Behavioral pathways linking influenza vaccine knowledge, uptake, vaccination intention, and recommendation behavior among healthcare workers: a cross-sectional study in Shijingshan District, Beijing.

OBJECTIVE: Healthcare workers are a priority group for influenza vaccination and play an important role in recommending vaccination to patients. However, the relationships among influenza vaccine knowledge, vaccination uptake, future vaccination intention, and recommendation behavior remain insufficiently understood. This study aimed to examine these associations and their behavioral pathway relationships among healthcare workers in Shijingshan District, Beijing. METHODS: A cross-sectional survey was conducted in January 2026 among healthcare workers from medical institutions in Shijingshan District, Beijing. Of 4,366 respondents, 4,238 valid questionnaires were included in the final analysis. Data were collected on influenza vaccine-related knowledge, vaccination uptake during the current influenza season, intention to receive influenza vaccination in the next influenza season, and recommendation behavior toward patients. Logistic regression analyses were used to identify associated factors, and SEM-based path analysis was performed to examine the direct and indirect associations among influenza vaccine-related knowledge, vaccination uptake, future vaccination intention, and recommendation behavior. RESULTS: Among the 4,238 participants, 22.1% received influenza vaccination during the current influenza season, 43.7% intended to be vaccinated in the next influenza season, and 82.0% reported recommending influenza vaccination to patients. Logistic regression analyses showed that knowledge score, training/publicity, free vaccination policy, institutional support, and prior vaccination were significantly associated with vaccination uptake, future vaccination intention, and recommendation behavior. The SEM-based path analysis model showed a good fit (CFI = 0.957, TLI = 0.941, RMSEA = 0.041, SRMR = 0.036). Knowledge score was positively associated with vaccination uptake (β = 0.09, p < 0.001). Current-season vaccination uptake strongly predicted future vaccination intention (β = 0.47, p < 0.001), and future vaccination intention was the strongest direct predictor of recommendation behavior (β = 0.41, p < 0.001). Mediation analysis showed that knowledge score indirectly influenced recommendation behavior through current-season vaccination uptake and future vaccination intention. CONCLUSION: Influenza vaccine-related behaviors among healthcare workers followed a progressive behavioral pathway from knowledge to vaccination uptake, then to future vaccination intention, and finally to recommendation behavior. Interventions targeting knowledge, institutional support, and actual vaccination uptake may provide evidence for developing targeted interventions among healthcare workers in similar settings.