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Abstract
Introduction Faith-based organisations (FBOs) and religious actors increase vaccine confidence and uptake among ethnoracially minoritised communities in low-income and middle-income countries. During the COVID-19 pandemic and the subsequent vaccine rollout, global organisations such as the WHO and UNICEF called for faith-based collaborations with public health agencies (PHAs). As PHA-FBO partnerships emerge to support vaccine uptake, the scoping review aims to: (1) outline intervention typologies and implementation frameworks guiding interventions; (2) describe the roles of PHAs and FBOs in the design, implementation and evaluation of strategies and (3) synthesise outcomes and evaluations of PHA-FBO vaccine uptake initiatives for ethnoracially minoritised communities.
Methods and analysis We will perform six library database searches in PROQUEST-Public Health, OVID MEDLINE, Cochrane Library, CINAHL, SCOPUS- all, PROQUEST - Policy File index; three theses repositories, four website searches, five niche journals and 11 document repositories for public health. These databases will be searched for literature that describe partnerships for vaccine confidence and uptake for ethnoracially minoritised populations, involving at least one PHA and one FBO, published in English from January 2011 to October 2023. Two reviewers will pilot-test 20 articles to refine and finalise the inclusion/exclusion criteria and data extraction template. Four reviewers will independently screen and extract the included full-text articles. An implementation science process framework outlining the design, implementation and evaluation of the interventions will be used to capture the array of partnerships and effectiveness of PHA-FBO vaccine uptake initiatives.
Ethics and dissemination This multiphase Canadian Institutes of Health Research (CIHR) project received ethics approval from the University of Toronto. Findings will be translated into a series of written materials for dissemination to CIHR, and collaborating knowledge users (ie, regional and provincial PHAs), and panel presentations at conferences to inform the development of a best-practices framework for increasing vaccine confidence and uptake.
- PUBLIC HEALTH
- Health policy
- International health services
- Organisation of health services
- INFECTIOUS DISEASES
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- PUBLIC HEALTH
- Health policy
- International health services
- Organisation of health services
- INFECTIOUS DISEASES
STRENGTHS AND LIMITATIONS OF THIS STUDY
This scoping review will apply an implementation science framework to assess the conceptualisation, design, implementation and evaluation of public health agency (PHA)-faith-based organisation (FBO) initiatives for vaccine uptake among ethnoracially minoritised communities.
A comprehensive document search will be performed. Six library databases, 11 public health repositories, 3 thesis repositories, 4 web engine searches and 5 niche journals, with the inclusion of multimedia (eg, podcasts, web conferences, webinars, television and radio) will be scanned to capture PHA-FBO initiatives.
The study will only extract literature published in English and include ongoing initiatives that may not have reported outcomes; evaluation of outcomes will be limited to programs that have been completed.
Introduction
Globally, around 10% of the population are considered minorities, defined as ‘national or ethnic, religious and linguistic minorities which constitute less than half of the population in the entire territory of a state’.1 Minorities experience structural disadvantages in employment, education attainment, housing and food security, and other social determinants of health. The COVID-19 pandemic accentuated health disparities among minorities and populations with lower SES (socioeconomic status), two highly correlated variables.2 For instance, Black communities,3 Indigenous communities,4 and other cultural and linguistic minoritised communities5 experienced higher morbidity and mortality6; thus, programmes to encourage vaccination among vulnerable subpopulations during the pandemic became a public health priority.
