Vaccine hesitancy and religiosity in a sample of university students in Venezuela

ABSTRACT

The ongoing humanitarian crisis in Venezuela has made it difficult to satisfactorily manage the COVID-19 pandemic in that nation. A vaccination program has begun, but its pace has been slow, as compared to vaccination in other countries. One considerable obstacle faced by vaccination efforts in Venezuela is vaccine hesitancy. Differences across religious groups regarding vaccine hesitancy in Venezuela have not been sufficiently explored. The present study consists of a sample of 230 university students in Venezuela, assessing their intention to get the COVID-19 vaccine. Their responses are compared across religious affiliations, and correlated with three variables: belief in vaccine conspiracy theories, religiosity, and acceptance of the theory of evolution. Results come out showing that Protestants are the religious group most hesitant to get the COVID-19 vaccine, followed by Catholics and the non-religious. Results also show that vaccine hesitancy is correlated with vaccine conspiracy theories and acceptance of the theory of evolution, but not with religiosity itself.

KEYWORDS:

• Vaccine hesitancy
• Venezuela
• religiosity
• Protestants
• Catholics
• non-religious

Introduction

As a result of socio-political and economic complications, Venezuela is currently undergoing what some have described as a “humanitarian crisis,” that has been especially hard on the healthcare sector.¹ This has had important implications on the management of the COVID-19 pandemic, as the country has not been sufficiently prepared to direct the needed resources in order to curb the effects of the pandemic.²

Furthermore, because of economic sanctions imposed by the United States and the European Union, Venezuela has been slow to receive vaccines and supplies. Eventually, Russian, Chinese and Cuban vaccines reached Venezuela, but there have been some difficulties in logistics in order to fully implement a vaccination program. Although the vaccination program has begun, it is still fairly slow in achieving its goals.³

As in many other countries of the developing world, one particular problem that vaccination problems encounter in Venezuela is vaccine hesitancy in some sectors of the population (i.e. the refusal to accept vaccine jabs, even if they are readily available).⁴ Vaccine hesitancy can be defined as a refusal to receive vaccine jabs, even when vaccine services are available. Vaccine hesitancy may be related to the acceptance of conspiracy theories in Venezuelan society at large. Due to its political instability in the recent years, researchers in Venezuela have noted an increase in the preponderance of conspiracy theories;⁵ and as it has been the case in many other nations, conspiracy mongering frequently impacts vaccine hesitancy.⁶

But, it is also important for policymakers in Venezuela to consider the role religious affiliation and levels of religiosity play into the psychology of vaccine hesitancy. Religiosity can be defined as the dimensions of ritual experience, culture, ideology, intellectual life, beliefs, communal participation, moral attitudes that center on religion. Venezuela has traditionally been an overwhelmingly Catholic country, but as in many other Latin American nations, in the last 50 years, Protestant denominations have had considerable growth in the population,⁷ especially amongst lower socio-economic strata. While this has not caused any significant conflict and Venezuela is not a nation experiencing deep religious divisions, researchers have still noted that the increasing religious diversity in the country has in turn had an effect on other psychosocial variables.⁸

Vaccine hesitancy may be one of such variables. For that reason, policymakers in Venezuela need to ponder whether some religious groups are more hesitant than others, when it comes to receiving the COVID-19 vaccine. Venezuela desperately needs to increase the pace of vaccination. In that regard, authorities need to orient their vaccine campaign efforts toward those groups that may be most hesitant to get the vaccine, as they may be at increased risks.

If particular religious groups are found to be more prone to vaccine hesitancy, then we also ought to consider what particular variables may be at play. As it happens, researchers have found that, overall, vaccine hesitancy is strongly associated with conspiracist beliefs.⁹ But, additionally, we ought to ask if the level of religiosity itself in subjects is predictive of vaccine hesitancy. Likewise, vaccine hesitancy may also have a relationship with denialism of scientific theories, especially the theory of evolution. This association may be explained as follows: to the extent that denialists consider that evolution has not taken place, they are not in a good position to understand the mechanisms by which vaccines work; likewise, inasmuch as denialism is related to poor scientific literacy, this lack of scientific understanding may prevent subjects from adequately appreciating the need to receive vaccines in order to curb pandemics, as immunotherapeutic principles rely on an understanding of the world that is informed by scientific knowledge.

