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Table 3 Association between influenza vaccination and SES, by three-measure SES

From: The association between influenza vaccination and socioeconomic status in high income countries varies by the measure used: a systematic review

Study; Country SES Concept (Level of SES measure) Description SES measure Adjusted mediating factorsa Data source; Data type (Year collected) Results
Education, Income, and Occupational Class measured separately (n = 6; 5 mixed findings, 1 negative association)
 Der-Martirosian 2013 [43]; US Education and employment (Individual) Level of education (<HS, HS, some college, college graduate)
Income ($15,000–$35,000; $35,000 or above)
Employment status (employed, unemployed)
Sociodemographic variables, source of care, and veteran status National Health Interview Survey; National survey (2010) Mixed findings. Adults had greater odds of H1N1 vaccination where they had some college (1.29OR, 1.07–1.55CI) or graduated college (1.80OR, 1.49–2.19CI), compared to persons with less than high school; only college graduation was associated with seasonal influenza vaccination (1.58OR, 1.34–1.86CI).
Higher income was positively associated (1.24OR, 1.11–1.40CI) only with seasonal influenza vaccination.
Employment status was not associated with either H1N1 or seasonal influenza vaccination.
 Laenen 2015 [44]; Belgium Education, employment, and income (Individual and household) Education: lower (no HS diploma), HS diploma, higher (beyond HS)
Family income: less than 1500 euros, 1500–3000 euros, more than 3000 euros
Work situation: fulltime, part-time, no job
None reported Survey, clinical, and administrative data; Questionnaire, medical charts, and registry data from University Hospitals in Leuven (2013–14) Mixed findings. Income or work situation did not influence vaccine coverage.
Higher education pregnant women were more likely (2.73OR, 1.46–5.29CI) to be vaccinated than those with secondary school.
 Liu 2012 [45]; Canada Neighbourhood level of education, income, and employment (Neighbourhood) Level 1 (lowest) to 5 (highest) assigned to neighbourhoods based on linked postal code records with Census data for highest level of education, median family income, and employment income Sociodemographic variables, health status variables, clinical variables related to pregnancy, and neighbourhood-level characteristics Better Outcomes Registry & Network; Birth records database (2009–10) Mixed findings. Women who gave birth in an Ontario hospital with the highest level of education and the highest level of income were more likely to receive influenza vaccination compared to women from lower levels.
Employment level was not significantly associated with vaccination.
 Shin 2012 [46]; Korea Education, employment, income (Individual) Education (HS and above, less than high school)
Employment (employed or unemployed)
Monthly income (equal to or more than 2 million KRW, less than 2 million KRW)
Sociodemographic variables, health status variables, cancer variables, and vaccine knowledge and beliefs variables Korean National Cancer Centre Survey; Nationwide survey (July – October 2010) Mixed findings. Among cancer patients age 18 years and older, higher vaccination rates were associated with higher levels of education (1.72 OR, 1.02–2.93 CI).
 Shono 2015 [47]; Japan Education, employment, income (Individual) Schooling years of the respondent
Annual household income quintile
Mother’s employment (Unemployed, employed)
Sociodemographic variables and vaccination recommendation Survey of Japanese parents with at least one child under 13 years of age; Survey conducted for study purposes (2013) Mixed findings. After controlling for sociodemographic variables and vaccination recommendation from a physician, the only significant relationship found was between the second-highest income quintile compared to the lowest (0.64 beta coefficient, 0.07 to 1.20 CI).
 Yang 2014 [48]; Korea Education, income, and occupational class (Individual) Education (less than HS, HS or more)
Monthly income (2 million KRW or more, less than 2 million KRW)
Occupational class (professional, service/manual worker, others)
Sociodemographic variables Korean Community Health Survey; Nationwide survey (2008–2012) Negative association. Across all seasons, lower levels of income, working in service or physical occupations, and lower levels of education were significantly associated with higher levels of vaccination among Korean adults.
