Attitudes towards COVID-19 vaccination and containment measures in Italy and the role of occupational physicians.

BACKGROUND: Vaccine hesitancy is the main barrier to the effective management of COVID-19. This study aims to evaluate attitudes towards vaccination and containment measures in Italy, and the role of occupational physicians in the management of COVID-19.
METHODS: Between 26 and 31 January 2022, we conducted a national online survey including 1000 respondents (631 workers) representative of the Italian population. A series of questions were asked to get information on attitudes towards COVID-19 vaccination, containment measures and management of COVID-19. Sampling weights were used to obtain national estimates.
RESULTS: The majority of respondents (92.6%) received at least two doses of SARS-CoV-2 vaccine (or one dose of Janssen, Ad26.COV2.S), only 4.9% did not get any dose. Most interviewees (79.2%) stated that the decision to be vaccinated was their own choice, while only 4.3% were convinced by the general practitioner or the occupational physician. History of SARS-CoV-2 infection was reported by 23.9% of the participants (30.2% among workers); and 40% of the infected workers were contacted/visited by an occupational physician.
CONCLUSIONS: Vaccine uptake was remarkably high in Italy. Occupational physicians played a relevant role in the management of COVID-19 in occupational settings.

Introduction

Italy was one of the countries most severely hit during the first wave of the COVID-19 pandemic (March-May 2020) [1-4]. At the end of 2020, the onset of the vaccination campaign raised great hopes for a rapid ending of the pandemic. Soon after, however, concern over the emergency authorization and testing of the vaccines and safety issues mounted in the population. Despite some scepticism, around 80% of the Italian population over 12 years received two doses of the vaccines against SARS-CoV-2 by the end of 2021 [5]. Albeit low, the share of the population who refused the vaccine caused a new surge in hospital beds occupation since October 2021, plunging the country into a new emergency and forcing the Government to maintain and, in some cases, reinforce containment measures. Thus, vaccine hesitancy remains among the main barriers to pandemic control.

We therefore conducted a survey to understand the reasons that prompted the Italian population to get vaccinated, and their attitudes towards SARS-CoV-2 vaccination and containment measures. We also evaluated the role of the occupational physician in the endorsement of immunisation and management of COVID-19 in infected workers.

Methods

The study is based on a national survey commissioned by the Italian Society of Occupational Medicine (Società Italiana di Medicina del Lavoro - SIML) and conducted by Doxa between 26 and 31 January 2022 in Italy.

A sample of 1000 individuals (631 workers) aged 18-74 years, extracted from a panel of 120,000, was interviewed using a Computer-Assisted Web Interview technique. A two-stage sampling design was used: participants were sampled in strata of sex and age groups within municipalities selected according to geographic area and size.

This sample size complies with the WHO recommendation of using 1000 participants when conducting behavioural insights studies related to COVID-19 [6].

The survey included a series of questions regarding attitudes towards COVID-19 vaccination and the containment measures the Government implemented. Weighted percentages are reported to account for oversampling of certain groups of the Italian population and survey nonresponse.

Differences by sex and age groups were tested using the modified Chi-square test proposed by Rao and Scott that considers the survey design [7].

A weighted logistic regression model, with standard errors clustered at the municipality level, was used to estimate the odds ratio (OR) and the corresponding 95% confidence intervals (CI) of not being vaccinated according to occupational categories. Due to the limited number of participants in some categories, we grouped the original categories in four groups: 1) Highly qualified non-manual workers (including entrepreneurs, professionals, executives, managers, armed forces, police officers, medical doctors and teachers), 2) routine non-manual workers (office and sales workers), 3) manual workers (manual workers, farmers and agricultural workers), 4) inactive population (unemployed, housewives, retired and students). The regression model was adjusted for sex and age group (18-34, 35-54 and 55-74 years).

Results

Table 1 describes the demographic characteristics of the sample and their weighted distribution. Around 46% of respondents were 35-54 years old, 11.6% had less than a high-school diploma, and almost one-third were office workers.

