Cover Page

Religious believe and vaccine hesitancy in

Nigeria and its implications for Public
Health in Nigeria

By …
2022
Acknowledgement
Table of Contents
Cover Page.............................................................................................................................................1
Acknowledgement.................................................................................................................................2
Table of Contents..................................................................................................................................3
Abstract.................................................................................................................................................4
Background............................................................................................................................................5
Geographic Focus............................................................................................................................7
Brief Overview of Public Health Systems in Nigeria....................................................................7
Vaccination in Nigeria.....................................................................................................................8
Justification......................................................................................................................................9
Study Goal and Specific Objectives.............................................................................................11
Specific Objectives........................................................................................................................11
Methodology.......................................................................................................................................12
Search strategy................................................................................................................................14
Determining the Database...............................................................................................................15
Inclusion & exclusion criteria...........................................................................................................16
Venn diagram..................................................................................................................................17
Data Management...........................................................................................................................18
Data analysis........................................................................................................................................19
Ethical considerations......................................................................................................................21
Resources and facilities...................................................................................................................22
Review................................................................................................................................................23
Vaccination and Immunization....................................................................................................24
Discussion..........................................................................................................................................27
Immunization and Vaccines in Nigeria.......................................................................................30
Conclusion...........................................................................................................................................34
References......................................................................................................................................35
Appendix 1 – Qualitative critique example..........................................................................................40
Appendix 2 – Qualitative critique example..........................................................................................41
Appendix 3 – Data handling table........................................................................................................42
Abstract
When it comes to public Health, Vaccines have proven to be one of the viable
strategies for propagating and sustaining a healthy society (Malone et al., 2007).
Vaccines are substances or products used to stimulate the production of antibodies
and provide immunity against one or several diseases, they are prepared from the
causative agents of a disease, its products, or a synthetic substitute, treated to act as
an antigen without inducing the disease (Korn et al., 2020).

However, Vaccination has also encountered several challenges that have impacted its
level of impact especially acceptance leading to a major concern known as vaccine
hesitancy, a situation where there is a delay in acceptance or refusal of vaccines
despite the availability of vaccination services

A major factor for vaccine has been linked to religious beliefs, following the influence
of religion today is not uncommon for religious faithful to demonstrate reluctance to
vaccination following the utterances and declaration of its leaders. Yendell et al
2020). A good example is the misfortune that befell the national polio vaccination
campaign of 2003 when two very influential Islamic groups in the North held a news
conference during which they declared that the vaccine contained anti-fertility
substances and was part of a western conspiracy to reduce the population of the
developing world (Madugba, 2003). The implication of this act was far reaching
beyond the shores of Nigeria into neighbouring Ghana, Chad, Benin Republic
slowing down the impact of the campaign at the time.

This literature review seeks to examine existing reports on the religious barriers to
vaccination in Nigeria and determine implication its implication for public health in
Nigeria. This literature review adopted a secondary research method which relies on
the review of existing and published literature on the topic as the major data source
for reaching its final findings (Johnston, 2014). The findings have been compiled in
this work as part of requirements for the fulfilment of a Master’s degree in Public
Health from the University of ….
Background
Religious and public health institutions work to improve the well-being of their
communities (Idler, 2014). Religion, medicine, and healthcare have been related in
one way or another in all population groups since the beginning of recorded history
(Idler, 2014). Only in recent times have these systems of healing been separated, and
this separation has occurred largely in highly developed nations; in many developing
countries like Nigeria, there is little or no such separation (Koenig, 2012). Scholars,
activists and development practitioners working at the very ‘local’ level of aid delivery
note the importance of the role of the religious leaders in international development
(Wilkinson, 2020; Tomalin,2012). This is because faith and religion are key influencing
factors in how communities relate and practice their cultures especially in
multicultural societies like Nigeria (Idler, 2014).

The trust that local religious leaders hold among their followers allows them to
negotiate these communities and cultural intricacies with more ease than other
practitioners (Idler, 2014). During the Ebola and the COVID-19 crisis, religious leaders
also played a key role in sharing accurate fact-based messages, combatting myths,
and offering vital support mechanisms (Idler 2014). Additionally, In the Ebola and
AIDS crises, religious leaders were also key to assisting in social justice roles such as
advocacy for women who required access to healthcare (Epko,2020). Conversely,
religious leaders have also been involved in harmful practices in these settings
(Epko,2020). This can range from stigmatising certain groups and creating barriers in
accessing necessary relief mechanisms as well as spreading misinformation regarding
health issues (Newman and Ranawana, 2021).

When it comes to public Health, Vaccines have proven to be one of the viable
strategies for propagating and sustaining a healthy society (Malone et al., 2007).
Vaccines are substances or products used to stimulate the production of antibodies
and provide immunity against one or several diseases, they are prepared from the
causative agents of a disease, its products, or a synthetic substitute, treated to act as
an antigen without inducing the disease (Korn et al., 2020). Vaccines were first used
some 200years ago when Edward Jenner used vaccines as a prevention for smallpox
in 1796 (Korn et al., 2020). Most vaccines protect both the vaccinated individual and
the society by reducing the transmission of infectious diseases. (Korn et al.,2020).
However, over the years, acceptance and adoption of vaccines has fluctuated due to
many factors including cultural and religious resistance.

The covid 19 pandemic further established the importance of vaccination in public

health. Evidence shows vaccination help prevent hospitalizations and deaths brought
about by Covid-19 infection (Nauman et al, 2022) and knowledge on the efficacy of
vaccination has also been established with medical and scientific basis (Nauman et al
2022). Vaccines work by allowing the immune system of the body to recognize, fight
and destroy the coronavirus when exposed (Garcia et al 2021). Furthermore, despite
the fact that historical evidence has proven the potency of vaccination as a viable
tool for controlling pandemics and outbreaks, over time we have also learnt that
availability is just one of the many challenges that faces uptake of vaccination
(Ophori EA, 2014). Beliefs and people’s way of life seem to pose even more
challenges especially vaccine hesitancy (Ophori EA, 2014).

Vaccination hesitancy is described as reluctance towards vaccination (Garcia et al

2021). There are a number of factors responsible for this hesitation to vaccination. In
Nigeria where religion and religious leaders represent key determinants of social
behaviours and exalted opinion leaders, it is not uncommon for religion to become a
major hinderance to voluntary vaccine up take (Oyo-Ita et al, 2017). Most religions
do not prohibit vaccinations; however, there are some concerns and in some cases
restrictions regarding vaccination in general (Garcia et al.,2021). These are based on
particular reasons for vaccination, or specific vaccine ingredients. A recent study, “The
role of religiosity in COVID-19 vaccine hesitancy by L. L. Garcia and J. F. C. Yap” found
that even medical students are unwilling to get vaccinated which poses a threat
towards attainment of herd immunity. (Garcia et al., 2021).
Despite the progress made in the last 200 years, vaccine hesitation driven by
religious obligations is increasingly becoming a public health concern and might
soon develop into a major barrier to healthier societies (The Lancet, 2019).

Geographic Focus
Nigeria is a country of black race located in West Africa’s sub-region, with an
estimated population of 200million people (NPC, 2018). Nigeria is easily the most
populated country in Africa. It has over 250 ethnic groups spread across her 36 states
and the Federal Capital Territory. Of the estimated 250 ethnic groups in Nigeria 3 of
these are the major ethnic groups identified with the country, they include the
Hausa-Fulanis, the Yorubas, and the Igbos (Blench & Dendo, 2003), each with their
own culture and traditions, including different languages. These 3 ethnic groups
make up about 70% of the country’s population. It is geographically situated
between the Sahel to the north and the Gulf of Guinea to the south in the Atlantic
Ocean. It covers an area of 923,769 square kilometres (356,669 sq mi), Nigeria
borders Niger in the north, Chad in the northeast, Cameroon in the east, and Benin in
the west. The country is predominantly Islamic in the north and Christians in the
south in terms of religious divide although other smaller religious groups including
animists do exist within the country. The two predominant religions are further
subdivided into various sects. Religion has grown to become a determinant factor in
every face of the Nigerian life and thus almost impossible to discuss any social issue
without taking into consideration the religious perspective and the impact it might
have on the health care systems especially public Health.

Brief Overview of Public Health Systems in Nigeria

One of the mainstays of a robust public health system is the presence of a
functioning healthcare system. This starts from the most basic level which is the
primary healthcare system (Alenoghena et al.,2014). While Nigeria has adopted the
Alma Ata declaration on Primary Health Care (PHC) which was made in 1978, the
country is yet to reach the fullest level of public Health efficiency attainable by the
declaration (Alenoghena et al.,2014). The major public health challenges in Nigeria
are infectious diseases, vector control of some diseases, maternal mortality, infant
mortality, poor sanitation and hygiene, disease surveillance, non-communicable
diseases and road traffic injuries etcetera (Muhammad et al.,2017). Nigeria is
currently working towards achieving the Sustainable Development 1 Goals but despite
the collaborative efforts of both the Nigerian Government, Donor Agencies and
NGOs to provide an efficient and effective health care delivery in Nigeria, there are
still major gaps in Nigeria’s health system (Muhammad et al., 2017).

