Exploring the Contextual Factors of Religious Leader Participation in Health Communication: Evidence from a Qualitative Study in Sierra Leone

"Although the influential role of religious leaders in health communication has received considerable attention, a nuanced analysis of the contextual factors and resulting risks and opportunities of the inclusion of these leaders has been neglected in the literature."

Scholars and practitioners are increasingly exploring strategic collaborations with faith-based organisations to influence health-related behaviours of religious groups and promote better health. Religious leaders have served as health messengers during acute public health threats, such as the Ebola oubreak, as well as non-emergency settings. This study explores the intersections of religion and health communication in Sierra Leone, a country with a long history of engaging religious leaders in finding solutions to health-related problems. The study provides insights into risks and opportunities of religious leaders' involvement in both emergency and non-emergency settings and offers recommendations for the incorporation of religious leaders in health promotion activities in different contexts.

Fieldwork for this study was conducted in November/December 2018 in Sierra Leone, where an Interreligious Council (IRC) with Islamic and Christian leaders had been established toward the end of the country's civil war to support peacebuilding and dealing with trauma. Religious and other local opinion leaders were involved in the emergency of the country's Ebola outbreak, which later led to policy changes (e.g., the National Health Promotion Strategy) during the post-epidemic phase. To glean an understanding of this emergency and post-emergency involvement, the research team conducted involved interviews with developers of health communication strategies who have worked with religious leaders (n = 11) and with local opinion leaders, including religious leaders (n = 11), as well as 8 focus group discussions with members of different religious communities (n = 60).

Results indicate that the contextual features of the Ebola epidemic largely supported the inclusion of religious leaders as health messengers. Due to an existing dense network of religious bodies throughout the country and public statements of religious scholars on conflicting issues in times of despair, study participants felt that religious leaders increased both message exposure in the local population and people's willingness to comply with the new emergency regulations. For example, the touching and washing of corpses during burial traditions were prohibited, which contradicted traditional and religious rituals. Thus, high-ranking Islamic and Christian scholars were asked to study their religious sources and offer supporting statements for the new law. Religious leaders believed that packaging health messages in a sermon helped to calm people and make them more likely to accept the messages. Study participants also emphasised their role of spreading hope alongside Ebola risk messages.

Due to their success in strengthening the Ebola response and increasing trust in health messages, religious leaders were subsequently integrated into the country's long-term health promotion strategy (non-emergency setting). However, many contextual factors changed, giving rise to several challenges concerning the role of religious leaders as health messengers. For instance, while religious leaders were largely described as trusted during the epidemic, there was ambivalence about their expertise in health matters and aptness to spread health information in a non-emergency setting. Post-Ebola, there was a chronic lack of funding, overall poor infrastructure, and resulting difficulties with disseminating health information regularly and equally to all members of society. Against these challenges, the dense network of religious institutions with community-based religious leaders was seen as a readily available resource for the dissemination of messages at low cost. However, while religious leaders in this study expressed openness to merging their religious beliefs with biomedical views, to speak about taboo topics, and to acknowledge the boundaries of their influence, the majority of other opinion leaders and developers interviewed had experienced opposition and problems in relation to health topics that conflicted with religious beliefs.

Based on these findings, the paper offers the following comparisons:

• The contextual features of a public health emergency can be beneficial in embedding religious leaders in health campaigns among populations with high religious affiliations. As religious leaders are locally known beyond their respective congregations, they can be identified quickly to reach the local population in their proximity. Using standardised messages spread by multiple messengers, religious leaders confirm the credibility of other messengers and likewise benefit from being reconfirmed by others, which can enhance their position as a reliable source of health information. Moreover, by spreading hope and encouragement alongside health messages, religious leaders appear to be in a position to encourage audiences to comply with required behaviours. The backing of legal force and a concentration on one health topic further strengthened this strategy during the Ebola outbreak.
• In a non-emergency setting, most health behaviours are less legally regulated, and religious leaders receive little training as they strive to deal with multiple health topics. These factors give rise to a range of potential risks when employing religious leaders as health messengers. For example, they might censor messages that conflict with religious beliefs or be conflicted by their need to make a living from spiritual healings. Nonetheless, continued integration of religious leaders as health messengers was also viewed as a strategy to expose these leaders to biomedical views, increase their health literacy, and thus mitigate some of the risks.

Recommendations for practice and policy include:

• Prioritise inclusion of religious leaders in the response to public health threats due to their impact on mental well-being in times of stress and required immediate behaviour change.
• Consider ways to support the compatibility of religious and biomedical perspectives. High-level religious leaders such as a sheikh or bishop (who were said to be more educated and experienced in merging their religious with scientific views) can potentially influence lower-ranking, community-based religious leaders - perhaps by sharing written-down health messages supported by religious scriptures.
• Provide proper training and supervision to religious leaders, as they typically have no medical background and may thus face challenges with providing comprehensive and at the same time short, memorable health messages on multiple topics. Various participants referred to messenger services such as WhatsApp as a low-cost technology to enable sharing more complex messages via audio and to supervise remote community-based religious leaders before potential negative effects for religious communities are felt.
• Refrain from relying on religious leaders as an exclusive source of information. In both emergency and non-emergency settings, the reputation of religious leaders benefits from being backed by other information sources, especially from the medical sector, and vice versa.