REVIEW ARTICLE

Effects of local faith-actor engagement in the uptake and coverage of immunization in low- and middle-income countries: A literature review

Sara Melillo a, Rebecca Strachan b, Carolyn J O’Brienc, Chizoba Wonodid, Mona Bormete, Doug Fountain f

a MPH, USAID’s MOMENTUM Country and Global Leadership

b MSc, USAID’s MOMENTUM Country and Global Leadership

c MSPH, USAID’s MOMENTUM Country and Global Leadership, Christian Connections for International Health

d MD, MPH, DrPH, USAID’s MOMENTUM Country and Global Leadership, Johns Hopkins Bloomberg School of Public Health, International Vaccine Access Center

e MPH, CHES, USAID’s MOMENTUM Country and Global Leadership, Christian Connections for International Health

f MPA, USAID’s MOMENTUM Country and Global Leadership, Christian Connections for International Health

Abstract

Introduction: Religious leaders are universally recognized as having an influence on immunization uptake and coverage in low- and middle-income countries (LMICs). Despite this, there is limited understanding of three questions: 1) how do religious leaders impact the uptake and coverage of immunization in LMICs? 2) what successful strategies exist for working with local faith actors to improve immunization acceptance? and 3) what evidence gaps exist in relation to faith engagement and immunization?

Methods: In January 2021, we searched PubMed and Google Scholar databases covering the period from January 1, 2011 to January 15, 2021 with key search terms related to faith engagement and immunization in peer-reviewed literature and conducted a gray literature review to answer these three questions. We excluded articles covering faith engagement and immunization in high-income countries, news articles, online blogs, social media postings, and articles in languages outside of English. Data were coded to guide thematic analysis.

Results: We found extensive evidence supporting the value of religious engagement for immunization promotion and acceptance in LMICs across faiths. However, there was limited rigorous evidence and examples of specific approaches for engaging local faith actors to strengthen immunization 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 local faith actors. 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 immunization in religions other than Islam and Christianity.

Conclusions: Our review findings reinforce the powerful role local faith actors play in diverse communities within LMICs in both promoting and inhibiting immunization uptake. The literature review comes at a critical time, given the urgent need to expand access to COVID-19 vaccination in LMICs. 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 context.

Key Words: vaccine hesitancy, systematic review, immunization, low- and middle-income countries, faith-based organizations, religious leaders, local faith actors

Introduction

Religious leaders and local faith actors are universally recognized as having an influence on immunization uptake and coverage in low- and middle-income countries (LMICs).1,2 This association between religion and vaccination dates back to as early as 1,000 AD, when a Buddhist nun was described as grinding scabs from a smallpox-infected person into a powder, and blowing it into a non-immune person’s nostrils to induce immunity.3-5

Today, many major religions commonly believe that vaccination—the act of administering a substance that stimulates the body’s immune response against diseases—supports their shared objectives of preserving and protecting life, health, well-being, equity, and prevention of suffering, especially among children and other innocents.5 Some religions even call for vaccination as a moral imperative to preserve the lives of children or within a community.3,6

Yet, despite the powerful positive potential to reduce and eliminate diseases such as smallpox and polio, religious factors remain the third most frequently cited reason for vaccine hesitancy in global surveys.7-13 Vaccine hesitancy in this case is defined as delay in acceptance or refusal of vaccines despite the availability of vaccination services. Religiously-linked, vaccine hesitancy concerns are especially pronounced and rising in LMICs, though often these concerns are inter-mixed with others related to political, economic, or social issues.13-15 Prominent media coverage and academic study of widespread polio vaccine hesitancy among Muslim communities in Northern Nigeria and Pakistan in the 2000s and 2010s has further heightened awareness and interest in vaccine hesitancy and faith communities.

Specific aims of the literature review

There is still limited information on and understanding of how faith actors impact the uptake and coverage of immunizations in LMICs, as well as what interventions work to counter vaccine hesitancy among local faith actors. To date, the bulk of research on vaccine hesitancy and faith communities has been conducted in high-income countries. We are unaware of efforts to validate vaccine hesitancy measurement tools in sub-Saharan Africa.16

This is a critical evidence gap, as vaccine hesitancy among faith communities has been demonstrated to negatively impact immunization coverage in certain LMICs.17 The rollout of COVID-19 vaccinations in LMICs also represents an acute challenge and opportunity to engage faith leaders in what will be the largest public health vaccination campaign in the past 100 years.

The Faith Engagement Team of the US Agency for International Development’s (USAID’s) MOMENTUM Country and Global Leadership program undertook a study of the role of faith communities in vaccine hesitancy. In January 2021, we conducted a literature review to answer three key questions: 1) How do religious leaders and faith-based organizations impact the uptake and coverage of immunization in LMICs? 2) What successful strategies exist for working with local faith actors and communities to improve immunization acceptance and reduce vaccine hesitancy? and 3) What evidence gaps exist in relation to faith engagement and immunization? Findings will advance understanding on how to more effectively engage local faith actors in promoting routine and supplementary immunization campaigns and reducing vaccine hesitancy.

Methods

Search strategy

The research team searched PubMed and Google Scholar databases for peer-reviewed literature for the period from January 1, 2011 to January 15, 2021 with key search terms related to faith engagement and immunization (Figure 1).



Fig 1

Figure 1. Literature review search terms

We supplemented the peer-reviewed database searches with a gray literature search, recognizing that many interventions related to religious leaders are not published in peer-reviewed journals. The review included a keyword search across several online databases and organizational websites for the same period: Google, the Vaccine Confidence Project Literature Archive, and USAID’s Maternal and Child Survival Program website. References in papers meeting inclusion criteria were searched for further relevant studies for potential review. The authors also solicited submissions from a cohort of key informants who included experts from the USAID MOMENTUM Country and Global Leadership program and from a cohort of 18 global faith engagement and immunization experts drawn from Christian Connections for International Health’s (CCIH) networks.

Inclusion/exclusion criteria

We included peer-reviewed studies and gray resources meeting the following criteria: 1) the study context was an LMIC; 2) it included any of the search keywords in the title or abstract; 3) the main focus of the study or resource was related to faith-actor engagement and immunization and/or vaccine hesitancy; 4) it was published between January 1, 2011 and January 15, 2021; and 5) it was published in English. Resources were excluded if they were about faith engagement and immunization in high-income countries, news articles, online blogs, or references to social media postings.

As depicted in Figure 2, the literature review found an initial 434 articles through initial search terms and an assessment of relevance using the pre-identified inclusion criteria. All articles that met the inclusion criteria (137) were included for quality assessment and data extraction. Of these, 27 duplicate references were manually removed, leaving 110 resources. These are presented in Appendix 1.