The inadequate programs designed to address the numerous health problems in

Nigeria have led to the little improvement in Nigeria’s health status. Overall life
expectancy at birth is 54 years; infant mortality rate is 86 per 1000 live birth while
maternal mortality ratio is 840 per 100,000 live births (Alenoghena et al., 2014). The
continued neglect of the importance of addressing public health issues would make
matters worse for most citizens of Nigeria, most of who are at the receiving end
(Muhammad et al.,2017).

Vaccination in Nigeria
The National Programme on Immunization was introduced in Nigeria in 1979, the
program was called Expanded Programme on Immunization (EPI) with objective to
give a national outlook to immunization and vaccination programmes in Nigeria
(Fawi et al.,2011). The NPI was created under Decree 12 of August 1997. This is to
effectively control the occurrence of all vaccine preventable diseases through
immunization and provision of vaccine and other consumable. However, the National
Programme on Immunization (NPI) suffers recurrent setbacks due to many factors
including ethnicity and religious beliefs in Nigeria (Tula et al.,2014). The main targets
of the NPI are Children aged ≤11month, all pregnant women and women of
reproducing age group (Fawi et al., 2011).

1
Major Public Health Problems in Nigeria: A reviewhttps://www.banglajol.info› article › viewPDF
by F Muhammad · 2017 · Cited by 79 — 2017 Muhammad et al., publisher and licensee Public Health.
Foundation Bangladesh. ... diseases.5 These diseases with a rising burden in Nigeria.
Immunization rates in Northern Nigeria are some of the lowest in the world (Fawi et
al.,2011). According to the 2003 National Immunization Schedule, the percentage of
fully immunized infants in the States to be targeted was less than 1% in Jigawa, 1.5%
in Yobe, 1.6% in Zamfara and 8.3% in Katsina. As a result, thousands of children are
dying as victims of vaccine preventable diseases (Fawi et al.,2011). Furthermore,
Immunization utilization in Nigeria is also influenced by interlinked community and
health services issues (Akwataghibe et al.,2019). During the Covid 19 pandemic,
resistance or barriers to vaccination in Nigeria became even more apparent and
despite the desperate need for interventions from vaccines, there is still considerable
apathy and hesitancy around the acceptance and use of the approved vaccines made
available in many places in Africa and especially Nigeria (Kayode et al.,2021).

This apathy has even been proven to still exist among staff and students in a
Nigerian university and it is significantly influenced by the Christian denominational
affiliation (Uzochukwu et al.,2021).

In summary, A number of factors have been listed to be responsible for the

widespread hesitancy to vaccination in Nigeria, but this study focuses on religious
related barriers to vaccination in Nigeria.

Justification
According to the world Fact book, between 1993 and 1999 when Nigeria experienced
chronic economic decline and one of its notable political instabilities coupled with
attendant harsh micro-economic policies, U-5 mortality rate increased from 130- 194
deaths per 1000 live births. All these affected children under five (WHO, 2007; The
World Fact Book, 2010). Compared to records in developed societies, there is high
rate of significant reduction of infant mortality. For instance, in Finland and France it
was reduced from 17.0% to 3-7%) between 1960 and 1985, and 1985 to the present,
the reduction was to 0-6 or 0-7% in these countries. Authors attributed this decline
to the activities of PHC in those countries (Price, 1994).
As proposed by the Alma Ata declaration, PHCs are some of the most important
structures for driving mass vaccination for the masses especially children (Masuda et
al.,2018). The benefits of vaccination are clearly demonstrated by the eradication or
enormous decline in the incidence of many vaccine-preventable diseases, but the
coverage of many highly recommended vaccines is still frequently inadequate, and
children continue to suffer from diseases that could have been prevented (Esposito
et al.,2014). The consistent failure of Nigeria to completely eradicate the wild
poliovirus (WVP) transmission is largely attributed to children (especially in the north)
not sufficiently vaccinated through routine and repeated supplemental vaccination
activities (Pathog Glob Health. 2012).

As an important element of national security, public health not only functions to

provide adequate and timely medical care but also track, monitor, and control
disease outbreak (al., Masuda et al.,2018). The Nigerian health care had suffered
several infectious disease outbreaks year after year. Hence, there is need to tackle the
problem, with immunization remaining one of the most viable options in delivering
this (Akwataghibe et al.,2019). Immunization is aimed at the prevention of infectious
diseases. In Nigeria, the National Programme on Immunization (NPI) suffers recurrent
setbacks due to many factors including ethnicity and religious beliefs. (Trop Med
Health. 2014)

The very heavy religious followership in Nigeria means that if Nigeria must reach
meaningful standards in its public health profile, then vaccination and immunization
will remain a topic that must addressed on the basis of logical and scientific premises
rather than on religious or sentimental basis which often forms the underlying basis
for religious prohibition or restriction to vaccination (Ajaegbu, 2020). As such, it
becomes very necessary to review religious related barriers to vaccination and reach
systematically constructed evidence of the issues so as to inform practical,
programmatic and policy driven solutions to addressing it (Eric Wombwell, 2015).
Study Goal and Specific Objectives
The goal of this research is to determine how religion constitutes barriers to
vaccination in Nigeria and the wider implication for public health in Nigeria. Typically,
it focuses on an empirical investigation of religious beliefs and their direct or indirect
impact on religious faithful’s public health related decisions particularly on
vaccination.

Research Question

Religious believe and vaccine hesitancy in Nigeria and its implications for Public
Health in Nigeria.

Specific Objectives
The specific objectives will be focused on

i. Understanding to what extent religion impedes on voluntary vaccine uptake in

Nigeria
ii. Determine how religious leaders impact on people’s attitude towards
vaccination in Nigeria
iii. The wider impact of religious believe on vaccination in Nigeria
Methodology
Research methods are the specific procedures for collecting and analysing data
(Shona McCombes, 2021). This section of this work outlines the methods used for
this study.

Research methods include all the processes and steps which have been taken by an
author or a researcher in conducting a research. It also defines the approach a
researcher or a team of researchers have undertaken in responding to a research
question or in addressing a research problem.

Quantitative research methods rely on the countable or numeric quality of a subject

in completing the measurement of that subject. It leverages the volume, value or
countable or quantifiable nature of a specific subject in reaching conclusion about a
given research topic. It focuses on collecting or putting together and analysing the
numeric value of data to determine patterns in outcomes.

Quantitative research methods draw research conclusions using tables, facts, graphs,
charts, etc. it is one of the most common research methods among researchers
especially beginners and those conducting field-based studies. Some of the most
common quantitative research methods include experiments, observations recorded
as numbers, surveys with closed-ended questions and quasi-experiments.

Qualitative research is different from Quantitative because it expresses research

solutions in words in the form of narratives. It gives deeper understanding to
concepts or experiences. Some of the common qualitative research methods include
interviews -these could be Key Informant interviews (KIIs) or a Focus Group
Discussion with open-ended questions, observations recorded in words, and
literature reviews that investigates concepts and theories about a topic. Qualitative
research enables the author and their target audience to gain in-depth
understanding of a subject. Most studies will combine a mixed method of qualitative
and quantitative approaches to their research as they complement each other.

Data collection for both Qualitative and Quantitative research could either be
Primary data collection or secondary data collection. Primary data involves original
information collected for the first time during a study. They are usually collected in
response to questions listed in a questionnaire in the form of surveys, discussions,
observations and experiments While secondary data are the information gathered
from already completed reports of a study or research. Secondary data relies on the
report of other researchers to generate their own conclusion.

This Literature review adopted a secondary research method which relies on the
review of existing and published literature on the topic as the major data source for
reaching its final findings (Johnston, 2014). This involved carrying out a search of
already completed relevant research work and examining the findings to reach new
conclusions (Smith, 2008, p.4). Relying on existing data meant that the study didn’t
require any form of primary data collection or physical field visits to gather data for
this work.

According to (Preston&Aveyard,2018) literature review is used to determine one or

more research questions that are subsequently answered using a systematic
methodology. More so, a literature review can address research questions with a
power that no single study can match by combining findings and interpretations
from a variety of empirical data, (Snyder,2019). Hence, the methodology for this
study aims to synthesize findings in order to present evidence on a meta-level and to
identify areas where more research needs to be done, which is an essential step in
developing theoretical frameworks and conceptual models, (Snyder,2019).
Additionally, the choice of this method allowed leverage on a key advantage of
secondary data which is its cost effectiveness (O’leary 2017, p.268). The author would
have been responsible for the main cost of the data generated for the reports
through primary methods as such the researcher does not have to commit too much
monetary resources to this phase of the study (O’leary 2017, p.268). In cases where
authors must pay to access secondary data, the cost are usually for less than the cost
of generating primary data which usually include stipends or salaries for
enumerators, transportation, and other field related logistic cost that is usually
associated with collecting primary data. (P Joaquim. 2017 p.53).

