Promising Practices for Engaging Local Faith Actors to Promote Uptake of COVID-19 Vaccination - Lessons Learned from Four Countries: Ghana, Indonesia, Sierra Leone, and Uganda

"Church leaders are sharing pictures of being vaccinated on social media platforms. They went viral encouraging their followers to do the same. They are leading by example." - key informant interviewee, Sierra Leone

Communities tend to trust local religious leaders, faith communities, and/or faith-based organisations (FBOs), who are typically influential in household decision-making and setting social norms. Local faith actors (LFAs) have long contributed to promoting and achieving increased immunisation uptake, coverage, and equity. In the case of COVID-19 vaccination, LFAs have sparked vaccine enthusiasm and quelled their adherents' fears by being publicly vaccinated, issuing theological proclamations on COVID-19 vaccine acceptability, and working with ministries of health (MOH) to implement COVID-19 messaging campaigns. This report from the United States Agency for International Development (USAID)'s MOMENTUM Country and Global Leadership project summarises evidence about engaging LFAs to promote uptake of COVID-19 vaccination in low- and middle-income countries (LMICs). Consisting of a PowerPoint presentation and policy brief, it is an investigation into lessons learned from four countries: Ghana, Indonesia, Sierra Leone, and Uganda.

In July 2021, MOMENTUM conducted a rapid informal desk review of peer-reviewed and gray literature on COVID-19 immunisation in the four selected countries. The team then conducted virtual semi-structured qualitative interviews with expert key informants drawn from 17 FBOs, government, and civil society organisations in the four countries. The goal was to:

• Identify actionable recommendations for engaging LFAs in promoting the uptake and/or delivery of COVID-19 vaccination in USAID partner countries, building on an earlier global evidence summary on the effects of faith actor engagement on the uptake and coverage of immunisation in LMICs. (See Related Summaries, below.)
• Unearth specific promising practices and interventions for COVID-19 vaccine promotion that could be adapted in similar contexts.
• Advance learning and evidence around how vaccination programmes can effectively work with FBOs and religious leaders to address vaccine misinformation and promote vaccine uptake.

While the review found few major religious objections to COVID-19 vaccines among religious leaders in all four countries, several trends were identified that may inform interventions:

• Pockets of minority religions in these countries have publicly objected to COVID-19 vaccination (indigenous faiths [Ghana], National Assemblies of Church [Ghana]; Jehovah's Witnesses, Seventh Day Adventist Communities [Sierra Leone]; Abajiri/People of the 666 Gospel [Uganda]). Other vaccine objections by LFAs may be lodged more clandestinely.
• COVID-19 vaccine social media disinformation - at times promulgated by LFAs - is an unprecedented threat to vaccine uptake in study countries; it is also an opportunity.
• Perceived divine will is an important determinant to COVID-19 vaccine acceptance among healthcare workers in rural areas and not important to those in urban areas (Sierra Leone).
• The perception of inclusion of haram (forbidden) ingredients within vaccines or their components may influence uptake of COVID-19 vaccine among Muslim populations (Indonesia).

The qualitative interviews also identified additional non-religiously-linked vaccine hesitancy drivers for the general population, which may have implications for overall vaccine messaging (including that shared by LFAs).

Overall, the research found numerous promising practices for engaging LFAs that go beyond "Sermon Guides". In particular, public COVID-19 vaccination by top religious representatives seems to have a positive effect on increasing vaccine uptake in highly religious settings. Based on the findings (see the full PowerPoint presentation for country-specific details), the report explores 15 promising practices for increasing vaccine uptake through strategic engagement of LFAs. Grouped in four themes, these promising practices range from high-level governance approaches to grassroots-level community interventions. MOMENTUM stresses that all of these approaches require strong partnerships between global technical agencies and religious governance structures, MOHs, and national LFAs to be successful. The practices include:

