Reasons for Non-Acceptance of The Covid-19 Vaccination by Some Muslims in The Three Southern Border Provinces of Thailand

(1) Background: This qualitative research had the objective to study the reasons for non-acceptance of the COVID-19 vaccination by some Muslims in the three southern border provinces of Thailand; (2) Methods: Data collection was done in a community of Pattani province and communities along the Thai-Malaysian border of Narathiwat province by observation and in-depth interview. The 40 key informants were community Muslims, religious leaders and public health workers selected by purposive sampling according to their knowledge of the situation. The data were tested by triangulation and analytical descriptive conclusion; (3) Results: Some Muslims did not accept the COVID-19 vaccination for six important reasons: 1) The belief that the village health volunteers (VHV) who persuaded them to have vaccination only hoped for the state reward. 2) Death is the will of God so vaccination is not necessary. 3) Every kind of vaccine is not halal. 4) Vaccination is the cause of weakened ability. 5) Vaccination had caused death, and 6) Fear of re-vaccination impact because they had the vaccination in Malaysia. (4) Conclusions Involving religious leaders and fostering Thailand-Malaysia cooperation are key to combating health misinformation. Culturally sensitive health education can improve public health responses in the southern border region.

Keywords:

non-acceptance of vaccination

;

covid-19

;

Muslim

;

three southern border provinces of Thailand

Subject:

Arts and Humanities - Humanities

This preprints belongs to the Collection

Preprints on COVID-19 and SARS-CoV-2

1. Introduction

At present, the world is in the globalization age. The world is connected economically, socially, and culturally. Connectedness causes everything to spread rapidly, which has advantages and disadvantages. Duangkaew noted that as humans become closer, national borders become blurred. The ease and speed of world travel has also resulted in the spread of infection. The outbreak of COVID-19 via the network connecting domestic and foreign countries seriously affected Thai society and economy [1]. Globalization with the ideas of modernity affected the ways of communities around the world. Globalization has also affected attitudes, both positive and negative, towards the prevention of disease [2].

The three southern border provinces of Thailand were particularly hard-hit by the COVID-19 virus with high mortality rates in border areas such as Su-ngai Kolok and Waeng sub-districts of Narathiwat province in the border area of Thailand and Malaysia. One factor was the high patient statistics in Malaysia. In the past, Thailand promoted learning about the spread of disease through television, radio, social media, and public health professionals for groups at high-risk. However, interpretation of and attitudes towards disease prevention differ. Langputeh said that, “Communication is the heart of controlling epidemic disease and preventing infection. But (I) accepted that it is hard, especially when people must adapt some of their religious practices, because many people said that they fear sin.” This idea severely affected the effort of the Thai state to prevent epidemic disease [3].

COVID-19 is a contagious disease caused by the unknown 2019 species of coronavirus. The first reported outbreak was in Wuhan, China in December 2019, resulting in a global pandemic [4]. In Thailand, the Department of Public Health stated that the first Covid-19 patient in Thailand was found on January 13, 2020; a Chinese tourist from Wuhan, China, who came in via Bangkok Suvarnabhumi Airport [5]. After that, the disease spread rapidly resulting in hospitalizations and death. Measures were brainstormed by various sectors to prevent the spread of the disease. One of the measures for the three southern border provinces was to adapt the way to prevent and to cure according to the religious principle and local context. There is a significant Muslim population in Thailand’s deep south who practice Islam as framework for the way of life. The National Commission for Health found that Muslims in the south were well prepared to prevent the disease because health prevention measures such as hand washing, social distancing, and home isolation (fitnah) were in accordance with religious doctrine. The avoidance of large community gatherings during an epidemic is also part of the religious doctrine [6].

From the many ripples of the COVID-19 outbreak, Muslim people perceived new information differently. In the first outbreak, Muslims in three southern border provinces thought that they could prevent it, because there was a small spread of infection and death statistics were low. So, there was still gathering for activity, praying in Masjid with mask wearing, and increasing cautiousness. The perception of the disease was gained from the work of local agencies, such as village health volunteers (VHV) and the Southern Border Provinces Administration Centre (SBPAC). They communicated with Muslim villages in the area to understand the dangers of COVID-19 and to co-operate in preventing the disease by using Melayu of Pattani dialect. The second outbreak spread faster and many died from the Covid-19 variant. Most Muslims still perceived that they could prevent the disease by strict cautiousness. Various agencies increased learning resources to the community. The authorities in the three southern border areas also encouraged vaccinations give the high number of hospitalizations and deaths [7]. Some Muslims learnt this fatal threat from their family members who came back from Malaysia. Nonetheless, some Muslims did not accept vaccination. One of the reasons was that this new ripple generated confusing information. Some perceived that vaccination was against the will of God because life was a matter of destiny. One source of this perception was from extremist religious leaders [8]. In general, the community lacked understanding of vaccinations and were suspicious of it. The SBPAC had to campaign hard to educate the community about the efficacy of prevention measures and the vaccine and to dissuade Muslim workers in Malaysia from illegally returning to Thailand. Tareh, a public health worker in the area, stated that, “There are still Muslims who do not want doctors to involve with their men, which was also related to politics. Like vaccination, if anyone does not have vaccination is in their side. We must try to explain, not to use emotion, to speak nicely with them; explaining what is what. We did not tell them to follow us immediately, but just made understanding, bargaining for half-way; they came half-way and we go half-way” [9].