In this report, we examine whether there are differences in vaccine hesitancy amongst religious groups in Venezuela, in a sample of university students. We also examine if there are any relevant differences amongst religious groups concerning conspiracy beliefs, religiosity, and acceptance of the theory of evolution; and finally, we examine if these variables are correlated with vaccine hesitancy.

Methods

Enrolled students from an Education Department in a public university in the state of Zulia were considered as the population for the present study. As per the department’s records and database, the population consists of 845 persons. Using Slovin’s sampling method (n = N/ [1+ Ne2]),¹⁰ with a confidence level of 95% and a margin error of 5%, 265 were randomly selected for the study.

Participants were contacted via e-mail requesting them to answer a survey. The survey was approved by Institutional Review Board of University of Zulia (Ref # 509–987-C); participants were requested to provide informed consent, and they were instructed that that they could refuse to answer; they were also assured their responses would remain anonymous.

In the sample, exclusion criterion was having already received the COVID-19 vaccine. Of the 265 contacted participants, 7 were removed as they reported already having received the COVID-19 vaccine, 3 returned the questionnaire with incomplete answers, and 25 did not return the questionnaire. A total of 230 participants (119 females, 111 males, mean age: 21.83, s.d.: 2.34) successfully provided answers, returning the completed survey by e-mail. Answers were collected in a period from February to May 2021.

The survey was made up of 4 parts. In the first part, participants were asked if they had already received the COVID-19 vaccine. If the participant provided a negative answer, he/she was asked if he/she was planning to take the vaccine when it is made available, with three options: “Yes,” “Maybe/Unsure,” “No.” Then, participants were asked basic demographic information (age, gender, ethnicity). They were also asked what their religious affiliation was, with the options “Catholic,” “Protestant,” “Jew,” “Muslim,” “Non-religious,” “Other.” Although Hinduism and Buddhism may be considered world religions, in Venezuela they are demographically irrelevant, and consequently, any participants who profess these faiths would respond “Other.”

In the second part of the survey, participants were asked to respond to the Vaccine Conspiracy Beliefs Scale (VCBS) questionnaire. The VCBS is made of 7 items, which evaluate the degree to which participants endorse conspiracy theories concerning vaccines.¹¹ In this questionnaire, participants are asked to manifest their level of agreement on a Likert scale from 1 (strongly disagree) to 5 (strongly agree), to the statements (e.g. “Vaccine data is often fabricated”; “Vaccine efficacy data is often fabricated”). In previous studies, the VCBS has good reliability, with Cronbach’s alpha at 0.94. This questionnaire has also been validated, one study concluding that “using the VCBS, researchers will be able to investigate how such beliefs impact vaccine hesitancy and uptake.”

In the third part of the survey, participants were asked to respond to the Measure of Acceptance of the Theory of Evolution (MATE).¹² This is a 20-item questionnaire with answers arranged on a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree). The questionnaire assesses the degree to which respondents accept the tenets of the theory of evolution, with items such as these: “Organisms existing today are the result of evolutionary processes that have occurred over millions of years”; “there is a significant body of data which supports the theory of evolution.” The MATE has good reliability; in previous studies, Cronbach’s alpha has been 0.98.¹³ It has also been validated in college students.

In the fourth part of the survey, participants were asked to respond to the Duke University Religion Index (DUREL) questionnaire. The DUREL is made up of 5 questions, arranged on a Likert scale (1 to 6 and 1 to 5, depending on the item).¹⁴ The DUREL assesses the level of religiosity in subjects, in terms of organizational religious activity, non-organizational religious activity, and intrinsic religiosity, with questions such as “How often do you attend church or other religious meetings?,” or asking participants to rate their agreement with statements such as this: “My religious beliefs are what really lie behind my whole approach to life.” In multiple studies, Cronbach alpha coefficients for the DUREL have ranged from 0.78 to 0.91¹⁵ and it is considered very reliable.¹⁶ It has also been validated across various cultures,¹⁷ and it has demonstrated strong positive correlations with other measures of religiosity.