Fig 2

Figure 2. Literature Review Search Strategy

Data extraction and analysis

We reviewed the 110 relevant papers and entered qualitative and quantitative descriptive information into an Excel data extraction matrix template that included the following categories: author, year, publication; country(ies), and/or region covered; type of study/article/resource; focal religion(s); and topical area of focus (including vaccine hesitancy, specific types of vaccine). The matrix also captured key observations and findings, vaccine hesitancy findings, evidence-based interventions related to engaging local faith actors and immunization, promising practices for faith engagement and immunization, and reported evidence gaps. Data were coded using a predefined set of themes and sub-themes from the matrix categories to answer the three literature review questions.

Results

Description of the resources reviewed

Despite results, there is still scant published evidence of the role of religion and local faith actors on immunization.1 Most studies treat religion as a confounding variable without a detailed examination of the nuanced impact or inter-related factors (social/political/economic) that impact immunization uptake.1,2 The review did find a number of key thematic foci, as depicted in Table 1.

Table 1. Key Themes Found in Literature Review (see Appendix 1 for full listing of resources)
Theme Relevant Materials
Main Topical Focus of Article
Religion/local faith actors and immunization Akseer, N (2018); Alemu M (2016); Ames H (2017); Asress A and Bezabih L (2018); Bangura JB (2020); Berkley Center (2020); Berkley Center (2012); Boulton ML and Wagner AL (2021); Catholic Relief Services (2019); Christian Connections for International Health (2017); Costa JC (2020); Gavi (2015); Glatman-Freedman A and Nichols K (2012); Grabenstein JD (2013); International Interfaith Peace Corps (2016); Jalloh MF (2020); Makoka M (2020); Malande OO (2019); Marshall K (2013); Morry C (2019); Mukungwa T (2015); Mupere E (2020); Nnadi C (2017); Olivier, J (2016); Oyo-Ita A (2020); Soura A (2013); UNICEF (2012); UNICEF (2015); Vatican Commission for COVID-19 (2021); Vermandere H (2016); Wesevich A (2016); Wilkinson O and Marshall K (2021); Wonodi CB (2012); Woo, YL (2012); World Council of Churches and World Jewish Congress (2020); World Faiths Development Dialogue (2012); World Health Organization (WHO) (2017); (WHO) (2018); WHO/Sage Working Group on Vaccine Hesitancy, systematic review (2014); World Vision, barrier analysis (2021)
Religion/local faith actors and vaccine hesitancy Abakar MF (2018); Abubakar A (2019); Agrawal A (2020); Ahmed A (2018); Ahmed S (2014); Ansari, MT (2020); Anyene, B (2014); Balbir Singh HK (2019); Barmania S and Reiss MJ (2020); Berkley Center (2021); Cobos Muñoz D (2015); Cooper S (2018); de Figueiredo A (2020); Dubé E (2014); Ebrahim, AF (2013); Evans D (2019); Falade BA (2014); Gallup and Wellcome Global Monitor (2018); Gerede R (2017); Ghinai I (2013); Grandahl M (2018); Greenberger C (2017); Guzman-Holst A (2020); Ha W (2014); Habib MA, community engagement (2017); Habib MA, knowledge and perceptions (2017); Hamdi S. (2018); Harapan H (2021); Hussain SF (2016); International Vaccine Access Center (2020); Jalloh MF (2019); Jamal D (2020); Jarrett C (2015); Kalok A (2020); Khan MU, Muslim scholars’ knowledge (2017); Khan MU, knowledge, attitudes (2017); Khowaja AR (2012); Kriss JL (2016); Kucheba F (2021); Lane S (2018); Larson, HJ (2016); Machekanyanga Z (2017); Marti M (2017); McArthur-Lloyd A (2016); Muslim religious scholars (2014)l Nasir JA (2017); Nasir SG (2014); Ndiaye K (2013); Njeru I (2016); Olivier J. (2014); Olorunsaiye CZ (2017); Olufowote JO (2016); Owoaje E (2020); Padela AI (2014); Padmawati RS (2019); Peckham R (2018); Pelčić G (2016); Pugliese-Garcia M (2018); Remes P (2012); Renne E (2010); Sabahelzain MM (2019); Syiroj ATR (2019); Taylor S (2017); Tefera YA (2018); Turiho AK (2017); Wagner AL (2019); Wong LP and Wong PF (2020); Wong LP (2020); WHO/Sage Working Group on Vaccine Hesitancy, systematic review (2014); WHO/Sage Working Group on Vaccine Hesitancy, report (2014)
New vaccine acceptance Padmawati RS (2019); Wonodi CB (2012)
Faith-Based Concerns or Interest with Specific Vaccines
Polio Agrawal A (2020); Ahmed S (2014); Falade BA (2014); Ghinai I (2013); Habib MA, community engagement (2017); Habib MA, knowledge and perceptions (2017); Hussain SF (2016); Khan MU, Muslim scholars’ knowledge (2017); Khan MU, knowledge, attitudes (2017); Khowaja AR (2012); McArthur-Lloyd A (2016); Nasir JA (2017); Nasir SG (2014); Ndiaye K (2013); Njeru I (2016); Olufowote JO (2016); Owoaje E (2020); Peckham R (2018); Renne E (2010); Taylor S (2017)
COVID-19 Barmania S and Reiss MJ (2020); Berkley Center (2021); Berkley Center (2020); Vatican Commission (2021); Wilkinson O and Marshall K (2021); World Council of Churches and World Jewish Congress (2020); World Vision, PowerPoint (2021); World Vision, website (2021)
Rotavirus Padmawati RS (2019); Wesevich A (2016)
Religion of Focus in Relation to Immunization Exploration
Multiple religions or no specific religion Akseer, N (2018); Bangura JB (2020); Barmania S and Reiss MJ (2020); Berkley Center (2021); Berkley Center (2020); Berkley Center (2012); Boulton ML and Wagner AL (2021); Catholic Relief Services (2019); Christian Connections for International Health (2017); Cobos Muñoz D (2015); Cooper S (2018); Costa JC (2020); Dubé E (2014); Gavi (2015); Glatman-Freedman A and Nichols K (2012); Grabenstein JD (2013); Guzman-Holst A (2020); International Interfaith Peace Corps (2016); Jalloh MF (2020); Jarrett C (2015); Lane S (2018); Larson, HJ (2016); Marshall K (2013); Marti M (2017); Morry C (2019); Mupere E (2020); Nnadi C (2017); Olivier J (2014); Olivier J (2016); Olorunsaiye CZ (2017); Remes P (2012); Soura A (2013); Tefera YA (2018); Turiho AK (2017); UNICEF (2012); UNICEF (2015); Wagner AL (2019); Wilkinson O and Marshall K (2021); Wonodi CB (2012); Wong LP (2020); World Council of Churches and World Jewish Congress (2020); World Faiths Development Dialogue (2012); WHO (2018); WHO (2017); WHO/Sage Working Group on Vaccine Hesitancy, systematic review (2014); World Vision, barrier analysis (2021)
Muslim Abakar MF (2018); Abubakar A (2019); Agrawal A (2020); Ahmed A (2018); Ahmed S (2014); Ansari, MT (2020); Anyene, B (2014); Balbir Singh HK (2019); de Figueiredo A (2020); Ebrahim AF (2013); Falade BA (2014); Ghinai I (2013); Habib MA, community engagement (2017); Habib MA, knowledge and perceptions (2017); Hamdi S (2018); Harapan H (2021); Hussain SF (2016); Jalloh MF (2019); Jamal D (2020); Kalok A (2020); Khan MU, Muslim scholars’ knowledge (2017); Khan MU, knowledge, attitudes (2017); Khowaja AR (2012); McArthur-Lloyd A (2016); Muslim religious scholars (2014); Nasir JA (2017); Nasir SG (2014); Ndiaye K (2013); Olufowote JO (2016); Owoaje E (2020); Oyo-Ita A (2020); Padela AI (2014); Padmawati RS (2019); Peckham R (2018); Remes P (2012); Renne E (2010); Sabahelzain MM (2019); Syiroj ATR (2019); Taylor S (2017); Vermandere H (2016); Wong LP and Wong PF (2020); Woo, YL (2012)
Christian Alemu M (2016); Ames H (2017); Asress A and Bezabih L (2018); Evans D (2019); Gerede R (2017); Ha, W (2014); Kriss JL (2016); Kucheba F (2021); Machekanyanga Z (2017); Makoka, M (2020); Malande OO (2019); Mukungwa T (2015); Njeru I (2016); Pugliese-Garcia M (2018); Remes P (2012); Vatican Commission for COVID-19 (2021); Wesevich A (2016)
Non-Muslim or Non-Christian Grandahl M (2018); Greenberger C (2017); Malande OO (2019)