1. Engage in dialogue with religious leaders using traditional books/scripture, exploring the theological dimensions of specific antigens, and linking COVID-19 interventions and vaccination to spiritual principles. Example: In Ghana and Sierra Leone, World Vision's Channels of Hope COVID-19 modules combine dialogue, analysis of religious texts, and exploration of social norms to increase the adoption of vaccination.
2. Where appropriate (i.e., countries with sizable populations following hierarchically organised religions), attempt to secure a theological blessing from religious leaders on the acceptability of COVID-19 vaccines, and publicise that endorsement. Example: The December 2020 Vatican pronouncement of the COVID-19 vaccine's moral acceptability was helpful in assuaging hesitation among Catholic Ugandans.
3. Create virtual or in-person safe spaces where religious leaders can ask questions about COVID-19 vaccination in a private or "closed" setting, airing their own concerns about the vaccine in a non-judgmental environment prior to launching further messaging or outreach campaigns. Example: The Christian Health Association of Sierra Leone held special private sessions in its annual general membership meeting for religious leaders to share concerns around COVID-19 vaccination and address them in advance of rollout.
4. Hold joint dialogues with top clerics and scientists, and conduct site visits to vaccine production facilities to address vaccine hesitancy concerns related to antigen halal (permissible by Islam) status. Example: In Indonesia, the FBOs Muhammadiyah and Fatayat NU (FBOs) used this approach in 2017 to address halal-related vaccine hesitancy concerns for polio and measles, mumps, rubella (MMR) immunisations, engaging the Ulema Council, the nation's top body of Islamic scholars and imams to increase vaccine acceptance.
5. Consider working with interfaith councils for COVID-19 vaccine delivery and social mobilisation campaigns to harmonise messaging, reduce duplication, and maximise resources. Example: The Inter-Religious Council of Sierra Leone disseminated joint COVID-19 vaccine messages through radio, TV, and congregational meetings.
6. Hold interfaith discussion forums on COVID-19 vaccination among FBOs to share promising vaccine promotion/delivery practices. Example: In Indonesia, the FBO Fatayat NU previously held HIV- and stunting-focused interfaith discussion forums and advocacy campaigns around health issues that were instrumental in developing joint health and social and behavioural change (SBC) campaigns.
7. Conduct "pulpit swaps" where religious leaders from Christian and Muslim places of worship preach to each other's congregation, demonstrating unity and harmonised health messaging. Example: During the West Africa Ebola pandemic, World Vision and other FBOs worked with religious leaders to do pastor exchanges across religions, sharing the message "Ebola impacts us all, so we must act in solidarity"; this approach could be adapted for COVID-19 vaccination in similar settings with high levels of interfaith collaboration.
8. Increase government–LFA coordination on COVID-19 vaccination by supporting coordinating bodies with the mandate and authority to address the crisis. Example: Ghana's government established a State-Church COVID-19 Committee to coordinate COVID-19 response, which recognised the importance of FBO actors for COVID-19 response and funded them.
9. Encourage respected religious leaders to be publicly vaccinated at houses of worship and to serve as vaccine champions. Example: Key informants in all four countries emphasised how important public vaccination of religious leaders was to encourage COVID-19 vaccine uptake and reduce vaccine hesitancy in their country.
10. Capitalise on LFAs' infrastructure for COVID-19 vaccine promotion and administration/delivery (e.g., houses of worship, communications networks, etc.) by providing funding and materials (in coordination with government). Example: In Indonesia, the FBO Muhammadiyah's COVID-19 Command Center's COVID-19 vaccine promotion and delivery efforts have reached more than 4 million people with a variety of interventions through its networks of 18,000 schools and 427 health facilities and its communication networks.
11. Hold discussions on COVID-19 vaccination with men at religious gathering points (mosques, houses of worship, men's groups), led by respected religious leaders. Example: In Ghana, under the Gavi/Muslim Family Counseling Services project, religious leaders in Muslim communities of Kumasi promoted uptake of routine child immunisation after Friday prayers through community gatherings.
12. Consider pairing religious leaders with doctors/nurses, especially those from the same congegration, for COVID-19 vaccine social mobilisation campaigns. Example: Surveys show that health workers are the most reported trusted source of information in Sierra Leone and Uganda to help someone decide whether to take the COVID-19 vaccine; they can be paired with religious leaders, who may address theological acceptability of the vaccine.
13. Support LFAs to conduct evidence-based social media COVID-19 vaccination SBC messaging via existing FBO social media networks. Example: In Indonesia, the FBO Muhammadiyah features more than 10,000 users of its WhatsApp group consisting of religious leaders and other key influencers, which it uses to promote COVID-19 vaccination messaging.
14. Engage respected scientific intermediaries, such as faith-based health associations, to provide COVID-19 vaccine technical information to religious leaders. Example: In 2021, the Uganda Catholic Medical Bureau and Uganda Muslim Medical Bureau conducted individual sensitisation sessions with faith-based health facilities on COVID-19 vaccination.
15. Provide technical assistance and/or fund LFAs to conduct rapid assessments to adapt COVID-19 vaccine promotion campaigns so their SBC messaging and approaches on COVID-19 vaccination fit the local context. Example: In Sierra Leone, World Vision conducted a barrier analysis that identified the main behavioural determinants of COVID-19 vaccine acceptance; findings were used to advocate with the MOH to decentralise vaccination sites.

While there are many opportunities to succeed, this review revealed the potential complexities of working with LFAs for COVID-19 immunisation. For example, tension exists at times between government and LFAs over COVID-19 bans on worship gatherings (Sierra Leone, Uganda). This tension may spill over into the broader relationship and can impact communications. Creating closed WhatsApp groups and providing discussion guides and agenda support for MOH-LFA meetings may be helpful in fostering transparency on decision-making by governments.

In short, findings from this promising practices review support continued engagement and investment in LFAs as collaborators in COVID-19 vaccination efforts. Some suggestions going forward include:

• Engage and invest in LFAs in highly-religious LMICs to serve as central partners to their respective MOHs and to global technical bodies in COVID-19 vaccination promotion and delivery.
• Build on current enthusiasm among LFAs in combating COVID-19, leveraging their extensive infrastructure and cash and in-kind donations for increased impact.
• Review recommended promising practices (summarised above and expanded upon in Section 03 of the PowerPoint), and identify where your institution can play a role based upon your mission and mandate.
• Adapt and scale promising practices in similar settings, recognising that COVID-19 vaccine acceptance drivers vary by country, requiring analysis and tailored approaches by context.
• Conduct formal, informal, and practice-based assessments and evaluations to gather new learning and fill knowledge gaps around the engagement of LFAs in COVID-19 vaccination efforts.

The report concludes that LFAs are currently being sub-optimally engaged and supported for COVID-19 vaccination promotion and delivery, a missed opportunity as vaccine supply increases in LMICs.