The three questionnaires were translated to Spanish, and then back to English, in order to screen for errors. No corrections were necessary. Participants were instructed to specify if they did not understand any of the questions; no participant expressed an inability to understand what was asked.

Regarding the question about the intention to receive the COVID-19 vaccine once it is available, a chi-square analysis was done, comparing the results across religious groups. Statistical significance was placed at alpha value 0.05.

Mean scores for the VCBS, MATE and DUREL questionnaires were compared across religious groups, doing a one-way ANOVA, with statistical significance placed at alpha value 0.05. A post hoc 2-tailed t-test was done comparing the mean scores for the same variables, between Catholics and Protestants. Statistical significance was placed at alpha value 0.05. This analysis was done, because ANOVA analysis only established a statistically significance difference in comparing all religious groups, but for purposes of this research, a more specific analysis was required comparing Catholics and Protestants.

Spearman’s coefficients were calculated for the correlation between VCBS, MATE, DUREL, and the intention to get the COVID-19 vaccine once it is made available. In order to do so, the intention to get the COVID-19 vaccine was quantitively assessed by assigning numerical values to the ordinal data (1 = yes, 2 = maybe/unsure, 3 = no). Statistical significance was placed at alpha value 0.05.

Results

84% of non-religious participants intend to get the COVID-19 vaccine, 7% are unsure, and 7% do not intend to get the COVID-19 vaccine. 58% of Catholic participants intend to get the COVID-19 vaccine, 23% are unsure, and 20% do not intend to get the COVID-19 vaccine. 42% of Protestant participants intend to get the COVID-19 vaccine, 24% are unsure, and 35% do not intend to get the COVID-19 vaccine.

Table 1 shows the chi-square analysis, revealing that across the three religious groups, there is a statistically significant difference regarding intention to receive the COVID-19 vaccine.

Table 1. Chi-square analysis of intention to get the Covid-19 vaccine, by religious groups

	Yes	Maybe	No
Non-religious	11	1	1
Catholics	87	34	30
Protestants	28	15	23

χ²: 11.27.

p-value: 0.02.

Table 2 shows descriptive statistics (mean and deviation standard) for mean scores of VCBS, MATE and DUREL. Results are presented in variations according to gender, age and religion.

Table 2. Descriptive statistics (mean ± s.d.)

	VCBS	MATE	DUREL
Gender
Female (n = 119)	16.60 ± 5.98	71.08 ± 17.42	20.98 ± 4.02
Male (n = 111)	18.30 ± 5.89	68.67 ± 16.10	19.93 ± 4.82
Age
18–20 (n = 68)	17.32 ± 6.36	69.99 ± 17.24	20.44 ± 4.06
21–23 (n = 106)	17.65 ± 5.87	70.16 ± 16.80	20.49 ± 4.89
24–26 (n = 56)	17.18 ± 5.79	69.46 ± 16.55	20.49 ± 4.21
Religion
Non-religious (n = 13)	16.08 ± 6.40	88.62 7.15	8.62 ± 1.56
Catholics (n = 151)	16.85 ± 6.42	75.67 ± 12. 71	21.01 ± 3.23
Protestants (n = 66)	18.98 ± 4.47	53.08 ± 13.34	21.59 ± 3.88
Total (n = 230)	17.42 ± 5.99	69.92 ± 16.80	20.47 ± 4.45

Table 3 presents one-way ANOVA results comparing religious groups’ mean scores for VCBS, MATE and DUREL. There are statistically significant differences in all three variables. Protestants score highest for VCBS, followed by Catholics and non-religious participants. Non-religious participants score highest for MATE, followed by Catholics and Protestants. Protestants score highest for DUREL, followed by Catholics and non-religious participants.

Table 3. One-way ANOVA for comparison of religious groups (Non-religious, Catholics, Protestants)

	f-ratio	p-value
VCBS	3.34	.04
MATE	88.121	.0001
DUREL	86.13	.0001

Table 4 presents post hoc t-test results, showing that in comparing Catholics and Protestants there are statistically significant differences in scores for VCBS and MATE, but not in DUREL.

