Engaging Faith-Based Organizations for Promoting the Uptake of COVID-19 Vaccine in India: A Case Study of a Multi-Faith Society

"Communication strategies centered around faith leaders have led to favorable outcomes in tackling misinformation and reducing the spread of infectious diseases....FBOs acted in unison with the local community leaders, political leaders and acted as a trigger for the vaccination which ensured success of COVID-19 vaccination program in India."

Vaccine hesitancy emerged stronger than it did initially when India's massive COVID-19 immunisation programme was launched on January 16 2021; by September 2021, only 13.73% of the priority population had received the vaccine. The spread of mis/disinformation, multiplied with the increased use of social media and the internet, contributed to this vaccine hesitancy, which is complicated and multifaceted. This article presents experiences from John Snow Inc. (JSI)'s strategic engagement with faith-based organisations (FBOs) to promote uptake of COVID-19 vaccination in India, especially among vulnerable and marginalised communities.

As JSI explains, religious faith represents a key social and environmental driver that can influence an individual's beliefs, health behaviours, and practices. Religion is an especially important part of life for the majority of the Indian population. Faith leaders are members of the community who are recognised for their role in guiding and inspiring religious and faith-based beliefs and practices of the community, playing an authoritative and influential leadership role. Faith leaders and organisations represent a key resource in building vaccine confidence in the community by promoting messages of best practices with regard to vaccines. For all these reasons, in prior vaccination drives, such as for polio, FBOs in India had a significant role in guiding vaccine confidence, promoting healthy behaviours, and providing physical safe spaces to both address concerns of their congregation and run vaccination camps from churches, temples, gurudwaras (places of assembly and worship for Sikhs), and mosques.

The project team believed that co-creating interventions with faith leaders, who are often the gatekeepers of tight-knit communities, can lead to the creation of positive messages about the COVID-19 vaccine that people in the community can relate to. Because FBOs are a crucial resource in helping the community develop vaccine trust, the team designed the community engagement and mobilisation approach to make FBOs frontrunners in areas with a high inclination towards religion and faith and low confidence in the vaccination drive due to faith-based reasons, as well as states representing religious minorities. Merging a science-based approach with a faith-based outreach was essential to persuade those who were hesitant purely based on a religious perspective. Ultimately, the project team collaborated with 18 FBOs and more than 400 religious institutions across 18 states.

The key implementation strategies used to achieve community engagement goals were based on an operational framework depicted in the figure above. They are described in detail in the paper but, in brief, at the core of the effort was ensuring that the FBO leaders understood the efficacy, safety, and benefits of the vaccine and also became long-term change agents in communities for public health interventions. The project adopted a list of strategic activities to achieve its goals and objectives:

• Listing FBOs in the project geography that could influence the priority communities;
• Identifying vaccination champions from FBOs who could be recognised for supporting COVID-19 vaccination;
• Building capacities of FBOs on the virus that causes COVID-19 and on vaccination through sensitisation meetings with religious leaders to clear myths and misconceptions related to COVID-19 vaccination - thereby creating a sustainable network of FBOs duly sensitised and oriented on COVID-19 vaccination;
• Disseminating written appeal/video snippets from key religious leaders in support of COVID-19 vaccination;
• Reaching out to vulnerable populations in project areas by the intense use of social media (e.g., live streaming on Facebook of sermons at religious events and dissemination of vaccination-camp-related information through WhatsApp), along with mass media and mid-media, featuring appeals of FBO leaders;
• Dispelling rumours related to vaccination through announcements and appeals during religious meetings/gatherings;
• Organising COVID-19 vaccination sessions within FBO premises to increase vaccine confidence; and
• Leveraging mass gatherings at religious places (e.g., Friday prayers, Eid al-Fitr gatherings) for vaccination. For example, the project team collaborated with the Sikh Gurudwara Prabandhak Committee and organisations like Dhan Dhan Satguru and Radha Swami Satsang in Punjab to organise vaccination camps on the grounds of gurudwaras and other FBOs; more than 100,000 beneficiaries were immunised on the grounds of FBOs in that state alone.

As a result, a sustainable network of sensitised FBOs from diverse faiths was created that went on to mobilise and facilitate the vaccination of 0.41 million beneficiaries under the project from August 2021 to January 2023. In the geography of 298 districts across 18 states of India, 3,717 camps were organized with the support of FBOs, which included mobilisation efforts, the presence of local FBO leaders, and sessions in the premises of the religious practice.

Based on this partnership with the FBOs across the 18 states and union territories enrolled in the project, thousands more continue to get fully vaccinated and protected every day. (Four case studies of this work from various geographies in India are offered in the paper to illustrate these trends.) The engagement efforts are expected to bring community-level acceptance to vaccination in the long run. Some efforts were initiated by project team, such as the creation of support groups to facilitate an enabling environment for vaccination, which can act as behavioural drivers to create a positive atmosphere for vaccination among vulnerable and marginalised communities. Sustaining the gains can be ensured by:

• Connecting with religious leaders to create a movement to support vaccination and motivate and educate followers to adopt other healthy behaviours that are compatible with religious teachings;
• Facilitating COVID-19 support groups in the community;
• Ensuring long-term participation of FBOs in grassroots mobilisation and tackling vaccine hesitancy related to faith-based concerns;
• Establishing religious sites such as temples, mosques, and gurudwaras as having a key role in vaccination drives; and
• Forging at least one state- and district-level partnership with FBOs to enhance ownership of vaccination programmes by FBOs.

In short, "This study highlights the significance of partnering with FBOs and religious leaders in vaccination programs to engage communities meaningfully by dispelling myths, clearing up misunderstandings, building vaccine confidence, and encouraging vaccine uptake....[It] also suggests that hyper-local efforts that take into account the local dialects and beliefs are going to be critical in sustaining vaccination efforts especially as we pivot back to focusing on routine immunization, coverage of which has slipped significantly during the COVID-19 pandemic..."

Based on this experience, the paper offers some recommendations (for practitioners, for researchers) and lessons learned. For example:

• Most of the faith-based leaders (except "Brahma Kumaris", a spiritual movement in India known for the prominent role played by women) were men. Moving forward, it would be advantageous to investigate and facilitate the participation of female faith leaders to invite higher female participation and resolution of gender-specific issues.
• Some groups could not be mobilised despite being approached through FBOs. They had deeper apprehensions that required efforts at a personal level rather than a mass approach. Although not a significant number, some of the faith leaders themselves were not convinced about vaccination, even after the orientation; their own resistance might affect the behavioural pattern of the community.
• Suboptimal ownership of the few faith leaders in the programme because of their indifferent opinions was also evident in a few low-performing areas.
• Despite repetitive efforts, the project team could not reach or engage a few prestigious religious bodies with strong influence in the community.
• Working with FBOs requires efforts and multiple meetings to sensitise them fully and to secure their buy-in for the cause.

The authors conclude: "The role of FBOs was critical in addressing myths especially related to faith/beliefs, building confidence among community members thereby leading to increased acceptance of COVID-19 vaccine and behavior change in communities....We see FBOs as a direct bridge with community. Partnerships with them might even become more significant over time, particularly for routine immunization and life course vaccination."