JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR COMMUNITY AND HEALTH SYSTEMS STRENGTHENING August 2014

Joint Learning Initiative on Faith and Local Communities – JLIF&LC

Scoping Review

LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR COMMUNITY AND HEALTH SYSTEMS STRENGTHENING

Version – August 2014

Compiled by Jill Olivier

On behalf of the Joint Learning Initiative on Faith and Local Communities http://jliflc.com/

Companion pieces:  An annotated bibliography on local faith communities and immunization for community and health systems strengthening  Companion scoping reviews commissioned by the JLIF&LC on ‘Maternal Health and HIV/AIDS’ and on ‘Resilience in Humanitarian Contexts’

Acknowledgements: Many thanks for review comments from the following individuals: Andrew Tomkins, Angela Shen, Elizabeth Fox, Jean Duff, Katherine Marshall and Mwayabo Kazadi – and special mention for the review assistance from John Grabenstein

Report prepared by Jill Olivier (author correspondence: [email protected])

Suggested citation: Olivier, J. 2014. Local faith communities and immunization for community and health systems strengthening, Scoping review report for the Joint Learning Initiative on Faith and Local Communities, London.

© Joint Learning Initiative on Faith and Local Communities August 2014 Contact: Jean Duff, JLIF&LC Coordinator [email protected]

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JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

Executive Summary Immunization has often been viewed as the leading light of public health intervention, and the World Health Organisation (WHO) notes that the two public health interventions that have had the greatest impact on the world's child health are clean water and vaccines. Immunization sits at the heart of maternal and child health (MCH) activities as well as primary health care (PHC), and is seen as one of the major public health interventions to prevent childhood morbidity and death. Millions of dollars have been spent globally on immunization campaigns, and in 2010, the Bill and Melinda Gates Foundation called for a ‘Decade of Vaccines’, citing the potential of vaccines to save million lives. However, alongside every success with vaccine development have been equally frustrating failures. In high‐ income countries, within some communities there is general resistance to the idea of immunization (not necessarily specific to a particular disease). And in lower to middle income countries (LMIC) recurring challenges over the elimination of poliomyelitis despite massive campaigns and spending has demonstrated the major challenges – especially in vaccine delivery and intervention. In many LMICs, there continue to be missed populations and closed communities. And ironically, where the burden of disease is higher, the health systems are the weakest, making delivery of vaccines a greater challenge in the places they are most needed. If immunization is one of the leading stars of public health, then religion is the one of the frustrating complexities. However, the literature and evidence on religion and immunization is highly limited, with little coherence and major evidence gaps. The literature is dominated by grey literature and news articles which tend to present highly polarized views of religion and religious leaders. However, there is still a strong suggestion that ‘religion’ is important to immunization – in its many forms and guises. It might influence communities to refuse vaccines; or religious leaders might be essential partners in communicating immunization messages; local faith communities might be involved in immunization outreach; local faith‐ based health providers might be providing routine immunization to hard to reach communities; or international faith‐based development agencies might be intervening with communities for improved immunization as part of child health packages. We report on a broad scoping review here which set out to map and understand the available literature on ‘religion and immunization’ – in search of relevant information on how immunization impacts with religion (or ‘faith’), religious institutions and communities. The basic intention is to make note of where evidence and information can be found, and what key areas for further research, engagement and partnership can be drawn from the existing literature. This review forms part of the Joint Learning Initiative on Faith and Local Communities (JLIF&LC) which aims to develop and communicate robust, practical evidence on the under‐documented role of local faith communities (LFCs) for community systems strengthening. JLIF&LC brings together practitioners, academics, faith leaders, local community members and other stakeholders in a joint‐learning approach organized around ‘learning hubs’, each of which has a particular exploratory focus. To date, the JLIF&LC has five learning hubs: Resilience in Humanitarian and Disaster Situations, Capacity Building for Local Faith Communities, HIV/AIDS and Maternal Health, Gender‐based Violence, and Immunization, the focus of this report. This review draws together diverse materials (after assessment for quality and relevance) – and has a particular focus on LMIC settings, although given the paucity of materials, and the way issues relating to immunization cross over migrant communities, this is not a clear division (that is, information from higher income settings is included where considered highly relevant).

The materials are clustered and presented in three main sections: the first focusing on religion as a determinant of individual behavior; the second on ‘interventions’ which engage deliberately with religious

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 leaders, communities or institutions, with a focus on social mobilization, intervention and local action; and the third, the (extremely limited) literature which addresses community‐ or health systems strengthening in relation to religion and routine immunization.

Key summary points and recommendations for further joint learning and research: History shows a number of intersection points between religion and immunization that extend further back than the recent surge of international interest: Understanding these histories helps to understand the current context and the current discourses visible in the different intersection points (from religious authorities opposing state control, to the effects of colonial systems on health systems and communities’ perceptions about public health interventions). It should be useful for historical reflection to be undertaken on specific contexts, and for those seeking to intervene with LFCs in relation to immunization to put serious effort into understanding local histories and contexts, otherwise it has been shown how this can become a major obstacle. There is a high level of interest in ‘missed populations and closed communities’: There is a particular interest on how religion ‘closes’ such communities to outside immunization attempts – ranging from concerns about gender empowerment, to fear and suspicion, to communities literally not opening the door. As a corollary, religion can therefore also open doors – for example, religious leaders or groups acting as intermediaries into such communities, or communication utilizing particular religious lenses. Engagement on this issue would feed well into current research and policy interests. Traditional and ‘other’ religions still missing from mobilization: Traditional (religious) and non‐mainstream religious groups remain conspicuously absent from published reports on religion and immunization. We would suggest that an urgent area for further research is considerations of mixed health and religious modalities, and how they impact on immunization uptake or refusal. Furthermore, certain un‐networked religious groups require significantly more attention (including groups that are growing massively in development contexts, such as charismatic and Pentecostal Christians – but who remain less popular and less visible at the policy and intervention levels). Further deliberate attention on ‘missed’ countries is required: The current literature and international attention is massively focused on a small handful of countries, such as India, Pakistan and Nigeria – it would seem driven in part by the resourcing of the global polio initiative and the general focus on polio in these contexts. We would suggest that attention is needed on less highly profiled countries and contexts – in which the intersection of religion and immunization would be just as valid although perhaps less spectacular. There is a particular literature gap on South America, Asia‐Pacific, and Eastern Europe. Considerations of context and complexity are important – especially working with local faith communities: Much of the argument above suggests that generalizing about immunization and ‘religion’ on broad international scales raises certain challenges. For example, considering how religious behaviors and perceptions; interventions with LFCs; and routine immunization systems intersect and interact highlights the complexity of the issue, especially when local context is taken into account. Complexity should not however prevent engagement. That is, while an understanding of local context is required for social mobilization, for health systems strengthening, and indeed for any work seeking to really understand the impact of religion or considering how to engage with local faith communities – at the same time there are key cross‐over themes, such as communication lessons, trust‐building and systems strengthening through human resource motivation that can be shared. ‘Religion’ is a challenging variable and is closely related to other social/cultural/political/economic factors: any cross‐sectional and econometric studies demonstrate that ‘religion’ is significant in relation to immunization. However, such studies are limited in their ability to interrogate the meaning of the

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 demonstrated variations that are found. Many of the studies looking at religious beliefs and immunization uptake argue that although vaccine refusal may be articulated in overt religious terms, other determinants are closely linked, such as gender, education, or literacy. This may require broad‐scope engagement which seeks to understand multiple influencers and effects. Getting to grip with the complex world of religion and vaccine resistance is key: Vaccine resistance is often articulated in religious terms, but it has been widely demonstrated that other social/cultural/political/ economic/historical factors are usually intertwined – sometimes inseparably. Some immunization campaign planners might be resistant to dealing with the ‘messiness’ of multiple causal factors and the elusiveness of ‘religion’. We would argue that unpacking and dealing with this complexity is necessary and important. Not only to move beyond the (potentially dangerous) game of blaming ‘backwards religious clerics’ but also so that we can understand the real root causes of resistance and act appropriately. The need for interdisciplinary and multi‐sectoral and engagement on religion and immunization: The broad scope of this review demonstrates the need for interdisciplinary and multi‐sectoral engagement on religion and immunization. Single‐focus interrogation is unlikely to have much success in relation to this fairly complex range of issues. There is a need to deliberately integrate epidemiological, public health, social science, and theological perspectives – with those of practitioners, health professionals, program planners, policy makers, religious and community leaders. This is necessary, but will require intent – and we would suggest a deliberate process of practice‐research engagement. The need for cross‐over interdisciplinary studies and actions, which draw lessons from different areas of engagement: We would strongly suggest that interdisciplinary efforts are required to engage on religion and immunization, as narrow or single lens views are not able to adequately unpack this complexity (for example with multiple causal explanations). At the same time, there is likely to be great potential in drawing from other areas of existing research and engagement. For example, massive effort has gone into understanding how to engage with LFCs in relation to HIV/AIDS, and while delivery mechanisms are often different, there are many similarities too (for example, touching on issues of individual behavior and belief, community engagement and health systems functioning). We would suggest that there are important lessons that could be transferred from areas such as ‘religion and HIV/AIDS’ into the investigation on ‘religion and immunization’ (whereas at the moment there is a complete disconnect). For example, lessons on mechanisms for social mobilization with LFCs and religious leaders can be drawn from HIV/AIDS initiatives, and existing trusting relationships and communication networks built around HIV/AIDS response could be leveraged for immunization. In reverse, the emergence of HPV vaccine implementation in development contexts has the potential to lead the way for a future HIV vaccine – given the similar religious elements that emerge around risk perception and uptake. These examples demonstrate the need to build stronger bridges across ‘sectors’ – especially to prevent wasting hard‐earned lessons and resources. Working with local theologies is required – but there is only limited engagement of religious studies scholars and theologians in immunization response: Given the need for understanding of religious perceptions around vaccine uptake, and the need for information about local (religious) context for targeted response – it is astounding how little immunization is being taken up by religious studies scholars and theologians (the outlier being Muslim scholars, and certain Catholic groupings such as the Vatican’s Pontifical Academy for Life). Although studies with a public health focus have demonstrated that religious doctrine or reasoning is applied to justify vaccine refusal (such as God heals not vaccines), as well as vaccine uptake (as a gift of God to be used in gratitude) ‐ immunization is barely present in the academic theological literature, and certainly not with the attention given so enthusiastically to HIV/AIDS. It may be a useful practice to more strategically engage religious academics or theologians to support further unpacking of the complexities of local (practical) theologies, as well as to evaluate the targeted social mobilization currently underway with religious leaders and LFCs.

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

The need for religiously‐competent program staff and health workers: In all areas of engagement, there is a high level of demand for program staff, policy makers and health workers that are sensitive to different religious practices and beliefs in their specific context. There therefore needs to be some further consideration for what this means for engagement, intervention and training. Many studies conclude by calling for ‘training’ in intercultural and religious competence – however, there is limited description of exactly what this training should entail or who should undertake it. This is an important area for possible joint engagement (including academic as well as practitioner partners). Similarly, more and improved ‘guidelines’ for field‐staff should be developed by intervention and funding institutions – for example, the key points to consider when engaging with religious leaders and local faith communities when undertaking a vaccination program. Engaging religious leaders in genuine social mobilization and advocacy: There has been a massive interest in religious leaders, both as barriers to and as advocates for vaccine uptake. However, increased quantity of engagement does not necessarily equal improved quality of engagement ‐ or actual behavior change. Several studies in this review demonstrate that half‐hearted engagement with religious leaders can be counter‐ productive or even damaging. The actual impact of religious leader mobilization is not well understood, with conflicting reports on their actual effectiveness. Understanding the quality and nature of social mobilization with religious leaders better would be hugely useful – not only for immunization intervention but also other public health and development actions with community participation and mobilization elements. (Note that Muslim clerics from Nigeria and Pakistan dominate the literature and media at present. Care should be taken that other varieties of religious leader be considered and included). Unpacking best and ‘could be better’ practices for social mobilization with religious leaders and LFCS: There is already encouraging analysis of some of the targeted social mobilization put into place with religious leaders and LFCs (such as the work connected to UNICEF and the Polio Communication Initiative). However, there is significant room for further learning and investigation. For example, understanding how responses to ‘pragmatic’ or ‘activist’ approaches differ with LFCs would be valuable. As would knowing what specific mechanisms have been developed for engagement (beyond ‘meetings with religious leaders’). Good practice models for encouraging ‘genuine’ participation of religious leaders should be encouraged. Useful approaches of connecting to LFCs besides religious leaders need to be profiled (for example, efforts through women’s or youth groups, faith‐based schools or choirs). Practitioners and implementation partners (agencies, NGOs and FBOs) should consider pooling best practices for engagement with religious leaders and LFCs. A ‘safe space’ should be created for implementation partners to share ‘poor’ practice as well – such as ‘failed’ attempts at engagement or unexpected consequences of intervention. At this time, practitioners are strongly oriented to only reporting on engagement for promotional reasons which we argue will not improve practice or understanding as well as sharing important lessons on what was learnt and adapted. Improving communication strategies (interpersonal, local, national and international) with and through LFCs should be considered: It could be valuable to consider and assess different communication mechanisms utilized by LFCs – from ‘religious folk methods’ such as loudspeakers to social media on the internet. The impact of broad anti‐vaccination movements that ‘reside’ on the internet but impact on local communities (such as the bioethics discourse) is not well understood. It has been noted that religious communities have particular transnational ties, and this has implications not only for communication of information and beliefs – but also the communication of disease (as the Dutch and Israeli examples attest). Also, there is nothing that we can see on how televised media from one country impacts on others in development contexts (for example, in many parts of Africa, American televangelism is widely watched, even in remote areas). While the importance of interpersonal communication has been noted – there is not a significant amount of information on what this means in practice in relation to engagement with LFCs, messaging or vaccine promotion. Communication might well be an important area for engagement (existing groups such as the Polio Communication Initiative might be asked how they engage with these issues).

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

There is a huge gap in evidence on the specific nature and extent of routine immunization services provided by faith‐based health providers: There is a massive evidence gap on the unique characteristics and contributions of FBHPs to routine immunization. Many questions were raised in the previous chapter. For example: to what extent do FBHPs participate in and contribute to national immunization programs and targets; what quality of routine immunization services are provided; how are supply or cold chains maintained; are FBHPs providing access to poor or rural communities that otherwise do not have access to immunization; are health worker practices different in FBHPs, e.g. do they spend more time explaining immunization to clients; are health workers more motivated and does this impact on routine immunization; are FBHPs generally more or less trusted by the communities in which they operate (and does this relate to immunization services or uptake); do FBHPs have different access to the communities in which they are operating to public services; are primary health care services and outreach activities any more or less effective – and the list could go on. This is an obviously important general area for possible study and engagement. We need to understand the resilience of health systems and FBHPs providing immunization services in fragile and post‐conflict contexts better: he case example from the DRC demonstrates that particular attention is needed on the activities of religious leaders, LFCs and FBHPs in fragile and post‐conflict contexts. Their formations, partnerships and innovative service delivery solutions in challenging circumstances all require more attention. Does immunization impact on or strengthen the health systems that FBHPs are a part of?: Very little is known about how immunization or health systems strengthening interventions impact on FBHPs. Or what health systems strengthening interventions are being carried out with FBHPs that might strengthen routine immunization. This is a massive area for further engagement. We need to investigate ‘trust’ at all levels: The importance of trust to this issue (the intersection of religion and immunization) cannot be understated. Trust appears as a central factor, in relation to vaccine refusal or uptake, in relation to public trust, in relation to influencers, social mobilization, communication and engagement with LFCs. Trust also appears strongly when looking at immunization from a health systems perspective, for example in relation to patient‐provider trust and community accountability. There is a strong (un‐evidenced) suggestion that LFCs, religious leaders, FBOs and FBHPs have certain intrinsic ‘valued‐added’ components, and the most frequently cited is ‘trust’. There is an urgent need to explore and unpack ‘trust’ in a thorough and evidence‐based manner. In addition, engagement over ‘trust’ can be utilized as the bridge over these diverse areas of interest, and as a tracer issue around which joint learning could be initiated.

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

Contents Executive Summary Contents Acronyms 1. INTRODUCTION AND APPROACH 1 1.1. Review Method and Approach 4 1.2. Approach of the JLIF&LC 4 2. RELIGIOUS DETERMINANTS, REFUSALS AND MISSED POPULATIONS 10 2.1. Main Themes: Individual Religiosity and Uptake 10 2.2. Challenges Separating out ‘Religion’ 18 2.3. Transnational and Local Relgio‐Cultural‐Politics 24 Table 1: Primary Studies Reporting on Religion as a Determinant 32 3. INTERVENTION, SOCIAL MOBILIZATION, SUPPORT AND COMMUNICATION 38 3.1. Social Mobilization 38 3.2. Building Trust with Religious Leaders and Local Faith Communities 45 3.3. Religion, Immunization and Communication 49 Table 2: Interventions and Support Services with/though LFCs and RLs 55 4. HEALTH AND COMMUNITY SYSTEMS STRENGTHENING 60 4.1. Why Health Systems Strengthening for Immunization? 62 4.2. Access to Services and Primary health Care 66 Table 4: Faith‐based Health Providers and Routine Immunization 78 5. CONCLUSION 81 5.1. Summary Points 81

References 86

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

Acronyms

ADRA Adventist Development and Relief Agency IEC Information, Education and Communication AFP Acute Flaccid Paralysis IFFm International Finance Facility for Immunization AFRO Africa Regional office of WHO IIP Immunization in practice AIDS Acquired Immune Deficiency Syndrome IMCI Integrated Management of Childhood Illness AIIMS All India Institute of Medical Sciences IMF International Monetary Fund ARISE Africa Routine Immunization System Essentials IP Immunization Post ART Anti‐retroviral therapy/treatment IPPI Intensive Pulse Polio Immunization BCG Bacillus Calmette‐Guerin vaccine JLILFC Joint Learning Initiative on Local Faith Communities BMGF Bill & Melinda Gates Foundation LFC Local faith community CBO Community‐based Organisation M&E Monitoring and Evaluation CCRDA Consortium of Christian Relief & Development Assocs MCH Mother and child health CDC U. S. Centers for Disease Control and Prevention MDG Millennium Development Goal CDD Community Driven Development MMR measles‐mumps‐rubella CGPP CORE Group Polio Project; CORE Group Polio Partners MO Medical Officer CHA Christian Health Association MoH Ministry of Health CHAG Christian Health Association of Ghana MOU Memorandum of Understanding CHS Catholic Health Services NGO Non‐governmental Organization CHW Community health worker NID National Immunization Day CMC Community Mobilization Coordinators NPO National Professional Officer CMO Chief Medical Officer NPSP National Polio Surveillance Project CORDAID Catholic Organisation for Relief and Development NSS National Service Scheme CRS Catholic Relief Service OPV Oral Polio Vaccine CSS Community systems strengthening OVC Orphans and vulnerable children CVI Children’s Vaccine Initiative PE polio eradication CVSFP Community Volunteer Surveillance Focal Point PEI Polio Eradication Initiative DHMT District Health Management Team PFP Private for Profit DHS District Health Service PHC Primary Health Centre DRC Democratic Republic of Congo PNFP Private not for Profit DTP Diphtheria, Tetanus, and Pertussis PPI Pulse Polio Immunization DTP3 Diphtheria‐tetanus‐pertussis vaccine, third dose PPP Public‐Private Partnership EAA Ecumenical Advocacy Alliance PVO Private Voluntary Organization EPI Expanded Programme on Immunization RAP Rapid Assessment Procedures FBO Faith‐based organization RI Routine Immunization FGD Focus Group Discussion SAP Structural Adjustment Programs FIC Fully immunized child SIA Supplemental Immunization Activity FP Family planning SM Net Social Mobilization Network GAVI Global Alliance for Vaccines and Immunization SM Social Mobilization GPEI Global Polio Eradication Initiative SMO Surveillance Medical Officer HBC Home‐based care TB Tuberculosis HepB Hepatitis B vaccine TSA The Salvation Army HEW Health Extension Worker UNAIDS United Nations Joint Programme on HIV/AIDS HiB Haemophilus influenzae type b UNFPA United Nations Population Fund HIPCI Heavily Indebted Poor Countries Initiative UNICEF United Nations Children’s Fund HIV Human Immuno‐deficiency virus UP Uttar Pradesh HPSR Health Policy and Systems Research USAID United States Agency for International Development HR Human resources VCT Voluntary Counseling and Testing HRH Human Resources for Health VVM Vaccine Vial Monitor HSS Health systems strengthening WB World Bank IAC Immunization Action Coalition WFDD World Faiths Development Dialogue ICC Interagency Coordinating Committee WHO World Health Organisation IDSR Integrate Disease Surveillance and Response

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

1. INTRODUCTION AND APPROACH

Immunization has often been viewed as the leading light of public health intervention – the ‘magic bullet’ providing a seemingly straightforward solution to some of our most complex disease problems. The World Health Organisation (WHO) notes that the two public health interventions that have had the greatest impact on the world's child health are clean water and vaccines (see Andre et al 2008). Immunization sits at the heart of maternal and child health (MCH) activities as well as primary health care (PHC), and is seen as one of the major public health interventions to prevent childhood morbidity and death. This can be seen, for example, in the worldwide momentum behind the Expanded Program on Immunization (EPI) which was launched in 1974 (see Streefland et al 1999). Immunization is seen as a core component of achieving the Millennium Development Goals – in particular MDG 4, the reduction of the number of deaths of children under age 5 by two‐thirds by 2015. Millions of dollars have been spent globally on immunization campaigns, and in 2010, the Bill and Melinda Gates Foundation called for a ‘Decade of Vaccines’, citing the potential of vaccines to save 8 million lives by 2020. However, alongside every success, has come some equally frustrating failures. In high‐income countries, within some communities there is general resistance to the idea of immunization (not necessarily specific to a particular disease). And in lower to middle income countries (LMIC) or development contexts, recurring challenges over the elimination of poliomyelitis despite massive campaigns and spending has demonstrated the challenges. These challenges include the high level of politicization of the polio vaccine (and humanitarian and global health efforts in general) in such areas. And nothing reminds of this as much as the recurring reports of polio‐vaccinators being shot in the streets of Pakistan or Nigeria (see WHO 2013). Not only is the global health community now focusing on immunization in development contexts – but more specifically on ‘missed populations’ and closed communities. However, where the burden of disease is higher, so too are the health systems weaker, making delivery of vaccines a greater challenge in the places they are most needed. So while new vaccines might be more needed in LMIC settings, they are more common in higher income countries (see Aylward 2012). If immunization is one of the leading stars of public health, then religion is the one of the frustrating complexities. Speaking in general terms, religious communities and institutions have often been ignored by the worlds of public health or development. In the broader literature on faith and public health, there has been a significant argument made that because of the effects of secularization, public health and development actors became significantly ‘religion‐blind’. What this meant was that religion was not included in many studies on determinants of health or illness, and religious institutions similarly ‘disappeared’ off the health systems radar for several decades, even in countries where they continued to contribute significantly to health services and programs. However, there has been something of a resurgence of interest in religion and public health over the last few years, and broad‐scale attempts have been made at a number of levels to bring faith‐based institutions ‘back to the table’ and to ‘map’ them more effectively. Under the uncomfortable realization that the world is as religious as ever, especially in development contexts, religion has slowly come back onto the agenda of global agencies and collaborative tables. This has been particularly driven by the forces of the HIV/AIDS pandemic and response, which resulted in an exponential increase in interest in and publications on religion and public health from around 2000 (see Olivier and Wodon 2012e). However, what this review demonstrates is that in comparison with many other public health issues, the intersection of religion and immunization is one area that has not suffered from inattention as greatly as some others. It has been recently re‐emphasized that there have been links between religion and vaccination since its earliest records – for example, the practice of the variolation technique has been credited to an 11th century Buddhist nun 1

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 in China (see Fenner et al 1988, Grabenstein 2013). In an early 1988 WHO report on smallpox eradication, the role of ‘Gods, Goddesses and Saints Associated with smallpox’ are highlighted. For example, T'ou‐Shen Niang‐Niang was a goddess of smallpox in China – and during the mid‐19th century she was one of the most popular objects of worship among the people at large across all religious affiliations. In Europe, St Nicaise, the Bishop of Rheims, who was killed by the Huns in 452, became the patron saint of smallpox (just before being killed, he had just recovered from an attack of smallpox), and was revered during the Middle Ages. Sitafii (Shitafa) Mata appears to have been an Indian folk goddess from early times, who had a later association with smallpox from the 18th century onwards. In Africa, worship of Sopona, a smallpox deity, existed among the Yorubas and some of their neighbors in south‐west Nigeria, Benin and Togo, introduced from the north at the beginning of the 18th century. Worship of Sopona was controlled by Jticheurs, who were in charge of the shrines and also carried out variolation (see Fenner et al 1988, Hopkins 1983) As this review will show, there are many such connection points in history between religion and immunization. For example, in the nineteenth‐century Europe and its colonies, the state established itself as accountable for public health. Streefland (1999) notes how smallpox vaccination and sanitary measures were wielded as one of the major instruments of the colonial mechanism. Streefland also points out that the introduction of smallpox vaccination resulted in resistance, most often from religious groups, and that this resistance was tied up with resistance against state control of individual liberties and the colonies (see Streefland 2001). This brief example gives some hint at the complexities with individual perceptions about immunization overlapping with contextual issues of religion, culture, power and politics. And nothing shows this complex overlapping of issues as well as the massively publicized rejection of polio immunization that occurred in Northern Nigeria in 2003, vocalized by local Muslim clerics, but driven by interweaving social, political, economic and religious concerns (see case explanation of this below). The rejection of the polio vaccine spread like wild‐fire through the country and beyond, resulting in renewed outbreaks of polio in many countries in the region which had previously been declared polio‐free, and resultantly leading to high‐ level political blaming‐and‐shaming. The Nigerian example also resulted in a flurry of publications about religion and immunization – with even high level journals such as The Lancet publishing commentaries on this episode (a journal which has only rarely accepted publications on ‘religious’ issues to date). Generally, there has been a shift of interest which is visible in the literature – a greater sensitivity towards ‘religion’ which has not been previously seen. As we will see in this review, the current literature is overwhelmingly focused on religion as a determinant of individual immunization resistance or risk perception. However, there are now also hints of increased attention towards strategies and approaches for working with religious communities. International agencies such as The United Nation’s Children’s Fund (UNICEF) has led an amazingly ‘religious‐sensitive’ engagement through social mobilization in many different countries and has been regularly publishing case examples of engagement with religious communities since the turn of the century (see UNICEF 2001, 2004, 2013). Enthusiasm for engaging with religion and religious leaders on immunization is currently running high. UNICEF has established a ‘Brain Trust’ to develop innovative communication solutions in Pakistan, Afghanistan, and Nigeria, which now includes an Islamic Advisory Group, saying “while not relevant everywhere, in many of the places polio still circulates evidence‐based religious messaging through Islamic fatwas is a powerful tool against misinformation about the polio vaccine. And rather than solely defend polio vaccination, Muslim clerics have gone a step further in describing vaccination as a duty for Muslim parents” (IMB 2013). The Global Polio Eradication Initiative (GPEI) also released a new strategy in 2013, and its overarching framework has five items, one of which is ‘Religious leaders advocacy’ and is described as the intention to “markedly step up

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JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 advocacy by international, national and local Islamic leaders to build ownership and solidarity for polio eradication across the Islamic world, including for the protection of children against polio, the sanctity of health workers and the neutrality of health services” (WHO 2013). The Global Alliance for Vaccines and Immunization (GAVI) has also recently begun looking toward religious communities with increased curiosity ‐ commissioning a report on religion and immunization from the World Faiths Development Dialogue (WFDD, see Aylward 2012), and beginning new faith‐focused interest groups at GAVI meetings in 2013. However, as with the literature on religion and public health, the literature on religion and immunization is highly limited, with little coherence and massive evidence gaps. The literature is dominated by grey literature – and electronic news articles are frequently utilized to support arguments in this field. Such media articles are abundant, but tend to present a highly polarized view, with religion (and particularly religious leaders) often portrayed in extreme stereotype. On the one hand, religiously motivated individuals or communities are frequently described as illogical or ‘backwards’ obstacles to the advances of science and the humanitarian goals of global health targets. And on the other hand, religious leaders and communities are also described as potentially key facilitators for immunization interventions (sometimes even in the same community, after being swayed through consultation), and as the primary drivers of successful immunization campaigns.

This scoping review ‐ outline This scoping review therefore sets out to scope a fairly broad range of literature – spanning several different disciplinary and practice areas – in search of relevant information on how immunization impacts with religion (or ‘faith’), religious institutions and communities. The basic intention is to make note of where evidence and information can be found, and what key areas for further research, engagement and partnership can be drawn from the existing literature. We have arranged the diverse literature roughly in three main chapter sections – based on the nature of the uncovered literature. These divisions are somewhat artificial, and there is a significant amount of overlap that can be expected. There is also an over‐balancing of attention on some issues and areas, such as the polio event in Nigeria, as a result of the over‐emphasis of published literature on these particular aspects as opposed to others such as everyday immunization practices within health systems (for which there is barely any systematic or empirical material, see below). In chapter two, we focus on religion as a determinant of individual behavior, which is where the bulk of the currently available literature is focused. In this section we consider how religious views and identification impact positively or negatively on uptake of immunization or vaccines. In chapter three, we shift to ‘interventions’ which engage deliberately with religious leaders, communities or institutions, with a focus on social mobilization, intervention and local action. In chapter four, we review the (extremely limited) literature which addresses community‐ or health systems strengthening in relation to religion and routine immunization. Finally, in chapter five, we briefly raise some potential areas for further engagement that emerge from this review.

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JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

1.1. Review Method and Approach This scoping review forms part of the Joint Learning Initiative on Faith and Local Communities (JLIF&LC) which aims to develop and communicate robust, practical evidence on the under‐documented role of local faith communities (LFCs) for community systems strengthening. JLIF&LC brings together practitioners, academics, faith leaders, local community members and other stakeholders in a joint‐learning approach organized around ‘learning hubs’, each of which has a particular exploratory focus. To date, the JLIF&LC has five learning hubs: Resilience in Humanitarian and Disaster Situations, Capacity Building for Local Faith Communities, HIV/AIDS and Maternal Health, Gender‐based Violence, and Immunization, the focus of this report. Box 1: Joint Learning Initiative on Faith and Local Communities The JLIF&LC was formed in 2011, and start‐up funds and in‐ GOALS: kind support were provided by the participating institutions 1. To build an improved evidence base providing insight into (including development organizations, UN agencies, the impact of local faith communities (LFCs) in addressing their health and well‐being; 1 academic institutions and religious bodies ). This group was 2. To provide actionable recommendations for potential drawn together by a shared conviction that there is a need partners, including governments, donors and to more effectively partner with the local faith communities practitioners, who work with faith assets and LFCs for improved partnership at local levels, as well as broader to tackle poverty and injustice all over the world – but that national and international level strategies; robust evidence for activities, and contributions of faith 3. To develop the capacity of researchers, practitioners and groups, as well as for effective collaborative models, is community members and their affiliated networks and required in order to scale‐up lasting partnerships. institutions through shared language tools, knowledge‐ resources and network building. The overarching goal of the JLIF&LC is to provide participating and other practitioners, policy makers, and Joint learning is framed in a two‐phase process donors with robust evidence and actionable policy and Phase 1: Mapping Existing Knowledge and Evidence ‐ including systematic and scoping reviews of available programmatic recommendations that will, in turn, influence evidence. This phase will also include consultation with policy, praxis, and funding decisions, improving the quality, academics, researchers and practitioners to enhance the effectiveness, and impact of partnerships between LFCs and scope and quality of the review work, as well as to establish relationships and engagement for the possible future work. other development and public health actors. Review work will therefore not only include published materials, but also seek out ‘grey literature’ – including Interested stakeholders work together in joint learning practitioner accounts and field experiences where possible. communities to explore the broad question: What is the Recognizing the extensive work already in place, the JLI influence and impact, both positive and negative, of local F&LC Surveys will also build on the existing literature reviews and mapping efforts if at all possible. Preliminary faith communities on community mobilization and systems? findings from this initial phase will highlight key evidence More specifically, each Learning Hub asks: What do we gaps, partners and data sources for future work. already know—what evidence exists? How can we better Phase 2: Agenda Setting, Resource Allocation, Primary Research & Joint Learning communicate that evidence to policy makers and The scoping review in Phase One will provide guidance on practitioners? And, what new research is required to fill key the value of further engagement on these particular topic information gaps? clusters. It will also act as the basis for setting a research‐ engagement agenda and provide justification for the allocation of key resources to further primary research and joint learning. If a decision is taken to continue to the 1.2. Approach of the Learning Hub on Immunization second phase, clusters of practitioners and researchers would be formed around key issues for further research Each learning hub has followed a similar overarching and joint learning – ultimately leading to improved approach combining stakeholder consultation with knowledge translation, and better evidence‐informed policy and decision making in relation to LFCs. documentary review, to identify key actors and issues

1 The JLI F&LC has received seed funding from a variety of partner organizations, including: CAFOD, McKinsey, Christian Aid, The MacLellan Foundation, Tearfund, World Vision, Samaritan’s Purse, and UNFPA. 4

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 requiring further research and engagement in order to explore the given thematic area. However, given the technical nature of the immunization focus, and the limited number of stakeholders and previous reviews on this issue, a slightly altered process was undertaken with the immunization hub.2 The process was broken into four main parts: 1. Initial consultation and semi‐structured interviews with (6) immunization specialists: to define areas of focus and sources of data 2. Scoping review of published literature: Scoping review over an eight‐month period of published grey and peer‐ reviewed literature (of which this report is the main product) 3. Second round of comment and contribution by stakeholders: Invitation for review of draft scoping review report, including invitation for addition of internal institutional (grey) literature 4. Systematic review of identified themes: A parallel systematic review ‐ focused on key themes (with more rigorous selection criteria; running over a longer 12‐month period as is standard for systematic reviews) 5. Finalization of scoping report and stakeholder face‐to‐face consultation: After finalization of the scoping review (and related publications), further consultation will be held to draw out key areas for further engagement, and decide on the value of pursuing this line of joint‐learning

The aim of this joint‐learning and review activity is to assess interest, the availability of evidence, and key knowledge gaps (possibly) leading to further primary research and engagement, should that be considered substantively relevant and viable.

Method of this scoping review This broad scoping review aims to address three exploratory questions: 1. What evidence exists on religion and immunization, where is this situated, and how are related issues approached? 2. What are the key evidence‐gaps in relation to engagement with local faith communities in relation to immunization? 3. Is further joint‐learning useful on this specific issue, and who are the potential partners in such a process? The study began with searches of digital platforms (MedLine, EBSCO, GoogleScholar, etc), utilizing the following search terms:  ‘religion’: including variations such as: faith, religious, orthodox, religious ethics, traditional religion, congregation, faith communities, faith‐based organization, faith‐inspired institution, clerics, Muslim, Christian, church, mission, Islam, Bahá’í, Buddhism, Confucianism, Daoism, Hinduism, Jainism, Judaism, Shinto, Sikhism, Catholic, Amish, Anglican, Baptist, Church of Christ (Scientist), Church of Jesus Christ of Latter‐day Saints, Mormon, Dutch Reformed, Episcopalian, Jehovah’s Witnesses, Lutheran, Methodist, Pentecostal, Presbyterian, Seventh‐Day Adventist…  ‘immunization/immunisation’: including variations such as: outbreak, poliomyelitis, polio, vaccination, vaccine, exemption, non‐acceptors, vaccine safety, risk perceptions, social mobilization, community

2 The main difference being that the other hubs conducted earlier face‐to‐face consultation, and did not conduct systematic reviews. 5

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

influencers, noncompliance, expanded programme on immunization, utilization, non‐utilization, influencers, routine immunization, child survival, HPV (human papillomavirus, cervical), pneumococcal, rotavirus, diphtheria, Haemophilus influenzae type b, hepatitis A, measles, mumps, pertussis, poliomyelitis, rubella, tetanus, immunization systems, health systems… All documents identified were assessed. For the GoogleScholar searches, at least the top 50 entries for each individual search were evaluated, more when the search results delivered relevant documents. After each search, reference lists were scanned to identify other relevant documents. Using this method, over 500 documents were collected in a database.3 Researchers then went through each item (main text, abstract and reference list) to assess relevance. From that process, 206 articles were selected as relevant and included in the analysis for review and in the annotated bibliography (note that the references listed at the end of this report also include additional resources that were needed for the broader argument). We understand this extended report to be a ‘working document’ in the sense that we invite further contribution of grey and other materials. While we will be publishing more concise articles from this large document, we will also continue to update this bibliography and scoping review should that prove to be a useful activity as part of the joint learning process.4 The companion bibliography provides some indication of relevance of documents to this topic. Those documents that are marked as ‘minor relevance’ have only a small mention of ‘religion’ in relation to ‘immunization’ – whereas those marked as ‘main relevance’ are either entirely or substantially focused on this issue (relevance is therefore not a value judgment on the quality of that resource).

This scoping study is limited and defined by the following criteria:  This study focused mainly on materials published in the last ten years (2004‐2014) although key earlier publications are included when they are traced back and considered important.  As determined by the limitations of the research team and time, this review is focused primarily on English publications (a rapid survey was conducted of French and Portuguese materials and only a few limited texts were uncovered).  As determined by the limitations of the available literature, there is an unfortunate overwhelming focus on ‘mainstream’ religions, and in particular Muslim or Islamic practices. Other diverse Christian perspectives and other religious or philosophical views such as Buddhism, Confucianism or Traditional religions are unfortunately barely represented. There is a particular lack of evidence on ‘local’ Christianities – for example charismatic and Pentecostal groups that are not networked into religious hierarchies. This are multitude and influential, but there has been little work on their relation to immunization or vaccination uptake.  As determined by the limitation of the available literature, despite the stated aim of focusing on community‐ level perspectives, very little is written about this ‘congregational’ level or the mechanisms which connect to this level.

