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Table 2 Themes that emerged at structural, intermediate, and health care systems levels

From: Social determinants of health and seasonal influenza vaccination in adults ≥65 years: a systematic review of qualitative and quantitative data

Level Theme Summary definition Example citation References
1. Structural determinants
1.1 Policy and governance level Vaccine supply Insufficient seasonal influenza vaccine available for all countries to reduce immunization inequities.   MIV [41], Partridge [38], Kieny [5]
  Finances Fully funded immunization programs. Reimbursement. Strong recommendations may be insufficient because patients might accept the vaccine but cannot afford it. Kunze [43], Lataillade [10], Fedson [39]
  Public health promotion Awareness of the population through public health information. Promotion about influenza, policy recommendations, and high risk groups for vaccination. “There was little knowledge about target groups for vaccination in Poland, Turkey and South Africa- countries without immunization programs” (Lataillade). Lataillade [10], Kwong [44]
“Awareness of influenza in countries without influenza immunization programs was poor. In South Africa and Turkey in 2005–06 influenza was not distinguished in severity from the common cold” (Lataillade).
1.2 Provider and healthcare system related Programmatic barriers: lack of consensus on immunization practices, strategies, and target groups Recommendations, strategies and practices to vaccinate elderly adults, in outpatient clinics or in nursing homes, are not standardized and vary from country to country. Lack of harmonization of target groups and strategies.   Michel [42], Lataillade [10], Fedson [39], MIV [41], Ropero-Alvarez [37], Kroneman [7], Nakatani [45]
1.3 Patient-related Gender Some reports suggest that men are more likely to be vaccinated, and that likelihood of vaccination may change with age for both genders, but both without confirmation in multivariate analyses. No difference by gender was reported in other studies.   Nowalk [47], Shemesh [48], Evans [49], Mangtani [33], Abramson [50], Sarría Santamera [28], Gauthey [51], Chiatti [53], Lopez de Andres [32], O‘Malley [27], Armstrong [52]
  Gender and occupational roles Occupational roles and responsibilities for childcare may decrease the likelihood of being vaccinated. “Responsibilities for childcare may also influence access to care” (Adonis). Adonis [2], Daniels [67], Peña –Rey [32]
“Non–care givers (of children, old people, or sick people) had an increased probability of being vaccinated” (Peña-Rey).
  Age Age has been associated with vaccination uptake in some cross-sectional surveys. Overlap of other factors such as chronic diseases or limitations of functional status must be considered. Others report no difference by age.   Peña-Rey [32], Lopez de Andres [32], O‘Malley [27], Shemesh [48], Evans [49], Chiatti [53], Armstrong [52]
  Marital status Being married or living with others has been associated with vaccination acceptance in some studies. However, other reports found no relationship. Overlap with issues about social support, access difficulties, or regular preventive health care must be considered.   Mangtagni [34], Damiani [14], O‘Malley [27], Nowalk [47], Gauathey [51], Sarria- Santamera [28], Zimmerman [30] Abramson [50]
  Education Higher education level has been associated in some reports with higher vaccination rates. However, scales to measure educational attainment and results are not consistent. Others report no influence of education in vaccine uptake or a reverse gradient. Health-related print literacy may have an influence.   Abramson [50], O‘Malley [27], Chiatti [53], Damianni [14], Sarría Santamera [28], Mullahy [55] Bennet [56]
  Race – ethnicity Higher vaccination rates in whites than in African Americans and Hispanics have been found in the US. Other reports found no differences by ethnic group. In other countries, minority groups may have lower vaccination rates. Language and education may also be related.   O‘Malley [27], Lindley [31], Zimmerman [29, 30], Shemesh [48] Nowalk [57], Bardenheier [58]
  Some ethnic groups have specific fears and mistrust of modern medicine, provider, or the health care system Specific racial groups, like African-American elderly in the US, commented mistrust of the healthcare system and fears. “We have a general distrust of the medical profession, and we have beliefs in home remedies and that kind of thing.” “Black, people, we have fears. We have fears of the healthcare community - you know, the Tuskegee stuff” (Daniels). Daniels [67] Harris [63]
  Language and literacy barriers for physician contact or for written campaign information Minority elders prefer to speak to their provider or read written materials in their native language. “… I like to go to the Haitian doctor because I can speak with him and do not get embarrassed”. Participants preferred to be interviewed in Creole (Adonis-Rizzo). Adonis-Rizzo [2], Lasser [71], Daniels [67], O‘Malley [27]
  Socio-economic level This multi-dimensional concept was measured with different variables across studies. Lower socio-economic status has been correlated with lower vaccination uptake; however, other reports showed no difference, or even reverse gradient.   Peña- Rey [32], O’Malley [27], Nowalk [47], Chiatti [53], Mangtani [34], Sarría-Santamera [28], López de Andres [32].