Study/resource type and quality

The review found a total of 110 relevant articles, 69% of which were peer reviewed, and the other 31% were from gray literature. While the literature review did not explicitly assess and score study quality, the quality of literature reviewed appears mixed based upon the study designs found. Most peer-reviewed literature cited was observational in nature; gray literature or discussion papers represented 44.5% of resources reviewed. The review found only three intervention studies (2.7%) examining approaches for engaging faith leaders. As the dominant resource type, the descriptive literature consisted of cross-sectional studies, qualitative studies, mixed methods, and data analysis. Additionally, there were several commentaries and discussion papers along with both literature and systematic reviews. The gray literature consisted of tools, guidelines, various resources, and reports. There were a variety of additional gray resources found including books, evaluations, poster/oral presentations, and unpublished theses.

Topical focus

The relevant literature was predominantly focused on vaccine hesitancy (60%) among different faith groups, versus a general exploration of religious engagement and vaccines (36%). The remaining 4% of resources focused on new vaccine acceptance among local faith actors and vaccines delivered by local faith actors in humanitarian environments. Of the articles that examined a specific vaccine type, there was a focus on campaign-based vaccinations and so-called “controversial” vaccines (those causing hesitancy), rather than routine immunizations. The resource breakdown included:

Time period

At least five articles have been published every year since 2012 on the topic of local faith actors and immunization in LMICs. Interest in the topic appear to be rising as 70% of the resources identified were published within the last five years of the review (2016–2020). Last year (2020) was the peak, with 20 articles published.

Religions of focus

Just under half the resources found (42%) focused on multiple religions or general local faith-actor engagement and immunization rather than specific religions. The majority of studies with an explicit religious focus examined large-scale organized, monotheistic faiths (Islam, Christianity), and mainline religions—those linked to established denominations in the global North. Only eight studies explored immunization and faith engagement in traditional, folk, or growing non-networked religions such as Pentecostal or Charismatic denominations (12.5%), a growing proportion of religions in LMICs. We found few studies exploring immunization in the context of Buddhist or Hindu faiths in Asia.

The literature also reflects a heavy focus on polio vaccine hesitancy among Muslim populations, with 19% of all resources focused on that topic. The hesitancy literature in general focuses primarily on countries with large or predominantly Muslim populations, with the exception of Apostolic Christian denominations within Zimbabwe.

Geographic focus

Nearly half of the studies that met the inclusion criteria (44%) offered a global or multi-country focus in LMICs, rather than zeroing in on a specific geographic area. The other resources were localized to specific regions, predominantly sub-Saharan Africa (34%), followed by Southeast and South Asia (19%). Within sub-Saharan Africa, the majority of resources focused on Nigeria (16 articles), with fewer resources from Ethiopia, Kenya, Uganda, Tanzania, Zambia, and Zimbabwe (Figure 3).



Fig 3

Figure 3. Literature review findings: Top focal countries (as of January 15, 2021)

Within the Southeast and South Asian region, the majority of resources were specific to Pakistan (12 articles), while Afghanistan, Bangladesh, India, Indonesia, and Malaysia had fewer published research resources. The literature review uncovered major research gaps for the Latin American and Caribbean region, and only three resources were found for the Middle East and North Africa. There were no articles published for Eastern Europe nor the Asia Pacific region.

Discussion

Question 1: How do religious leaders and faith-based organizations impact the uptake and coverage of immunization in LMICs?

Measuring the precise impact and causality of local faith actors on immunization rates is challenging. Most studies generally treat religion as a confounding variable without a detailed examination of the nuanced impact or inter-related factors (social/political/economic) that effect immunization uptake.1,2 This remains an important area for future research and exploration.

The reviewed literature did demonstrate four main mechanisms through which religious leaders and faith actors impact immunization uptake in LMICs: 1) influencing caretaker beliefs and values,1,2,17,18 2) impacting access to resources that facilitate immunization uptake,1 3) communicating immunization messages and conducting mobilization,2 and 4) providing routine immunizations in hard-to-reach areas or humanitarian settings. These findings suggest that continued investment in and engagement with faith leaders can be a valuable strategy for immunization programming.2,19 At the same time, the review did not find detailed explorations and analysis of the dynamics and mechanisms of how faith actors specifically influenced immunization uptake and coverage within local communities. This may warrant additional research in this area to unpack the influence and interplay of local faith actors within communities to better understand these mechanisms and design evidence-based interventions.

