Evidence Review: Religious Marginality and COVID-19 Vaccination - Access & Hesitancy

"The issues addressed are important for COVID-19 vaccination roll out, but also contain lessons for all vaccination programmes and many other preventative health measures."

Experience shows that being situated on the margins due to religious affiliation shapes experiences of vaccine access and uptake. This Social Science in Humanitarian Action Platform (SSHAP) brief is based on the conviction that study and awareness of this religious marginality is crucial for the success of vaccination programmes, including COVID-19 vaccination. It presents key considerations for addressing differentials in access to and willingness to undergo vaccinations (demand factors) that are linked to religious minority status, experiences, authorities, or doctrine. It also explores ways in which religious marginality intersects with other identity markers to influence individual and community access to vaccines (supply factors). Finally, the brief examines vaccine hesitancy in relation to religious minorities and outlines practical, socio-religiously sensitive approaches to community health engagement that are designed to enhance vaccination confidence.

The brief explains that immunisation coverage depends on two main factors: demand and supply. Religious minority status affects both, and it can be difficult to disentangle whether immunisation gaps or disparities are the effect of one, the other or both acting simultaneously. Other social determinants of health and vaccine coverage (income, education, etc.) also correlate with minority religious status to varying extents. But some examples include:

• Supply side: Health services, including vaccinations, must be accessible, appropriate, and affordable. Even in settings where quality services are available to all, some religious minorities may experience barriers due, for example, to language, discrimination, affordability (time cost), a low sense of entitlement, difficulties accessing ID documents, and lower access to information.
• Demand side: Historic and systemic inequalities can put members of minority religious communities at a higher risk of infection and can create mistrust between authorities and minorities. Previous experience of single vaccination campaigns targeting religious minority communities (e.g., polio) elicited important learning relevant to the COVID-19 vaccination rollout. In these campaigns, distrust between religious minorities and health authorities led to lower uptake, which in turn resulted in increasingly punitive attempts to force polio vaccines on an unwilling minority community.

In light of the limited multi-factorial data available, it is a challenge to identify how religious affiliation intersects with class, caste, gender, and/or geographic location to affect demand for and access to health services, including vaccination. For example, in Pakistan, COVID-19 vaccinations were at first prioritised to frontline health workers and senior citizens. However, one group that the authors of this brief argue should have been prioritised on account of their work is sanitation workers. Here, the intersection of religious affiliation (sanitation workers are mostly Christian in a Muslim majority context), caste (they are mostly considered to be of Dalit background), poverty, and illiteracy meant they were not originally prioritised. Also complicating matters is that the experience of one religious minority group in a community cannot serve as a proxy for other religious minorities in the same country or same region.

The links between vaccine hesitancy and religion, which the brief discusses next, are more explicit and obvious than the links between barriers to access and religion. In discussing hesitancy links, the authors offer two considerations: (i) Religious doctrine and norms can be a major factor underpinning vaccine hesitancy; and (ii) there are many other reasons, other than religious norms, that lead to vaccine hesitancy within a given population. However, earlier incidents highlight some of the ways in which religious marginality and vaccine hesitancy are connected. For instance: "Conspiracy theories stating COVID-19 causes infertility, sterility and impotence are the result of the very same 'conditions' that were associated with vaccinations against polio, measles and smallpox. Conspiracy theories can bypass religion (e.g., those that centre on political ideological differences), but many also centre on the purported aim of one religion to overcome, subdue or even exterminate another."

The analysis delves into the issue of misinformation, noting, for example, intersections with trust: "Lack of transparency or attention to religious rules in vaccine manufacture or contents feeds into the lack of trust in the authorities. This mistrust will fuel the spread of such misinformation in future cases. One successful strategy in the past, which has again been adopted in COVID-19 vaccination production and supply, is to ensure that vaccines are produced in diverse religious contexts."

In the vein of offering strategies, the paper outlines the following suggestions for building vaccine confidence among religious minorities:

• Work proactively and inclusively with faith leaders, where it is possible and appropriate to recruit them for a public health awareness campaign.
• Recognise that religious authority is one of many authoritative sources of knowledge and influence in the community, noting that who the trusted individuals are varies from one context to another.
• Create or reinforce broad-based partnerships between health providers and religious and lay leaders from within a religious minority community that are perceived by that community to be legitimate and authoritative.
• Ensure access to information - including on the part of religious minorities who are isolated, linguistically distinct, and/or socioeconomically excluded - about the availability of vaccinations and the criteria of eligibility, perhaps by working with religious leaders but not necessarily exclusively so.
• Reject a one-size-fits-all approach to partnerships with religious minorities, and tailor the terms of these partnerships to address the intersection of religious and socio-economic factors.
• Where vaccine hesitancy is widespread within a religious minority, capitalise on the cases of positive deviance - women and men who defy the mainstream within the community and choose to be vaccinated and are happy for this to be publicly shared - which can encourage a domino effect by assuring religiously marginalised members that people like them have taken the vaccine and are well.
• Avoid generalisations about the influence of belief on vaccine practices of entire religious minorities, being aware that within each faith, there are many different denominations, as well as individual interpretations and choices.
• Do not assume that a religious motive is the only factor influencing the vaccination decisions of members of a religious minority.
• Where conspiracy theories and misinformation stray into hate speech inciting discrimination against religious (or other) minorities, challenge and remove it - attempting to do so without breaching freedom of speech.
• Counter hate speech about the relationship between the vaccine source and its intention to eradicate a people, and hold perpetrators accountable, even if they are members of another religious minority (e.g., Black Muslims belonging to the Nation of Islam espousing hate speech towards Jews).
• Where high levels of hesitancy remain despite all of the above, take great care in constructing incentives or penalties linked to vaccine uptake - for example, making welfare benefits conditional upon vaccination may raise ethical issues of penalising the socio-economically excluded members of religious minorities.

Click here for a 5-page summary in French.