3 This figure increases to over 800 if news articles are included. Note that we attempt not to utilize such news reports as far as possible in this review. This is something of a challenge, however, as a lot of the peer‐reviewed academic literature utilizes news reports as their main source. A rapid analysis of the collected news reports shows two current issues holding attention: 1) religious leaders (usually evangelical Christian or Muslim) leading their congregants into vaccine refusal on religious grounds, and 2) the religious connotations of polio‐ vaccinators (community health workers) attacked in Pakistan. 4 Note that this scoping review is following a more flexible and consultative process than the parallel systematic review, and is therefore more inclusive of ‘grey’ literature and internal institutional documentation – whereas the systematic review only includes peer‐reviewed publications. 6

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

 Academic publications were prioritized, although grey literature was included when of particular relevance (including institutional reports, policy papers, technical reports and meeting records) – in particular those who showed evidence of internal peer‐review.  News articles (which are abundant on this topic) were not included, although were collected.  Further unpublished institutional documentation (such as evaluation reports) will be sought out as part of the consultation process of this review, since these were not immediately picked up on through scoping review methods.  The literature is geographically unbalanced, with certain countries, such as Nigeria, India, Pakistan, Afghanistan, The Netherlands, the United Kingdom and the USA dominating the literature. This review began with an intention to focus on development or LMIC contexts – however, as displayed below, where there is barely any information relating to LMICs, information on other higher income settings then provides important insight (this is particularly apparent in relation to this particular topic, for example, when diseases spread between closed communities in LMIC and HIC settings).  As noted above, there is a strong imbalance towards literature relating to polio in studies of lower to middle income countries (LMIC). This imbalance affects this review – and is created by the massive weighting of literature and empirical research relating to polio in the West African region.  This is a broad review which is intended to scope the field of potential engagement – there is a need for targeted systematic review on specific issues, such as religion as a determinant of immunization refusal or specific implementation strategies through targeted faith communities.  There has been a significant increase in relevant publications during 2012 and late 2013. This review had to be finalized in accordance with the needs of the JLIF&LC. However, it should be noted that there are several relevant publications emerging at the same time as this report, which will still need to be included as they become available. It is important to note that in this rapidly emerging area, an ongoing review process or project would therefore be of use.  This review did not set out to focus on individual determinants of uptake or refusal – however, we find it necessary to represent this body of literature (in the next chapter), as this represents the bulk of the available evidence, and establishes the argument for why further engagement with faith communities is necessary. We deliberately rapidly skim over some of the more reactionary issues such as the engagement through a bioethics lens – which require intensive review in their own right, but are not directly relevant to this study (we suggest those interested look at the new review by Grabenstein 2013, which begins to engage with issues such as different religious views on cell cultures and bioethics in relation to vaccine production.5)  This review does not include material on how religious belief might impact on internal immune status (or psychosomatic effects of religion), on which there has been some significant publication. For example Woods et al (1999) looks at how religiosity is associated with affective and immune status in symptomatic HIV‐ infected gay men. Or Levin (1996) who seeks to revitalize social epidemiology by surveying the ‘epidemiology of religion’, looking at how religion influences morbidity and health and discussing how a “protective religious effect on morbidity is examined in terms of three important epidemiologic concepts: the natural history of disease, salutogenesis and host resistance”, arguing that the behaviours of certain religious denominations (e.g. Mormons and Seventh‐day Adventists) have favourable epidemiologic profiles which demonstrate the

5 For example, see articles such as: Pontifical Academy for Life. 2005. "Moral reflections on vaccines prepared from cells derived from aborted human fetuses." Natl Cathol Bioeth Q 6(Autumn): 541‐550. 7

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

role of ‘behavioural immunogens’. Koenig has also famously engaged on these more internal connections between religiosity and individual health, for example, Koenig et al (1997) look at whether attendance at religious services impact on immune function (see also Koenig and Cohen 2002). It should be noted that there is one further significant weakness in this reviewed literature – and that regards the literature which provides ‘cases’ or ‘examples’ of engagement with religious traditions or faith communities. Said differently, while the studies on religiosity as a determinant of immunization uptake or refusal are fairly robust, with several cross‐sectional studies as well as a smattering of qualitative studies, the literature that addresses interventions or activities of local faith communities is in contrast fairly weak. Most of these are descriptions found in institutional reports or newsletters, and it is difficult to assess how this information was gathered. Furthermore, many of these reports reference news articles as their main source (whose evidential quality is near to impossible to assess). The descriptions that come from NGOs (faith‐based or not) are also difficult to assess, as they are usually intended as promotional tools. For example, few if any reports from the NGO sector reflect on failed attempts at engagement in immunization or vaccination. It is also difficult for the external reader to assess whether ‘engagement with religious leaders’ represents a genuine and sustained engagement or a single consultative meeting. In Table 2 we have listed a series of such examples as they are found in the published literature. It would be a valuable undertaking to continue (with more rigorous primary research) to examine such cases in a more intensive manner, and for NGOs and other institutions to be encouraged to be engaged in discussion and research on what works, as well as what does not work when engaging with local faith communities on these issues. There is in any case something of a disconnect between different forms of evidence relating to ‘religion’ and those relating to ‘immunization’. Evidence on immunization tends to be highly technical and based in a positivist framework (with the randomized control trial as the gold standard of quality research), while studies on ‘religion’ tend to be qualitative, emerging from a constructivist paradigm, and are often highly descriptive. We will not resolve this tension here, but the reader should be made aware that there are different and sometimes contesting forms of knowledge and ‘evidence’ when considering the intersection of religion and immunization.

The conflicting terminologies of ‘religion’, ‘faith’ and the ‘faith‐based organizations’ As may have already been observed in this introduction, there is some tension around the terminologies of ‘religion’ or ‘faith’. Indeed, one of the main constraints of this study is the lack of reliable frameworks for defining a particular lens on this issue. Please note that the nomenclature around ‘religion’ is hugely complex and sometimes impossible to resolve. We will not go in‐depth into this discussion here, which has been covered in detail some elsewhere (for a description of some of the more intense battles around the nomenclature of ‘FBOs’, see Olivier 2011, Olivier & Wodon 2012e). Suffice it to say that there is no single agreed definition or framework, and it is increasingly problematic to name any institution that has a religious element as a ‘faith‐based organization’ (FBO), whether it is an international development agency or a local grassroots women’s group. Indeed, many individuals do not classify themselves as religious (such as Bhuddist or traditionalist) and many organizations that might be classified as community‐based organizations (CBOs) or NGOs by the outside world, might be deeply driven by religious motivations. An international organization that labels itself as an ‘FBO’ might be indistinguishable from an international NGO (for example in relation to organizational governance, or whether they engage with faith communities or not). A faith‐based hospital might operate as a district hospital in the public health system in many countries. These few examples demonstrate how difficult it is to name something as distinctly ‘religious’ or ‘secular’ in nature. (An issue that is raised repeatedly in the report below, especially in relation to immunization ‘refusals’ which are often overtly described as religious, but which are covertly a mixture 8

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 of different influencing factors.) These tensions are not resolved in this broad scoping report. At the most basic level, a caution can be made that care is needed in any publication or interaction when defining what element or kind of ‘religion’ is being examined in relation to immunization or vaccines.

In this report we have kept to the following descriptions where possible – although in direct quotes we have left the author’s descriptor unchanged:  religion (as inclusive of ‘faith’ and ‘spirituality’): for an overarching term, and in relation to motivational factors, for example religion as a determinant of immunization refusal or uptake  religious leader: as individual community leaders such as an Imam, priest or pastor who might operate at a local/national/international level  local faith community (LFC): as a local level formation held together by a shared religion or faith, whose members reside in relatively close proximity, such that they can regularly meet together for religious purposes, often in a dedicated physical venue, such as a congregations, mosques, temples or other such ‘faith‐forming entities’ and their offshoot activities  faith‐based organization: such as faith‐inspired institutions, faith‐based non‐governmental organisations or overarching religious bodies and networks  faith‐based health provider: institutions whose primary purpose is the provision of health (such as Christian/mission/church/Islamic health facilities and their overarching umbrella organizations)

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2. RELIGIOUS DETERMINANTS, REFUSALS AND MISSED POPULATIONS

In this section, we review literature that addresses religious beliefs and affiliations that impact on behaviours relating to vaccine refusal or acceptance This review did not set out to focus on individual determinants of uptake or refusal – rather, our intention was (and is) to focus on how immunization intersects with the actions of local faith communities, especially those in development contexts. However, through the review process, we found that the majority of available literature and evidence is strongly focused on religion as a determinant of individual behavior in relation to immunization. In particular coming from epidemiological and econometric perspectives, and mainly cross‐sectional studies on whether religiosity is an indicator of immunization refusal. Table 1 at the end of this chapter summarizes the key features of these studies, and the discussion that follows draws out key focus areas, findings and complexities. It is worth noting that Grabenstein (2013) has recently published a useful companion review of the intersection of the world’s six major religions with immunization – in particular their scriptural, canonical basis for main interpretations and passages that support immunization (of Hinduism, Buddhism, Jainism, Judaism, Christianity, and Islam). Grabenstein’s review is primarily focused on aspects of religious teaching that impact on the acceptability of vaccines and immune globulins, so has significant relevance to this chapter. It more thoroughly addresses higher‐income countries (HIC) than lower to middle income (LMIC) or developmental contexts.6

2.1. Themes Emerging from the Literature: Individual Religiosity and Uptake ‘Religion’ appears in a variety of ways in the literature – but, as we will see, most dominantly as a determinant of immunization refusal, and in particular in relation to orthodox or immigrant communities in high vaccination contexts (such as The Netherlands, the USA or the United Kingdom). However, since a series of high profile boycotts rose against immunization campaigns in development contexts, this particular approach has increasingly been applied to development contexts in the last few years – most particularly to Nigeria and India.

Religion as a determinant of broad‐scale anti‐vaccination movements One of the most widely publicized and yet under‐researched areas is the engagement of religious groups and individuals in broad‐scale anti‐vaccination movements, most visible on the internet through news reports or online commentaries. We do not set out here to analyse this substantial grey literature, but this can nevertheless be clustered in particular discourse areas – such as discussions on whether certain vaccines are potentially harmful and have religiously‐unauthorized ingredients, or discourse that is clustered around issues such as bioethics and the remote fetal origins of cell‐culture media (see below and Grabenstein 2013). However, there are few empirical studies on these broad‐scale movements and their religious character or drivers. Blume (2006) tracks the anti‐vaccine activities that have developed globally over the last three decades, and argues that anti‐vaccination inclinations (in the UK and The Netherlands) are not necessarily religious in nature, and that such sentiments emerge from multiple sources and arguments.

6 As noted above, this JLIF&LC review strives to maintain a focus on LMIC settings – although this is not always possible given the dearth of relevant literature in those contexts. 10

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014

UNICEF (2013b) has also recently published an Box 2: Grabenstein 2013 ‐ Review of literature on the world’s interesting report which shows the results of tracking major religions intersection with immunization Finds over 60 reports of vaccine‐preventable infectious‐disease anti‐vaccination sentiment in Eastern European social outbreaks within religious communities or that spread from media networks. This report shows significant them to broader communities. differences in relation to language and gender – but Different sects within a faith tradition interpret the same found that while religious or ethical beliefs were scriptural passages differently. As vaccines did not exist when significant drivers in Russian‐language anti‐vaccination the foundational texts were written, subsequent interpretations are fundamental. discussions; Polish and Romanian anti‐vaccination Did not identify any canonical doctrine that has led to religious discussions were mainly driven by arguments about objection to vaccines or immune globulins for Bahá’í Faith, side effects and toxins in vaccines. “Religious and Confucianism, Daoism, Shinto, or Sikhism. Revealed few ethical discussions are especially active in discussion in canonical bases for declining immunization, with Christian Scientists a notable exception. Russian, with 96% of all anti‐vaccination discussions Most objections to immunization attributable to religious belief focused on that issue. In English discussions, 32% of all fell into three categories: (a) violation of prohibitions against anti‐vaccination discussion use religious and ethical taking life, (b) violation of dietary laws, or (c) interference with arguments. The arguments are less relevant in Polish natural order by not letting events take their course. (5%) and Romanian (0%) speaking antivaccination Identified multiple religious doctrines or imperatives that call discussions” (UNICEF 2013b). for preservation of life, caring for others, and duty to community. However, there is little analysis (in this report or Found few instances of personal objections that are properly elsewhere) of how religious beliefs or doctrines feed theological in nature – most would more accurately be defined as philosophical or personal choice. For several religious groups, into large‐scale or transnational anti‐vaccination declination of immunization is more traditional or social than an discourse or movements. As will be discussed below, essential religious precept. studies that engage with religion tend to do so in Summary of key points from main religions: relation to a specific national context or individual Jainism, Buddhism, Hinduism: Respect for all life, favoring belief, rather than how it is communicated on the nonviolence; Recognize the need to sustain human life; internet.7 Acceptance of cooking food, boiling water, using antibiotics and vaccines. Judaism: Imperative for Pikuakh nefesh, acting to save one’s own or another’s life; Consider the duty to protect one’s Interpretation of religious doctrine or ‘rules’ that children and one’s neighbors; do not stand idly by; Dietary create opposition to vaccines kosher limitations on medications with porcine components apply to oral administration, but not to injection. Consider the Grabenstein (2013) finds few canonical bases for importance of medicine in preserving life. declining immunization (with the Christian Scientists Christianity: Vaccines with remote fetal implications are morally the notable exception), especially since most texts acceptable (with a duty to protect children), unless alternative were established before vaccines arose. As a result, he products are available; Jehovah’s Witnesses may accept certain blood derivatives, including immune globulins, interferons, argues, current religious interpretations are varied and coagulation factors, erythropoietin, and others; Concern that are also therefore critically important to understand. In ‘the body is a temple not to be defiled’ contrasts with other the broader literature, there are multiple examples of Scripture passages and modern quality‐control requirements for vaccines. individual’s interpretations of religious text and laws Islam: Consider the law to protect life, the principle of resulting in vaccine refusal (Table 1). Refusals are preventing harm (izalat aldharar), and the principle of the public commonly articulated on the grounds that the content interest (maslahat al‐ummah); Transforming haram components of the vaccines have not been approved, around blood may generate halal products (e.g., wine to vinegar); Extensive dilution of components of concern may result in minute products, porcine or bovine pharmaceutical excipients, quantities per dose; Vaccines are intended for important or the remote fetal origins of cell‐culture media and medicinal purpose, not diet; Vaccines help protect others; Consider the law of necessity, whether alternative vaccines are

7 This section is considering what are called ‘anti‐vaccine movements’ in the literature – we address the physical movement of particular vaccine‐preventable diseases across national borders below. 11

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 rubella strains. Individuals might raise concerns that vaccines are not halal or kosher, or might contain forbidden ingredients (see Grabenstein 2013, Khowaja et al 2012).8

Interpretations of ‘God’s will’, for or against vaccination There are varieties of interpretations of ‘God’s will’ visible in the current literature, where vaccine refusal is frequently articulated as fear of opposing a divine plan or ‘God’s will’. For example, Spier (2002) addresses the ‘fear of damnation’ that drives risk perception in relation to vaccine adverse effects. Spier notes that even in the earliest accounts of smallpox vaccination in the 18th century, there were concerns that this process represented a thwarting of God’s will. For example, in 1761, Kirkpatrick says there was opposition from theological authorities to the practice “…and these Reflections may deserve the Attention of those mistaken Theologists, who terming the Small Pocks the Flagellum Dei, make the very Success of Inoculation (instead of observing the divine Admonition of judging of the Tree by its Fruit) an Objection to the Use of it; as it is endeavoring, they say, to elude the divine Scourge” (Kirkpatrick in Spier 2002). In a rare theological interpretation of early public health interventions, Spier continues to examine which biblical resources were relied on in the 18th century to argue against vaccination, one argument being that “…as a proportion (however small) of people who took the inoculation died of the smallpox, to voluntarily expose one’s self to this risk was to court a personal suicide. This was against God’s will and therefore forbidden” (Spier 2002). Several studies also demonstrate that immunization is sometimes refused on religious grounds because of the perception that ‘God heals, not medicine’. For example in ultraorthodox Jewish communities in Israel, Muhsen et al (2012) found current anti‐vaccination reasoning based on religious beliefs such as ‘God will protect children; there is no need to vaccinate them’, ‘To save your soul, avoid a doctor without faith’, and ‘Diseases occur due to disrespect to God and not due to under‐vaccination.’9 However, it should be noted, that while there are references to religious interpretations of vaccine refusal or uptake, there is barely any theological work being done on these issues. That is, while cross‐sectional studies might be demonstrating these issues to be important, theologians have barely engaged (apart from the bioethics discussion as mentioned above). This might be a result of the generally poor engagement between religion and public health – however, in the context of HIV/AIDS theologians of all flavors have dived into interpretations of religious perceptions relating to HIV/AIDS, resulting in thousands of articles in theological journals on ‘religion and HIV/AIDS’. The same cannot be said for immunization or vaccination – where theologians have not crossed over in great numbers into what may be seen as the home territory of epidemiologists and public health specialists – despite articulations as demonstrated above. Of course, perceptions around vaccine uptake or refusal might place those with religious beliefs in direct opposition to immunization specialists. This often embodies a clash of belief systems – with immunization specialists often operating from an epidemiological or medical positivist perspective, which comes into opposition against a more constructivist or descriptive perspective often employed by theologians or religiously‐steeped individuals (see Olivier 2014). This arena of competing belief systems can be seen in the age‐old battles between

8 Making an interesting observation, Gatrad (1994) notes that religious customs carry particular risks ‐ looking at Muslim customs surrounding death, bereavement, postmortem examinations, and organ transplants. Gatrad notes that as Muslims are always buried, never cremated, and it is a religious requirement that the body be ritually washed and draped before burial (as soon after death as possible), those who carry out these duties should be properly immunized against hepatitis B (and be aware of the hazards of AIDS). 9 One of the most interesting, but unexplored interpretations, can be seen in a study by Arora (2000), while evaluating Pulse Polio intervention (PPI) in India, that the majority of the community members believed that the disease had decreased in New Delhi after five years of the PPI program, but that others “…attributed this decreasing trend to ‘God’s will’.” 12

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‘science’ and ‘religion’ – a tension that is still strongly visible in relation to religion and immunization. This is not simply a philosophical debate, but might have a direct impact on current belief and practice. For example, in work on religion and public health, it has been broadly noted that in the context of HIV/AIDS, religious or faith‐healing practices have been strengthened in the last decades because science has failed to develop a solution or vaccine. Edelheit (2004) argues that in the context of HIV/AIDS the ongoing conversation between religion and science comes to a critical juncture: “The global community has not yet found a vaccine or cure for this virulent virus…there is a common prophetic religious imperative among Western faith communities that urgently requires both science and religion to respond.” These ideas hint at a complex inter‐relationship between religion and immunization, however such is as yet poorly explored.

The interweaving of ‘traditional’ practices and beliefs In a related argument, one of the most difficult issues to disentangle are those that are sometimes labeled as ‘traditional’ practices and beliefs – which are sometimes considered ‘religious’ and at other times ‘cultural’. The cross‐sectional studies in Table 1 demonstrate the difficulties of picking up on traditional beliefs through large‐ scale survey methods, which usually ask the respondent to give a primary religious identity or affiliation. In most development contexts, traditional practices are intertwined with other religious identities and practices. This can also be seen in pluralistic health‐seeking behaviors, when individuals might access ‘modern’, ‘religious’ and ‘traditional’ healing modalities at the same time. However, while there has been some significant anthropological work done on pluralistic health‐seeking behaviors, this has not been properly connected to immunization or vaccine‐uptake, especially not adding other religions into the mix at the same time. In the broader literature, there are some hints that this might be significant in development contexts. For example, as a landscaping study on religion and public health in Mali, Schmid et al (2008) observe: “In all regions of Mali, there are traditional religions which persist or syncretically adapt to mainstream faiths such as Christianity or Islam. Traditional healers and health systems therefore are part of the Malian health system, as plural health‐seeking behavior shows, e.g. mothers in Mali’s Dogon country will seek out traditional amulets from Islamic teachers; give their babies a traditional enema every day to prevent illness; and simultaneously use ante‐natal and immunization services if there is a health clinic nearby” (Schmid et al 2008). Or as a traditional healer from Zambia noted in another study, “Although we are traditional healers, we are also Christians…when a person is sick or has died, we pray for that person. When a person is in hospital we go to visit them, take them food parcels and such” (ARHAP 2006). In the same study, a community member from a different region in Zambia argued, “…with traditional healing, the medicine comes from the roots, and we all use the same [modern] medicine, so when someone goes to a traditional healer it doesn’t mean that they don’t trust in God, it is the God who created these things and gave wisdom to a traditional healers to use those roots…and to that person who was given the wisdom to make the drugs from those roots…all the medicines comes from the roots” (ARHAP 2006). Such observations demonstrate the complex weaving of interpretations that lead to belief and practice at a local level (indeed, it is mainly those operating in academia and policy who become stressed while they struggle to classify or explain different determinants and effects.) However, the studies on religion and immunization (as shown in Table 1) rarely take traditional or pluralistic religious perspectives into account. Again, there are some hints: Gyima et al (2006) includes the category ‘traditionalists’ in their survey of maternal health in Ghana and observe that traditionalists are (22%) less likely to receive tetanus immunizations during pregnancy than mainstream Catholic women. Antai et al (2009) who look at polio vaccination refusal related to religion that affect child morbidity and mortality in Nigeria, have results that 13

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 show that mother's affiliation to traditional indigenous religion is associated with increased under‐five mortality. Muula et al (2009) find that mother's use of traditional healer services was negatively associated with vaccination of Haitian children – but add that “it is possible for people in Haiti to belong to a mission religion such as Catholicism or Protestant Christianity but still practice Vodou”, noting that this limits the findings and interpretation. From a refreshingly different angle, Jolles and Jolles (2000) look at Zulu rituals and immunization in South Africa, examining both ‘traditional immunization practices’ (that are ritualistic), and the interaction between traditional healers and modern hepatitis immunization. On the whole, however, there is a paucity of studies on pluralistic health‐seeking behaviors and the related ‘traditional’ beliefs that might influence immunization uptake.10

Legal exemption from vaccination on religious grounds There is a particular cluster of literature addressing legal exception from public health vaccination policies. This is most visible in the USA, where most states allow for exemption on religious grounds, in particular exemption from vaccination before school entry.11‐12 Most of the literature focuses on the legal ramifications of religious liberty versus the good of the public in relation to public health interventions (See Curran 1971, Ross & Aspinwall 1997). However several of the studies indicate that religious exemption or ‘personal belief exemptions’ are often used as a cover for other reasoning – such as objections to government control or personal concerns of the risks of vaccines (see Gaudino & Robison 2012, Salmon & Siegel 2001, Salmon et al 2005). Streefland (2001) argues that this merging of religious and socio‐cultural reasoning dates back to the earliest times of vaccination. For example, to understand resistance to vaccination in the 19th century, you need to understand debates on the role of the state and of state control, and about the limits of individual liberties, and ongoing discussion between religious groups and the state that relate to this. “Religious claims on exemption would be based on arguments pertaining to illness and its outcome being the will of God in which man should not interfere. But, as was the case in the Netherlands, religious and philosophical arguments could also serve to defend people’s rights to refuse school education and public health interventions imposed by the state by declaring the state out of bounds when interfering with such important matters as bodily integrity and becoming God‐fearing adults” (Streefland 2001). Knight (2004) questions what a bona fide religious exemption actually is in North Carolina, raising the following case: “The mother of a child about to enter kindergarten in a North Carolina public school asks her pediatrician to certify that her child should receive a medical exemption from North Carolina’s childhood immunization requirement. He refuses because he determines that immunization is not medically contraindicated. She asks another doctor to certify her exemption request. He also refuses. Two days later, she walks into the school office and requests a religious exemption from the immunization requirement. The mother of another new kindergartner requests a religious exemption from the immunization requirement. The school nurse knows that the child’s older sibling has been immunized” (Knight 2004).

10 There is a disturbing discourse in the grey literature which describes the religious or traditional communities that refuse vaccines as ‘backwards’. This is particularly problematic in relation to the rational‐science versus irrational‐religion discourse and would benefit from closer examination (see Arora et al 2000, Sensarma et al 2012). 11 There are some differences over this, 48 states allow exemptions to immunizations for medical, religious, or philosophical reasons, but legal definitions and enforcement differ. For example, in Oregon ‘religious’ exemptions are allowed for any system of beliefs, practices, and ethical values (see Gaudino & Robison 2012). 12 Note that this review is primarily focused on LMIC contexts however, issues such as legal exemption and orthodox minority communities (below) have significant relevance given the transnational concerns within immunization circles. It is also important (as noted in the text below) that in our global contexts, there are often vulnerable migrant ‘LMIC’ communities situated in HIC settings. 14

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This argument demonstrates the cross‐over between religious and other beliefs and determinants for vaccine uptake (which is a continuous theme in this review).

Religious orthodox communities as pockets of refusal in contexts with otherwise high‐vaccination and high level of access to health services A substantial section of the current literature focuses on conservative or orthodox religious communities as ‘pockets’ of anti‐vaccinating and missed communities within contexts of otherwise high vaccination coverage. In the literature there also seems to be an underlying assumption that ‘religious orthodoxy’ equals non‐vaccination in these contexts. This is demonstrated in the way some epidemiological or clinic studies deliberately draw their samples from religiously orthodox communities in order to have an un‐vaccinated sample (with the study actually having little to do with religion).13 We outline some of the themes within this cluster of literature: The orthodox Reformed Protestants in the Netherlands:14 The most widely studied communities are orthodox (Reformed) Protestant communities in the Netherlands – a country with a strong national promotive vaccination regime. However, the Netherlands also has a history of opposition to vaccination, such as the Bond ter Bestrijding van Vaccinedwang (Association to Oppose Compulsory Vaccination) which was established in 1881 with many clerics among its membership. During a notable polio outbreak of 1978 orthodox Protestant religious objections were also noted (see Ruijs et al 2012). Today, there are two clusters of resistance to vaccination in the Netherlands: anthroposophy and New Age followers (usually highly educated parents), who especially resist the combination measles‐mumps‐rubella (MMR) vaccination; and the minority clusters of orthodox Protestants who base their resistance on religious convictions. Of about 250,000 orthodox Protestants nationally, about 40% are found not to be vaccinated at all – and several epidemics of vaccine‐preventable diseases have been experienced, mainly confined to this minority community. For example, Knol et al (2013) have just published on a large measles outbreak in this orthodox Protestant community that has been ongoing since May 2013. It should be noted, this literature mainly presents survey results, showing reported perceptions. For example, it is not possible from these studies to understand whether it really was ‘religious’ theology which prevented parents from utilizing an MMR vaccination – or whether it was other concerns (such as the controversy raised around MMR vaccination and the claims made about its possible linked to autism), which are then reported through a religious lens or language. There appears to be a particular concern in this literature about epidemics of polio, measles, rubella, and mumps which have broken out among this group and spread to their relatives in other countries. For example, in 2008 a particular strain of the mumps virus spread from a Dutch orthodox Protestant community to a Canadian orthodox Protestant community, presumably through family ties (see Wielders et al 2009). Interestingly, Ruijs et al (2012) have found that within this group, both vaccinating as well as non‐vaccinating parents predominantly used religious arguments to justify their decision – that is, orthodox Protestant objections to vaccination focus on trust in divine providence, and at the same time biblical arguments are made for vaccination (as a gift of God to be used in gratitude).

13 See for example Bersen et al (2006) who study the relationship between diphtheria tetanus pertussis (DTP) vaccination and atopic disorders – and choose a population of children attending Orthodox Reformed (Protestant) primary schools in the Netherlands. The focus of the study is not on their religiosity or refusal, but selects this population to find an unvaccinated (or blind) population. 14 This summary is drawn from a cluster of similar materials – see Bersen et al 2006, Hahne et al 2009, Knol et al 2013, Oostvogel et al 1994, Ruijs et al 2011a, Ruijs et al 2012a, Ruijs et al 2012b, Ruijs et al 2012c, Streefland et al 1999, Van den Hof et al 2002, Veenman and Jansma 1992, Wielders et al 2011 15

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Ultra‐orthodox Jewish communities in Israel (and globally):15 Several other studies look at the low vaccination uptake of the closed ultraorthodox Jewish communities in Israel – where access to health care is otherwise high, and the population vaccination coverage is reported to be over 90% at the age of two years. Muhsen et al (2012) find that factors that were significantly associated with vaccines underutilization in Bnei Brak were large families and mothers with academic education, as well as parental religious beliefs against vaccination, perceived risk of vaccine preventable diseases as low, and mistrust in the Ministry of Health (MOH). Similarly, in Jerusalem, religious beliefs against vaccination (and related perceived low risk) increased the likelihood of under‐immunization. Similar to the Netherlands, not only has this population experienced large outbreaks of vaccine‐preventable diseases, but these have also been communicated to other Jewish communities in Israel, Europe and in the United States. There are also related studies on orthodox Jewish communities in other countries. For example, Gordon et al (2011) showed that Jewish mothers were less likely to vaccinate against human papillomavirus (HPV) – usually since religiosity was perceived as resulting in lower risk (see below for more on HPV). In contrast, Cuninghame et al (1994) looked at immunization uptake and parental perceptions in a strictly orthodox Jewish community in north‐east London, and found no significantly difference in uptake of the strictly orthodox Jewish community from that of the surrounding health district. The authors ask whether health professionals’ preconceptions about religion should not be challenged: “Responding parents had positive attitudes to the value and safety of immunizations but wished better access to services. Health professionals need to question their perceptions so that efforts to improve uptake amongst ethnic minority groups are based on facts and are responsive to identified needs.” Non‐vaccinating Amish communities in the USA: There are also similar studies on non‐vaccinating Amish communities in the USA – communities who have a preference for folk and alternative medicine. However, Crawford et al (2009) note that Old Order Amish are a religious group that values health and actively participates in its health care decisions. They argue that the observed Amish are “…open to the use of folk medicine, complementary and alternative medicine, and conventional care when deemed necessary…care should be given to avoid stereotyping patients because Amish rules and customs differ across districts.” Religious minority migrant communities that settle in countries with high vaccination rates: Similar to the studies of orthodox communities – some studies look at minority and migrant communities, which are often identified by their religious affiliation as well as their national or cultural origins. For example, in 1988, Bhopal and Samin looked at immunization uptake of Glasgow Asian children, and closely examined religious affiliation in relation to cultural identification: “Asian children were identified by a names analysis and categorized as Muslim, Hindu or Sikh…Sikhs had the highest immunization rates (90% or more) for DPT, measles and polio. Muslims and Hindus had higher uptake of pertussis vaccination but were on a par with their controls for other immunization.” Brooke and Omeri (1999) considered beliefs about childhood immunization among Lebanese Muslim immigrants in Australia, and found “…significant care themes for Lebanese Muslim informants based on their cultural values, beliefs, and practices related to health and immunization.” Bray and Keating (2012) examine immunization and informed decision‐making among Islamic primary school parents and staff in Australia – and among other things, found concerns about the halal nature of vaccines. This only samples the broader literature on orthodox or ‘closed’ communities with a strong religious identity. One cross‐over theme is the consideration that in an increasingly globalized world, with transnational communication

15 This summary is drawn from a cluster of similar materials: see Anis et al 2013, Cuninghame et al 1994, Gordon et al 2011, Lernout 2009, Muhsen et al 2011, Muhsen et al 2012, Stein‐Zamir et al 2008, Stewart‐Freedman et al 2007 16

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 of diseases – otherwise ‘closed’ local faith communities can pose a significant risk, not only to themselves, but also to the communities around them and the broader international community at large. This means that while orthodox religious communities may often be a small minority in their country‐context, they still remain a key public health consideration.

Risk perception with human papillomavirus (HPV) vaccination16 HPV vaccination is being introduced to girls and women mainly to reduce incidence of cervical cancer,17 and raises interesting dynamics in relation to religiously motivated vaccination choices and risk perception. Several studies have examined whether religious perceptions create a barrier to HPV vaccination uptake (see footnote below). A key question seems to be whether those with a strong religious identity have a different perception of risk in relation to HPV. For example, whether religiosity is related to sexual activity delay which in turn relates to lower risk of cervical cancer – actual or perceived. Most of these studies find similar concerns relating to HPV in religious communities as to other vaccines, for example, fears of whether the ‘new’ vaccine has been properly tested or of side‐effects. Several studies do find low HPV vaccine uptake among those with a strong religious affiliation or identification – which is in turn linked to low risk perception. Mothers from religious communities which demonstrated strong beliefs about sex before marriage, often had a low perceived susceptibility to cervical cancer, and saw this as a reason not to vaccinate (see Brabin et al 2006, Gordon et al 2011, Katz et al 2009, Marlowe et al 2009). Gordon et al (2011) explored attitudes to HPV vaccination and reasons for accepting or declining the vaccine in a British Jewish community and showed many mothers who thought HPV vaccination was a good idea in general, but did not perceive it as necessary for their daughters, citing Jewish religious laws governing family purity and abstinence until marriage as reasons for daughter’s low susceptibility. Mothers in this study felt that their attitudes were more reflective of their religion than their ethnicity. Interestingly, the study participants noted that this was the first vaccination for which their religious opinions had entered the decision‐making process. That is, they perceived that religious beliefs had not contributed to previous vaccine decisions. In contrast, some of the participants also gave religious reasons for taking the HPV vaccination, quoting a Jewish obligation to save life. Gordon et al (2011) therefore suggest that HPV might therefore be more acceptable when offered at a later age in religious schools. Marlow et al (2009) looked at ethnic minorities in the UK and found that in a subsample of mothers, ethnicity and religion were strongly associated with acceptability of HPV vaccination. Those from non‐Christian religions were also less accepting of the vaccine, and religion was associated with awareness and acceptability, with fewer ‘acceptors’ among Hindus and Muslims compared with those with no religion. Again, ‘religious reasons’ were one of the main reasons cited for declining the vaccine, related to a strong belief in sexual abstinence until marriage. McCaffery et al (2003) also look at minority groups in the UK, and note that Indian and Pakistani women perceived testing to reflect nontraditional cultural or religious practices concerning sex and monogamy, and that some Pakistani women described Muslim beliefs that were prohibitive of screening. However, others felt that Islamic beliefs would support HPV screening as good for women’s health, and family health. Natan et al (2009) also found that Israeli mothers who scored highly on religiosity were less likely to vaccinate their daughters against HPV.

16 This summary is drawn from a cluster of literature: see see Brabin et al 2006, Cuninghame et al 1994, Gordon et al 2011, Katz et al 2009, Marlow et al 2009, McCaffery et al 2003, Natan et al 2009, Remes et al 2012, Wong 2009, Zimmerman 2006 17 In men, an HPV vaccine might be intended to prevent genital warts, penile or anal cancer – however, the bulk of the literature in relation to HPV and religion is focusing on HPV and women. 17

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Gordon et al (2011) point out that Jewish women have historically had a very low risk of cervical cancer – which has been attributed to factors such as circumcision and abstinence until marriage. From this perspective, a Jewish mother’s perception of lower susceptibility may well be based on this. While most of the material on HPV has emerged in higher‐income settings, now that the vaccine price has come down, there are a few emerging studies looking at HPV vaccine acceptability in development contexts. For example, Wong (2009) looks at HPV vaccine delivery in Malaysia, noting that Malay Muslim physicians have a higher level of cultural and religious sensitivity when recommending HPV vaccines. Remes et al (2012) looks at HPV vaccine acceptability among health workers, teachers, parents, female pupils, and religious leaders in northwest Tanzania – noting that the religious leaders interviewed knew little about cervical cancer or the HPV vaccine, and that the study was the first time that staff from a health program had come to discuss a health intervention with them. The religious leaders in this study then said they would discuss cervical cancer and HPV vaccination with their congregations. Unfortunately, not many other studies in development contexts consider religion as a significant factor in relation to HPV uptake, and this might be an important area for further study.18‐19

Linking to religiosity and behaviors in HIV/AIDS As discussed above, there is a significant body of literature on religion and religious behaviors in the context of HIV/AIDS (see Olivier et al 2013). Given the current absence of an HIV vaccine, there is not an obvious connection between this available literature and the focus of this review. However, there are several interesting parallels between HPV and HIV which might be explored further. For example, both HPV and HIV are linked (primarily) to sexual activity, and therefore perceptions about religion and risk are important and possibly similar. There is some literature on the ‘social and cultural’ dimensions of introducing an HIV vaccine in development contexts, for example, Streefland (2003) raises the need to understand ‘local vaccination cultures’, the socio‐cultural aspects of the introductory process, and tailoring health education and social marketing to local conditions and local interpretations of globally provided information. However, at this time, there is very little consideration of religion or LFCs in this literature – even with the lessons on acceptors and non‐acceptance by religious world‐views as above. Doupe and Kurian (2006) noted that in the context of HIV/AIDS, churches and their health care institutions need to play a major role in promoting the acceptance of new technologies such as medicine adherence, microbicides and vaccines. We would argue that it is potentially useful to draw from the extensive literature on religion and HIV/AIDS, and apply this to other areas such as HPV vaccination. This might provide an advantage in understanding the complex interaction of religious, cultural and other factors. And vice versa, the experiences from HPV vaccination in LMIC settings might prove to be a partial precursor to HIV vaccination – at least in relation to religious influences on risk perception and uptake.

2.2. The Challenges in Separating out Religion One of the greatest challenges found across all of this literature, is unpacking the complexity of ‘religion’ as a determinant or causal factor of immunization‐related beliefs and behaviors. For example, if a study finds that fewer Muslims in a particular community are less likely to immunize their children, this seems important. However, what could the underlying reasons for this be? Is this because Islamic doctrine around halal ingredients

18 For example, Coleman et al (2011) look at HPV vaccine acceptability in Ghana, but while the table indicates that 46% of respondents believed that the HPV vaccine would be against their religious beliefs, the authors do not pick up on this in their analysis or discussion. 19 Slightly unrelated, but worth noting is work by Zimmerman (2006) which addresses religious ethics in relation to HPV vaccination – taking note of the religious positions for and against HPV from a theoretical perspective. 18

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 causes hesitancy? Because Muslims in that area tend to be poorer and have less access to health services anyway? Because of religiously‐related gender dynamics, such as son‐preference or Muslim women not being allowed to see male health workers outside their home? Because of international and historical politico‐religious dynamics in that region? Did the overt response actually reflect the covert reasoning going on? Any of these suggestions could have relevance. We unpack some of the explanations currently provided, and note some of the trends in this particular cluster of literature on religion and immunization‐related behaviors and beliefs. It is important to note however, that within the substantial body of media reports there is a tendency to stereotype religion and religious behaviors. As noted above, while such media reports attribute vaccine refusals to directly to religion, there are often many other underlying factors at play. For example, Blume (2006) notes that the Orthodox Protestants in the Netherlands refusal of vaccination was attributed in the media wholly to religious views, however, “…interviews showed that other motives and considerations were also involved.” Similarly, we seek to understand the more complex and covert connections between religion and immunization‐related behaviors and beliefs.

