An article in Vaccine: X in August 2023 acknowledges that previous research has identified religion as one of “numerous factors” contributing to a potential delay or refusal of vaccination. Therefore, the author, PhD candidate Hanne Amanda Trangerud of the University of Oslo, seeks to present a “comprehensive overview” of the “essence” of religious objections to vaccination. This could be used to inform vaccination strategies with a greater understanding of vaccine decision-making. Trangerud offers five main types in the typology: 

  1. A worldview clash type – in which vaccines do not make sense as a health intervention 
  2. A divine will type – which represents a form of passive fatalism 
  3. An immorality type – which considers vaccines unethical because of their production or effect 
  4. An impurity type – pointing to ingredients that will defile the body 
  5. A conspiracy type – in which a vaccine plot is targeting a religious group 

Vaccine decision-making and religion 

“Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of vaccine services. Vaccine hesitancy is complex and context specific, varying across time, place, and vaccines. It is influenced by factors such as complacency, convenience, and confidence.” 

In a previous post we have explored the 5c model that examines these factors and more. It is important to note that vaccine hesitancy is distinct from low immunisation coverage due to supply and delivery. The notion of vaccine hesitancy as behaviour has been challenged by some, who argue that it should be understood as a “state of indecisiveness”. However, for Trangerud, the key point is that “a person’s vaccine decisions are the result of a complex process” that should be understood as resulting from “a complex process that needs to be understood in its particular context”.  

Religion is listed and recognised as a potential factor for vaccine behaviour but may or may not be associated with vaccination status. Larson et al. found that 15.4% of respondents to a global survey thought vaccines were incompatible with their religious belief, yet the study also showed that there was not a direct link between a particular faith type and vaccine response.  

“It is imperative to consider the impact of religion in light of other factors, such as politics (both national and international), history (e.g. colonialism), and cultural values (e.g. gender roles).” 

Therefore, the relationship between religion and vaccine hesitancy is “complex and context specific”. Hoping to “shed light” on the role of religion in influencing vaccine decisions in practice, the article claims to offer a “complete and coherent typology of religious vaccine scepticism (RVS), based on a literature review.  

“RVS here denotes an attitude of doubt or disbelief towards vaccines that originates in, is related to, or is explained as religion.”  

Literature review 

The typology was developed on a literature review of research into religion’s influence on vaccine decisions. This review included peer-reviewed articles, written in English, across different fields and kinds. Sometimes religion was not the primary focus, but findings involved “significant religious arguments against vaccination”. With the goal of identifying as many arguments as possible, the review was “broad” and “paid equal attention both to frequently mentioned and to rare objections”. 

The types were structured according to the “essence of what is considered problematic with vaccines” in the eyes of a religious individual or group in answer to the question “what is the problem with vaccines?” The essence of each type may “span across different religious traditions and groups” because the types encompass elements that are not specific.  

The types 

Vaccines as irrelevant or destructive 

The first type is the “worldview clash” type, in which the “causal explanations of life, health, and disease make vaccination inappropriate as a health intervention”. Considering certain premises, vaccination is “irrational” because it is either “unnecessary” or brings about “negative consequences”.  

For example, Trangerud states that members of Christian Science “may not only reject vaccines” but other medical interventions due to a belief that “diseases are illusions” and “only the realisation of this can bring about healing”. In this worldview, human beings are the image of a spiritual God and cannot be sick, a material phenomenon. Furthermore, sin, ignorance of God, or fear (such as that of disease), may cause disease. The appropriate remedy would be prayer and the “correct mindset”.  

Another example of a worldview clash type is the perception of polio by the Hausa communities in northern Nigeria, for whom polio (or cutar shan-Inna) is a result of a powerful spirit drinking the blood of a victim’s limb. Healing can be achieved through offering the spirit whatever she informs the traditional healer that she wants, such as food, accompanied by prayer, incense, and herbal massage. Healing occurs when the spirit is satisfied. Thus, the oral polio vaccine “makes very little sense”.  

Vaccines interfering with God’s will or revealing distrust 

Trangerud indicates that, as with the first type, this second type is “rooted in the premises of a particular worldview”. However, in this type, the role of human beings is not active, as in the first.  

“The divine will type describes the passive acceptance of an outcome that is believed to be decided by God, be it health or disease, life or death.” 

As an example, Trangerud identifies orthodox Protestants in the Netherlands, whose decisions to accept or reject vaccines are “often” based on religious arguments. Members believe that one shouldn’t, and indeed can’t, interfere with divine providence.  

The divine will type is “three-pronged”, involving belief in: 

  1. God’s protection from disease 
  2. God’s sending of disease 
  3. God’s help during disease 

Evidently, argues Trangerud, trust is key, but for some “fear might be the other side of the coin”. This could be fear of displaying distrust or of making a bad decision, she suggests. If disease is God’s will, doing nothing and “leaving the outcome to God” might be a “safer alternative” to intervening with vaccination. This type therefore represents a form of “passive or classic fatalism”, the belief that “something will occur regardless of one’s intention or behaviour”. People who hold these views are “generally less compliant with expert advice”.  

Passive fatalism is contrasted to active fatalism, which involves both acceptance and active attempts to influence the outcome. Here Trangerud presents the case that “most Muslims” believing diseases occur by God’s will, yet studies suggest this is not an obstacle to seeking medical interventions. Instead, Muslims might accept vaccines as “part of their duty to protect their health”.  

Vaccines as unethical 

The RVS of the third type relates to issues that are considered “ethically problematic”, and does not apply to all vaccines in general, but certain vaccines. The value judgement of these vaccines relates either to the production of the vaccine (cause-related subtype) or the use of the vaccine (effect-related subtype).  