Socioeconomic status, as a composite measure (n = 3; 2 positive association, 1 no association)
 Bohmer 2012 [49]; Germany Socioeconomic status (Individual) High, medium, or low (determined based on education, income, and professional education) Sociodemographic and health status variables Germany Health Update; National survey (2009–10) Positive association. High SES adults were more likely (1.61OR, 1.23–2.11CI) to be vaccinated against pandemic influenza compared to low SES adults.
 Maher 2013 [50]; Australia Socio-economic index summarizing information about the economic and social conditions of people and households within an area (Neighbourhood) Index of Relative Socio-economic Disadvantage Sociodemograhpic and antenatal care experience variables Survey of women who delivered a baby in public hospitals; South Western Sydney and Sydney local health districts (2012) No association. There was no significant association between level of SES disadvantage and influenza vaccination after adjusting for sociodemographic and antenatal care variables.
 Schwartz 2013 [51]; Israel Socioeconomic status (Neighbourhood) Defined by the income quartile assigned by the zip code of the patient’s residence, using census data (High SES = 4, low SES = 1) Sociodemographic variables, primary care variables, and comorbidities Data from Maccabi Health Services; Maccabi Health Services (2004–09) Positive association. There was a positive stepwise relationship between SES status and influenza vaccination status, whereby persons in high SES at Level 4 SES (ref) were more likely to be vaccinated compared to Levels 3 (0.82 OR, 0.79–0.85 CI), 2 (0.74OR, 0.71–0.77 CI), or 1 (0.72 OR, 0.68–0.77 CI) among the elderly aged 65 years and older.
Deprivation index (n = 3; 3 positive association)
 Brien 2012 [52]; Canada Material and social deprivation (Neighbourhood) Deprivation quintile (1 = low to 5 = high) derived from Pamplaon and Raymond’s index of material and social deprivation Sociodemographic and clinical variables Immunization records from National Public Health Institute of Quebec; Administrative data (2009) Positive association. There were lower levels of vaccination in neighbourhoods with higher levels of material deprivation (per unit increase, approximately 7, 15, and 17% decrease in odds).
No association was found between social deprivation and neighbourhood-level vaccination rates.
 Calder 2014 [53]; New Zealand Socioeconomic deprivation (Neighbourhood) Level of socioeconomic deprivation, measured by NZDep 2006 quintile (1 = low, 5 = high deprivation) None reported Data from the patient management system of primary health organizations; Administrative data (2012–13) Positive association. Vaccination among children improved after introducing a school vaccination programme. Vaccination was lowest in the most deprived quintiles (Dep1 = 30.2%, Dep2 = 29.2%, Dep3 = 36.6%, Dep4 = 24.3%, Dep5 = 21.9%)
 Green 2015 [54]; England Multiple deprivation (Neighbourhood) Overall score assigned to each census lower super output area level summarizing relative deprivation based on: income, employment, health, education, crime, service, access, and living environment. Higher score = higher deprivation. Population-level characteristics (e.g., sociodemographic, rural/urban classification) Clinical and program data; 2–3 yr. olds: data collected from GP practices through ImmForm
4–11 yr. olds: data collected at schools from each of 6 pilot sites (2013–14)
Positive association. Children ages 4–11 were significantly less likely to be vaccinated in the two areas of highest deprivation, with scores of 26.1 to 39.9 (− 5.55 SC, − 9.54 to − 1.56CI) or 39.9+ (− 7.9 SC, − 12.16 to − 3.64 CI).
  1. Acronyms: CI confidence interval, NZDep New Zealand Index of Deprivation, OR odds ratio, HS highschool, PR prevalence ratio, SES socioeconomic status, US United States
  2. aSociodemographic variables included: age, sex, place of residence, education level, rural residence. Clinical variables included: underlying chronic disease, preventive health practices, health status, health care worker, primary care provider, continuity of care, low birth weight, respiratory illness. Health belief variables included: knowledge, attitudes, practice