Cross‐sectional studies on religiosity and vaccine uptake: challenges in unpacking religious belief Studies that ask simple questions about immunization uptake can result in highly complex answers. Several studies now note that overt religious reasons given for immunization refusal often mask a variety of covert reasons, which are either not picked up on by survey study design, or are hidden intentionally. As Grabenstein (2013) finds in his review of over 60 reports of vaccine‐preventable infectious‐disease outbreaks that occurred within religious communities, “in multiple cases, ostensibly religious reasons to decline immunization actually reflected concerns about vaccine safety or personal beliefs among a social network of people organized around a faith community, rather than theologically based objections per se.” Looking at the sample of studies in Table 1 below, it is possible to see how religiosity (as usually measured in cross‐sectional studies) is mostly found to be a critically important factor, both in terms of statistical significance and how it ties to other determinants ‐ with only a very few studies finding religion not to be statistically significant. Indeed, there is a trend for such studies to conclude in their final paragraphs that religion, religious leaders and religious‐contextual factors need to be taken into account (see Box 3 below), although little detail is given on ‘how’ this should best be done. As can be seen in Boxes 3‐6, several studies find ‘religion’ to be statistically significant in relation to immunization acceptance or refusal, but shy away from unpacking what this significance means, or how it relates to the other findings (see Antai 2009, Gyimah et al 2006, and below).

Box 3: Samples of Conclusions Arguing for the Importance of Religion in Primary Studies On HPV vaccine uptake in Jewish communities in the UK, Gordon et al (2011) conclude: “Attitudes to HPV vaccine in religious communities may lead to reduced vaccine coverage. The development of community‐specific information about the importance of the vaccine may help address concerns.” On ethnic minority groups in the UK, Marlow et al (2009) conclude: “The importance of religion appears to come from a strong belief in sexual abstinence until marriage, and this is a barrier that will be a challenge to overcome. Liaising with religious groups about the best ways to communicate HPV information may help to make HPV vaccination more acceptable.” On religious subgroups influencing vaccination coverage in the Dutch Bible belt, Ruijs et al (2011) conclude: “Municipal vaccination coverage in the Dutch Bible belt is largely dependent on the membership ratios of the various orthodox Protestant denominations. Control of vaccine preventable diseases should therefore be focused on these religious risk groups.”

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On ultraorthodox Jewish communities in Israel, Muhsen et al (2012) conclude: “The risk factors of under‐immunization are in part modifiable, by means of health education…and by improving the trust in the MOH. The leaders of the ultraorthodox communities could play an important role in such interventions.” On vaccination uptake in Haiti, Muula et al (2009) conclude: “Findings underscore the potential to enlist the support of traditional healers in promoting child health by educating, mentoring them in supporting vaccination efforts.” On immunization coverage in Burkino Faso, Sanou et al (2009) conclude that children in Muslim families in rural areas having lower rates, suggesting that interventions “…can neither neglect religious considerations nor the particular learning environments of specific groups. Health intervention planners should…consider the distribution and involvement of religious groups…while comprehensive communication may improve understanding about immunization, it is necessary that local interventions also take into account religious specificities and critical economic periods.” On immunization in Kolkata India, Sensarma et al (2012) conclude: “The current national immunization program should focus on the children from the Muslim community and those belonging to scheduled castes, tribes and other backward classes…” On immunization in Lucknow, India, Nath et al (2007) conclude: “The intervention programs need to be tailored specifically for the Muslim community and those belonging to the low socioeconomic status…”

One consideration might be that ‘religion’ as a determinant is not seen as something that can be shifted or targeted itself. For example, Weiss et al (2013) look at polio eradication efforts in India and found religion and mother’s educational status to be significant determinants of routine immunization outcomes. They conclude: “To address these two determinants, programs need to tailor their strategies such as promoting immunization through religious leaders or use IEC materials better suited for illiterate populations.” They come to this conclusion because “…religion is not a target of change, and improving education status on a population level will require a long‐term effort.” We do not have the space here to engage on this in more detail, however, it is interesting that religion is seen as ‘untouchable’. This has a direct impact on the lack of precise suggestions for further engagement (beyond ‘involving religious leaders’, or utilizing ‘religiously‐appropriate materials’). It also explains why so much attention is placed on the correlates of religion in these studies, as they might seem as greater opportunities for engagement. Indeed, one of the key challenges appears to be whether ‘religion’ can be taken as a determinant itself, or whether it is a place‐holder or indicator of a range of other factors that coincide with religion, such as poverty, lower education, poor communication, or unequal gender relations. Oluwadare (2009) argues that “the greater explanatory factor is not religion itself, but religiously fuelled social tendencies of poor education, low economic status and isolated livelihood, which predict low uptake of immunization.” We outline some of the key explanations that are provided ‐ reasons for missed populations, higher risk and lower vaccine acceptance that relate to ‘religiosity’ in these studies: Region of residence: A common starting point is to consider whether area or region of residence impacts on vaccine uptake. For example in the Netherlands, the clusters of Orthodox Protestants tend to live in the same geographic region. There are multiple such arguments about distribution of different religious groups and immunization uptake in India and Nigeria. For example, Antai (2009) looks at regional distribution of vaccination acceptance in Nigeria and argues that the higher risks associated with children may be related to the widespread distribution of adherents of Islam (see Box inserts on India and Nigeria below). And of course, distinguishing between urban and rural populations is the first step of such cross‐ sectional studies. When religion impacts on access of immunization health workers to closed communities: Others argue that religious communities are often missed because they are physically inaccessible or ‘closed’ to immunization campaigns and systems, and that this is strongly influenced by religious and cultural beliefs and practices. For example, because women and children stay inside the family home or compound for religious reasons, or will not open doors to male immunizers – or because immunization campaigns take 20

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place at the same time as periods of religious festivals or Box 4: Samples of ‘uncertain’ connections observance (see Antai 2009, Arora 2000, Bababola between religion and determinants 2011). UNICEF (2011b) notes that in Afghanistan, Looking at Vodou affiliation and vaccination rate in approximately 50% of children are missed due to ‘child Haiti, Muula et al (2009) note that while Vodou and not available’. They note this data still needs to be Catholicism were associated decreased vaccination rates, they are not clear on what resulted in this unpacked further, but still conclude that vaccination in figure, saying this “…may be an indication that madrasas or religious schools should be explored. Vodou practice may not be favorable to vaccinations… or that Vodou affiliation may just be Religiously‐supported gender inequities such as son an indicator of some unmeasured variable which preference and low female literacy: An area of high may also be associated with non‐vaccination of children.” interest is the connection between religiosity and Sahoo (2012) looks at child immunization in India gender equity or empowerment. Several studies that and note that “…it is clear that children belonging to demonstrate a strong connection between religiosity the Muslim community are less likely to go for full as and immunization refusal, attempt to connect this to well as partial immunization than their Hindu counterparts”… and then go on to speculate “…[it] gender dynamics found within religious groups. Antai may be that is partly because the utilization of health (2009) notes that in Nigeria, Muslim women are care services is lower among Muslims” – however, generally discriminated against in their access to they remain uncertain. education, and that the “associated decrease in Yadav et al (2004) look at immunization in the Indian North‐East states and find that religion plays a role in women’s empowerment results in increased risks for availing of the health care services to a great extent, these children not being immunized.” Ghatak (2006) speculating that this “may be due to the fact that observes a strong son‐preference in south Asian many other characteristics are influenced by religion.” (Muslim) communities and that this impacts on polio immunization. Ghatak observes that problems arose in In a study on immunization refusal in Nigeria, UNICEF finds that (2011a) ‘religious’ and ‘political’ West Bhengal when “large numbers of Muslim men reasons for refusals appear much less significant – forbade their wives from taking children to however they note that “A more in‐depth analysis will be required to understand what this really immunization clinics.” Bababola (2011) similarly found means and how communication interventions need that in northern Nigeria many children were not to be adjusted.” immunized because their fathers opposed immunization Sanou et al (2009) assess factors associated with and would not give permission for the children to be complete immunization coverage in children in a immunised. Bababola goes on to argue that engaging district of Burkina Faso, and note that after controlling for both locality (rural/urban), and with men is clearly important, saying, “While the economic status, in rural areas, in the poorer three motives for husband’s opposition to immunization were quartiles, children from Muslim families had lower immunization coverage rates, but that religion was not explored in this study…religious and community not significantly related to lower immunization leaders (who are typically men) should play an coverage rate in the urban areas. They continue “In important role in all efforts to promote child our study, children of Muslim families (controlling for economic status) have significantly lower rates of immunization, in general, and to reach men, in complete immunization coverage in rural areas…We particular.” Marlow et al (2009), looking at UK ethnic suggest, however, that in Nouna the problem is minorities’ acceptance of HPV vaccine, found that ethnic more related to access to information…In some Muslim communities, external informants have only minority mothers (with a strong religious identity) were limited and controlled access to women…Combining more likely to believe the father would play an these findings, it appears that the complex important role in the decision to vaccinate against HPV. relationships between religious matters and health outcomes must be questioned more deeply.” Several other studies consider how low vaccination uptake and religiosity is then linked to parental literacy rates. Some authors argue that certain religious groups tend to down‐play the education of women, and that education is central to understanding immunization interventions and having access to proper information (see Elliott & Farmer 2006, Ghatak 2006, Sanou et al 2009, Singh et al 1996). However,

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it should be noted that in several studies mother’s education was not significantly associated ‐ for example, Muula et al (2009) note that while Vodou and Catholicism were associated with 54% and 39% decrease in the odds of being fully vaccinated in Haiti, “mothers' education was not significantly associated with child vaccination.” Similarly, in several of the studies on orthodox religious communities in high‐vaccination contexts, in some cases, more highly educated mothers were less likely to vaccinate (see Muhsen 2012) – showing the complex relationship of determinants such as religion to decision‐ making around immunization. Social hierarchies related to religion: Another interesting connection is between social status or class and religion. For example, Bonu et al (2003) note that female and Muslim children are significantly less likely to be immunized than male and Hindu children (especially in North India). They argue that these significant disparities in immunization coverage by caste are “…the basis of hierarchical organization of Hindu religion.” In effect, arguing that the caste system in India is driven by the Hindu religion – and demonstrating the complex weaving of culture‐religion‐society. Vaccination full courses and large family sizes: Another example of a correlation being made is the link between typically large‐family sizes found in some religious groups – arguing that they are less likely to get their full course of immunization as a result. For example, Khairkar (2013) notes that in Hyderabad India, the rate of coverage for non‐Muslim and Muslim children under primary vaccination was initially the same but it dropped significantly by the fourth and the fifth dose. Khairkar argues that this shows that parents are not opposed to the idea of vaccinations and other reasons for non‐completion needs to be considered such as access to health facilities or large family sizes causing interruption (see more in Ch 4).

Unpacking these correlations is complex Ojikutu (2012), looking at pediatric vaccination in Lagos State Nigeria notes that marital status, education and religion significantly influence vaccination uptake, and conclude that “…culture and beliefs of the Yoruba in Lagos State is too complex to be ignored in any public health plan.” However, it should be noted that unpacking this complexity and these correlations remains a challenge (see Box 4 for examples of some of these frustrations). Gyima et al (2006) directly tackle this complexity, asking whether there is a relationship between religion and the use of MCH services, and whether such an association is mediated through other socioeconomic, socio‐cultural and demographic factors. They conclude that in their cohort the groups “mainly reflect differential access to social and human capital rather than religion per se…religious affiliation masks other characteristics which are known to associate with health‐related behavior.” However, they do conclude that although religion partly affects MH service utilization through other factors, it is still epidemiologically important and these results “challenge the notion that religious differences in MH service utilization mainly reflect socio‐economic disparities.” One of the main issues in such cross‐sectional studies is how the analysis is done, and what kind of association can be made with religiosity. Gyimah (2007) engages with the complexities in this method of analysis noting that “although previous child mortality studies often include religion as a control variable, there has been little theoretical articulation of the pathways through which this happens.” Gyimah (2007) looks at the Ghana Demographic and Health Surveys, and notes that “at the bivariate level, children whose mothers identified as Muslim and Traditional were found to have a significantly higher risk of death compared with their counterparts whose mothers identified as Christians. However, in the multivariate models the religious differences disappeared after the mediating and confounding influence of socioeconomic factors were controlled.” Gyimah concludes that

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JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 these findings support the “selectivity hypothesis, which is based on the notion that religious variations mainly reflect differential access to social and human capital rather than religious theology…” Chaturvedi et al (2011) question whether we are generally reluctant to address cultural and religious determinants, arguing that “epidemiologists and public health managers generally harbor a belief that cultural determinants of health would be suitably taken care of if the broader domain of social causations is addressed.” They argue that several of the social determinants currently under use may be mere proxies of deeper, and probably causal, cultural determinants. They use the example of community based systematic resistance to supplementary immunization activities of polio eradication campaign witnessed in several pockets in India, Pakistan, Afghanistan and Nigeria which “…cannot be totally explained as behavior of economically disadvantaged communities. There has been little recognition of the component of cultural resistance behind this phenomenon, and sometimes the imperatives of political correctness smothers such enquiries.” While many studies note that this is a confounding variable, Antai (2007) is one of the few who wrestle directly with this complexity in relation to religion and immunization. Looking at data on Nigeria, Antai compares a particularized theology hypothesis and a characteristics hypothesis. The characteristics hypothesis (like the selectivity hypothesis above), “…posits that religious affiliation per se has little or no independent influence but rather it is the difference in the demographic, social and economic composition of religious groups that largely accounts for observed differences in child survival.” In contrast, the particularized theology hypothesis “…asserts that differences in child survival within religious groups are a result of specific doctrines of a religion, i.e. the presence or absence of specific religious tenets directly pertaining to child health, and the influence of beliefs and values of the various religious groups that influence child health and survival. The prescription or proscription of certain lifestyles as well as the regulation of health‐related behaviours of its adherents may lead to the adoption of health‐damaging or health‐promoting behaviours and thereby impact child health and survival” (Antai 2007). Antai finds that both of these hypotheses are present in relation to immunization and religion in Nigeria: “Despite the identification of multiple factors as contributing to the low immunization coverage in Nigeria, such as inadequate vaccine supply and distribution, poor understanding of immunization, suspicions, myths and rumors, it is the role of religion in the risk of living children 12 years of age and older not being immunized that is the most disturbing…the results of this study indicate that religion (Islam) has played a role in the risks of non‐immunization of children in Nigeria, which supports the particularized hypothesis that posits that the religious differences in the risks of children 12 years of age and older not being immunized are largely due to the specific doctrines, beliefs and values associated with religion. The results further indicate that religion (Islam or Traditional) was not associated with the risks of children 12 years of age and older receiving partial immunization, supporting the characteristics hypothesis that posits that the observed religious differences in the risks of children being immunized are largely due to the differences in demographic, social and economic composition of the religious groups” (Antai 2009) One of the best examples of this complexity in practice can be seen in relation to vaccination uptake in India. As this case (in Box 5 below) demonstrates, religion as a determinant at a broad national scale is found to be of only limited value for understanding the associated behaviors. Looking at the characteristics of specific communities and targeting interventions directly to them would seem to be of greater value and effectiveness.

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Box 5: India – religiosity in a multi‐religious context One of the most fascinating examples of mixed determinants must be the multi‐cultural and multi‐religious context of India. Most of these studies observe that Muslim children in India are significantly less likely to be immunized than Hindu children – although the degree of significance changes by region and tends to intensify in North India (see Bonu et al 2003, Elliott & Farmer 2006, Yadav & Singh 2004) For example, Borooah (2004) noted that Dalit and Muslim parents have, relative to Hindus, had a lower propensity to fully immunize their children – and that they embedded a gender bias into this lower propensity. Borooah notes that a distinct disadvantage stemmed from the communities (defined in terms of caste/religion) to which the children belonged: the likelihood of Hindu children being fully vaccinated was 20 percentage points higher than that for Muslim children. However, they argue that all children in India suffered more severe, but less publicized, forms of disadvantage than that engendered solely by religion and gender. Kumar et al (2010) found that religion was a significant factor in their study of immunization status of children admitted to a tertiary‐care hospital of north India – and that a low coverage of complete immunization among Muslim patients was observed. However, in the qualitative section of this study, religion was never given as a reason for partial or non‐immunization. Sahoo (2012) examines coverage of child immunization in India and say “it is clear that children belonging to the Muslim community are less likely to go for full as well as partial immunization than their Hindu counterparts, maybe that is partly because the utilization of health care services is lower among Muslims.” Yadav et al (2004) note that religion played a role in availing of the health care services to a great extent, which “may be due to the fact that many other characteristics are influenced by religion”. Bhalotra et al (2009, 2010) calls it a puzzle that Muslim children in India face a substantially lower mortality risk than Hindu children – as one would expect the opposite, given that Muslims have, on average, lower socio‐economic status, higher fertility, shorter birth‐spacing, are a minority group in India that may be expected to live in areas that have relatively poor public provision – and have lower vaccination rates than Hindu children. Bhalotra et al (2009) examine a range of different possible factors, such as mother’s BMI (which is higher in Muslim women), consumption of meat (Hindu women are usually vegetarian), Muslim mothers are less likely to work than Hindu mothers, and a possibly greater son preference amongst Hindus – all of which might explain the ‘Muslim advantage’. It has been noted that India has long been considered one of the toughest places in the world to eradicate endemic polio (Murphy 2012) – this confluence of social, cultural and religious determinants have been one of the challenges. Interestingly, Bonu et al (2003) notes that the polio campaign was successful, to some extent, in reducing gender‐, caste‐ and wealth‐based inequities, but had no impact on religion‐ or residence‐based inequities. (See Arora 2000, Bhalotra et al 2009, Bhalotra et al 2010, Bonu et al 2003, Elliott & Farmer 2006, Khairkar 2013, Kumar et al 2010, Nath et al 2007, Singh et al 1996, Yadav & Singh 2004)

2.3. Transnational and Local Religio‐cultural‐politics There are multiple examples of religious leaders or LFCs rejecting vaccines and immunization campaigns – but authors are increasingly arguing that while their rejection might be labeled as ‘religious’, it is often underpinned by social and political concerns. Das et al (2000) point out that “public health officials and political parties in power tended to respond to a health crisis by mapping out a geography of blame…when a number of deaths occurred in a Muslim‐dominated area following the administration of measles vaccine in one case and polio drops in another, the community was blamed for being superstitious…Emphasis is placed on their religion or ethnicity rather than their poverty or lack of education.” In fact, religion is frequently placed at the forefront of blame in relation to refusals which are arguably just as influenced by hugely complex, social, political and cultural factors. For example, the following account from UNICEF (2011a) on refusals in the DRC is worth reading in its entirety as it provides a useful account of this complexity: “Refusals in DRC are high, at a national average of 16%, with extremely high rates of up to 29% in Kinshasa. Religious beliefs frequently contribute to refusal, but politically fuelled rumours have been on the rise since February, and can lead to dramatic spikes in refusals. Religious beliefs are often cited as a reason for refusal in DRC. On the surface, concerns seem to be about fears of multiple doses weakening children, OPV causing sterilization, or a general belief that only God‐not‐vaccine can protect children from disease. But deeper analysis is required to understand the true reasons behind refusals in some communities. While religious beliefs undoubtedly play a prominent role in some caregiver’s refusal to vaccinate, rumours are sometimes fuelled by religious leaders who have other motives for discrediting the vaccine. In Katanga, for example ‐ 24

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where refusals are consistently above 10% ‐ the district of Kalemi has had persistent clusters of refusal for several rounds. Here, religious leaders and clusters of households banded together to resist polio vaccination, citing various different reasons. Deeper probing revealed that refusals were organized as a collective demonstration of dissatisfaction with political and social developments in the region” (UNICEF 2011a). One of the most challenging areas to disentangle is where religion, politics and personal agendas collide, with immunization frequently caught in the cross‐fire. A dominant example of this in the literature is the example of the Nigerian polio boycott of 2003 (see Box 8 insert below). However, there are many other such examples which merit attention mentioned in the literature. Nishtar (2010) looks at Pakistan, and discusses the conflation of religious, political and cultural issues which results in resistance to vaccination. Nishtar looks at the Federally Administrated Tribal Areas in Pakistan which are currently conflict zones. Not only does this make it generally impossible to deliver services to war‐ridden populations, but “‘Talibanization’…and misinterpretation of religion has led more than 90% of the clergy in conflict‐ridden zones to campaign against polio vaccination on a wide scale, causing parents to refuse vaccination for their children on the mistaken grounds that it is haram (forbidden by the religion)” (Nishtar 2010). Nishtar goes on to argue that with ‘talibanization’ resistance to vaccination is likely to spread across the country as well. Nishtar (2010) concludes that through the creative use of quotes from the Quran, “polio eradication can be presented as a ‘right to life’ issue. Improved understanding of the religion may assist in negotiating access in areas where refusal is an issue and soliciting a ceasefire for vaccination campaigns. For all we know, this could be a step towards peace in Pakistan’s war‐riddled zones.” However, Pakistan demonstrates that transnational politics are just as significant a factor. While not widely reported in the scholarly literature as yet, there are multiple news reports alleging to a vaccination campaign organized by the United States Central Intelligence Agency – which was primarily intended as a mechanism to try to track down Osama Bin Laden. Khowaja et al (2012) note that the CIA allegedly were “…surreptitiously obtaining blood samples from his family members for deoxyribonucleic acid (DNA) testing. The campaign was run by a Pashtun government physician from the tribal area of Khyber Agency who had worked in polio vaccine campaigns.” Khowaja et al noted related distrust of government‐run programs in their study, given as the reason for having refused to get their children vaccinated. They argue, “The publicity surrounding the bogus vaccination campaign is probably not the only reason for people’s mistrust of the polio vaccine, since vaccine refusals Box 6: Polio resistance in Kenya had been documented in the Pashtun population In 1997, a Catholic bishop and priests in the Central Province region of Kenya (apparently acting on their own auspices), even before the incident. However, reports of the spoke out against government‐run polio National Immunization incident may have reinforced or perpetuated Days (NIDs). There was nominally a religious basis, in that it was negative perceptions. The long‐term impact of this rumored that the polio vaccine was laced with contraceptives. However, in retrospect, the clergy’s warnings seemed fed by the incident on polio eradication efforts in Pakistan fact that Central Province was the heartland of the political remains to be determined.” opposition and the timing of some of the NIDs was in the run‐up to a presidential election. One of the most troubling effects of the religio‐ Later it was observed that the bishop was not acting on political collision with immunization is the theological concerns per se, but rather out of a sense of endangerment and assault of community health protecting his flock. Notably, the rumors had no perceptible effect on the routine immunization program; generally workers. There has as yet not been any significant vaccination opposition tends to emerge more around publication on this phenomenon in the academic campaigns or NIDs, rather than around routine programs. The Kenyan government and partners took action, and by 2001, a literature, but again, the media is full of reports of prominent opposition politician appeared with government health workers being attacked for engaging in staff, administering the polio vaccine on camera, at a Catholic immunization work, and its seeming connection to church in the Central District. higher political (and religious) issues. (Aylward 2012, direct extract, original source unclear)

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We do not seek to conduct an in‐depth analysis of socio‐political influences on immunization in this scoping review (for that would be an entire project unto itself). Teasing out the connections between politics and religion in contexts such as Pakistan requires significantly more attention than we can provide. However, we do pull out a few clusters or issues which are related most strongly to religion in the current literature: Resistance to state control: In the introduction we mentioned the historical resistance to vaccines which were embedded in resistance to state control. For example, the Dutch Association to Oppose Compulsory Vaccination (established in 1881) – with clerics among its membership “…opposed compulsory vaccination on the grounds it represented an infringement of individual liberty. The Association argued that objections to vaccination out of religious conviction had to be respected ‐ a view that was finally accepted, with exemption allowed on religious grounds, in the early years of the 20th century” (Blume 2006). Such resistance to state control (in the form of public health intervention) continues to be strongly visible across the literature and the media. As mentioned above, religious groups are often the associational bodies around which such resistance to state control are organized. Rumours and resistance to ‘Western’ control: There are a multitude of examples of transnational politics influencing vaccination and immunization. For example, resistance to immunization is frequently articulated as part of an anti‐western sentiment (in Africa and beyond). In the colonial context, Streefland et al (1999) note how resistance to smallpox vaccination in British colonies (which involved religious leaders) was intrinsically political – as a statement of resistance to Box 7: Resistance to Tetanus Toxoid Vaccination in the colonial rule. “The introduction of smallpox vaccination Philippines as a routine public health measure did not always In the Philippines, where the Roman Catholic Church has a proceed smoothly, however. Resistance came from very strong position, fertility regulation is an important various sources: effective traditional ways of subject. There is a sharp social and political divide in society between ‘pro‐lifers’, supported by the Church and a preventing smallpox by way of variolation, religious significant part of the popular press, and those who want objections, and disapproval of the leading role of the to allow contraception. state” (Streefland et al 1999). In 1995, an international pro‐life organization, supported by spread rumors via the internet that the tetanus toxoid The most publicized example of this is the Nigerian vaccine (TT) intentionally contained a contraceptive polio boycott example – which is unpacked in detail hormone so that women in Mexico and the Philippines were supposedly unknowingly receiving anti‐fertility below. However, it is worth noting that in the broader vaccinations under the guise of being inoculated against literature there is an increased attention being paid to tetanus. The rumors that TT vaccinations were being used ‘rumours’ which influence vaccine refusal. A common for family planning purposes were picked up and expanded in The Philippines, where local ‘pro‐lifers’ began to claim theme for anti‐vaccination ‘rumour’ emerges from that the Department of Health used TT vaccinations as anti‐Western sentiment. For example, the rumour that aborticants or even to sterilize women. They obtained a court order which forbade the Department to continue a particular vaccine has been infected with anti‐fertility giving the vaccination. Substantial claims were made in the medication or HIV/AIDS as an attempt to de‐populate press of conspiracy between the WHO and the MOH. Such Africa or non‐Western societies (see Antai 2009 and resistance was strongly supported by the Roman Catholic Church. The situation was resolved when (supported by below). Rumours of western plots have been the WHO) six independent laboratories in five countries significantly tied to HIV/AIDS as well as other ran tests on TT and determined that it did not contain the development response initiatives. Kaler (2009) points suspected substance. out the persistence of rumour such as sterility stories Several years later, the same rumor about TT re‐emerged in Tanzania, when a Catholic nun there who had read across African public health campaigns – extending about the Philippines incident raised concerns, leading to well beyond the particular issue of immunization. strong localized vaccination opposition – which was There is also an interesting religious dynamic, as anti‐ eventually resolved through dialogue. Western sentiment emerges in relation to some (Aylward 2012, Ramos‐Jimenez et al 1999, Streefland 2001, Tan 1995) rumours articulating the ‘West’ as Christian in 26

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character, and therefore distrusting development or health initiatives that originate in the West, based on the belief that, “Christian countries’ concern to export biomedicine to all parts of Africa is not as charitable gesture but as self‐ interested and dangerous” (Last 2005). Religious vaccine refusals linked to transnational movements: Perhaps not as clear as the political examples above, there are examples of how local religious vaccination refusals are linked to transnational sources. See, for example the Philippines example in the box insert (above), in which international pro‐lifer institutions influenced local Pilipino sentiments towards polio, which in turn had support from local religious leaders, got caught up in transnational public health politics with the WHO, and was then picked up later in Tanzania. Similar examples can be seen across the literature. We discuss transnational rumours in more detail below, but it is worth noting here that ‘rumours’ and those who promote them are fluid and cross regional boundaries. The WHO (2013) evaluation report on the Global Polio Eradication Initiative (GPEI) notes that “religious communities in particular extend beyond the local” which argues for a particular need to consider LFCs in relation to rumours and communication, and not too tightly bounded by geographic framing.

Religious leadership as trusted key influencers One of the most common observations across the literature is the role and potential of religious leadership in influencing individual behaviours or decision‐making. There are numerous examples in the literature where the explanation for polio campaign failure is ascribed to ‘Muslim clerics’ who influenced community belief and resulted in rejection and resistance to the immunization campaign. These statements usually demonstrate a complex weaving of religious, cultural and political beliefs. For example, the statement that ‘religious leaders supported the belief that a particular vaccine was a US plot to depopulate Muslim lands by causing sterility and spreading AIDS’ – depict a messy weaving of influencing factors. As demonstrated above, religious leaders are also influenced by the social and political contexts in which they are based – so the fact that they are religious leaders does not necessarily mean that religious considerations are their primary influence. In addition, in the literature, several studies name ‘Muslim community leaders’ – yet it is nearly impossible to unpack whether their primary function is religious leadership (for example, a priest or cleric), or whether they were some other kind of community leader, who happens to be a Muslim. We will unpack the issue of religious leaders as influencers in relation to immunization interventions in more detail in the chapter that follows – however, it is important to note here that religious leaders are often described as a main source of vaccine resistance in the current literature, and that is based on an assumption of their influence in the communities in which they are based. It is perhaps necessary to point out that clearly not all resistance to vaccines is driven by Muslim clerics. Because the bulk of the literature on rejection of immunization by religious leaders and communities is focused on Islamic countries, and Nigeria in particular, care needs to be taken that this does not dominate analysis or response (said differently, lest we begin to believe that religion is only relevant in relation to vaccine rejection among Muslim clerics in northern Nigeria). Rejection of vaccines is not always religious, nor is it limited to Islamic communities. And of course, as we will see in the next chapter, many Islamic scholars and leaders have utilized their influence to promote vaccines (the most obvious example being the compulsory vaccination of travellers to the Hajj in Mecca, see below).

‘Religious’ vaccine refusals in the context of ongoing local and social conflict Streefland (1999) looks at vaccine non‐acceptance in Bangladesh, Ethiopia, India, Malawi, the Netherlands and the Philippines – and argues that context affects acceptance of vaccinations, and that collective resistance to 27

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 vaccination must be understood “in the specific context of ongoing social conflicts.” The bulk of the literature which relates to this focuses on the Nigerian polio boycott20 – where what has been widely reported as a refusal driven by extremist Muslim clerics in fact seems to demonstrate persistent socio‐political concerns.

Box 8: The Case of the Nigerian Polio Boycott The story so far: There are a mass of news accounts and commentaries on the Nigerian polio immunization boycott of 2003‐2004. We amalgamate the available published accounts and relate the following story: In the middle of 2003, the UN‐backed campaign to kick polio out of Africa was gathering pace. At a global level, the Global Polio Eradication Initiative (GPEI) had spent more than US$3 billion and involved some 20 million volunteers over a period of 16 years, and it was widely felt that polio eradication was in sight. Nigeria was targeted to be free of polio by the end of 2004. Then, seemingly out the blue (although in hindsight there were several warning signs), some Muslim clerics or Islamic community leaders from the North of Nigeria argued that OPV vaccines needed to be checked for safety – claiming they rendered children sterile, might be cancer‐causing, or contaminated with HIV/AIDS. Obadare (2005) notes that the Supreme Council for Islamic Affairs (SCIA), who is the putative umbrella body for Nigerian Muslims, claimed to have learned from the internet “that the oral polio vaccine championed by the WHO and UNICEF had been deliberately contaminated with carcinogenic, anti‐fertility and AIDS‐inducing agents” (Obadare 2005). SCIA and others such as the Supreme Council for Sharia in Nigeria (SCSN) immediately embarked on a campaign to stop immunization in the north of Nigeria, which is predominantly Muslim, pending an official investigation and assurance that the vaccines were free of the alleged contaminants. Datti Ahmed, a doctor and president of Nigeria’s SCIA stated, “There were strong reasons to believe that the polio immunization vaccines was contaminated with anti‐fertility drugs, contaminated with certain viruses that cause HIV/AIDS, contaminated with Simian virus that are likely to cause cancer” (in Chen 2004). All this led to widespread boycotting of OPV in many of the Islamic majority northern states of Nigeria, with the cessation of OPV vaccination lasting a full year in the state of Kano which was at the center of the boycott (with the Kano governor endorsing the cessation until July 2004). Further rumors circulated in the region: for example, that the contamination was a US plot to limit Nigeria’s population by spreading AIDS and increasing infertility in the populous Nigerian region. Extensive effort was put into lifting the boycott, which included immediate pressure from the WHO, UNICEF, international agencies and other African countries. The SCSN and the Nigerian state reached a compromise by agreeing to procure vaccines only from an Indonesian company (with Indonesia trusted as a Muslim country) ‐ and vaccines were duly tested for the presence of contraceptives and other toxins in trusted laboratories in Muslim nations. Tests were carried out at the National Hospital Abuja and the Ahmadu Bello University Teaching Hospital, witnessed by state health officials, representatives of the WHO and religious leaders. Obadare (2005) reports that a committee set up by the federal government released results declaring the vaccine safe, but that this report did little assuage concerns. Obadare says the situation did not change until another committee, this time set up by the Jama’atul Nasril Islam (JNI) under the leadership of the Sultan of Sokoto, the spiritual leader of Nigerian Muslims declared the vaccine safe. However, by then, the boycott had left large populations of unvaccinated zero‐dose children in Nigeria, in whom poliomyelitis rapidly reestablished itself. Numbers of children paralyzed with poliovirus went from 56 in 2001 to 355 in 2003, and by the end of 2004, Nigeria accounted for 70% of global cases of polio (Agbeyegbe 2007). This was followed by virus exportation and re‐infection of many previously polio‐free countries across Africa and the Middle East – up to 20 countries, including Ethiopia, Sudan, Yemen, and Indonesia (Indonesia, for example, had seen their last case in 1995, Clements et al 2006). As Kaufmann and Feldbaum (2009) note, “The suspension in Northern Nigeria, particularly in Kano State, led to a global outbreak of polio; the disease spread into countries across Africa, the Middle East, and Southeast Asia and caused 80 percent of the world’s cases of paralytic poliomyelitis during the stoppage. The vaccine boycott eventually led to costs of more than US$500 million to control the polio outbreak, and it essentially ended hopes of eradicating polio in this decade.” This in turn turned into a substantial international controversy. As Obadare (2005) says, “the controversy over the safety of the vaccines snowballed into a heated political drama, with northern political and religious leaders and federal government and WHO spokespersons passionately trading accusations.” In the aftermath, Nigeria and religious leadership in Nigeria came under intense international scrutiny. In the decade since, there has been intensive engagement at national and local levels – including education campaigns, national and subnational immunization days, and the increased involvement of political and religious leaders, which Giwa et al (2012) argue has led to a decline in the number of polio cases since 2006. There was another unfortunate incident when polio vaccination was hampered again in 2007 when the vaccine was found to have induced polio in 69 children (see Kaler 2009). However, extensive social mobilization has continued, seeking to restore community confidence in OPV and immunization more generally. Unless otherwise referenced, this section is drawn from the following sources: Antai 2009, Aylward & Tangerman 2011, Babalola & Aina 2004, Chen 2004, Clements et al 2006, Giwa et al 2012, Jegede 2007, Kaler 2009, Kaufmann and Feldbaum 2009, Murphy 2012, Obadare 2005, Oluwadare 2009, Ozohu‐Suleiman 2009, Renne 2006 2009 2010 2012, Tomori 2011, UNICEF 2003, Yahya 2006

20 So much has been written about the Nigeria polio ‘incident’ that easily a third of all the literature on religion and immunization is about Nigeria and polio in the twenty‐first century. 28

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The Nigeria polio boycott: explanations and discussion Before the boycott there was only limited publication of the intersection between religion and immunization in Nigeria. Oluwadare (2009) also points out that while in Nigeria “…the greatest challenge to the acceptance of immunization is religiously entrenched, especially among the Northern Nigeria Muslims” ‐ at the national level the 2003 Nigeria Development and Health Survey did not have religion as a factor for analysis. As a result of this boycott, religion became significantly more visible in academic literature, policy and the media. Religious factors were also discussed for the first time in serious academic publications such as the Lancet and the British Medical Journal (see Kapp 2003, Rafu 2004). However, in the public media, ‘religion’ and Muslim leaders in particular initially took most of the blame for this extensive outbreak which came as such a shock to international polio campaigns and targets. However, more recently, there has been an increase in explanations that extend beyond ‘religion’, which mirror the thematic areas described in this chapter so far. Renne (2006) notes that, “the difficulties in eradicating polio in Nigeria have been widely reported in the Nigerian and Western press. While the Western media has, with some exceptions, tended to attribute resistance to the polio campaign in Nigeria to Muslim leaders, recent analyses of the polio campaign in Northern Nigeria have discussed the problems of this intervention in a broader sociocultural and political context.” However, in the same way as the above, recent studies struggle to unpack religion from other determinants or influencing factors such as socio‐economic determinants, cultural or political factors. Several authors have pointed to the interconnection of other explanatory factors for the Nigerian immunization boycott – noting that religion was not the only driving force behind the boycott – so too were issues such as (sometimes religiously fuelled) poor education and poverty (see Antai 2009, Antai et al 2009, Bababola 2011, Oluwadare 2009. At the same time, arguing that there are other underlying factors does not negate the importance of looking at religion. For example, in the Antai (2009) study the analysis indicates that religion (in particular Islam) plays a role in the risk of non‐immunization, “indicating that there is a significant relationship between Islam and the risk of non‐ immunization, that cannot be explained away by socioeconomic and women’s empowerment indicators.” Several authors point out that in this particular case, rumors were also underpinned by local politico‐religious tensions. As Renne (2006) says, the questioning of the polio eradication initiative “…was compounded by north– south political dynamics associated with ethnicity and religion within Nigeria itself. Northern Nigerians’ sense that their interests were being ignored by President Olusegun Obasanjo (who is Yoruba, Christian, and from Southwestern Nigeria) contributed to their belief that Northern Hausa‐Fulani politicians and Muslim religious leaders who criticized Western medicine were genuinely trying to protect them” (see Obadare 2005). Indeed, local politics were unavoidable, as Kaler (2009) points out that “the agency leading the protests was the Supreme Council for Sharia in Nigeria, an organization which had also fought for political autonomy from the Christian‐ dominated south, and against the implementation of legal codes based on secular rather than religious principles.” A source in the Nigerian polio program said, “This was one of the clearest examples of a public health issue being hijacked for political reasons” (in Kaufman & Feldbaum 2009). Several studies reflect that the boycott was fuelled by general resentment of the South and its political dominance of the country, and a general lack of government ‘control’ over its population. Jegede (2007) points out that the rumor about contraceptives being placed in the polio vaccine was as a result of lack of public trust in the government, and tied to prior population control attempts in the 1980s, when President Babangida’s administration adopted a population policy that set a limit of four children per woman. As Jegede (2007) says, “some people connected this population control campaign with immunization, believing that vaccination was one way the government might be reducing the population.”