Secondary methods also comes with lesser challenges and so saves the author time
since the data has already been collected and, in most cases, processed into findings
in the form of reports or briefs usually stored in physical and or electronic format
(SMS Kabir, 2016). Secondary data also allows the author to exercise preference on
the time saved from data collection, instead these become useful resources spent on
testing hypothesis or vetting findings from selected journal articles to determine
their alignment with the objectives of the proposed study and their suitability in
responding to the research question (S Martins, 2018 p. 35).

While the study has benefitted from some of the major advantages of engaging a
secondary method in research, there were some limitations associated with a
literature review as a major research methodology. The research topic also hold
potential to influence the authors reasoning (Lee Jussim 2012 p. 141), considering
the sentiments that is usually associated with religion especially in Nigeria (Dowd,
2016). Following this, it was necessary for the author to maintain neutrality in
investigating the different resources pulled for this research, all studies were
considered with critical attention to the context, tone and logic that framed their
arguments (P Leavy 2017 p. 4), this was quite similar to conducting a multiverse
analysis. Deploying a multiverse analysis involves identifying all potential analytic
choices that could justifiably be made to address a given research question,
implementing them all and reporting the results. Notably, this method differs from
the traditional approach in which findings from only one analytic method are
reported. (J Baldwin 2022).
It was therefore important to be deliberate about emotions and seek ways to limit
sentiments, this can be managed by putting together findings across different
studies and identifying points of similarities and divergent opinions to identify the
specific contribution of the different studies to the research question (J. Baldwin
2022, p.2). Ascertaining studies with strong alignments to the research question and
focusing more on them was effective and this strategy have benefitted from a
deliberately selected approach in reaching the final search yield ensuring only studies
with strong evidence base were selected for this review (C Hoadley 2004 p.58).

The study also relied on some set of theories; this was to guide what to look for in
the different studies pieced together in this Literature review. Theories are useful in
predicting outcomes of a study and they also help in analysing and interpreting the
data pulled together across different resources (Sutton & Staw 1995). This means
writing critically looks beyond just summarising different theories to explaining how
they guide research design and data interpretation as well as stating any limitations
and how they have been dealt with (Olayinka et al.,2020 p. 105). Where possible,
theoretical perspectives or school of thoughts are key in providing justification for
the choices reached in this investigation (Saunders et al., 2009 p.128).

The key for this investigation was being able to establish what constituted existing
knowledge about the study and what is not yet known, and this allows the author to
understand the current state of knowledge about the research question to ensure
effective linkages with this work and to identify gaps in existing knowledge
(Aveyard,2016). A literature review helps to resolve a debate, establish the need for
additional research, and or define new topics of inquiry. (A Norin 2015 p. 8)

Search strategy
As stated by Aveyard (2014), this study has adopted a search strategy that enabled it
narrow its focus to only studies that related to the research question, this was further
refined to a geographical location limiting interest to studies in Nigeria and Africa at
most. Key consideration in the research strategy included
Key Terminologies and Synonyms: Key terms (figure 1) guided the search for this
study, key terms about the research topic have been used to identify relevant studies
from the selected data base used for this work, they enabled the author narrow in on
publication based on their relevance to the subject matter. (Aveyard et al., 2016,
p.67-68). The adoption of key terminologies and synonyms were strategic to
reaching the final yield by limiting the search to specific topics as well as identifying
alternative and entirely exclusive or excluded topics that could deviate the search.
(Aveyard et al. 2016, p.75)

S/N Key words Synonyms

1 Religion Faith, belief, Creed,
2 Vaccination Jab, Immunization,
Inoculation
3 Public Health Communal Health,
4 Believe systems Spiritual leader
5 Religious Leaders Faith leaders
6 Faith actors Religious Leaders, Religious
groups

Figure 1: Key terms

Determining the Database

A database system is a unified collection of related articles, with details of the
description of the contents. In fundamental terms, the database system is similar to a
computer-based record keeping system used for recording and managing
information or data. (G Bhojaraju 2003). The search strategy included a
comprehensive search using The University of Northampton Electronic Library Search
Online (NELSON) which comprises of: CINAHL, Biomed Central Journals, Wiley Online
Library Journals, Medline, PubMed, SAGE Journals Online, Science Direct, PMC and
other web-based and electronic database system using defined inclusion and
exclusion guides to prioritise the search process. The search used relevant, specific
databases to maximise the identification of appropriate literature (Aveyard et al.
2016, p.72). The table below presents the list of the databases used to reach the
search yield for this investigation.

S/N Database Mode of Storage Area searched

1 Research Gate Web Based Research Methods
2 PDF Drive Web Based Combined Articles
3 Academia Web Based Combined Articles
4 Scientific Research Web Based Social Science and Life
Science
5 PubMed Central Web Based Public Health and
Religion
6 Cambridge University Press Web Based General Research Topics
7 CINAHL
8 Medline
9 Sage journals online

Inclusion & exclusion criteria

The inclusion and exclusion criteria guide are effective for refining the search and
ensuring continuous alignment of data to the objective of the study and most
importantly keeping a focus on reports that are relevant to the research questions
(Aveyard et al. 2016, p.76). They also help investigators describe precise components
of their study objectives as well as contribute to transparency which is a key
systematic review value (Petticrew & Roberts, 2006). The table below present a
snapshot of the inclusion and exclusion criteria for this work.
 S/N Inclusion criteria Exclusion criteria
1 Peer reviewed research Scope of the literature
2 Vaccination campaign Studies older than 10 years
3 Qualitative studies exploring Systematic reviews
voluntary vaccine up-take in
Nigeria
4 Public Health specific religious Online Blogs and Editorials
quotes
5 News item
Figure 2: Inclusion and Exclusion criteria

PRISMA Flow
An important part of a systematic review in research is to note and include a report
of the total number of records or publication collected during the search process of
related scientific literature for a review (Millard T et al. 2019 p325). The PRISMA
statement recommends that literature reviews use a PRISMA flow diagram to show
the flow of report through the different phases of the systematic review (McKenzie M
et al 2020). Even though the PRISMA flow diagram is widely used among scholars
for depicting the flow of reports in a systematic review, it is not meant to include the
results of continual searches typically used in literature systematic reviews. This work
has only adopted the PRISMA flow diagram to show the process and of search flow
and how the search yield has been narrowed to the final articles used for this study.
 Prisma Flow Diagram for the Systematic Review
Ide Total number of reports Additional Records from
identified from database other Sources
nti
search (Total Yield)
fic (n=5)
ati
on Records after extracting duplicate
reports/publications
Scr (n=34)
ee
nin
Records Screened Records Excluded
g
(n=28) (n=6)

Eli
Full articles assessed for Full text articles excluded
gib eligibility based on defined exclusion
ilit
(n=22) criteria
y
(n=10)

Exclusion Criteria
Records Included using the
Scope of the literature (3)
defined review inclusion
Inc Studies older than 10 years (2)
criteria for Qualitative analysis
lud Systematic reviews (0)
(n= 12) Online Blogs and Editorials (3)
ed News Item (2)
rec
ord
s

Venn diagram
The Venn diagram is a popular tool for showing relationships in biomedical studies.
(C Gao, 2021 p. 24). The Venn Diagram is a graphical representation of the
distribution of the key search terms in the final search yield. (B Hur, 2019, p. 58). The
Venn Diagram for contains 3 circle labelled A, B and C. Circle A depicts all research
that have been reviewed for this study (i.e., reports that directly contributes to
responding to the research questions, Circle B for articles that contributed
background and context information and Circle C for articles that contributes to
introductory and formatting related information. The search yield has been rated
based on the weight of the key word contained in them.
Set A = Reports with key terms that directly contributes to responding to the
research questions

Set B = Reports with key terms that contributed to background and context
information

Set C = Reports with key terms that contributes to introductory and formatting

B
AC
BC

related information

Figure 3: Venn diagram (C Gao, 2021)

Data Management
This study adopted a systematic approach to data handling for the reports or
publications selected for this study (Aveyard et al., 2016, p.79). This included a table
chart with headers for key themes of interest in each publication, for this study the
focus was on the Title of the publication, the Author(s), Year of publication, Research
Methodology, relevance among others. The table below shows details of the key
 headers in the data collection tool used for this study. See the annexes for a
completed table with the total search yield.

