Procedural Dimensions of Religious Exemptions to Covid-19 Vaccine Mandates: Promoting Clarity, Fairness, and Transparency in Applications

Abstract

This study examines the procedural ethical considerations surrounding religious exemptions to Covid vaccine mandates, specifically focusing on immigrant healthcare personnel (HCP) and HCPs of color. It emphasizes communication issues with applicants by investigating exemption applications and their accompanying guidelines. While there is extensive literature on the ethical implications of religious exemptions, a notable gap remains in addressing the procedural aspects of religious exemption applications and their reviewing processes. The study scrutinized religious exemption application forms and accompanying guidelines from 32 selected non-teaching and teaching hospitals for the years 2022–2023. The findings highlight significant variability in exemption application criteria and processes across institutions. Importantly, many application forms lacked comprehensive procedural information, which may result in subjective evaluations and potential misinterpretations of non-Western and non-mainstream religious beliefs, especially those of immigrant HCPs and HCPs of color. The study proposes various strategies to advocate for more equitable and transparent procedures, underlining the significance of diversity, equity, and inclusion in the religious exemption review process for vaccine mandates.

Keywords:

• Religious exemption
• covid-19
• pandemic
• vaccine mandate
• vaccine exemption
• procedural justice

Introduction

The Supreme Court first upheld vaccine mandates under the states’ police powers in Jacobson v. Massachusetts (1905). In this case, the majority ruled that “there can be manifold restraints to ensure every individual is vaccinated for the common good” (Jacobson v. Massachusetts, 1905). Vaccine mandates have been described as “the most intrusive and restrictive form of vaccine policy” (Gur-Arie et al. 2021). Although the ethicality of vaccine mandates remains controversial—often pitting patient safety against healthcare worker autonomy—such mandates have proven markedly effective in increasing vaccination rates (Babcock et al. 2010; Ross and Aspinwall 1997).

Title VII of the Civil Rights Act of 1964 protects employees from employment discrimination based on religion through religious accommodation. Once an exemption is granted, healthcare workers are expected to receive accommodation according to the Equal Employment Opportunity Commission (EEOC) guidelines. During the Covid-19 pandemic in 2021, Executive Order 14042 mandated the Covid vaccine for federal employees. Those who did not comply faced potential termination from their federal positions, unless they qualified for legally permitted exemptions. Later the same year, the Centers for Medicare & Medicaid Services (CMS) issued a vaccine mandate for healthcare workers employed at Medicare-certified or Medicaid-certified facilities. Exemptions were allowed on medical or religious grounds, potentially impacting over ten million healthcare workers (Gostin et al. 2022). Employer and government Covid-19 vaccine mandates sparked widespread controversy during the pandemic. Numerous bioethicists engaged in debates, seeking a balance between religious freedoms and public health protection (Eyal et al. 2023; McGuire et al. 2020). For certain vaccine-hesitant individuals under these mandates, a religious exemption became the sole means to retain their jobs.

General sentiment in the US regarding religious exemptions is largely skeptical. Many public health experts argue that no major religion entirely opposes vaccination (Giubilini et al. 2021; Thinane 2021). They suggest that some individuals with vaccine hesitancy might misuse the religious exemption system. One survey highlighted that roughly two-thirds of US adults believe individuals exploit religious exemptions as an excuse to evade covid vaccination (Nortey 2022). A number of evangelical pastors initiated a “religious exemption letter request” feature on their personal or ministry websites. They offered religious exemption support letters to online members without inquiring about personal religious beliefs (Bailey 2021). These pastors often encouraged donations to their ministry or mandated church membership as a prerequisite for obtaining a religious exemption support letter, thereby making the letters relatively easy to procure (Bailey 2021; Rivera). Consequently, some employees might have leveraged these religious exemption opportunities, even when their resistance to vaccination was based on philosophical or personal reasons rather than religious beliefs.

On the other hand, many vaccine-hesitant employees with genuine "sincerely held religious beliefs" were not granted religious exemptions and consequently lost their jobs during the pandemic (Mansoor 2021; Mccrary 2022). This was due to their religious exemptions being denied by review committees. These individuals may possess limited English writing proficiency or may be unaware of how to effectively articulate their religious beliefs. In their quest for clarity, they might have researched online for religious principles opposing vaccination, found sample letters for religious exemption from vaccines, and modified these online texts or sample letters (Antommaria et al. 2023). Their reliance on external sources might not have been due to insincerity but rather a lack of understanding about what to include in their exemption applications. How, then, do we determine who qualifies for a religious exemption? This study presents numerous questions for bioethicists to consider. Do the exemption application processes adhere to principles of procedural justice? How do employers communicate their expectations and procedural issues with their employees through vaccine religious exemption applications and accompanying guidelines? Do they inform applicants about the selection process for review committee members? Who is tasked with making this critical decision that can lead to an employee’s termination? This study does not answer all of these questions. The collected data do not fully disclose the review standards, procedures, and expectations of the review committees. However, by investigating application materials, we can find some clues about how employers communicate procedural issues to their applicants for religious exemptions. Moreover, low-paid immigrant healthcare workers of color might face challenges when completing the religious exemption application due to language and cultural barriers. Additionally, review committee members might not fully grasp these employees’ religio-cultural contexts. The study highlights procedural issues from the perspectives of marginalized communities and suggests improving equity and inclusion in the review process through clearer communication in exemption applications.

The aims of the study

This study examines the procedural challenges and communication issues in religious exemption applications for Covid-19 vaccine mandates, focusing on the interaction between healthcare institutions and HCPs, as reflected in the applications and accompanying guidelines. While existing literature delves into the ethics of vaccine mandates and the associated religious exemptions, the procedural nuances of decision-making and communication issues related to religious exemptions remain scarcely addressed. Procedural inconsistencies in the religious exemption review process can lead to grave ethical and legal repercussions. For instance, Kansas Attorney General Derek Schmidt impelled two public universities in Kansas to align with the new state law, urging against the use of "intrusive written application materials" when assessing employee exemption requests (Schwartz, 2021). A major teaching hospital confronted multiple lawsuits filed by ex-employees terminated for not complying with vaccine mandates (Longworth, 2022). The intricacy of the review procedure largely rests on institutional discretion. However, institutions may encounter a heightened risk of litigation if they fail to adhere to a transparent review process with clear communication or neglect strict legal guidelines. Thus, critically evaluating current applications and accompanying guidelines to foster procedural justice is of paramount importance. This study does not aim to scrutinize the ethical grounding of vaccine mandates or the moral justifications for religious vaccine exemptions. Instead, it seeks to shed light on the present procedural challenges associated with religious exemption evaluations. The aim of this study is to examine hospital vaccine religious exemption application forms, to investigate communication issues within the application process and guidelines, and to address procedural matters related to applying for and reviewing these forms. In the discussion section, the study suggests implementing enhanced communication strategies with applicants to ensure equity and inclusiveness. This suggestion would strengthen trust between employers and employees and ward off implicit bias, discrimination, or retaliation—particularly against HCPs of color and immigrant HCPs. Ultimately, the study advocates for procedural justice by promoting a more equitable and inclusive review process with clear communication.

