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

Vaccine hesitancy, characterized by a reluctance to receive vaccines, and vaccine refusal, defined as the decision to decline vaccination, rank among the top ten global health threats. Vaccines currently prevent 4 million child deaths annually and have the potential to save an additional 50 million lives by 2030. Despite the increasing popularity of vaccines, various barriers have emerged, including structural, behavioral, and informational challenges. Structural barriers involve issues like transportation and clinic availability; behavioral barriers include misperception and mistrust; and informational barriers encompass health literacy, cultural relevance, and misinformation.

Following the COVID-19 pandemic, vaccine hesitancy has continued to rise. Parents who were hesitant about the COVID-19 vaccine and lacked trust in vaccination information now have controversial vaccine attitudes towards the recommended childhood immunizations for their children. As the COVID-19 vaccine becomes routine, similar to the annual flu shot, implementing effective evidence-based interventions to address vaccine hesitancy is crucial. Previous studies on vaccine hesitancy have focused on knowledge and perceptions of vaccine safety to mitigate informational and behavioral barriers at the individual level. In high-income countries, safety concerns predominantly influence hesitancy, where most current intervention efforts are concentrated. However, in lower–middle-income countries (LMICs), social factors, cultural dynamics, and religious beliefs exert more influence on vaccine hesitancy. Religious beliefs were found to be the leading cause of vaccine hesitancy during a qualitative analysis of thirteen high-, middle-, and low-income countries.

Vaccine hesitancy associated with cultural and religious factors in Asia remains understudied. Indonesia, the third largest country, with 275 million people, and a LMIC country in Southeast Asia, offers a unique cultural blend of Asian patriarchal customs and Muslim family values. Overall, 99% of the Indonesian population self-identifies as religious. With 87% of its population identifying as Muslim, Indonesia represents the world’s largest Muslim population, accounting for 13% of global Muslims. This unique culture is unparalleled compared to any other country. Only one known study documented Indonesians’ cultural misperceptions regarding COVID-19, showing how some Indonesians thought they were safe from COVID-19 due to its tropical climate and the belief that herbal medicines can cure COVID-19. In such contexts, religious beliefs can deeply influence public health behavior by supporting or contradicting scientific recommendations. Moreover, understanding 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.

Policy is crucial for ensuring vaccine uptake. During the pandemic, most countries recommended citizens get the COVID-19 vaccine, but only a few countries, including Indonesia, implemented vaccine mandates. Indonesia’s Ministry of Health introduced PeduliLindungi smartphone application, which issued digital vaccine certificates. Individuals were required to present or scan the QR code to enter public places such as stores, restaurants, workplaces, and schools. While PeduliLindungi could theoretically address vaccine hesitancy by encouraging vaccination, its impact on hesitancy and refusal has not been investigated. In Indonesia, examining the impact of a mandatory health app on vaccine decisions can illuminate how digital enforcement mechanisms interact with social values and religious beliefs, providing a holistic understanding of both technological and socio-cultural factors in public health interventions. This new insight will be highly relevant currently as the Indonesian Government decided to strengthen the digital health intervention by transforming the PeduliLindungi, which was mainly developed for COVID-19 control and prevention, into SatuSehat Platform, which is designed as an app to provide a digital transformation of health service delivery for all relevant diseases or health problems.

This study aimed to identify factors at multiple levels associated with vaccine hesitancy and refusal based on the Social–Ecological Model (SEM) to improve community health through the promotion of prevention in Indonesia. This model can be employed to adopt a multi-level approach, an aspect that has been underrepresented in the recent literature concerning vaccine hesitancy and refusal. The SEM has been shown to capitalize on an interplay of factors on the societal, community, interpersonal, and individual levels, creating more sustainable solutions for populations. Thus, this research sought to address knowledge gaps in developing culturally competent, system-based approaches for vaccine strategies and policies in LMICs. The findings will inform multisectoral stakeholder collaborations to enhance future vaccination efforts.

source :

https://www.mdpi.com/1660-4601/21/10/1335