Vaccinations are one of the most cost-effective public health interventions in preventing vaccine-preventable diseases (VPDs), reducing morbidity, mortality, and economic and social disruption in whole populations. Despite these promising benefits, confidence in vaccines has been on the decline, leading the WHO to include vaccine hesitancy on the 2019 list of global health threats.7 The factors driving vaccine hesitancy are complex and context-specific. Acceptance of vaccines is related to the three C’s: complacency (ie, when risks of VPD are perceived as low and vaccination is not considered necessary), convenience (ie, the availability, accessibility, quality and/or understanding of a vaccination service) and confidence. Vaccine confidence is a social construct when there is trust in ‘(1) the effectiveness and safety of vaccines; (2) the system that delivers them, including the reliability and competence of the health services and health professionals and (3) the motivations of policy-makers who decide on the needed vaccines’.8 Multiple sectors involved in the development and delivery of vaccines are all susceptible to being mistrusted, including government officials, industry, and public health professionals.9
Vaccine confidence has been particularly undermined by historical and contemporary contexts of systemic racism, marginalisation and oppression faced by Indigenous, Black and other racialised groups in Canada and other countries. Historical precedence of systemic medical maltreatment, unethical clinical trials and discrimination towards minoritised populations in the public health and healthcare system resulted in mistrust in health institutions among ethnoracially minoritised populations. Atrocities such as the Tuskegee Syphilis Study in the USA10 have contextualised the interpretation as to why only 14% of Black and 34% of Latin-American survey respondents trusted vaccine safety during a vaccine confidence poll conducted by the National Association for Advancement of the Colored People and UnidosUS in 2020.11 Elsewhere, Indigenous Mayans in Guatemala, a country with the highest proportion of Indigenous peoples in Latin America, experience discrimination in accessing public health services, and are neglected by health service providers who are predominantly non-Indigenous.12 In the Philippines, the population has geopolitical memories of colonialism and capitalist exploitation; and has experienced deep mistrust in vaccination after 154 children, without a history of prior dengue fever infection, died from vaccine-induced antibody enhancement on receiving Dengvaxia between 2016 and 2018.13 Given the context of historical and ongoing discrimination observed in these few examples, culturally safe and community-centred/led interventions are needed to support vaccine confidence among ethnoracially minoritised populations.
Vaccine interventions that apply knowledge of local, social, cultural and religious norms have successfully reduced vaccine hesitancy among ethnocultural minorities with lived experiences of systemic racism and oppression.14 15 Though religious populations have gradually declined since the 2000s globally,16 ethnographers and sociologists maintain that religion is a social identity for refugees, newcomers and immigrants to negotiate a sense of belonging.17 18 In low-income and middle-income countries (LMICs), enrolment of trusted faith leaders increased vaccine confidence and uptake for minoritised populations who belong to the same faith.19 20 Not only do faith leaders partner with ministries of health and regional departments of health to co-create immunisation interventions that align with the religious beliefs of its congregation,21 they can more effectively reach minoritised populations who distrust government interventions due to mistreatment, compared to their public health counterparts.22 Global communicable disease eradication programmes such as the Global Polio Eradication Initiative (GPEI) have relied on local religious leaders and faith-based organisations (FBOs) as one of their many community partners to reach populations in conflict zones and vaccine hesitant communities, eradicating 99.99% of polio cases since its inception in 1988.23 24
Public health agencies (PHAs) are defined as ‘institutions or organisations with the authority responsible for, or who advocate for public health matters as its official mission and mandate’.25 PHAs find strength in partnering with FBOs, defined as ‘entities whose organisational control, expression of religion and programme implementation are tied to values and beliefs belonging to specific religious identities26’ that jointly apply principles of inclusivity, flexibility and trust in the community to promote vaccines.27
Traditionally, reviews on PHA-FBO partnerships to increase vaccine confidence and uptake have focused on interventions in LMICs.28–31 Olivier and colleagues from the Joint Learning Initiative on Faith and Local Communities published a comprehensive report and a journal publication looking at 43 examples of faith community participation in immunisation programmes in LMICs.29 30 Another review conducted by the Faith Engagement Team of the US Agency for International Development’s MOMENTUM Country and Global Leadership programme, collected 110 studies on evidence of local faith actors’ influence on community vaccine hesitancy28. Its most recent review described PHA-FBO partnership strategies that may improve COVID-19 vaccine confidence in 4 sub-Saharan countries.31 Besides written reviews, conferences and panel sessions hosted by the WHO, UNICEF and Global Alliance for Vaccines and Immunisation (GAVI) offered collaborative opportunities for FBOs to share how PHA-FBO partnerships increase vaccine confidence and uptake in the context of LMICs; and open dialogues on issues of governance in equitable distribution.32–34