Methods

This study examines the 2022–2023 Covid vaccine religious exemption forms for institutional-level vaccine mandates across 32 non-teaching hospitals and teaching hospitals affiliated with medical schools. These online application forms include additional guidelines about the review process. The study evaluates the questions included in these exemption applications for healthcare personnel (HCP). It adopts a comprehensive definition of HCP, as outlined by Gur-Arie et al. which encompasses "all frontline workers in healthcare settings who may be directly or indirectly exposed to patients or infections. This includes, but is not limited to: physicians, nurses, therapists, laboratory technicians, healthcare assistants, professional students on rotation, cleaning personnel, administrative staff, dining service employees, and security staff" (Gur-Arie et al. 2021). This broad definition is suitable for a hospital setting as it encompasses a wide range of roles of all frontline workers who maintain the hospital’s healthcare system and ensure patient care and safety.

The primary data for this study were collected through a systematic online search aimed at gathering applications and accompanying instructions for vaccine religious exemptions specifically within hospital settings. The inclusion criteria for these applications were their clear relevance to vaccine religious exemptions and their accessibility in terms of availability. The search was conducted using the Google search engine, utilizing the term “hospital vaccine religious exemption applications.” This search term was chosen for its specificity and relevance to the subject matter, ensuring a focused collection of pertinent data. The search results yielded a diverse range of application materials from various hospitals and the materials were carefully examined. The search continued until a total of 32 relevant applications were found for further analysis, taking into consideration of two key characteristics: location and type of hospital. Upon collection of the data, the applications were categorized based on the location and type of hospitals, ensuring geographical diversity, and hospital type (refer to Table 1). Except for one medical center, whose application was previously available online during the pandemic but is no longer accessible, all forms were found online. This particular file, acquired during the pandemic in.doc format from the center’s website, was used for the study. The other documents were sourced in HTML, Qualtrics, PDF, or.doc formats. To capture regional nuances in policies, practices, and socio-political atmospheres, the study encompassed various regions: 6 institutions in the Northeast, 11 in the Midwest, 10 in the South, and 5 in the West. Furthermore, the research encompassed a variety of hospital types, such as private, public, teaching, non-teaching, and those affiliated with religious organizations. Some hospitals in the US, affiliated with integrated health systems or managed care organizations, operate both hospitals and their own health insurance plans. This study included several such institutions. The researcher stored HTML links and downloaded forms on a personal computer. A few hospitals imposed restrictions on the use of the forms, specifying that they should not be used for any purposes other than applying for the exemption and included copyright notices. Forms bearing these copyright notices were excluded from this study. Although many hospitals have ceased to publicize their vaccine religious exemptions and guidelines post-pandemic, a diversified sample was secured by considering various hospital types across US regions. To safeguard institutional reputations, the study avoids direct quotations from these documents and conceals the names of the institutions. Instead, institutions are referred to by numbers (e.g., Institution 29) to maintain anonymity. Given its nature, the study didn’t necessitate IRB approval as all analysis materials were publicly available without human subject research.

Table 1. Demographics of institutions: Location and type.

Institutions	Location	Type
Institution 1	South	Not-for-profit, a tertiary care teaching hospital
Institution 2	South	Not-for-profit, public teaching hospital
Institution 3	Midwest	Not-for-profit, a network of hospitals
Institution 4	Midwest	Not-for-profit, private teaching hospital
Institution 5	South	Not-for-profit, private teaching hospital
Institution 6	West	Not-for-profit, public teaching hospital
Institution 7	Northeast	Not-for-profit, private teaching hospital
Institution 8	South	Not-for-profit, public non-teaching hospital
Institution 9	Midwest	Not-for-profit, private, Catholic health care system owning hospitals, nursing homes, hospice, etc.
Institution 10	Midwest	Not-for-profit, public teaching hospital
Institution 11	South	Not-for-profit, private teaching hospital
Institution 12	Northeast	Not-for-profit, private teaching hospital
Institution 13	West	Not-for-profit, public teaching hospital
Institution 14	South	Nonprofit, public teaching hospital
Institution 15	Midwest	Nonprofit, public non-teaching hospital
Institution 16	South	Nonprofit, public teaching hospital
Institution 17	South	Nonprofit, private teaching hospital
Institution 18	West	Nonprofit, private, Catholic healthcare system operating hospitals and clinics
Institution 19	Northeast	Nonprofit, private teaching hospital
Institution 20	Midwest	Nonprofit, private teaching hospital
Institution 21	Midwest	Nonprofit, private, integrated health care system operating hospitals and health insurance
Institution 22	Northeast	Nonprofit, private teaching hospital
Institution 23	South	For profit, private, non-teaching health care system
Institution 24	West	Nonprofit, private, non-teaching, community hospital
Institution 25	Midwest	Nonprofit, public, teaching hospital
Institution 26	Midwest	Nonprofit, public, teaching hospital
Institution 27	South	Nonprofit, private, non-teaching hospital
Institution 28	Midwest	Nonprofit, private, teaching hospital
Institution 29	West	Nonprofit, public, non-teaching community hospital
Institution 30	Northeast	Nonprofit, private, teaching health care system operating hospitals and
Institution 31	Northeast	Nonprofit, public, non-teaching, integrated health care system operating hospitals
Institution 32	Midwest	Nonprofit, public, teaching hospital

The analysis of the collected applications involved qualitative methods, including thematic analysis. Following the collection of the application forms, the researcher employed linguistic discourse analysis on samples from 32 institutions, based on grounded theory (Patton, 2015). The researcher undertook multiple readings of each document, identifying recurring issues and themes, and annotated them with codes. Further readings refined these codes and categories, leading to a comprehensive understanding of the materials. It is important to note that coding conducted by a single individual may exhibit limitations in the methodology. However, to overcome these limitations, the research involved refining the codes and themes multiple times. A thematic analysis was employed to identify common patterns, terms, and conditions mentioned in the exemption applications, as well as any accompanying instructions. This qualitative approach provided insights into the language and framing of religious exemption applications in various hospital settings. It is worth noting that the results demonstrate how a number of institutions meet specific criteria. However, due to the limited sample size, quantitative analysis has not been included in the Results section.

