Gender and citizenship disparities in the COVID-19 vaccination campaign in Italy

BACKGROUND: The literature identifies several cultural, religious, and gender-related factors associated with vaccine hesitancy. To guide a fair and more effective vaccination campaign, we investigated the association between these factors and adherence to COVID-19 vaccination in the 815,000 population assisted by the Local Health Authority (LHA) of Tuscany South-East, Italy. METHODS: Anonymized data on the vaccination status of patients (≥5 years) assisted by the LHA from December 2020 to January 2022 were extracted from the Health Information System of Collective Prevention. We evaluated vaccination coverage (≥2 doses, also considering any previous or subsequent infections) by age, gender and nationality. We performed logistic regression with STATA/MP13, setting the significance level at p < 0.05. RESULTS: Adherence to vaccination was significantly lower among foreign patients (68.1% vs 86.6% p < 0.01); after adjusting for age and nationality, a significantly lower propensity to vaccination was observed among women (adjOR 0.90 CI95% 0.89-0.91), also of Italian nationality (aOR 0.94 0.93-0.95). The gender difference was more marked among non-Italian citizens (aOR 0.82 0.79-0.84) and is accentuated in specific ethnic groups: Macedonian (aOR 0.61 0.52-0.71), Kosovar (aOR 0.53 0.45-0.61), Pakistani (aOR 0.63 0.52-0.75), Nigerian (aOR 0.49 0.38-0.64). CONCLUSIONS: Lower vaccination coverage in women, particularly of foreign nationality, can be due to lower participation in social and working life, as it was decisive by law to access jobs with regular contracts. Public health has the task of removing these barriers and protecting the health of all citizens equally. According to our findings, we implemented equity-oriented measures, such as vaccination sessions without an appointment and with the presence of a cultural mediator, specific awareness campaigns aimed at personal assistants, dissemination of information material translated into several languages. KEY MESSAGES: • Women, especially of foreign nationality, have lower vaccination coverage. • Gender is a determinant of health: Public health has the task of removing these barriers and protecting the health of all citizens equally.