  • The cause-related subtype describes scepticism towards vaccines “deemed unethical because their production somehow is related to the illicit killing or suffering of a being”. Trangerud’s example is of the cell lines from voluntarily aborted foetuses used to grow viruses, point for rejection for Catholics or other Christians who strongly oppose abortion. Another example is the use of bovine ingredients like foetal bovine serum, identified as a potential concern to Hindus to whom cows are sacred. This is “underresearched in the context of vaccines”, but for drugs and medical products studies have identified a “reluctance” in Hindus.  
  • The effect-related subtype involves scepticism towards vaccines that are found “ethically unacceptable” because they are perceived as encouraging “sexually immoral behaviour”. This association between vaccines and sexual behaviour can be traced to vaccines preventing diseases transmitted through sexual intercourse (human papillomavirus and hepatitis B). Parents may reject these vaccines for their children in favour of the principle of abstinence set down for Christians, Jews, and Muslims, or so studies suggest. Furthermore, some parents fear these vaccines can themselves “trigger early sexual debut or promiscuous behaviour”. Finally, the fear of social stigma if one is “perceived to need such vaccines” may cause hesitancy in cultures where sexual abstinence before marriage is the norm.  
Vaccines as defiling the human body 

The RVS of the fourth type is based on the idea that “some vaccine ingredients are religiously impure”, either by nature or preparation. They can therefore “defile the human body”. This notion of impurity is different to that of immorality. The impurity type “rejects vaccines because of ingredients that, according to a divine order, are defined as unclean or harmful in essence”.  

The example that Trangerud offers is that of pigs, regarded as unclean by Muslims, Jews, and some Christians. Studies have demonstrated that, “to many Muslims”, porcine ingredients are “major concerns and barriers to immunisation”. This can only be overcome by halal certification or proof that the vaccine does not contain prohibited ingredients. Some Islamic leaders and medical experts have declared gelatine to be permissible, having become clean through a process of transformation, but not all scholars accept this.  

Porcine ingredients were a problem illustrated by a drop in vaccination coverage in Indonesia after the Indonesian Ulama Council said the new measles-rubella vaccine in 2017 was forbidden by Islamic law. By contrast to other religious groups, some Christians, who “have no problems with eating different types of meat and using other animal products”, hold the belief that the body will be “polluted” if vaccine ingredients from the same animals, alongside chemicals, are injected.  

Vaccines as a means of harm 

The final RVS is a type “rooted in conspiracy beliefs” that associate vaccines with a plot for “extensive, negative consequences”. These beliefs “need not be related to religion”, but as an RVS type pertain to vaccine conspiracies that target a religious group or community. Some of these conspiracies involve population control through fertility reduction or deadly diseases, with vaccines functioning as “vectors or camouflage for a secret, harmful substance”. Therefore, vaccination threatens both the existence of individuals and their whole community. 

“While some people deliberately spread conspiracy rumours to achieve other goals, ordinary people may genuinely believe in the, and be struck with fear or anger.”  

The occasional engagement by trusted religious authorities lends credibility to these rumours. This is a complex type, demonstrated by the boycott of the oral polio vaccine by some of the Muslim-majority states in northern Nigeria in 2003. This may appear a “classic religious conspiracy theory” driven by local political and religious leaders, warning that the vaccine had been deliberately contaminated with anti-fertility agents or HIV viruses as part of a plot to reduce Muslim populations. However, later analyses show that the accusations were “only a small piece” of a “larger and much more complex political picture” comprising years of national struggle for political power between the Christian and Muslim regions, poor health infrastructure and differing priorities, previous negative experiences with Western colonialism, racial prejudices, and a vaccine scandal from 1996.  

Another aspect of the conspiracy type includes the linking of conspiracy beliefs to a religious narrative. For example, some Christians rejected the COVID-19 vaccine because “they feared it might contain microchips and hence represent ‘the mark of the beast’”. This biblical phrase is associated with end times events, such as persecution of Christians.  

Trangerud’s conclusions 

“For policymakers and public health workers, it is imperative to know when the solutions to counter vaccine hesitancy are found outside religion.”  

Trangerud suggests that the benefits of this study include knowing that RVS is “not necessarily reflected in the canonical doctrines of a religious institution”. While there are examples of teachings that prohibit immunisation, “most religious groups do not have straightforward teachings on the matter”. However, religious doctrines still inform vaccine decision-making. Often, one doctrine is interpreted differently by different groups, such as the case of the religious duty to “preserve life”. Thus, the same doctrine “may be relied on by both acceptors and rejectors of a vaccine”.  

The typology that Trangerud offers is based on research that identifies how RVS affects vaccine decisions “on a practical level”. It is useful for those who want to understand the effect of religion on vaccine hesitancy and can help match types to interventions: 

  • For the worldview clash type, the solution may be found within the worldview in question – following the rules of logic laid down by the applicable premises. 
  • For the divine will type, the solution could be to aid believes from passive fatalism to active fatalism, encouraging active participation in caring for one’s health at the same time as respectfully preserving belief in providence or other external forces. 
  • For the immorality and impurity types, some believes may be convinced by arguments or the provision of vaccines with alternative ingredients. 
  • For the conspiracy type, the building of trust is key. The roots of the beliefs must be identified and dealt with individually. Some religious arguments might be helpful.  

If you consider yourself religious, are there any aspects of the typology that strike you as interesting or surprising? Have you had to overcome, whether personally or professionally, any of these types? What do you think this paper contributes to the vaccine hesitancy space?  

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