Table 1

Sociodemographic characteristics of the survey sample

	No. of respondents	Sample %	Weighted %
Total	1000	100	100
Sex
Men	506	50.6	49.5
Women	494	49.4	50.5
Age group
18-34	291	29.1	24.2
35-54	463	46.3	40.5
55-74	246	24.6	35.3
Education
Master/PhD	43	4.3	3.9
Master degree	162	16.2	6.2
Degree	154	15.4	6.9
High-school diploma	525	52.5	43.4
Middle-school diploma	109	10.9	31.8
Primary school	5	0.5	5.8
No education	2	0.2	2.0
Occupational category
Entrepreneurs	20	2.0	2.1
Professionals	72	7.2	5.2
Executives	16	1.6	1.0
Managers	20	2.0	0.7
Full-time office workers	316	31.6	25.8
Part-time office workers	54	5.4	5.0
Sale workers	23	2.3	2.0
Manual workers	61	6.1	6.8
Armed forces officers	25	2.5	2.2
Other armed forces workers	7	0.7	0.9
Other teachers	8	0.8	1.4
Medical doctors	6	0.3	0.04
Farmers	3	0.3	0.06
Housewives	71	7.1	8.6
Retired	44	4.4	8.0
Unemployed	78	7.8	7.7
Students	108	10.8	9.1
Other	68	6.8	13.4

Table 2 shows self-reported history of COVID-19 overall and by time of infection, and, for those reporting infection, contact tracing and infection management by family and occupational physicians by age and sex: data are reported as weighted percentages (and absolute numbers in brackets). Around 24% of respondents reported having been infected by SARS-CoV-2. About half of these occurred between December 2021 and January 2022, i.e. during the Omicron phase. Symptomatic COVID-19 was reported in 19.5% of the interviewees and was more frequent among younger individuals (33.7% at ages 18-34, 15.4% at ages 35-54, and 14.4% at ages ≥55 years). Their contacts were traced in two-thirds of the cases. The prevalence of SARS-CoV-2 infection among workers was 30.2% (189 respondents), and 40% were contacted/visited by their occupational physician (50% among those with a referent occupational physician).

Table 2

Self-reported COVID-19 and management of infection by age group and sex

	Age group				Sex
	18-34(n=291)	35-54(n=463)	55-74(n=246)	P value	Men(n=506)	Women (n=494)	P value	Total(n=1000)
Self-reported COVID-19
Never	59.8 (185)	81.5 (342)	81.1 (194)	0.026	73.0 (359)	79.2 (362)	0.406	76.1 (721)
Asymptomatic	6.4 (31)	3.2 (27)	4.5 (18)		3.4 (39)	5.5 (37)		4.4 (76)
Symptomatic, no hospitalisation	27.7 (74)	13.6 (90)	14.4 (33)		20.4 (106)	14.2 (91)		17.3 (197)
Symptomatic, hospitalized	6.0 (1)	1.8 (4)	0 (1)		3.2 (2)	1.2 (4)		2.2 (6)
Year of infection among participants who reported COVID-19 a
2020	36.5 (32)	31.0 (40)	56.9 (22)	0.360	35.9 (50)	46.3 (44)	0.637	40.5 (94)
2021	42.4 (40)	36.4 (64)	21.1 (14)	0.333	34.3 (68)	34.9 (50)	0.944	34.6 (118)
2022	30.1 (42)	33.9 (26)	23.3 (18)	0.745	31.1 (41)	27.2 (45)	0.859	29.4 (86)
Have your contacts been traced? b				0.255			0.545
No	12.6 (32)	37.7 (33)	34.3 (15)		25.2 (40)	28.2 (40)		26.5 (80)
Yes	79.7 (57)	56.9 (81)	58.9 (27)		69.9 (89)	62.7 (76)		66.7 (165)
Does not know	7.8 (17)	5.3 (7)	6.9 (10)		4.9 (18)	9.1 (16)		6.7 (34)
Have you been contacted/visited by the general practitioner/occupational physician? c
Does not have an occupational physician	21.6 (7)	16.3 (14)	19.6 (7)	0.738	18.3 (13)	19.9 (15)	0.512	18.9 (28)
Ever been visited/contacted by	49.6 (15)	28.4 (30)	47.6 (14)		32.3 (34)	52.4 (25)		40.6 (59)
Never been visited/contacted by	28.8 (25)	55.3 (63)	32.8 (14)		49.5 (64)	27.8 (38)		40.4 (102)