Title Auth Year Objective Method Participa Critical Themes Outcome Relevanc
or nts appraisal / Findings e

Figure 4: Data handling table headings

As a study carried out using a secondary research method this work prioritised
carefully screening selected publications to gain insight of the strengths, limitations,
and relevance of the selected studies as a criterion for assuring the reliability of the
findings and conclusion reached in them. The study also ensured that methods
including data collection data collection and data analysis tools suits the study and
appropriate to respond to the research question. (Bowling, 2014, p.166). Observation
and excerpts were noted down and reviewed taking note of the citation details and
page numbers where relevant for easy tracking of key findings.

This study adopted the reviewed version of the popular McMaster University
Occupational Therapy Evidence-Based Practice Research Group Critical Review Form.
The guidelines of this tool were critical in enabling the appraisal of the selected
articles for this work, focusing on key study components like Citation, Study Purpose,
Literature, and the entire Study Design (Letts et al., 2007). These tools were originally
designed by the McMaster University Occupational Therapy Evidence-Based Practice
Research Group, they are easy to deploy as they written in basic terms that can be
understood by researchers as well as clinicians and students interested in conducting
critical literature reviews.

The Critical Review Form allowed for a detail review of the study and understanding
of how the author(s) have reached their final findings based on an understanding of
the key study component (McMaster University, 2021). Adopting critical appraisal
tools that allows for effective analysis of the process authors have adopted in the
design and implementation of their studies enhances the confidence in the findings
they put forward as well facilitate easy acceptance among target audience. (Aveyard
et al. 2016, p.109)

Data analysis
This study has reached its findings by analysing relevant data on the impact of
religion on vaccination in Nigeria, it reviewed, critiqued, and synthesized
representative literature on the impact of religion on vaccination in Nigeria to reach
new frameworks and perspectives on the topic of this work. (Arshed, Norin &
Danson, Mike. (2015)). This study prioritised the relevance of reports from the search
yield in responding to the research questions then proceed to identify data across
these studies that related to the objective of this work and then putting them
together to reach the final findings of this work. The analysis meant that we are able
to propose a new argument that looked entirely different from those you could
deduce from reading the different literature used for this work individually. (H
Aveyard, 2014 p. 138-140). The goal is to ‘produce a new and integrative
interpretation of findings that is more substantive than those resulting from
individual investigation’ (Finfgeld 2003, p. 894).
This has been completed bearing in mind that literature reviews are usually supposed
to consider the research question, especially in terms of clarity and specificity, the
search strategy, Methodology, presentation of findings and recommendation (H
Aveyard, 2014 p.22). Using existing data has allowed the quick review of existing
opinions and scientific evidence on public health issues focusing on howe religion
facilities or limits voluntary vaccine uptake in Nigeria. It is important that most
existing data sets have been designed to capture belief and behavioural outcomes
and their linkages to religious influences it has become easier to link papers or
studies with similar these and then complete a comparative analysis on the
justification for the conclusion reached across papers and varying authors. (T. P.
Vartanian 2011 p. 15)
Putting together the summaries from different articles posed some challenges as a
result of the complexity related to how different authors present information. This
study was interrogative in nature using a research question that has been framed to
be investigative in outlook. (H Aveyard, 2014 p. 28). Literature reviews that uses
interrogative form in framing research question … clarity rather than appearing as
regular statements. In her argument Helen Aveyard believes adopting interrogative
form of research questions helps to keep literature reviews focussed which she also
believes enables the entire work to remain aligned to responding to the questions
and objectives of a study. (H Aveyard, 2014 p. 30). This approach enabled this study
to prioritise data from different articles according to relevance and closeness to the
research question. The subjective nature of most authors and the sentiments that can
arise from dealing with a socially complex topic like religion is further minimised by
continuously focusing on seeking answers to the research questions minimising bias
and emotional deviations, acknowledging that deviations in a process are common,
but noting that what is more important is how and what one does about the
deviation (S. Ostrove 2016)

Ethical considerations
The methodology adopted for this work largely minimized most Research Ethics
related risks, however, this didn’t entirely constitute waiver entirely for ethical
considerations. (Smith, E. 2008, p. 79). This study still made effort to adhere to the
Royal College of Occupational Therapists (RCOT, 2015) direction that all studies and
their authors exercise duty of care to service users, including consent to participate
and capacity to understand the research context (RCOT, 2015, p.19). As such this
research was deliberate about examining studies to be sure they have fulfilled ethical
considerations and requirement for conducting acceptable studies. This means that
all resources included in this study had been conducted with consideration to its
costs and benefits to participants, as well as confidentiality and anonymity (Punch,
2016, p.25 & 101), in this study anonymity has been prioritised over confidentiality
except in cases where very sensitive information has been noticed in a publication,
understanding how and where a study-related data has been collected was useful in
determining the sensitivity and gravity of any potential ethical concern.
Cresswell and Cresswell’s recommendation on the importance of personal privacy
when engaging internet-based resources (Cresswell and Cresswell 2018, p.88) have
been strictly adhered to in this study. The study has been deliberate in completing
checks for compliance with ethical guides to ensure statements of ethical approvals.

Resources and facilities

Resourcing for data for this study heavily relied on the internet following the
continuously growing dependency on the internet as ready source of information.
There have always been viable alternatives to source for information for different
studies and by different categories of people (Burkell, et al., 2006; Wong and Sam
2010; Hersberger, 2001; Yusuf 2012; Ukachi, 2007), However, the universality of the
Internet and its ability to deliver information on virtually any topic of interest with
simple clicks of a button at minimal costs has made it a preferred option to physical
alternatives in search for information. The Web has exploded into an information
platform of tremendous importance, with several hundred million users and over a
billion Web pages (Buscher, et al., 2009; Pitkow, et al., 2009).
While this study has relied heavily on internet resources, it also benefitted from other
sources of information and more importantly on guidance from colleagues,
practitioners, professorial supervision among others to ensure alignment to
acceptable research practices (Biggam, 2009, p.27-29).

Below is a table listing the data sources that contributed to this work.

Academic library

Professional project supervisor

Computer
Study space at home

Logbooks

Aid and Development Workers

Review
Religion is a system of social coherence commonly understood as a group of beliefs
or attitudes concerning an object, person, unseen or imaginary being, or system of
thought considered to be supernatural, sacred, divine or highest truth, and the moral
codes, practices, values, institutions, and rituals associated with such belief or system
of thought. (Johnston, D. and Sampson, C. Religio 1994). It is a framework within
which specific theological doctrines and practices are advocated and pursued; usually
among a community of like-minded believers (Johnston, D. and Sampson, C. Religio
1994).

The role of religion and religious institutions is scrutinized during three principal
public health challenges in recent history (Stephen C. Ko 2014). These include
HIV/AIDS, influenza, and Alz-heimer’s disease. Each is unique in its epidemiology,
pathophysiology, morbidity, and mortality (Stephen C. Ko 2014). Yet, each possesses
epidemic potential beyond geopolitical borders. In particular, the complex role of
religious institutions within the history of the HIV/AIDS crisis is conveyed (Stephen C.
Ko 2014). This includes positive impacts such as the creation of the AIDS National
Interfaith Network along with more nuanced tensions resulting from religious beliefs
that HIV virus is a punishment from God, the consequence of immoral behaviour, or
the result of karma. (Stephen C. Ko 2014)

Conceptually religion provides believers a guideline about life and the life-after and
thus provides much-needed incentives for indulging in productive activities during
lifetime. (O O. Ajaegbu, 2020). Religion can be considered as a promoter of growth as
they direct people towards honesty, discipline, hard work, education, thriftiness
which can become a source of capital for livelihood investment and absenteeism
from harmful activities; though it can also encourage violence in the name of doing
the will of God (O O. Ajaegbu, 2020). Religion Involves beliefs, practices, and rituals
related to the transcendent, where the transcendent is God, Allah, HaShem, or a
Higher Power in Western religious traditions, or to Brahman, manifestations of
Brahman, Buddha, Dao or ultimate truth/reality in Eastern traditions. (Johnston, D.
and Sampson, C. Religio 1994). This often involves the mystical or supernatural.
Religions usually have specific beliefs about life after death and rules about conduct
within a social group. Religion is a multidimensional construct that includes beliefs,
behaviours, rituals, and ceremonies that may be held or practiced in private

Religious doctrines influence decisions about health and health behaviours. In the
Judeo-Christian scriptures, for example, there is an emphasis on caring for the
physical body as a “Temple of the Holy Spirit”. (H G. Koenig, 2012). Religious
scriptures in other faith traditions also emphasize the person’s responsibility to care
for and nourish their physical body. Behaviours that have the potential to harm the
body are usually discouraged. (H G. Koenig, 2012). This is reflected in teachings from
the pulpit and influences what is considered appropriate within religious social
groups. (H G. Koenig 2012). Spirituality is distinguished from religion and all other
things by its connection to that which is sacred, the transcendent. (H G. Koenig 2012).
The transcendent is that which is outside of the self, and yet also within the self and
in Western traditions is called God (H G. Koenig 2012). These two, (Religion and
spirituality) share something in common, and that is the role of a leader. A religious
leader is … there level of influence depends on a variety of factors but most
commonly by the size of their followers.

