Upward intergenerational support and vaccination decisions among community-dwelling older adults in China: A multicenter qualitative study

Routine vaccination coverage among older adults in China remains suboptimal despite established public health recommendations. Family engagement, deeply embedded in Chinese culture, is shown to influence health decisions; however, the specific role of upward intergenerational support (UIS) from adult children in older adults' vaccination decisions remains understudied in the post-pandemic era. To explore the forms and mechanisms through which UIS influences vaccination decision‑making among community‑dwelling older adults in post‑pandemic China, we conducted this multicenter qualitative study. From November 2024 to August 2025, a total of 261 semi‑structured interviews were conducted with older adults (≥ 60 y) and adult children (18‑59 y) across seven Chinese cities selected for maximum variation in socioeconomic status and vaccine policies. Thematic analysis revealed five key forms of UIS, including financial, practical, informational, emotional, and appraisal support, through which adult children influence parental vaccination decisions. Across families, these five forms were enacted in two qualitatively different patterns: a substitutive pattern, where adult children assumed decision-making authority, and a facilitative pattern, where support preserved and strengthened older adults' autonomy. The salience of these supports and patterns was contextualized by regional socioeconomic disparities, local vaccine policies, and lingering post‑COVID vaccine concerns. Findings reveal that UIS is a central social mechanism influencing vaccination decisions among older adults. Public health strategies need to shift from individual-focused to family-systems interventions, equipping adult children as facilitative supporters who respect older adults' autonomy, while concurrently addressing structural and relational barriers to improve routine vaccine uptake among community-dwelling older adults in China.