COVID-19 Vaccination Coverage and Female Healthcare Workers: A Look at the Gender Gap

We conducted a cross-sectional study using an online questionnaire. It included HCWs from various professions and examined participants' sociodemographic and work-related variables, anti-vaccination attitudes, and COVID-19 vaccination uptake. Anti-vaccination attitudes were assessed using the Vaccination Attitudes Examination Scale. We computed vaccination coverage and assessed its predicting factors using descriptive and analytical statistics, including multivariable models.


Results
The vaccine coverage was signi cantly lower among female HCWs [59.6% (95%CI: 55.5%-63.7%)] than males [74.9% (95%CI: 70.7%-78.8%)]. Female HCWs had signi cantly higher anti-vaccination attitudes and lowered perceived COVID-19 vaccine knowledge. Vaccine uptake was shown to be age-related in female HCWs, with 52.7% in the less than 30-year age group and 70.7% in the ≥50-year age group. Higher monthly income and smoking status were signi cant predictors of female HCWs vaccine uptake. Conclusions vaccine coverage is signi cantly lower among females with higher anti-vaccination attitudes. Historical scepticism towards vaccination, mistrust of the medical literature, and the myth of infertility could be possible reasons.
Background COVID-19 has quickly escalated into a major public health catastrophe, affecting millions of people and resulting in millions of deaths worldwide. Apart from implementing social distancing measures, it is critical to establish a high vaccination coverage to prevent disease and death [1].
The race to develop COVID-19 vaccines was recognized early on that it would not be enough to stop the pandemic unless the public widely accepted the vaccine. COVID-19 vaccination hesitancy has been extensively studied, with signi cant variation in willingness to be vaccinated across communities [2].
Males, older adults, persons of different racial and cultural backgrounds, and college and/or graduate degree holders are more likely to accept the vaccine if it is advised for them [3].
Healthcare workers (HCWs) on the front lines contribute to the nation's ght against COVID-19, so issues like vaccine acceptance and coverage should be taken seriously. HCWs, who are likely to be the most knowledgeable about COVID-19 morbidity and mortality issues, are more likely than others to accept the vaccine, according to expectations. While it is recommended that all HCWs get vaccinated, gender differences in vaccine acceptance and uptake have been documented. A scoping review providing a comprehensive global assessment of published evidence on COVID-19 vaccine hesitancy among HCWs found that male HCWs were more likely to receive the vaccine [4][5][6]. Males were three times more likely than females in Palestine to accept the COVID-19 vaccine [7].
This gender disparity could be due to a variety of factors. Although there have been numerous media debates about fertility concerns, data from clinical trials also addressed whether the COVID-19 vaccines harm fertility [8,9], with sparse but reassuring results. Even though a new expert guidance report states that there is "absolutely no evidence" that the COVID-19 vaccine affects women's or men's fertility, there are numerous blatant falsehoods on social media that the vaccine affects younger people women's fertility [10].
Despite numerous studies assessing vaccination intentions around the world, few studies have evaluated actual HCW vaccination uptake. Furthermore, our study may be the rst to look at COVID-19 vaccination uptake by gender, focusing on female HCWs, to identify the factors that keep them from receiving the vaccine. The study's objectives are to (a) determine the proportion of female and male HCWs who received the COVID-19 vaccine, (b) compare anti-vaccination attitudes between female and male HCWs, and (c) identify predictors of COVID-19 vaccine uptake. The study's ndings will assist policymakers and healthcare administrators develop protocols, policies, and interventions to promote vaccination uptake among female HCWs at their workplace. In addition, this study will serve as the foundation for future analytical studies to evaluate the impact of various interventions on addressing barriers and antivaccination attitudes among HCWs.

Study design and participants
This study used data collected as part of another study assessing vaccine coverage among all HCWs (unpublished yet). We used an anonymous online questionnaire to conduct this cross-sectional study. We targeted HCWs of different professions; physicians, nurses, and allied healthcare personnel in hospitals and primary health care centres. A convenience sampling technique utilizing Google forms were implemented to collect responses. Raosoft software was used to compute sample size using a 95% con dence level, a 50% prevalence estimate, and a 3% margin error. The sample size of 1024 was calculated.

