations, comprehensively addresses the vaccination decision-making process. And in the analysis of the relative importance of attributes, the self-rated importance scores of older adults for each influenza vaccine attribute were compared and discussed alongside the results derived from model calculations, serving as a practical supplement to the theoretical analysis. However, this study also has certain limitations. This study was conducted only in Shihezi City, Xinjiang, with a sample representing a typical region in Northwest China characterized by high latitude, a relatively high degree of aging, and low vaccination rates. Due to variations in economic development levels, healthcare resource allocation, and ethnic-cultural backgrounds across different regions, caution is warranted when extrapolating these findings to the whole country or other areas (e.g., eastern coastal or southern cities). Future research should conduct multi-center, cross-regional DCE studies, enrolling elderly populations from diverse geographical areas (e.g., urban-rural differences, North-South differences) to compare preference heterogeneity, thereby constructing more universally applicable vaccination strategies. Although the DCE design followed international guidelines, certain limitations exist. First, while the selection of attributes and levels was based on literature and expert opinions, it may have omitted other important factors (e.g., advice from family/friends, trust in the healthcare system). Second, the absence of an “opt-out” option in the questionnaire might overestimate the actual vaccination willingness of older adults, as individuals can choose not to be vaccinated in real-world scenarios. Future research could employ mixed methods, using qualitative interviews (e.g., focus groups) prior to the DCE to more comprehensively explore potential attributes influencing preferences.DCE measures"stated preferences” of older adults in hypothetical scenarios, rather than “revealed preferences” in the real world. Although studies suggest consistency between the two, hypothetical scenarios cannot fully replicate the complex factors encountered during actual vaccination (e.g., physical condition on the day of vaccination, temporary vaccine shortages).Future research could link and validate DCE results with real-world data(e.g., vaccination records, routine operational data from community health centers). Furthermore, implementation studies could be conducted to put preference-based interventions (e.g., SMS reminders, community outreach) into practice and observe their impact on actual vaccination rates. Conclusions This discrete choice experiment revealed that, among community-dwelling older adults, vaccine safety (specifically the incidence of non-serious adverse events) was the most influential attribute affecting influenza vaccination decisions, followed by vaccine effectiveness (protection rate). This finding, which contrasts with the participants’ self-reported importance rankings, underscores that safety concerns represent a primary, yet potentially underestimated, behavioral barrier. Although convenience (proximity of vaccination sites) and disease severity also significantly influenced preferences, out-of-pocket cost was the least influential factor. More importantly, we identified significant preference heterogeneity across subgroups defined by age, marital status, educational level, self-rated health status, and the presence of chronic diseases. These insights provide actionable evidence for policymakers and practitioners: improving vaccination uptake requires not only ensuring vaccine safety and efficacy but also tailoring communication strategies to address the distinct concerns of specific subgroups—for example, emphasizing protection rate for the oldest-old or providing safety assurances for those with lower educational levels. Furthermore, the strong preference for local vaccination sites supports the strategy of decentralizing immunization services to community health stations. In conclusion, optimizing influenza vaccination among older adults depends on a multi-pronged approach that integrates safer vaccines, convenient services, and targeted, preference-based health messaging. Acknowledgements The authors would like to extend their sincere gratitude to all the community-dwelling elderly respondents who participated in this discrete choice experiment study. Your precious time and invaluable insights have been the cornerstone of this research. Your support and dedication to public health research serve as a direct driving force for the advancement of this field. Authors’ contributions Conceptualization: Yiyao Li, XiaoJu LiData curation: Yiyao Li, Xinmeng WangFormal analysis: Xinmeng Wang, Yuhan ZhangMethodology: Yuhan Zhang, Ruiying PengWriting -original draft: Yiyao LiWriting - review & editing: Xinmeng Wang, XiaoJu LiAll authors read and approved the final manuscript. Funding This study was funded by Provincial-level Project((No.2024ZD024). Data availability The datasets used and analyzed during the current study are available from thecorresponding author on reasonable request. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the First Affiliated Hospital of Shihezi University School of Medicine (Ethics Approval No. KJ2021-135-01). All participants provided written informed consent prior to their inclusion in the study. The research was conducted in accordance with the ethical principles of the Declaration of Helsinki and relevant national regulations. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Yiyao Li and Xinmeng Wang contributed equally to this work. References 1. Javanian M, Barary M. A brief review of influenza virus infection. J Med Virol 2021 J Med Virol. 2021;93(8):4638–46. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Lu JJ, Zhao GJ, Zhao HY, et al. 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