In contrast, in high-income countries (HICs), the documentation of PHA-FBO partnerships to implement vaccine interventions among minoritised communities, encompasses case studies,35 36 recommendations37 and PHA-disseminated toolkits.38–40 The evaluation of PHA-FBO partnerships for vaccine interventions is also limited to specific minoritised groups such as Latinos41 and Black42 43 populations who are of Christian or Catholic faith. To the best of our knowledge, studies that are exclusively focused on examining PHA-FBO partnerships where FBOs are engaged in collaborative top-down models, are limited to the USA. An exemplar is the ‘Model Practices Framework’, developed by Emory University’s Interfaith Health Programme, whose facilitation of FBO collaboration with the Centers for Disease Control and Prevention (CDC) and local Departments of Health, increased influenza vaccine uptake,38 44 45 and later on, that of COVID-19 vaccines.46
Reviews of FBOs as public health collaborators of publicly sponsored community-based initiatives for vaccine promotion are scarcer. To date, we have found a report commissioned by The National Academy of Sciences that synthesised 23 qualitative articles to have mentioned FBOs as members of community partnerships which influenced community decisions to vaccinate.47 A recent systematic review of 37 studies showed FBO’s ability to establish trust, mitigate barriers, disseminate and sustain efforts, and tailor public health campaigns; but did not examine interventions specifically for minoritised communities.48
Religious activities of immigrants in HICs have interested labour scholars for decades as to how processes of integration are affected by immigrant culture, ethnicity and religious backgrounds.49 Meanwhile, faith-based partnerships for vaccine interventions and programmes to increase vaccine uptake among newly arrived immigrants,50 undocumented migrants,51 and asylum seekers and refugees52 has been a recent development in the realm of vaccine outreach. In Canada, for example, immigrant labour accounts for 84% of the growth in total labour forces since 2010.53 The growth in immigrant populatons is reflected in the rise in Muslim, Sikh and Hindu faiths that make up 10% of the total population of Canada.54 As religion is important social capital for bridging and bonding among immigrants,55and in light of current migrant labour policies and implications of decreasing vaccine confidence in HICs, scholarly recommendations have called for partnering with FBOs to develop faith-appropriate vaccination programmes.56 57 Therefore, vaccine interventions should not overlook the importance of involving faith leaders in recipient countries of global immigration and religious pluralism.58 59
Despite applications of faith-based vaccine interventions within HIC and LMIC contexts, respectively, gaps remain with the description of the PHA-FBO partnerships for minoritised ethnoracial populations; the characteristics and outcomes of the vaccine interventions; evidence of the theories/models/frameworks used to support the design, implementation and evaluation of the intervention; and appraisal of implementation science theories/models/frameworks.60 There is a need to take a macrolevel approach to scope out and characterise the various partnerships and approaches to strengthen evidence-based support for PHAs enrolling FBOs in community-engagement partnerships to improve vaccine confidence and uptake.
Our study differs from other existing scoping reviews and systematic reviews for its emphasis on understanding the role of PHA-FBO partnerships in improving vaccine uptake among minoritised ethnoracial populations on a global scale. We aim to conduct a scoping review of these partnerships across the globe with two main goals. First, to identify, explore and map the literature on FBO engagement and collaboration with PHAs to increase vaccine confidence and uptake. Second, to inform public health policy-makers on best practices to engage faith-based groups and further generate evidence to design faith-based interventions.
Methods and analysis
This protocol is for a scoping review guided by the Joanna Briggs Institute (JBI) Method.61 We will conduct a systematic scoping review search from 20 October 2023 to 30 October 2023 on how PHAs (international, national, regional) and other organisations involved in health promotion (including community-based organisations and academic research institutes) collaborate and partner with faith-based communities to improve vaccine confidence among ethnoracial minorities. We chose the JBI method because it addresses broader questions beyond typical ‘effectiveness’ evaluations of a given intervention; it facilitates identification and clarification of working definitions and conceptual boundaries.62 This method is suitable for exploring the scope of faith-based collaboratives that exist to encourage vaccine confidence and uptake among ethnoracially minoritised communities in three ways: (1) delineating the extent in the use of implementation frameworks/theories/models in guiding interventions and the scope of intervention typologies applied; (2) describing the extent of collaboration and partnership, including the roles of PHAs and FBOs in the design, implementation and evaluation of vaccine confidence and uptake strategies; and (3) outlining the presence of, and documentation of the processes of evaluation or appraisal of the intended outcomes of these interventions.