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Clements et al (2006) remind us that without considering this historical context, the behavior of Nigerian Muslim clerics and those who followed this might seem extreme and ‘backwards’. They point out that during the Spanish Flu pandemic of 1918: “The Muslim population generally ignored what British colonial medical assistance there was during the epidemic. In the north, they attempted different treatments…While Europeans inhaled eucalyptus vapors, Muslims drank water that contained slips of paper inscribed with prayers and extracts from the Koran. The Muslim population of the Northern states also did not go to the colonial hospitals in as large numbers as other ethnic groups. The Muslim villagers mainly kept to their houses and did not interact with British medical officers as they passed through their districts…British sanitary officers noted the increasing levels of tension and unrest they experienced...The influenza epidemic in Nigeria …highlighted the tensions already present between Nigerians and the British colonial regime…” Clements et al (2006). Renne (2012) reminds us that lameness associated with polio has been known in Nigeria for a long time, but that during the colonial period immunization efforts focused mainly on expatriates, indicating a health system not oriented towards these communities in the north. Indeed, Jegede (2007) is convinced that another key factor that drove the boycott was “general distrust of aggressive, mass immunization programs in a country where access to basic health care is not easily available” (see Ch 4 for more). Chen (2004) says the troubled historical relationship between Africa and the West “has created a lasting resentment of the Western world and may call into question the underlying motives of Western actions on the continent. Humanitarian agencies may be seen as the vehicles through which Western countries seek to impose their policies on non‐Western countries resulting in increased level of distrust of these organizations.” Indeed, rumors of Western plots to sterilize populations in development contexts were not new to Nigeria in 2003 – similar rumors linked to HIV/AIDS and antiretroviral therapy (ART) have been observed for decades. As described above, in Muslim‐majority Northern Nigeria, such rumors gain a further impetus as global health interventions are sometimes perceived as Western‐Christian plots against a Muslim world (see Ozohu‐Suleiman 2009). Chen (2004) argues that “the lack of trust of the humanitarian agencies, directly reflecting a distrust of the Western countries, by the Nigerian communities was a major factor in the extent to which the rebellion gained momentum…The fact that the claims of the leaders had such a sweeping effect across the country illustrates that trust of humanitarian agencies was low to begin with.” Jegede (2007) notes that anti‐Western sentiment was particularly acute at the time of the boycott, as a result of the aftermath of the September 11th, 2001, attacks on the United States and the resultant ripples of military action in the Middle East. In addition, many Northern Nigerians remembered the trial antibiotic, trovafloxacin (distributed in Kano) which Achebe (2004) argues reinforced a distrust of Western pharmaceutical companies and Western biomedicine. Renne (2006) says this in turn led to some Northern Nigerians questioning the government’s advocacy of the polio eradication initiative (Renne 2006, see Obadare 2005, Olusanya 2004). The Nigerian case also demonstrates the global dynamics inherent in immunization campaigns. For example, Obadare (2005) says that the “disagreement over the safety of the oral polio vaccine pitted ordinary citizens and community leaders in the predominantly Muslim north of Nigeria against the World Health Organization, the United Nations Children's Fund and Nigeria's federal authorities.” Yahya (2006) quotes as Nigerian doctor saying, ‘‘we all know that the WHO is just an extension of the US government; we also know that the US feel they can control the rest of the world. At least the Sharia states [such as Kano] are telling the Americans they can’t just do what they like.” The tensions between the local and global were intensified when polio spread into neighboring countries and beyond. Nigerian political leaders were placed in a hugely uncomfortable position of having to apologize to an angry international community, many of whom had thought that the fight against polio was almost over. As Cheng

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(2006) notes, “The rest of Africa is growing very impatient with Nigeria, which now bears the bulk, 91%, of the continent’s poliomyelitis cases…Not only is Nigeria struggling to contain its poliomyelitis outbreak, it is now exporting the virus across its porous borders.” Raufu (2004) published an article in the BMJ which noted that “Nigeria has apologized for exporting wild polio virus to its six West African neighbors, Togo, Niger, Benin, Chad, Cameroon, and Burkina Faso. Nigeria’s health minister, Professor Eyitayo Lambo, blamed the spread of the virus on the controversy over the efficacy of polio vaccines…saying ‘I formally tender my apology on behalf of the Nigerian government for this development and at the same time pledge to work harder to make polio a history by the end of this year.” Jegede (2007) also points out that many Islamic leaders were equally embarrassed and uncomfortable by the actions of the Northern religious leaders, for example, Sheikh Qaradawi is said to have blamed the SCSN for creating a negative image of Islam: “They distort the image of Islam and make it appear as if it contradicts science and medical progress” (in Jegede 2007). Either way, a key theme that is demonstrated in this case example is the power of local religious leaders as key influencers in relation to immunization. Antai (2009) argues that religious leaders play a significant role in forming societal norms and individual attitudes and behaviors in Nigeria – and while there is a wave of Pentecostalism associated with promises of miracles in the south of the country, the north is experiencing a rise in Islamic Sharia law advocacy, which suggests an even greater influence by religious leaders. Another key theme in the literature on the Nigerian polio boycott is ‘trust’. Jegede (2007) does an extensive study of ‘public trust’ in relation to the Nigerian polio boycott. He argues that public trust plays an essential role in promoting compliance with vaccination programs, which target mainly healthy people “Where public trust is eroded, rumors can spread and this can lead to rejection of health interventions” (Jegede 2007). Trust appears in relation to several different issues, such as trust of vaccines, trust of key influencers, trust of religion and religious leaders, trust of ‘Western’ global health interventions, or trust within and between countries (the trusting of the Muslim Indonesian pharmaceutical supplier being a particularly interesting point). Obdare (2005) describes the entire polio boycott as a ‘crisis of trust’. In the aftermath, the key conclusions seem to be that ‘religion’ was a main vehicle for the boycott, but not its only explanatory factor; that in hindsight this could have been anticipated; that very local issues can become massively global problems; that local religious leaders are significant influencers in relation to vaccine refusal and are also powerful potential advocates for immunization acceptance. Little surprise then that scholars, policy makers and global health actors quickly began to demand renewed investigation of the relationship between religion and immunization – and that the ‘involvement’ of religious leaders and local faith communities would seem to be an important factor in such contexts.

Leading into the chapters that follow In this chapter we set out to review literature that addresses religious beliefs and affiliations that impact on behaviours that relate to immunization refusal or acceptance. The Nigerian case described above demonstrates the complexity involved in the interaction of ‘religion’ interacts with immunization. It also has a large part of this story still missing. Firstly, the aftermath of the Nigerian boycott is almost more interesting than the initial incident. The interventions at local, national and international levels all took the question of religion on‐board in a serious manner, and resulted in a series of religiously‐sensitive interventions. In addition, several commentators on the Nigerian boycott note that another key factor underlying the response is one of health systems strengthening – and in particular the lack of access to basic health care (which increased resentment on the targeted polio campaign). We will move on to such considerations in Chapter 4. In Table 1 below, we outline the key studies with primary content that contain elements relating to religion as a determinant of immunization uptake or refusal (this draws from but does not entirely represent an ongoing systematic review of these issues).

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Table 1: Sample of studies with elements relating to religion as a determinant of immunization Author‐year Focus, Religion, Region Method Finding relating to Religion & Immunization 1988 Immunization uptake of Cross‐sectional study ‐ Asian children were identified by a names analysis and categorized as Muslim, Hindu or Sikh. Sikhs had the highest Bhopal & Glasgow Asian children [UK] matched controls using a immunization rates for DPT, measles and polio. Muslims and Hindus had higher uptake of pertussis vaccination Samin retrospective cohort study but were on a par with their controls for other immunization. 1994 Immunization uptake and Questionnaire‐based For all immunizations, uptake in the orthodox Jewish community is not significantly different from that of the Cuninghame parental perceptions in enquiry to parents of (100) district. Responding parents had positive attitudes to the value and safety of immunizations but wished better et al orthodox Jewish community orthodox Jewish children – access to services. Health professionals need to question their perceptions so that efforts to improve uptake [UK] from random sample of 575 amongst ethnic minority groups are based on facts and are responsive to identified needs. 1996 Pulse polio immunization in Coverage evaluation survey Coverage levels for male and female children were similar. Parental literacy was seen as a definite factor, positively Singh et al Delhi, India of PPI using modified cluster affecting the coverage levels. Television and health workers were found to be the main sources of awareness sampling and pre‐structured about PPI. The percentage of ‘non‐acceptors’ was significantly higher in Muslims in the studied sample as proforma (609 children) compared to the Hindus. This difference is statistically significant. 1999 Analysis of beliefs about Qualitative ethnonursing The findings revealed significant care themes for Lebanese Muslim informants based on their cultural values, Brooke & childhood immunization study – using observation‐ beliefs, and practices related to health and immunization. Omeri among Lebanese Muslim participation‐reflection, and immigrants in, Australia in‐depth interviews 2003 Impact of the national polio Before‐and‐after study Female and Muslim children are significantly less likely to be immunized than male and Hindu children are. Bonu et al immunization campaigns on design using representative Significant disparities in immunization coverage also seen by caste. Compared to Hindu children, Muslim children levels and equity in samples from rural areas. had a significantly lower likelihood of being immunized for all four immunization indicators. The polio campaign immunization coverage in Pooled data from the was successful in reducing gender‐, caste‐ and wealth‐based inequities, but had no impact on religion‐ or four North Indian states National Family Health residence‐based inequities. Persistent inequities in coverage by caste and religion may impede PPI from achieving Surveys I&II as pre‐ and its ultimate goal as lower castes and Muslims tend to live in clusters in rural India. post‐intervention data 2003 Attitudes and beliefs Qualitative study from Although some women welcomed the introduction of HPV testing, they were not fully aware of the sexually McCaffery et towards HPV testing among purposively selected sample transmitted nature of cervical cancer. For Indian and Pakistani women, testing was perceived to reflect al women in four ethnic groups of women from four ethnic nontraditional cultural or religious practices concerning sex and monogamy. Muslim beliefs were described by in the UK groups (white British, some of the Pakistani women as potentially prohibitive of screening, with Shari’a law identified as particularly African Caribbean, Pakistani restrictive. Others felt that Islamic beliefs would support HPV screening as good for women’s health, and hence and Indian) ‐ using focus family health. Among the white British women, taboos surrounding sex within Catholic families were raised as group discussion potentially restrictive to women participating in HPV testing. 2004 The likelihood of Indian Econometric analysis of data Girls are 5% less likely than boys to be fully vaccinated, and their likelihood to receive a nutritious diet depended Borooah children being immunized for a sample of over 4000 on whether or not their mothers were literate. The likelihood of Hindu children being fully vaccinated was 20% against disease and children (1‐2 age). higher than that for Muslim children. Dalit and Muslim parents have, relative to Hindus, a lower propensity to fully receiving a nutritious diet immunize their children, and also embed a gender bias into this. 2004 Immunization of children WHO30‐cluster survey of The proportion of fully immunized children and mothers was lower among illiterate mothers and those living in Yadav & and mothers in North‐ 1400 children (1‐2 yrs) and inaccessible villages. Religion played a role in availing of health care services maybe due to the way other Singh Eastern Indian states mothers from a district in characteristics are influenced by religion. 64.6% of Hindu to 39.7% of Muslim children were fully immunized. each NE state 2006 Parental attitudes towards Population‐based survey. Results suggest that in socially and ethnically mixed populations an HPV vaccine uptake rate of 80% may be Brabin et al future acceptance of Random sample of parents achievable if the vaccine is perceived to be safe and effective. However, most parents lack knowledge about HPV

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Author‐year Focus, Religion, Region Method Finding relating to Religion & Immunization adolescent HPV vaccination of 11–12yr old pupils (from and some are concerned about sexual health issues that would arise. Although not reaching statistical significance, in Manchester [UK] sample of 1300 ‐1900) of 8 the data suggests a lower potential uptake among some ethnic and religious minority groups. Moral risks secondary schools (including associated with vaccination may be perceived to outweigh its benefits. These issues need further exploration voluntary schools linked to because cultural and religious beliefs that influence family structure, sexual behavior and parental control are not Catholic / Anglican bodies) best characterized by race/ethnicity. 2006 Immunization status of Observational study in 10 A lower immunization rate was found in Muslim families (65.4%) compared with Hindu (85.2%). A comparison Elliott & children under 7 years in villages around Herbertpur revealed a higher rate for all three vaccinations in the Hindu population. Parental literacy had a beneficial effect. Farmer Vikas Nagar area [North Christian Hospital ‐ 470 The direct relationship between religion and literacy was examined, and showed a significantly higher literacy level India], to assess vaccination families visited and details of in the Hindus (51.9%) of this study population than the Muslims (17.9%). These results suggest a link between rates and potential socio‐ immunization status of the literacy and religion. There was little difference between male and female vaccination rates. Results showed that cultural, economic and oldest child under 7 years in social, cultural and religious factors had an important effect on immunization, in particular religion. Methods to religious influences on each household taken improve vaccination uptake would be best focused upon general education and literacy including healthcare vaccine uptake issues. Targeting specific populations, in particular illiterate and Muslim families would be of most value. 2007 Determinants of WHO 30‐cluster sampling.. 44% of the children studied were fully immunized. An illiterate mother, Muslim religion, scheduled caste or tribes Nath et al immunization coverage Mother, father or relative of and higher birth order were significant independent predictors of the partial immunized status of the child; Those among 12–23 months old 510 children with 17 associated with the unimmunized status of the child were low socioeconomic status, Muslim religion, higher birth children in urban slums of children per cluster were order, home delivery and belonging to a joint family. Children belonging to Muslim families are less likely to get Lucknow [India] interviewed fully immunized compared with children from Hindu or other religions. 2007 Status and performance in Cross‐sectional study ‐ data A large number of children who have contact with services providers are missed out of subsequent services. Sharma 1980‐2004 of the child sources are secondary data Among other indicators, Hindu children are much more likely (47%) than Muslim children (36%) to have received immunization program in from the National Family each of the recommended vaccinations. A significantly higher proportion of Hindus (75%) retained their India ‐ immunization Health Surveys and RCH vaccination card compared to Muslims (32%). Recommendation to revitalize and strengthen routine immunization coverage in Uttar Pradesh Surveys services with particular reference to urban areas, Muslims, illiterate parents, populations residing in the plains, and and Uttarakhand [India] population groups or areas hitherto not reached. 2008 Knowledge and practices Household survey from Muslims and girls tend to have lower immunization coverage compared to their corresponding counterparts. Key Subedi related to immunization three central Terai districts demand side barriers to full immunization coverage are lack of knowledge and misconception about immunization, schedule and demand side of Nepal – sample from 450 lack of access to services such as service centers, heavy household work and carelessness including culture/family barriers associated with low married women with at least barriers. The study concludes that full immunization coverage is still beyond in case of DPT1 and measles – and this immunization coverage in one child aged 12‐23 months holds especially for Muslims and girl children. Cultural barriers such as no permission from family to visit the health Terai [Nepal] from 30 clusters facility to the young mothers, caste and gender discrimination warrant more complex interventions. 2009 The role of religion in Cross‐sectional survey Religion was not associated with the risk of partial immunization ‐ however, religion was significantly associated Antai childhood immunization in analysis – using data from with the reduced risk of full immunization. For non‐immunization, analysis showed that children of Muslim and Nigeria DHS 2003 data, with logistic Traditionalist mothers had a 3 times higher risk of not being immunized than children of Christian mothers. regression analysis Controlling for demographic variables reduces the risk to 2 times for children of Muslim mothers, and on controlling for socioeconomic and women’s empowerment indicators the risk was reduced to about 42% indicating that there is a significant relationship between Islam and the risk of non‐immunization, that cannot be explained away by socioeconomic and women’s empowerment indicators. 2009 Examines why Muslim Analysis of data controlling Muslim children in India face substantially lower mortality risks than Hindu children. This is surprising because Bhalotra et children in India face for covariates and mother Muslims have lower socio‐economic status, higher fertility, shorter birth‐spacing, and are a minority group in India al substantially lower mortality and village level unobserved that may be expected to live in areas that have poor public provision. Muslim women have better short term risks than Hindu children – heterogeneity health as measured by BMI – which may be due to religious rules. Hindus may be less careful about their despite expectations [Uttar daughter’s health than Muslims, and Hindu boys are more likely to die than Muslim boys. The analysis confirms the existence of differences in education, and fertility characteristics that are unfavorable to the survival of Muslim 33

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Author‐year Focus, Religion, Region Method Finding relating to Religion & Immunization Pradesh, India] compared to Hindu children. Hindu women appear to have better antenatal care and child immunization rates. 2009 Ethnic differences in HPV A cross‐sectional study ‐ Awareness of HPV was lower among ethnic minority women than among white women. In a subsample of Marlow et al awareness and vaccine participants recruited using mothers, ethnicity and religion were strongly associated with acceptability of HPV vaccination. Those from non‐ acceptability in the UK quota sampling of ethnic Christian religions were less accepting of the vaccine (17–34%). Fewer Muslim (10%) and more Christian women minorities (Indian, Pakistani, (27%) were aware of HPV than women with no religion (18%). Religion was associated with acceptability, with Bangladeshi, Caribbean, fewer acceptors among Hindus (34%) and Muslims (18%) compared with those with no religion (64%). In African and Chinese women multivariate analyses, which included SEC, only ethnicity and religion remained significant. ‘Religious reasons’ were n=750) with comparison one of the main reasons cited for declining the vaccine. The importance of religion appears to come from a strong sample of white British belief in sexual abstinence until marriage, and this is a barrier that will be a challenge to overcome. Liaising with women (n=200) religious groups about the best ways to communicate HPV information may help acceptance 2009 Immunization coverage and Sero‐survey among (2419) Immunity to diphtheria and tetanus was significantly lower among Muslim and female children. Compared with Murhekar et immunity to diphtheria and children in randomly others, Muslims had a coverage that did not differ for primary vaccination. However, the coverage among Muslims al tetanus among children in selected schools. Tested sera was significantly lower for the fourth and fifth dose. Coverage of booster doses as well as the immunity against Hyderabad [India] for antibodies against these diseases was significantly lower among Muslims. This lower booster coverage among Muslim children could diphtheria and tetanus. either be related to a poor offer of vaccine by the health services or to a poor demand of vaccine in the Information collected on community. There is a need to improve the coverage for boosters especially among Muslims and females. The religion and reasons awareness of mothers about the importance of booster doses must be improved. 2009 Association between Questionnaire‐based survey Vodou and Catholicism were associated with 54% and 39% decrease in the odds of being fully vaccinated. The use Muula et al maternal use of traditional to 691 mothers (from 720 of traditional healers was negatively associated with vaccination. For those children whose mothers often or healer services and child stratified sample) ‐ bivariate always used the services of traditional healers, a 53% decrease in the odds of vaccination (vs children whose vaccination coverage in and multivariate logistic mothers never used traditional healers). There were negative associations between practice of Vodou and Ponte‐Sonde [Haiti] regression vaccination and distance from the nearest health care service facility. Findings underscore the potential to enlist the support of traditional healers in supporting vaccination efforts. 2009 The social determinants of Qualitative study of key Key local influencers included: Religious leaders (Muslim and Christian); Local political leaders; Women leaders; Oluwadare routine immunization in Ekiti ‘influencers’ relating to up‐ Patent medicine hawker/provider; Faith‐ based maternity center staff (Anglican, Christ Apostolic Church and State [Nigeria] take of immunization. Key Catholic faithfuls); Director PHC‐MOH; the WHO representative; and traditional leaders. Some communities of informant interviews, focus Muslim settlers from north central Nigeria had little or no knowledge of immunization. The main source of group discussions and information is the health clinic in all the local government areas. Health authorities work through town criers, secondary data of state and churches and mosques to get information to the people. There are no specific cultural, social or religious barriers national surveys to routine immunization – with the main barriers from the supply‐side. 2009 Assessment of factors Cross‐sectional study (41 After controlling for both locality (rural/urban), and economic status, in rural areas in the poorer three quartiles, Sanou et al associated with complete rural communities, 1semi‐ children from Muslim families had lower immunization coverage rates (48.86%) compared to others (51.2%). immunization coverage in urban). Data on 476 children Children of polygamous fathers were more likely to have an incomplete vaccination status in rural areas. Marital children aged 12‐23 months aged 12‐23 months (from status and religion were not significantly related to lower immunization coverage rate in the urban area. Good in Nounda [Burkina Faso] sample of 489), drawn from communication about immunization and the importance of availability of immunization booklets, as well as the Nouna Demographic economic and religious factors appear to positively affect children’s immunization status. Comprehensive Surveillance System (DSS) communication may improve understanding about immunization, but it is necessary that local interventions also database take into account religious specificities and critical economic periods. 2009 Physicians’ experiences with Mailed questionnaire to Malaysia is a moderate Islamic country with the majority of Muslim Malays and other ethnicities living together. Wong HPV vaccine delivery in physicians Issues dealing with sex and STIs are seen as taboo and sensitive. The Muslim Malay physicians showed a multiethnic population of heightened sensitivity to recommendation of an STI vaccine. Strong religious beliefs and stringent cultural norms Malaysia among the Muslim Malays may play an important role.

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Author‐year Focus, Religion, Region Method Finding relating to Religion & Immunization 2010 Immunization status of Parents of 325 Immunization status varied significantly with sex, education of parents, urban/rural background, route and place of Kumar et al children admitted to a consecutively‐admitted delivery. On logistic regression, place of delivery, maternal education, and religion were significant. When the pediatric ward of a tertiary‐ children aged 12‐60 months characteristics of the group with complete immunization were compared with the combined non‐immunized or care hospital in Delhi [North interviewed using a semi‐ partially‐immunized group, significant effect seen on education of fathers and mothers, place of delivery, and India] structured questionnaire. religion. A low coverage of complete immunization among Muslim patients was observed. 2011 Maternal reasons for non‐ A 2007 questionnaire Reasons for non‐immunization have to do with ideational and normative factors. In contrast, supply‐side factors Bababola Immunization and partial survey. with open‐ended are the reasons most often advanced for partial immunization. About one‐tenth of the women gave reasons immunization in Northern questions. Statistical analysis related to maternal availability, including sickness, travel and time constraints. A few women mentioned that they Nigeria of the differences in reasons normally stayed inside the family compound for cultural/religious reasons. Increasing knowledge about for non‐immunization and immunization, changing negative attitudes about immunization, debunking myths and rumors about partial immunization. immunization, and addressing religious, ethnic and political bases for resistance to immunization are necessary to encourage parents to initiate child immunization. 2011 Acceptance or declining HPV Qualitative interviews with Although mothers thought HPV vaccination was a good idea, many did not perceive it as necessary for their Gordon et al vaccination among mothers (20) mothers of girls offered daughter, citing Jewish religious laws governing family purity and abstinence until marriage as reasons for in the British Jewish HPV vaccination purposively daughter’s low susceptibility. Mothers who accepted the vaccine generally did so to protect their daughters health community [UK] sampled through Jewish and because they felt unable to predict their daughters future behavior. Many mothers expressed a wish to wait secondary schools until their daughter was older and the vaccine more established. Attitudes to HPV vaccine in religious communities may lead to reduced vaccine coverage. The development of community‐specific information about the importance of the vaccine may help address concerns. 2011 Attitude of Israeli mothers Questionnaires distributed Behavioral beliefs, normative beliefs, and level of knowledge had a significant positive effect on mothers' intention Natan et al towards vaccination of their among convenience sample to vaccinate their daughters. High levels of religiosity were found to negatively affect mothers' intention to daughters against HPV of 103 mothers of daughters vaccinate their daughters. The TRA combined with level of knowledge and level of religiosity succeeds in predicting [Israel] 18 years and younger. mothers' behavioral intentions regarding vaccinating daughters. 2011a Report on internal UNICEF [Method not provided] Nigeria: The main reasons for non‐compliance are ‘no reason’ (23%), ‘no felt need’ (23%), and ‘too many rounds’ UNICEF data relating to polio (12%). When combined with ‘no caregiver consent’ (13%), it accounts for another quarter. ‘Religious’ (9%) and communications – including ‘political’ (5%) reasons for refusals appear less significant. 60% of missed children are reported to be due to ‘child statistics on ‘reasons for absent’, of which a proportion may be a reflection of covert refusal. Refusals are largely based on safety concerns refusal’ from various about OPV, combined with anti‐Western sentiments and religious beliefs. countries and districts [DRC DRC: Refusals in DRC are high at a national average of 16% (and up to 29% in Kinshasa). Religious beliefs frequently & Nigeria] contribute to refusal, but politically fuelled rumors have been on the rise and can lead to dramatic spikes in refusals. Religious beliefs are often cited as a reason for refusal. On the surface, concerns seem to be about fears of multiple doses weakening children, OPV causing sterilization, or a general belief that only God‐not‐vaccine can protect children from disease. Deeper analysis is required to understand the true reasons behind refusals. While religious beliefs undoubtedly play a prominent role in some refusals, rumors are sometimes fuelled by religious leaders who have other motives for discrediting the vaccine. 2011b Report on internal UNICEF ‘Rapid analysis’ of DRC: Most refusals (27%) are from parents who don’t trust the vaccine, 25% percent cited religious beliefs (usually UNICEF data relating to polio independent monitoring stating a belief that only God can protect their children). A further 21% said they refused vaccination because the communications – including data from 20 high risk main decision‐maker was not at home during the visit; and 9% said that their child was sick and could not take the statistics on ‘reasons for Health Zones with highest vaccine. Such reasons vary significantly by province. e.g. In the northern part of Katanga, where 31% of all missed refusal’ from various numbers of refusals children are due to refusals, 44% are due to religious beliefs. These differences highlight the importance of countries and districts [DRC] collecting and analyzing social data at local levels to ensure that communication, engagement, and operational strategies are tailored to the specific needs of particular communities.

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Author‐year Focus, Religion, Region Method Finding relating to Religion & Immunization 2012 Immunization and informed Qualitative study of parents Qualitative responses reflected concerns associated with side effects and the halal nature of vaccines. By taking Bray & decision‐making amongst and staff at an Islamic the time to communicate material risks to Muslim parents, health professionals ensure confident, informed Keating Islamic primary school primary school, recruited decision‐making and consent. parents and staff in Australia through survey forms 2012 Risk factors of Study of 430 children from The factors that were significantly associated with vaccines underutilization in Bnei Brak were having >6 siblings, Muhsen et al underutilization of childhood ultraorthodox Jewish maternal academic education, parental religious beliefs against vaccination, perceived risk of vaccine preventable immunizations in communities in the Bnei diseases as low, and mistrust in the Ministry of Health. Similarly, in Jerusalem, religious beliefs against vaccination, ultraorthodox Jewish Brak city and Jerusalem and the perceived low risk of vaccine preventable diseases significantly increased the likelihood of under‐ communities despite high district – analysis of medical immunization. The risk factors of under‐immunization are in part modifiable, by means of health education on the access to health care records and parental risks of vaccine preventable diseases and by improving the trust in the MOH. The leaders of the ultraorthodox services [Israel] interviews communities could play an important role in such interventions. 2012 Beliefs, knowledge and Questionnaires distributed The result shows that although, many parents have knowledge about the efficacy of vaccination for their children, Ojikutu perception of parents to to a sample of 1000 parents culture overrides such knowledge in some cases. Gender of parents does not significantly affect their belief about pediatric vaccination in and a general literature immunization or their willingness to present children for routine immunization. Marital status, education and Lagos State [Nigeria] review on immunization religion significantly influence such belief. Culture and beliefs of the Yoruba in Lagos State is too complex to be coverage in Nigeria ignored in any public health plan. 2012 HPV vaccine acceptability Qualitative study prior to a Most respondents had no knowledge of cervical cancer or HPV vaccines – and the majority stated that they would Remes et al among health workers, cluster‐randomized phase IV support HPV vaccination of their daughter. Religious leaders interviewed knew about cancer in general but nothing teachers, parents, female trial of HPV vaccination of cervical cancer, HPV, or the HPV vaccine. The five male teachers who opposed vaccination also commented that pupils, and religious leaders delivery strategies. Semi‐ the vaccine might give girls a license to start sexual activity. A few religious representatives also echoed this in Northwest Tanzania structured interviews (31) concern but most found the vaccine a ‘good thing’ because it would protect adolescent girls. Some religious and group discussions (12) representatives asked what could be offered to their wives and adult sisters. Religious leaders reported that this were conducted with a total was the first time that staff from a health program had come to discuss a health intervention with them, and that of 169 respondents they would discuss cervical cancer and HPV vaccination with their congregations. Adequate sensitization, through school and/or community meetings and mass media, of all relevant populations will be essential for the success of a national HPV vaccination campaign in Tanzania. 2012 Measuring vaccination Integration of two sub‐ Estimated vaccination coverage among the orthodox Protestant minority and its various subgroups Ruijs et al coverage orthodox studies: 1) An online survey (denominations) looking at overall vaccination coverage and vaccination coverage per denomination. Overall Protestant communities in of (1778) orthodox vaccination coverage was estimated to be at minimum 60%. In both sub‐studies three clusters of denominations The Netherlands Protestant youngsters, could be identified, with high (>85%), intermediate (50–75%) and low (<25%) vaccination coverage. Based on these invited via media, and 2) A results, we recommend to focus prevention and control of vaccine‐preventable diseases on the orthodox national sample study on Protestant subgroups with intermediate and low vaccination coverage. vaccination 2012 Coverage of child Cross‐sectional study, data Muslim children (33%) are less likely to be fully immunized than Hindu (45%) and other religious groups (42%). Sahoo immunization and its from DLHS‐RCH (2002–04), With respect to religion, it is clear that children belonging to the Muslim community are less likely to go for full as determinants in India bi‐variate and multivariate well as partial immunization than their Hindu counterparts, which may be because the utilization of health care analysis services is lower among Muslims. 2012 Immunization status and its Cross‐sectional survey with The significant predictors for complete immunization among the children of the people living with HIV are: Sensarma et predictors among children of pre‐structured interview mothers having received antenatal care, mothers having postprimary education, children of Hindu and Christian al HIV‐infected people in schedule. 256 caregivers of religion, children not belonging to scheduled castes, tribes and ‘other backward classes’. The current national Kolkata [India] children from the Bengal immunization program should focus on the children from the Muslim community and those belonging to Network of HIV+ people scheduled castes, tribes and other backward classes to improve coverage

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Author‐year Focus, Religion, Region Method Finding relating to Religion & Immunization 2013 Determinants of routine Secondary analysis of the Routine immunization coverage has increased between the first survey (2005‐2008) and the latest (2011). A Weiss et al immunization coverage 2011 project household mothers’ exposure to specific communication materials, her religion and education were associated with whether within the context of polio immunization survey, or not her children receive one or more doses of DPT. However, religion is not a target of change, and improving eradication activities in Uttar comparing this to past education status on a population level will require a long‐term effort. To address these two determinants, Pradesh [India] surveys in the program area programs need to tailor their strategies such as promoting immunization through religious leaders or use IEC materials better suited for illiterate populations. Source: Author’s compilation – drawing on a selection of studies from the systematic review Note: We continue to invite further contributions ‐ providing the original source material when possible: [email protected]

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3: INTERVENTION, SOCIAL MOBILIZATION, SUPPORT AND COMMUNICATION

In this chapter, we look at immunization or vaccine‐related social mobilization, interventions, support services and responses through religious leaders, local faith communities (LFCs) and faith‐based organizations (FBOs) Leading from the previous chapter, given that it has been argued that religion can be a significant factor or determinant in relation to immunization (even if the precise causal links are not yet clear), it is no surprise that several sectors and agencies have begun to say that religion needs to be properly taken into account in relation to immunization interventions. One of the reasons it has become easier to look at religion in a context dominated by clinical and epidemiological research has been the confounding experiences described in the previous chapter. At a policy level, given experiences such as the Nigerian polio boycott, there is a visible shift towards implementation at a local level – and an increased attention to social science concerns such as beliefs, attitudes and perceptions.21 As demonstrated, several studies conclude by arguing for the necessity for engaging with immunization at a very local and context‐specific manner, and that includes taking ‘local’ forms and interpretations of religion into account. Murphy (2012) notes, “Marking a shift from the earlier dominance of epidemiological perspectives, today behaviour‐change communication ‐ advocacy, interpersonal communication, and social mobilization ‐ is recognized internationally as the way forward in this final phase of polio eradication.” This is really where the intersection between religion and immunization takes form and begins to raise significant opportunities. However, it should be noted that from this point on, the available literature becomes much more scattered and fragmented, and the experiences often anecdotal or unsubstantiated. The main outlier to this observation is UNICEF‐linked activities, which are by far the most well‐documented engagement experiences with religious leaders and LFCs. In particular the UNICEF‐linked ‘Polio Communication Initiative’ is worth a special mention, whose work is demonstrated by Obregón et al (2009) who note that in the context of the GPEI, “…the recent focus on communication strategies have become increasingly research‐driven and innovative, particularly through the introduction of sustained interpersonal communication and social mobilization approaches to reach unreached populations.” As in the previous chapter, we outline some of the key themes that emerge from this literature – and provide a table at the end of the chapter, in this case, Table 2 lists observations of ‘interventions’ in immunization involving religious leaders or LFCs grouped by country.

3.1 Social Mobilization Murphy (2012) reports for UNICEF on social mobilization (SM) in relation to polio – providing lessons from the CORE Group Polio Project in Angola, Ethiopia, and India. Here, SM is described as: A broad‐scale movement to engage people’s participation in achieving a specific development or health goal through self‐reliant efforts ‐ those that depend on their own resources and strengths. It involves all relevant segments of society: policymakers and other decision‐makers, opinion leaders, the media, bureaucrats and technical experts, professional associations, religious groups, the private sector, NGOs, community members, and individuals. It is a planned decentralized process that seeks to facilitate change through a range of players engaged in interrelated and complementary efforts. It takes into account the

21 This is supported by a general re‐orientation in global health and development contexts towards participatory‐community‐driven health and development (although this has been widely shown to be fairly difficult in practice) 38

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felt needs of the people, embraces the critical principle of community involvement, and seeks to empower individuals and groups for action. Mobilizing the necessary resources, disseminating information tailored to varying audiences, generating intersectoral support, and fostering cross‐ professional alliances are part of the process. Several authors have noted that in practice, SM is being interpreted in vastly different ways (see Murphy 2012, Obregon & Waisbord 2010). Obregon and Waisbord (2010) identify three different kinds of SM used in polio eradication efforts: pragmatic SM, activist SM, and a hybrid SM that combines both pragmatic and activist elements. Pragmatic SM can be understood as practical ways in which health programs ‘utilize’ community groups and leaders to pass along important information to intended beneficiaries and assist the program in performing other important tasks ‐ involving community actors as instruments to help achieve predetermined (program) goals.22 Activist SM is characterized by community ownership, where decision‐making power is transferred from global or national institutions to local communities who identify their own goals and strategies (see Murphy 2012, Obregon & Waisbord 2010). We have inserted a significant piece of Obregon and Waisbord’s argument in the following box, believing that it has significance to how the engagement of LFCs in immunization is understood.

Box 9: Highlights from Obregon and Waisbord (2010) SM should not be approached casually as a top‐down informational strategy to advance pre‐established health goals, particularly in underserved communities with enormous needs and poor health services: SM is a complex, open‐ended process. Community participation is not conflict‐free, consensual mobilization. The unfolding and consequences of SM cannot be predicted precisely because participation puts in motion uncertain dynamics and demands whose results cannot be established beforehand. Various contextual factors determine whether communities support or oppose external initiatives. From trust and quality of government health programs to circumstantial local politics, a host of factors shapes the evolution and characteristics of SM. This is why global programs should not take a cookie‐cutter approach. Social mobilization is not simply about relying on community associations; rather, it needs to be informed by the recognition of local distinctiveness, including health needs, perceptions, and attitudes vis‐a‐vis health services, structures, and dynamics of local power and participation, and the role of local influencers. When local needs do not match global goals, there are greater chances of program dissonance with respect to what different stakeholders may expect from program implementation. Also, the relevance of local context should be recognized ex ante. Centralized strategies hardly amount to SM: Bottom‐up micro‐planning and strong local commitment are essential to SM. Without local empowerment (the process by which communities gain control over decisions and believe that their actions are directly relevant to the improvement of health conditions) SM is unlikely to be effective or sustainable. Without the devolution of power, SM functions as a top‐ down strategy that aims to capitalize on local resources to maximize external goals. The experience of polio eradication confirms the insufficiencies of informational approaches to SM and communication: Local voluntary associations, the media, religious and political leaders, and informal social networks should not be seen narrowly as channels for raising awareness about vaccination campaigns, or about changing attitudes about immunization. They are essentially social and political actors rooted in local contexts. Just as they can relay information that is functional to health programs, they also express community needs, are immersed in local and national political battles, and pursue various interests and goals. In countries where the quality of health services is extremely poor and communities have a vast array of demands, SM linked to global health initiatives may act as opportunities for the expression of local needs and politics rather than smooth information channels in support of pre‐established goals.

Given the limited nature of the literature, at this time it is impossible to unpack the specific nature of different mobilization efforts relating to LFCs – and this is certainly an area which could benefit from further research and engagement. Table 2 at the end of this chapter demonstrates there have been substantial efforts to be inclusive of LFCs and religious leaders. However, such descriptions rarely allow for in‐depth analysis, and certainly do not allow assessment of the kind of social mobilization approach that has been applied with religious leaders and

22 It should be noted that several commentators from faith communities and organizations have objected to the way that they and FBOs are frequently ‘instrumentalized’ by global health and development actors – see Olivier and Patterson 2011 39

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LFCs. Many of the descriptions in Table 2 appear to be more ‘pragmatic’ than ‘activist’ SM, (a judgment perhaps unfairly based on a surface reading of the descriptions of how the religious leaders and LFCs were ‘used’ to spread vaccine‐promoting messages). On the other hand, the case description of an intervention in the DRC (Box 10 below), describes a case of immunization program staff spending months engaging with a single religious leader in the DRC, allowing him to dictate the terms of the engagement and the nature of the immunization intervention – suggesting a more activist approach to engagement and behavior change. Murphy (2012) suggests there are challenges with both pragmatist and activists approaches, noting that “many pragmatist SM efforts evolved to add activist SM features because pragmatist approaches have limitations: even though cordial and cooperative liaisons are formed, it is essentially a top‐down process and thus does not usually benefit from the insights, suggestions and strategies that would emerge if community actors became true partners rather than information conduits.” On the other hand, activist approaches can be considerably costly (in time and finances), and “As desirable as the empowerment of communities to solve their own problems may seem, purely activist SM is not feasible in a global program to eradicate polio.” (Not to mention the initial resistance of the Muslim community in Northern Nigeria to the polio campaign could rightly be perceived as ‘genuine’ activist social mobilization, but certainly was not in line with global goals). The social mobilization efforts in India, Pakistan, Nigeria, Angola, the DRC and Ethiopia (see Table 2) all report being highly inclusive of religious leaders and LFCs, and reportedly have attempted a more ‘bottom‐up’ approach, resulting in significant success in some areas. Murphy (2012) suggests that the UNICEF‐led social mobilization activities in Angola, India, and Ethiopia are representative of a hybrid form of social mobilization (blending pragmatic and activist strategies), and by many accounts have been successful in accessing hard‐to‐reach populations, and resulting in these countries recently being declared polio‐free (now in the three‐year certification period). Obregón et al (2009) looks at the social mobilization around GPEI in India and Pakistan, and argue that the deliberate engagement with religious leaders and LFCs was highly effective – pointing to data from 2007 which shows that after involving religious leaders in polio eradication activities, coverage of children in families who usually refused due to religious reasons had increased, and argues “When properly engaged, religious and community leaders become strong community allies to eradicate polio.” Of course, the key words in that sentence are ‘properly engaged’ – and this remains the significant challenge, to draw out lessons of specific mechanisms and approaches for ‘genuine’ and ‘proper’ engagement with religious leaders and LFCs.

