ArticleBMC infectious diseases2026
The role of vaccination, underlying health conditions, and working in healthcare in the socioeconomic disparities in COVID-19 hospitalization: a mediation analysis using interventional effect models.
Article in BMC infectious diseases, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundPrior research has established an association between socioeconomic determinants and COVID-19 hospitalization rates. This study explores the potential mediation of this association by vaccination status, underlying health conditions, and working in healthcare.
methodsWe conducted a retrospective cohort study including 111,159 and 337,232 adults living in the Walloon or Brussels regions in Belgium with a confirmed SARS-CoV-2 infection during the Delta-predominant period (1 September 2021 to 22 December 2021) and the Omicron-predominant period (4 January 2022 to 1 September 2022), respectively. Data on COVID-19-related hospital admissions, education, vaccination, underlying health conditions, and individuals working in healthcare were retrieved from multiple national registers, linked at an individual level using the Belgian social security number. Mediation analyses using interventional effect models were used to assess the mediation role of vaccination, underlying health conditions, and working in healthcare in the relationship between education and COVID-19 hospitalization.
resultsShifting from moderate or high education to low education increased the probability of COVID-19 hospitalization by 0.694% points (95% CI 0.561–0.819) during the Delta period and 0.547% points (95% CI 0.491–0.603) during the Omicron period. Most of this increase was due to the direct effect of education, accounting for 84.6% of the total effect during Delta and 93.1% during Omicron. During the Delta period, education disparities in COVID-19 hospitalization were partially mediated by vaccination (10.1%) and underlying health conditions (6.3%). During the Omicron period, education disparities in COVID-19 hospitalization were partially mediated by underlying health conditions (4.8%), vaccination (1.4%), and working in healthcare (0.7%).
conclusionsThis study demonstrates that socioeconomic disparities in COVID-19 hospitalization rates are partially mediated by vaccination and underlying health conditions. This suggests that public health interventions aimed at increasing vaccination rates and preventing underlying health conditions could mitigate some of the effects of socioeconomic disparities in COVID-19 hospitalization outcomes. However, future research is needed to investigate additional mediating factors of education in COVID-19 hospitalization, such as living and working conditions, to better elucidate the causal pathways of social inequalities in severe COVID-19. CLINICAL TRIAL NUMBER: Not applicable.
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