Results

The analysis of the selected institutions’ applications, along with the accompanying instructions included in these applications, revealed significant variations in:(a) The number of questions; (b) The content of the questions; (c) The required list of supporting documents; (d) The department handling vaccine religious exemptions; (e) The method of access and submission; and (f) The content of guidelines. Furthermore, the applications of most institutions do not clearly communicate the review process and the expectations of the review (refer to Table 2).

The number of questions

The number of questions ranged from none to six. Four institutions (Institution 3, 8, 15, 25) didn’t pose any questions but required the submission of a religious statement or supporting documents, offering more flexibility rather than specific guidelines. One institution (Institution 7) provided six detailed questions, complete with sub-questions, explanations (e.g. what “sincerely held belief” means), and expectations.

The content of the questions

A significant number of documents included the term "sincerely held belief," but most didn’t elaborate on its meaning. Although several institutions explain that social, political, or economic philosophies or personal preferences are not considered religious beliefs, a majority of institutions do not specify, nor explain what “sincerely held religious beliefs” means. Only two institutions (Institution 7 and 31) asked an applicant to address ultimate questions about purpose, life, and death for non-theistic, non-Abrahamic religions. While the majority of applications did not specifically mention non-theistic religions, one institution (Institution 7) was unique in recognizing the validity of religious beliefs outside of formal religious affiliations. This institution clarified that individuals need not be currently associated with any religious organization to be eligible for an exemption. The key determinant was whether their opposition to the Covid vaccine arose from a comprehensive belief system, which could include non-theistic worldviews. Additionally, a noticeable trend among several institutions was the investigation into the consistency of an applicant’s vaccine opposition. Institutions sought to understand if the hesitancy was exclusive to the Covid vaccine or extended to other vaccinations as well. To gain insights into this, institutions inquired about the applicant’s past immunization records (Institution 7, 9, 20, 32) and the duration of their specific religious beliefs, practices, or observances that may oppose vaccinations (institution 7, 9, 16, 20, 22, 29). Interestingly, only one institution (Institution 27) incorporated language that recognized philosophical or moral beliefs alongside religious ones. They introduced terms like “strongly held moral beliefs” within their religious exemption application, broadening the scope of possible reasons an applicant might oppose vaccination.

The required list of supporting documents

Eight institutions (Institution 1, 2, 4, 7, 12, 18, 29, 32) require or encourage applicants to submit information from religious leaders or the name and address of their religious affiliation. It is worth noting that this information alone may not suffice to meet the required review standards. One of these institutions (Institution 1) offers an option for an applicant to provide information about religious scholars who can address the applicant’s request for a religious exemption.

The department handling vaccine religious exemptions

The Human Resources department is responsible for managing religious exemptions to vaccinations at a majority of institutions. Five institutions (Institution 15, 19, 20, 30, 31) assign this task to the Employee Health Service department. One institution (Institution 24) has a guideline stating that retaliation against applicants for a religious exemption is prohibited. Applicants with concerns about retaliation are encouraged to report those concerns to Human Resources. Five institutions (Institution 13, 14, 16, 17, 22) have made the Department of Diversity, Equity, and Inclusion (DEI) and/or the Employee Disability Management office responsible for this area. Three out of these five institutions (Institution 14, 16, 17) are located in the South.

The method of access and submission

Most institutions post religious exemption guidelines and applications on the Human Resources website, although a few institutions post them on the Department of DEI. One institution (Institution 14) states that the Department of DEI has approved the accommodation for applicants whose exemption is denied. Another institution (Institution 13) posts their guidelines and links to applications on the Employee Disability Management Services website. A majority of institutions require applicants to submit the exemption applications directly to Human Resources either via email or through the Human Resources website. A couple of institutions (Institution 15, 25) require a notary’s signature before submitting the application.

The content of the accompanying guidelines

Most institution’ accompanying guidelines do not mention any expectations regarding the length of the review process. Two institutions (Institution 8, 27) provide a brief explanation of the appeal process within a certain timeframe (e.g. the committee will notify applicants within five business days; an applicant may appeal within seven days of receiving the decision). However, the vast majority of institutions do not mention an appeal process. It’s unclear whether they do not allow the appeal process, or if they discourage applicants from appealing. One institutional guideline (Institution 17) states that the review decision is final, but applicants can file a complaint with the Equal Employment Opportunity Commission or Human Resources if they believe the decision violates their civil rights. Guidelines at four institutions (Institution 4, 10, 14, 31) require applicants to describe their accommodation needs or specify the type of accommodation that employees can access once notified of the decision. Many institutions (Institutions 1, 2, 3, 8, 9, 16, 17, 31) outline applicants’ obligations to undergo regular testing every week if the exemption is granted. Additionally, numerous applications highlight the consequences of noncompliance with vaccine mandates for applicants when a religious exemption is not granted.

The majority of guidelines do not describe how they select a review committee or how the committee evaluates applications. Three institutions (Institution 20, 21, 30) mention the potential creation of a multidisciplinary vaccine exemption team. Most institutions do not specify which department will review the application. While some institutions establish an ad-hoc committee (e.g., the Covid-19 Religious Waiver), they do not specify the departments or specialty areas to which members belong. At three institutions (Institution 14, 16, 17), the Department of DEI or the Office of Equal Opportunity reviews religious exemption applications. These institutions post the application and guidelines on the Department of DEI websites. These websites also emphasize the institution’s commitment to diversity, inclusiveness, and nondiscrimination in support of their employees. One institution (Institution 13) posts the applications on the Employee Disability Management Services. Another institution (Institution 22) displays the application and guidelines on their Office of Equal Opportunity and Access website. Additionally, one institution (Institution 23) states the possibility of reviews by a third party, separate from their office. Lastly, two institutions (Institution 13, 15) require applicants to receive and review educational materials about vaccines before submitting their applications. Overall, the results show a lack of uniformity among applications in terms of the questions asked, the content of the guidelines, the required supporting documents, and the methods of accessing and submitting applications. More importantly, by reviewing the application questions and the accompanying guidelines, applicants may not fully understand how to complete the application, the procedures involved, or the expectations regarding review standards.