  Presence of chronic diseases Vaccination rates have been higher among patients with chronic diseases, adjusting for gender, age, and other factors. Other reports have found the association only in bivariate analysis.   Chiatti [53], Evans [49], Damiani [14], López de Andres [32], O‘Malley [27], Abramson [50]
  Cultural values and health beliefs: healthy living for prevention of illness Health beliefs include the desire to improve health, the importance of healthy living, and behaviors and lifestyles important for prevention of illness and health promotion. Refusers may have reliance on healthy lifestyle and avoidance of close contacts. Community perceptions to not get vaccinated are a barrier to immunization. “My father had a saying, which he repeated again and again: it is better to pay the butcher and the baker than the doctor … I still continue today in the way my father and mother brought us up, meat, fish, vegetables …” (acceptor) “keep away from people, you know, because I think myself, what gives you flu if you don’t have the needle, I think you get flu by being with a lot of people you see” (acceptor who became refuser) (Telford) Sengupta [65], Telford [66], Cornford [62], Adonis-Rizzo [2], Evans [64], Daniels [67], Kwong [69], Zimmerman [30]
“Well, it’s for my health so I’m going to do it, if it’s the best thing for me” “If they (churchgoers) felt that the flu shot were to their advantage, they would stand in line for five or 10 minutes and get the shot and then go home” (Daniels).
  Sense of community - protect others Sense of responsibility to protect self and others in the community. Word-of-mouth from the community to get the flu shot. “I think so, yes I think so a lot (friends say that to you as well, a general feeling that vaccination is a good thing to do), that’s the first think on their minds. You all see that you all get it. It reminds you and you remind others. Make sure we all get it” (Vaccinated from UK). Sengupta [65], Schensul [36]
  Local beliefs, perceptions, and knowledge: indigenous health practices to avoid or treat influenza Local understandings of the cause of influenza as a natural illness (as opposed to other that come from outside- competing paradigms), that can be treated with natural remedies, food and warm clothing, as well as the awareness of the potential severity of the disease. “I thought that it is just a big cold … Can you explain it to me? … I don’t know what is it, I though I was just a cold” [they consider flu a natural illness, traditional preventive practices would seem sufficient, and the potential for complications was not considered] (Adonis-Rizzo). Kwong [8, 69], Cameron [70], Sengupta [64] Adonis-Rizzo [2], Daniels [67]
  Trust or lack of it in the health care system, provider, or modern medicine Lack of trust in the vaccine. Fears and mistrust in the healthcare system. “Well I would say, if you get recommendations from the Government and the medical profession and they both urge you to do these things, well do’em …” (acceptor) “The first time, I had it on the Tuesday morning and by night I was out with my sisters and friends, .. I went shivering, shaking, so I left them, and got a taxi home and took a couple of powders and went to bed. The next morning I was as right as rain, and I’ve had it twice since then and it’s never affected me”. “We have a general distrust of the medical profession, and we have beliefs in home remedies and that kind of thing.” (Daniels). “I don’t like doctors and hospitals all that much” (Evans) Harris [63], Telford [66], Evans [64], Daniels [67]
2. Intermediate Determinants
2.1. Policy and governance level Housing – place of residence Data about differences between rural and urban settings are contradictory and depend on country and health system characteristics. Place of residence may determine ease of access to vaccination, and socio-economic status may affect living conditions (central heating or not, rented or owned house).   Mangtani [33, 34], Lopez de Andres [32], O‘Malley [27], Sarría Santamera [28], Zimmerman [30]
2.2. Provider and healthcare system related Type of practice VA system has higher vaccination rates compared to non-VA practices due to its use of multimodal interventions to increase rates such as freestanding vaccination clinics, patient reminders, standing orders, and regular assessment of vaccination rates with incentives to clinicians.   Zimmerman [30]
  Influenza vaccination in the previous year One of the most important predictors of vaccine uptake. However, does not always reflect current attitudes towards vaccination.   Lasser [71], Harris [63], Telford [66], Kwong [8], Evans [49], Zimmerman [30], Armstrong [52] Cornford [62], Nowalk [47]
2.3. Patient-related Behavioural beliefs about consequences of vaccine uptake Different frameworks proposed. Behavioral beliefs are based on the patient’s probability calculation of susceptibility to and severity of influenza, their knowledge about vaccine effectiveness, and their healthcare and social cost of the vaccine.   Bosompra [35], Zimmerman [29], Nowalk [47], Kwong [8, 44]
  Social influences. Advice from family or peers may trigger vaccine acceptance Cautious willingness. Patients trust their family members, as well as peers or known community members’ advice. “My daughter told me about it, I had it done based on her recommendation. I had it done because I trust my daughter. I didn’t hesitate (Vaccinated, South Korea, Kwong). “I have to ask my children before that. If they say I should, I’ll receive this injection. If they say no, I will not receive it …” “I will talk with my friends, people of the same age and with the same health condition could help us decide whether to get the flu shot or not. If they decide against it, I do not want to do it either” (Payaprom). Evans [64], Adonis-Rizzo [2], Lasser [71], Payaprom [46], Schensul [36], Daniels [67], Kwong [8, 61], Zimmerman [29, 30], O‘Malley [27], Lau [73]