Religiously-linked vaccine hesitancy

Vaccine hesitancy is a complex phenomenon. Few religious groups or their sacred texts explicitly reject immunization (Figure 4).3,5,11,12,20,21



Fig 4

Figure 4. What major religions say about vaccines

Multiple resources reviewed suggested that vaccination hesitancy is often cloaked under the guise of “religion,” without a theologically-grounded objection.3,12 Instead, religious objections to vaccination serve as a cover or proxy for concerns about safety, social norms, socio-cultural issues, political, and economic factors.2,3,5,26,27

Common faith-linked vaccine hesitancy views across religions included the belief(s) that:

The review found additional vaccine hesitancy themes, including: promotion of faith healers and/or the power of prayer over the use of vaccines or medicine,11,29,30 distrust of Western medicine/fear that vaccines are being tested on their community,29,30 worry that vaccines will sterilize recipients/impact fertility, and the promotion of traditional remedies rather than biomedical solutions.8,30,31

While these vaccine hesitancy themes were explored in numerous resources in the review, we did not find systematic analysis or study of the specific actions that local faith actors took to translate these beliefs into action and influence social norms, outside of specific references to case studies of vaccine hesitancy in certain countries among local faith actors. In these specific country examples, actions taken by local faith actors included 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 immunizing their children.

Heavy emphasis on Islam and vaccine hesitancy

The literature review found extensive documentation and exploration of Islam and vaccine hesitancy in LMICs, amounting to 69% of all studies with a specific single religion focus. This 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.32,33

Several references underscore the principle that Islamic theology generally supports immunization,14,22,23 and there are predominantly Muslim countries with low rates of reported vaccine hesitancy, including Bangladesh, Malaysia, Niger, and Saudi Arabia. The review did find multiple studies that suggested lower coverage of immunizations among Muslim populations in LMICs (across countries and within countries of heterogenous religions).1,14-16,34 Major drivers of vaccine hesitancy among Muslim faith communities identified in the studies included concerns that vaccines may contain haram materials (those prohibited under Islamic law),14,33,35 fears that immunization would impact the fertility of recipients,32,36 and beliefs that vaccinations were part of a Western conspiracy to harm their population.29,30

Other religions of interest

Christian denominations accounted for 23% of all resources with a single religious focus in the literature review, with a strong focus on Apostolic denominations in Zimbabwe and Southern Africa. Originating from the Protestant Pentecostal church, Apostolic churches reflect a desire to emulate first-century Christianity in its faith, practices, and government and have historically objected to most medical interventions in lieu of prayer for healing.9,11 Multiple studies showed lower basic immunization uptake and completion in Zimbabwe among Apostolic communities, with varying attitudes and degrees of refusal toward immunization among sub-sects, indicating a need for further study and interventions to address this growing population in Southern Africa.8,9,11,20,37

Despite much coverage in news media and popular culture focused on the use of cells from aborted fetuses to develop vaccines, the review only found two resources meeting inclusion criteria focused on vaccine hesitancy among Catholic populations where Catholic bishops in Kenya led a call for the boycott of the maternal tetanus toxoid (fertility concerns) and childhood polio vaccines (safety concerns).29,38

Vaccines of concern to faith actors

Religiously-linked polio vaccine hesitancy featured most prominently within the literature (representing 20 articles/41.7% of all articles with a specific vaccine focus), with examples from Pakistan,32,35,39,40 Nigeria,4143 and Kenya.38 This hesitancy contributed to increased reported caretaker vaccine refusal in Kenya due to safety concerns.38 Polio vaccine rejection by religious and community leaders was linked with overall reduced polio vaccine coverage in Nigeria.41,43 In Pakistan, multiple barriers were found, including concerns that vaccines include non-halal ingredients35 and fears of a Western plot to sterilize Muslims or reduce the Muslim population.32,39

HPV immunization was found to be the second most frequently cited vaccine with religious objections. The HPV vaccine creates faith-linked challenges in both higher- and lower-income countries due to its perceived links to sexual activity. The review found broader religious objections to HPV vaccination among Catholic7 and Muslim44 communities globally and specific concerns in Brazil,8,45 Indonesia,8,45 Kenya,46 Malaysia,47 Tanzania,8,45 and Zambia.28 The literature review also found instances of religiously-linked vaccine hesitancy among the following specific immunizations (as opposed to general immunization hesitancy): measles, mumps, and rubella (Indonesia18,34, Sudan 48); rotavirus (Indonesia33, Zambia49); cholera (Zambia30); and pertussis (Nigeria14,36).

Question 2. What successful strategies exist for working with local faith actors and communities to improve immunization acceptance and reduce vaccine hesitancy?

The literature review found limited high-quality evidence and examples of specific approaches for engaging local faith actors to strengthen routine immunization and campaign-based immunization uptake. Most interventions involved engaging religious leaders and the local community in dialogue-based interventions50 and engaging religious leaders and church structures in social mobilization and advocacy.1,2,44,49,5153

Improving immunization uptake and coverage

One study found that working with religious leaders on a multi-pronged immunization promotion and delivery strategy, including targeting priority populations and increasing service delivery availability, was more effective for increasing vaccine uptake than messaging with religious leaders alone.50 Using church infrastructure, faith-based health facilities, and religious rituals as vaccination messaging or delivery points, including in humanitarian settings, was also found to be effective for increasing vaccine coverage.19,28,54

Reducing religiously-linked vaccine hesitancy

The review found limited examples of evidence-based approaches for tackling faith-linked vaccine hesitancy. Engaging faith-based organizations and faith leaders in the rollout of new vaccines was found in multiple studies to be important for increasing community acceptability and uptake and preventing potential vaccine hesitancy.5557 Several studies found that religious concerns focused on the bioethics of vaccine production may be effectively addressed through theological analyses of sacred text and dialogue with faith leaders, including understanding the alternatives among available vaccines.25,55,58 In Muslim countries, where there is concern that vaccines were manufactured with haram (forbidden) materials, acknowledging these concerns and communicating effectively about them with Muslim faith leaders and structures is critical.14,59

Question 3. What evidence gaps exist in relation to faith engagement and immunization?

The literature review found promising evidence of the value of religious engagement for immunization promotion and acceptance in LMICs across faiths. In particular, we found multiple articles demonstrating the value of religious engagement for immunization promotion and acceptance,2,16, 60 studies of vaccine hesitancy among Muslim leaders,32,33,35,36,40,41 comparisons of immunization among different faiths within the same countries,14,15,34 and reviews and discussion papers on the correlation between faith engagement and vaccine acceptance.1,2,17,18

Despite these findings, this literature review found significant evidence gaps—described below—that limit the generalizability of some findings, such as:

Limitations

It is well-known that many local faith-based organizations and actors maintain practice-based knowledge and are less likely to publish their findings in journals. This literature review and its conclusions may therefore be subject to publication bias, in that unsuccessful interventions may be less likely to be documented in either the peer-reviewed or gray literature. In addition, the review excluded non-English language resources, potentially missing observations and promising practices.