Top‐down public health (pragmatic) approaches to immunization In the midst of all this enthusiasm for social mobilization and community participation, it is perhaps necessary to be briefly reminded that there is still a strongly prevalent top‐down public health approach that often comes to the fore in immunization campaigns. The dynamics of such an approach are when the good of the public is weighed against the good of the individual (freedom of choice in public health terms); and a strong power dynamic of national and global health forces claiming authority and better knowledge over local communities. The historical precedent is discussed above – when religious groups resisted vaccination when it was imposed as a colonial tool, or perceived to be inappropriate levels of state control over individual liberty in the Netherlands. With all this discussion of community participation and mobilization, it should not be forgotten that vaccine ‘promotion’ can have a forceful side to it. For example, Arora (2000), discussing PPI in India, reports on strategies to overcome resistance, and found wide reports of harsh methods being utilized to ‘motivate’ unwilling parents. The examples provided have a distinct religious overtone (understanding that Muslims are understood to be a

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JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 target population in that region). Arora (2000) found that, “most of the Muslim non‐utilizers complained that some force was used to feed these drops to children of their community. According to their description (which was claimed to have happened in front of their eyes in some instances) children were fed polio drops while they were playing on the street and even in their own houses against the wishes of their parents.” The following excerpts are drawn from participants in this study: ‘In certain areas we have to give the drops forcibly so that they get the message that they cannot go without it. Some sort of a battle is going on’ (District Health Official) ‘Force is being applied only on some sections (Muslims) and nothing was said about others…’ (non‐ utilizer) ‘I have seen it myself that the force was not used on Hindus but when they (health workers) approached Muslim houses, they used force to give drops to their children. These things make people feel discriminated’ (non‐utilizer) ‘Force (police) is being used. This might have created some doubts in the minds of a few’ (Influencer, Religious Leader) We do not have the space here to unpack the religious elements and tensions within these reports. However, it is a useful reminder that ‘genuine’ community participation in the context of global and national immunization campaigns can be elusive – or is at least can be faced with competing priorities within the intervention process and strategy. An instrumental and top‐down public health approach is also visible in other ways in the literature. For example, a well‐known example is the application of compulsory vaccination for visitors to Mecca in Saudi Arabia on Hajj, such as compulsory vaccination against meningococcal meningitis for all Hajj pilgrims (see Shafi et al 2008). Clements et al (2006) suggest that there might be a significant impact if the “…leadership from such a highly respected country within the Islamic world may offer a way out of the current dilemma relating to polio vaccine.” An interesting area of study would be a more theologically‐focused work on ‘divine’ authority in relation to immunization interventions – especially in view of different top‐down and bottom‐up approaches (with ‘God’s Will’ being one of the most extreme top‐down perspectives in existence). We do not want to get too caught up in the dynamics of different social mobilization approaches as they relate to LFCs. Nevertheless, such issues of power and participation weave throughout the literature. We turn now to looking at specific mechanisms for social mobilization and intervention in immunization campaigns relating to LFCs, in particular engagement through religious leaders, LFCs and FBOs.

Social mobilization and advocacy through or with religious leaders We do not want to repeat what has already been noted above about religious leaders as influencers in the context of immunization campaigns. However, it is necessary to consider whether there are specific approaches or ‘mechanisms’ being put forward for engagement and intervention with religious leaders. There are historical accounts of religious leaders promoting vaccination – such as the Aga Khan III being publicly inoculated in a 1897 bubonic plague epidemic in order to allay fears of vaccination (described in Aylward 2012). Today, on both local and international levels, there has been a significantly increased effort to involve religious leaders in promoting immunization (see above and Table 2). Taking the Nigerian polio boycott example further, a key lesson from that experience for the international community was a reminder of the local power of religious leaders – a power that held its own against that of the international global health agencies and medical experts. It is little surprise then

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JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 that the local and global health actors turned to religious leaders to lend influence and ‘trust’ in the opposite direction, by drawing communities back towards immunization (see Ozohu‐Suleiman 2009). Kaufman and Feldbaum (2009) describe the response, which shows engagement with religious leaders in a number of ways: “Quietly, with support from the GPEI, the Organization of the Islamic Conference (OIC) secretariat and the regional director for WHO’s Eastern Mediterranean Regional Organization worked to get religious leaders to speak out on polio. Ultimately, a number of fatwas, or Islamic religious rulings, were issued on polio vaccination.23 These were important in countering the argument that the vaccine was a Western plot to wipe out Muslims. They also gave…‘space and options for the political decision makers to move the issue from one of religion concern to the political realm, where they could come up with a deal.’ Heymann says of the outreach to the OIC and to other regional organizations, ‘The most valuable thing was getting the OIC involved and they were helpful in many, many ways…Plus getting some Islamic interpretation through the Fiqh [Islamic Academy], which was helpful in understanding…that the vaccine was safe. We had great help from the Islamic community.” However, it is important to note that while the influence of religious leaders is unquestioned in this context, the nature and extent of such influence is not yet well understood, and it could certainly vary from situation to situation. In a unique study, Ozohu‐Suleiman (2009) studies the extent to which polio eradication campaign resistance and risk perception in northern Nigeria is associated with leadership and personal persuasions. While the method is not entirely clear, Ozohu‐Suleiman finds that ethnic and religious persuasions by traditional and religious leaders were actually of lesser significance than interpersonal persuasions from husband/wife and friends/relations in the campaign acceptance and resistance decisions – and that ethic and religious leaders are therefore reported to be of weak influence in the polio eradication campaign in northern Nigeria. (Part of the challenge may be the ill‐defined ‘religious leader’ which generalizes together a wildly different group of individuals – who have been engaged in immunization campaigns in very different ways and at different levels). While evaluating the PPI intervention in India, Arora (2000) observes that while religious leaders were involved, this involvement was sometimes “limited to making announcements through loudspeakers” and it was unsurprisingly then found that “…the majority of the clients said that people listen only to their own mind and act according to their own will. Religious leaders were said to have an influence but ‘only when they talked sensibly’.” Arora (2000) continues, by observing that in a context in which the communities were already suspicious of PPI activities, “religious leaders (Imams and Moulvis) extended only half‐hearted support to this program. The endorsements obtained from the influencers and religious leaders to the district level officials about the safety and efficacy of polio drops and credibility of the prevalent rumors did not percolate to the lower levels of the society and hence largely remained ineffective.” Arora (2000) concludes that “half‐hearted participation by key influencers can also be counter‐productive”, and that key influencers need to be educated and convinced about program objectives and benefits before obtaining their endorsement. This example demonstrates the challenges that extend way beyond bringing religious leaders ‘to the table’. Ensuring genuine and fully enthusiastic engagement from religious leaders (as opposed to overt ‘lip‐service’) remains a significant challenge. Chen (2004) argues that the immunization campaigns prior to the Nigerian boycott in 2003 mainly demonstrated the WHO’s top‐down approach, which then became part of the problem: “Although the published literature about polio eradication stresses the inclusion of ‘political, community and religious leaders’, in practice the WHO did not involve them effectively…Local community

23 Fatwas on polio vaccination were issued in late 2003 and early 2004 by Dr. Mohamed Sayed Tantawi, Grand Imam of El Azhar Al Sharif; the Islamic Fiqh Academy (circulated by the OIC); Abdul Alim, Grand Mufti of Egypt; and, Abdul Aziz Ibn Abdullah Ibn Baaz, Grand Mufti of Saudi Arabia and president, Committee of Muslim Scholars (see Kaufman and Feldbaum 2009) 42

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organizations and leaders were not involved in the planning or development of immunization campaigns. Prior to the rebellion, the WHO met with the Nigerian Minister of Health, who declared the federal government’s support of the immunization programs. However, local political and religious leaders who have a greater influence in their communities were not included. By utilizing a top‐down approach, the WHO normally controls how immunization programs were implemented without consulting with the community. Exclusion of community members and leaders translates to communities’ lack of share in ownership of the program. As a result, questions of vaccine safety could take a firmer hold because communities are not invested and the program is imposed by outside agencies…Local political and religious leaders must be included in the development of programs as well…” (Chen 2004) As a continuation of a classic development sector conundrum, it might not necessarily be the ‘top‐down’ approach that was or is problematic, but rather that top‐down approaches rarely reach far enough ‘down’.24 Waisbord (2004) supports this, noting that in Northern Nigeria “...advocacy and SM with political and religious leaders has been sporadic and only carried out recently, as local resistance to the PEI became more visible in the national media.” This suggests that understanding the nature and quality of social mobilization might be more important than counting the number of representative religious leaders engaged in immunization programs.

The ‘value‐added’ unique characteristics of religious leaders In the broader literature, it is argued that religious leaders have unique social capital, trust and reach into communities – resulting in influence that is characteristically different to those of other community leaders. For example, Diamenu and Eshetu (2005) argue that religious leaders have unique ‘comparative advantages’. They describe the support provided from the WHO for the Ghanaian Reaching Every District (RED) approach, which included a strategy for ‘utilization’ of religious leaders. This was done because it was observed that: “Religious leaders are recognized as influential individuals, with attributes that can support health care delivery programs if they are involved. These attributes are: they have very large followings and interact regularly with a cross‐section of society, especially mothers and caregivers; they command respect among their congregation and society at large; and their advice and instructions are heeded by a majority of the community with little reservation or hesitation.” UNICEF’s (2004) guidebook ‘Building Trust through Immunization and Belief’ has an entire section relating to the ‘value‐added’ of religious leaders and religious groups. They provide the following guidance to program staff: Whether immunizing children house‐to‐house or providing services at fixed sites, the support of the community is essential in achieving broad coverage. One way of eliciting such support is to gain the trust and confidence of religious leaders, who often wield tremendous authority at the grass roots. Religious leaders not only have the power to shape public opinion, they can also mobilize their constituencies and improve the links between communities and health services. By approaching religious groups with an informed respect for their views, communication and health officers can often gain the trust needed to garner their support…Allies among religious organizations can be crucial collaborators in reacting in an appropriate and effective way. The guidebook goes on to provide the following reasons for why actors should engage with religious leaders: “Because they: wield considerable social and political influence; have an established network of people and an organizational and physical infrastructure that reaches from national to district and community levels; are a source of credible information for their followers; Provide motivation to act for the wider social good; can

24 We acknowledge John Grabenstein’s review comments in relation to this argument 43

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 sanction certain behaviors or actions; can become allies in dispelling rumors and reducing resistance; and are often willing to act on their own with minimum support” (USAID 2004). However, we add a cautionary note here, and point out that the ‘value‐added’ of religious leaders, and the extent and nature of religious assets can be a contentious issue ‐ while there is a great deal of anecdotal support, it is poorly evidenced (see Olivier & Wodon 2012). This is an issue which could benefit greatly from focused research.

Shifting religious leaders’ behavior As described above, religious leaders can utilize their influence in different ways – they can be key barriers to immunization, or key promoters. This logically suggests that it would be valuable to be able to ‘shift’ religious leaders from the former to the latter position. However, while there are many anecdotal examples of how religious leaders were ‘convinced’ and became key advocates for vaccine interventions, this is poorly documented. One useful resource is the UNICEF‐linked Polio Communication group – which have begun to address communication interventions more thoroughly. In the box below, we provide one descriptive example of a case of social mobilization (and possibly ‘behavior‐change’) through long‐term engagement with a religious leader in the DRC. This provides a fascinating look at the elements necessary for such intervention.

Box 10: Behavior Change with Religious Leadership in the DRC UNICEF describes a case example in which the behavior of a single pastor of a Magico‐Christian Group in Katanga Province was shifted – with broad‐reaching effect Pastor Paul II, an influential pastor of the Kitawala Filadelphie Sect in DR Congo, used to counsel his thousands of followers to refuse the polio vaccine. Now, years after the GPEI first approached him in 2009, he has become an ally…The road to acceptance has been neither short nor easy. Katanga Province, where Pastor Paul II’s followers live, had the world’s highest rate of refusal of the polio vaccine until recently…The following lessons were learned in the course of forming an alliance with a religious leader who calls himself the ‘Elephant King of the World.’ Listen First: Pastor Paul II was first approached by the DR Congo’s Ministry of Health and UNICEF communication staff in 2009. He had never before been in contact with any health authorities. It took many months to gain his trust and to understand his doctrine and its foundations. The ‘Elephant King’ expressed his beliefs fiercely but was open to dialogue. Over time, he shared more about why the group was refusing the vaccine. The Kitawalas’ doctrine held a deep mistrust for nearly everything that came from outsiders…The Kitawalas’ fear was further stoked when mass immunization teams marked numbers on houses to show how many children had been vaccinated. The Kitawalas cited the Apocalypse and the marking of homes, which they associated with ‘the mark of the beast’. Equipped with a better understanding of the Kitawalas’ perspective, the local vaccination team…(began) a long discussion…one that revolved mainly around the role of divine will in the death of children... Be Open to Creative Ideas: Pastor Paul II himself was now convinced that his community should be vaccinated against polio. But many of his followers – who lived in 128 missions spread across five health districts – were people who had for decades, or for their whole lives, been guided by teachings that rejected almost everything from the West. UNICEF‐supported community mobilizers and health officials spent many hours discussing the situation with Pastor Paul II…Together they hit upon an idea…Pastor Paul II agreed to identify three boys from the mission to receive free training in hygiene and disease prevention…Pastor Paul II expressed his acceptance of the plan as long as its final objectives remained secret. He sent three of his own children to be trained. Since Pastor Paul II’s power was derived from his father and he is training one of his sons to succeed him, it is likely that these boys will be among the community’s influential leaders…And during a vaccination campaign last October, Pastor Paul II publicly stated to a surprised crowd, “There are three important things in the life of a human being: prayer, cleanliness and vaccine.” Adapt Vaccination Strategies to Local Needs: As greater trust was built with the interlocutors, Pastor Paul II became open to bringing the polio vaccine directly into the Kadima Mission, where he and a large group of his followers live…Still, because of the group’s historical mistrust of western medicine, all stages of the vaccination process needed to be negotiated…the vaccination team adapted its usual approach…there would be no finger‐marking with ink…There would be no marking of houses. Very few social mobilizers would be allowed, and those who were allowed would be among Pastor Paul II’s closest followers. Only the nurse in charge of the local health center, a man Pastor Paul II knew well and trusted, would be allowed to vaccinate. And finally, the vaccination must be carried out by night. This way, it would be less likely to attract the attention of those who might not approve. It would also avoid giving the impression to outsiders that Pastor Paul II had in any way ’yielded.’…Over the course of 2012, three night vaccinations were completed. More than 90% of children under age 5 have been vaccinated against polio in a community that had once been impenetrable to vaccinators. (see UNICEF 2013a)

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3.2. Building Trust with Religious Leaders and LFCs for Genuine Engagement One of the key themes in any kind of social mobilization is trust. This can be seen in the example in DRC above, where building trust involves long‐term engagement and careful appreciation. UNICEF place trust as a central issue ‐ even naming various reports on ‘trust and immunization’ (see UNICEF 2004a, UNICEF 2013a). As mentioned briefly above, Chen (2004) draws attention to the issue of lack of trust in humanitarian or development agencies – which is linked to a lack of trust in Western powers. Chen argues this was a major factor in the extent of the Nigerian polio boycott. “Within the context of Nigeria, the trust of humanitarian agencies within the communities was quickly overcome by the beliefs of influential religious leaders. The fact that the claims of the leaders had such a sweeping effect across the country illustrates that trust of humanitarian agencies was low to begin with.” Larson et al (2011) discuss ‘public trust’, saying that “Public trust in vaccines is highly variable and building trust depends on understanding perceptions of vaccines and vaccine risks, historical experiences, religious or political affiliations, and socioeconomic status.” They argue that research is needed, not just on the individual determinants of public trust, “…but on what mix of factors are most likely to sustain public trust. The vaccine community demands rigorous evidence on vaccine efficacy and safety and technical and operational feasibility when introducing a new vaccine, but has been negligent in demanding equally rigorous research to understand the psychological, social, and political factors that affect public trust in vaccines.” In the same vein, it is possible to note that research on trust in relation to religion and immunization or vaccines has also been greatly neglected. While trust is mentioned frequently as a ‘value‐added’ of religious leaders or LFCs, there is barely any research on what this actually means or how such can be leveraged for social mobilization and immunization. Religious leaders as negotiators in conflict contexts: One of the most powerful examples of religious leadership, advocacy and trust in relation to immunization has to be the anecdotes that suggest a strong role for trusted religious leadership in cease‐fire negotiations in conflict contexts (focusing in this review on humanitarian cease‐ fire episodes which are agreed on to allow for the provision of health and humanitarian assistance, in particular immunization). For example, the WHO has a list of negotiated Humanitarian Cease‐fire episodes, titled ‘Health as a Bridge for Peace’.25 An example on this list describes the 1991 formal truce declared in El Salvador, “…during which as many as 20,000 health workers got 250,000 children immunized against polio, measles, diphtheria, whooping cough, tetanus and other diseases. Food and essential medicines were delivered to civilian populations threatened by famine or ‘food blockade’. The process generally facilitated by ICRC and the Catholic Church, with the support of Rotary Club, UNICEF and PAHO/WHO.” Hanmer (2010) says that in this particular case, “the Catholic Church negotiated a ceasefire to allow children on both sides of the conflict to be immunized. Similar efforts have been replicated in other conflict affected countries, such as Sri Lanka and Sudan.” UNICEF (2004a) describes polio vaccination in the context of the Angolan conflict during the late 1990s, engaging in social mobilization which drew religious leaders and volunteers from both sides of the conflict (the Council of Christian Churches in Angola and a Catholic lay group, the Legion of Mary). And Nishtar (2010) looks at Pakistan immunization in the Federally Administrated Tribal Areas in Pakistan which are currently conflict zones, arguing that with applied quotes from the Quran, polio eradication can be presented as a ‘right to life’ issue, and that “improved understanding of the religion may assist in negotiating access in areas where refusal is an issue and soliciting a ceasefire for vaccination campaigns. For all we know, this could be a step towards peace in Pakistan’s war‐riddled zones.” Indeed, a better understanding of the potential role of religion and religious leaders in conflict management in relation to immunization might be a powerful area for further study.

25 See http://www.who.int/hac/techguidance/hbp/cease_fires/en/ [Accessed 10 November 2013] 45

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Engagement in collaboration with faith‐inspired universities: Less dramatic, but nevertheless interesting, is a trend in the literature and in a number of immunization campaigns that are reaching out to religiously‐affiliated universities, possibly to tap into a particular kind of authority (although this is unexplored). For some, the relationship is direct, such as Aligarh Muslim University and Jamia Milla Islamia engaged in GPEI (with UNICEF) in India (see Hussain 2012, Obregón et al 2009). In Pakistan, the Prime Minister’s Polio Monitoring and Coordination Cell’s progress report describes meetings with the Vice President of International Islamic University Islamabad “…to discuss the more proactive and positive role of religious leaders in Polio Eradication Initiative”, as well as collaboration with International Islamic University Islamabad (Nisar and Kanwal 2012). For others, the relationship is less overt, for example Khan et al (2006) from Agha Khan University and Muula et al (2009) from Loma Linda (Adventist) University are conducting research on immunization (although the ‘religious’ connection is not as apparent with the latter two examples). Engagement in collaboration with local faith communities:26 As can be seen in Table 2, while there are many suggestions for engagement with religious leaders, strategies for direct engagement with LFCs (such as congregations, churches, mosques or women’s groups) is significantly less developed in the literature. That is, while there are many observations that this is important, or that a certain social mobilization campaign worked with ‘religious groups’, there is barely any description of specific mechanisms or approaches for working with LFCs.27 This could be because religious leaders are understood to be the gate‐keepers to LFCs, so the relationship might be inferred; however, it does mean that there is only limited description of engagement with other potential assets and avenues which are distinct from ‘dialogue with religious leaders’. However, it has been broadly noted in the literature that LFCs (like religious leaders) potentially have inherent ‘value‐added’ characteristics that other civil society institutions might not have. For example, access to community, reach, trust, or communicative capacity, especially for reaching missed populations. However, few studies engage directly on these issues in a substantive way – and especially not in relation to immunization. As mentioned previously, there are several mentions made of engagement (or the presumed potential of engagement) through religious schools – Christian, Muslim (madrasas) or other. For example, the literature discussed in Chapter 2 notes the importance of engaging with orthodox communities through religious schools (such as the issue of HPV intervention age differences in religious schools, or engagement through immunization at madrasas, see Arora 2000). A handful of studies assess US‐based congregations and their willingness to engage in vaccination. For example, Bond et al (2013) look at the resources and interest among faith‐based organizations for influenzae vaccination programs in the USA, looking at Project VIVA which “mobilized community members and organizations to implement an influenzae vaccination program in Harlem by administering vaccines in ‘non‐traditional’ venues, such as community‐based organizations, pharmacies, and faith‐based organizations” (FBOs here being congregations). Bond et al continue, “FBOs have been recognized as important venues for health promotion initiatives within medically underserved communities…Most FBOs expressed interest in common health promotions programs; 60% expressed interest in providing on‐site influenzae vaccination programs within their organization. Health programs within FBOs can be a point of access that may improve the health of their

26 Note that we address this again in the chapter that follows, but there focus more on mention of actual (and routine) vaccination within the LFC (rather than related or supportive activities such as promotion) – however the distinction is somewhat fuzzy given the lack of detail in the literature being reviewed. 27 Oluwadare (2009 addresses Christian resistance to immunization in Nigeria – mainly among the charismatic sect, the Christ Apostolic Church, and suggest that while adherents hold to the doctrine of refusing drugs (preferring prayer and fasting), this doctrine has been rapidly giving way due to the persistent advocacy and sensitisation led by the community leaders (we mention this as it is something of an outlier in the material on engagement with Muslim LFCs). 46

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 congregants as well as the larger community.” They argue that the main finding of this survey was the untapped potential of FBOs to be avenues for health promotion “Interest in health‐related topics was high, yet the proportion of FBOs with health‐related programs and staffing or contact with the local health department was relatively low” (Bond et al 2013). Box 11: "UNICEF taps religious leaders in vaccination push" And UNICEF (2011b) recently reported that in the Sokoto Extract from commentary in The Lancet: State of Northern Nigeria, “…the program is piloting several The participation of religious leaders in mobilizing families and communities is crucial to the successful implementation ‘bottom‐up’ approaches to mobilization. This will of vaccination programs and in reaching the 31 million complement the ‘top‐down’ messaging from religious children in Africa and Asia that have no access to vaccines, leaders that has been successful, but insufficient for building says UNICEF. “There are many communities without schools, health lasting social commitment…MODIBO is a faith‐based facilities, or sanitation but there is hardly any community women’s association in Sokoto state whose members without a place of worship”, said UNICEF chief Carol conduct sensitization and compound meetings with women Bellamy at a meeting in Geneva (May 13) to address the role of religious groups in immunization. More than 50 public‐ during social events, such as naming and wedding health and religious community insiders attended the ceremonies.” This demonstrates the intention to seek conference. avenues beyond (usually) male religious leaders for We need the support of communities and families and they intervention on immunization. The example of woman’s should be convinced that vaccination is good for children, said Rima Salah, UNICEF regional director for West and groups has been argued elsewhere to be a particularly Central Africa. “To solicit this we need to gain the trust and powerful formation within LFCs for engagement on health confidence of the religious leaders and groups”, she added. and development issues. Again, this could be a potentially To coincide with the conference, UNICEF launched a guide ‐ Building trust in immunization ‐ which describes how to important area for further exploration and research. develop and maintain strong working relationships with religious leaders and groups, and approaches that should be Engagement in collaboration through or with FBOs: avoided. The guide, which includes case studies, also urges Interestingly, there is also only limited material available on program officers and immunization partners to “take care to intervention through faith‐based non‐governmental show respect for the beliefs and values with whom you are working”. organizations, or ‘FBOs’.28 Of course, ‘FBO’ is an indistinct James Cairnes, director of the program on children at the classification, which covers local or grassroots community‐ World Conference on Religions for Peace, says the world’s based organizations (CBOs) as well as massive international major religions are deeply concerned about the wellbeing of non‐governmental organizations (INGOs). children and families. “So there is deep ground for partnership [with UNICEF] because we believe in the same Murphy (2012) argues that “After many years of experience things.” in polio eradication, a consensus has emerged that reaching In Sierra Leone, a 2‐year collaboration between UNICEF and Muslim and Christian leaders increased immunization high‐risk and unconvinced populations calls for intense and coverage of children under 1 year of age from 6% to 75%. varied social mobilization efforts and that the role of NGOs, Similarly, Muslim leaders in India in the state of Bihar and its neighbor Uttar Pradesh are working with UNICEF to counter largely ignored in earlier days of GPEI, is critically important. resistance to polio vaccination fuelled by misperceptions Underserved communities are more likely to respond about the vaccine’s safety…The promotion of vaccination by positively to grassroots NGOs because they have a history of Imams during their sermons and in discussions with congregation members has increased the coverage of polio serving community needs, their outreach workers come from vaccination. the communities they serve, and they engage highly Because religious leaders have great authority, are respected community leaders as integral parts of social respected by their communities, and are credible sources of mobilization efforts. The accomplishment of India, Angola, information for their followers, Salah added, they can be instrumental in dispelling rumors and reducing resistance. and Ethiopia in being free of polio cases for more than a (Zarocostas 2004) year…is largely attributed to successful social mobilization efforts of NGOs in reaching underserved populations.”

28 In contrast, the literature on religion and HIV/AIDS is dominated by reports on the ‘religious response to HIV/AIDS through FBOs’ – see Olivier et al 2013 47

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UNICEF (2012b) describes the Rapid Response Outreach Model that was developed in India that ‘utilizes’ NGOs already on the ground. Box 12: CORE Group in‐country partners CORE Group Partners in India These NGOs in turn mobilize religious leaders (as practiced in India  Project Concern International and Angola). Neither of these examples indicates whether these  Adventist Development and Relief Agency local grassroots NGOs are faith‐based or not, so it is not possible to  Catholic Relief Services assess whether FBOs might have been given preference for dealing  (and 11 in‐country NGO partners) with faith‐inspired communities.29 CORE Group Partners in Angola In fact, Ghatak (2006) addresses some of the challenges and rewards  Africare of two ‘secular’ NGOs engaging on the issue of religion and health in  Catholic Relief Services India, arguing that it requires sensitivity to religion from the program  Salvation Army  World Vision and staff, but was often easier to not be a religious institution when  (formerly also included Save the Children & CARE engaging with religiously sensitive issues: Int)

“…(by) ensuring that people understand that the work they CORE Group Partners in Ethiopia do is not founded on any political or religious mandate...One Host: of the most important strategies used to work towards this  Consortium of Christian Relief and Development goal is to ensure open communication channels with Association (CCRDA) religious leaders…As Ghosh says, ‘Religion cannot be ignored International partners: in a devout community, but we need to see that religion is  American Medical Research Foundation not used as a tool to justify ignorance and the oppression of  CARE women’…Despite being secular in their remits, both  ChildFund International (formerly Christian Children’s Fund) organizations are staffed mainly by people from the majority  International Rescue Committee Hindu community, with their own prejudices and  PLAN misconceptions around those from other faiths. Staff of both  Save the Children  World Vision organizations therefore need to enhance their understanding and knowledge of Islamic tenets and practice Local partners and to work on deeply held apprehensions about the ‘other’.  Alemtena Catholic Church  Harerghe Catholic Secretariat The organizations are aware that partnerships with the most  Ethiopian Evangelical Church Mekane Yesus marginalized will require them to transform themselves  Pastoralist Concern Association of Ethiopia from within. It is this internal transformation that will (Murphy 2012) provide the strength to work with communities who are embarking on a difficult voyage” (Ghatak 2006). In relation to internationally‐based FBOs, it is interesting to note the strong presence of FBOs in the CORE Group local partners (Box 12 above). Without conducting an extensive review of faith‐based INGO’s websites, this review does not as yet pick up on other significant examples of FBO engagement in immunization ‘interventions’ and support (we will address ‘FBO’ provision of routine immunization in Chapter 4 below). However, we acknowledge that this form of scoping review within these set criteria might not be picking up on what we suspect is a more substantial level of engagement of FBOs in local intervention than is described here, possibly even with specific strategies and mechanisms for engagement with and through LFCs. We therefore anticipate that this review might give impetus for such FBOs to share their project information more openly (not only program promotional material, but also program experiences and lessons learnt).

29 It should be noted that while there is limited specification of engagement through FBOs – there is even less on non‐Christian FBOs. Weiss (2007) talks about the rapid expansion of Muslim NGOs in Ghana in the last few decades, especially since the 1990s which tend to have supportive transnational links to foreign Muslim governments and institutions. 48

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3.3. Religion, Immunization and Communication We have indirectly addressed communication in some detail already. Social mobilization is fundamentally based on ‘authentic’ communication and there has been a recent intensification of interest in communication strategies, channels and communicative interventions. Obregón et al (2009) describe the successes towards global polio eradication as being partly because of such communication interventions: “Mass media and information dissemination approaches used in immunization efforts worldwide have contributed to this success. However, reaching the hardest‐to‐reach, the poorest, the most marginalized and those without access to health services has been challenging. In the last push to eradicate polio, Polio Eradication Initiative communication strategies have become increasingly research‐driven and innovative, particularly through the introduction of sustained interpersonal communication and social mobilization approaches to reach unreached populations.” We raise here a few key themes that emerge from the existing literature in relation to religion, immunization and communication:

Religious leaders and LFCs as communicative channels and actors for intervention Much of the literature, although not strong, suggests that one of the key ‘value‐added’ aspects of working with religious leaders, LFCs or FBOs is because they have existing and extensive communication channels which are trusted, reach vulnerable populations, and can or could be utilized to pass ‘correct’ information to affected and missed communities (often reflecting a more pragmatic approach, when seeking to ‘utilize’ these channels for immunization‐campaign communication). There are a variety of ways religious leaders and LFCs are addressed in the literature: It’s about gaining access into otherwise ‘closed’ communities: As discussed in chapter 2, studies which point to missed populations and ‘closed’ religious communities tend to suggest working with religious leaders as a solution to gain access to these communities and improve information flows. The issue of literacy is raised here again, as it has been argued that some religious groups are against the empowerment of women, which means they would have a lower literacy rate. The dynamics of this are not well articulated in the existing literature, but this does raise some interesting suggestions about the appropriateness of utilizing mostly male religious leaders to communicate to mostly female missed populations. Obregon and Waisbord (2010) address some of these issues in Pakistan, noting that they found that male door‐to‐door teams were not effective due to the custom of not permitting unrelated males to enter homes. “As a result, female vaccinator teams, who could reach female child caretakers with the youngest children under their care, were formed and trained to visit families unwilling to vaccinate newborns…[and] in India, community meetings and dialogues also created space for women to engage in discussion and dialogue about polio and other local issues.” They relate that a ‘Itjema’ (a religious gathering of Muslim women which is preached by a female religious leader) was created, led by ‘Maulanai’ who are highly respected in Muslim communities, “in critical pockets 15 Maulanai were identified and led ‘Itjema’ at some community leader or influencer’s residence whose house was among or in vicinity of refusal families. Maulanai recited ‘Hadees’ (religious message) on health and later on explained how important oral polio vaccination is to 0– 5 year kids’’ (Obregon & Waisbord 2010). Such examples provide a useful example of careful social mobilization and communication. Thankfully the group from which these observations emerge have a strong orientation towards rigorous evidence‐based communication interventions, so there is some hope that more careful analysis of such activities will emerge. Getting the ‘right’ information across, and counteracting harmful rumors: As the example above also demonstrates, there has been increasing attention paid to the utilization of communicative opportunities presented by religious leaders and LFCs, to counteract harmful rumors and improve the content and quality of 49

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 information being communicated. For example, incorrect beliefs such as ‘you only need one dose of OPV to be immune to all diseases’ might be a non‐sensitive issue that could be communicated more effectively in an instrumental fashion through religious leaders and into LFCs. Significantly more attention has been given to involving religious leaders in counteracting rumors, as described above. It is interesting to note that even in 2001, UNICEF was publishing on approaches to combat anti‐ vaccination rumors (a report that pays significant attention to religious leaders and groups). One of the great challenges to this is the increasing access to the internet and social media, where anti‐vaccine rumors can be easily ‘substantiated’ from such resources. Rumors also cross over national borders in this way (as seen in the box examples on The Philippines and Nigeria in Ch2). Several authors are now engaging on rumors and how to counter them, all of whom mention religion to some degree (see Arora 2000, Chaturvedi et al 2009). What is interesting is that in Arora’s account of the work necessary for countering anti‐vaccine rumors, we are reminded that anti‐ vaccine communication is not only limited to ‘word of mouth’ casual conversation, but in some contexts might involve opposing ‘communication campaigns’ using print media and the like. This lengthy extract from Arora (2000) describes this kind of intervention in an Indian context: “It was apparent that such rumours were mostly prevalent among some minority sections, socio‐ economically backward sections of all religions, who were generally illiterate as well. Though it was almost impossible to find the source of rumours and misinformation, indications were that some influential persons like religious leaders, local private practitioners who specialized in treating and are dependent on polio cases (“jhola doctors”) …were behind it all. Word of mouth was the channel most effective in such situations and had been used very effectively to spread the misinformation…However, according to some providers as well as clients, pamphlets and announcement through a mike mounted on a cycle rickshaw a day before National Immunization Days (NID) were also used at some places to spread misinformation…The team came across a news item in Medical Darpan published from Bulandshehar which printed this misinformation…The newspaper was found at one of the booths on NID in a Muslim dominated area…Remedial measures to negate the ill/adverse effects…were taken. Assembling village pradhans (who were mostly Muslims) addressed by Shahi Imam of Moradabad, printing pamphlets with the Imams appeal to the community, printing posters depicting the Imam giving polio drops to children and pasting them all over the town, opening immunization posts at all madarsas, medical officers visiting the troubled areas and explaining to the parents, SDM and DM using force (the Police) to give polio drops to all children in the problematic villages were some of the strategies adopted… “Spreading rumors very systematically is the ‘gupt mission’ (secret mission) of these religious leaders’ (District Health Officer) “Village Pradhans are basically Muslims and they appear convinced during meetings but after going back to the village from the meeting they don’t show the enthusiasm” (District Official) Chaturvedi et al (2009) also look at rumors in India and report on similar anti‐vaccine campaign strategies, most of which had a ‘religious’ element. “The rumors were often supported by one or more of the following: locally circulating religious leaflets and magazines, mostly disowned by the sources; locally restricted announcements through static and/or mobile (rickshaw bound) public address systems; address by a religious leader inside a mosque after a prayer ceremony; quasi‐confirmed religious edicts, that were often disowned by the sources…” (Chaturvedi et al 2009).30

30 Agbeyegbe (2007) argues that the overlooked factor in the Nigerian polio immunization boycott was ‘risk communication’ and reviews the question on the safety of the vaccine and the role of religion in the boycott. 50

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Box 13: The Marklate Social Mobilization Program in Sierra Leone (Edited extract from UNICEF 2004a) A social mobilization program called Marklate or ‘vaccinate’ in the local language was begun – and in a radical move, 25% of program resources were dedicated to social mobilization and training. This UNICEF‐supported social mobilization effort included both Islamic and Christian leaders and groups. In an initial attempt to involve religious leaders in Marklate, the social mobilization team invited representatives from all religions in Sierra Leone to a leadership workshop. This proved unproductive because participants were more interested in debating the differences in their beliefs than in finding common ground on how to promote immunization. Six months later, the social mobilization team tried a different tactic…the team organized a leadership workshop specifically for Islamic leaders. During the three‐day workshop, the team helped the attending religious leaders, Islamic scholars and prominent Muslims from government and business to form a new NGO – the Islamic Action Group – which became an important vehicle for disseminating the messages. Quotations from the Koran were also identified to support child survival and other development initiatives. The Islamic Action Group encouraged different Islamic organizations around the country to use their networks to spread these messages and inspire local leaders. Smaller action groups were established in each of Sierra Leone’s 12 districts. At that time, a new generation of Islamic scholars was rising to prominence. Many had studied overseas, were open to the ideas of modern medicine and welcomed working with the UNICEF team. Nevertheless, some religious leaders remained resistant to the idea of vaccination. They considered the practice anti‐Islamic or were wary of UNICEF’s motives. Some even suspected a secret family planning agenda. In response, the social mobilization team organized a series of national and district‐level workshops to win over these leaders. It didn’t take long before the leaders that attended the workshops had adopted the Marklate campaign as their own. They explained to their congregations that parents held a duty to secure their children’s well‐being. Imams included messages promoting child survival and development in their sermons and announced the times and locations of immunization sessions. Sometimes they allowed their mosques to be used as vaccination sites. A poster in Arabic showing a child polio survivor and suggesting that immunization could have prevented his disability was a particularly effective communication tool. Even though few people could understand Arabic, the language was associated with Islam and displayed in mosques, which provided additional credibility among the Muslim population. The poster proved so popular, in fact, that the social mobilization team used the number of posters displayed in mosques as an indicator of campaign reach. Islamic women were also important agents for change. The National Council of Muslim Women – an umbrella organization of 96 different women’s groups – attended leadership workshops and conferences. Some of the leaders then organized their own meetings and special events to further promote Marklate and enlist the support of their members. The women soon became familiar figures at vaccination sites, preparing food for vaccination workers, assisting in registration and providing entertainment by singing about Marklate. They also went door‐to‐door to find children not being brought for immunization. The women, mostly mothers themselves, were particularly credible as advocates, winning over reluctant families with arguments in favor of vaccination. Christians, inspired by the work of the Muslim groups, also wanted to get involved. They approached UNICEF, asking how they could help. The UNICEF social mobilization team, again in close cooperation with the Ministry of Health, organized a national leadership conference with the Christian Council of Sierra Leone. Participants formed an NGO similar to the Muslim group, called the Christian Action Group, to help organize district‐level activities. They selected biblical passages supporting childcare and community development to use as messages. Pastors and priests shared information on immunization with their parishioners and organized workshops and special events, such as ‘crusades’ in sports stadiums featuring preaching, testimonials, gospel singing and talks by health providers. Other awareness‐building activities included an evening candlelight parade and a thanksgiving parade with floats built by community organizations to promote child survival and other development themes. Mothers’ Unions, a long‐established women’s network in local churches, played a role similar to the Islamic women’s groups, going directly to communities to promote and support vaccination. Initially, Christian and Muslim women and men went separately to the communities. They were so keen to help that soon fierce competition arose for places on the UNICEF bus that took the Marklate campaign into the districts. Eventually, the group leaders saw the advantages of making field visits together, and a bus schedule was organized to accommodate both Christians and Muslims on the same trip. By arriving together in a community with the same objectives and activities, but targeting their own congregations, they sent a powerful message to the community, thus increasing the impact of their work. The relationship built up between Christian and Muslim women persisted long after the immunization campaign was successfully concluded. Working collaboratively for results: This collaborative effort, led by Muslim and Christian leaders, was highly successful in increasing community involvement and demand for vaccination. In 1990, after just two years of activity, the immunization program reached its goal, moving from 6 per cent to 75 per cent coverage of Sierra Leone’s 135,000 children under one year of age. Churches and mosques – along with village meeting places – became forums for debate, not only on immunization, but for other ongoing development issues. (UNICEF 2004a)