In Nigeria, this group of people are very powerful considering that about 46.9% of
the population identify as Christian and 51.1% as Muslims. That represents 98% of
the total population of Nigeria. The history of religious leaders and their influence in
Nigeria dates back to colonial times when the British conferred so much political
powers on the then chiefs and Emirs who stood as religious leaders, they related with
them as political leaders using their office or position to enforce policies and laws. (M
L Yesufu 2016).
Vaccination and Immunization
The invention of vaccines has completely revamped the prevention of diseases. (K. M.
Malone and A. R. Hinman). Vaccination is the administering of weakened or inactive
parts of a particular organism (antigen) that triggers an immune response within the
body (National Institute of Allergy and Infectious Diseases 2018). Consequently, the
result of this immune response is the production of antibodies specific to the
identified pathogen. An important characteristic of most vaccines is that they provide
both individual and community protection. Most of the diseases against which we
vaccinate are transmitted from person to person. When a sufficiently large
proportion of individuals in a community is immunized, those persons serve as a
protective barrier against the likelihood of transmission of the disease in the
community, thus indirectly protecting those who are not immunized and those who
received vaccine but are not protected (vaccine failures). (K. M. Malone and A. R.
Hinman)

A study conducted among large ethnic groups in Nigeria found that many of the
people's traditional beliefs promoted good health practices and complemented
modern health promotion efforts.

Adogo Patience Inyamuwa

Immunization is considered one of the most cost-effective health interventions,

reducing under-five mortality (WHO 2009). Global immunization coverage from 2010
to 2015 shows that at least 85% of children received three doses of diphtheria-
pertussistetanus (DPT) vaccine (WHO 2016). However, in 2015, the number of
children without routine immunization (RI) was 19.4 million globally (WHO 2016). The
majority (75%) of non-immunized children live in 10 countries, including Nigeria
(WHO 2009).
Immunization and vaccination are two of the most important public health
interventions and constitute a cost-effective strategy to reduce both the morbidity
and mortality associated with infectious diseases. E A Ophori et al 2013

Vaccine hesitancy, which is defined by WHO as a “delay in acceptance or refusal of

vaccines despite availability of vaccination services”

Vaccination mandates can be ethically justified; however, their ethical justification is

contingent upon several conditions and considerations, including the contexts within
which they are implemented

In 1979, the government introduced the Expanded Programme on Immunization

(EPI) intending to improve children’s health by eradicating six killer diseases: polio,
whooping cough, measles, diphtheria, tuberculosis, and yellow fever (18). There was
an initial success with an ideal immunization coverage level of 81.5% in the 1990s,
but that success petered out to an abysmal 12.9% in 2003 (Fatiregun AA, 2014)

In Nigeria, the greatest challenge to the acceptance of immunization is a religious

one especially among the northern Nigerian Muslims. Generally, the Muslim north
has the low immunization coverage, the least being 6% (northwest) and the highest
being 44.6% in the southeast. (E A Ophori et al 2013)

In their study ‘COVID-19 vaccine hesitancy among staff and students in a Nigerian
tertiary educational institution’ Ikemefuna Uzochukwu et al tested the relationship
between religious denomination and the willingness to get vaccinated, their
investigation returned that there is a significant association between church
denomination and attitude toward COVID-19 vaccination. The odds ratio value of
0.366 obtained showed that Roman Catholics and Protestants are more likely to
accept the COVID-19 vaccine than the Pentecostals and Sabbaterians. The
association of COVID-19 vaccination and the end of the world (conspiracy theory) by
some popular Pentecostal evangelists on social media may be responsible for the
higher hesitancy among the Pentecostals and Sabbaterians. (I C Uzochukwu et al,
2021)

Discussion
Religion is deeply rooted into Nigerians' national identity with about 46.9% of the
population identifying as Christian and 51.1% as Muslims. This groups have their
leaders, and these religious leaders are publicly idolised and revered. In fact, many
Nigerians are more likely to listen and believe in the words of their religious leaders
than government leaders given the general lack of trust between citizens and the
political elite. While there is no compulsion in religion, the Nigerian Constitution pre-
supposes that an individual has freedom to practise religion of his or her choice
without government interference. This is where secularism comes into play.
Secularism is a legal position in the supreme law of Nigeria, stating that religious
belief should not influence any public and/or governmental decisions and
considering that for many Nigerians, religious values and practices remain deeply
entwined in the fabric of their daily lives, religious leaders remain critical stakeholders
in influencing and shaping health behaviour.

While most development initiatives have acknowledged and strategically engaged

religious leaders to positive effects, the government is still not able to fully engage
with and maximise the powers wielded by this hallowed group of leaders. Yes, there
have been some success stories in government and religious leaders relationships,
for example, in the government's efforts to eradicate polio the engagement of
Quranic school teachers and Muslim clerics in disseminating accurate information to
non-compliant and hard to reach communities was essential in the uptake of polio
vaccinations in northern Nigeria, where local populations have initially boycotted the
polio vaccine due to fears that it was unsafe.

There is also the recent disregard or grudged adherence by religious leaders to

government efforts to tame the COVID pandemic, indeed, when the government first
announced its lockdown measures in March last year, several religious leaders and
organisations were suspended for violating the government’s directive that
prohibited religious gatherings. They went ahead with religious services while
contending that religious spaces should be considered an essential service and
accorded the same privilege as markets, banks, and other businesses that were
allowed to operate.

In the study, ‘The Role of Religious Actors in the COVID-19 Pandemic: a theory-based
empirical analysis with policy recommendations for action’ by Yendell et al, the
authors have argued that it is the role of religious leaders, a position they considered
undisputedly valuable in the circumstance to deal with the important tasks of
convincing their followers to voluntarily take up the COVID 19 vaccine (Yendell et al
2020). They further argued that the global COVID-19 pandemic which has negatively
affected the nations of the World especially the poorest countmries of the South is
possibly the first global health crisis since the Spanish flu, whose catastrophic effects
in the wake of World War I resulted in 50 million deaths worldwide and were only
really understood in retrospect. At least, the danger presented by both virus strains
may well be of a similar magnitude, despite the lack of comparability between the
basic death rates and the medical and hygiene standards then and now (Faust et al.
2020). Such is the magnitude and relevance of religion and belief systems in the
world today that they frame or influence key issues globally and how religious
followers respond to topical issues like public health.

In poorer or less developed nations where the citizens tend to look more towards
religious promises, especially of a kingdom to come where there will be no sufferings
as a source of hope in the face of failing government systems, Religion becomes
even bigger and more influential, as it gets bigger so do religious leaders also
become bigger, wielding immense social influence on almost every sphere and topics
ranging through governance, culture and very interestingly how people seek health
services.
Scholars, activists and development practitioners working and thinking at the very
‘local’ level of aid delivery note the importance of the role of the religious actor in
international development. (Wilkinson 2020, Tomalin 2012). This is because faith and
religion are key influencing factors in how communities relate to change, both
behavioural and structural.

Particularly in countries like Nigeria where religious dynamics are an important

cultural, social and political factor. Local faith actors often operate at national levels
and link to grassroots, community initiatives. As Tomalin (2020) and others have
argued, religious actors and religious traditions have historically played a major role
in supporting- spiritually, politically and materially- those who were experiencing
poverty, both at the individual as well as the community level. This importance of the
faith actor has been seen vividly during times of public health crises

In their work ‘Evidence review: Religious marginality and covid-19 vaccination -

access & hesitancy’ Mariz Tadros recognises the place of religious leaders and have
recommended that it is important that any intervention aimed at enhancing
voluntary vaccine uptake prioritises working proactively and inclusively with faith
leaders to deliver positive results and recognizing that religious authority is one of
many authoritative sources of knowledge and influence in the community and to
capitalize on the existence of multiple actors who are considered authoritative, for
example, health professionals, women leaders, minority political and community
leaders and community volunteers in dealing with vaccine hesitancy. However, they
have also cautioned that care be taken not to assume that all religious leaders can be
recruited on a public health awareness campaign highlighting the importance of
recognising counter voices from within

Ayeni et al (1985) found out that utilization of health services among rural women
depend on religious belief, awareness of the services, beliefs in their efficacy,
proximity and availability of the services. In a similar study conducted by Gordis
(1993) in Oyo and Bauchi States with respect to attitudes and practices of women to
pregnancy, childbirth and post-partum care, the data revealed that cultural taboos,
religious beliefs and socio-economic factors often place women at a disadvantage
position from the start of pregnancy. Jegede, (1999), in his study of socio-cultural
factors influencing therapeutic choice also identified religion as a determinant factor
to use of health services among community members.