Several other factors also warrant caution on extrapolating findings more broadly. While the literature did not explicitly assess and score study quality, the quality of literature remains mixed, based upon review of study/resource type, limiting generalizability and rigor of conclusions. As noted above, the review found evidence gaps among certain geographies, religion types, and different vaccines.

Finally, this literature was conducted amid the early launch and rollout of COVID-19 vaccination (January 2021). As such, the review found very limited and explicit gray or peer-reviewed literature on the topic of faith engagement and COVID-19 immunization. While many of the findings and interventions may be applicable and effective if applied to COVID-19 immunizations, further study and investigation is warranted for this urgent public health crisis.

Conclusions

Our literature review findings suggest that continued investment in and engagement with local faith actors can be a valuable strategy for immunization programming in LMICs. The 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.

More investigations and evidence are needed regarding what interventions that involve local faith actors are most effective, and in which contexts, in promoting vaccine uptake. Vaccine hesitancy is a highly complex phenomenon. The current peer-reviewed and gray literature does not provide an adaptable, concise roadmap for tackling these issues in different geographic, cultural, linguistic, and other contexts. In particular, further study is needed on the role of faith leaders in the promotion of routine immunization (rather than campaign-based immunization), the impact of local faith actors on vaccine uptake among growing Pentecostal, Charismatic, and so-called “un-networked” faiths, and vaccine hesitancy among Buddhist and Hindu faiths in Asia.

Multiple studies and resources within the review did 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. These review findings should reinforce an important caution for public health planners, policymakers, and implementers to avoid the temptation to oversimplify or blame faith actors for vaccine hesitancy. Evidence repeatedly demonstrates that apparent faith-based objections are sometimes a convenient proxy for more complex, inter-related socio-cultural, and political issues related to immunization. In cases where vaccine hesitancy is identified among local faith actors, the review suggests that listening and dialoguing with faith leaders is critical to finding theologically-acceptable solutions to vaccine hesitancy.

In addition, this review suggests that more work is needed to foster global and national-level discussions to engage faith leaders in vaccine hesitancy reduction efforts. Country-level strategies to stimulate research and dialogue with religious structures, interfaith networks, and theological institutions may help identify some of these underlying socio-cultural and political issues. To increase understanding and scale-up of successful strategies, we also encourage local faith actors and implementers to more widely share their experiences engaging religious leaders in immunization programs, which are largely absent from peer-reviewed and gray literature.

This review comes at a critical time, given the rollout of COVID-19 vaccination in LMICs. At the time of the literature review, most COVID-19 vaccine hesitancy research in LMICs was just getting underway. However, emerging research in six countries shows that endorsement of the COVID-19 vaccine by faith leaders will be critical to vaccine acceptance.61,62 On a positive note, many religious leaders and groups have taken a lead role on calls for vaccine equity in LMICs and are leading the charge to promote COVID-19 immunization in their countries. It will be critical to adapt and scale successful strategies from previous immunization efforts with faith leaders to successfully respond to this urgent public health crisis.

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Peer Reviewed: Submitted 5 Oct 2021, accepted 1 Feb 2022, published 20 June 2022

Competing Interests: None declared.

Funding: Christian Connections for International Health (CCIH) received primary research funding from the United States Agency for International Development (USAID) MOMENTUM Country Global Leadership Project (Grant/Award Number: Cooperative Agreement #7200AA20CA00002), led by Jhpiego and partners

Correspondence: Carolyn J. O’Brien, CCIH, Virginia, USA. carolyn.obrien@ccih.org

Cite this article as: Melillo S, Strachan R, O’Brien CJ, Wonodi C, Bormet M & Fountain D. Effects of local faith-actor engagement in the uptake and coverage of immunization in low- and middle-income countries: A literature review. Christ J Global Health. May 2022;9(1):2-32. https://doi.org/10.15566/cjgh.v9i1.587

© Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/

Appendix 1. Articles Reviewed

Reference and year Country(s) and/ or Region Religions Resource Type/ Study Type Areas of Focus/ Key Themes Link to reference
2010
Renne, E. Islam and immunization in Northern Nigeria. Nigeria Islam Draft book chapter Vaccine Hesitancy; Polio https://www.ascleiden.nl/Pdf/paperrenne.pdf
2012
Berkeley Center for Religion, Peace & World Affairs/World Faiths Development Dialogue. Faith and immunizations meeting report. Global Multiple Meeting report Religion & immunization https://berkleycenter.georgetown.edu/news/new-meeting-report-faith-and-immunizations.
Glatman-Freedman A, Nichols K. The effect of social determinants on immunization programs. Global - Low income countries Multiple Review Religion & immunization Hum Vaccin Immunother. 8;3:293-301.
https://doi.org/10.4161/hv.19003
Khowaja AR, Khan SA, Nizam N, Omer SB, Zaidi A. Parental perceptions surrounding polio and self-reported non-participation in polio supplementary immunization activities in Karachi, Pakistan: a mixed methods study. Pakistan Islam Mixed methods study Vaccine Hesitancy; Polio Bull World Health Organ. 90(11):822-30.
https://doi.org/10.2471/BLT.12.106260
Remes P, et al. A qualitative study of HPV vaccine acceptability among health workers, teachers, parents, female pupils, and religious leaders in northwest Tanzania. Tanzania Christian; Islam Qualitative semi-structured interviews Vaccine Hesitancy; HPV Vaccine. 30(36):5363-7.
https://doi.org/10.1016/j.vaccine.2012.06.025
UNICEF. Partnering with religious communities for children. Global Multiple Report Religion & immunization https://sites.unicef.org/about/partnerships/files/Partnering_with_Religious_Communities_for_Children_(UNICEF).pdf
Wonodi CB, et al. Using social network analysis to examine the decision-making process on new vaccine introduction in Nigeria. Nigeria None Mixed methods study using qualitative [key informant interviews (KIIs)] and quantitative (survey) data collection methods Religion & immunization Health Policy Plan. 27(suppl 2): ii27–ii38.
https://doi.org/10.1093/heapol/czs037
Woo YL, Razali SM, Chong KR, Omar SZ. Does the success of a school-based HPV vaccine programme depend on teachers' knowledge and religion?–a survey in a multicultural society. Malaysia Islam; multiple faiths Survey Multi-cultural society; HPV Asian Pac J Cancer Preve. 13(9): 4651-4.
https://doi.org/10.7314/apjcp.2012.13.9.4651
World Faiths Development Dialogue. Faith & immunization: past, present, and potential roles of faith-inspired organizations. Global Multiple religions White paper Religion & immunization; New Immunizations https://berkleycenter.georgetown.edu/publications/faith-immunization-past-present-and-potential-roles-of-faith-inspired-organizations
2013
Ebrahim AF. Islam & vaccination. Global Islam Book Vaccine hesitancy Islamic Medical Association of South Africa.
Ghinai I, Willott C, Dadari I, Larson HJ. Listening to the rumours: what the northern Nigeria polio vaccine boycott can tell us ten years on. Nigeria Islam Mixed methods data analysis and qualitative analysis Vaccine Hesitancy; Polio Glob Public Health. 8(10):1138-50.
https://doi.org/10.1080/17441692.2013.859720
Grabenstein JD. What the world's religions teach, applied to vaccines and immune globulins. Global Hindu, Buddhism, Judaism, Jainism, Christian, Islam Review Immunization and faith Vaccine. 31(16):2011-23.
https://doi.org/10.1016/j.vaccine.2013.02.026
Ndiaye K. The Influence of religious and traditional rulers in polio vaccination efforts in Northern Nigeria. Nigeria Islam Discussion paper [Unpublished research paper] Vaccine Hesitancy; Polio https://ssrn.com/abstract=2250207
Marshall K. Engaging faith communities on immunization: what's next? Global Multiple faiths Technical Brief Vaccine Hesitancy; Religion & immunization The Berkley Center for Religion, Peace & World Affairs.
https://berkleycenter.georgetown.edu/publications/engaging-faith-communities-on-immunization-what-next
Soura A, Pison G, Senderowicz L, Rossier C. Religious differences in child vaccination rates in urban Africa: Comparison of population surveillance data from Ouagadougou, Burkina Faso Burkina Faso Islam, Catholic Statistical analysis Religion & immunization; Routine Immunization Etude Popul Afr. 27(2):174-187.
https://aps.journals.ac.za/pub/article/view/439/393
2014
Ahmed S, et al. Resistance to polio vaccination in some Muslim communities and the actual Islamic perspectives—a critical Review. Pakistan; Nigeria; Afghanistan; India Islam Review article Vaccine Hesitancy; Polio J Pharm Technol. 7(4):494-5.
https://doi.org/10.52711/0974-360X.2022.00001
Anyene B. Routine immunization in Nigeria: the role of politics, religion and cultural practices Nigeria Islam; Christian Discussion paper Vaccine Hesitancy Afr J Health Econ. 3.
https://www.ajhe.org.in/uploads/55/3075_pdf.pdf
Dubé E, Gagnon D, Nickels E, Jeram S, Schuster M. Mapping vaccine hesitancy—country-specific characteristics of a global phenomenon. Global None Mixed methods study Vaccine Hesitancy Vaccine. 32(49):6649-54.
https://doi.org/10.1016/j.vaccine.2014.09.039
Falade BA. Vaccination resistance, religion, and attitudes to science in Nigeria. Nigeria Islam PhD thesis [Unpublished doctoral dissertation thesis]. Vaccine Hesitancy; Religion & immunization; Polio http://etheses.lse.ac.uk/911/1/Falade_Vaccination-resistance-religion-and-attitudes-to-science-in-Nigeria.pdf
Ha W, Salama P, Gwavuya S, Kanjala C. Is religion the forgotten variable in maternal and child health? Evidence from Zimbabwe. Zimbabwe Apostolic Statistics review Vaccine Hesitancy; BCG Vaccine Soc Sci Med. 1982;118:80–8.
https://doi.org/10.1016/j.socscimed.2014.07.066
Muslim religious scholars. Dakar declaration on vaccination. Africa Islam Declaration Vaccine Hesitancy International Conference on Vaccination and Religion. Dakar, Senegal.
https://www.afro.who.int/sites/default/files/2017-09/Religious%20Leaders%20Declaration.pdf
Nasir SG, et al. From intense rejection to advocacy: how Muslim clerics were engaged in a polio eradication initiative in Northern Nigeria. Nigeria Islam Analysis Vaccine Hesitancy; Polio PLoS Med. 11(8):e1001687.
https://doi.org/10.1371/journal.pmed.1001687
Olivier J. Local faith communities and immunization for community and health systems strengthening. Global Multiple Literature review Vaccine Hesitancy; Religion & immunization Joint Learning Initiative on Faith and Local Communities. https://jliflc.com/wp-content/uploads/2014/09/LOCAL-FAITH-COMMUNITIES-AND-IMMUNIZATION-FOR-COMMUNITY-AND-HEALTH-SYSTEMS.pdf
Padela AI, Furber SW, Kholwadia MA, & Moosa E. Dire necessity and transformation: entry-points for modern science in Islamic bioethical assessment of porcine products in vaccines. Global Islam Bioethical commentary Vaccine Hesitancy Bioethics. 28(2):59-66.
https://doi.org/10.1111/bioe.12016
World Health Organization/Sage Working Group on Vaccine Hesitancy. Strategies for addressing vaccine hesitancy— systematic review. Global None Review article Vaccine Hesitancy; Religion & immunization https://www.who.int/immunization/sage/meetings/2014/october/3_SAGE_WG_Strategies_addressing_vaccine_hesitancy_2014.pdf
World Health Organization/Sage Working Group on Vaccine Hesitancy. Report of the Sage Working Group on vaccine hesitancy Global None Report Vaccine Hesitancy https://www.who.int/immunization/sage/meetings/2014/october/SAGE_working_group_revised_report_vaccine_hesitancy.pdf?ua=1%20