Discussion

To fully grasp the context of religious exemptions to mandatory vaccinations among HCPs, it’s crucial to comprehend the demographic information about the applicants. The results do not provide a detailed analysis of healthcare personnel (HCPs) in all 32 institutions, but it would be valuable to gain an overall understanding of the demographics of HCPs in the U.S. This section will provide context and background information regarding HCPs. Subsequently, the Discussion will analyze the results and offer recommendations for enhancing the quality of comprehensive reviews with clear communication, while ensuring diversity, equity, and inclusion in the evaluation processes for vaccine religious exemptions (refer to Table 2).

Table 2. Comparative analysis of religious exemption application processes across 32 institutions.

	a. The number of questions	b. The content of questions	c. The required list of supporting documents	d. The department handling applications	e. The method of access and submission	f. The content of guidelines
Institution 1	4	A, B, E, F	Information about religious scholars (optional)	HR	Fax, email, or mail to EHS	N
Institution 2	4	A, B, D, E	Supplementary document from a religious leader	HR	Email to employee health	N
Institution 3	0			Employee service center (HR)	Submit to the staff member	N
Institution 4	4	A, B, E, N	Supplementary document from a religious leader	Employee service center (HR)	Email to employee service center	I, R
Institution 5	2	A, B		HR	Email to the exemption request
Institution 6	3	A, B, F		HR	Submit to the staff member	I
Institution 7	6	A, B, C, D, E, F	Supplementary document from a religious leader	Not clear	Email to the exemption request email or submit to Dropbox	O, S
Institution 8	0			Not clear	Email to the exemption request email	H, N
Institution 9	4	A, B, C, F		Not clear	Email to the exemption request email address	N, O
Institution 10	2	A, B		HR	Email to the exemption request email address	Q
Institution 11	2	A, B		HR	Submit it to HR
Institution 12	3	A, B, E	Supplementary document from a religious leader	Not clear	Email to the exemption request email address	M
Institution 13	2	A, B		Employee disability management in HR	Posting applications on the Employee Disability Management Services website. Email to exemption request email.	P, Q
Institution 14	2	A, B		DEI office	Fax or mail to the DEI office	Q, R
Institution 15	0			EHS	Email to exemption request email with the notary’s signature (J)	P
Institution 16	4	A, B, C, F		DEI office	Submit it to the DEI office	N, Q
Institution 17	2	A, B		DEI office	Submit to the DEI office website	K, N, Q
Institution 18	3	A, B, E	Supplementary document from a religious leader	HR	Email to the exemption request email	I
Institution 19	2	A, B		EHS	Email to employee health service
Institution 20	3	A, B, C		EHS	Email to employee health	L, O
Institution 21	3	A, B, F		HR	Post it to the HR website or email to HR	L, M
Institution 22	4	A, B, C, F		DEI office	Posting the application on the DEI website
Institution 23	3	A, B, F		HR and/or potential third-party involvement	Submit to HR or email to HR
Institution 24	2	A, B		HR	Submit to HR or email to HR
Institution 25	0			HR	Upload the scanned application with the notary’s signature (J)
Institution 26	2	A, B		Employee health committee	Upload the form to the health committee
Institution 27	2	A, B		HR	Email to HR	G, H
Institution 28	2	A, B		HR	Email to HR
Institution 29	5	A, B, C, D, E	Supplementary document from a religious leader	HR	Email to HR
Institution 30	2	A, B		EHS	Upload to the employee health website	L
Institution 31	2	A, B		EHS	Email to EHS	N, R, S
Institution 32	3	A, B, E	Supplementary document from a religious leader	HR	Email to HR	O

Questions in applications include:

A. “Sincerely Held Religious Beliefs”.

B. “Write all relevant information supporting your exemption request.”

C. Duration of Applicant’s Practice of Their Religion, Belief, or Observance.

D. “Name/Address of Religious Affiliation”.

E. “Contact Person Who Can Provide Supportive information”.

F. “Description of Relevant Doctrines or Practices”.

G. “Explanation of Strongly Held Moral or Ethical Beliefs”.

H. Appeal Process.

I. Consequences for Deliberately Supplying False, Misleading, or Incomplete Information.

J. Notary Signature Requirement.

K. Assurance of Exemption Request without Fear of Retaliation.

L. Involvement of a Multi-disciplinary Panel in the Review Process.

M. Terms for Termination or Compliance within a Specific Time Window, without Creating an Undue Hardship for institution.

N. Regular Testing Requirements for Employees if an Exemption is Granted.

O. History of Receiving immunizations.

P. Educational Materials Explaining the Benefits and Risks of Vaccines.

Q. Involvement of the Diversity, Equity, and Inclusion Office in the Review Process.

R. Employer-provided Accommodations if an Exemption is Granted.

S. “Ultimate inquiries about life’s purpose and the nature of existence, particularly for non-theistic, non-Abrahamic beliefs”.

Diversity and education disparity in HCPs

While a majority of HCPs, such as physicians, hold advanced degrees, many healthcare support positions only require high school diplomas. HCPs without higher education often work in roles such as home health aides, personal care aides, assisting nurses, and other healthcare support. They offer a range of health services, from monitoring patients with chronic illnesses or disabilities to assisting with daily activities in nursing homes and helping pharmacists dispense prescription medications (U.S. Bureau of Labor 2022). Most of these lower-paid positions primarily require high school diplomas. According to data from the U.S. Census Bureau’s 2021 American Community Survey, as reported by the Migration Policy Institute, healthcare workers in personal care aide roles constitute 8.7% of employment in the industry, while home health aides account for 2.7% (Batalova 2023). There has been a recent surge in such lower-paid positions in healthcare. Personal care aides and home health aides play essential roles in supporting vulnerable populations, with immigrant healthcare workers having a disproportionately significant presence in these areas. One survey indicates that almost 40% of HCPs in home health aide roles are immigrants, and about 28% of HCPs in personal care aide roles are also immigrants (Batalova 2023). A considerable number of these immigrants hail from Latin America and Africa. The survey revealed that more than half of these home health aides and personal care aides reported limited proficiency in English (Batalova 2023). Many of these immigrant healthcare workers may not possess strong writing skills in English. Immigrants in the US tend to be more religious than the U.S.-born population. For instance, a 2021 report from the Pew Research Center shows that 75% of African-born immigrants identify as Christians (Diamant 2021). This suggests that African immigrants in the US are more religious than U.S.-born Black adults (Diamant 2021). Several studies have noted that immigrants from Latin America contribute to the growth of the Catholic population in the US (Krogstad et al. 2023). Therefore, Black and Brown HCPs are more likely to be religious and may need religious exemptions for vaccinations more frequently than other HCP groups. These immigrant HCPs might face difficulties in effectively communicating their deeply held religious beliefs.

Sincere but not eloquent?