Data are reported as weighted percentages (number of respondents).

a Participants may have been re-infected.

b Question asked only to participants who reported having had COVID-19.

c Question asked only to employed participants who reported having had COVID-19.

Table 3 gives the weighted percentages of the attitudes towards vaccination by age and sex. Almost one-fourth of the respondents were vaccinated against influenza, while the majority (92.6%) received at least two doses of the SARS-CoV-2 vaccine (or one dose of Ad26.COV2.S, Janssen). Most (91%) of individuals who did not receive any dose were not willing to be vaccinated in the future, with higher frequencies at older ages than at age 18-34 years (63%). Among workers, 89.2% received at least two doses of vaccine (or one dose of Janssen) and 7.5% did not receive any dose. Of these, almost 60% reported no intention to get vaccinated in the future. Almost 80% of interviewees stated that it was their own decision to be vaccinated, Government regulations convinced 12%, and 4% were convinced by the general practitioner or the occupational physician.

Table 3

Self-reported vaccination status and attitudes towards influenza and SARS-CoV-2 vaccination

	Age group				Sex
	18-34 (n=291)	35-54(n=463)	55-74 (n=246)	P value	Men (n=506)	Women (n=494)	P value	Total(n=1000)
Influenza vaccination
No	82.9 (236)	80.3 (381)	68.1 (156)	0.232	77.8 (380)	75.4 (393)	0.780	76.6 (773)
Yes	17.1 (55)	19.7 (82)	31.9 (90)		22.2 (126)	24.6 (101)		23.4 (227)
SARS-CoV-2 vaccination
No	2.8 (14)	7.0 (36)	3.9 (13)	0.339	6.2 (31)	3.7 (32)	0.655	4.9 (63)
Yes, one dose	4.1 (11)	3.2 (22)	0.4 (6)		3.2 (20)	1.6 (19)		2.4 (39)
Yes, two doses or Janssen	37.6 (98)	31.2 (116)	27.8 (38)		31.5 (129)	31.6 (123)		31.5 (252)
Yes, three doses	55.4 (168)	58.6 (289)	67.9 (189)		59.1 (326)	63.1 (320)		61.1 (646)
Are you going to get vaccinated against SARS-CoV-2? a
No	59.6 (10)	44.5 (21)	84.0 (7)	0.004c	72.3 (19)	33.6 (19)	0.049	57.7 (38)
Probably No	3.2 (2)	51.5 (10)	10.1 (3)		18.4 (6)	57.4 (9)		33.1 (15)
Probably Yes	37.2 (2)	2.3 (4)	5.9 (2)		9.3 (5)	6.4 (3)		8.2 (8)
Yes	0	1.7 (1)	0 (1)		0 (1)	2.6 (1)		1.0 (2)
Who advised you to get vaccinated against SARS-CoV-2? b
Nobody (my own decision)	72.8 (220)	76.6 (325)	86.7 (199)	0.423	77.9 (380)	80.5 (364)	0.797	79.2 (744)
Relatives, friends, acquaintances	11.5 (26)	3.6 (24)	4.1 (10)	0.300	5.0 (28)	6.5 (32)	0.747	5.8 (60)
Government regulations	9.4 (34)	16.7 (65)	8.7 (25)	0.651	12.6 (61)	11.5 (63)	0.878	12.0 (124)
General practitioner/Occupational physician	6.2 (5)	3.3 (23)	4.1 (8)	0.843	4.2 (18)	4.5 (18)	0.943	4.3 (36)
Social media, TV, newspapers	6.4 (4)	0.1 (5)	0.2 (2)	<0.0001	3.3 (9)	0.1 (2)	0.001	1.7 (11)
Institutional sources	0 (1)	3.5 (11)	0 (1)	<0.0001	1.1 (5)	1.7 (8)	0.706	1.4 (13)

