Differing influenza vaccine uptake and recommendation behavior among healthcare workers in primary health centers, secondary and tertiary hospitals, and schools in a metropolis of southern China

Background Healthcare workers (HCWs) play a key role in recommending influenza vaccination. Few studies have examined HCWs’ influenza vaccination and recommendation behavior in China.Research design and methods A cross-sectional survey was conducted among HCWs in primary health centers, secondary and tertiary hospitals, and schools in Guangzhou, China, in January 2026.Results Among 3,153 HCWs, 46.2% reported vaccination in at least one of latest four influenza seasons. Average seasonal uptake was 28.2%. Uptake varied by occupation, with higher uptake among public health practitioners (OR = 2.53, p < 0.001) and lower among school healthcare providers (OR = 0.64, p < 0.001), compared with physicians. Knowledge of influenza was negatively associated with vaccination (OR = 0.90, p < 0.001), whereas knowledge of influenza vaccines was positively associated with vaccination (OR = 1.09, p < 0.001) and recommendation behavior (OR = 1.11, p < 0.001). Personal vaccination was positively associated with recommendation behavior (OR = 3.12, p < 0.001). Exploratory generalized path analysis showed knowledge of influenza vaccines was positively associated with recommendation behavior (β = 0.131), mainly through recommendation attitude and personal vaccination, whereas opposite indirect pathways for knowledge of influenza resulted in no significant association.Conclusions Influenza vaccine uptake remained insufficient among HCWs. Different knowledge domains showed diverse association with vaccination and recommendation behavior. Vaccine-specific knowledge and risk-benefit perceptions were more consistently associated with HCWs’ vaccination and recommendation practices.