The review will allow us to capture insights across a wide variety of sources of evidence to synthesise research evidence, and map the presence, frequency, and scope of faith-based vaccine confidence and uptake collaboratives that exist.
Identifying the research question
The overarching question is, ‘Who and what processes do PHA-FBO partnerships engage in to increase vaccine confidence and uptake among ethnoracially minoritised communities, and what are the characteristics and outcomes of the vaccine interventions?’
The subquestions are:
RQ1. How do PHA and FBOs engage with one another to improve vaccine confidence and uptake among ethnoracially minoritised communities?
Who were the partners involved in the implementation process?
What types of vaccine and among what faiths were the interventions designed to promote?
RQ2. What were the characteristics and outcomes of the vaccine interventions?
What were the intervention purposes?
What were the theories, models and frameworks used to support the design, implementation and evaluation of the intervention?
In what ways were the outcome(s) of the intervention objectives evaluated and reported?
This review will use PCC (population, concept and context) to align the inclusion of relevant evidence with the research question (see table 1). Per JBL’s Reviewer Manual, we provided clear definition to the intended extraction population (or ‘type of population’), the ‘important characteristics of participants, […] including age and other qualifying criteria’; articulated the concept that guide the scope and breadth of the inquiry; and defined the context with inclusion to ‘geographical location and/or specific racial or gender-based interests’.63
PCC to inform search strategy of the scoping review
Identifying relevant studies
A search will be conducted for published and unpublished grey literature on the research area in the following six electronic libraries: PROQUEST-Public Health, OVID MEDLINE, Cochrane Library, CINAHL, SCOPUS- all, PROQUEST - Policy File index. We will also conduct handsearches of known portals, institutional archives and websites that have documented substantive research and implementation capacity around faith-based initiatives and/or vaccination efforts to identify potentially relevant literature. These will include 3 theses repositories (ie, PROQUEST Dissertations & Thesis Global, Thesis Canada, Networked Digital Library of Thesis and Dissertations); 11 document repositories for public health (ie Health Evidence, Rural Health Information Hub); and 4 website searches (ie, the WHO, the GAVI, UNICEF). Five niche journals will be handsearched including: The Review of Faith and International Affairs, Journal of Urban Health, Journal of Religion and Health, Christian Journal of Global Health, and Journal of Immigrant and Minority Health. The references from highly cited articles, scoping reviews, systematic reviews and review of reviews will be handsearched.
Studies from January 2011 to October 2023 will be included. The time frame of the inclusion covers the global onset of vaccine hesitancy and subsequent reduction of vaccine confidence for VPDs,64 65 including confidence towards HPV,66 Polio,67 MMR vaccines68 and other childhood vaccines.69 The conclusion of the search would encompass at least one COVID-19 programme delivery cycle (2021–2023) where faith-based interventions would have been performed.
Keywords or Medical Subject Heading (MeSH) terms related to ‘vaccination’, ‘faith-based organizations’, ‘public health agencies’, and ‘public health authorities‘ will be collected and used based on the PCC framework. The search strategy will be piloted by two researchers to validate the appropriateness for each of the databases. The following textbox outlines keywords included in our intended search strategy (figure 1).
Keywords to inform search strategy.
In addition, we will perform a general Google search using a combination of keywords filtered to extract non-profit (.org), education institutions (.edu, .ca), as well as government sites (.gov) to extract non-governmental organisations (NGOs) and educational reports and statements (eg, statements, reports, documents, white papers, media releases). Using the same engine, we will search for news media reports, webinars, presentations and toolkits that show evidence of PHA-FBO partnerships that are otherwise undocumented in formal reports, and published journal articles which meet our inclusion criteria.