Data are reported as weighted percentages (number of respondents).

a Question asked only to participants who did not get any dose of the COVID-19 vaccine.

b Question asked only to participants who got at least one dose of the COVID-19 vaccine.

c Due to 0 frequencies in some cells, “Yes” and “Probably yes” were considered together in the statistical test for the difference by age groups.

Table 4 gives the OR of not being vaccinated against SARS-CoV-2 according to selected occupational categories. The prevalence of unvaccinated individuals among manual workers was higher than among highly qualified non-manual workers. Despite the difference between the corresponding prevalences (12.5% vs 8.4%, respectively), the odds ratio estimate is affected by low precision due to the small sample size (OR: 2.37, 95% CI: 0.26-22.0). The prevalence of unvaccinated individuals among routine non-manual workers (6.0%) did not substantially differ from that of highly qualified non-manual workers, the OR being 0.88, 95% CI: 0.19-4.18.

Table 4

Odds of not being vaccinated against SARS-CoV-2 according to occupational categories

	Weighted percentage (No. of unvaccinated workers/No. of workers in the category)	OR (95% CI)a
Occupational category
Highly qualified non-manual workers	8.4 (12/174)	1
Routine non-manual workers	6.0 (25/393)	0.88 (0.19-4.18)
Manual workers	12.5 (7/64)	2.37 (0.26-22.01)
Inactive population	2.3 (16/301)	0.44 (0.05-3.52)

OR: Odds ratio

aOR estimated using a weighted logistic regression model adjusted for sex and age group (18-34, 35-54 and 55-74 years) with standard errors clustered at the municipality level.

The main reported reasons for not being vaccinated were: concern about possible side effects (77%), doubts over a too rapid vaccine development and consequent inadequate testing (66.5%), doubts over their efficacy (51.7%). A sizeable fraction of the sample did not believe COVID-19 to be dangerous (28.4%), but the prevalence of subjects not worrying about being infected was low (4.1%). Practically non-existent was the fear of needles (0.3%).

The majority (70-80%) of the participants agreed with all the containment measures (Table 5), although only 62.9% agreed with an extensive lockdown for unvaccinated people. Agreement was generally lower among younger individuals.