The statistics showing lower vaccination rates in this southern border area than other parts of Thailand raise questions concerning the community’s perception and understand of Covid-19 and the vaccine. Although this research was conducted in the early stages of the Covid-19 pandemic and prevention measures, it is intended to assist local health authorities to understand the perceptions of the local Muslim community in combatting infectious disease.

2. Research Objective

To study the reasons for non-acceptance of the COVID-19 vaccination by some Muslims in the three southern border provinces of Thailand.

3. Literature Review

Acceptance or non-acceptance of anything is related to personal attitude; a result of learning. Khaemanee said that learning forms three changes in a person: knowledge, practical skill, and attitude. When there is learning of anything, a new attitude may be formed or changed from positive to negative, or negative to positive. The change of attitude may result in other aspects. Attitude is the main mechanism of behavioral expression [10]. Gibson said that attitude is the embedded part of a person’s personality. A person has attitude that is the structure of any feeling or belief. A change in any element may cause change in the other element. The three elements are: (1) Affective - emotional or feeling element of attitude, receiving transmission or learning from another person. (2) Cognitive – cognitive element of attitude consists of personal perception, opinion, and belief; focusing on the use of reasoning in the thinking process. The important element of cognition is the belief in evaluation or the belief, which was self-evaluated. These beliefs often express out of impression, liking or not liking. (3) Behavioral – meaning the orientation or intention of people to show something or some actions (behavior) in one way or another, such as, friendly, giving warmth, aggressive, and hostility [11]. Phansuma and Boonruksa researched knowledge, attitude, and behavior in COVID-19 prevention of the people in Pru Yai sub-district, Mueang district, Nakhon Ratchasima province., The study concluded that the sample had average point of knowledge at a middle level and attitude and behavior in COVID-19 prevention at a good level (62.4%, 71.3%, and 72.4% respectively). A statistically significant relationship was found between knowledge and attitude (rs= 0.49), knowledge and behavior (rs= 0.47), and attitude and behavior (rs= 0.79). This research helped to support the concept that knowledge and attitude are related with behavior of COVID-19 prevention. This may be used as an approach for more effective prevention and epidemic control of COVID-19 for the community [12].

McQuerrey postulated that the expression of attitude can be divided into two categories: (1) Positive Attitude is the feeling towards environment in a good way or accepted; satisfied. Having a positive attitude resulted in a person having better morale, ability in overcoming hardship, willing to think creatively and trying new things, willing to share data and ideas, and increasing friendliness. (2) Negative Attitude is the expression or feeling towards environment as unsatisfied, evil, unaccepted; disagreed. Negative attitude resulted in a person being depressed lower quality of work, unwilling to co-work, hardship in overcoming obstacles; looking on others with dislike. The research of Hajiwangah (2013) about attitude towards AIDS and social stigmatization in a Muslim community found that the reason for wrong knowledge of AIDS and influence of Muslim culture derived partly from religious principle. This resulted in an HIV infected person to be looked at with dislike and one who causes social and religious degeneracy. The study found that lowering stigmatization by providing correct knowledge and adapting religious doctrine into practice would be the approach to increase more potentiality of social help for an HIV infected person [13].

Allport claimed that attitude arises as follows: (1) Learning, culture and tradition from family, teacher or other people, both directly and indirectly, including seeing the practice and adopt to follow into practice. (2) Differentiation ability – distinguish good things from bad thing; an adult and child will have different reason. (3) Personal experience, which is different for everyone. For example, someone had bad attitude towards Tok Guru (Islamic teacher) who blamed them, but other ones had good attitude towards him because he appreciated them. (4) Imitation or accepting other attitude to be one’s own; children may accept attitude from parents or movie stars whom they admire to be their own [14]. A study by Pichayapaiboon reflected on the way of Muslims related to attitude, especially religion. The author found that Muslims had a positive attitude towards anything originated from religious strictness more than from other religions as Islam cultivated the right behavior of young people. For people of the Suan Luang community, the practice according to Islamic principles became the normal way of life and influenced the attachment of Islam and Islamic law enforcement [15].