Academic studies, as well as reports from development organisations have noted

that during crises such as the Ebola epidemic, the ongoing AIDS crisis, as well as the
recent COVD-19 pandemic, the importance of religious actors as trusted community
leaders with vital social access and spiritual capital was further reemphasized
(ReliefWeb 2021, Marshall 2017. This is because there exist complex
interrelationships of culture, tradition, stigma, and discrimination that affect uptake
of health services and shape how health systems’ interface with communities. The
trust that local religious actors enjoy allows them to negotiate these intricacies with
more ease than other actors. During the Ebola and the COVID-19 crisis, religious
actors also played a key role in sharing accurate fact-based messages, combatting
myths, offering vital support mechanisms.

What is important, however, is that the local community recognises the actor/s as a
trusted leader (Marshall 2017). This is especially true in a country like Nigeria where
the religious actor is more often also a community representative or mobiliser. Many
studies do understand that there is great variety, formality and informality to
religious actors. Yet, both academic research and development /humanitarian action
do not always engage or include traditional healers or spiritualists or syncretic actors
as religious actors. Diversifying our understandings of religious actors may then also
provide key lessons for how practitioners deliver development aid. Moreover, in a
country where a third of its adult population is illiterate and where only 46% have
internet access, religious leaders remain crucial in the transmission of information.
These religious leaders include men, women and youth who hold formal or informal
positions of spiritual and organisational authority.
Immunization and Vaccines in Nigeria
Immunization is aimed at the prevention of infectious diseases. In Nigeria, the
National Programme on Immunization (NPI) suffers recurrent setbacks due to many
factors including ethnicity and religious beliefs. At the end of 2011, Nigeria was
estimated to have a population of 167 million [1]. The Expanded Programme on
Immunization (EPI), introduced in 1978 with the aim of providing routine
immunization to children less than the age of two years, recorded initial but
intermittent successes. The optimum level was recorded by the early 1990s with the
country achieving a universal childhood immunization coverage of 81.5%. But since
that period of success, Nigeria has witnessed gradual but consistent reduction in
immunization coverage

Despite these improvements, Immunization rates in Nigeria especially in northern

Nigeria remains among some of the lowest in the world. According to the 2003
National Immunization Schedule the percentage of fully immunized infants in the
targeted states was less than 1% in Jigawa, 1.5% in Yobe, 1.6% in Zamfara and 8.3%
in Katsina. As a result, thousands of children are victims of vaccine preventable
diseases. In other words, the implication is that there is a form of vaccination
hesitancy in Nigeria, vaccination hesitancy is described as the reluctance toward
vaccination (Louiegi L Garcia and John Federick C Yap, 2021). Often time there are
several factors are responsible for this hesitation to vaccination. In Nigeria were
religion and religious leaders represent key determinant of social behaviours and
exalted opinion leaders, it is not uncommon for religion to become a major
hinderance to voluntary vaccine up take. Most religions do not prohibit vaccinations;
however, there are some concerns and in some cases restrictions regarding
vaccination in general based on particular reasons for vaccination, or specific vaccine
ingredients. A recent study found that even medical students are unwilling to get
vaccinated which pose a threat toward attainment of herd immunity.

Over two million deaths are delayed through immunization each year worldwide
Despite this fact, vaccine-preventable diseases remain the foremost common reason
behind childhood mortality with an estimated three million deaths yearly. Recently,
vaccination has had a significant impact on measles deaths. From 2000 to 2005, over
360 million children globally received measles vaccine through supplementary
immunization activities. Moreover, improvements have been made in routine
immunization in this time. Even though vaccination has proven to be a an effective
strategy for public health intervention, there are still widespread evidence that shows
that vaccination uptake is still poor in many low-income and middle-income
countries. Traditional and Faith Leaders play a key role in encouraging the uptake of
health services such as immunization in Nigeria. There are several reasons for these
low rates in vaccination in Nigeria and especially with voluntary vaccination. While a
number of factors exists for the low rate of vaccination in Nigeria, Religious
opposition by Muslim fundamentalists is a major factor in the failure of immunization
programs against polio in Nigeria …

In the review of the study … we see that following the rampant nature of the polio
epidemic in 1996 African leaders had launched the polio eradication campaign
tagged “Kick Polio out of Africa.” However, by 2002 even though most countries,
including several states in Southern Nigeria, were declared free of the disease, there
were still major concerns in Northern Nigeria (WHO, 2005). Government have set
aside national immunisation days in Nigeria from the last quarter of the year 2000.
But Ogundipe have worthily noted that this campaign was resisted from the onset by
some religious leaders in the north who described the exercise as being against
Islamic injunctions (Ogundipe, 2001) and rumours of contamination with the AIDS
virus were also widespread (Abuh, 2002). The crisis was further aggravated in July
2003, when in the midst of a nationwide campaign, two very influential Islamic
groups in the North: the Supreme Council for Shari’ah in Nigeria (SCSN) and the
Kaduna State Council of Imams and Ulamas held a news conference during which
they declared that the vaccine contained anti-fertility substances and was part of a
western conspiracy to reduce the population of the developing world (Madugba,
2003).
Ordinarily these statements shouldn’t bring too much worry but given the revered
status of the two groups among Muslims, the stage was set for a major revolt.
Notably however, politicians in the south campaigned for the use of the vaccine
(Obinna, 2003; Nkwopara, 2004) thereby distancing themselves from the western
conspiracy theme. At the time Nigeria was split along regional and religious divides
on this very important issue which soon transformed from a conspiracy against the
developing world to one against Muslims.

This antagonistic action of Muslim religious leaders in Northern Nigeria climaxed

with a number of states in Northern Nigeria placing a ban on the use of the Oral
poliovirus vaccines on the controversial argument that it contained substances that
had potentials to sterilize the male reproductive abilities of recipients (Sabiu and
Shobayo, 2003). Expectedly, the ban threatened the gains already reached between
by the 2005 world-wide fears of the reversal of the gains already made by the “Kick
Polio out of Africa.”campaign leading to a rise in the re-infection of most previously
declared polio free countries, including (UNICEF, 2009). The rumours of a western
plot to sterilise Muslims even spread beyond Africa to Pakistan where some clerics
issued a ‘Fatwa’ or decree against vaccination (New Scientist, 2007).

As we see religious attitudes and resources can prove to be appropriate instruments,

at least in their tendency to provide adequate intellectual and supportive orientation
on this difficult path. Up to a certain degree, they are predestined to function as a
bulwark against the (sometimes religion-like) conspiracy theories, not least because
such theories must be addressed in a primarily emotional, emphatic and
sociopsychological manner rather than a purely matter of fact, rational one.
Theoretically, religions already play a significant role in this respect, but have yet to
prove their worth in empirical terms.

In some positive reflection religious leaders in Nigeria have also facilitated the uptake
of contraceptives and have been at the forefront of shaping opinions and influencing
behaviours in the fight against infant and maternal mortality through awareness
campaigns. Thus, deploying religious leaders as change agents was crucial to
increasing family planning adoption and promoting family health in Nigeria.

The empirical analysis carried out on the role of religious actors during the COVID-19
pandemic also shows that there is need for further research. This is an exciting and
complex subject area, from which important insights for further, probably
unavoidable (health) crises can be gained. At the time this study was drawn up,
research on the COVID-19 pandemic, focussing specifically on the religious
phenomenon, had only just begun. This report can, therefore, serve as a basis and an
incentive for further research, especially for more in-depth, country- and region-
based studies or case studies of individual religious communities

In the Nigerian controversy, vaccination was seen by northern elites through the lens
of a western world that is against Islam, and it became part of a western conspiracy.
For some Muslim clerics, it was seen as science playing God and described as un-
Islamic.

Following the influence of religion In Nigeria, the greatest challenge to the

acceptance of immunization very much seems to be a religious one especially among
the northern Nigerian Muslims. While this seems bold to state, the figures also
suggest so. For instance, the lowest immunization and vaccination coverage in
Nigeria are recorded in the Muslim dominant north with the least being 6% for the
northwest region and the highest being 44.6% in the southeast. If we become more
location specific, we see that in Ekiti state, a southwest state, the northeast and
western part of the state with a stronger Islamic influence also records low
immunization coverage and poor educational attainment. Christians have 24.2%
immunization coverage as compared to only 8.8% for Muslims (Babalola S. 2011)
Ophori EA et al 2013

Conclusion
As we have noticed in this review, Nigeria is a highly religious society with religious
leaders wielding various degree of influence largely based on the size of their
followership. There are also some misleading interpretation of scripture related
quotes across religion in Nigeria. These go a long way in framing the belief systems
and attitude of religious faithfuls. These attitude can prove to be appropriate
instruments, at least in their tendency to provide adequate intellectual and
supportive orientation on this difficult path. Up to a certain degree, they are
predestined to function as a bulwark against the (sometimes religion-like) conspiracy
theories, not least because such theories must be addressed in a primarily emotional,
emphatic and sociopsychological manner rather than a purely matter of fact, rational
one. Theoretically, religions already play a significant role in this respect, but have yet
to prove their worth in empirical terms.