2015
Cobos Muñoz D, Monzón Llamas L, Bosch-Capblanch X. Exposing concerns about vaccination in low- and middle-income countries: a systematic review. Global - LMICs Review Vaccine Hesitancy Int J Public Health. 60:767–80.
https://doi.org/10.1007/s00038-015-0715-6
Gavi. Approach to engagement with the faith-based community. Global Multiple religions White paper Religion & immunization
Jarrett C, Wilson R, O’Leary M, Eckersberge E, Larson H. Strategies for addressing vaccine hesitancy—a systematic review. Global None Review Vaccine Hesitancy Vaccine. 33(34):4180-90.
https://doi.org/10.1016/j.vaccine.2015.04.040
Khan MU, et al. Knowledge, attitudes and perceptions towards polio immunization among residents of two highly affected regions of Pakistan. Pakistan Islam Descriptive cross-sectional study Vaccine Hesitancy; Polio BMC Public Health. 15:1100.
https://doi.org/10.1186/s12889-015-2471-1.
Mukungwa T. Factors associated with full immunization coverage amongst children aged 12–23 months in Zimbabwe. Zimbabwe Apostolic Data analysis Religion & immunization Afr Popul Stud. 29(2): 1761–74.
https://doi.org/10.11564/29-2-745.
UNICEF. A global mapping: UNICEF engagement with religious communities. Global Multiple Report Religion & immunization http://www.arcworld.org/downloads/UNICEF_engagement.pdf.
2016
Alemu M. Religious leaders’ knowledge on immunization communication and social mobilization, semi pastoralist, Ethiopia: Qualitative Study. Oct. 29-Nov. 2. Ethiopia Ethiopian Evangelical Mekane Yesus Church/Lutheran Oral conference presentation [Conference presentation abstract]. Religion & immunization; Routine Immunization Annual meeting and expo of the American Public Health Association, Denver, CO, United States.
https://apha.confex.com/apha/144am/meetingapp.cgi/Paper/348510
Hussain SF, Boyle P, Patel P, Sullivan R. Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue. Pakistan Islam Analysis/Commentary Vaccine Hesitancy; Polio Global Health. 12(1):63.
https://doi.org/10.1186/s12992-016-0195-3.
International Interfaith Peace Corps. Religious Leaders Declaration: reaffirming their commitment to the Dakar Declaration on the issue of vaccination. Global Multiple religions Declaration; Gray Religion & immunization https://www.afro.who.int/sites/default/files/2017-09/Religious%20Leaders%20Declaration.pdf
Kriss JL, et al., (2016). Vaccine receipt and vaccine card availability among children of the apostolic faith: analysis from the 2010-2011 Zimbabwe demographic and health survey. Zimbabwe Apostolic (Zimbabwe) Descriptive analysis Vaccine Hesitancy Pan Afr Med J. 24:47.
https://doi.org/10.11604/pamj.2016.24.47.8663.
Larson HJ, et al. The state of vaccine confidence 2016: global insights through a 67-country survey. Multiple faiths Survey Vaccine Hesitancy EBioMedicine. 12:295–301.
https://doi.org/10.1016/j.ebiom.2016.08.042
McArthur-Lloyd A, McKenzie A, Findley S, Green C, Adamu F. Community engagement, routine immunization, and the polio legacy in Northern Nigeria. Nigeria Islam Literature review Vaccine Hesitancy; Polio Global Health Commun. 2;1:1-10,
https://doi.org/10.1080/23762004.2016.1205887.
Njeru I, et al. Did the call for boycott by the Catholic bishops affect the polio vaccination coverage in Kenya in 2015? Kenya Catholic Cross-sectional survey Vaccine Hesitancy; Polio Pan Afr Med J. 24:120.
https://doi.org/10.11604/pamj.2016.24.120.8986.
Olivier J. Interventions with local faith communities on immunization in development contexts. Global Discussion paper Rev Faith Int Aff. 14;3:36-50.
https://doi.org/10.1080/15570274.2016.1215843.
Olufowote JO. Identity constructions and inter-organizational collaboration: Islamic faith-based organizations and the polio vaccination stoppage in Northern Nigeria. Nigeria Islam Media analysis Vaccine Hesitancy; Polio Communn Q. 64;5:518-35,
https://doi.org/10.1080/01463373.2015.1129354.
Pelčić G, Karačić S, et al. Religious exception for vaccination or religious excuses for avoiding vaccination. Global Essay Vaccine Hesitancy Croat Med J. 57(5): 516-21.
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2017
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Machekanyanga Z, et al. Qualitative assessment of vaccination hesitancy among members of the Apostolic Church of Zimbabwe: a case study. Zimbabwe Apostolic (Zimbabwe) Case Study Vaccine hesitancy J Relig Health. 56(5):1683-91.
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2018
Abakar MF, et al. Vaccine hesitancy among mobile pastoralists in Chad: a qualitative study Chad Islam Qualitative study Int J Equity Health. 17(1):167.
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Ahmed A, et al. Outbreak of vaccine-preventable diseases in Muslim majority countries. Pakistan, Malaysia, Nigeria, Afghanistan, Egypt Islam Review Vaccine Hesitancy J Infect Public Health. 11(2):153-5.
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Asress A, Bezabih L. Assess role of religious leaders and caretakers’ knowledge to child immunization. Ethiopia Ethiopian Evangelical Mekane Yesus Church/Lutheran Poster presentation [Conference presentation abstract] Religion & immunization; Routine Immunization Annual meeting and expo of the American Public Health Association, San Diego, CA, United States.
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Grandahl M, et al. Correction: parents' knowledge, beliefs, and acceptance of the HPV vaccination in relation to their socio-demographics and religious beliefs: a cross-sectional study in Thailand. Thailand Buddhism Cross-sectional study Vaccine hesitancy; HPV PloS One. 13(4):e0196437.
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Hamdi S. The impact of teachings on sexuality in Islam on HPV vaccine acceptability in the Middle East and North Africa region. Middle East and North Africa Islam Review Vaccine hesitancy; HPV J Epidemiol Glob Health. 7{1}:S17-22,
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Tefera YA, Wagner AL, Mekonen EB, Carlson BF, Boulton ML. Predictors and barriers to full vaccination among children in Ethiopia. Ethiopia Islam; Protestant Cross-sectional survey Vaccine Hesitancy Vaccines (Basel). 6(2):22.
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2019
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Malande OO, et al. Barriers to effective uptake and provision of immunization in a rural district in Uganda. Uganda Traditional religions Cross-sectional mixed methods Religion & immunization PLoS ONE. 14(2): e0212270.
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Morry C. Reflections on polio lessons from conflicted affected environments. Global - LMICs None Report Humanitarian environments; Religion and Immunization USAID/MCSP project.
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Padmawati RS, et al. Religious and community leaders' acceptance of rotavirus vaccine introduction in Yogyakarta, Indonesia: a qualitative study. Indonesia Islam Qualitative - semi-structured in-depth interview Vaccine hesitancy; Rotavirus; New Vaccine acceptance BMC Public Health. 19(1):368.
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Sabahelzain MM, et al. Towards a further understanding of measles vaccine hesitancy in Khartoum state, Sudan: a qualitative study. Sudan Islam Qualitative semi-structured interviews Vaccine Hesitancy; Measles PLoS One. 14(6):e0213882.
