To analyze the changing trends and the stability of influencing factors of influenza vaccine hesitancy among university students in central and western China between 2022 and 2025, and to provide evidence for targeted interventions in universities.

Two rounds of repeat cross-sectional surveys were conducted among university students in central and western China in June 2022 and between January and February 2025. Propensity Score Matching (PSM) was used to balance baseline characteristics. Binary Logistic Regression analyses were employed to identify factors associated with vaccine hesitancy.

A total of 1 786 matched pairs were included in the analysis. From 2022 to 2025, the vaccine hesitancy rate significantly decreased from 47.65% (851/1 786) to 33.31% (595/1 786) (P<0.001). Logistic regression revealed that perceived severity of influenza (2022 OR=0.799 (0.763-0.837), 2025 OR=0.845 (0.793-0.900)), perceived necessity of vaccination (2022 OR=0.275 (0.131-0.579), 2025 OR=0.157 (0.068-0.361)), and previous influenza vaccination history (2022 OR=0.284 (0.222-0.363), 2025 OR=0.469 (0.363-0.606)) were stable protective factors against hesitancy in both years (allP<0.05). Influenza vaccine knowledge changed from a risk factor in 2022 (OR=1.118 (1.009-1.240), P=0.033) to a protective factor in 2025 (OR=0.827 (0.730-0.938), P=0.003). The protective effect of recommendations from family, classmates, or friends was significantly strengthened in 2025 (OR=0.362 (0.278-0.473), P<0.001).

The influenza vaccine hesitancy rate among university students in central and western China decreased significantly between 2022 and 2025, primarily driven by improved vaccine knowledge, enhanced positive social norms, and heightened risk perception. Further efforts to reduce hesitancy should focus on optimizing knowledge dissemination, leveraging social networks, and strengthening guidance from authoritative sources.