All downloaded articles from the database and search engines will be imported into Covidence,70 a web-based collaboration software that streamlines the production of literature review; its functions. such as enabling automatic duplicate article removal, article thematic tagging and keyword highlighting, facilitate the scoping review process for teams working virtually.
Selection of eligible studies
The title and abstract screening will be guided by the PCC framework (table 1) and the following inclusion and exclusion criteria:
Inclusion criteria:
Must involve a PHA, defined as an institution or organisation with the authority responsible for, or who advocate for public health matters as its official mission and mandate, including ministry of health, health authorities, department of health, health agencies, community health centres, Indigenous health centres or any government-funded health unit/department/agency.
Must involve religious entities, faith leaders, FBOs, spiritual leaders of any faith, as well as government sponsored institutes and organisations that provide service to all faiths.
Must involve interventions related to improving vaccination confidence and uptake, including any infectious disease awareness programme that has a vaccine promotion component (eg, HIV education programmes to increase vaccine willingness).
Must be published in English.
Published between January 2011 and October 2023.
Exclusion criteria:
Documents not in the English language.
Commentaries, opinion pieces, meta-analysis, systematic reviews, review of reviews.
All electronic database records will be searched and documented (see online supplemental appendix A: Scoping Review Search Strategy). If reviews (meta-analysis, systematic reviews, scoping reviews, and review of reviews) are encountered that may include relevant literature, they will be tagged with ‘scan reference for relevant literature to import’. For the preliminary screening, two reviewers (DB-H and MYS) will independently review document titles and abstracts to determine whether they meet the eligibility criteria. We will conduct pilot-testing on the first 20 abstracts to discuss and refine the eligibility criteria to ensure that the criteria is sound and encompasses the scope of the intended review. If the two reviewers have different opinions about whether the article should move forward to the full-text screening phase, weekly meetings will be held to discuss and resolve differences. Each title and abstract will be approved to progress to full-text screening only when the two reviewers have reached consensus.
Supplemental material
Full-text screening
Each article that has been included after the title and abstract screening phase will be reviewed by any two out of the four independent reviewers (DB-H, MYS, TS, DC), assigned at random, to progress to the extraction phase. Tags will be developed to document the type of articles encountered such as surveys, reports, focus groups, reviews, in-depth interviews, etc. Since this scoping review excludes any review articles, two additional tags will be generated to communicate how to screen review-type articles. A document labelled with a ’This is a review, exclude’ tag will allow reviewers to exclude a review article without additional bibliography screening. A document labelled with a ‘This is a review, screen bibliography’ tag will allow reviewers to send the review article to full-text screening to review its bibliography and import any articles that may meet the inclusion criteria to the abstract screening phase.
Conceptual frameworks/models/theories used in implementation science will also be tagged and coded into broadly two categories: (1) determinant frameworks, classic theories and implementation theories used to explain what influences implementation outcomes and (2) evaluation frameworks used to evaluate vaccine intervention outcomes.71 Pilot testing of 10 articles will be conducted to refine the eligibility criteria, and any disagreements will be resolved in the same weekly meeting for the article to progress to extraction phase. Two reviewers (DB-H and MYS) will resolve all conflicts and assign articles in the following six categories of exclusion: ‘cannot find full text’, ‘outside inclusion date range’, ‘did not meet more than two inclusion criteria’, ‘did not have an intervention’, ‘did not involve faith-based groups’, ‘did not involve public health agencies/authorities’, ‘did not involve vaccination confidence/uptake’.
We will follow the checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR)72 and its PRISMA flow chart to demonstrate the number of articles excluded and why, as well as report the eventual number of articles eligible for extraction (see checklist in Research Checklist: PRISMA-ScR).
Data extraction and synthesis
A data extraction template will be developed iteratively to retrieve relevant and consistent information from each document (see table 2), the template will then be input into the COVIDENCE online application (see online supplemental appendix B: COVIDENCE Full-text Data Extraction Categories and Definitions). Like the full-text review, 10 articles of variations of document types will be pilot-tested and revised to confirm the adequacy of the extraction categories and definitions. The four reviewers aim to extract three articles per day, depending on the number of documents included. Each article will be extracted by two independent reviewers (DB-H and MYS.) who will compare and provide consensus to each extracted document. A narrative synthesis approach will be used to identify and summarise relevant information from the extracted articles to answer the research questions.