Table 5

Attitude towards containment measures by age group and sex

	Age group				Sex
	18-34(n=291)	35-54(n=463)	55-74(n=246)	P value	Men (n=506)	Women (n=494)	P value	Total(n=1000)
Mandatory green pass in restaurants, shops, public offices, etc.
Strongly agree	33.2 (149)	49.3 (242)	69.9 (152)	0.002	52.4 (279)	53.0 (264)	0.341	52.7 (543)
Agree	32.5 (80)	34.1 (111)	19.4 (50)		25.5 (114)	31.6 (127)		28.5 (241)
Disagree/Strongly disagree	34.3 (62)	16.6 (110)	10.7 (44)		22.2 (113)	15.4 (103)		18.8 (216)
Mandatory super green pass in the workplace
Strongly agree	29.9 (136)	57.8 (229)	67.5 (146)	0.004	49.2 (259)	59.7 (252)	0.127	54.5 (511)
Agree	40.0 (82)	21.7 (107)	18.5 (54)		31.3 (120)	18.8 (123)		25.0 (243)
Disagree/Strongly disagree	30.1 (73)	20.5 (127)	13.9 (46)		19.5 (127)	21.5 (119)		20.5 (246)
Mandatory vaccination at ages 50 and over
Strongly agree	29.4 (153)	60.7 (243)	74.2 (159)	<0.0001	54.9 (283)	60.9 (272)	0.391	57.9 (555)
Agree	30.8 (77)	18.7 (108)	15.4 (44)		19.5 (106)	21.5 (123)		20.5 (229)
Disagree/Strongly disagree	39.7 (61)	20.6 (112)	10.4 (43)		25.7 (117)	17.6 (99)		21.6 (216)
Mandatory face mask in open spaces
Strongly agree	34.9 (155)	50.4 (234)	66.9 (149)	0.063	49.8 (277)	55.1 (261)	0.556	52.5 (538)
Agree	27.3 (76)	27.1 (102)	12.6 (47)		21.2 (106)	22.8 (119)		22 (225)
Disagree/Strongly disagree	37.9 (60)	22.5 (127)	20.5 (50)		29 (123)	22.1 (114)		25.5 (237)
Lockdown for unvaccinated people
Strongly agree	19.6 (80)	30.8 (139)	46.1 (90)	0.097	29.6 (146)	37.3 (163)	0.307	33.5 (309)
Agree	29.7 (92)	28.2 (147)	30.7 (80)		28.4 (146)	30.4 (173)		29.4 (319)
Disagree/Strongly disagree	50.7 (119)	41 (177)	23.2 (76)		41.9 (214)	32.3 (158)		37.1 (372)
Chargeable medical care for unvaccinated people
Strongly agree	23.0 (131)	51.7 (220)	73.2 (140)	<0.0001	47.3 (234)	57.2 (257)	0.470	52.3 (491)
Agree	25.5 (82)	22.9 (100)	11.9 (45)		21.3 (123)	18.0 (104)		19.6 (227)
Disagree/Strongly disagree	51.5 (78)	25.4 (143)	14.9 (61)		31.3 (149)	24.8 (133)		28.0 (282)
Mandatory vaccination for specific occupations
Strongly agree	27.1 (115)	56.6 (210)	57.5 (102)	0.014	50.2 (216)	49.3 (211)	0.300	49.7 (427)
Agree	37.4 (75)	17.2 (86)	16.4 (61)		25.1 (105)	18.7 (117)		21.8 (222)
Disagree/Strongly disagree	35.5 (101)	26.2 (167)	26.1 (83)		24.7 (185)	32.0 (166)		28.4 (351)
Mandatory vaccination in all workplaces
Strongly agree	35.5 (150)	53.9 (255)	84.6 (180)	<0.0001	53.3 (293)	67.1 (292)	0.131	60.3 (585)
Agree	32.6 (81)	28.6 (109)	4.7 (28)		27.1 (114)	15.3 (104)		21.2 (218)
Disagree/Strongly disagree	31.9 (60)	17.5 (99)	10.7 (38)		19.6 (99)	17.6 (98)		18.6 (197)

Data are reported as weighted percentages (number of respondents).

Discussion

Prevalence of self-reported COVID-19 was 24%, compared to 18% officially registered by the end of January 2022, thus confirming a considerable underestimation of COVID-19 in Italy [8]. This survey indicates that most respondents got vaccinated against SARS-CoV-2 mainly by their own choice, and most of them agree with the containment measures to fight the spread of SARS-CoV-2 infection. At the time of our survey (January 26-31, 2022), the prevalence of unvaccinated people was around 5%, and almost 60% of them did not intend to get vaccinated any time soon. The role of the general practitioner and occupational physician in the endorsement of vaccination was limited, being around 4%, without any age- or sex-related difference. Almost 40% of SARS-CoV-2 infected workers were contacted or visited by an occupational physician (50% among those who had an occupational physician).

In a previous survey we conducted in Italy between 16 and 28 September 2020 [9], when COVID-19 vaccines were not yet available, 54% of the interviewees would have accepted to receive a potential vaccine against SARS-CoV-2. Despite the initial scepticism, only 4.9% of the Italian population remained unvaccinated when vaccines became available. At the beginning of 2022, Italy was among the European countries with the highest vaccine uptake [10]. In addition, the prevalence of influenza vaccine was almost double in winter 2021-22 as compared to pre-Covid-19 calendar years [9].