Measurement Tool and variables
An online Google Form based on a pre-designed questionnaire was created and sent to the HCWs' personal accounts via social media, email, or other online systems. We sent the survey with an invitation message that explained the study's purpose and a consent form. It started with a mandatory question about whether or not the HCW wanted to participate. A second reminder was issued to healthcare workers to remind them to complete the online questionnaire that they hadn't led. The data were collected between the months of April and June 2021.
The questionnaire was made up of three parts: the rst part consisted of questions about sociodemographic and work-related characteristics. The variables were chosen in light of the available literature and investigator input. HCWs were asked about their age, gender, marital status, job title, employment, having a child, years of experience, smoking status, physical activity, and monthly income. The second part explored HCWs' anti-vaccination attitudes using the Vaccination Attitudes Examination (VAX) Scale adjusted to the COVID-19 vaccine. It has 12 items and sub-categorized into four sub-scales: (1) mistrust of vaccine bene ts, (2) worries over unforeseen future effects, (3) concerns about commercial pro ts, (4) preference for natural immunity. It is a self-reported measure that has been validated in HCWs and takes 5 to 7 minutes to administer. Each item's score ranges from 1 (strongly agree) to 5 (strongly disagree), except for sub-scale #1, which has a coding range of 1 (strongly disagree) to 5 (strongly agree). A higher overall score indicates that HCWs have more negative attitudes toward COVID-19 vaccination. Previous research [11] has shown a high level of internal consistency. The authors of this study translated the VAX scale into Arabic, and a native English speaker checked the backtranslation. Cronbach's alpha was calculated to determine the scale's internal consistency for this study, which was 0.83.
The third part assessed the study's primary outcome variable, COVID-19 vaccine coverage (vaccinated vs unvaccinated). This part also inquired about other COVID-19 vaccine variables such as the type, the number of doses received side effects, perceived COVID-19 knowledge, and vaccine knowledge.
The questionnaire validation (face and content validity) was carried out by a panel of experts, including one family physician, a community medicine consultant, and a public health consultant. Then, we conducted an online pilot study with 30 HCWs to assess its clarity, understanding, and feasibility.
Participants in the pilot study were excluded from the larger sample.

Analysis Plan
The statistical analysis was performed using IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, NY, USA). Frequency distribution was used to summarize the categorical variables. The normal distribution of continuous variables was assessed using the Kolmogorov-Smirnov test. Categorical variables were expressed as frequencies and percentages. Univariate analyses and cross-tabulation were used to determine differences between groups, using the Chi-square test and the Mann-Whitney U test, as appropriate. Multivariable analyses using binary regression were used to identify factors that are independently associated with vaccination uptake. Results were considered statistically signi cant at a pvalue ≤ of 0.05.

The study obtained ethical approval from the Institutional Review Board (IRB) of [Blank for blind review]
(Ref #: Med. March. 2021/23). Before beginning the online survey, all participants were informed about the study's purpose, and their participation was entirely voluntary. Using a web-based survey method allowed respondents to remain anonymous; when returning the questionnaire, web-based tools protect information con dentiality and prevent other participants from accessing it. Moreover, we didn't include identifying questions in the survey.

Background characteristics
A total of 1018 HCWs participated in this study; 560 females (55%) and 458 males (45%). Table 1 presents the sociodemographic characteristics of the participants by gender. Almost 40% of female and male HCWs were under the age of 30. Nurses account for 34.5% of female HCWs, whereas physicians comprise the majority of male HCWs. Almost two-thirds of both male and female HCWs were married and had children, and the majority worked in the government sector.  group. For both female and male HCWs, higher monthly income levels and smoking were signi cantly related to vaccine uptake. Vaccine uptake was almost distributed equally across professions among female HCWs (56.12-62.2%), but much higher among male physicians (81.8%) than male nurses (65.7%) and others (66.3%). Furthermore, male HCWs working in non-government sectors, unmarried and smokers, reported signi cantly higher vaccine uptake levels ( Table 1).
Antivaccination attitudes and perceived COVID-19 vaccine knowledge were also related to uptake for female and male HCWs (Table 3). Anti-vaccination attitudes were signi cantly higher among vaccinated male and female HCWs than among non-vaccinated groups on the overall anti-vaccination attitude scale and its four subscales; mistrust of vaccine bene ts, worries about unforeseen future effects, and concerns about concerns commercial pro ts, and preference for natural immunity (P-value <.001). In addition, vaccinated females and male HCWs had signi cantly higher perceived vaccine knowledge than non-vaccinated groups, with P-values of .003 and .052, respectively.