Increasing the quantity of information by working through LFCs: A lot of the focus has been on increasing the quantity of information to local communities and missed populations, with a particular focus on communication through religious leaders to their congregations or communities. For example, Oluwadare (2009) describes how in Nigeria, “Health authorities work through town criers, churches and mosques to get information to the people

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JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 especially on polio vaccination.” There are several examples of Box 14: Interpersonal Communication religious leaders speaking over the radio as an intervention Interventions: The Christian polio eradication method – including large national polio campaign interventions. partnership in Angola Beginning in 1998, UNICEF created alliances with Yahya (2007) notes that Nigeria “…can boast a media campaign Angola's Christian churches in a communication that saw influential political and religious leaders raising initiative to end polio, one household at a time. In awareness and encouraging polio immunization” – but goes on to response to the news that some of Angola's Catholic clergy, including bishops and archbishops, point out that while the radio is the greatest medium for news in were preaching against polio vaccination (saying northern Nigeria, it has become a luxury in very poor rural that the vaccine being used had been altered to communities. Unsurprisingly then, immunization programmers cause sterilization), UNICEF set out to stop the rumors as well as to recruit the churches as active have sought to leverage the ‘informal’ communication allies in polio elimination. mechanisms of LFCs, which are sometimes the only access points Through face‐to‐face meetings and interpersonal for information in some communities. Obregón et al (2009) communication channels, a partnership was formed to help correct misunderstandings about prioritize “involving religious leaders as spokespersons and using polio vaccination and to encourage parents to faith‐based folk media (i.e. mosque announcements) to reach immunize their children against the crippling community members.” disease. In essence, UNICEF Angola's program However, we do not yet have sufficient information to know how communication team sought to dispel growing effective such interventions have been. Murphy (2012) points out misconceptions and rumors about vaccination, and to engage church organizations to participate in that previous approaches used to treat local media in a pragmatic social mobilization training and other activities. way: “Initial efforts had considered media outlets merely as Because of the high level of illiteracy and poor information channels and this sometimes had unexpected media coverage in Angola, interpersonal communication channels were used to take negative consequences.” Murphy (2012) notes that polio planners messages to hard‐to‐reach areas and isolated began to realize that media are community actors too with their populations. own viewpoints, and needed to be actively engaged. In addition, (Direct extract: The Communication Initiative. 2004, "Christian polio eradication partnership‐Angola". increasingly immunization programmers are realizing “…that Http://www.comminit.com/en/node/127795/292 interpersonal communication is more effective than mass media Accessed 21 May 2009) in bringing about positive behavior change among hardly reached and resistant households that have not responded positively to more general, mass media messages” (Murphy 2012). Enhancing ‘inter‐personal’ communication: Inter‐personal communication sounds like an effective intervention approach, however it has some challenges, in particular the amount of effort that is required as opposed to mass media communication strategies. However, nearly all of the studies in this section stress the necessity of inter‐ personal communication, in particular in relation to engaging with religious leaders or LFCs. Arora (2000) says, “all channels of communications are to be used. Interpersonal communication will remain the cornerstone for poor, backward and marginated communities who remain isolated and have minimal contact with mass media.” Interestingly, Waisbord (2004) found that interventions with religious leaders were less effective in rural than in urban areas (although the actual strategy is difficult to assess). Waisbord (2004) goes on to say note that sources of information are very different in urban and rural settings: “…whereas radio, television, and religious organizations (mosques, churches) and leaders (priests, imams) are effective means of information in cities ‐ interpersonal communication between caretaker with local leaders and health workers is crucial in towns and villages.” 31

31 It is interesting that although Waisbord (2004) observes that a particularly hard‐to‐reach community are those living on the move (migrants and refugees), they do not suggest religious leader engagement with this community. This might be an area for further engagement – as it has been strongly demonstrated elsewhere that migrants and refugees tend to tap into religious community networks wherever they land (see JLI report on resilience report as well). 52

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It is strongly motivated in the literature that interpersonal communication relies on a trusting relationship. Social mobilizers seek to leverage the ‘value‐added’ trust that religious leaders are supposed to have to make the information being communicated more authentic and effective. Intervention examples (to play on the trust of religious leaders) ranges from: local meetings with religious leaders, congregational announcements, vaccine posters having the image of religious leaders being given the vaccine, to communication and public trust at a national or international scale. Larson et al (2011) describe leveraging ‘trusted intermediaries’, and gives the examples of ‘brokers’ who rebuild trust in the OPV vaccine in Muslim constituencies, or “…when fears spread through Catholic pro‐life groups that the tetanus vaccine had sterilizing elements, WHO officials requested that the Vatican choose the laboratory in which the vaccine was tested, because it was a trusted institution for these groups.” However, it is important to note that a handful of studies indicate that religious leaders hold considerable trust and communicative ‘power’ at a very local level. It is suggested that religious leaders engaging in national level communication interventions are not as effective as local level engagement. Chaturvedi et al (2009) provide an interesting example of this, describing the mistrust marginalized Muslims have of (Muslim) elites in India – who “often appeared to have little credibility…(the) level of cynicism was so high in some of the extremely marginalized sections of minority that they even considered civil society as an intruder. Metro‐based minority institutions were perceived as the Muslim mask of Western influence. Information, Education and Communication attempts by Muslim celebrities and metro‐based Islamic institutions were seen with suspicion…” It’s about managing (the effects of) transnational information flows: One of the most interesting examples of the power of the internet is described by Larson et al (2011) – who point out that when a single pro‐life Catholic group, Human Life International, suggested that tetanus vaccines could cause sterilization, this travelled widely on the internet, as Human Life International communicated this to their members in more than 60 countries. This resulted in vaccine resistance in Mexico, the Philippines, Tanzania, and Nicaragua. (In Nicaragua, Catholic Cardinal Obando, a member of Pro‐vida, played a substantial part in stopping the tetanus immunization campaign in that region). UNICEF (2013b) observes that in June of 2012, the Polish Parliament voted to change the existing laws on vaccinations. “The Act on Preventing and Fighting Infections and Infectious Diseases in Humans and in The Act on National Sanitary Inspection has created controversy among social media users because of it makes vaccination mandatory. The anti‐vaccination advocates were sending petitions to the Polish President demanding him to stop the act. The petition received support from some representatives of the Catholic Church, but not an official support from the church as whole. Radio Maryja, the most powerful independent Catholic media in the country, also critiqued the act based upon the argument that vaccines are made based on cell lines derived from the bodies of babies killed by abortion; and the notion of unethical activities by campaigning teenagers and women to be vaccinated against HPV infection and it is ‘promoting immoral, and disorderly behavior in the area of sexuality’” (UNICEF 2013b).32 Larson et al (2011) note that “Although the damage caused by these anti‐vaccination campaigns has been largely mitigated by proactive measures by the Pan American Health Organization ‐ through engagement with the media and the Vatican ‐ the notion that vaccines contain sterilizing substances periodically resurfaces, most recently in the polio campaigns in Nigeria and India.” Kata (2010) conducts a study of anti‐vaccination misinformation on the internet and notes that (2010) points out that “the theme of morality, religion, and ideology was the least common content theme. Only 25% of websites argued against vaccination based on religious.” And as mentioned

32 We select this example from a range of others mainly because it is one of the few examples from Eastern Europe. 53

JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 earlier, UNICEF (2013) conducted an analysis of anti‐vaccination messages in eastern European social media, and found that religious and ethical discussions were active in Russian (with 96% of all anti‐vaccination discussions focused on this), however, this dropped considerably in other languages such as English, Romanian and Polish.

Leading to the next chapter As mentioned, as the literature becomes more fragmented and scattered, seeking to present a cohesive argument becomes more challenging. Some of the observations made in the sections above may seem somewhat contradictory at times. This might be because of the way we have chosen to cluster the material. However, it is also because the findings are themselves contradictory. For example, on the one hand are a mass of brief mentions of social mobilization efforts with religious leaders and local faith communities (so we know it is happening). However, there is not really enough information to judge the quality of that engagement, or the precise approaches or mechanisms that were utilized. The same can be said for communication activities – of which there are many slightly scattered remarks – from announcements from Mosque loud‐speakers, to guided interpersonal communication between small groups of women, to internet‐based international engagement in which the Vatican is asked to intervene. Although conflicting in specific intervention impact, these messages all indicate that religious leaders have influence – and that LFCs often have a coherent shared belief that can be leveraged for change. ‘Engagement’ with religious leaders and LFCs then becomes essential, and this engagement also needs to emerge from within a genuine understanding of local contexts and belief. Key strategies, lessons and intervention experiences (good or bad) still need to be properly recorded. All of this also requires programmatic staff and policy makers who are trained, sensitive and competent in local religious dynamics. With that in mind, after providing Table 2 (which references the various interventions as they appear in the current literature), we move on to Chapter 4, which addresses religion and immunization in relation to health systems.

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Table 2: Interventions and support services with/through LFCs and religious leaders This table provides a listing of examples available in the literature on interventions and support services with or through religious leaders, LFCs and FBOs. It is not in any way comprehensive, but rather gives some examples of practice (current and historical), arranged by country. In some cases, there is duplicate reporting on different aspects of the same intervention. INDIA Several studies point to the UNICEF‐linked polio strategy as being a multi‐pronged intervention which engages religious leaders and communities at several different levels, with a particular focus on the Uttar Pradesh region (we only provide samples here of a massive literature, see Hussain et al 2012, Murphy 2012, Obregón et al 2009, UNICEF 2004, UNICEF 2012b) UNICEF 2004 The Underserved Strategy: entails massive engagement of religious leaders, intellectuals, thinkers, doctors, teachers in UNICEF2012b Madrassas and undergraduate students in the monumental public health movement to eradicate polio. This includes Weiss et al partnership building, advocacy and interpersonal outreach targeted at certain segments of communities, including 2011 Muslims, scheduled caste Hindus, scheduled tribes and the poor. The Social Mobilization Network made up of over 3,000 community mobilizers, forming an interpersonal communication channel to reach nearly the entire state. This organizes a collaborative network of partners (ranging from WHO, Rotary, the Center of Diseases Control, the Government of India, GOI‐WHO National Polio Surveillance Project, state governments, the CORE Group of International NGOs, Rotary India, local NGOs and individuals of stature). The Rapid Response Model that originated in India (West Bengal, following the Murshidabad outbreak in 2011). “This model, utilizing NGOs already on the ground, is built upon a principle of rapid response and the opportunities that come from drawing on local resources already in place…Building on the strength of existing NGOs and civil society organizations, this model is used in areas of FATA and Balochistan, where workers from the NGO NRDF mobilize religious leaders based on their extensive social networks and experience with this group.” Coates et al SMNet in India: while some religious leaders had previously issued fatwahs condemning participation in child vaccination, 2013 “…after they began meeting with CMCs, they adopted SMNet messages, promoted participation in routine and campaign immunization services, and announced upcoming campaigns during worship services and meetings.” Obregón et al Social mobilization on polio is a focused strategy which includes the engagement of “influential Muslim training 2009 institutions (such as Aligarh Muslim University and Jamia Milla Islamia) and religious and community leaders were engaged in building public confidence and credibility in the Polio Eradication Initiative, improving coverage in underserved communities, providing support at district and settlement levels and countering resistance to polio vaccination in Uttar Pradesh. “In 2004, Muslim religious (2697) and community (1892) leaders were asked to participate in the polio campaign, resulting in 77% and 79%, respectively, of these leaders supporting the program’s efforts to convince resistant caregivers. They succeeded in 87% of cases in their coverage area, reaching 100% in some districts. This was a critical contribution to the reduction of the immunity gap among Muslim and Hindu children in Uttar Pradesh’s western region. The number of Muslim children who had not received at least two polio drops was reduced from 5% in 2002 to nearly 0% in 2004.” Obregon In 2004, UNICEF and PEI contacted a total of 2,697 Muslim religious leaders and 1,892 Muslim occupational and &Waisbord community leaders and asked them to take part in the polio campaign. 2,082 religious leaders (77% of those contacted) 2010 and 1,500 occupational and community leaders (79% of those contacted) participated in the campaign. Muslim influencers mobilizing or supporting efforts at converting resistant caregivers to vaccinate their children succeeded, on average, in 87% of the houses in their area of operation, reaching 100% in some districts. Government officials in the health sector also joined the alliance to both gain the trust of and help educate the Imams about OPV, followed by efforts aimed at encouraging community members to accept OPV. Involvement of religious and community leaders and influencers contributed to the reduction of the immunity gap among Muslim and Hindu children in the Western region of Uttar Pradesh. Muslim children in Uttar Pradesh who had not received at least two polio drops went from 5% to nearly 0% between 2002 and 2004. Hussain et al UNICEF’s Underserved Strategy and Social Mobilization Network (SMNet) improved communication between the GPEI and 2012 local communities by holding educational skits and plays about polio, and recruiting grassroots stakeholders such as religious clerics to advocate for vaccination. Murphy 2012 Engaging influencers: Involving high‐level community leaders as champions for a cause has been an effective behavior change strategy throughout the world. CGPP made it central to SM activities. In Muslim neighborhoods families have been particularly resistant to immunizing their children. They may believe that Islam is against immunizations or an imam may have spoken out against polio immunization. In such instances, high‐level Islamic leaders who are involved as community partners have taken action. Although not directly confronting those giving negative messages, they make positive statements about polio immunization from the pulpit (minbar) or from mosque loudspeakers and also give information on when and where children can be vaccinated. In group meetings called Ijtemas, held separately for men and women, both male and female leaders use exhortations from the Koran and the Haddiths to stress the obligation of parents to protect the health of their children. CMCs are often invited to speak at these meetings and are trained to do so. Many Muslim leaders also visit the homes of resistant caregivers to counsel them to immunize 55

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their children. The authority of male religious leaders combined with women’s trust in female CMCs is a powerful combination. Young women CMCs also have an opportunity to gain influence, respect, and visibility in their communities. In non‐Muslim areas, CMCs engage with Hindu and Christian religious leaders, who then speak in favor of immunization in their sermons and in other gatherings. CMCs also involve local political leaders such as members of the panchayat (town council) and other civil society leaders in the fight against polio and other vaccine‐preventable diseases. These leaders then encourage their constituencies to immunize their children and also visit homes of caregivers when necessary. CMCs and often their supervisors escort religious and other influential persons when they visit resistant homes. Visits from such influentials have been successful. In addition, Muslim and Hindu religious leaders have become convinced of the importance of immunization ‐ mosques and temples often offer space to vaccinators to set up booths in their premises. Arora 2000 It is broadly noted that the Pulse Polio Immunization Campaign in India has involved significant engagement with religious leaders as influencers. “Providers at district level were appreciative of the help rendered by religious leaders who accompanied health teams for motivating non acceptors. Influencers were of the opinion that religious bodies (Madarsa Shahi, Mufti Shahi) can help to counter the rumors prevailing regarding the polio drops that they cause sterility in children. District health authorities obtained endorsement from the Muslim religious leaders…’Shahi Imam has lot of influence and other imams will listen to him’ ‐ District Health Official”…“As a large section of the population comprised of Muslims, efforts were made beforehand for an effective and culturally acceptable delivery system. Imams (religious leaders) were invited to take part in public rallies, their appeal was printed on hand bills in Urdu and distributed, several immunization posts (polio booths) were opened at Madarsas, and to the extent possible women (health workers) were included in teams going for house to house visits on day 2 and 3 accompanied by the local school teachers.” Ghatak 2006 Two ‘secular’ development organizations, the Association for Social and Health Advancement (ASHA), and its partner organization ActionAid International‐India (AAI‐India), respond to the issue of religion as they work with working women and girls in a Muslim majority community in the district of Murshidabad in West Bengal, eastern India. Religious and political tensions were evident from the start of the work in Murshidabad, and trouble began when ASHA teamed up with the government on the polio campaign, when ASHA’s connection with the government made the community suspicious of its motivations and allegiances. “Some people in the community were persuaded to refuse immunization, and large numbers of Muslim men forbade their wives from taking children to immunization clinics. However, some prominent Muslims, including maulvis or religious leaders, spoke out in favor of immunization. Despite this difficult start, ASHA has gradually come to be treated with less suspicion and more trust…Plans are going ahead for discussions on these sensitive issues with academics, religious leaders and women and girls from the community. Both ASHA and AAI realize that religious and cultural practices have to be questioned systematically.” PAKISTAN Several studies point to the UNICEF‐linked polio strategy as being a multi‐pronged intervention which engages religious leaders and communities at several different levels in Pakistan (see UNICEF 2004, UNICEF 2012b) Obregón et al “Engagement of religious leaders to counter refusals due to religious reasons or misperceptions has yielded similar results 2009 in Pakistan’s north‐west frontier province. Data from 2007 show that, after involving religious leaders in polio eradication activities, coverage of children in families refusing due to religious reasons increased from 13% in August to 17%in October, and coverage of families refusing due to misconceptions increased from 37% to 50% in the same period.” Obregon and “Religious leaders also have contributed to addressing refusals and misperceptions in Pakistan’s North‐West Frontier Waisbord 2010 Province (NWFP). Results from 2007 showed a sustained increase in coverage and vaccination of children among families who previously had refused OPV…Engagement of community and religious leaders has shifted from enlistment to disseminating messages that motivate families to vaccinate their children, to weekly community meetings and targeted interaction with religious leaders to discuss benefits of polio vaccination and address rumors and misperceptions in a more dialogic manner. This process has turned community meetings into broader community dialogues that allow them to interact with local authorities and address local development issues. In the long run, this component of SM has increased the motivation of religious leaders and community influencers to support PEI.” “Male door‐to‐door teams were not effective due to the custom of not permitting unrelated males to enter homes. “As a result, female vaccinator teams, who could reach female child caretakers with the youngest children under their care, were formed and trained to visit families unwilling to vaccinate newborns” UNICEF 2011a UNICEF describe a case in 2010 in Urmar Mera, Peshawar district – where “local Imam Maulana Humayun refused to immunize his children. Despite typically high acceptance rates, the entire village followed the Imam’s example and refused immunization. A Jirga, or meeting of religious and tribal leaders, was held at which the Imam was able to express his concerns. Attending Inter‐religious Council on Health (IRCH) workers engaged the group in dialogue on the value of immunization in light of Islamic teaching, and they shared numerous fatwas already issued in favor of vaccination. They also invited the Imam to inaugurate the next immunization round, to which he agreed, immunizing his daughter before the entire village. He followed with a speech expressing his satisfaction that the vaccine was both safe and effective. After the Imam answered further questions, the community took the step of requesting routine immunization services” UNICEF 2012 “FATA, Karachi and the Quetta Block remain the strongholds of mistrust. In addition, lack of access in some areas of FATA and Karachi means that the real magnitude of the challenge in the most difficult areas is not fully understood. Deeper analysis of 2012 Knowledge, Attitudes and Practices (KAP) survey data has shown that FATA parents are 40% more likely

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to refuse OPV than in any other part of the country, mostly due to beliefs that it leads to sterility and is composed of ingredients that are not halal. Despite such sentiments, refusals have been on a consistent decline…This data does not reflect the opposition to the program and the strong tendency to reject the vaccine in the districts of North and South Waziristan, where Taliban‐inflicted polio‐bans have prohibited all access since July. Against this background, the stark decline of refusals in Pakistan’s other high‐risk areas is all the more impressive, particularly because it demonstrates the power and effectiveness of social mobilization that engages all segments of society, focuses on addressing specific misconceptions and utilizes multiple communications channels. Progress in FATA is largely due to the concentrated and rigorous outreach to religious and traditional leaders, alongside persistent mobilization by Communications Network (COMNet) staff and localized media support.” UNICEF 2013 “Almost 5,000 schools and madrassas promote polio eradication on a monthly basis, and religious leaders have issued more than 30 fatawa in support of OPV. Mobilizers and vaccinators promote these fatawa using a fatwa booklet that they carry with them…” “…Qari Aqeel. As a teacher at a madrassa in one of Karachi’s poorest areas, Aqeel educates children in the fundamentals of Islam and the Holy Quran. He also tells students, from his own painful experience, what it is like to live with polio…As a devout Muslim, Aqeel takes his role as guardian of the children under his care very seriously. He talks to parents and children about the importance of vaccination from an Islamic perspective and tries to personally ensure that every child at the madrassa is vaccinated against polio. Clear guidelines are given, in an Islamic Hadith, about the personal responsibility of every Muslim to care for others: “All of you are guardians, and all of you will be asked about the wellbeing of those who you are responsible for.” Pakistan’s government, with support from UNICEF, has begun to shift its polio communication approach to highlight the risk of the disease and emphasize vaccination as an Islamic responsibility. As a part of this initiative, Aqeel has recently stepped further into his role as guardian…In a video aired on Pakistani television, which aims to reach 71 million Pakistani households, Aqeel takes the spotlight away from the politics and misunderstandings that can muddy the dialogue about polio vaccination…” Nisar and Prime Minster’s Polio Monitoring & Coordination Cell Progress report, shows a range of religiously‐affiliated activities, Kanwal 2012 such as meeting with Imams of Mosques “A meeting of Imams of various mosques of Islamabad and Vice President of Islamic International University with Ms. Shahnaz Wazir Ali and Advisor to DG WHO was held in Jama‐e‐Banoria on September 17, 2012. Participants discussed the inclusion of polio and child health in teachings to Imams”; meeting with the Vice President of International Islamic University Islamabad “…to discuss the more proactive and positive role of religious leaders in Polio Eradication Initiative”; collaborating with the International Islamic University Islamabad; and meeting with the Mission of Islamic Development Bank” Yasmeen 2012 In 2012, the head of the moderate Pakistan Ulema Council, alongside the leader of the largest madrassas in Lahore, said CIFA‐WFDD that 24,000 mosques and madrassas would preach against the killings of health workers during Friday prayers. The 2013 response was accompanied by nationwide protests led by Pakistani clerics following a series of shootings of polio vaccine workers, including the death of five female health workers in Karachi PHILIPPINES O’Keefe in Catholic Relief Services partners with local Muslim NGO Kaatuntaya Foundation to provide EPI and pneumonia and Aylward2012 diarrhea care in Maguindanao, a conflict region in the Philippines NORTH KOREA Aylward2012 In 2010, Caritas worked with North Korea’s Health Ministry to immunize one million children against Hepatitis B CAMBODIA Aylward2012 Buddhists have participated in national immunization days in Cambodia, and through collaboration between Buddhist monks and UNICEF in the Mekong region, thousands of monks and nuns have educated people about HIV/AIDS, avian influenza, and other diseases. TAJIKISTAN Aylward2012 For the polio campaign in in June 2010, UNICEF’s communication and social mobilization effort included distributing leaflets and posters to mosques USA Bond et al 2013 Project VIVA engages in annual influenza vaccination through CBOs and FBOs – noting … FBOs in particular were recognized as important for outreach education and possible sites for immunizing the community” Hirano 1998 The Arizona partnership for infant immunization (TAPII) is/was a PPP intended to achieve the year 2000 goal of 90% infant immunizations. Created in 1992 as a means to develop a statewide approach to improving infant immunization rates, TAPII is a broad‐based partnership that includes public health departments, managed care plans, professional organizations, medical organizations, pharmaceutical companies, businesses, the faith community, and many others Danielsetal2007 US‐based on‐site adult vaccination program and study involving 15 churches (intervention group) and a control group EL SALVADOR Hanmer2010, During the Civil War in El Salvador, the Catholic Church negotiated a ceasefire to allow children on both sides of the UNICEF2012c conflict to be immunized

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GUATAMALA Flores et al Since around 2007 thousands of young missionary members of the Church of Jesus Christ of Latterday Saints (Mormons) 2011 went door‐to‐door in Guatemala as part of a social mobilization campaign promoting measles vaccination HAITI Yemen 2010 Adventist Development and Relief Agency conducts immunization for children as part of maternal health package program JAMAICA Kiser & Michael In the early 1970s, the Bethel Baptist Church Ministry began offering over 20 different health services in Jamaica, and as a 1999 result of this program, 90% of teens and young adults used family planning services, there was a documented decrease in adolescent pregnancies, and the child immunization rate increased to 100% EGYPT UNICEF2012c Before announcing Egypt as polio free, UNICEF Egypt requested the Grand Mufti to issue an important fatwa that encouraged and mobilized caregivers during the undertaking of the intensive polio campaigns Kaufmann & When rumors about the polio vaccine circulated among Coptic Christians in Alexandria Egypt, in 2002, vaccinations were Feldbaum2009 done in the churches, to counter the rumors ANGOLA UNICEF2004a Beginning in 1998, UNICEF created alliances with Angola's Christian churches in a communication initiative to end polio. Churches were enlisted as social mobilizers. Religious leaders and volunteers from both sides of the conflict—the Council of Christian Churches in Angola and a Catholic lay group, the Legion of Mary—to gather over 20,000 religious mobilizers in their respective churches in 10 of the country’s 18 provinces. Volunteers were trained to dispel rumors and link the goal of saving lives through vaccination to Christian values. Murphy 2012 UNICEF applies the same Rapid Response Model that originated in India in Angola, “where over 10,000 religious leaders UNICEF2012b are engaged through NGO networks in and around Luanda” DRC UNICEF2011a In response to a sharp increase in refusals, a series of communication interventions were carried out to engage religious groups in stronghold areas of resistance. Most notable is a social mapping of refusals in the Kalemi district. All religious groups were identified, together with high risk populations living in the area. In‐depth meetings were held with all the groups, and their concerns documented and discussed in detail over the course of several weeks. This resulted in 7 of 9 resistant religious groups accepting vaccination, with some even signing ‘petitions of engagement’ that documented their commitment to advocating for OPV vaccination amongst their religious followers. Similar activities are now being implemented in Bas Congol, Kasai Orientale, Bandundo, Kinshasa and Sud‐Kivu to tackle persistent refusals in these areas. The five big religious entities in the country have also established a formal partnership with UNICEF, and have enlisted their leaders to promote polio vaccination. UNICEF 2012b In Katanga, more than 40% of missed children have remained unvaccinated due to overt refusal during the first quarter of 2012. Religious refusals account for an estimated 3%–4% of the province’s total population of under‐5 children. The reduction of missed children in Katanga can be traced to substantial engagement with religious leaders who oppose OPV. In January, communications staff met with leaders of the country’s seven most resistant religious groups, including the Kitawala Philadelphie, Watch Tower Bible, Postolo, and the Church of Blacks in Africa (Église des Noirs en Afrique). The meeting resulted in a breakthrough, with three groups agreeing to comply with vaccination campaigns. Some continued to refuse actively, while others wished to consult with their communities before making a decision. More work is needed, but progress is being made (UNICEF 2012a). “Local community members from some of the major religious groups who refuse the vaccine are asked to participate in the program by facilitating debates about vaccination. In place of more aggressive, coercive vaccination techniques used in the past, this dialogue has led to excellent results. The project is now expanding this work to another 240 facilitators in six more health zones in the area” Hanmer 2010 “UNICEF is working with five of the largest Christian, Muslim, and Traditional religious groups to promote at household and community levels key child survival practices, such as exclusive breastfeeding, hand washing, immunization, and use of insecticide‐treated mosquito nets. The five groups were strategically selected based on their credibility and capacity to promote behavior and social change, as well as their representation of a vast majority of the Congolese people. Together, their networks have the potential to reach more than half of the estimated 65 million people…” ETHIOPIA Hanmer 2010 UNICEF partnered with the Ethiopian Orthodox Church so that at baptisms caretakers are asked by priests about the immunization status of the child and encouraged to complete the vaccination schedule within the child’s first year Murphy 2012 The Secretariat of the UNICEF‐linked CORE Group project (CGPP) in Ethopia is hosted by the Consortium of Christian Relief and Development Association (CCRDA). The 11 CGPP partners include seven PVOs with on‐the‐ground experience in Ethiopia — American Medical Research Foundation, CARE, ChildFund International (formerly Christian Children’s Fund) International Rescue Committee, PLAN, Save the Children, and World Vision — and four local NGOs: Alemtena Catholic Church, Harerghe Catholic Secretariat, Ethiopian Evangelical Church Mekane Yesus, and the Pastoralist Concern Association of Ethiopia. As part of this suite of activities, volunteers identify leaders in the community and approach them

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to solicit their aid in influencing families to immunize their children and participate in surveillance. These include Christian religious leaders in most communities and Muslim leaders in the predominantly Muslim areas such as the Somali region. “The religious leaders are true partners and suggest and implement ideas such as including immunization and surveillance messages in sermons during services and at other meetings of the faithful” NIGERIA UNAIDS 2007 “Following initial success in reaching more zero‐dose children through the partnership with Mallams of Koranic schools in December last year, many States have expanded this initiative. The figures of children being reached are constantly in the tens of thousands. Of particular example are the efforts of the three high risk States of Kano, Katsina and Jigawa during the March 2006 round of Immunization Plus Days…Groups like the Federation of Muslim Women Associations (FOMWAN) visit households to promote the benefits of polio and routine immunization. A primary outcome of their efforts is that they are able to identify newborns and zero‐dose children and to follow up to ensure that they are immunized during the campaign or mop‐ups. In addition they conduct advocacy visits to Islamiya schools, often followed by sensitization of the teachers on the benefits of polio and routine immunization. They also facilitate Tafsirs (religious pronouncements) during Walimas (community social events) or Islamic gatherings. Cases of non‐compliance are referred to the group Leader (the Amira) who often works with senior Mallams and the traditional leaders to resolve the situation.” UNICEF 2011b “UNICEF works with local partners such as Modibo, a local FII in Sokoto State of Northern Nigeria ‐ piloting several ‘bottom‐up’ approaches to mobilization. MODIBO is a faith‐based women’s association…whose members conduct sensitization and compound meetings with women during social events, such as naming and wedding ceremonies” GHANA Diamenu & “WHO provided both technical and financial support for 6 districts in 2003 to begin the implementation of the Reaching Eshetu 2005 Every District approach…implementation process included: support for low performing and hard‐to‐reach districts, involvement of private mid‐wives, immunizing on market days, and use of leaders of religious groups and traditional rulers. Part of the strategy to increase the communication network for immunization services involved funds for four districts to organize orientation and sensitization workshops for religious leaders (Jasikan, Kpando, Nkoranza and Afram Plains). Through this initiative, Religious leaders are recognized as influential individuals, with attributes that can support health care delivery programs if they are involved. More than 300 representatives from various religious groups, including Muslims, attended workshops in the districts – and it was noted that ‘Church groups will from time to time monitor the immunization status of children in their congregation and inform health authorities for the appropriate action’” SUDAN Aylward 2012 Tearfund provides EPI in parts of South Sudan where the vaccination coverage rate is as low as 6, percent, coordinating with the government, UNICEF, and other partners SIERRA LEONE UNICEF 2004a A social mobilization program called Marklate or ‘vaccinate’ in the local language was begun – and in a radical move, 25% of program resources were dedicated to social mobilization and training, involving all levels of society. This UNICEF‐ supported social mobilization effort included Islamic and Christian leaders and groups at all levels. ZAMBIA Aylward 2012 Episcopal Relief & Development, in partnership with the Global Alliance on Vaccines and Immunization (GAVI), Zambia's ministry for health and the Zambian Anglican Council, began rolling out a pneumonia vaccination program in 2012 MOZAMBIQUE Chand & World Relief’s Care Group Model trains volunteer health promoters in Mozambique: every household in five health Patterson 2007 districts learns the truth about hygiene, nutrition, immunizations, diarrhea, malaria control. The project demonstrated massive increase in immunization uptake as a result.

Source: compiled by authors (direct quotes paraphrased)

Note: many of these ‘mentions’ are presented anecdotally in the literature, so their sources have not been verified further

Note: still to be added are the activities of institutions known to be engaged in immunization support but for which there is no obvious literature. In particular – a quick survey of organizational websites, suggests the following organizations are engaged in routine and programmatic immunization interventions: Aga Khan Health Service; Catholic Relief Services; Consortium Christian Relief and Development Assoc (Ethiopia); CORDAID; Catholic Medical Mission Board; Ecumenical Pharmaceutical Network; Episcopal Relief and Development (who are known to be engaged in immunization support through local faith communities in Bangladesh, Angola and Zambia); Ethiopian Orthodox Church Development and Inter‐Church Aid Commission (Ethiopia); IMA World Health (working in Sudan and DRC); Islamic Relief; Map International; Salvation Army; SANRU (Santé Rural, Democratic Republic of Congo); World Vision et al

Note: We continue to invite further contributions: [email protected] 59

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4. HEALTH SYSTEMS, COMMUNITY SYSTEMS AND IMMUNIZATION

This chapter addresses issues of religion and immunization that relate to health systems – such as access, human resources and in particular, ‘routine’ immunization services This last chapter is in the unenviable position of being the area that has been least explored in the past and which might be the most relevant to the questions being raised by the JLF&LC and others, but also has by far the least available Box 15: Clarification about FBHPs information. Data on faith‐based health providers (FBHPs) is By ‘FBHP’, we include all institutions whose primary function is the provision of health care – usually Christian notoriously fragmented with significant data gaps. Although or Muslim hospitals and clinics, as well as their organizing many FBHPs might have been in operation for decades, and umbrella organizations. might have in fact established modern health systems in many As noted above, there is some ‘fuzziness’ to these classifications. For example, this is inclusive of countries, they tend to operate ‘under the radar’ – and only a  local FBHPs such as the members of the Christian few years ago were considered ‘invisible’ to the health systems Health Associations in Africa in which they operate (see Olivier and Wodon 2012a 2012b).  large international ‘denominations’ that support their local religious bodies in operating local health services, It is interesting to consider that in the colonial era, ‘mission such as the Salvation Army who operates local health providers’ were often the primary providers for vaccine delivery services and programs in 124 countries in many countries. However, over time, global health and  and international FBOs, such as IMA World Health or Islamic Relief Worldwide that support health systems national health planners became collectively blind to FBHPs. and services globally and in fragile contexts, which FBHPs are now most commonly classified as part of the private‐ might include direct support of health facilities. not‐for‐profit (PNFP) sector, although this classification is Key Characteristics of FBHPs sometimes not entirely comfortable, as FBHPs tend to operate We identify some of the key arguments that are made in support of or as part of the public system in many ways. Said about the distinctive nature of FBHPs in development differently, they are usually more ‘public’ than ‘private’ in their contexts: orientation towards providing quality health services to the  FBHPs provide a significant amount of services, although the exact degree of that significance is ‘rural’ poor. challenged (e.g. in some countries in Africa have a very low presence, and in others operate most of the health Most (if not all) FBHPs would be engaged in routine systems) immunization services of some kind or another – as will be  FBHPs are usually clustered as private‐not‐for‐profit discussed, either as part of routine maternal and child health providers in the national health system layout, but are (MCH) services (on which FBHPs tend to place a significant also frequently designated or subcontracted as ‘district’ (public) hospitals focus); in partnership with national public vaccination  Have a stated intention of providing the poor in rural programs; or as part of public health ‘outreach’ activities into areas with quality services – although the financing of communities. this remains a fundamental challenge, and often requires creative financing setups We will suggest upfront that a valuable area of further research  Are often considered to have ‘value‐added’ character would be to gather this fragmented information on FBHPs’ such as higher quality, preferential option for the poor, higher availability of drugs, or a more people‐centred routine immunization services as a worthwhile research project quality of care in its own right. Certainly, the published accessible literature  Have huge variation, and little evidence: e.g. from does not do justice to what those on the ground report is a massive FBHP networks in the USA to isolated Islamic hospitals in Africa significant contribution to immunization targets and MCH more  In Africa are commonly represented at a national scale broadly. by ‘Christian/Muslim Health Associations’ – who increasingly have contracted relationships with This chapter draws heavily from the data archives of the government that cover issues such as financial or staff International Religious Health Assets Programme (IRHAP), as subsidy or immunization involvement. well as from a collection of paper published through the World  Are often connected to international funding and Bank that gathers evidence of African FBHPs (see Olivier and coordinating bodies in a variety of ways (see Olivier & Wodon 2012a 2012b 2012c 2012d)

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Wodon 2012b, 2012c, 2012d), for which there is also only limited date, but still more than other regions. It is important to note that FBHPs in other development contexts are hugely and problematically under‐represented in the current literature. There is barely any information on Asian or South American FBHPs. In addition, the data on Africa, is also unfortunately slanted towards the Christian health providers (who have a larger presence in most countries, and more established organizing and advocacy bodies), and those whose reporting is done in English (that is, Anglophone countries). For example, we know that there has been continued growth of Islamic FBHPs in Africa, but these are currently barely visible. There is some literature on FBHPs which is deeply embedded within other texts, and therefore does not get picked up by standard searches and reviews. For example, Levin and Kaddar (2011) review the literature relating to the private sector provision of immunization services in LMICs. They note that the private sector is playing different roles and functions – depending on factors such as economic development levels, and the configuration of the private sector in that system. While Levin and Kaddar do not directly use the word ‘religion’ or ‘faith’ – they do note that “The not‐for‐profit sector plays an important role in extending access to traditional EPI vaccines, particularly in low‐income countries…Although numerous studies on non‐governmental organizations (NGOs) suggest that the extent of NGO provision of immunization services in low‐ and middle‐income countries is substantial, the contribution of this sector is poorly documented, leading to a lack of recognition of its role at national and global levels.” In many LMICs, FBHPs make up most of the PNFP sector, however, such extrapolations need to be drawn out of the literature. At this time, estimates of the degree and character of engagement of FBOs and FBHPs in immunization services involves quite a lot of guesswork. For example, previous reports on religion and immunization might present the general market share of FBHPs versus public provision in a particular country, and conclude from that that immunization services ‘must be’ a similar percentage share. In the same way, in this field of enquiry it is common to reference to reports on CSOs or NGOs, and draw from that the conclusion that since FBOs are present within that cluster, they must have similar estimates. For example (and not a critique as this is a common strategy), Aylward (2012) notes in their report on religion and immunization that “GAVI reports that CSOs provide up to 60 percent of immunization services across the 56 GAVI‐eligible countries. While the activity of [faith inspired organizations] is not broken out, given the large share of FIOs within civil society, the statistic suggests a significant role for FIOs in immunization. GAVI further reports the country‐specific information that CSOs provide 8 to 12 percent of routine immunization in Bangladesh, 30 to 50 percent in Cambodia, and up to 40 percent in Ghana.”33 We mention this here, as it is our intention in this review to avoid extrapolated estimates as far as possible (although as can be seen below, given the paucity of actual data, this is sometimes impossible to avoid). We would argue that to be able to provide actual evidence‐based estimates on the size, character and significance of the contribution of FBHPs to immunization campaigns, routine immunization and health systems ‐ more (and urgent) research work is required that cannot be satisfied through further review, secondary analysis and stakeholder interviews (as is the main method of this review, and the ones that precede it). As in the previous chapters, in Table 4 at the end of this chapter we provide a listing of reference data grouped by country. In this case, we list references to evidence of FBHPs engagement in routine immunization services. It should be noted that there is some fuzziness around what is routine and what is episodic. For example, FBHPs might frame immunization services as part of routine MCH or primary health care, as a side program, or as public health community outreach. We have attempted to focus mainly on those descriptions of immunization services

33 We will not unpack this here too much, however, it is worth noting that in Ghana, for example, FBHPs (under the umbrella of the Christian Health Association of Ghana) are noted to provide around 30‐40% of health services in Ghana. It is unclear whether this figure from GAVI is a simple extrapolation of this commonly held wisdom, or whether this is an actual estimation based on GAVI data.