There is evidence that religious constitute major barriers to vaccination in Nigeria

even though religion have at times also served as leverage for the delivery of
effective vaccine campaigns. The
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Nauman et al 2022
Appendix 1 – Qualitative critique example
Critical Review Form - Qualitative Studies (Version 2.0)

© Letts, L., Wilkins, S., Law, M., Stewart, D., Bosch, J., & Westmorland, M., 2007

McMaster University

CITATION:
 Appendix 3 – Data handling table
Final key articles for critique

Only articles used in this review have been included in this table

Title Author Year Objective Method Participan Critical Themes Outcome / Relevance
ts appraisal Findings
The Effect Adamu 2018 This paper Mixed Health weak Religion, The cholera Low
of Nuhu, focuses on Method Workers, Methodolo Violent outbreak in
Religious MBBS, studying (Primary IDP Camp gy Conflicts 2018 is a
Conflicts MBA the and Managers, description, and major
in resultant Secondar IDPs poor access to public
Northern large y data) presentatio Public health
Nigeria numbers of n of Health event with
on Public IDPs from findings Services deleterious
Health the impacts on
Outcomes religious sociocultur
: A Case conflicts al and
Study of and the economic
Cholera impact on activities;
Outbreak specific and
public indicative
health that
attaining
the global
strategic
goals,
especially
in relation
to cholera-
related
deaths,
While there
is evidence
on the risk
factors for
cholera
infection
including
inadequate
WASH
interventio
ns The
religious
conflicts
limited
access to
health
services
which could
 have
positively
impacted
on the
number of
causality.
Religion Ellen L. 2014 Exploring Qualitativ NA A detailed Religion, The High
as a Social Idler the e and book on Policy, objective of
Determin intersection Secondar Religious Public public
ant of between y data intersection Health health is to
Public religious ality with conduct
Health institutions Public research
and Public Health and act on
Health issues. it to
institutions. improve
the health
of society;
it is an
ethical
imperative
to include
religious
communitie
s as
fundament
al parts of
social life.
Religion Okech 2020 Examining Secondar NA Weak Religion the Medium
and ukwu the y Method description and relationship
National O. influence of of Relevance between
Developm Ajaegb religion on methodolo of religion and
ent in u. the gy, Poor Religion developme
Nigeria developme result to Social nt is likely
nt of presentatio Service to be
Nigeria. n and complemen
Developm tary as long
ent as religious
beliefs and
practices
promote
‘moderatio
n’ rather
than
‘extremes’.
A peaceful
coexistence
of various
religious
groups (or
sects) in a
country and
various
 nations
with
different
religious
affiliations
within the
global
community
is a
prerequisite
for growth
and
prosperity
in today’s
highly
interconnec
ted world
Major Faisal 2017 To review qualitativ NA Detailed Public Nigeria is High
Public Muha the e study, Health currently
Health mmad implication approach Good result challenge working
Problems of public presentatio s, The towards
in Nigeria: health n, strong impact of achieving
A review service on literature health the
maternal review and service on Millennium
mortality in analysis Maternal- Developme
Nigeria Mortality nt Goals. To
reach the
targets for
the
reduction
of child
mortality,
which form
MDG 4,
Nigeria
should
reduce
under-five
deaths per
1,000 live
births to 71,
and
increase
measles
immunizati
on to 100
per cent by
2015.
Religion Chatte 2000 Literature NA Good result Spiritualit to provide High
and rs, L. M review presentatio y, Religion high-
Health: n, strong and quality care,
Public description Public and simply
Health of Health common
Research methodolo sense, all
and gy underscore
Practice the need to
integrate
spirituality
into patient
care
Religion, Harold 2012 To provide Literature NA Good result Spiritualit to provide High
Spiritualit G. a review presentatio y, Religion high-
y, and Koenig comprehen n, strong and quality care,
Health: sive review description Public and simply
The of research of Health common
Research on methodolo sense, all
and religion/spir gy underscore
Clinical ituality (R/S) the need to
Implicatio and both integrate
ns mental spirituality
health and into patient
physical care
health.
Nigeria’s C Dan- 2020 A review of Mixed NA Detailed A rapid, Medium
public Nwafo Nigeria’s Method study but holistic,
health r Preparedne weak cohesive,
response ss and methodolo whole-of-
to the Response gical governmen
COVID-19 to the emphasis, t approach
pandemic: COVID-19 Good result that
pandemic presentatio encompass
n, strong es civil
literature society and
review and local-
analysis communitie
s in the
response
will be
absolutely
critical to
combating
the COVID-
19
pandemic
in Nigeria
The Iulia O. 2011 provides a Mixed Patients, Detailed Religion religion High
influence Basu- briefly Method Health study and seems to
of religion Zharku discuss Service Health be a
on health concerning providers Good result service psycho-
the bond presentatio social factor
between n, and the
health and biological
religiosity in Strong benefit in
the cure literature the
 process and review and recovery of
diseases analysis physical
treatment and mental
diseases.
Independen
t of the
possible
mechanism
s, if
individuals
receive
health
profits by
religion;
those
should be
motivated,
respecting
the faith
individualit
y of each
one
The Joyce 2013 Assessing Mixed Communi Detailed Religion, In order to High
Socio- Rumun The Socio- method ty study Public combat the
Cultural Cultural of members, Health, problem of
Factors Factors Primary Health Good Maternal maternal
Influencin Influencing and care Result Health and child
g the The Secondar providers presentatio care mortality
Utilization Utilization y data n and
of of Maternal morbidity,
Maternal and Child Good the
and Child Healthcare analysis standard of
Healthcar Services living ofthe
e Services including Nigerian
in vaccination populace
kwande in Nigeria must be
Local raised.
Governm Extreme
ent Area poverty and
of Benue religion are
State, not only
Nigeria the source
of disease
and
mortality,
but it is
also one of
the chief
causes of
bottleneck
in public
health
 delivery in
Nigeria
Enablers Paul F 2021 This Primary Adults, Detailed Vaccinatio indicates High
and Burke research Research living in methodolo n, Belief, that various
barriers examines Method Australia gical Public cohorts
to COVID- individuals’ using an (39%), the description HEalth based on
19 psychologic online United age,
vaccine al beliefs survey States Good result employmen
uptake: that may (21%), presentatio t, and flu
An act as Canada n vaccination
internatio enablers (16%), uptake, will
nal study and barriers England Clear differ in
of to (12%) conclusions their
perceptio vaccination orNew participatio
ns and intentions Zealand n in a
intentions (11%) COVID-19
vaccination
pro-gram.
The results
also show
rates of
intentions
for
vaccination
uptake, as
well as the
levels and
effects of
various
drivers of
uptake
significantly
differ
across the
countries
sampled.
Examinin Alicia L 2019 This study Primary college Detailed Vaccinati sexual High
g the Best examined Research women mythologi on and activity is
Influence the role of Method cal Religion the main
of religious/sp factor
narrative,
Religious iritual associated
and beliefs on with HPV
Good
Spiritual HPV vaccination;
vaccination result and sexual
Beliefs on
HPV among presentati activity fully
Vaccine college on mediates
Uptake women the
Among relationship
College between
Women religious/sp
iritual
beliefs and
 HPV
vaccination
Barriers Oliver 2019 The Mixed Farmers, Detailed Vaccinatio Immunizati High
to Ombe objectives Method fishermen study n/ on services
effective va of this and local Immuniza in Hoima
uptake Malan study were caregivers Good tion District
and de et to evaluate Result require
provision al the state of presentatio urgent
of immunizati n improveme
immuniza on services nt in the
tion in a and to Good following
rural identify the analysis areas:
district in gaps in
Uganda immunizati vaccine
on health supply,
systems expanding
that service
contribute delivery
to low points,
uptake and more
completion health
of workers,
immunizati transport
on and
schedules tailored
in Hoima mechanism
District s to ensure
adequate
communica
tion
between
health
workers
and
caretakers
Barriers Moreni 2015 To assess Primary Parents, Detailed Vaccine High High
to uptake ke the Barriers Method Care study Belief and pricing and
of human Oluwat to the givers, human low health
papilloma oyin voluntary Health Good papilloma insurance
virus Folaya uptake of workers, Result virus coverage
vaccine in n human Religious presentatio vaccine limit access
Nigeria: A papillomavi faithfulls n to this
populatio rus vaccine essential
n in need in Nigeria Good potentially
analysis life-saving
vaccine
Perceptio Afiong 2017 explore the Primary Caregiver Detailed Vaccinatio Communica High
ns and Oku perceptions Research s, study n, Belief tion about
experienc and communit and vaccination
es of experiences y leaders Good Communi involves
childhood of Result cation more than
vaccinatio caregivers presentatio the
n and health n message