Religious exemption committees are designed not to test an applicant’s eloquence but rather their “sincerely held belief.” Review guidelines shouldn’t emphasize the writing skills of applicants. However, if an applicant cannot articulate a compelling argument in writing, their application may be less persuasive (Lee 2024). For example, an immigrant personal care aide with limited English proficiency may not have the training to craft a tightly-knit argument in English. As a result, their statements might not appear sufficiently convincing. Some applicants may not be adept at expressing their religious beliefs because they have never had to articulate the reasons behind their belief. Many applicants who grew up in non-Western culture might find their religious beliefs and practices so intertwined with their culture that they can’t easily verbalize or explain their religio-cultural beliefs (Alvord 2013; Lee 2024). For example, consider an immigrant from an East Asian country who subscribes to the "naturalness-is-better bias" based on Daoist religious beliefs and cultural practices (Cao and Li 2022). Meier et al.’s study indicates that a naturalness bias can negatively impact willingness to be vaccinated (Meier et al. 2021). East Asian immigrant HCPs who lean toward a naturalistic approach grounded in Daoist beliefs might resist mandatory vaccinations. Their religious convictions and worldviews could influence their perceptions of vaccines, leading them to trust in harmonizing with the natural world as a defense against Covid over synthetic vaccines. However, most Daoist immigrant HPCs might find it challenging to systematically convey Daoist concepts. Unlike Confucianism, Daoism doesn’t emphasize studying the teachings of the dao (translated as "way" or "path"), and the dao is described as beyond human language, conceptualizations, and systemizations. The practical nature of Daoism could pose difficulties for adherents trying to persuasively articulate their beliefs based on Daoist teachings. Unlike structured teachings in Christianity, the Daoist principle that nature should be left to its course hasn’t been systematically imparted. For many low-wage immigrant HCPs, expressing their traditional lived religions can be challenging, further compounded by limited English writing skills (Lee 2024). However, none of the application forms mention that the review committee evaluates solely the content, rather than the eloquence, of the applications.

Furthermore, many reviewers may not be familiar with non-Western religions. They might inadvertently overlook these traditions, especially considering that the vast majority of applicants for religious exemptions are Christians (Antommaria 2023; Boone et al. 2021). When immigrant HCPs attempt to explain their non-Western religious beliefs in their applications, their statements might be extremely brief, often spanning just a few sentences. Applicants from marginalized communities might mention that they have held these beliefs throughout their lives, inheriting them from family and community. While these might be sincere beliefs, the applicants may be uncertain about how to elaborate or provide additional evidence to make their case more persuasive. Consequently, their statements might appear insubstantial due to their brevity. Additionally, they might not be affiliated with any religious institutions, and thus the requirement to provide the name and contact information of a religious leader, as mandated by some institutions (Institution 2, 4, 7, 12, 18, 29, 32) in their applications, may not apply to them.

From the data gathered in the “Results” section, only two institutions (Institution 7 and 31) prompt an applicant to address profound questions about purpose, life, and death, particularly for non-theistic, non-Abrahamic religions (Welsh v. United States 2016). It would be beneficial for the review committee to include members who understand the limitations faced by marginalized communities in elaborating on minoritized religious beliefs. These members should possess the knowledge that affiliation with a religious organization is not a prerequisite for justifying an exemption. Additionally, it would be also helpful for the review committee to include members who are familiar with non-Western religious traditions. Otherwise, there’s a risk that the religious beliefs of immigrants of color or those rooted in non-Western traditions might not receive a fair assessment due to the committee’s lack of expertise in these areas. Lastly, the application should pose questions relevant to non-theistic religions and explicitly state that the committee will sensitively assess lesser-known or minoritized religions in the US. This approach would make applicants from non-Western religious backgrounds feel more at ease and confident in the review committee’s evaluation. To ensure that these non-native English speakers’ non-Western lived religions are considered as fairly as other Western religions, the review committee should offer clear procedural guidelines on how to interpret applicants’ statements. For instance, the review guidelines should stress the importance of avoiding biases related to writing skills when assessing applications. Employers should communicate clearly that reviewers would focus solely on content, keeping in mind that the writing proficiency of some non-native English speakers might be limited. Additionally, none of the institutions mention the possibility of conducting interviews in their applications. But the review committee could conduct follow-up in-person interviews with applicants who display limited English writing skills. With the assistance of an interpreter, these applicants might be able to better articulate their stories and beliefs drawn from their lived experiences in response to probing questions during an optional oral interview. However, offering interviews would incur additional time and financial costs during pandemic emergencies, and some applicants might feel less protected due to the lack of anonymity.

Who should be the reviewers?

The definition of religion in the context of vaccination can be broadly interpreted (Lee 2024; Miller 2016). Additionally, there are different approaches to sincerity tests, leading to potential variances in review standards and procedures based on the committees and their members (Johnson 2015; Miller 2016). Applicants may have questions regarding how members of the review committee are selected. However, from the data collected, most institutions don’t specify how review committee members are selected in their applications and procedural guidelines. Only three institutions (Institution 20, 21, 30) describe the review committee as a "multi-disciplinary" team, and one (Institution 23) states the possibility of a third-party review outside their institution. This lack of clarity in applications and procedural guidelines raises numerous questions regarding the selection of review committee members. Is it more ethical to outsource the review process to third-party entities like consulting firms or law offices? Employers might argue that by using external experts, they are ensuring independent and objective reviews. However, these third parties might still cater to the preferences of the employer, as they are the ones footing the bill for these services. Using external consultants can also prove costly for hospital administrations, potentially leading to increased healthcare rates for patients.

On the other hand, if the review committee is composed entirely of employees, which employees should be chosen? Options may include members of the hospital ethics committee, human resources representatives, employee health representatives, infection control experts, risk management team members, and/or chaplains. If, for instance, the committee consists only of human resources representatives, potential conflicts of interest might arise. An applicant with a history of union activism might face potential retaliation, especially if their application may reveal identifiable information. While an anonymous review could address this issue, selected institutional guidelines in this study seldom discuss anonymity or confidentiality. It would be ethical for institutions to explicitly communicate with applicants about the review process, including how committee members are selected (without revealing personal identities). Without this transparency, some employees might harbor legitimate concerns about facing retaliation.