Extraction template
Patient and public involvement
Patients and members of the public were not directly involved in the planning or preparation of this review. Any views collected from the public were gathered through secondary data collection.
Reporting of results
Following data extraction, results will be presented numerically, including a synopsis of (1) the number of studies and the prevalence of (2) types of publication by field of study and study design by its percentage, (3) the prevalence of literature carried out in HICs and LMICs by country GDP, and (4) the prevalence of literature that applied theories, models, or frameworks to the design, implementation, and evaluation of faith-based vaccine interventions, reported in percentages. Following, descriptive results will answer RQ1, namely, how PHAs and FBOs partner with one another, including other parties that were involved as well as funding sources, a description of their respective organisational roles (by prevalence) in the implementation process, and the characteristics of the ethnoracially minoritised populations receiving the intervention. Tables reporting the religions, languages and types of vaccines used in the interventions will be included.
A narrative synthesis will follow to answer RQ2 and its subsets of questions, including (1) the characteristics of intervention purposes, (2) the models, theories and frameworks that support faith-based interventions and (3) an appraisal and a synopsis of the ways in which intervention outcomes are reported (eg, by number of vaccines administered, by amount of vaccines distributed, by percentage increase in vaccine confidence postintervention). The reporting of results will be finalised in November 2023, but iterations or updates may be incorporated if the authors see fit.
We will also report the implications to PHAs, community engagement practitioners, community-based organizations (CBOs) and FBOs, who are key stakeholders in the promotion of vaccine interventions among ethnoracially minoritised communities. The perceived strength of the scoping review is its potential to inform potential collaborations between public health policy-makers and decision-makers of future research and implementation designs. The review may also address gaps in knowledge on how to critically assess policy and guidelines for community-oriented partnerships to improve vaccine confidence and uptake in communities made structurally vulnerable. Perceived limitations of the scoping review are that only interventions reported in English are included and the inclusion time frame is limited (2011 to 2023). However, we believe these limitations will be offset by the vast database and website searches that will yield published articles and reports from global, regional, and local PHAs, NGOs, non-profit organizations, and FBOs that cover a wide array of interventions that promote at least 15 types of vaccines. The document will provide a rich synthesis of information to facilitate the discovery of the characteristics and outcomes of faith-based interventions for minoritised communities in both HICs and LMICs.
Ethics and dissemination
This multiphase research project received ethics approval from the University of Toronto. This review is the first phase of a Canadian Institutes of Health Research (CIHR)-funded study. Our findings will be translated into a series of written materials for dissemination to CIHR, and collaborating knowledge users (ie, regional public health units, provincial PHAs), as well as panel presentations at national and international conferences for public health practitioners, researchers, CBOs and FBOs. The scoping review outcome will be part of the evidence-informed vaccine uptake guidebook to engage equity-deserving groups in Canada. It will also support public health practitioners affiliated with the Structured Operational Research and Training IniTiative (SORT-IT), hosted at the WHO, in partnership with the Dalla Lana School of Public Health, University of Toronto.
Ethics statements
Patient consent for publication
Acknowledgments
We would like to thank Tanvii Sharma, Anna Karbasi, and Dhra Chourey for their support in reviewing the protocol.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
SF, SA, AA and EDR are joint senior authors.
Twitter @MelodieYJSong, @ed4socialchange
Contributors MYS, DB-H, SF, SA, AA and EDR participated in the conception, design and development of the protocol. MYS and DB-H drafted the manuscript, made edits and revisions to the manuscript. SF, SA, AA and EDR provided feedback on drafts and approved the final manuscript.
Funding The study received an authorisation of funding (AFF) from the Canadian Institutes of Health Research (CIHR; Grant #179239).
Disclaimer The funder had no role in the design, collection, analysis, and interpretation of data, nor in the writing and decision to submit this manuscript for publication.
Competing interests The authors declare no competing interests.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.