4. Materials and Methods

4.1. Subjects and Data Collection

This research was launched during the vaccination campaign around the second half of 2021 when many Muslims in the three southernmost provinces refused vaccination for various reasons despite the worsening coronavirus epidemic reported in the media. It was only after proactive campaigns with the involvement of public health officials and religious leaders in educating them with medical facts and religious principles that more people started to get vaccinated

Qualitative methodology was used with two methods of data collection: 1) documentary data collected from documents and related research to study facts and to understand the problem. 2) Field data were collected from two groups of key informants purposively sampled for the desired information: 1) 28 Muslims with multiple rejections of the COVID vaccination, and 2) Six religious leaders and 3) six public health workers continually engaging in the vaccination campaign and making friends with Muslims rejected vaccination

Observation and in-depth interview was used to collect data of three communities: 1) a community in the area of Mueang district, Pattani province. Another two communities along Thai-Malaysian border in: 2) Su-ngai Kolok district, and 3) Waeng district, Narathiwat province. The two latter communities have a natural border facilitating human smuggling, a risk of COVID outbreak from Malaysia, high statistics of infected persons, while having a small-vaccinated number. The three communities had 34 informants for in-depth interviews. It also depended on the data saturation to search for in-depth data and to confirm reliability of the data.

4.2. Research Instruments

Research instruments were semi-structured interviewing form, observation recording form, recording instrument, and notebook for recording interviews.

4.3. Data Analysis

For data verification and analysis, data from interviews were verified via data triangulation by re-asking the same person the same question at a different time and place. The triangulation of data involved four groups of informants: Muslims refusing vaccination, district healthcare service workers, social welfare officers of District Administration Offices chosen, and village health volunteers. Then, the data were analyzed, and the results were reported and discussed to reach a conclusion of the analysis.

5. Results

As the Thai state had a campaign for people to have a Covid-19 vaccination during the outbreaks of Delta and Omicron in three southern border provinces, it was found that some Muslims did not accept COVID-19 vaccination because of six important reasons. Each reason was weight as follows 1) there was an attitude that village health volunteers (VHV) who persuaded them to be vaccinated only hoped for reward money from the state, reason carries weight 11 percentage 2) the belief that death is the will of God, so vaccination is not need, reason carries weight 14 percentage 3) believing that every kind of vaccine is not halal, reason carries weight 21 percentage 4) the attitude that vaccination is the cause of weakened ability, reason carries weight 36 percentage 5) the attitude that vaccination caused death, reason carries weight 7 percentage 6) fear of the impact of re-vaccination impact because they were vaccinated in Malaysia, reason carries weight 11 percentage.

5.1. There Here Was an Attitude That Village Health Volunteers (VHV) Who Persuaded Them to Be Vaccinated Only Hoped for Reward Money from the State

There was rumor that if a VHV persuaded a villager to be vaccinated, he/she will receive reward per head. The work of VHVs looked insincere. It was done for self-interest more than epidemic prevention. There was also negative attitude towards VHVs because they were Thai state instruments. Accordingly, the villagers did not obey and believe what VHVs disseminated to their families. One interviewee stated, “Sometime VHVs were driven out and condemned after talking. They were not accepted, and were accused of forcing them to have vaccination, though they just visiting and asking. They were asked how much salary they received. They were not trusted.” (personal, interview, February 20, 2022). Some saw that the role of VHV in inviting people to have vaccination was done for reward and the rumor spread. VHVs had to explain that in fact they received not much regular income. Reward for the number of vaccinated person was untrue. It took time to change Muslim villagers’ attitude towards the image of VHVs.

5.2. The Belief That Death Is the Will of God, So Vaccination Is Not Need

Some Muslims believed that all Muslims are under the mandate of God. Human’s life is destined, when to be born or to die, so vaccination is not necessary. Let it be natural. One may have self-cautiousness not to cause trouble for oneself and others. This is as the will of God. Man has wisdom and rights to choose to have a vaccination or not. There is the belief that death is the will of God. Death is like the bridge connecting to the next world. Muslims who understand this will not fear death because they will go to meet God and be in the eternal world. This world is a temporary living place, not an eternal one. Everything has a beginning and ending point. Human death is the beginning of the next world. Those who are strict and understand this principle will not be shaken when they are ill and must face death. They will meet God who gives birth and death. One participant said, “Our lives are destined by God when to be born and to die, so there is no need to dedicate oneself in curing.” (personal, interview, February 27, 2022). “They do not fear. Why fear? When to die, they said is destined. They believe that just a common influenza, but to have influenza vaccination they do not listen, not enthusiastic.” (personal, interview, November 22, 2021).

