Effects of Local Faith-Actor Engagement in the Uptake and Coverage of Immunization in Low- and Middle-Income Countries: A Literature Review

"...findings suggest that continued investment in and engagement with faith leaders can be a valuable strategy for immunization programming..."

Despite the powerful potential of vaccination to reduce and eliminate diseases such as smallpox and polio, religious factors remain the third most frequently cited reason for vaccine hesitancy in several global surveys. Religiously linked vaccine hesitancy concerns are especially pronounced and rising in low- and middle-income countries (LMICs). This review sought to explore: (i) how do religious leaders impact the uptake and coverage of immunisation in LMICs? (ii) what successful strategies exist for working with local faith actors (LFAs) to improve immunisation acceptance? and (iii) what evidence gaps exist in relation to faith engagement and immunisation?

For the review, the Faith Engagement Team of the United States Agency for International Development (USAID)'s MOMENTUM Country and Global Leadership programme searched PubMed and Google Scholar for peer-reviewed literature published from January 1 2011 to January 15 2021; they also conducted a gray literature review spanning this timeframe. They excluded articles covering faith engagement and immunisation in high-income countries, as well as news articles, online blogs, social media postings, and articles in languages outside of English.

The review found 110 relevant articles, 69% of which were peer reviewed. The relevant literature was predominantly focused on vaccine hesitancy (60%) among different faith groups, versus a general exploration of religious engagement and vaccines (36%) or new vaccine acceptance among LFAs and vaccines delivered by LFAs in humanitarian environments (4%). There was a focus on campaign-based vaccinations and vaccines that have been found to cause hesitancy, including: polio (20 articles), human papillomavirus, or HPV (9), COVID-19 vaccination (8), childhood immunisation generally (5), and rotavirus (2). In particular, the literature reflects a heavy focus on polio vaccine hesitancy among Muslim populations, with 19% of all resources exploring that topic. This heavy emphasis is likely due, in part, to very visible cases of vaccine hesitancy and boycotts in the early 2000s in northern Nigeria, Pakistan, and Afghanistan, as well as the finding that Muslim religious leaders are especially influential in impacting vaccine uptake and hesitancy.

Multiple resources reviewed suggested that vaccination hesitancy is often cloaked under the guise of "religion", without a theologically-grounded objection. (Few religious groups or their sacred texts explicitly reject immunisation.) Instead, religious objections to vaccination serve as a cover or proxy for concerns about safety, social norms, socio-cultural issues, or political and economic factors. Sometimes, LFAs can perpetuate vaccine hesitancy by sharing anti-vaccine messaging within houses of worship, disseminating anti-vaccination messaging informally within the community outside religious structures, broadcasting anti-vaccine messaging on mass media channels, and establishing formal or informal boycotts and encouraging adherents to avoid immunising their children.

On the positive side, the literature review found evidence (though limited high-quality evidence) and examples of specific approaches for engaging LFAs to strengthen routine immunisation and campaign-based immunisation uptake. Most interventions involved engaging religious leaders and the local community in dialogue-based interventions and engaging religious leaders and church structures in social mobilisation and advocacy. Broadly, the reviewed literature demonstrated four main mechanisms through which religious leaders and faith actors impact immunisation uptake in LMICs: (i) influencing caretaker beliefs and values, (ii) impacting access to resources that facilitate immunisation uptake, (iii) communicating immunisation messages and conducting mobilisation, and (iv) providing routine immunisations in hard-to-reach areas or humanitarian settings.

However, there was limited rigorous evidence and examples of specific approaches for engaging LFAs to strengthen immunisation uptake in LMICs. As a result, there is a lack of widely shared knowledge of what works (or doesn't) and successful models for engaging LFAs. Additional current evidence gaps include: few rigorous study designs; a lack of vaccine hesitancy studies outside of Nigeria and Pakistan; and limited exploration of faith engagement and immunisation in religions other than Islam and Christianity.

Thus, this review found that "engaged religious leaders have long contributed to achieving full immunization coverage within their communities and today offer the potential to help counter growing vaccine hesitancy in some LMICs. At the same time, the review found numerous troubling examples of religiously-linked vaccine hesitancy, some well-known, such as Indonesia, Nigeria, and Pakistan, and some lesser- known examples in Burkina Faso, Chad, and Sudan."

Reflecting on these findings, the research team points to multiple studies and resources within the review that identify:

• the importance of listening, understanding, and diagnosing some of the complex and inter-related socio-cultural factors that contribute to religiously-linked vaccine hesitancy;
• the need to avoid the temptation to oversimplify or blame faith actors for vaccine hesitancy and instead to engage in dialogue with faith leaders to find theologically-acceptable solutions to vaccine hesitancy;
• the value of global and national-level discussions to engage faith leaders in vaccine hesitancy reduction efforts, as well as country-level strategies that could help identify some of the underlying socio-cultural and political issues; and
• the utility of efforts to encourage LFAs and implementers to more widely share their experiences with engaging religious leaders in immunisation programmes, which are largely absent the literature.

In conclusion: "Findings from this review will advance understanding on how to more effectively engage local faith actors in promoting immunization campaigns and addressing vaccine hesitancy, which is more complex than expected. Further study is needed to understand how to most effectively counter vaccine hesitancy in different geographic, linguistic, and socio-cultural contexts."