Using the Social-Ecological Model to Assess Vaccine Hesitancy and Refusal in a Highly Religious Lower-Middle-Income Country

"[U]nderstanding factors associated with family and religion in Indonesia could inform culturally competent interventions addressing vaccine hesitancy at interpersonal and community levels in other LMICs. Social and religious concerns could be used as a leverage to enhance public health strategies and vaccine uptakes in populations that might otherwise be resistant."

In lower– and middle-income countries (LMICs), social factors, cultural dynamics, and religious beliefs exert more influence on vaccine hesitancy than in high-income countries, where safety concerns predominate. One such LMIC, Indonesia, features a unique cultural blend of Asian patriarchal customs and Muslim family values. In this context, religious beliefs can deeply influence public health behaviour by supporting or contradicting scientific recommendations. This study aimed to identify factors at multiple levels associated with vaccine hesitancy and refusal in Indonesia based on the Social-Ecological Model (SEM), with the goal of facilitating development of culturally competent, system-based approaches for vaccine strategies and policies in LMICs. The SEM capitalises on an interplay of factors on the societal, community, interpersonal, and individual levels.

Data on demographics, religiosity, family dynamics, and perceptions of public health efforts were collected from 224 respondents through an online survey. Questions about vaccine hesitancy and refusal were asked in the context of any vaccine a person has received. The study defined vaccine hesitancy as any reluctance in receiving a vaccine and defined vaccine refusal as any time a person refused a vaccine. Types of vaccine hesitancy were defined through the World Health Organization's Strategic Advisory Group of Experts (SAGE) 5C model: confidence, complacency, constraints, calculation, and collective responsibility.

Select findings and implications:
 

• Approximately one-third (34.4%) of participants reported experiencing vaccine hesitancy and 17.6% experiencing vaccine refusal at some point in their life, including before and during the COVID-19 pandemic. The vaccine hesitancy rate in this study aligns with the findings of previous studies in Indonesia, which found hesitancy ranging from 16 to 60%.
• Constraints defined by the 5C model, such as distance to clinics and appointment timing, were the primary barriers to vaccine compliance. This result and others from studies in the region underscore the need for governments and healthcare sectors to enhance accessibility by addressing social and economic determinants of health. The pandemic-era practice of utilising mosques and churches as community vaccination centres exemplifies an effective strategy to mitigate structural barriers.
• Religion can promote values and service to protect health of others, which can include vaccination. While there was no significant correlation between high religiosity and vaccine hesitancy or refusal, when controlling sex and geographical setting, participants who believed that a higher power supported the COVID-19 vaccine had a 58% lower likelihood of vaccine hesitancy (adjusted odds ratio (AOR) = 0.415; 95% confidence interval (CI) 0.217-0.792; p = 0.008). Religious leaders were significantly associated with vaccine decisions in both the vaccine-hesitant (p = 0.027) and refusal participants (p = 0.005). An important intervention on the community level would be to engage religious leaders and faith-based organisations to partner with healthcare workers to provide factual information on vaccines for their communities. Religion has a powerful network and communication level, specifically with the ability to reach out to rural dwellers and uneducated people.
• In this study setting, men demonstrated more vaccine hesitancy than women, which could be due to the fact that the female participants in this study were highly educated compared to the average population. There were no specific differences in family dynamics concerning vaccine hesitancy or refusal; however, Indonesian traditional cultural norms often position men as household decision-makers. Male head of households had a significant influence on vaccine decisions in the refusal group (p = 0.016). These findings highlight the potential significance of empowering women, who could be less hesitant than men with upper education, to promote vaccine acceptance and mitigate hesitancy. Empowerment programmes could teach women to confidently discuss vaccine benefits, address misinformation, and make informed choices. Having local female healthcare workers or respected community figures lead these initiatives would further increase trust and receptiveness.
• Misperceptions and mistrust significantly increased the likelihood of vaccine hesitancy among participants. Hesitant and refusal participants trusted and used the same sources. Among hesitant participants, healthcare providers were identified as the most trusted vaccine information source (34.6%), followed by the government (30.8%) and the internet (17.9%). Similar patterns followed in the refusal group. However, the sources most frequently used by hesitant participants differed from the most trusted: social media (37.2%), the internet (30.8%), and the government (10.3%). Individuals with vaccine refusal were more than twice as likely to share information with others without fact-checking. To minimise informational barriers to accessing reliable sources, individuals should be provided with trustworthy facts via social media platforms to make factual information convenient. The 5C model outlines that calculation, the process of weighing risk and benefits of vaccination, can be improved with accurate vaccine information.

Thus, this study shows how policy, religion, family influence, and accurate vaccine information play significant roles in vaccine hesitancy and refusal. It thus emphasises the importance of targeting interventions at each of these levels to understand cultural factors relating to vaccine hesitancy and refusal. Collaboration and communication among stakeholders at different levels is necessary for vaccination promotion interventions. Lessons learned about vaccine hesitancy from this study will be used in improving current and future vaccine deployments.