61 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 that involve the actual administration of the vaccine to the patient (although FBHPs are commonly also engaged in a variety of immunization support activities such as education, transport or training); those that are conducted in a sustained manner, rather than once‐off vaccine drives or campaigns; and HSS activities that are related to strengthening routine immunization.

4.1 Why Health Systems Strengthening for Immunization? In the last few years this has been a massive shift of attention in global health generally, and immunization intervention more specifically, towards ‘health systems strengthening’. This emerged based on a realization that the delivery of immunization services and vaccines is largely dependent on the strength of the existing health system for delivery. And worryingly, the health systems in the contexts where immunization is most urgently required – such as the development contexts discussed above – tend to be weak (see Levin and Kaddar 2010). Many international institutions have now stressed the importance of health systems strengthening in relation to immunization. For example, one of the GAVI Alliance’s main strategies (for immunization) is health systems strengthening (HSS) – noting that “by the end of 2010, GAVI had committed US$568 million to health system strengthening support.”34 Murphy (2012) highlights the importance of HSS to the CORE Group’s social mobilization efforts in support of polio eradication, noting that in all their operational countries, efforts were made to support the government’s immunization program in areas such as cold chain management, health worker training, quality control, logistics, and supportive supervision. Murphy also notes the importance of implementing activities: “…targeted to a specific disease in a way that supports and strengthens related health services. Health facilities in poor communities are understaffed and underfunded, making it difficult to provide good‐ quality routine immunization and other child and maternal health services. Mothers referred to poor‐ quality health facilities for routine immunization who must wait for hours and face stock‐outs understandably form negative opinions and these opinions spread through social networks. Furthermore, children vaccinated only through [Supplemental Immunization Activities] are less likely to receive enough doses to ensure immunity. A strengthened routine immunization system is essential to gain acceptance among communities and to achieve full immunity to the wild poliovirus. Supporting the routine system for delivering immunizations is not an add‐on component that would be a nice extra benefit, but an indispensible element of successful eradication” (Murphy 2012). Clements et al (2006) concludes that one of the main determinants of the Nigerian OPV vaccine boycott was a weakened health system. They note that the national health system has suffered in the last three decades, the primary health care system (through which routine vaccination would occur) has been in decline, especially in the northern regions and there is one consistent pattern “where routine vaccination rates are poor, poliovirus infection rates are high.” Of course, strengthening health systems (a ‘horizontal’ approach) around immunization (traditionally a ‘vertical’ program) is sometimes a challenge. In fact, several studies note the sometimes damaging effects of global vertical immunization programs on the local health system (for example, noting that the huge attention and budget of the global polio eradication program has skewed attention away from other important issues and unbalanced

34 http://www.gavialliance.org/support/hss/ [Accessed 10 November 2013]

62 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 routine systems functioning, see Closser et al 2012).35 The strongest example of this concern can be seen in the revitalization of a WHO working group, the ‘Strategic Advisory Group of Experts on Immunization’ (SAGE) to examine the question of whether “..new vaccine introductions (NVIs) have positive or negative impacts on immunization and health systems of countries?” (see Wang et al 2013). This group finds that "while reductions in disease burden and improvements in disease and adverse events surveillance, training, cold chain and logistics capacity and injection safety were commonly documented as beneficial impacts, opportunities for strengthening the broader health system were consistently missed during NVI. Weaknesses in planning for human and financial resource needs were highlighted as a concern…future NVI should explicitly plan to optimize and document the impact of NVI on broader health systems” (Wang et al 2013). Tomori (2011) analyses the Nigerian polio boycott and argues that “Initial efforts to counter these allegations failed woefully, as it centered on citing scientific evidence, while paying little attention to the cultural and religious sensitivities and political dimensions and ramifications…The concerns were not confined to the safety of polio vaccine only, but also relate to questions about the appropriateness of vertical health interventions, where levels of routine immunization are low. While the GPEI was considered to be cost‐effective by Western donors, field workers saw the initiative as undermining primary health care.” Weiss et al (2012) evaluate the unanticipated consequences of polio eradication efforts by the CORE Group Polio Project (CGPP) in India which has explicitly focused on strengthening routine immunization. Weiss et al (2012) find that while routine immunization coverage increased over their study period, it is possible that routine immunization coverage would have increased even more in the absence of polio eradication efforts, but note there is little evidence. Bonu et al argue: “As the global polio eradication efforts narrow down to a few geographical regions of the world with wild poliovirus transmission, geographical regions that also share some of the most challenging social and health systems barriers to public health, it may be essential to strengthen health systems and address social challenges in addition to ongoing polio campaign. A multidisciplinary understanding of social, cultural and health systems‐related realities in these areas may be essential to resolve the remaining challenges to polio eradication. Questions remain about the other consequences of globally mandated disease eradication program on floundering health systems in the most backward regions of the world. What have been the ‘opportunity’ costs of global disease eradication program for poor societies that had committed scarce resources to fulfill a global mandate? How can a disease eradication program ensure ‘efficiencies’ and ‘effectiveness’ in reducing overall disease burden by strengthening the routine health systems, while also succeeding in eradication of a disease? Unfortunately, we do not have convincing answers. Further health systems operational research to evaluate different aspects of global disease eradication program implementation ‐ including polio ‐ can contribute to make health systems more effective and efficient” (Bonu et al 2003). The ARISE (Africa Routine Immunization System Essentials) project that was set up in 2009 (to consolidate learning on routine immunization strengthening) observes in a recent report that while routine immunization has been called the ‘backbone’ of immunization programs, in concrete terms its importance is not yet realized (we apologize for another lengthy extract, however this seems an important observation). “When it comes to provision of support for RI, however, particularly for the recurrent costs essential to program operations, a gap remains between the rhetoric and the reality. Initiatives to eradicate polio and

35 The title of a recent paper by Closser et al (2012) is rather descriptive of this issue: “Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care"

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eliminate measles have built support for RI, to a limited extent, into their budgets and into the activities of their technical field staff as time permits. But the vast majority of their resources cover costs directly associated with controlling those diseases…The GAVI Alliance, with its focus on the introduction of new and under‐utilized vaccines (NUVI), has a strategic objective of strengthening health systems and immunization service delivery. However, less than 15% of GAVI’s budget is for non‐commodity support, including support to the country programs responsible for ensuring that children and other target groups actually receive the newly‐introduced vaccines. A similar situation is apparent in the plans of technical agencies; for example, less than 5% of the budget for the 2012 immunization plan of action for the Africa Regional Office of the World Health Organization is devoted to routine immunization system strengthening—and that line item is not fully funded. This situation has been observed each year for over a decade” (Fields 2012). They also observe in this report that in districts with highly functioning routine immunization, there is good formal engagement with “local political, religious, and traditional authorities, women’s associations, and local NGOs. And give the example from a key informant: ‘At the mosque, we welcome nurses and vaccinators during immunization campaigns. Sometimes they just come and give us the messages for us to communicate to our members. We have a health committee. Ismala, one of the followers of the mosque is the chairman of that committee” (in Fields 2012). A tantalizing hint that well‐functioning routine immunization services are those that have good relationships with (amongst others) local faith communities. It is important to understand that this is the scholarly and policy context into which a focus on FBHPs, immunization and HSS falls. However, while there has been some recent attention in health systems research on immunization, or the introduction of a new vaccine, as a ‘tracer’ for health systems strengthening ‐ as far as we can see, there is little literature which considers these issues of HSS in relation to FBHPs specifically. Said differently, there is no health policy and systems research which addresses, for example, the impact of the introduction of a new vaccine program on the PNFP faith‐based sector in particular; what routine immunization might mean in specific health systems contexts; or what investment or interventions have been made in strengthening the health systems of which FBHP are a part. It would seem logical that these are all urgent areas for further investigation.

FBHPs immunization assumed (and subsumed) as a part of national strategies We suspect that part of the reason for this lack of attention (apart from the general religion‐blindness of public health) is that the routine immunization provided by FBHPs is often assumed to amalgamated as part of national immunization strategies (often called an Expanded Programme on Immunization, EPI). Aylward (2012) points out that “Global health policy maintains that immunization is primarily the province and responsibility of the national government since cradle‐to‐grave vaccine provision is a complex business. Thus, faith‐inspired organizations do not, and arguably should not, engage in administering vaccines to patients unless in conjunction with the government, except in specific circumstances such as fragile states or emergencies. As a USAID official said, ‘The days when FBOs operate apart from and unknown to the Ministry of Health and with their own vaccination schedule are past.’” This raises some questions at a policy level about whether FBHPs are not seen as important in routine immunization or systems strengthening. It also raises questions about whether FBHPs see immunization as important – and whether they understand HSS to be connected to the ‘add‐on’ routine immunization services they provide for government. A study conducted in Uganda hints at this, when a participant from the Uganda Catholic Medical Bureau (UCBM) talked about the nature of PPP in Uganda, saying: “…the issues raised by the MoH for discussion tended not to be about the main concern for PNFPs, namely, human resources [which is a

64 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 main concern]. Instead, they focused on logistical or technical problems like reforming the accounting or health information system, or how to increase the vaccination coverage, issues on which PNFPs might not feel they had a particular contribution to make” (in Schmid et al 2008). Aylward reports on a 2009 analysis by the WHO on private sector immunization LMIC countries.36 “The authors found that not‐for‐profit private sector organizations (NFPs), which would include faith‐ inspired organizations, tend to provide the same vaccines as national programs, but reach areas where access to government health services is low. They thus increase access to basic vaccines, serve the under‐ served and marginalized, and reduce disparities in vaccine coverage. The study found that when NFPs administer vaccines, governments generally provide the vaccines and related supplies, and that governments and/or donor agencies sometimes contract out or contract in with NGOs for service provision. The survey of the literature conducted in the WHO analysis found that, for the time periods covered in the different studies, NFPs accounted for 22 percent of immunization in Bangladesh and 30 to 40 percent in Cambodia. No data on immunization by NFPs was found for Latin America. For Africa, the identified data were for percentage of facilities providing immunization services, and indicated that the share of NFP facilities that provide vaccinations is 70 percent or higher in Ghana, Kenya, Rwanda and Uganda; for Kenya, it was reported that 97 percent of the country’s NFP health facilities provide immunization” (WHO 2009 as reported in Aylward 2012). Again, this would be absolutely key data – however, it is difficult to unpack these estimates (not knowing how they were calculated or just how many were faith‐based or not. However, supporting Aylward’s assessment, certainly ‘most’ PNFP healthcare providers in Africa are, in fact, faith‐based. In addition, as can be seen in Table 4, from the FBHPs perspective, the majority of FBHPs in Africa do report being engaged in national immunization programs, and that this is often a formal and contractual arrangement with government. An interesting report by IFC and the World Bank in 2011 called, Healthy partnerships: how governments can engage the private sector to improve health in Africa – mentions several times that public private partnership (PPP) around immunization is one of the few areas of collaboration between African governments and private providers that is working well.37 In a section titled ‘Good public‐private collaboration: Specific disease or vaccine programs’, the authors observe that “The private sector participates widely in government disease and immunization programs across the region, marking one of the better areas of engagement. Private providers are included in these programs in 66% of [45 surveyed] countries…Significant, positive spillover effects emerge from this collaboration, especially in terms of increased dialogue and information exchange.” They stress the strategy where private health providers are receiving vaccines from government for distribution as part of a national immunization strategy. This report also then gives the example of the Christian Health Association of Lesotho (CHAL), as the ‘private sector’ to which the Lesotho government supplies drugs and vaccines to as part of its national program (and indeed, stresses the importance of FBHPs as a core component of the ‘private sector’ they are reviewing). The authors comment that this is “one relatively uncontroversial avenue for engaging the private sector…providing financial or technical assistance for activities that have large public health benefits.” This goes counter to an argument made by Khaleghian (2013), also of the World Bank, that ‘private providers’ are not interested in immunization, saying: "constraints on geographic exit have been discussed already, but other types of exit ‐ attending private providers rather than public clinics, for example ‐ are also of limited relevance

36 It would appear to be based on a presentation by Levin and Kaddar (2009), ‘Role of private sector in provision of immunization services in low to middle income countries’ – however we were unable to verify this reference or source the presentation. 37 It is interesting to note that it appears that most of the data in this report is primarily based on PNFP data (which is much more readily available in Africa than private‐for‐profit.

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when, as with immunization in developing countries, Box 16: FBHPs and the Expanded Program on Immunization private providers generally have little interest in the in Malawi service or are unaffordable to the majority of The Christian Health Association of Malawi (CHAM) is households…” However, we question whether perhaps estimated to provide around 40% of health services in Malawi this observation is not based on private‐for‐profit (as estimated on hospital bed distribution in comparison with public facilities). providers, who would certainly not necessarily be that CHAM has a formal agreement with the Malawian interested in immunization or the public good. This government, which includes an essential health package and observation actually then supports the argument that participation in national disease control program (e.g. TB and PNFP or FBHP participation in national immunization ARV distribution) as well as the Expanded Program on Immunization. programs is of even more value, if PFP providers are not As part of this agreement, the government of Malawi has part of those estimates or the PPP described above. placed Child Health Monitors into CHAM member facilities (who are government employed staff), who conduct As mentioned (and as seen in Table 4) most of the vaccinations and a range of other public health and Christian Health Associations in Africa (umbrella bodies community outreach activities inside CHAM member representing mainstream ChristiannFBHPs), have this kind hospitals and clinics. These government employees in effect become an integrated part of the CHAM facility staff, but of arrangement in the countries in which they are present utilize the CHAM facilities for the immunization service (for – serving as providers for a substantial part of the example the fridges and vaccine supply chain). national immunization programs (EPI). The character and An interesting twist to this story is added, when you consider content of such collaborative agreements is varied, and that these Child Health Monitors are also providing contraceptive services to the communities ‘just outside’ the the precise implementation details not very well CHAM member facilities, of which a large proportion are understood (see the Malawi example in Box 13 right). Catholic facilities who have strong policies against the provision of ‘artificial contraception’. However, the The IFP‐WorldBank (2011) report also shows that routine arrangement seems to be based on the implicit agreement immunization data is one of the strongest flows of that so long as these services are not provided within the walls of the facility, they do not clash with the rules of the information from the private sector to local governments. facility. This demonstrates the complexity of negotiated That is, immunization is one of the key indicators that is relationships that are in place and which potentially impact actually tracked with some vigor and rigor (although on the sustainability and strength of local routine immunization services. there is noticeably limited data on or from the PFP sector). “…When compliance with provision of data is Dimmock et al 2012, Olivier 2014 incentivized by the provision of consumables like anti‐retroviral drugs or vaccines, the private providers have been found to comply well. Medicines or vaccines are provided to private health facilities on the condition that they report how much has been delivered and to whom…For example, in the city of Bulawayo in Zimbabwe, the municipal health department provides vaccines to private health facilities for distribution in exchange for timely provision of information” (IFP‐WB 2011). Information is a key issue in HSS, and health systems research, however, despite such hints that data on immunization is better than others, there is little visible in the published literature which extrapolates out the provision of FBHPs from the national figures. Certainly few of the innovative or characteristic routine immunization activities or partnerships are noted in the current literature. All of these could usefully be undertaken in the future.

4.2. Access to Basic Services and Primary Health Care One of the clearest arguments made in the literature collated in the preceding chapters, is that very often, non‐ or partial‐ immunization is a result of ‘health systems’ concerns from the individuals and local communities. Most of these (which might well be articulated as religious resistance) can be understood as concerns of ‘access’ which is a major concern of health systems research. We cluster some of the different themes here:

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Refusal based on objection to lack of other primary health services There are several examples in the literature of communities or individuals resisting immunization campaigns as a demonstration of protest at the lack of access to basic health services in their area.

Table 3: Examples of arguments that weak health systems is the main barrier to uptake Source Argument Extract Bonu et al Argues that one of the primary explanations for difficulties in mass immunization campaigns is the inherently ‘top 2003 down’ approach of these campaigns which prioritizes global priorities rather than the immediate needs of local communities, “In poor communities, where scarce resources find competing interests, more immediate needs such as food, security, employment may take priority over other nationally ‐ and internationally ‐ set goals and programs” Jeffrey & Critique the Underserved Strategy of the PPI in India, arguing that Muslim children in the target areas are Jeffrey 2011 ‘underserved and overdosed’, and that the marginalized Muslim minority in western Uttar Pradesh have reason to be suspicious: “…PPI arguably reflects the agendas of global funders, not the priorities of local communities. Villagers (Hindu and Muslim alike) have repeatedly criticized government health services for failing to deal with the health issues that worry them most. Their concerns echo other critiques of the PPI, particularly the diversion of resources from other health‐related activities that could address the social determinants of health and health inequalities.” Cheng 2006 In Nigeria, “…would‐be poliomyelitis eradicators face a non‐compliant population whose resentment is ever‐ hardened by failure of the country’s health system to meet their most basic needs.” Murphy “In some countries, campaigns that focused only on polio have met resistance because the community has felt that 2012 its other important health needs are being ignored or that the intense focus on polio over other immunizable diseases is in itself suspicious.” Clements et “Because the rumors about vaccine safety were circulated by some religious leaders, a lot of work to reverse the al 2006 perception that poliomyelitis vaccination was somehow against God’s will has been done, including engaging the Koranic schools and getting the malaams involved in the vaccination campaign. But many believe it is health‐care failures, and not religion, that is now the main reason that parents reject poliomyelitis vaccination. Parents have watched children die of infections, dehydration, and malnutrition and are rejecting poliomyelitis vaccination ‐ often the only free health intervention available to them ‐ in protest. ‘It was a communication gap. It wasn’t a religious gap’, says Nasidi. Parents say ‘How come we go to primary health‐care centers and there are no drugs to treat us?’ For parents of susceptible children, poliomyelitis vaccination is a long way down the list of their needs.” Renne 2006 In Northern Nigeria, “…a Professor Emeritus who pioneered in polio research in Nigeria stated that: ‘My honest view is that the mass immunization program is not what we need. What we need is a program of effective child immunization conducted in infant/child clinics and hospitals…This [polio problem] could have been taken care of by having an effective child immunization program.’ What happened in the North? There might have been some religious bias but that became possible because we weren’t doing the right thing in the first place…’” Source: references provided, author’s compilation As the bottom two extracts in this table demonstrate, while religious reasons might be provided for vaccine resistance or refusal, this can also be a covert protest against the lack of access to basic health care – and prioritization of other needs.

The lack of physical and financial access (affordability) to health services One of the major issues raised in the literature is the lack of physical access to immunization services (or health care generally) – especially for remote or rural ‘missed’ communities. Muula et al (2009) reviews several studies which identify the long distances to vaccination sites as being the major risk factor for failure to be vaccinated (for example, Reichler et al reported that in Egypt, being farther than 10 minutes by foot from the nearest National Immunization Day site was a risk factor for failing to receive vaccines. In Kenya, Ndirutu et al found that vaccination coverage was reduced with every kilometer of distance from home to vaccination clinic). Looking at the results of their study in Nigeria Oluwadare (2009) says that their study revealed:

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“…most parents have a good knowledge of the benefits of routine immunization, but that accessing the service is not always easy. There are no specific cultural, social or religious barriers to routine immunization. Neither, at the community level, is there evidence of rumors or scare stories that are deterring parents from taking their children for routine immunization. But people living in remote and physically and ethnically isolated settlements tend to be marginalized…There is no evidence that such communities suffer overt discrimination from health workers when they access health services, but their minority status coupled with their physical isolation clearly put them at a disadvantage…Barriers to the uptake of routine immunization stem primarily from the supply‐side.” (An interesting area for investigation would be to consider whether and how religious vaccine refusals differ between routine and episodic vaccine offerings, and what role LFCs and FBHPs have in either.) It is strongly argued that FBHP’s have a strong tendency to serve the poor – especially the rural poor – and this is in fact why many governments in development contexts have developed partnerships with FBHPs, acknowledging that they are providing access to services where the public health system cannot, and often to a poor population who are also the government’s responsibility. While the financial landscape is shifting rapidly for most FBHPs (for example in Ghana the introduction of national health insurance has major implications for their operation) ‐ FBHP’s are known to develop creative financial arrangements (such as a ‘robin hood’ sliding user fee systems) to ensure that the poor can access services (see Olivier and Wodon 2012a). Immunization has been identified as the cornerstone of primary health care – and vice versus, an effective PHC system as the cornerstone of routine immunization (see Brooke and Omari 1999). It has also been argued at a broad level that FBHPs tend to be PHC specialists. This is not well evidenced, however, for example, in Africa, many FBHPs have historically focused on the ‘mission’ hospital as the core of their local health systems, with primary care efforts spreading out from each hospital. In many of the contexts in which FBHPs are strongly present, in the last two decades, governments have been the main developers of PHC networks. An interesting dynamic can be seen, for example, in the Salvation Army health services internationally, which have traditionally been hospital‐centric, but are now embarking on a massive reorientation towards primary level care, as this is seen as more closely aligned with the needs and the religious intent behind the provision of health care (see Pallant 2012). In other contexts, health systems arrangements have been made to extend immunization services into FBHP facilities at a PHC level (or to ‘integrate’ FBHPs into the national immunization strategy and system). For example, in Malawi, an agreement between the Ministry of Health and certain FBHP networks, has resulted in the MoH placing government employed ‘Health Surveillance Assistants’ into FBHP health centers – where they conduct routine immunization as well as a range of other services such as family planning and HIV/AIDS testing and counselling (see Olivier and Van Mensvoort 2014). Furthermore, a central focus of health systems work is human resources and health worker motivation – acerbated by the fact that most of these development contexts are facing intense human resources for health shortages. One of the key factors in availability of services in rural and remote areas is the availability of staff to work in these outposts, and the motivation for them to stay there (see Olivier and Wodon 2012b). Successful routine immunization is also dependent on the availability of trained staff, especially in remote areas. Arora et al (2000) note that “administration needs to ensure that vacant posts of PHC Medical Officers and Health workers are filled particularly in high risk/difficult to reach areas.” FBHPs have engaged in a series of innovative strategies to maintain health workers in the remote areas they are keen to serve. These range from additional (financial, educational or extramural) incentives, to ‘home town’ placement, to rotational staff placement systems such as

68 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 employed by the Salvation Army above (see Olivier 2012 2014). All of these considerations would be important in understanding the sustainability of routine immunization services to ‘missed’ populations. In a unique study, Reinikka and Svensson (2003) asked whether ‘working for God’ matters – and conducted a survey of PNFP (mainly FBHP) providers in Uganda, comparing them with public providers. They found that FBHPs in Uganda provided similar services to those of the public sector in terms of inpatient care, laboratory services and immunization (with government slightly more likely to carry out immunizations, followed by the FBHPs and then the PFPs – although they note this difference is likely as a result of the availability of vaccines in the public facilities). FBHPs were more likely than their public counterparts to provide outreach, health education, antenatal care and training of nurses and community health workers – services with a strong public good component. They also found that health workers in the FBHP facilities were willing to work for longer hours for less pay (which is a significant consideration in relation to human resources and health systems). A potentially fruitful area for further investigation would be to consider the particular efforts made with FBHPs at primary level care, which potentially strengthen routine immunization. At this time, any proof of this is fleeting and often observational. For example, Schmid et al (2008) conducted a case study of FBHP provision in Uganda. Participants observed the strong motivation of health workers in FBHP facilities which extended out into primary level care. “Staff were also resourceful in bringing their services to their clients: ‘People will put a vaccine carrier on their bicycle or even walk with it on foot, sit under a tree, to give services’.” In an evaluation study of primary level services of the Salvation Army in the Asia‐Pacific region, several examples of innovative primary care solutions were observed. For example, in Indonesia, it was leadership strategy for husband‐wife teams of Salvation Army officers to be located in remote areas, with the husband running the church and other social activities, while the female officer has been trained as a nurse – running the small PHC clinics attached to the church. In several of the observed sites, as these health centers did not have electricity, the fridge in the couple’s home (also owned by the Salvation Army) was being utilized to store vaccines (see Olivier 2012). Such examples hint at potentially important considerations for strengthening PHC and routine immunization in remote and inaccessible locations. However, the particular contribution of FBHPs to access in such contexts is not well evidenced. Certainly this suggests that if FBHPs are situated in remote rural areas, and providing routine immunization to those who cannot otherwise access or afford such services, then they are an even more essential component of the immunization system than currently understood. We would strongly recommend further research in this area.

Acceptability – cultural access and quality perceptions One of the key areas which would seem to have potential is the issue of ‘acceptability’ of routine immunization services through FBHPs. There are clusters of related discussion or investigation points: Perceived higher quality and faith‐character increases access: There is a great deal of anecdotal literature that argues that FBHPs provide a higher quality of service than their public‐provider counterparts. Gemignani and Wodon (2012) look at user choice in Burkina Faso and show that users still rely on traditional healers for many health issues that they encounter. In relation to modern providers, the users perceived faith‐inspired clinics and hospitals as being characterized by lower costs and higher quality of service than public facilities. “Faith‐inspired facilities are well regarded in their surrounding communities and patients are willing to travel significant distances to receive care from the facilities. Although these providers vary in size and religious affiliation, they share a similar goal of offering affordable services to the poor and doing so in a way that fosters closer relationships between individuals, communities and the healthcare system. Their approach and services thus helps in

69 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 expanding options for care, especially for those who for feel marginalized in the public health system” (Gemignani and Wodon 2012). One of the few studies that actually examines whether FBHPs do provide a different quality of service in relation to routine immunization was conducted back in 1995 by Gilson et al in Tanzania. They found that ‘church facilities’ performed MCH services relatively poorly, few church facilities undertook health education regularly, and that MCH equipment was more scarce in church facilities. “Outreach service scores were uniformly low, but were least for church facilities whose performance was well below the standards for immunization sessions (monthly), home‐visiting (weekly), and school visits (at least one in the previous two months)…In terms of [in‐patient] services, immunization scores were comparatively high but performance was still not good enough, given the strong supply system and considerable available resources.” Gilson et al (1995) continue by noting that church dispensary performance was lower than that of other facilities, and that problems ranged from refrigerator temperature levels to irregular vaccine and kerosene supplies: “There was only a 30% chance, for example, of having unexpired vaccines available and of having kerosene regularly available in the previous 3 months in the typical church dispensary compared to a 50% chance of both in the government facility. The typical church facility had an 80% chance of the refrigerator temperature being incorrect for more than 4 days in the preceding month, compared to 70% for the government dispensary.” The authors conclude that the differences in the immunization and support variables reflect, in large part, district management practice differences. They conclude that vaccine supply problems appeared to be caused by a variety of factors: “delays in delivery of vaccines to the district level; shortages of, and difficulties in getting funds for purchasing kerosene within districts; vehicle breakdowns; and access difficulties to some facilities.” This (possibly dated) study raises a number of important issues. Do FBHPs have different performance in relation to routine immunization services? Do they have different challenges in getting vaccines out to rural areas, keeping them cold, and providing them to patients? Are there different quality‐assurance (accountability and governance) mechanisms in place in FBHPs as in public facilities? At this time we simply do not know. There is a great deal of qualitative description of FBHPs being perceived by patients to have a better provision of drugs than public providers (see Olivier and Wodon 2012b). A handful of studies have emerged which seek to evaluate the efficiency of FBHP drug supply chains and management (see Kawasaki and Patton 2002).38 However, such studies generally do not count vaccines (rather focusing on other ‘essential medicines). It is therefore not clear exactly where vaccines (which are often supplied by government) feed into the FBHP systems. Certain it would be useful to consider what strategies are in place to transport vaccines to the sometimes remote (and often seasonally cut‐ off) areas in which FBHPs often operate. While there is some emerging work that examines whether or not FBHPs provide a higher quality of service generally, what is more immediately relevant to this review is the perception that FBHPs provide a higher quality service, which suggests that users might find routine immunization services more acceptable (and therefore accessible) when provided by FBHPs. That is, these services and vaccines might well be identical to those being provided in public facilities, however, if perceived to be different by the clients, this might affect vaccine uptake and return rates significantly. Thomas et al (2006) look at the provision of ART in a South African Moravian health clinic, and find that the ARVs (which are provided through government so are known to be the exact same drug) are nevertheless perceived to be more effective or powerful by the clients because of a number of additional

38 Indeed, in some development countries, there are FBHP‐owned drug supply systems, where one agency undertakes procurement, warehousing and distribution for the entire sector (and sometimes regionally as well). For example, the Mission for Essential Drugs and Supplies (MEDS) in Kenya, The Christian Health Association of Nigeria’s CHAN‐Pharm in Nigeria, the Joint Medical Store (JMS) in Uganda, and the overarching Ecumenical Pharmaceutical Network (EPN), see Table 4 and Budge‐Reid et al 2012.

70 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 religious ritual elements (such as prayer as part of the ART schedule). However, all of these issues need to be explored in more detail. Culturally and religiously aligned routine immunization services: It would be fascinating to investigate whether FBHPs have a different access in community outreach for routine immunization. As discussed in chapter 2, one of the main concerns in immunization intervention is the missed populations that are not vaccinated because of closed communities – in some cases a literally closed door, if women or children are not allowed to leave the compound for cultural or religious reasons. Some studies hint that the religious affiliation of community vaccinators is important. For example, Chaturvedi et al (2009), looking at social resistance to immunization in India, notes that the “the health workers were largely Hindus and represented the face of the state to the Muslim communities. Overcoming reluctance or resistance among Muslims was reported by health workers (Hindus) to be a far more difficult task.” This suggest that the religious affiliation of health workers (whether immunization outreach staff or regular facility‐based staff) needs to be carefully considered. Wong (2009), looking at HPV vaccine delivery in Malaysia, noted that Malay Muslim physicians have a higher level of cultural and religious sensitivity when recommending HPV vaccines, “The Muslim Malay physicians showed a heightened sensitivity to recommendation of an STI vaccine…strong religious beliefs and stringent cultural norms among the Muslim Malays may play an important role.” Several others note the importance of health workers having ‘religious and cultural competence and sensitivity’ when dealing with vaccine reluctance based on religious reasons (see Brooke and Omeri 1999 on Lebanese Muslim immigrants in Australia, or Crawford et al 2009 on dealing with Amish patients in the USA). A handful of studies now look at health worker practice when faced with such circumstances (but rarely in relation to health services in LMICs). For example, Leask et al (2012) write about the critically important communicative interaction between health professionals and parents in framing parents’ ultimate decision whether or not to vaccinate: “For the hesitant, late or selective vaccinators, or refusers, strategies should include use of a guiding style and eliciting the parent’s own motivations to vaccinate while, avoiding excessive persuasion and adversarial debates…Health professionals have a central role in maintaining public trust in vaccination, including addressing parents’ concerns.” Ruijs et al (2012) also examine how healthcare professionals respond to parents with religious objections to vaccination, and argue that (in the Netherlands) healthcare professionals face increasing concerns about and objections to childhood vaccination, which they may find difficult to deal with. “In general, healthcare professionals are advised to listen respectfully to the objections of parents, provide honest information, and attempt to correct any misperceptions regarding vaccination…Although religious objections have a long history, little is known about the way healthcare professionals deal with these specific objections.” They observed three manners of response to religious objections to vaccination: providing medical information, discussion of the decision‐making process, or adoption of an authoritarian stance. “Whether the decision‐making process was discussed depended on the willingness of the parents to engage in such a discussion and on the religious background, attitudes, and communication skills of the health care providers” (Ruijs et al 2012). They observe that providing extra medical information in such situations is not helpful, and instead what is needed is a process for discussion and decision‐making: “…The religious background of HCPs influences their attention to religious considerations in general clinical practice…HCPs with an (orthodox) Protestant background discussed the decision‐ making process and the religious considerations involved…Some extra education on religious aspects of vaccination and training in communication skills could for the other HCPs possibly facilitate the discussion…” (Ruijs et al 2012).

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Therefore, there is a combination of considerations. Firstly, the religious affiliation of the health worker might be an important factor in the success of vaccine acceptability (affecting the encounter between health worker and parent or patient). Secondly, or alternatively, the sensitivity (competency) of the health worker to local religious dynamics is important. And finally, appropriate training on religion and communication needs to be considered in relation to routine (or other) immunization services. Again, all of these issues need to be explored in more detail.39‐40 While advocating for cultural and religious sensitive and competent care – we should not forget the personal and physical danger facing some frontline health workers, danger often laced with religious overtones. Considerations of religious sensitivity, competency and training might be considered for immunization program and planning staff in such contexts as well (see Closser and Jooma 2013). The example of the health workers boycotting a polio vaccination campaign in Pakistan (Box 17 below) demonstrates the complexity of health systems governance issues in such contexts, and the multiple ‘religious’ undertones that impact on human resource management and health systems functioning (see further discussion below on HSS in fragile or post‐conflict states).

Box 17: Health workers boycott polio vaccination in Bajaur Agency (news article excerpt) KHAR: Health workers in a Pakistani tribal area on Monday announced a boycott of a polio vaccination drive to protest the killing of one of their colleagues last week. Abdul Ghani Marwat, who headed the government’s vaccination campaign in Bajaur near the Afghan border, was returning after meeting a local religious leader when his vehicle was hit by a bomb, killing him and injuring three others. The blast came amidst rumors the vaccination drive was a US plot to sterilize Muslim children. Some 1,500 health officials, including doctors, nurses and paramedical staff, on Monday wore black armbands and observed a “complete strike” in the region to protest against the killing, said a Health Department spokesman. “The strike will be observed till Wednesday to protest against the lack of security for health workers in the region,” the chairman of the doctors’ action committee, Daud Jan, told reporters. “The health workers have also decided to boycott the three‐day polio vaccination drive beginning from Tuesday and they will take out a protest rally in Khar,” he said. Local health officials said that some 140,000 children could be affected by the action. The government said on Friday that the parents of some 24,000 children had refused to give them the polio vaccine because of a campaign by Muslim clergy. Health officials have been trying to dispel rumors – sometimes spread on radio stations or from the loudspeakers of mosques – that the polio campaign is a Western conspiracy to reduce Muslim populations… Daily Times (2007) Http://www.dailytimes.com.pk/default.asp?page=2007%5C02%5C20%5Cstory_20‐2‐2007_pg7_29 [Accessed 20Nov2013].

Access to routine immunization and plural health systems We should not forget that choice of health provider also includes ‘traditional’ providers in many development contexts (a different ‘religious’ provider not usually included with FBHPs, but still requiring some attention). Muula et al (2009) point out that in Haiti, Vodou, Catholicism, living more than an hour away, and the use of traditional leaders were negatively associated with vaccination. They suggest that one aspect might be that traditional healers do not support the use of the formal health sector which includes vaccination. They note that several studies have indicated that “collaboration between traditional healers and the formal health care sector is possible, useful and crucial in order to bridge the treatment gap in developing countries.” In the study on user choice in Burkina Faso, Gemignani and Wodon (2012) remind us that users still rely heavily on traditional healers for many health issues. They show in this anthropological study that different healing

39 There are few studies which consider the organizational culture of FBHPs as impacting on immunization update. Sadly, studies such as Elliott and Farmer (2006) which looked at immunization status of children in North India, conducting the study in a Christian hospital, and addressing religious affiliation in relation to immunization uptake ‐ never make any connection to the fact that the services were being provided by a FBNP. 40 It might be important to consider the vaccination uptake of health workers themselves (although there is no current study looking at that in relation to FBHP staff)

72 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 modalities can clash over vaccination. “Religious and cultural beliefs about health and disease were often mentioned here, especially regarding the idea that vaccination can weaken natural immunities and make a person more rather than less vulnerable to future illness. Some said that vaccination is also thought to weaken the strength of traditional medicines against disease…polio vaccinations were said to be the most controversial, because of the side effects experienced by some children who are vaccinated. However, all vaccination campaigns were seen by health center administrators to be a difficult and time consuming process.” The involvement of traditional healers and leaders in routine immunization is not well articulated in the literature (and lest the reader has some image of a dark rural dwelling, it may be necessary to point out that in many developing countries, such as Zambia, traditional healers not only lay claim to medical titles such as ‘Dr’, but they also have built modern ‘hospitals’ ‐ see ARHAP 2006).