  Prior experiences of influenza or with influenza vaccine (IV) Own or observed prior experiences, positive or negative, of influenza or with IV in previous years. “My brother in law got it and he was in the hospital for more than a month with the flu, with fever, vomits, he got everything.” “Ay cuñada don’t do it”, so I never got it. No, no, I won’t do it” (Lesser). Lasser [71], Harris [63], Telford [66], Kwong [8, 44], Bardenheier [58] , Bosompra [35], Evans [64]
  Concerns about the vaccine safety, effectiveness, side effects. Fear of pain, injections, and getting the disease with the vaccine Negative experiences or anecdotes and fear of mild or severe side effects and pain. Refusers are more likely to believe IV had serious side effects, that it is ineffective, and be skeptical or have no confidence in the vaccine. “… it was purely that I didn’t like needles and people, you’d hear about these side-effects; al the side affects you have from that flu jab, oh you can’t lift your arm and you’re sick” (refuser who became acceptor) (Telford) “I’ve heard so many people being bad (ill) after it …” (Evans) Lasser [71], Telford [66], Evans [64], Daniels [67] Kwong [44, 61], Armstrong [52], Bardenheier [58], Harris [63], Cameron [70], Sengupta [65], Adonis –Rizzo [2], Shemesh [48], Zimmerman [29, 30], Kwong [44]
“My sister has the flu every year, and she takes the shot! … I said well that doesn’t make sense. And she has it real bad. So I never bothered with it”. “I thought if I took the flu shot I might get a cold, get the flu”. “I take it, the flu shot, then, I get the flu” (Cameron) “I don’t think it gives you overall protection” (refuser).
  Willingness to continue, adherence If positive experiences occurred after the first shot, every year the patient will continue with IV. “I took it and I will take it from now on” (Schensul). Harris [63], Schensul [36], Lau [73], Zimmerman [30]
“The habit of being vaccinated” (Zimmerman).
  Perceived risk or susceptibility Perceived susceptibility based on patient’s awareness and previous knowledge of the disease. “I think the good part outweighs the risky part of it. Just like with normal shots, the same thing. You may get pneumonia you may get sick, but probably 96% of people, this is going to save them in some way”, “I take it so I won’t be as sick. It does make me feel bad, but I still get up and go. You know?” Evans [49], Kwong [8, 44], Telford [66], Bosompra [35]
  Perceived severity of influenza, previous awareness and knowledge about influenza Fear of disease. Knowledge and beliefs about severity of influenza and its contagiousness. Some patients think influenza is serious for others, but not themselves. Contrasting opinions. “It is not the worst thing in the world. It can be dealt with” vs. “You really, really, really feel really sick”, “you feel like you going to die” (Cameron). Being knowledgeable about the severity of the flu: “I have had the flu, and I know how sick you can get from it” (Payaprom). Cornford [62], Cameron [70], Payaprom [46], Kwong [8, 44], Bardenheier [58]
  Lack of knowledge. Misconceptions about influenza or IV. Curative vs. preventive effect. Misconceptions about adult vaccination Misconceptions about influenza and about the vaccine might be prevalent in some communities, and should be approached with correct information sources. “I normally get the tetanus booster every 10 years as it comes up. And I can see the benefits of the pneumonia, the pneumovac … For older people. As far as the flu, I’ve never had the flu, so I don’t get the vaccine” (Daniels). “The vaccine is good, really, so that it will take out all the infection that you have, like that, really”, “then they put the vaccine (flu), the flu comes, and you throw out a lot of phlegm” (Daniels). Payaprom [46], Daniels [67], Armstrong [52]
  Perceived or self-appraised health status. Awareness of IV indications Self-perception of “poor” health has been associated with vaccine acceptance, whereas self- perception of “good” health may be a reason for non-uptake. Perceived risk (low or high, age related) of contracting influenza, the knowledge of personal risk factors and awareness of vaccine indications are important factors. Some elders believe that influenza carries no risk for healthy older people. Some patients are not able to relate the potential risk of mortality from influenza to themselves or to others unless a pre-existing condition or other health issue is present. “Young people can fight it”, “I think because you’re older, resistance is low” (Cameron). “Well, I really don’t be sick … I ’m in a pretty good shape the doctors say”. “I am a person that don’t catch colds very easily” (Cameron) “Yes, I believe it could be (that death could occur) but not directly because of the flu, because when the flu is developed where there is high temperature and low defenses, that could trigger another kind of disease that is present but unseen. … he could have lived for a long time, but he caught a very bad flu, and it forced him to stay in bed. That happens to elderly people when they stay in bed for a long time, especially on their backs, and it gets complicated. It complicates with the lung, and he died, but truly, you can’t say that it was only because of the flu” (Daniels). Cornford [62] Evans [49], Cameron [70], Sengupta [65], Payaprom [46] Daniels [67], Kwong [69], Zimmerman [30], Damiani [14], Peña-Rey [32], López de Andres [32], Mangtani [33].