Drawing lessons from the institutional review board (IRB)

Both the Institutional Review Board (IRB) and the review committee for vaccine religious exemptions are composed of members chosen by each institution at their discretion. While the IRB is established to protect human subjects, the exemption review committee is created to safeguard patients and HCPs. Compared to the vaccine exemption review committee, the IRB is subject to stricter monitoring by federal regulations. The guidelines that govern the IRB can provide a constructive framework for creating a review committee for vaccine religious exemptions. According to the Code of Federal Regulations (CFR), the IRB must have: a. “At least five members with diverse backgrounds; b. An effort to ensure gender diversity, preventing a committee composed entirely of men or women; c. At least one member with a nonscientific background; d. A minimum of one member who is not affiliated with the institution and whose immediate family isn’t affiliated either. And e. Members without any conflicts of interest concerning projects they review.” (45 CFR 46.107)

While Klitzman’s study suggests that nonaffiliated and nonscientific IRB members sometimes struggle to grasp the scientific nuances of protocols and may feel sidelined, their insights, especially regarding areas like informed consent, are invaluable for policy and practice (Klitzman 2012). Drawing parallels to the IRB and considering procedural justice, a vaccine religious exemption review committee should similarly include members with various perspectives. This can include at least one community member who has no ties to the institution and is devoid of any conflicts of interest. This ensures a system of checks and balances in the decision-making process. Alternatively, a representative from a recognized employee union, if one exists within the institution, can be included to balance the interests of both the employer and the employees, and to provide an avenue for the employees’ viewpoints. Without such representation, there’s a risk that the committee might solely cater to the institution’s managerial or administrative priorities. If the committee solely comprises members from departments like human resources or risk management, it may inherently lean toward safeguarding the employer’s interests. To mitigate this, institutions should consider incorporating at least one community or union representative. Committees shouldn’t be exclusively populated by management personnel. If not carefully structured, such a committee could inadvertently become a tool for retaliation or excessively prioritize management efficiency at the expense of employee values and concerns.

Incorporating diversity in the exemption review committee

The composition of the exemption review committee in terms of incorporating diversity is unclear from the collected data, as the application and instructions rarely provide information on this aspect. Yet it is paramount that the exemption review committee undertakes a nondiscriminatory approach to ensure representation from varied racial/ethnic backgrounds. This mirrors the IRB regulation that emphasizes the inclusion of members with “varying backgrounds” to ensure an equitable and thorough review (45 CFR 46.107). While “varying backgrounds” can be interpreted in numerous ways, research has underscored the significance of diversity in IRB memberships for conducting fair, reliable, and high-quality protocol reviews (Churchill et al. 2022). Drawing from this, the vaccine exemption review committee should actively prioritize both racial/ethnic and gender diversity. The inclusion of female members and members from the LGBTQ community is pivotal. Their unique perspectives can shed light on potential implicit biases that might be overlooked by a homogenous committee, particularly biases against marginalized communities. For instance, if the committee solely consists of male or heterosexual members, their interpretation of “religious belief” or “religious practice” could vastly differ from the perspectives of women or LGBTQ individuals. Studies in the realm of lived religion highlight that religious practices are deeply intertwined with "gender-linked body practices." This is due to the integral role that body practices play in lived religious experiences (Ammerman 2020; Lee 2024; McGuire 2008, 182). For a multitude of women and LGBTQ individuals, religious or spiritual communities present avenues to discover and embrace new gender identities and foster relationships that can transcend prevailing biased societal norms (McGuire 2008, 183). Given this nuanced relationship between religion, gender, and sexuality, having representation from these groups in vaccine religious exemption review processes is essential for facilitating holistic, fair, and rigorous assessments. In addition to this, the inclusion of at least one expert in Diversity, Equity, and Inclusion (DEI) can further enhance the breadth and depth of the review process. Although three institutions (Institution 14, 16, 17) in the South incorporate DEI offices, the collected data indicate that the majority of institutions have not indicated the involvement of DEI experts.

Prioritizing racial/ethnic diversity in the review committee

Racial/ethnic diversity is a crucial consideration when selecting members for the review committee. Within the broad spectrum of Christianity in the U.S., diverse racial or ethnic groups have cultivated unique rituals and harbor varied religious moral values. Some religious practices distinctly “draw boundaries between racial or ethnic groups” (McGuire 2008, 90). Beyond religious practices, the historical exploitation of Black bodies in U.S. medical history has engendered deep mistrust in the healthcare system among many Black Christians (Batelaan 2022; Scharff et al. 2010; Washington 2006). While these historical events might not directly pertain to religious factors, they have indelibly shaped religious beliefs and culture over time. This intricate meld of historical and religio-cultural traditions might be challenging for some reviewers to grasp fully. Consequently, the vaccine religious exemption review committee should be deliberate in including individuals of color. Such members can provide invaluable insights into the nuanced interplay of historically rooted, hybridized religious cultures, and the broader racial or ethnic narratives. Furthermore, given that many healthcare professionals are either immigrants or come from immigrant families, the committee should seek to understand the multifaceted religio-cultural beliefs these individuals may hold. Considering that many non-Western religious perspectives are closely interwoven with specific racial or ethnic traditions, representation from individuals from these backgrounds would be essential.

Taking a cue from the Code of Federal Regulations (CFR) governing Institutional Review Boards (IRB), such committees should seek representation from a wide range of departments and specialties within the institution. This includes, but is not limited to, members from the ethics committee, chaplaincy, clinical departments, and the risk management team. Each group brings a unique perspective, representing the myriad interests of both employers and employees. Moreover, it’s essential for members of the review committee to understand the meaning of “religion” or “religious.” Religious studies scholars’ work can offer this framework and members can be equipped with this knowledge by understanding comprehensive guidelines (Lee 2024). Additionally, some members should be familiar with the diverse religious beliefs and practices of the local population (e.g., chaplains, priests, local religious leaders), ensuring the committee is well-equipped to assess exemption requests accurately and empathetically.

The need for a standardized procedure in exemption reviews

A viable method to evaluate the sincerity of applicants’ religious beliefs is to closely examine or listen to their personal narratives (Lee 2024). It is important that both reviewers and applicants are equipped with comprehensive guidelines that detail the qualifying criteria for religious beliefs, practices, and observances in the context of vaccine mandate exemptions. Without such clarity, determining what qualifies as a "sincerely held religious belief" becomes a daunting task. An employee’s religious beliefs need not align with traditional, organized religions, such as Christianity, Judaism, or Hinduism, as highlighted in Thomas v. Review Board, 1981. Furthermore, legal protection under the EEOC guidelines stipulates that an applicant need not be affiliated with any religious organizations. However, the collected data show that only two institutions (Institution 7, 31) explicitly state this. Without communicating explicit guidelines, it becomes exceedingly challenging to ascertain whether an applicant’s belief is both religious and sincerely held. Historically, the court has not provided a clear definition of what constitutes a religion. In the review process, the committee should focus on two primary determinants: (a) whether the applicant’s belief is "religious" in nature, and (b) if that belief is "sincerely held." As many established guidelines suggest, determining a religious exemption request necessitates a case-by-case approach and is inherently situational.