Table 4. Post hoc t-test (2-tailed) comparing Catholics and Protestants

	t-score	p-value
VCBS	−2.46	.02
MATE	−11.86	.00001
DUREL	−1.15	.25

Table 5 presents Spearman’s correlations for all variables. There is a statistically significant strong relationship between intention to get the vaccine and VCBS. MATE has statistically significant moderate correlations with intention to get the vaccine, and VCBS. There is a statistically significant but weak negative correlation between DUREL and MATE. DUREL has no statistically significant correlations with either the intention to get the vaccine, or VCBS.

Table 5. Spearman’s correlation coefficients

	Intention to get the vaccine	VCBS	MATE	DUREL
Intention to get the vaccine	-	rs = 0.87569 p (2-tailed) = 0	rs = −0.57218 p (2-tailed) = 0	rs = 0.04461 p (2-tailed) = 0.50083
VCBS		-	rs = −0.61051 p (2-tailed) = 0	rs = 0.05221 p (2-tailed) = 0.43072
MATE			-	rs = −0.17484 p (2-tailed) = 0.00787
DUREL				-

Discussion

Non-religious participants are more inclined to get the COVID-19 vaccine than Catholics and Protestants. Prima facie, there is no obvious explanation for this result, as neither Catholic nor Protestant doctrine have a specific dictum against vaccination. It is admittedly true that in the 1970s and 1980s, some processes of vaccine development relied on cellular tissue obtained from fetuses.¹⁸ Given the Catholic (and in most Protestant denominations) opposition to abortion and embryonic cell research as a whole, in the past there has been some vaccine hesitancy within Catholicism and some Protestant denominations.¹⁹

For the case of Catholics, the Vatican has issued the following statement: “It is morally acceptable to receive Covid-19 vaccines that have used cell lines from aborted fetuses in their research and production process. Due to the situation of the ongoing pandemic, ‘all vaccinations recognized as clinically safe and effective can be used in good conscience with the certain knowledge that the use of such vaccines does not constitute formal cooperation with the abortion from which the cells used in production of the vaccines derive.”²⁰ Nevertheless, in some countries, there has been a split amongst bishops concerning this statement, and some still recommend not getting the vaccine, because of its alleged moral shortcomings.²¹ Venezuelan bishops have so far not commented on this issue.

For the case of Protestants, there is no central authority discussing the ethics of vaccination, although it may be presumed that this religious group may also have the same moral uncertainty regarding the fetal tissue potentially used in vaccine research (but to a lesser degree than Catholics). Nevertheless, precisely to the extent that there is no central authority in Protestantism, opinions regarding moral issues can be very diverse. Although most Protestants in Latin America are conservative evangelicals, Protestantism is quite diverse. With this caveat, it is important to keep in mind that whatever conclusions are drawn about vaccine hesitancy and moral issues amongst Protestants, no sweeping conclusions should be made.

It is important to note that in the United States, evangelicals remain the religious group most opposed to vaccination.²² This fact is important, as in recent decades Protestantism has grown substantially in Latin America, largely as a result of American missionary efforts; in Latin America, the overwhelming majority of Protestant denominations are evangelical.²³ As a result, currently American evangelical socio-cultural trends have an impact on Protestant communities across Latin America, and it is therefore not surprising that, just as their American counterparts, Protestants in Venezuela are the religious group most hesitant about receiving the COVID-19 vaccine.

Yet, perhaps the more accurate explanation for the difference in vaccine hesitancy amongst religious groups surveyed, has to do with their endorsement of vaccine conspiracy theories. In fact, in the present study, there is a strong statistically significant correlation between vaccine hesitancy and the endorsement of conspiracy theories regarding vaccines. Prior research has found similar results,²⁴ including vaccine hesitancy for the COVID-19 pandemic.^25–27