communi workers in but is also
cation Nigeria on Good influenced
strategies vaccination analysis by the
among communica environmen
caregivers tion t and the
and strategies attitudes
health implemente and beliefs
workers d in their of the
in Nigeria: settings deliverer
A and
qualitativ receiver. It
e study is pertinent
for health
policy
makers and
programme
managers
to
understand
these
factors so
as to
effectively
implement
communica
tion
approaches
Exploring gozi 2019 This study Mixed Children Detailed Immuniza Immunizati Medium
Factors Akwat aimed to Methods and study tion on
Influencin aghibe identify Study Caregiver utilization
g factors in s Good was
Immuniza Remo- Result influenced
tion North presentatio by
Utilization influencing n interlinked
in Nigeria the use of community
—A immunizati Good and health
Mixed on services, analysis services
Methods in order to issues.
Study inform Interventio
intervention n
approaches approaches
to tackle should
barriers to ensure that
immunizati communitie
on s’ priorities
utilization are
addressed,
actors at
both levels
involved
and
 strategies
are
adjusted to
suit
contexts
The John 2021 Highlightin NA NA Weak Religious Religious High
Pervasive Campb g the Methodolo Leaders, leaders can
Influence ell influence of gical Vaccinatio be a force
of religious reference n for good,
Nigeria's leaders on they can
Religious social issues Good also
Leaders Result undermine
presentatio public
n health and
human
Good rights
analysis initiatives.
The role Wilhel 2013 To assess Primary Religious Good Religious Religious High
of mina L the role of Research Leaders Methodolo Leaders leaders’
religious M religious gical attitudes
leaders in Ruijs leaders in reference Vaccinatio towards
promotin promoting n vaccination
g acceptance Good vary from
acceptanc or refusal of Result full
e of vaccination presentatio acceptance
vaccinatio within an n to clear
n within a orthodox refusal.
minority Protestant Good According
group: a minority analysis to orthodox
qualitativ group with Protestant
e study low church
vaccination order, local
coverage in congregati
The on
Netherlands members
appoint
their
religious
leaders
themselves.
Obviously
they
choose
leaders
whose
views are
compatible
with the
views of the
congregati
on
members.
 Moreover,
the
positions of
orthodox
Protestant
religious
leaders on
vaccination
will not
change
easily, as
their
objections
to
vaccination
are rooted
in religious
doctrine
and they
owe their
authority to
their
interpretati
on and
application
of this
doctrine.
Insights John 2021 To review Literature NA Weak Religion conservativ High
on H. the role of Review Methodolo e
Vaccine Evans Religion in gical Science Protestants
Hesitancy challenging reference were less
from scientific Health likely than
Religious efforts to Good others to
People’s health Discussion think that
View of manageme and scientists
Science nt analysis of were
themes working for
the good of
Weak result humanity,
presentatio and more
n likely to
think they
were
serving
their own
narrow
interests. It
is this
perceived
moral
conflict that
is the
 problem.
Factors UNICE 2016 To explore Primary Caregiver Detailed Vaccinatio To drive High
Influencin F reasons for Method s with Methodolo n soft
g Vaccine vaccine children gy techniques
Hesitancy hesitancy Qualitativ under 5 Vaccine in social
and and refusal e data years Good Hesitancy and
Immuniza and identify Discussion behavioural
tion barriers and Local and Religion change,
Coverage facilitators leaders analysis of and sustained
in to uptake of themes Vaccinatio communica
Zimbabw vaccination Health n tion
e among workers Good result interventio
socio- presentatio ns are
cultural and n crucial in
religious improving
groups in knowledge
Masvingo of
and vaccination,
Manicaland interperson
Provinces in al
Zimbabwe relationship
in order to between
strengthen health
evidence- workers
based and
communica caregivers
tion and and key
programmi social
ng influencers
strategies like
to improve religious
vaccination leaders
adherence,
utilization
of routine
vaccination
services,
and MNCH
services.
Determin Astaw 2022 This study Primary NA Good Vaccinatio The High
ants of us aimed to Research Discussion n number of
COVID-19 Alema assess Method and people
vaccine yehu, determinan analysis of COVID 19 vaccinated
uptake M. ts of themes was higher
and Yusuf vaccine among 50–
barriers uptake and Good result 60 age
to being barriers to presentatio groups
vaccinate being n than those
d among vaccinated who are
first- among >60 years.
round first-round Being
eligible eligibles for female,
for coronavirus being a
COVID-19 disease person with
vaccinatio vaccination no
n in in Harar, schooling,
Eastern eastern being a
Ethiopia: Ethiopia. merchant,
A being a
communit farmer, and
y based having low
cross- coronavirus
sectional disease
study prevention
practice
was found
to be
significantly
associated
with
coronavirus
disease
vaccination.
Religious Retna 2019 This study Primary Religious Detailed Religion This study High
and Siwi aimed to Research leaders Methodolo highlights
communit Padma explore the gy Religious the need
y leaders’ wati views of Communi Leaders for better
acceptanc religious ty Good stakeholder
e of and represent Discussion Vaccinatio engagemen
rotavirus community atives and n t prior to
vaccine leaders analysis of vaccine
introducti regarding themes availability
on in the and the
Yogyakart rotavirus Good result potentially
a, vaccine to presentatio important
Indonesia inform n role of
: a future religious
qualitativ communica and
e study tion community
strategies leaders in
rotavirus
vaccine
acceptabilit
y in the
majority
Muslim
community
of
Yogyakarta,
Indonesia.
The Momo 2016 This study Secondar NA Detailed Religion The impact Medium
Impact of h explores the y Methodolo of religion
Religion Lawani impact of Research/ gy Developm in a secular
on a Yesufu religion on Literature ent state seems
Secular certain Review Good History to have
State: The aspects of Discussion played out
Nigerian Nigerians and Politics negatively
Experienc living within analysis of and in Nigeria,
e a secular themes Policies as politics
state and religion
Good result are mixed
presentatio in the
n attempt to
gain
political
hold on the
population.
For a very
long time,
religion has
been used
by the
(Nigerian)
oligarchy as
its main
weapon to
hold on to
power
(Kukah
1993)
Positive Willia 201 To provide Qualitativ NA Detailed Religion Culture, High
and m H. 9 a e/ Methodolo religion,
Negative Foege, thoughtful Secondar gy Culture and
Influences MD, account of y research tradition
of MPH how Good Public changes
Religion, religion, Discussion Health over time.
Culture, culture, and and At one
and tradition analysis of time, there
Tradition can provide themes were
in Public positive and religious
Health negative Good result objections
influences presentatio to women
on public n voting,
health. holding
power, or
preaching.
This is
changing.
At one
time,
religious
groups
accepted
slavery.
Even now,
the
 acceptance
of poverty
by religious
groups is in
need of
change.
Religious D.N. 2010 The study Qualitativ NA Detailed Religion These High
leaders' Uchea highlights e Method Methodolo findings
response ga differences gy HIV AIDS indicate
to AIDS in in messages that
Nigeria between Good Public religious
mainstream Discussion Health organisatio
and and ns are
Pentecostal analysis of already
Christians themes playing a
and role in HIV
Muslims in Good result prevention,
Combating presentatio but their
HIV AIDs in n responses
Nigeria are not
uniform.
Public
health
organisatio
ns and
policymake
rs should
be aware of
these
denominati
onal
differences
as they
engage
with
religious
institutions
and leaders
in HIV
prevention
and care
An John O 2010 This study Qualitativ Parents Detailed Religion It is High
Assessme Umoh examines e study Methodolo important
nt of the the using Religious gy Health to note that
Relevance relevance Primary Leaders Service even with
of and/or role Data Good delivery the
Religion of religion Health Discussion indifference
to Health in modern workers and Governme shown by
Care health care analysis of nt health the
Delivery delivery in themes policies governmen
in Nigeria: Nigeria. It t and her
Case of uses Good result agencies on
Akwa Christianity presentatio the
Ibom as its n contributio
State reference n of
point. religion to
health care
delivery, it
remains
relevant to
Nigeria’s
health care
system.
Patients
and health
care
providers
still resort
to the
miracle of
healing.
Vaccinati Falade 2014 This Primary Strong Vaccine Science and High
on , research is Method Methodolo Resistanc technology
Resistanc Bankol about gical e, are crucial
e, e common reference to Nigeria’s
Religion Adeba sense Religion, growth and
and yo making; Good developme
Attitudes how a new Discussion Science in nt and
to Science phenomeno and Nigeria some
in Nigeria n is analysis of respondent
absorbed themes s are of the
into our view that
existing Strong and they may
pictures of detailed also be
the world result instrumenta
drawn presentatio l to its
through n stability.
personal However,
and shared this is an
experiences, area that
conversatio needs more
n, writing research
and other
forms of
communica
tion.