The data collected in this study underscore a lack of standardization in applications and review procedures due to the absence of robust guidelines. Institutions ought to develop standardized forms that incorporate checkboxes with optional probing questions, as well as spaces for supplementary information, to ensure a review process that is fair, equitable, inclusive, and efficient. Immigrant applicants might glean insights from these guided questions about the review committee’s expectations, and the provision of spaces for supplementary information would offer them an opportunity to include their personal narratives.

For immigrant HCPs hailing from non-Western regions, distinguishing between philosophical, cultural, and religious elements can be challenging. This is because the hybridized religions of many immigrants often incorporate both religious facets and philosophical worldviews deeply rooted in their culture. A significant number of people of color might share a habitus—“a set of dispositions learned through socialization and deeply ingrained in their identities” (Attwell et al. 2018). Drawing from Bourdieu’s concept of habitus, individuals operate within particular cultural systems that influence their daily actions, thoughts, speech, and emotions (Attwell et al. 2018). Many find comfort and a sense of naturalness within their habitus, which in turn shapes their moral, religious, or cultural values and practices. Consequently, habitus introduces variations among social groups. Different social groups might not always understand the habitus of others, potentially leading to feelings of isolation and misunderstanding, particularly among people of color or immigrants within a mainstream society.

If these individuals are required to produce an extensive statement on their religious beliefs, practices, or observances related to vaccination without communicating comprehensive guidelines explicitly, they might struggle to convincingly convey their beliefs to reviewers who operate within a vastly different cultural habitus. By incorporating more specific questions and providing detailed guidelines, coupled with examples of non-Eurocentric religious perspectives, the application process can be made more equitable and inclusive. For instance, the following questions can be included in applications: 1. Does your religious belief prevent you from receiving the Covid-19 vaccines only, or does it apply to other vaccines as well? Explain why you choose not to receive those particular vaccines; 2. List all the vaccines that you have received over the past 10 years (e.g. MMR, flu); 3. Has your religious belief or practice that has made you hesitate about vaccination changed over time? If so, explain your experience about when and how it changed; 4. Do your religious beliefs or practices address ultimate questions about life, death, or the purpose of life?; 5. Is your religious belief affiliated with traditional religions or specific ethnic culture, or is it an isolated belief separate from those traditions? This approach with optional probing questions will not only provide applicants from non-Western and/or nonwhite communities clearer direction on how to articulate their beliefs but also encourage them to express themselves more confidently. Moreover, Rota et al.’s study (2001) argues that the frequency of exemptions is linked to the complexity of requirements for exemption applications. Similarly, an increase in probing questions might raise vaccination rates by making the procedure more complex.

From the collected data, it appears that four institutions (Institution 3, 8, 15, 25) do not offer specific questions and 13 institutions (Institution 5, 10, 11, 13, 14, 17, 19, 24, 26, 27, 28, 30, 31) rely on two open-ended questions, inviting free-style responses from applicants. For example, a certain teaching institution asks applicants to identify their religious belief and practice and elucidate why it prevents them from receiving vaccinations. Such a broad question, devoid of detailed guidelines or explicitly stated expectations, may leave applicants perplexed about how best to articulate their religious beliefs (Antommaria et al. 2023). If the religious exemption form were to incorporate more specific questions, addressing a wider range of perspectives, it would be easier for applicants to share their stories authentically. The application can set a clear expectation, such as: “to aid reviewers in their decision-making, we encourage applicants to furnish evidence of their religious practices in the space provided below. Please share some examples of your religious beliefs and/or practices as a testament to your religious beliefs.” Antommaria et al.’s study reveals that approximately 20% of applicants voluntarily offer examples of their religious observances, and about 6% include references to their emotional states as a testament to their convictions (Antommaria et al. 2023). A standardized application with detailed guidelines and tangible examples of applicants’ religious practices would benefit immigrant HCPs. This would provide them with hints about what the review committees are looking for, rather than having to start from a blank sheet without detailed questions or guidelines. I posit that applications enhanced by clear communication and overseen by a multidisciplinary team, incorporating appropriate checks and balances, would foster a more equitable process for religious vaccination exemptions. This approach would cultivate mutual trust between healthcare institutions and HCPs.

Researchers have observed that numerous applicants resort to copying and pasting from vaccine religious exemption letter samples or templates available online (Antommaria et al. 2023; Boone et al. 2021). Antommaria et al.’s study indicates that some applicants directly replicated these sample letters without any attribution (Antommaria et al. 2023). Applications should clearly notify applicants that solely using online sample letters without their personal input could diminish their chances of obtaining an exemption. The application should also include comprehensive guidelines and optional probing questions that elicit personal narratives for supplementary information, thereby discouraging the practice of simply copying from online templates. The focus should not be on the applicant’s religious affiliations but on their unique stories regarding religious beliefs and practices when determining eligibility for a religious exemption. Although multiple applicants might identify as Protestant Christians, their lived religious experiences could be diverse. For instance, the religious practices of Black individuals might diverge significantly from those of Caucasian congregations. Korean immigrant church congregations may hold beliefs distinct from African immigrant congregations. Even though the Catholic Church might have an official stance on vaccination, individual Catholic beliefs and practices might not necessarily align with the Church’s formal doctrines. To truly understand the multifaceted religious perspectives of applicants, both the application and the review committee should be structured to draw out applicants’ genuine religious beliefs and narratives about their religious journeys.

Although review standards might vary among healthcare institutions, it is essential for these institutions to establish objective review criteria based on ethical tenets and practical considerations. Without such guidelines being communicated, applicants may experience confusion and break trust in both the review committee and their employing institution.