Discussion
Throughout history, females have shown a higher tendency for vaccine hesitation [12]. The historical bias against females in the scienti c literature can be an integral cause as women are often more sceptical of medicine and the pharmaceutical industries [13]. Expectedly, females had a higher mistrust of the vaccine in our study. In addition, females often exhibit a more heightened responsibility sense for the family's health as a whole. Hence, they engage in medical research and consultations with experts, but they are also exposed to negative news and social media opinions [14]. Interestingly, it has been previously reported that women comprise most people with anti-vaccination tendencies on social media [15].
Therefore, these factors can interplay, among others, affecting females' negative attitudes towards vaccinations.
With the recent surge of COVID-19 and the development of vaccines, this trend has proved to be still in effect, with many studies reporting higher levels of COVID-19 vaccine concern among females and lower uptake rates [16][17][18]. Similarly, our study found that female HCWs have lower vaccine uptake rates than males, which is worrisome considering their substantial role in inpatient care, particularly given the high proportion of female nurses. Consequently, this study used the VAX scale and its sub-items to examine gender differences in attitudes toward vaccine uptake and other associated variables.
Gender-related issues such as infertility and pregnancy were of particular importance debating the difference between genders, while other factors such as profession and parenthood were proposed and reported as signi cant indicators for vaccine uptake, among others [19,20]. The myth of infertility persists despite the lack of any evidence to support this notion [10]. A recent study exploring the factors nurturing conspiracy theories regarding COVID-19 and its implication on vaccine uptake has found that 23% of respondents believed the COVID-19 vaccines could lead to infertility [21]. While this speci c concern was not addressed in this study, there was an increase in vaccine uptake with increasing age in female HCWs. In males, however, this relationship was reversed; younger males had the vaccine at a higher rate than older males. When this is connected to vaccination attitudes, we can explain this variation in the signi cant difference in females' attitudes by the increased concerns about unforeseen future effects.
Many recent studies have reported profession as an essential indicator of vaccination, with physicians having higher vaccination rates [19,20]. In this study, male physicians are higher than their female counterparts. However, contrary to the recent reports, there was no signi cant difference in vaccine uptake among females of different professions, with similar vaccine uptake rates between female physicians, nurses, and others. This indicates that working in higher-ranking professions, such as physicians, is not predictive of vaccine uptake but rather that gender plays a signi cant role. Being a female physician, nurse, or even administrative worker is associated with lower COVID-19 vaccine uptake.
Hence, the reluctance of female HCWs to take the vaccine may be due to other reasons, possibly exclusive to females. Likewise, our analysis shows a signi cant difference between male and female HCWs' perceived knowledge of COVID-19 and its vaccine; although this gap warrants further investigation to understand its cause, it might play a big factor in driving the negative attitude of females HCWs towards vaccination against the virus.
Other studies have identi ed having a child as a negative predictive factor for vaccine uptake [19,22]. Our study results indicate a similar tendency for females. The concerns for local and systemic reactions against the vaccine in most unvaccinated females might make them unsure of their ability to take care of their children under such circumstances. This comes in line with other reports that cited concerns for side effects as a signi cant barrier in the face of vaccination [17,[23][24][25].
The overall negative attitude of female HCWs towards the vaccine could be a signi cant obstacle for healthcare in general and the resolution of the COVID-19 pandemic in particular. To combat this devastating implication, we need to target speci c concerns that support this attitude, including components explored in this study, such as worries over unforeseen future effects or concerns about commercial pro ts.
Despite the signi cant contributions made by this research, a number of limitations should be addressed. First, the generalizability of this study is limited due to its convenience-sampling approach; however, this is an exploratory study that has provided insight into the current COVID-19 vaccine uptake in HCWs based on their gender. Second, relying on an online survey to collect data may introduce non-response bias, undermining the study's generalizability. To avoid this bias, we did not require respondents to reveal their identities. Third, some potential confounders associated with female HCW vaccination uptake were not collected, such as being pregnant, planning to become pregnant shortly, or vaccination-related fertility issues. However, the VAX scale measures these issues indirectly through different items.

Conclusion
In conclusion, female HCWs had signi cantly higher anti-vaccination attitudes, lower vaccine uptake, and lower perceived COVID-19 vaccine knowledge than males. Historical scepticism towards vaccination, mistrust of the medical literature, and the myth of infertility could be possible causes. Positive indicators of vaccination include older age, smoking, and a higher income. While having a child at home is a negative indicator. Declarations Ethics and Consent: Following an explanation of the study's purpose, risks, and bene ts of participation, all subjects were invited to participate voluntarily. A waiver for signed consent was obtained because the study poses low risk to subjects and does not include any procedures that require written consent. The

List Of Abbreviations
An-Najah National University institutional review board approved the study. It was ensured that the participants' privacy and con dentiality were respected.
Consent for publication: "Not applicable." Availability of data and materials: The dataset supporting the conclusions of this article is included within the article and its additional le.