  Perceived cost of the vaccine. Free, low, or high cost. Reimbursements If financial barriers exist, even patients who have accepted the vaccine will not receive it. Misunderstandings or misinformation about cost of influenza vaccine exist. “Right now, I don’t have a good income and so even if I wanted to couldn’t get the flu shot” (Kwong) “I got mine because it was free”, “some of the problem [is] they don’t have health insurance and cannot afford to pay for these things” “Also cost, better health insurance for, insurance making it (flu vaccine) available that way” (Sengupta). Kwong [8, 61], Cameron [70], Sengupta [65], Lasser [71], Lau [73]
  Perception of health care cost and social cost Cost of treatment of disease or its complications. “The flu shot is not expensive if it is effective $80 is cheap … I need to pay several hundreds to treat influenza-related diseases. The cost of the flu shot is lower” (vaccinated from China, Kwong). Kwong [8], Lau [73], Cameron [70], Sengupta [65], Lasser [71]
An increase of the chances to infect their family members, particularly for elderly adults living with other persons including family and grandchildren.
My doctor advised my daughter to have me get the flu shot, so I do so every year. My daughter as two lovely children … and they usually get sick during winter … We live together” (vaccinated from Greece, Kwong).
3. Health systems
3.1. Policy and governance level Accessibility to seasonal influenza vaccine Different aspects of accessibility for the elderly are distance to the health center, convenience of its location, transportation, language, access to healthcare, and legal status.   
  Convenience. Vaccine delivery may be enhanced in more convenient places for elderly people Elderly people may consider having the vaccination if it is provided locally, near their home, or in convenient community delivery places as pharmacies, shopping malls, and supermarkets. “The health center is fine. It’s near our houses and it’s not crowded. If it’s the hospital, you have to spend one day because the hospital service is very slow and my children have to take me there” (Payaprom). “In terms of flu shots, it’s, I think, a whole matter of convenience” “The only reason my husband had a flu shot was that he happened to be in supermarket, and they were doing them” (Daniels). Payaprom [46], Cameron [70], Daniels [67], Adonis –Rizzo [2],
  Faith based organizations or other community organizations as venues for adult immunization delivery Churches were perceived as convenient and accessible community locations, trusted organizations in the community, and sites where a significant number of older adults regularly convened. Peer models, bulletin posters, and support from faith-based leaders may be used to give encouragement. “I think the church is a good place for vaccinations because a lot of people go there”, “I think it would be a good place. Obviously, there needs to be other places too, for people that don’t go to church. But I think you would find a lot of them - I know that the older generation does tend to go to church or go back to the church at some point” (Daniels). Daniels [67]
  Depend on others for transportation Most patients did not drive and are dependent on their children, friends, or church members for transportation. This dependence makes return visits more difficult to schedule. “It is hard to drive … If my children can take me where the vaccine is being offered, I will definitely take it” (Adonis) Adonis-Rizzo [2], Daniels [67], Zimmerman [29], Lasser [71]
  Language and literacy barriers for physician contact or written campaign information Cultural competencies of provider are desirable and needed to deliver preventive messages and to convince patients to get vaccinated. “… I like to go to the Haitian doctor because I can speak with him and do not get embarrassed”. Participants preferred to be interviewed in Creole (Adonis). Adonis-Rizzo [2], Lasser [71], Daniels [67], O‘Malley [27], Kwong [61]
  Immigration status Having to sign forms with names and addresses may elicit fears related to legal immigration status. Some adults fear losing access to services. “Yes, yes, I have heard commentaries that they don’t get near the vaccines because “I am illegal”. Now, yes and they are distrustful, really, because you have to sign papers with your name” “The hospital that I go, they tell you every year to go and get the vaccine. Then, I go and get the vaccine because I am scared that they would take away my assistance” (Daniels). Daniels [67]