In the present study, non-religious participants are the least likely to accept vaccine conspiracy theories, followed by Catholics and Protestants. Prior research has found a relevant dimension of religiosity in conspiracy theories, as the cognitive mechanisms by which such theories are accepted, have some resemblance with religious faith, with one study describing conspiracy theories as part of a “quasi-religious mentality.”²⁸ Conspiracy theories frequently rely on so-called “incorrigible beliefs” (i.e., beliefs that cannot be refuted by evidence),²⁹ and this is structurally similar to faith statements that are believed in the absence of evidence. Consequently, it comes as no surprise that non-religious participants are less prone than Catholics and Protestants to believe in vaccine conspiracy theories, given that non-religious participants are less likely to accept beliefs on the basis of faith.³⁰

However, it is important to note that, in the present study, no statistically significant correlation has been found between religiosity and vaccine hesitancy or endorsement of vaccine conspiracy theories. Furthermore, while non-religious participants predictably have much lower scores for religiosity, Catholics and Protestants have very similar levels of religiosity, as no statistically significant difference has been found between them. Yet, Protestants have a statistically significant higher propensity than Catholics to accept vaccine conspiracy theories.

This may indicate that the differences in COVID-19 vaccine hesitancy and acceptance of vaccine conspiracy theories amongst all three groups in the present study, are not so much rooted in religiosity per se, but rather, in particular approaches to scientific theories within each religious tradition. How intensively religious subjects are, does not predict hesitancy about getting the vaccine; however, how much of established scientific facts are accepted by members of particular religious groups, may be predictive of vaccine hesitancy.

This hypothesis would appear to be confirmed by the findings regarding acceptance of the theory of evolution, in which there are statistically significant differences in comparing all three groups. Non-religious participants have higher levels of acceptance of the theory of evolution than Catholics, and in turn, Catholics have much higher levels than Protestants.

These results are fairly consistent with what has been found in other nations. For example, in a study in the United States, 91% of atheists embrace the theory of evolution;³¹ 65% of those who graduated from a Catholic high school believed in evolution;³² in contrast, around 40% of evangelicals in the United States accept such a theory.³³ Recall that American evangelical trends have a considerable impact on Protestant Latin American denominations.

These results also largely cohere with religious doctrinal positions regarding the theory of evolution. For the non-religious (and for atheists in particular), there is presumably no cosmic intelligence that brought about the current biodiversity in the planet. Consequently, species in their current form must have come about through a process of natural selection with no preconceived plan.³⁴ It is therefore not surprising that, in the current study, non-religious participants are the most likely to accept the tenets of the theory of evolution.

Catholicism has traditionally had a somewhat complicated relationship with the theory of evolution. In the years following the publication of Darwin’s The Origin of Species, low-ranking clergy expressed some opposition to the book, but the Vatican did not issue any official document either condemning or upholding the theory.³⁵ It wasn’t until 1950, when Pope Pius XII’s encyclical Humani generis specifically referred to evolution,³⁶ by adopting a neutral position regarding evolution, and proclaiming that the tenets of the theory of evolution do not contradict Catholic belief. By 1996, Pope John Paul II upheld that dictum, but added that evolution ought to be recognized “as more than a hypothesis.”³⁷ Nevertheless, Catholic doctrine still insists on divine intervention in the origins of human souls, thus rejecting fully materialist versions of the theory of evolution. In fact, this is the prevailing model of the theory of evolution amongst Catholic scholars. This model has been dubbed “guided evolution,” and asserts that, although evolution has taken place, it has been guided by God, so as to assure its outcome. Although this interpretation of evolution is now mainstream amongst Catholic scholars, when it was first proposed it proved to be very controversial, to the extent that one of its original formulators (Pierre Teilhard de Chardin) faced opposition from high-level clerics.

Protestantism’s approach to the theory of evolution has been far more confrontational. Although quite a few liberal Protestant denominations have upheld the theory of evolution, traditionally evangelicals have been the driving force behind the more extreme forms of creationism,³⁸ and its more recent version, Intelligent Design.³⁹ This difference in approaches to evolution may be related to the differing modes of Biblical interpretation. Catholicism has traditionally allowed for more allegorical readings of scripture,⁴⁰ and this has in turn allowed for a greater acceptance of the theory of evolution. In contrast, evangelical Protestants have favored a far more literal approach to scripture, and consequently, this makes acceptance of the theory of evolution more difficult.⁴¹ To the extent that evangelical trends of Christianity are the ones that are most influential amongst Protestant groups in Venezuela, it is not surprising that in this nation, Protestants are less inclined to accept the theory of evolution.