5.3. Believing That Every Kind of Vaccine Is Not Halal

Some Muslims used Islamic principle to interpret that consuming drinks and foods must be halal certified or approved according to Islamic provision for Muslims to consume or to apply, including medicine. This attitude was prevalent in the religious group and those influenced by extremist religious leaders. One interviewee said, “If you have to have pill or injection to cure COVID-19 it must be religious. The government approved them as halal or not?” (personal, interview, February 1, 2022). “It was claimed by religion that medicine has no halal. Medicine is not necessary to have halal. We still don’t know that medicine is made of what.” (personal, interview, March 19, 2022). “People are really afraid medicine without halal. So, we want the government, at least, the provincial Islam committee to tell that vaccine is not against religious principle. They will stop being afraid.” (personal, interview, December 27, 2021).

5.4. The Attitude That Vaccination Is the Cause of Weakened Ability

Weakened ability may cause limb weakness, muscle pain, and fatigue. In particular, elderly Muslims who did manual labor such as rubber tapping, carrying, normally get tried easier than the young. When there was COVID-19 vaccination, it was noticeable that those who were vaccinated could not work hard. They were tired. They had to periodically stop the work that they could do all day before. In addition, young people complained that their physical condition changed after vaccination. These symptoms included pale face, out of breath, weak walking or difficulty looking up and down, and the need to rest. Those who were tired after vaccination were impacted by lost income. Rubber tappers had to reduce the number of tappings. Orchard farmers lacked the manpower to look after the orchard reducing the produce to bring to market. Labor work or even housework and activity had to rest periodically to continue. A participant said, “The elders are afraid because they could not raise their hands. They are afraid to be paralysis.” (personal, interview, February 19, 2022). “It made me tried easily. I could not do the work all day; I was tried and had to rest.” (personal, interview, December 29, 2022). In summary, because of the agricultural way of life in the southern border area, the elderly was reluctant to be vaccinated for fear of losing physical strength necessary for agricultural production.

5.5. The Attitude That Vaccination Caused Death

Muslims in the study were most concerned about loss of life. Though death is destined by God, the loss of life from vaccination was to accelerate death. That was against the will of God. This attitude arose from many factors: information from mass media in both domestic and foreign countries that claimed the COVID-19 vaccination caused death. Some were persuaded by VHVs to be vaccinated. Others were illiterate and could not read Thai. Therefore, they relied on misinformation disseminated in the community by family and neighbors. Some believed that thy would die in two-three years after receiving the vaccine. “Villagers could not read, listened wrong information from descendants, from mouth to mouth, such as, living for three years or not over three years and died.” (personal, interview, February 19, 2022).

5.6. Fear of the Impact of Re-Vaccination Impact Because They Were Vaccinated in Malaysia

Muslims in communities along the Thai-Malaysian border like to work in Malaysia. Many had a Malaysian identity card. While living in Malaysia, the government encouraged every Malaysian to be vaccinated to reduce the severity of COVID-19. This included Thais with Malaysian nationality. When the Malaysian government imposed lockdown measures, some Thai people came back to Thailand. When the Thai government campaigned for Thai people to be vaccinated, this caused anxiety for them with various reactions. Someone did not receive a vaccination in Thailand because they had it in Malaysia, but they dared not inform the officials. Therefore, it seemed that southern border Muslims did not co-operate because if they informed that they already had the vaccine in Malaysia, this may have an impact on them. They will be seen as holding two national identifications, which is illegal. “Because they had vaccination in Malaysia, but did not inform Thai government.” (personal, interview, March 31, 2022).

6. Conclusion and Discussions

Some Muslims in the study did not accept the COVID-19 vaccination. The most important reason was that vaccination was against Islamic principles and every kind of vaccine was not halal. Consequently, this group did not accept COVID-19 vaccination, or avoided it initially, or did not have it at all, or had only one vaccine. Another reason was the interpretation of the Islamic principle and belief that death is the will of God. When one is ill, there is no need to resist natural law. Muslims who understand will not fear death; when they are ill and die of the epidemic they will meet with God. This was in line with the concept of Tan, Musa, and Su which said that believers claim that God will be the shield; so one has no need to prevent disease. This belief inhibited the efforts of those promoting health prevention. When one is ill, one has to be treated according to symptoms. Before next world or life after death, