ArticleBMC public health2026
Health system stakeholders' perceptions of religious and socio-cultural influences on measles vaccine hesitancy in Madagascar: a qualitative study.
Article in BMC public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundIn Madagascar, measles remains a leading cause of infant mortality, and recurrent epidemics highlight the urgent need to strengthen vaccination strategies. Despite regular mass immunisation efforts, such as the national campaign in October 2024, the effectiveness of these programmes is often undermined by complex non-medical factors. This study aims to qualitatively explore the specific religious and socio-cultural beliefs and perceptions that act as barriers to the acceptance of the measles vaccine across the country.
methodsThis qualitative exploratory study was integrated into the 2024 Post-Measles Campaign Evaluation conducted across all 23 regions of Madagascar. We used purposive sampling to conduct semi-structured, in-depth interviews with key health system stakeholders, including regional health officials, community leaders, and managers of Basic Health Centres. Data were analysed using manual inductive thematic content analysis to identify recurring patterns and cultural narratives related to vaccine hesitancy.
resultsThe results indicate that from the perspective of health system stakeholders, opposition to measles vaccination is perceived as being primarily driven by deep-seated religious and socio-cultural convictions. Opposition is also driven by limited health literacy; EPCR 2024 data reveals that 34% of caregivers are unable to name a single vaccine in the routine program, and only 4% possess high vaccine knowledge. Key barriers identified include explicit theological rejection specific to Evangelical or Pentecostal worldviews (e.g., 'Jesus heals, not your vaccine'), often characterized by 'healing theology' which views vaccines as an interference with divine sovereignty. This is accompanied by a fundamental functional misconception of vaccines as curative treatments for the sick rather than preventive tools for the healthy, and ancestral skepticism regarding modern medicine's impact on longevity. Additionally, institutional mistrust, fear of adverse side effects, and low educational levels among caregivers significantly contribute to resistance. Specific ethnic groups, such as the Antemoro and Antandroy, manifest localised social prohibitions against injections.
conclusionsResistance to measles vaccination in Madagascar is multifaceted, rooted in fatalism, institutional mistrust, and functional misunderstandings of immunisation. To achieve national elimination goals, public health strategies must move beyond traditional biomedical solutions. Engaging local and religious leaders as trusted messengers is essential for building community trust and developing culturally sensitive communication strategies that integrate local realities into future vaccination campaigns.
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