Among responding guardians, 86/323 (27%) reported receiving a HCW’s recommendation for influenza vaccination and 70/317 (22%) reported that their child was vaccinated in the prior year. Guardians who reported receiving a HCW recommendation were more likely to vaccinate their child than those who did not (35% vs. 17%, p < 0.001). The main reported reasons for not vaccinating their child were concerns for vaccine safety (62%), not receiving a HCW’s recommendation (37%); believing vaccination was unnecessary (25%), and limited vaccine effectiveness (23%). Reported preferences for information about vaccines included television (64%), internet (57%) and educational leaflets (51%).

Among 1673 pregnant women interviewed, 4% reported receiving a HCW recommendation for influenza vaccination in the prior year. None reported receiving the vaccine during pregnancy, and none planned to get vaccinated in the current year. The most common reasons reported for not getting vaccinated included fear of harm to the fetus (83%), vaccine safety for the pregnant woman herself (28%), and believing vaccination was unnecessary (22%). Preferred sources for vaccine information included television (56%), internet (39%), and doctors (34%). Nearly one third (31%) stated they would get vaccinated if they received a HCW’s recommendation.

Among 379 adults aged ≥60 years interviewed, 0.8% reported receiving the influenza vaccine in the prior year. The most common reasons for not getting vaccinated among those who responded (n = 268) were vaccination was unnecessary (33%), medical insurance did not pay for influenza vaccination (24%), and HCWs had not recommended vaccination (23%). Among all interviewed, 78% (296/379) reported willingness to get vaccinated if they received a HCW’s recommendation. Most (280/379, 74%) reported a preference for receiving health information from HCWs.

Among 1852 HCWs approached, 1301 (70%) completed both surveys; among these, 17% were community HCWs.

Post-influenza season, 5% HCWs reported receiving influenza vaccination during the prior season. Main reasons for not getting vaccinated included concerns about vaccine safety (43%), perceiving vaccination as unnecessary (27%), having insufficient time for vaccination (24%), and believing the vaccine was ineffective (20%).

HCWs wanted to learn more about influenza disease severity (68%), populations most susceptible to influenza illness (52%), vaccine contraindications (72%), safety (72%) and effectiveness (71%). Preferred sources of information on vaccines included internet (76%), television/radio (75%), newspapers/books (55%), and colleagues (50%).

Among all 1301 HCWs, 8% reported always recommending influenza vaccination to patients during the prior influenza season. Community HCWs were more likely to be vaccinated than hospital HCWs (P < 0.01) (Fig. 1), and were also more likely to recommend vaccination to patients at least once in the prior season (58% vs. 28%, P < 0.001).

Seasonal influenza vaccination coverage and factors influencing vaccination among high risk groups and healthcare workers are summarized in Table 1.

A common barrier to vaccination was concern about vaccine safety. Another common barrier was perceiving vaccination as unnecessary (22–33%); 23% guardians also cited low vaccine effectiveness as a barrier. These findings, in addition to the low seasonal influenza vaccine coverage among children less than 3 years of age and adults aged ≥60 years, are consistent with prior studies conducted in China [4,5,7–9]. We also found minimal coverage among HCWs (5%) and none among pregnant women.

More than a third of pregnant women and three quarters of adults aged ≥60 years reported wanting to receive information from HCWs regarding vaccination. Further, 31% pregnant women and 78% adults aged ≥60 years stated they would get vaccinated if a HCW recommended vaccination. Similarly, 37% guardians listed not receiving a HCW’s recommendation as a main barrier to vaccination, and guardians who received a HCW recommendation were more likely to vaccinate their child. These findings are consistent with studies in the US and China [11–14,18], in which high risk groups expressed trust in their physician, whose recommendation was a strong determinant of influenza immunization uptake.

Only 8% HCWs in Qingdao reported always recommending influenza vaccination, and only 4% pregnant women and 27% guardians of young children reported receiving a HCW’s recommendation for influenza vaccination in the prior year.

Several factors may prevent HCWs in China from routinely recommending influenza vaccination. First, in our study, HCWs themselves were not vaccinated due to concerns about vaccine safety, effectiveness, and perceiving vaccination as unnecessary. HCWs may also avoid recommending optional vaccines not included in EPI, such as influenza vaccine, to decrease risk of being held liable for adverse events.

Most HCWs, however, expressed interest in learning about vaccine contraindications, safety and effectiveness. As one Australian study found, improving HCWs’ knowledge in influenza infection and vaccination may increase the likelihood of their recommending influenza vaccine [19].

China’s health system may impact which HCWs are more likely to incorporate vaccine recommendations into their routine work. Community HCWs provide primary healthcare, disease prevention and health education, which target pregnant women, young children, older adults and adults with chronic diseases residing in the community [17]. Influenza vaccination services are usually offered at EPI clinics, which, in China, are most often located in community health centers. Therefore, when high risk groups receive recommendations from community HCWs, they have immediate access to on-site immunization. Although most HCWs in China do not routinely recommend seasonal influenza vaccination, we found that community HCWs were more likely than hospital HCWs to recommend vaccination and to get vaccinated themselves. These findings are consistent with studies conducted in the US and Australia [19,20].