  Affordability and cost Elderly people may consider having influenza vaccination if it is provided free of charge. Some patients felt that knowledge of the costs and benefits of the IV may be a motivating factor to increase immunization. “They should (get vaccination). But what would they do? Elderly people without any income support can only live day by day” (Payaprom) “ If the black community were more aware of these free vaccines - I mean, it’s going to be cost-effective for them health wise, and also for HMOs because you don’t need to fill up a hospital with a bunch of people with pneumonia” (Daniels). Payaprom [46], Cameron [70], Daniels [67], Lau [73], Kwong [8, 61], Sengupta [65], Lasser [71],
  Health insurance or preventive services. Lack of knowledge about insurance coverage and IV cost Some patients had limited knowledge and understanding of the existing healthcare insurance coverage for the flu vaccine. Lack of health insurance, insurance status, and cost were important considerations. “The lack of care would make people to seldom receive the vaccines or prevent them from receiving them. It is that they don’t have a doctor, people don’t have access to doctors “. Adonis-Rizzo [2], Lasser [71], Daniels [67], Zimmerman [29, 30], O‘Malley [27]
  Recent visits to the health care center The use of medical care or services and the frequency of contacts with the health care system may increase the opportunities for receiving counseling and immunization (but not always).   Abramson [50], O’Malley [27], Peña-Rey [32], Evans [49]. Sarría-Santamera [28]
3.2. Provider and healthcare related Health professionals’ influences. Advice from physician or professional health care provider Physicians’ recommendations are one of the most frequently reported influences on immunization status. Patients trust their provider’s advice. However, providers cover many topics in visits and may not talk about IV or recommend it. Providers must be proactive, have consistency in their recommendations, and promote vaccination with patient reminders. “My doctor never told me about it .... If he recommended I would take it” (Adonis). “I don’t remember being reminded to get a flu shot. I used to go to a general practitioner and perhaps he could mention that … My gynecologist doesn’t talk about flu shots. I have an oncologist, he doesn’t talk about flu shots - so most of my doctors are more linked to specific conditions, they’re specialist, and they don’t talk about flu shots”. “But, I don’t remember on any regular basis- any doctor or nurse- saying to me … for instance; I just got notice in the mail that it was time to have my mammogram. And then I thought - okay. I will do that. But I’ve never gotten anything in the mail or from my doctors saying “It is time to have your flu shot”. Adonis-Rizzo [2], Armstrong [52], Bardenheier [58], Evans [49, 64], Lasser [71], Daniels [67], Kwong [8, 61], Gauthey [51], Zimmerman [29, 30], Lau [73], Payaprom [46], Schensul [36], Shemesh [48], O’Malley [27], Nowalk [47] , Sengupta [65], Müller [74]
  Physicians’ awareness, knowledge, attitudes, and practice. Communication strategies and cultural competence Healthcare provider acceptance of seasonal influenza vaccine depends on demographic factors such as years of practice, being up-to-date with scientific journals, and cultural factors. Other factors that promote vaccine acceptance are communication strategies include information giving skills, cultural competency, empathy, persistence, trust, and vaccination by the provider. Availability and distribution of the vaccine in a timely basis are determinants of the perceptions of the practitioners. Other environmental factors include logistical and competing demands.   Zimmerman [31], Pavia [76], Lasser [71], Pyrzanowski [75], O’Malley [27]
3.2. Patient related Sources of information Suggestions on how to effectively provide information on the significance of influenza immunization to the health of older adults. Suggested strategies included those through the healthcare system, media, community-based organizations, and churches. Advertisements through television, radio, newspaper and magazines may not be as effective as desired. “I think if you had multiple sources of information - if you had it through the church, the announcements at church or the bulletin, on TV, on the radio, in the newspapers … then you could remember where and when (to get the flu shots)”. (Daniels) Daniels [67], Zimmerman [29]
Source of information about influenza vaccine recommendations are medical professionals, television, newspapers, friends/ family and other (Zimmerman 2002)