Local faith communities and health/community systems strengthening A central conceptualization of a ‘health system’ is that it is inclusive of the actors who live and work within it, as well as (or particularly) the patients and communities who a health system services (see Gilson 2012). In this sense, ‘community’ is increasingly being viewed as an essential (and often overlooked) part of the health system (see Gaitonde et al 2011). However, we would argue that this kind of thinking has not yet been applied in relation to routine immunization and HSS to any great degree. This kind of framing would connect the social mobilization ‘campaigns’ as described above, with the health systems strategies of strengthening the scope, nature and extent of community participation in health and health‐related decision‐making or community rights to health and community accountability. This is in contrast to some of the current descriptions of HSS in relation to routine immunization, which include ‘hardware’ issues such as transport, cold chains and financing – rather than the ‘software’ issues relating to the relationships within the system. We would argue that FBHPs might bring unique insights and into such considerations, of ‘people‐centered’ health systems for routine immunization. As already mentioned above, there are many examples in the literature of the ‘involvement’ of LFCs (such as congregations) in immunization promotion and social mobilization. It is virtually impossible to extract clear examples of LFCs mosques or congregations being utilized as direct points of vaccine provision in a routine way (rather than support or promotion). Aylward (2012) does argue that there is long‐standing precedent for the routine engagement of LFCs in immunization. For example, in Iceland and Sweden, “the clergy were made responsible for smallpox vaccination and keeping vaccination records for their parishes”, therefore possibly can be seen as part of the ‘health system’ around smallpox vaccination. There are also some examples of immunization services being run through LFCs in the USA (see above). In their study of HPV acceptability in Tanzania, Remes et al (2012) point out that while the interviewed religious leaders41 knew nothing about cervical cancer, HPV, or the HPV vaccine, they were eager to learn – reporting that this was the first time that staff from a health program had come to discuss a health intervention with them, and that they would discuss cervical cancer and HPV vaccination with their congregations. Of course ‘discussion’ is some way from actual provision within the walls of their buildings, but does suggest an openness for engagement. There are some hints at systems strengthening for routine immunization through community engagement in the literature. For example, Diamenu et al (2005) study how to bring immunization services closer to communities, with the case example of the ‘Reaching Every District’ (RED) project in Ghana. They note that (routine) outreach services of immunization programs are especially hindered by limitations in health infrastructure, particularly transport and logistics, and that the RED approach was adopted as an extension of routine immunization services

41 The interviewed religious leaders in the Remes et al (2012) study were identified as: Roman Catholic, Anglican, Lutheran, Tanzania Assemblies of God, African Inland Church, Seventh‐Day Adventist, Glory City Church, and Muslim.

73 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 in 2003. It was anticipated that this would strengthen the entire health system for primary health care. Within this approach, Diamenu et al (2005) note the importance of promoting community participation in immunization services through religious leaders and interest groups). “Services need to be linked with the communities to enhance community appreciation, ownership and demand. One way to achieve this goal is to involve communities in communication and social mobilization activities at all levels of the programme. As part of the strategies to increase the communication network for immunization services, four districts were provided with funds to organize orientation and sensitization workshops for religious leaders…Through this initiative, Religious leaders are recognized as influential individuals, with attributes that can support health care delivery programs if they are involved…More than 300 representatives from various religious groups, including Muslims, attended workshops in the districts…The training stressed the role that religious leaders can play in health care delivery considering the position they occupy in society. Participants at the meeting expressed their willingness to join hands to champion the cause of immunization in their communities and in religious services” (Diamenu et al 2005) One of the suggestions made by these religious leaders was that “Church groups will from time to time monitor the immunization status of children in their congregation and inform health authorities for the appropriate action.” This example is not vastly different from those in the chapter above, however it does hint at a particular approach to engagement through LFCs that is linked to routine immunization and the health system. Iyun (1989) provide an interesting evaluation of a rural health programme on child and maternal care: the Ogbomoso Community Health Care Programme (CHCP), in Oyo State, Nigeria. This study emerged before the attention on FBHPs emerged. Therefore, while it addresses a program where Village health workers (VHW) in Ogbomoso were trained by the nearby Baptist Medical Centre in rural health care, including family planning and immunization ‐ there are a few hints at a religious‐specific nature, such as the VHWs were also trained in key health topics and church teachings. The authors report that the mission program achieved higher immunization levels among women and children than similar government services implemented in the area. The Salvation Army example above provides perhaps the clearest observation of LFCs being ‘part’ of the health system – with the FBHP clinic physically next door the Salvation Army church, run by the officer pair, and sharing a fridge. In fact, the tight integration of many FBHPs and their local LFCs might well provide unique opportunities for routine immunization engagement – although this is unexplored. Many FBHPs are closely connected (and often ‘owned’) by their LFCs, which suggests potentially unique ‘access’ issues, or at least unique connection between community and health system (see Olivier and Pallant 2014). Many FBHPs still operate a ‘compound’ mentality – in that health, educational, and social services and ‘church’ buildings are commonly clustered in the same physical space. This suggests opportunities for truly ‘integrated’ routine immunization service. Furthermore, FBHPs tend to be involved in a series of integrated activities that extend well beyond health service provision. It is common to see a series of integrated health, educational, social and economic activities, sometimes all emerging from the same hospital. This integrated viewpoint might be important when you consider those resisting vaccine programs because they perceive that their basic needs are not being addressed (see above). A participant in the Gemignani and Wodon (2012) study who was a patient at a Catholic clinic in Burkina Faso observed: “The real problem for our children is hunger. This is the entryway for disease…We women have noticed that since the (Catholic) sisters began receiving us at the center and giving milk, porridge, and rice to the children, they no longer fall ill. For me, the true vaccine is food.” It has also been argued that FBHPs are more integrated into the communities they serve (and who often ‘own’ the facility), and as trusted providers might have better return rates from patients – although, again, such claims,

74 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 while made frequently in the literature are unsubstantiated by formal evidence. This might suggest longer‐term engagement with the life‐cycle of patients. It would be interesting to consider whether the observation that certain populations take up vaccination but start dropping off after the initial dosage (see above) is the same for routine immunization provided by FBHPs as by public providers. Certainly, as Khairkar (2013) and Murhekar et al (2009) have pointed out, the fact that these parents did not refuse the initial vaccination, but did not return for subsequent necessary boosters suggests a health systems failure rather than resistance based on religious, cultural or political terms. Murhekar et al (2009) suggest that in India, one of the key reasons is that “…children who drop out for booster doses are not followed up. The Hyderabad health system functions with sub‐optimal number of field staff. Overworked health workers do not spend sufficient time communicating with the mothers about the next dose of vaccine.” Do staff in FBHP facilities spend more time explaining such issues to patients as part of their higher quality of care, resulting in higher return rates? We simply do not know.

Box 18: The MIPROMA clinic of the Malian Association of Young Muslims This is an edited excerpt from a case study provided here because it depicts routine immunization services in a Muslim FBHP, linked to a Muslim FBO. Such examples are fairly rare. The Malian Association of Young Muslims (AMJM) was established in April 1991 following the advent of democracy in Mali. Its purpose was to contribute to the socio‐cultural and economic development of Mali, and to bring together the youth to educate them according to Islamic ethics, and to encourage their participation in activities useful to the country in areas such as education or health. Health had been an area of concern for AMJM from its inception, largely as a result of the difficulties faced by poor people, among them the need to travel long distances to Commune health centers and the high cost of consultation fees and medication. Health activities of AMJM include: health consultations for Moslems in mosques; free medical caravans in poor districts; Islamic materials and training for sensitization about issues like family planning; advocating spirituality in health; and sports activities The Mutuelle Inter Professionelle du Mali (MIPROMA) Muslim clinic: To deepen their involvement in health, the members of AMJM established a health center (with the status of non‐profit health mutuality or ‘insurance group’, called MIPROMA in 1994, located in the District of Bamako. The goal of the center is to "provide curative care to patients, and to facilitate treatment for patients through a chain of solidarity." It is run like a public health center in close relationship with the MoH. AMJM wanted to open more clinics in other areas, should MIPROMA prove successful. The health workers believed that the level of equipment at the center was satisfactory and in good condition, including a refrigerator for storing vaccines. The clinic had 11 staff, with the doctor, midwife and obstetric nurse paid by government. The wages of the other 8 employees were paid raised through user fees. To take advantage of its position opposite a bustling market, 5 female grocery vendors were chosen to support the health center as volunteers, as a way of encouraging women to attend the center for pre‐ and post‐natal consultations and child care. The clinic provides a range of primary care services, including antenatal and postnatal consultation, deliveries, vaccination, and the sale of essential drugs. The financial and other resources of the center came from a variety of sources: the AMJM’s own capital; a start‐up loan of 12 million FCFA (US $27,000); a state grant of FCFA 800,000 (US $1,800) a month to pay for 3 health workers; the provision of immunization equipment and vaccines for children by the MoH; sponsored health services and donations in cash and kind. For members of the Mutual Benefit Association the clinic charges the same user fee as other community health centers in Mali. The clinic was open to all persons who needed health care, regardless of religion and ethnic group. It seemed that although the community was excluded from direct management of the clinic, this had not frustrated the relationship with the community. Possibly the Mutuality offered the community some sense of participation. While the AMJM viewed the clinic as similar to a CSCom, the patients regarded it as a sacred place, which was clearly an important matter to them. Patients said that health workers received them with more respect than community health centers did, and they appreciated the fact that they might choose to be seen by either a male or female health worker. (Schmid et al 2008)

Community systems strengthening as integrated support: Recently an interesting concept has emerged – framed as ‘community systems strengthening’, which at this time is still operating somewhat in parallel to the framing of community engagement in health systems strengthening as described above. The Global Fund to Fight AIDS, TB and Malaria (GFATM) began consultations and producing materials on CSS around 2008. In these materials, community systems are defined as: “community‐led structures and mechanisms used by community members

75 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 and community based organizations and groups to interact, coordinate and deliver their responses to the challenges and needs affecting their communities” (GFATM 2010). The core components of CSS (as described by GFATM in 2010) are: enabling environments and advocacy; community networks, linkages, partnerships and coordination; resources and capacity building; community activities and service delivery; organizational and leadership strengthening; monitoring and evaluation and planning. It is important to note that CSS was not simply an idea held by GFATM, but that several large funding agencies placed CSS immediately and directly into their applications and outcomes (see GFATM 2010, UNAIDS 2013). We raise this here simply to frame the ongoing investigation – and to observe (as we have elsewhere, see Olivier and Pallant 2014) that perhaps FBHPs, with their wide variety of linked health, educational and development activities, and their deep connection community might provide unique insights and opportunities for ‘community systems strengthening’. Certainly this might be a useful area of investigation in relation to immunization, with its complex connections between program‐system and global‐local partners.

Box 19: Community systems strengthening as understood by the Global Fund …an approach that promotes the development and sustainability of communities and community organizations and actors, and enables them to contribute to the long‐term sustainability of health and other interventions at community level. The goal is to develop the role of key populations and communities, and community organizations, networks and other actors, in the design, delivery, monitoring and evaluation of services and activities aimed at improving health outcomes. CSS is a way to improve access to and utilization of formal health services but it is also, crucially, aimed at increased community engagement (meaningful and effective involvement as actors as well as recipients) in health and social care, advocacy, health promotion and health literacy, health monitoring, home‐based and community based care and wider responses to ensure an enabling and supportive environment for such interventions. This includes direct responses by community actors and also their engagement in responses of other actors such as public health systems, local and national governments, private companies and health providers, and cross‐sectoral actors such as education and social protection and welfare systems…This includes a strong focus on capacity building, human and financial resources to enable community actors to play a full and effective role alongside health and social welfare systems. CSS is a means to prioritize adequate and sustainable funds for specific operational activities and services and, crucially, core funding to ensure organizational stability as a platform for operations and for networking, partnership and coordination with others. (GFATM 2010)

Access to routine immunization fragile states or conflict contexts Special mention must be made of the role of FBHPs and international FBOs in stabilizing health systems to supply routine immunization in fragile states or contexts of conflict. This is where trying to create classifications between routine in‐country FBHP providers, international FBOs and local FBOs becomes counter‐productive. In conflict, health systems are often destroyed, and in many cases it’s a cooperative ‘shoe‐strong’ of drawing together all possible partners that creates a new health system. In these contexts, FBHPs and FBOs play a vital role – not only in stabilizing health systems – but also in relation to immunization (which might or might not in these contexts be considered ‘routine’). The best example of this is described in the DR Congo.

Box 20: Health Systems Strengthening and Routine Immunization in the DRC Eglise du Christ au Congo Direction des Oeuvres Medicales (Protestant Congo Church of Christ, Medical Office): In the DRC, the history of medical mission and health professionals working with FBOs goes back more than a hundred years: Protestant medical mission began in the area in 1882 and the Catholic mission in 1889 – including the creation of hospitals and health services. Conflict has been prevailing intermittently in the DRC since 1998. In 1999, in a major move, the acting Ministry of Health formally turned over responsibility for health care in 60 zones (then of a total of 306) with a population of 12,000,000 to a coalition of mostly faith‐based non‐profit health providers – with ECC‐DOM as the implementing partner. “Today, FBHPs provide 50% of health services in the country and also co‐manage approximately 40% of the health zones” (Chand and Patterson 2007). The story of ‘Projet Santé Rurale’ (The Rural Health Project): From 1981‐1991 a project named SANRU I/II began providing assistance to a 100 of DRC’s 306 health zones (as a process of coordinated management of zones around Protestant, Catholic, governmental, and other NGO‐managed hospitals in partnership with USAID). In 2001 this was revitalized as SANRU III, this time with IMA World Health partnering with ECC‐DOM, to rebuild the health zone system, providing assistance to rebuilding and strengthening primary health care services in 65

76 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 health zones co‐managed by Protestant and Catholic FBHPs, providing primary health care for approximately 10 million people. SANRU III represents a complex partnership model involving full engagement of Protestant (ECC), Catholic, Kimbanguist, secular organizations and government health authorities. Chand and Patterson (2007) note that “this project strengthened PHC interventions which include the MOH’s basic package of services (vaccinations, growth monitoring and ANC) and services for malaria, HIV/AIDS, nutrition A, water/sanitation and endemic diseases…IMA World Health has also leveraged supplemental funding from its members and other partners including Pfizer, Merck and Abbott, to support the country’s efforts to strengthen the health system.” What is interesting is that this complex network of FBHP facilities (hospitals and health centers) “…is considered to be part of the public rather than the private sector, and is fully integrated with health zones, which in many cases are co‐managed by FBOs” (Baer in Chand and Patterson 2007). Chand and Patterson 2007, Dimmock 2012, Schmid et al 2008

The DRC case demonstrates the careful orchestration of health systems strengthening in fragile contexts. Immunization in such contexts depends heavily on these (sometimes fragile) health systems. (For example, while GPEI was launched globally in 1988, because of the civil conflict in the DRC it was only begun there in 2000, the original target for global eradication, see Aylward and Tangerman 2011). The role of FBHPs in routine immunization (or any kind of immunization) cannot be understated in such contexts. However, again, while there are some emerging case examples of local social mobilization of religious leaders and communities for immunization in the DRC (as discussed above), there is little research yet on the health systems in such contexts, or whether the FBHPs have characteristic differences to their service provision or partnership models. This also raises some fundamental issues about systems resilience – which should certainly be an important consideration in relation to immunization and in particular the sustainability of routine immunization in development contexts. However, we found little if any consideration of the role of FBHPs and FBOs in supporting systems resilience in fragile or post‐conflict contexts (apart from the obvious example of the DRC above). Certainly this would seem to be an important area for further investigation.

Trust, immunization and health systems research As in both of the previous chapters, ‘trust’ is again an overarching theme here as well. Many authors note that households and patients “…carry out vaccinations based on their trust in the [provider] rather than the merits of the immunization per se” (in CHEN 2004). However, despite a massive amount of attention on trust, and within that a significant focus on religious leaders as trusted influencers ‐ we see no literature considering whether FBHPs might not have different trusting relationship with the communities they serve ‐ for better routine immunization services (see for example Obadare 2005, UNICEF 2004a). Is it so radical to consider that in a community that identifies itself mainly by its religion, and which defines its refusal of vaccinations on religious terms – might perceive a FBHP as a more trusted source for immunization? (when FBHPs are available, of course). There are several hints of this in the literature. For example, if (as the literature suggests) FBHPs are perceived as providing higher quality services and more personalized care, this might be related to or result in a higher level of trust. We have also suggested that FBHPs are often more deeply ‘embedded’ or integrated within the communities in which they operate – in fact, in many cases such as with the Christian Health Associations in Africa, the LFC is seen as the ‘owner’ of their FBHP facility. Would this deeper connection to the everyday lives of the community not suggest a potentially higher level of trust? Would the routine patient‐health professional encounter (as described above where the health professional has to be sensitive to religious vaccine‐related arguments) be different in a FBHP? If certain religious groups have a serious distrust of government or international vaccination teams (for all the reasons described above), might they note feel differently towards a local FBHP? Trust has become a central interest point in health systems research

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recently (see Gilson 2012), however, this focus has not yet been applied to FBHPs. We suggest that this is a useful area for future investigation.

Building on what we know – entry points for further engagement This chapter has rather uncomfortably had more observations to offer about what we do not know than what we do. However, scoping reviews such as this point to a number of exciting and potentially important areas for further engagement. The extent, character and innovations of faith‐based health providers engaged in routine immunization – and considerations of how their parts of the health system might be strengthened, shows many such opportunities. Table 4 below crudely lists examples of FBHPs (and FBOs) that the literature currently suggests are engaged in routine immunization services or health systems strengthening that relates to immunization. This listing is not complete, and requires primary research and joint learning to be considered representative.

TABLE 4: FBHPs that directly provide or support routine immunization services or HSS This table is still under construction – many of the reported details require verification and there is almost certainly missing information, for example on global FBHPs such as the Adventist group. (We have reached out to these for inclusion in later work. All additional contributions are welcomed.) Country/ Umbrella/ Description Refs Region provider Angola CICA Conselho das Igrejas Cristãs em Angola [Council of Christian Churches in Angola and Christian Dimmock et al 2012 Medical Commission] – umbrella of FBHPs that provide RI in coordination with the national EPI program ERD Episcopal Relief and Development partners in Angola to support immunization clinics Aylward 2012 Bangladesh ERD Episcopal Relief and Development partners with the Episcopal Church of Bangladesh ‐ to Aylward 2012 support immunization clinics Benin AMCES‐ Association des Œuvres Médicales Privées Confessionnelles et Sociales au Bénin [‘Association Dimmock et al 2012 Bethesda of Private Church Medical and Social Works in Benin’] – umbrella of FBHPs that provide RI in coordination with the national EPI program Botswana AMMB Association of Medical Missions for Botswana – umbrella of FBHPs that provide RI in Dimmock et al 2012 coordination with the national EPI program Cameroon CEPCA “The development of partnerships in the Cameroon health sector is largely explained by the Boulenger et al OCASC importance of the faith‐based sector in the national health supply. OCASC, CEPCA and the 2009 FALC FALC are the main partners in this set up and their facilities participate actively in various health policy initiatives (fight against HIV/AIDS, vaccination campaigns, etc).” See also Dimmock Umbrella organizations representing FBHPs that provide RI includes: Conseil des Eglises et al 2012 Protestantes du Cameroun [Council of Protestant Churches of Cameroon, Health Department] ; Organisation Catholique de la Santé au Cameroun [Catholic Health Council];

and Fondation Ad Lucem au Cameroun (an organisation of Christian background but non‐ denominational) CAR ASSOMESCA Oeuvres Médicales des Eglises pour la Santé en CentrAfrique [Church Health Medical Bureau Dimmock et al 2012 of Central African Republic] – umbrella of FBHPs that provide RI in coordination with the national EPI program Chad AEST/UNAD‐ Union Nationale des Associations Diocésanes de secours et développement – umbrella of Dimmock et al 2012 sante FBHPs that provide RI in coordination with the national EPI program DRC ECC‐DOM Eglise du Christ au Congo ‐ Direction des Oeuvres Médicales [The Protestant Church of Zaire – Dimmock et al 2012 Health Desk] – operates a significant portion of the DRC health system as part of the SANRU project SANRU Projet Santé Rurale [Rural Health Project]: a coalition of mostly FBHPs with ECC‐DOM as Chand and

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implementing partner (see box insert above) Patterson 2007 Ethiopia CHAE Christian Health Association of Ethiopia ‐ umbrella of FBHPs that provide RI Dimmock et al 2012

EECMY‐ The Ethiopian Evangelical Church Mekane Yesus Development and Social Service Dimmock et al 2012 DASSC Commission) Ghana CHAG Christian Health Association of Ghana – umbrella of FBHPs that provide RI in coordination Dimmock et al 2012 with the national EPI program (through contractual agreement) India CMC Vellore Christian Medical College – hospital system which provides RI at hospital and community levels Kenya CHAK Christian Health Association of Kenya – umbrella of FBHPs that provide RI in coordination Dimmock et al 2012 with the national EPI program (through contractual agreement) KEC‐CHC Kenya Episcopal Conference, Catholic Health Commission) – umbrella of FBHPs that provide Dimmock et al 2012 RI in coordination with the national EPI program Lesotho CHALe Christian Health Association of Lesotho – umbrella of FBHPs that provide RI in coordination Dimmock et al 2012 with the national EPI program Liberia CHALi Christian Health Association of Liberia – umbrella of FBHPs that provide RI services Dimmock et al 2012

ERD Episcopal Relief and Development partners with local Liberian Episcopal church to support Aylward 2012 immunization clinics Malawi CHAM Christian Health Association of Malawi – umbrella of FBHPs that provide RI services (through Dimmock et al 2012 contractual agreement) Olivier 2014 Mali APSM Association Protestante de la Santé au Mali (Association of Evangelical and Protestant Dimmock et al 2012 Groupings of Mali) – umbrella of FBHPs that provide RI services (through agreement with Schmid et al 2008 government) Namibia CCN‐ECN Council of Churches in Namibia – umbrella of FBHPs that provide RI services Dimmock et al 2012

Nigeria CHAN Christian Health Association of Nigeria – umbrella of FBHPs that provide RI services Dimmock et al 2012 (agreement with government), in particular through Primary Health Care Services CHAN‐ CHAN manages a drug supply service, CHANPHARM – which is responsible for essential drugs Dimmock et al 2012 PHARM importation, production and supply to member institutions (not vaccines though) Philippines CRS Catholic Relief Services and a Muslim NGO, Kaatuntaya Foundation, have provided EPI and Aylward 2012 pneumonia and diarrhea care in Maguindanao, a conflict region Rwanda BUFMAR Bureau des Formations Médicales Agréees de Rwanda [The Office of Church‐affiliated Dimmock et al 2012 Health Facilities in Rwanda] Senegal EPSCM Eglise Protestant du Senegal Commission Medicale – umbrella of FBHPs that provide RI Dimmock et al 2012 services Sierra Leone CHASL Christian Health Association of Sierra Leone – umbrella of FBHPs that provide RI services Dimmock et al 2012

Sudan CHAS Christian Health Association of Sudan – (new) umbrella of FBHPs that provide RI services Dimmock et al 2012

Tearfund Provides EPI in parts of Sudan where the vaccination coverage rate is as low as 6 percent, Aylward 2012 coordinating with the government, UNICEF, and other partners. Tanzania CSSC Christian Social Services Commission ‐ umbrella of FBHPs that provide RI services (through Dimmock et al 2012 agreement with government) Togo APROMESTO L'Association Protestant des Oeuvres Medico‐sociales du Togo [The Protestant Association Dimmock et al 2012 Medico‐Social Works of Togo] ‐ umbrella of FBHPs that provide RI services Uganda JMS Joint Medical Store – formed in 1979 by the UCMB and UPMB jointly as a PNFP drugs’ Dimmock et al 2012 procurement agency. JMS is now autonomous, but does not deal in vaccines. (Everyone in Uganda, public, PFP and PNFP get their vaccines through the UNEPI who is the monopoly Reinikka&Svensson supplier of vaccines in Uganda) 2003 UCMB Uganda Catholic Medical Bureau (of the Uganda Episcopal Conference) ‐ umbrella of FBHPs Dimmock et al 2012 that provide RI services (through agreement with government) Ssengooba 2010

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UMMB Uganda Muslim Medical Bureau ‐ umbrella of FBHPs that provide RI services (through Dimmock et al 2012 agreement with government) UPMB Uganda Protestant Medical Bureau ‐ umbrella of FBHPs that provide RI services (through Dimmock et al 2012 agreement with government) Ssengooba 2010 Zambia CHAZ Churches Health Association of Zambia ‐ umbrella of FBHPs that provide RI services (through Dimmock et al 2012 agreement with government) Zimbabwe ZACH Zimbabwe Association of Church Related Hospitals ‐ umbrella of FBHPs that provide RI Dimmock et al 2012 services (through agreement with government) International ADRA Adventist Development and Relief Agency reference their participation in RI programs (EPI) TBC Agha Khan the Aga Khan Foundation reference their participation in RI programs TBC Caritas Caritas reference their participation in RI programs (EPI) TBC Islamic Islamic Relief supports and runs immunization clinics internationally TBC Relief Tearfund Tearfund reference their participation in RI programs (EPI) TBC World Vision World Vision reference their participation in RI programs (EPI) TBC CORDAID CORDAID supports HSS in several countries TBC The Coordinates and supports Salvation Army health services in xxx countries – most of whom Pallant et al Salvation have immunization services as part of their primary care package Army EPN Ecumenical Pharmaceutical Network – coordination network based in Africa (not a direct supply or service provider) IMA World Supports HSS and RI services in DRC and Sudan Health Source: compiled by authors

Note: many of the listed umbrella organizations do not provide the services themselves, but represent the cluster of FBHP facilities or churches that own the facilities

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5. CONCLUSION In this review we set out to landscape a fairly broad range of literature – spanning several different disciplinary and practice areas – in search of relevant information on how immunization impacts with religion (or ‘faith’), local faith communities, faith‐based organizations and health providers. The intention was to understand where evidence and information can be found, what lenses are applied to different kinds of evidence, and what key areas for further research and engagement can be drawn from the existing literature. We created an artificial division in the three main chapters – between literature which addresses religion as a determinant of individual behavior (in which the main focus appears to be determining reasons for vaccine refusal); literature which addresses ‘interventions’ with and social mobilization of LFCs; and finally literature which addresses potential areas of intersection in relation to health‐ and community systems strengthening. We anticipate that part of the joint learning process would be to engage partners in unpacking some of the issues outlined above, to see what conclusions they draw from the available literature (and what further contributions they might have that has not yet made it into the discussion). Therefore, at this time, we will simply provide a summary of some of the main findings from the above review, including some of the areas identified for further possible engagement.

5.1 Summary Points

History shows a number of intersection points between religion and immunization that extend further back than the recent surge of international interest

Understanding these histories helps to understand the current context and the current discourses visible in the different intersection points (from religious authorities opposing state control, to the effects of colonial systems on health systems and communities’ perceptions about public health interventions). It should be useful for historical reflection to be undertaken on specific contexts, and for those seeking to intervene with LFCs in relation to immunization to put serious effort into understanding local histories and contexts, otherwise it has been shown how this can become a major obstacle.

There is a high level of interest in ‘missed populations and closed communities’

There is a particular interest on how religion ‘closes’ such communities to outside immunization attempts – ranging from concerns about gender empowerment, to fear and suspicion, to communities literally not opening the door. As a corollary, religion can therefore also open doors – for example, religious leaders or groups acting as intermediaries into such communities, or communication utilizing particular religious lenses. Engagement on this issue would feed well into current research and policy interests.

Traditional and ‘other’ religions still missing from mobilization

Traditional (religious) and non‐mainstream religious groups remain conspicuously absent from published reports on religion and immunization. We would suggest that an urgent area for further research is considerations of mixed health and religious modalities, and how they impact on immunization uptake or refusal. Furthermore, certain un‐networked religious groups require significantly more attention (including groups that are growing

81 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 massively in development contexts, such as charismatic and Pentecostal Christians – but who remain less popular and less visible at the policy and intervention levels).

Further deliberate attention on ‘missed’ countries is required

The current literature and international attention is massively focused on a small handful of countries, such as India, Pakistan and Nigeria – it would seem driven in part by the resourcing of the global polio initiative and the general focus on polio in these contexts. We would suggest that attention is needed on less highly profiled countries and contexts – in which the intersection of religion and immunization would be just as valid although perhaps less spectacular. There is a particular literature gap on South America, Asia‐Pacific, and Eastern Europe.

Considerations of context and complexity – especially working with local faith communities

Much of the argument above suggests that generalizing about immunization and ‘religion’ on broad international scales raises certain challenges. For example, considering how religious behaviors and perceptions; interventions with LFCs; and routine immunization systems intersect and interact (Chapters 2, 3 and 4) highlights the complexity of the issue, especially when local context is taken into account. Complexity should not however prevent engagement. That is, while an understanding of local context is required for social mobilization, for health systems strengthening, and indeed for any work seeking to really understand the impact of religion or considering how to engage with local faith communities – at the same time there are key cross‐over themes, such as communication lessons, trust‐building and systems strengthening through human resource motivation that can be shared.

‘Religion’ is a challenging variable and is closely related to other social/cultural/political/economic factors

Many cross‐sectional and econometric studies demonstrate that ‘religion’ is significant in relation to immunization. However, such studies are limited in their ability to interrogate the meaning of the demonstrated variations that are found. Many of the studies looking at religious beliefs and immunization uptake argue that although vaccine refusal may be articulated in overt religious terms, other determinants are closely linked, such as gender, education, or literacy. This may require broad‐scope engagement which seeks to understand multiple influencers and effects.

Getting to grip with the complex world of religion and vaccine resistance

Vaccine resistance is often articulated in religious terms, but it has been widely demonstrated that other social/cultural/political/economic/historical factors are usually intertwined – sometimes inseparably. Some immunization campaign planners might be resistant to dealing with the ‘messiness’ of multiple causal factors and the elusiveness of ‘religion’. We would argue that unpacking and dealing with this complexity is necessary and important. Not only to move beyond the (potentially dangerous) game of blaming ‘backwards religious clerics’ but also so that we can understand the real root causes of resistance and act appropriately.

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The need for interdisciplinary and multi‐sectoral and engagement on religion and immunization

The broad scope of this review demonstrates the need for interdisciplinary and multi‐sectoral engagement on religion and immunization. Single‐focus interrogation is unlikely to have much success in relation to this fairly complex range of issues. There is a need to deliberately integrate epidemiological, public health, social science, and theological perspectives – with those of practitioners, health professionals, program planners, policy makers, religious and community leaders. This is necessary, but will require intent – and we would suggest a deliberate process of practice‐research engagement.

Cross‐over interdisciplinary studies and actions, which draw lessons from different areas of engagement

We would strongly suggest that interdisciplinary efforts are required to engage on religion and immunization, as narrow or single lens views are not able to adequately unpack this complexity (for example with multiple causal explanations). At the same time, there is likely to be great potential in drawing from other areas of existing research and engagement. For example, massive effort has gone into understanding how to engage with LFCs in relation to HIV/AIDS, and while delivery mechanisms are often different, there are many similarities too (for example, touching on issues of individual behavior and belief, community engagement and health systems functioning). We would suggest that there are important lessons that could be transferred from areas such as ‘religion and HIV/AIDS’ into the investigation on ‘religion and immunization’ (whereas at the moment there is a complete disconnect). For example, lessons on mechanisms for social mobilization with LFCs and religious leaders can be drawn from HIV/AIDS initiatives, and existing trusting relationships and communication networks built around HIV/AIDS response could be leveraged for immunization. In reverse, the emergence of HPV vaccine implementation in development contexts has the potential to lead the way for a future HIV vaccine – given the similar religious elements that emerge around risk perception and uptake. These examples demonstrate the need to build stronger bridges across ‘sectors’ – especially to prevent wasting hard‐earned lessons and resources.

Working with local theologies is required – but there is only limited engagement of religious studies scholars and theologians in immunization response

Given the need for understanding of religious perceptions around vaccine uptake, and the need for information about local (religious) context for targeted response – it is astounding how little immunization is being taken up by religious studies scholars and theologians (the outlier being Muslim scholars, and certain Catholic groupings such as the Vatican’s Pontifical Academy for Life). Although studies with a public health focus have demonstrated that religious doctrine or reasoning is applied to justify vaccine refusal (such as God heals not vaccines), as well as vaccine uptake (as a gift of God to be used in gratitude) ‐ immunization is barely present in the academic theological literature, and certainly not with the attention given so enthusiastically to HIV/AIDS. It may be a useful practice to more strategically engage religious academics or theologians to support further unpacking of the complexities of local (practical) theologies, as well as to evaluate the targeted social mobilization currently underway with religious leaders and LFCs.

The need for religiously‐competent program staff and health workers

In all areas of engagement, there is a high level of demand for program staff, policy makers and health workers that are sensitive to different religious practices and beliefs in their specific context. There therefore needs to be some further consideration for what this means for engagement, intervention and training. Many studies

83 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 conclude by calling for ‘training’ in intercultural and religious competence – however, there is limited description of exactly what this training should entail or who should undertake it. This is an important area for possible joint engagement (including academic as well as practitioner partners). Similarly, more and improved ‘guidelines’ for field‐staff should be developed by intervention and funding institutions – for example, the key points to consider when engaging with religious leaders and local faith communities when undertaking a vaccination program.

Engaging religious leaders in genuine social mobilization and advocacy

There has been a massive interest in religious leaders, both as barriers to and as advocates for vaccine uptake. However, increased quantity of engagement does not necessarily equal improved quality of engagement ‐ or actual behavior change. Several studies in this review demonstrate that half‐hearted engagement with religious leaders can be counter‐productive or even damaging. The actual impact of religious leader mobilization is not well understood, with conflicting reports on their actual effectiveness. Understanding the quality and nature of social mobilization with religious leaders better would be hugely useful – not only for immunization intervention but also other public health and development actions with community participation and mobilization elements. (Note that Muslim clerics from Nigeria and Pakistan dominate the literature and media at present. Care should be taken that other varieties of religious leader be considered and included).

Unpacking best and ‘could be better’ practices for social mobilization with religious leaders and LFCS

There is already encouraging analysis of some of the targeted social mobilization put into place with religious leaders and LFCs (such as the work connected to UNICEF and the Polio Communication Initiative). However, there is significant room for further learning and investigation. For example, understanding how responses to ‘pragmatic’ or ‘activist’ approaches differ with LFCs would be valuable. As would knowing what specific mechanisms have been developed for engagement (beyond ‘meetings with religious leaders’). Good practice models for encouraging ‘genuine’ participation of religious leaders should be encouraged. Useful approaches of connecting to LFCs besides religious leaders need to be profiled (for example, efforts through women’s or youth groups, faith‐based schools or choirs). Practitioners and implementation partners (agencies, NGOs and FBOs) should consider pooling best practices for engagement with religious leaders and LFCs. A ‘safe space’ should be created for implementation partners to share ‘poor’ practice as well – such as ‘failed’ attempts at engagement or unexpected consequences of intervention. At this time, practitioners are strongly oriented to only reporting on engagement for promotional reasons which we argue will not improve practice or understanding as well as sharing important lessons on what was learnt and adapted.

Improving communication strategies (interpersonal, local, national and international) with and through LFCs should be considered

It could be valuable to consider and assess different communication mechanisms utilized by LFCs – from ‘religious folk methods’ such as loudspeakers to social media on the internet. The impact of broad anti‐vaccination movements that ‘reside’ on the internet but impact on local communities (such as the bioethics discourse) is not well understood. It has been noted that religious communities have particular transnational ties, and this has implications not only for communication of information and beliefs – but also the communication of disease (as the Dutch and Israeli examples attest). Also, there is nothing that we can see on how televised media from one country impacts on others in development contexts (for example, in many parts of Africa, American televangelism

84 JLIF&LC SCOPING REVIEW LOCAL FAITH COMMUNITIES AND IMMUNIZATION FOR SYSTEMS STRENGTHENING August 2014 is widely watched, even in remote areas). While the importance of interpersonal communication has been noted – there is not a significant amount of information on what this means in practice in relation to engagement with LFCs, messaging or vaccine promotion. Communication might well be an important area for engagement (existing groups such as the Polio Communication Initiative might be asked how they engage with these issues).

There is a huge gap in evidence on the specific nature and extent of routine immunization services provided by faith‐based health providers

There is a massive evidence gap on the unique characteristics and contributions of FBHPs to routine immunization. Many questions were raised in the previous chapter. For example: to what extent do FBHPs participate in and contribute to national immunization programs and targets; what quality of routine immunization services are provided; how are supply or cold chains maintained; are FBHPs providing access to poor or rural communities that otherwise do not have access to immunization; are health worker practices different in FBHPs, e.g. do they spend more time explaining immunization to clients; are health workers more motivated and does this impact on routine immunization; are FBHPs generally more or less trusted by the communities in which they operate (and does this relate to immunization services or uptake); do FBHPs have different access to the communities in which they are operating to public services; are primary health care services and outreach activities any more or less effective – and the list could go on. This is an obviously important general area for possible study and engagement.

We need to understand the resilience of health systems and FBHPs providing immunization services in fragile and post‐conflict contexts better

The case example from the DRC demonstrates that particular attention is needed on the activities of religious leaders, LFCs and FBHPs in fragile and post‐conflict contexts. Their formations, partnerships and innovative service delivery solutions in challenging circumstances all require more attention.

Does immunization impact on or strengthen the health systems that FBHPs are a part of?

Very little is known about how immunization or health systems strengthening interventions impact on FBHPs. Or what health systems strengthening interventions are being carried out with FBHPs that might strengthen routine immunization. This is a massive area for further engagement.

We need to investigate ‘trust’ at all levels

The importance of trust to this issue (the intersection of religion and immunization) cannot be understated. Trust appears as a central factor, in relation to vaccine refusal or uptake, in relation to public trust, in relation to influencers, social mobilization, communication and engagement with LFCs. Trust also appears strongly when looking at immunization from a health systems perspective, for example in relation to patient‐provider trust and community accountability. There is a strong (un‐evidenced) suggestion that LFCs, religious leaders, FBOs and FBHPs have certain intrinsic ‘valued‐added’ components, and the most frequently cited is ‘trust’. There is an urgent need to explore and unpack ‘trust’ in a thorough and evidence‐based manner. In addition, engagement over ‘trust’ can be utilized as the bridge over these diverse areas of interest, and as a tracer issue around which joint learning could be initiated.

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