Transparency in interactions with the review committee

Research indicates that vaccination-related matters can erode the trust between HCP and the review committee (Gur-Arie et al. 2021; Kwok et al. 2021). To bolster this trust, employers should offer guidance sessions that cover the application process, review standards, review committee membership, and the appeal procedure. Reviewers’ personal identification should not be revealed, but employers can reveal the representative roles of the reviewers, such as clinician, chaplain, ethicist, or community member. According to the collected data, only two institutions (Institution 8, 27) include information about the appeal procedure in their applications. If an exemption is denied, the committee must supply documents detailing the rationale behind the rejection. Yet none of the applications from the institutions state that the review committee will provide reasons for denying applications. Failing to do so might lead many HCPs who were denied exemptions to distrust the decision-making process or perceive the decision as a retaliatory action from the Human Resources department. Given the serious implications, including potential job termination, it is only fair for institutions to record the grounds for refusals and communicate them transparently to the applicant. Furthermore, procedural guidelines in applications should lucidly detail the selection process for review committee members. For instance, data from one institution (Institution 30) reveals their detailed plan to assemble a multidisciplinary team. Similarly, an institution could establish an ad-hoc committee dedicated to reviewing exemption applications. It would then be imperative to clearly communicate to employees the standards for reviewing applications and the selection process for committee members, including the criteria for selection (e.g., race, gender, areas of specialization). Additionally, a detailed timeline should be provided, covering submission, review, determination notification, and the appeal process.

Transparency in procedural matters is crucial in fostering trust between institutions and their employees, as well as between review committees and employees. According to a study by Stecula et al. as of 2019, 60% of US adults either "strongly" or "somewhat" opposed religious exemptions for vaccination (Stecula et al. 2020). Furthermore, other research suggests that many sought religious exemptions during the COVID-19 pandemic, not necessarily based on authentic religious beliefs, but rather due to ideological stances influenced by a highly polarized political environment (Flescher 2023). When religious exemptions are underpinned by political ideologies or personal/philosophical beliefs, this can lead to distrust among vaccinated employees. They might perceive their institutions as failing to maintain a safe work environment, particularly when numerous religious exemptions are granted, including those based on ideological beliefs.

The rigor with which review committees evaluate cases, coupled with their interpretation of "religious beliefs," can introduce a significant degree of subjectivity into the process. Consequently, the approval rate for religious exemptions can differ significantly based on the discretion of review committees. Comprehensive data on national success rates for COVID-19 vaccination religious exemptions is not currently available, but such information would be of significant value for future research.

The role of vaccine education in addressing misconceptions

Boone et al.’s research delves into the fundamental motives behind applicants’ requests for exemptions, specifically focusing on vaccine religious exemption applications within a teaching hospital setting (Boone et al. 2021). Data collected between 2015 and 2018 revealed that a significant portion of HCPs sought religious exemptions due to misunderstandings or misconceptions about vaccinations (Boone et al. 2021). Boone et al.’s in-depth review unearthed a list of commonly cited reasons for seeking exemptions. Notably, some of these reasons, such as the belief that vaccines contain "DNA from aborted fetal tissues" or "animal DNA," point toward misinformation that could be rectified with proper education (Boone et al. 2021; Hsu and Bond 2021). This observation is further reinforced by Babcock et al. who found that exemption requests often harbor misconceptions about vaccines, even among physicians and other HCPs (Babcock et al. 2010).

Two institutions (Institution 13, 15), as per the collected data from this study, mandate that exemption-seeking applicants familiarize themselves with vaccine educational materials. Requiring this educational step for HCPs contemplating religious exemptions could potentially amplify vaccination rates. It is crucial to recognize that certain demographics, such as low-paid healthcare workers, might not have had prior exposure to factual information concerning vaccines. By proactively offering education through in-person sessions or online seminars, organizations can directly engage with HCPs who exhibit vaccine hesitancy or delay. Stecula et al.’s study underlines the importance of dispelling vaccine misconceptions, emphasizing that correcting negative beliefs is pivotal to bolstering overall vaccination rates (Stecula et al. 2020). Rectifying misconceptions and enhancing understanding of both the scientific aspects of vaccines and the stances of various religious entities can potentially reshape perceptions.

Vaccine education should go beyond simply conveying scientific facts about vaccines. It should also encompass an emphasis on the professional responsibility that healthcare professionals have toward their patients and coworkers, encompassing the principles of "duty to care" and "do no harm." Achieving a balance between public health imperatives and religious freedoms is undeniably challenging (Ross and Aspinwall 1997). Nevertheless, during pressing public health crises like the Covid-19 pandemic, institutions might encourage HCPs to reflect on the implicit social contract they entered into: providing care for patients even in the face of potential infections and mortality risks (Gur-Arie et al. 2021). The message relayed should be constructed thoughtfully. It shouldn’t be framed in a manner that feels coercive or threatening. Education materials should also emphasize employers’ reciprocal responsibilities to create a safe working environment by providing appropriate personal protective equipment and accommodations.

Unclear communication and unjust procedures can lead to unfairness in the workplace for HCPs. For example, if HCPs who adhere to mainstream Christianity are granted exemptions, while immigrant HCPs of color who practice non-Western, minoritized religions are denied exemptions, it can result in discrimination and unequal protection in the workplace. Achieving transparent communication and fair procedures is ethically important to prevent the marginalization of vulnerable groups. Some may have concerns about the impact on reaching herd immunity by recognizing more minoritized religions under the legal protection of religious exemptions. However, hospitals hold a responsibility to protect patients’ health and promote public health, while also being employers who should treat all employees fairly under the Equal Protection Clause. The burden of vaccination exemptions should be evenly distributed among employees. Furthermore, fair procedures for religious exemptions may not necessarily hinder the goal of achieving herd immunity. Additionally, educational opportunities about vaccination can facilitate conversations between employers and employees, as well as among employees themselves. Educational opportunities can provide an opportunity for individuals to evidence-based views on vaccination.

Based on the principle of reciprocity, which involves responding to individuals who have taken risks to provide essential services to a community, providing education would be beneficial to all HCPs. This is particularly importnat because some HCPs, who hold misinformation about vaccines, could change their minds with accurate information (Fenton, 2021). Such educational efforts can lead to an overall increase in vaccination rates, protecting HCPs themselves and promoting public health. Offering educational opportunities would benefit frontline HCP communities as a whole (Fenton 2021). Moreover, institutions should clearly communicate their commitment to HCP safety—whether it’s through provision of adequate PPE, initiatives to safeguard collective occupational health, or the establishment of fair and inclusive procedures for religious exemption reviews.

Conclusion

The research data highlights a significant variance in religious exemption applications and accompanying guidelines across different institutions. Most of the reviewed exemption materials lacked detailed procedural information and consistent evaluation standards. The potential for variability and subjectivity in reviews is heightened, particularly if committee members lack a comprehensive understanding of non-Western or non-mainstream religious practices, especially those pertinent to immigrant HCPs and HCPs of color. To rectify these shortcomings and ensure procedural justice in the review process, institutions must clearly communicate procedures in the application and the accompanying guidelines. They should prioritize the establishment of fair and transparent procedures and guidelines for vaccine religious exemptions, with an acute focus on diversity, equity, and inclusion.

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Funding

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