The containment measures for unvaccinated people (i.e. mandatory green pass to access public spaces and workplaces) put in place by the Government have likely contributed to the high vaccine uptake in our country. However, 80% of the interviewees stated that they got vaccinated by their own choice.

Acceptance of vaccine results from a complex decision-making process based on several determinants, including contextual factors (e.g. communication, politics, culture, barriers to accessibility), individual and group influences (e.g. beliefs and attitudes towards public health interventions, trust in the governments and pharmaceutical industries, awareness of the risk/benefit) and specific characteristics of the vaccine (e.g. side effects, mode of administration, vaccination schedule) [11,12]. According to the model proposed by the WHO Strategic Advisory Group of Experts (SAGE) on Immunization Working Group on Vaccine Hesitancy, the propensity to be vaccinated is a function of confidence (i.e. trust in vaccine effectiveness and safety), complacency (i.e. risk perception of the disease) and convenience (i.e. accessibility). The following sentence our survey identified confidence as a critical issue in vaccine hesitancy, with the majority of unvaccinated people expressing doubts about their effectiveness and safety. Therefore, efforts are required to enhance vaccine acceptance in the Italian population, not only for COVID-19 vaccines but also for other vaccines, when they represent a safe and effective option to prevent the avoidable consequences of an infectious disease. Much of the responsibility falls on national governments, which have the power and the duty to make vaccines accessible and acceptable [13].

A survey [14] conducted during the first two weeks of January 2021, involving occupational physicians working in Italy and participating in Facebook groups and forums on occupational medicine, documented high awareness of COVID-19-related risks and high acceptance of COVID-19 vaccines, with the majority of occupational physicians endorsing vaccination mandates for high-risk workers such as healthcare workers. However, our data claim for greater involvement of the occupational physician in reducing vaccine hesitancy and managing COVID-19 in workplaces.

Concerning the Government containment measures, almost three-quarters of Italians were in favour of them, despite their strong nature compared to most other countries [15]. For instance, the US Supreme Court ruled against testing and vaccine mandates in business with 100 or more employees, leaving mandatory vaccination only for healthcare workers [16]. At the same time, the UK Government stepped back on compulsory vaccination even for the National Health Service (NHS) employees [17].

Charging for medical care for unvaccinated people needing hospital and even ICU admission is not compatible with the Italian Constitution, nor would it be consistent with the universalistic nature of the Italian Health System. In spite of this more than 70% of people interviewed would agree with such a measure, with an age- but not a sex-related trend, ranging from 48.5% in the group aged 18-34 to 85.1% in people over 55.

This study has some limitations. Response rate was 28.3%, a value which is in line with other online surveys based on questionnaires sent by e-mail [18]. The survey sample is not fully representative of the Italian population aged 18-74 years. A comparison with Italian demographic data [19] showed a substantial oversampling of the age groups 18-34 (29.1% vs 24.2%) and 35-54 (46.3% vs 39.7%) and of highly educated individuals. This is largely expected since we collected data using a computer assisted web interview and young people and highly educated individuals more frequently participate into this kind of studies. However, by using the sampling weights, we have partly or largely accounted for this potential bias. In addition, the relatively small sample size did not allow to assess differences between occupational categories, and to closely scrutinise healthcare workers, more exposed than others to the risk of infection and psychosocial consequences of the pandemic.

Despite these limitations, this study provides detailed and updated information on the attitudes towards COVID-19 vaccination and containment measures in Italy, including reasons for not getting vaccinated.

In conclusion, at the beginning of 2022, vaccine uptake in Italy was high, either in the general or working population. A central role of the occupational physician in the management of workers with COVID-19 is perceived as part of his duties, being desirable in order to achieve better control of the disease in occupational settings.