OBJECTIVES: Older adults have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. While COVID-19 vaccines are effective for reducing mortality and severe complications, vaccine hesitancy remains a substantial concern particularly among older adults. This was a qualitative study to explore how Chinese older adults reached a decision to delay or refuse the COVID-19 vaccines in Hong Kong. METHODS: Semi-structured in-depth interviews were conducted with 27 older adults aged ≥60 years who had never received COVID-19 vaccines. The grounded theory approach guided the selection of informants, data collection, data analysis, and report writing. RESULTS: Older adults' vaccine hesitancy and resistance weaved into the context of lacking sufficient decisional support and attitude roots of negative perception of aging, fatalistic risk attitudes, present-oriented time perspectives, and negative values on western biomedicine. Attitude roots were used as the decisional anchors to further shape older adults' peripheral processing of vaccine-related information, resulting into a spectrum of vaccine-resistant and vaccine-hesitant attitudes. While participants refused or delayed COVID-19 vaccination, they engaged in alternative coping strategies to regain self-control and justify their vaccination disengagement in the pandemic. DISCUSSION: Interventions to address vaccine hesitancy in older adults should focus on addressing attitude roots and strengthening the connectivity of older adults with family, doctors, and government to engage older adults in the vaccination decision making. Risk communication should shift to provide more personal relevant information in a caring style, meet older adults' preference for peripheral information processing, and address their existing misperceptions about COVID-19 vaccines.
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