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Syiroj ATR, Pardosi JF, Heywood AE. Exploring parents' reasons for incomplete childhood immunisation in Indonesia. Indonesia Islam Qualitative semi-structured interviews Vaccine hesitancy Vaccine. 37(43):6486-93.
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2020
Agrawal A, Kolhapure S, Di Pasquale A, Rai J, Mathur A. Vaccine hesitancy as a challenge or vaccine confidence as an opportunity for childhood immunisation in India. India Islam Literature review Vaccine Hesitancy; Polio Infect Dis Ther. 9(3):421-32.
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Ansari MT, et al. Knowledge, attitude, perception of Muslim parents towards vaccination in Malaysia. Malaysia Islam Observational Vaccine Hesitancy Hum Vaccin Immunothers. 1–6. Advance online publication.
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Barmania S, Reiss MJ. Health promotion perspectives on the COVID-19 pandemic: The importance of religion. Global Multiple Analysis/commentary Vaccine Hesitancy; COVID19 Global Health Promot. 1757975920972992. Advance online publication.
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Bangura JB, et al. Barriers to childhood immunization in sub-saharan Africa: a systematic review. Sub-Saharan Africa None Review Religion & immunization BMC Public Health. 20:1108.
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Berkeley Center for Religion, Peace & World Affairs/Joint Learning Initiative on Faith & Local Communities/World Faiths Development Dialogue. Religious responses and engagement on COVID-19 vaccines. Global Multiple Brief/event report Religion & immunization; COVID-19 https://berkleycenter.georgetown.edu/events/end-of-year-consultation-religious-responses-and-engagement-on-covid-19-vaccines
Costa JC, Weber AM, Darmstadt GL, Abdalla S, Victora CG. Religious affiliation and immunization coverage in 15 countries in Sub-Saharan Africa. Sub-Saharan Africa Christian, Islam Systematic multi-country survey analysis Religion & Immunization; Folk Vaccine. 38(5):1160-9.
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de Figueiredo A, Simas C, Karafillakis E, Paterson P, Larson HJ. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study. Global Multiple (mainly Islam) Lancet. 396:898–908.
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Guzman-Holst A, DeAntonio R, Prado-Cohrs D, Juliao P. Barriers to vaccination in Latin America: a systematic literature review. Latin America, Caribbean Literature Review Vaccine Hesitancy; Religions and Vaccines Vaccine. 38(3):470-81.
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International Vaccine Access Center. Vaccine hesitancy in South Asia. South Asia None Brief Vaccine hesitancy https://www.jhsph.edu/ivac/wp-content/uploads/2020/12/SAVI-Vaccine-Hesitancy-in-South-Asia-White-Paper.pdf.
Jamal D, Zaidi S, Husain S, Orr DW, Riaz A, Farrukhi AA, Najmi R. Low vaccination in rural Sindh, Pakistan: a case of refusal, ignorance or access? Pakistan Islam Vaccine hesitancy Vaccine. 38(30):4747-54.
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Jalloh MF, Wilhelm E, Abad N, Prybylski D. Mobilize to vaccinate: lessons learned from social mobilization for immunization in low and middle-income countries. Global LMICs None Commentary Religion and immunization Hum Vaccin Immunother. 16(5):1208-14.
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Kalok A, et al. Vaccine hesitancy towards childhood immunisation amongst urban pregnant mothers in Malaysia. Malaysia Islam Cross-sectional survey Vaccine hesitancy Vaccine. 38(9):2183-9.
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Makoka M. Health promoting churches: reflections on health and healing for churches on commemorative World Health Days. Global Christian White paper/guidebook; Gray Religion and health/immunization World Council of Churches.
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Owoaje E, et al. Conflict, community, and collaboration: shared implementation barriers and strategies in two polio endemic countries. Afghanistan; Nigeria Islam Gray literature review + online survey Vaccine Hesitancy; Polio BMC Public Health. 20(4):1178.
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Oyo-Ita, et al. Impacts of engaging communities through traditional and religious leaders on vaccination coverage in Cross River State, Nigeria. Nigeria Islam; Christian Program evaluation [3ie Grantee Final Report] Religion & Immunization; Routine Immunization New Delhi: International Initiative for Impact Evaluation (3ie).
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Wong LP, Wong PF, AbuBakar S. Vaccine hesitancy and the resurgence of vaccine preventable diseases: the way forward for Malaysia, a Southeast Asian country. Malaysia Islam Qualitative semi-structured interviews Vaccine Hesitancy Hum Vaccin Immunother. 16(7):1511-20.
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World Council of Churches/World Jewish Congress. Invitation to reflection and engagement on ethical issues related to COVID-19 vaccine distribution. Global Multiple White paper; Gray Religion and COVID-19 Immunization https://www.oikoumene.org/sites/default/files/2020-12/20_12%20COVID-19%20vaccination%20rollout%20ethical%20issues_WCC%20and%20WJC%20%20joint%20statement_FINAL.pdf.
2021
Berkley Center for Religion, Peace & World Affairs, Joint Learning Initiative on Faith and Local Communities, World Faiths Development Dialogue. Faith and COVID-19: Resource repository. Global Multiple Collection of links/Resource document Vaccine Hesitancy; COVID-19 https://docs.google.com/document/d/1FLxwvN6ICTxWWYOwRiv9sBLgf7v0vstsSzV7_o_1-B8/edit.
Boulton ML, Wagner AL. Advancing global vaccination equity. Global None Editorial Religion and Immunization; Vaccine Hesitancy Am J Prev Med. 60(1S1):S1-S3.
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Harapan H, Shields N, Kachoria AG, Shotwell A, Wagner AL. religion and measles vaccination in Indonesia, 1991-2017. Indonesia Islam Vaccine Hesitancy; Measles Am J Prev Med. 60(1S1):S44-52.
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Kucheba F, Mweemba O, Matenga T, Zulu J M. (2021). Acceptability of the human papillomavirus vaccine in schools in Lusaka in Zambia: role of community and formal health system factors. Zambia Christian Qualitative case study Vaccine Hesitancy; HPV Glob Public Health. 16(3): 378–89.
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Vatican Commission for COVID-19. (2021). COVID-19 vaccines: resources for church leaders. Global Catholic Guidance/tool COVID-19 https://www.humandevelopment.va/content/dam/sviluppoumano/vatican-covid19-response/reports/Resource%20Kit%20-%20March%202.pdf.
Wilkinson O, Marshall K. A quick analysis guide, Part I: for health and development actors: engaging faith actors in COVID-19 vaccine rollout. Multiple countries Multiple Guide/tool COVID-19 World Faiths Development Dialogue and the Berkley Center for Religion, Peace and World Affairs. Georgetown University. https://jliflc.com/wp-content/uploads/2021/02/Final_Faith-and-COVID-Vaccines-analysis-matrix-1.pdf.
World Vision. Barrier analysis studies on Covid-19 vaccines. Bangladesh, Mynamar, India, Tanzania, Kenya Multiple Barrier analysis/formative research/survey COVID-19 PowerPoint presentation.
World Vision. Faith leaders must play key role in COVID-19 vaccine roll-out. Bangladesh, Mynamar, India, Kenya, Tanzania Islam, Christian web article Religion and Immunization; COVID-19 https://www.worldvision.org/about-us/media-center/faith-leaders-must-play-key-role-in-covid-19-vaccine-roll-out.