Public Health Partnerships with Faith-Based Organizations to Support Vaccination Uptake among Minoritized Communities: A Scoping Review

"FBOs [faith-based organisations] provided PHAs [public health agencies] the tools (i.e., faith-based frameworks) to engage and network with communities in rural, remote, or conflict-ridden regions of the world where CBOs [community-based organisations] and PHAs previously had difficulty accessing vaccines, demonstrating FBOs' potential impact on equitable vaccine delivery..."

Ethnoracially minoritised communities and populations - that is, ethnic and racial groups who experience multiple forms of discrimination - have faced low vaccine confidence due to a legacy of systemic racism and medical maltreatments. Public health agencies (PHAs) have found strength in partnering with faith-based organisations (FBOs) that jointly apply principles of inclusivity, flexibility, and trust in community to promote vaccines. The objectives of this scoping review are to: (i) describe the role of partners and collaborators involved in carrying out vaccine initiatives; (ii) outline intervention strategies and implementation frameworks guiding interventions; (iii) and synthesise outcomes and evaluations of PHA-FBO vaccine initiatives.

The researchers carried out literature searches from October 20 2023 to October 30 2023 on OVID MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS, PROQUEST-Public Health, PROQUEST-Conference Paper, and PROQUEST-Policy File Index. Considering the changing landscape and wealth of community engagement approaches for vaccine uptake, only those published between January 1 2011 and October 20 2023, were searched. Eligible types of publications included case studies, news reports, observational studies, experimental and quasi-experimental studies. and multimedia content that describes PHA-FBO partnerships that created vaccine initiatives for marginalised and minoritised communities. The search yielded 1,361 results; 160 articles describing 167 initiatives were included in this scoping review for analysis.

The articles covered major vaccine-preventable disease eradication campaigns, such as influenza (e.g., H1N1), polio, measles, and COVID-19. The initiatives were carried out among 7 identified religions, including Christianity (160/331, 48.3%) and Islam (74/331, 22.4%). Initiatives were delivered in 48 languages. PHAs, FBOs, and other partners contributed to the implementation and delivery of initiatives to varying degrees. There were 38 frameworks, theories, models, and strategies applied across 44 initiatives. Six theories/frameworks/models/strategies were identified in more than 2 articles - namely, the social-ecological model (SEM); community-based participatory research (CBPR); community-engaged outreach (CEO); social and behaviour change communication (SBCC); social mobilisation implementation theory and strategy; and consolidated framework for implementation research (CFIR).

The interventions carried out by PHA-FBO partnerships attempted to increase vaccine uptake using any or all the following methods:

• Objective 1: Enrolling faith leaders (rationale: faith leaders' receptivity and proactivity to collaborate with PHAs is a contributor to vaccine acceptance). Key strategies included: (i) providing digital and in-person platforms for interfaith learning (e.g., the "Communities of Practice (COPs)" series hosted by the World Health Organization (WHO) Information Network for Epidemics (EPI-WIN), which fostered continuous collaboration and dialogue among faith leaders with local knowledge on ways to approach vaccine-hesitant communities on 5 different continents) and (ii) establishing training programmes to empower faith leaders to become vaccine ambassadors (e.g., the "Faith in the Vaccine" ambassador programme, sponsored by The Interfaith Youth Core (IFYC), which trained religious youth to engage with their own religious/ethnic communities).
• Objective 2: Increasing vaccine awareness and acceptance among minoritised groups. Key strategies included: (i) conducting awareness and education campaigns via digital pathways or in-person gatherings (e.g., PHAs partnering with FBOs to launch multipronged educational campaigns via webpages, statements, and webinars to combat myths and address safety and efficacy concerns from faith communities who mistrust government institutions and healthcare systems) and (ii) designing faith-sensitive vaccine communication that aimed to be sensitive to religious and gender norms (e.g., in 7 majority Muslim low- and middle-income countries (LMICs), using gender-sensitive campaigns where leaders separately addressed men and women on parental obligations to vaccinate children based on sacred text).
• Objective 3: Increasing equitable access to vaccines. PHAs-FBOs partnered to apply equity and faith-based frameworks (e.g., in LMICs, faith communities' vast volunteer networks were activated to facilitate vaccine appointment sign-ups, and mosques and churches were staffed to call its members to show up at vaccine appointments) and provided wraparound support to enable equitable vaccine access.

The majority of the initiatives reported that PHA-FBO partnerships improved vaccine confidence and uptake (71.3%). About 22.2% of the initiatives reported quantitative outcomes post-intervention. In short, the evidence shows that most PHA-FBO initiatives from 2011-2023 increased vaccine uptake and acceptance among diverse ethnoracially minoritised populations.

In reflecting on the findings, the researchers note that the reviewed studies confirm that PHAs benefited from FBOs' localised understanding of the needs and concerns of ethnoracially minoritised communities in these ways:

1. PHAs (e.g., WHO, United Nations Children's Fund (UNICEF), United Sttates Agency for International Development, or USAID) partner with FBOs (e.g., Religions For Peace, World Faiths Development Dialogue, Catholic Relief Services, World Vision, World Jewish Congress) to deliver interfaith learning to empower faith leaders to network and become ambassadors to their own communities. Faith leaders were recruited to advisory councils, which led to stronger commitments to participate in vaccine promotion digitally and in person.
2. PHA-FBO partners co-created vaccine awareness and educational materials and campaigns like "The Color Green Vaccination" and "Build Hope Together", with careful consideration to religious beliefs and local practices, thereby contributing to minoritised communities' acceptance and understanding of vaccines.
3. Improving equitable vaccine access is one of the many priorities of FBOs that PHAs have leveraged to create longstanding impacts to address the needs of communities made structurally vulnerable such as ethnoracially minoritised groups. Leveraging FBOs' shared commitment in providing humanitarian aid, wraparound services, and social supports [111] to marginalized communities in both LMICs and high-income countries (HICs) was seen as instrumental to the success of these partnerships.

Among initiatives that reported frameworks, models, and strategies, PHAs did not explicitly consider the socio-structural drivers of racial and health inequities. Rather, they took on community-centred implementation approaches (e.g., CBPR). Local faith-based partners' understanding of cultural and social norms and contextual needs, and as established and trusted leaders within their respective communities, positively informed vaccine outreach activities. A few applied vaccine hesitancy models/frameworks (e.g., the behavioural and social drivers of vaccination (BeSD) framework). Very few explicitly centred equity, applied intersectional approaches when analysing relationships between FBOs and PHAs (e.g., CFIR), or problematised the socio-structural influences of minoritisation impacting different ethno-racial groups (e.g., Taskforce on Racial Inclusion and Equity framework).

"Future research on the impacts of faith-based initiatives can be strengthened using theories/conceptual frameworks that help to interrogate and analyze the historical and sociopolitical processes of minoritization, complemented by implementation science methods to assess the processes and outcomes of implementing interventions and their health equity impacts."

In conclusion: "PHA-FBO vaccine initiatives improved vaccine uptake among faith-based communities and ethnoracially minoritized populations who are made structurally vulnerable due to racism, statelessness, stigmatization, oppression and/or marginalization. Collaborations between PHA-FBO and other partners promoted vaccine confidence and access by interfaith learning and training, awareness and education with faith-based sensitivities, and wrap-around services to increase accessibility based on principles of equity."