Women make up little more than half of the 5 million non-Italian nationals living in Italy- 8.5 per cent of the female residents, a percentage worth exploring.
Does gender represent another barrier to healthcare access for migrants? In order to answer this question it is helpful to think of the definition of gender medicine by the World Health Organisation, which describes it as “the study of the way biological differences (defined by sex) and socioeconomic and cultural ones (defined by gender) impact the health and illness status of each individual ”.
Gender can impact the prevalence/incidence of risk factors and illnesses and the different response to therapies. There can also be unequal access to healthcare because of it. Gender can represent a barrier to accessing treatment or it might expose individuals- usually women- to conditions that exacerbate certain risk factors. There are also gender-specific risks associated to the migrant population that lead to unequal access to services and healthcare compared to the Italian native population, even though migrants have better overall health status in terms of mortality and hospitalisation rates- also because they tend to be younger in age.
What the figures show
In Italy women make up roughly two thirds of hospitalisations of non-Italian nationals and half of the inpatient admissions of Italian nationals. This difference is mainly the result of the inpatient admission of women of childbearing potential into obstetrics- 61 per cent of non-Italian female nationals and 42 per cent of Italian women.
The pregnancies of non-residents seem to be managed less in terms of adherence to recommendations, check-ups and ultrasounds compared to Italian women, which suggests that despite the universality of the Italian National Healthcare Service migrant women still experience access related issues- often linked to bureaucratic, language and cultural barriers. The situation gets even more worrying when you consider the fact that non-Italian female nationals represent approximately a quarter of pregnant women. The percentage of known cases of pregnancies that end up with voluntary abortions is higher among non-Italian female nationals than Italian residents, especially after 24 years of age. Furthermore, the higher percentage of miscarriages recorded among non-Italian nationals under 30 might reflect the hidden use of illegal abortion procedures.
The amount of inpatient emergency hospitalisations is higher among non-nationals, even for ordinary reasons such as monitoring pregnancies, which is the most common cause of emergency inpatient admissions for foreign women. The frequency of day hospital admissions for women with childbearing potential is definitively higher among non-Italian female nationals compared to Italian women (67 per cent versus 37 per cent), seemingly due to the challenges related to access and to the use of local healthcare services. The higher standardised rate of avoidable hospitalisations observed among foreigners, for clinical conditions that should be managed at different healthcare levels, suggests that the management of health problems, even serious ones, is either delayed or completely lacking.
Another element demonstrating the lower use of local healthcare services (GP surgeries and local clinics) by non-Italian nationals is the fact that they get assigned white or green triage codes (similar to the green or yellow ones in the UK) in A&Es more frequently than Italian patients. A&Es offer the opportunity to overcome some of the barriers to primary care access, starting from the limited opening hours of GP surgeries, which can be an insurmountable barrier for migrants, who are often working in low pay jobs without any time flexibility (data on the times A&Es are accessed confirm this). Furthermore, even though women access healthcare more than men, when you do not consider the obstetric and gynaecologic visits, non-Italian female nationals are less likely to access medical support for illnesses or issues for prevention or check-ups compared to Italian women.
The greater difficulty to access local healthcare services is also confirmed by data showing a lower participation to oncological screening tests (pap smears and mammograms) by non-Italian nationals compared to Italian women. It should be noted that, in addition to socioeconomic factors and individual propensity to access prevention services, the level of engagement increases for women that have been residing in Italy for longer and for those who have an Italian partner- a positive result of integration, even though it is not distributed evenly based on the area of origin. Such differences are even more marked in the southern part of the country, where healthcare seems to be less efficient even for Italian women, which suggests that wherever the availability and access to screening tests are more efficient for Italian female residents that is also true for migrant women.
Data already report that during the current SARS-COV-2 pandemic the health inequalities between non-residents and residents worsened- even in Italy- with a higher risk of infection- also linked to gender- among migrants, due to exposure at work (jobs with lower opportunity for social distancing and self-isolation), at home (small and overcrowded dwellings) and on public transport.
In conclusion, in Italy foreigners seem to experience barriers, particularly gender-specific ones, when trying to access services and healthcare. Medicine and public healthcare should therefore take the complex interaction between gender and immigration status into account when planning their approach, trying to adapt to the needs of individuals, communities and societies.
Epidemiology should also adopt a “migrant-gender-sensitive” approach in this sense in order to fill some of the current research gaps and enable studies to generate data that are not “biased” because of missing analysis based on gender related factors.
Recommended reading list
• Di Napoli A, et al. Factors associated to medical visits: comparison among Italians and immigrants resident in Italy. Epidemiol Prev 2017;41:S1:41-9.
• Di Napoli A, et al. Evaluating health care of the immigrant population in Italy through indicators of a national monitoring system. Epidemiol Prev 2020;44S1:85-93.
• Di Napoli A, et al. Sistema di monitoraggio dello stato di salute e di assistenza sanitaria alla popolazione immigrata: risultati anno 2017. (System to monitor the health and healthcare support status of immigrants: data from 2017.) Quaderni di Epidemiologia (Epidemiology Diaries) 2021;3:1-136.
• Fabiani M, et al; Covid-19 working group. Epidemiological characteristics of covid-19 cases in non-Italian nationals notified to the Italian surveillance system. Eur J Public Health 2021; 31:37-44.
• Francovich L, et al. Cervical and breast cancer screening in Italy among immigrant women resident in Italy. Epidemiol Prev 2017;41;S1:18-25.
• Hayward SE, et al; Escmid study group for infections in travellers and migrants. Clinical outcomes and risk factors for covid-19 among migrant populations in high-income countries: a systematic review. J Migr Health 2021;3:100041.
• Ministry of Health. Plan for the application and diffusion of gender medicine. Published on 21 June 2019.
• Namer Y, et al. Access to primary care and preventive health services of LGBTQ+ migrants, refugees, and asylum seekers. In: Rosano A. Access to primary care and preventative health services of migrants (1st ed). Springer International Publishing, 2018.
• Wandschneider L, et al. Representation of gender in migrant health studies – a systematic review of the social epidemiological literature. Int J Equity Health 2020;19:181.