In the present study, there is a statistically significant negative strong correlation between acceptance of the theory of evolution, and acceptance of conspiracy beliefs about vaccine. Likewise, there is a statistically significant negative moderate correlation between acceptance of the theory of evolution, and intention to get the vaccine. This confirms the hypothesis that whereas religiosity itself is not predictive of vaccine hesitancy, particular religious beliefs are predictive of vaccine hesitancy. In this case, it is likely that Biblical literalist beliefs (more common amongst Protestants than amongst Catholics) are predictive of vaccine hesitancy, although more extensive empirical research is needed to test this hypothesis.

Prior research has established some cognitive similarities between so-called anti-vaxxers and creationists,⁴² although this line of research remains largely unexplored. For example, it has been tentatively found that both groups manifest a profound misunderstanding of the methods used by science; likewise, both groups are likely to endorse conspiracy theories, to the extent that they mistrust the establishment that advances scientific theories and vaccination efforts; both groups are also more prone to finding inexistent patterns in data.

The results from the present study suggest that there is a negative correlation between acceptability of the theory of evolution, and endorsement of vaccine conspiracy theories (and consequently, vaccine hesitancy). Yet, to the extent that it is only a correlation, the present study has not established if there is any direct causality.

It would seem more likely that there is a confounding variable at play, i.e., science denialism. This is the sort of cognitive approach that encompasses movements such as Holocaust deniers, climate change deniers, anti-vaxxers, creationists, etc.⁴³ who are very distrustful of the scientific establishment, and more easily endorse conspiracy theories. Science denialism may be the one variable that causes belief in all these conspiracy theories. In studies of science denialism, Biblical literalism frequently comes up as a variable at play,⁴⁴ but so far there is very little research on the direction of causality between those two variables. Further research is needed on this topic.

Limitations

The sample for the present study was sufficiently large (230) for a proper statistical analysis to be done, but given that these results may be used for policymakers in addressing vaccine hesitancy in the Venezuelan population at large, larger samples are needed in the future. Likewise, although the sampling method followed Slovin’s formula and the selection of participants was randomized, participants were students. That partially skews the data in terms of age and educational level, and consequently, the inferences from the present data have limitations, to the extent that a sample of university students is not necessarily representative of the Venezuelan population at large. The present study was done with university students, because traditionally they have been found to be more likely to cooperate with researchers. But, given the acknowledged limitation, future research must attempt to target more diverse samples.

Conclusion and implications for practice

In the sample of university students in Venezuela for this study, vaccine hesitancy is lowest amongst non-religious participants, followed by Catholics and Protestants. This information should be taken into account by public health officials, so as to dedicate special efforts to reach Protestant communities in their vaccination programs. Policymakers will need to devise plans in order to reach these communities. One possible course of action is to engage with Protestant communities via their religious services; vaccination booths can be set in churches on Sundays, so that congregants feel more motivated to take the jab. Another possible course of action is to work with Protestant ministers, so that in their homilies they stress the importance of getting vaccines, and encourage their congregations to get the jab.

Despite the fact that Protestants in this sample are least likely to get the COVID-19 vaccine, religiosity itself is not associated with it. Consequently, public health officials should not be concerned with religious practice per se, as this variable is not predictive of vaccine hesitancy. However, acceptance of the theory of evolution is negatively correlated with vaccine hesitancy, and Protestants in this sample are the most likely to reject the theory of evolution, and the most likely to be hesitant about receiving the COVID-19 vaccine. This is only a correlation, as in fact, science denialism as a whole may be a confounding variable impacting both vaccine hesitancy and acceptance of the theory of evolution.

Consequently, in the short term, public health officials must put greater efforts into reaching Protestant communities for vaccination programs, as they are the communities most hesitant to receive the COVID-19 vaccine. But, in the long term, policymakers should also approach Protestant communities so as to enhance a greater acceptance of scientific theories, as it is likely that reduced levels of science denialism will also reduce vaccine hesitancy.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.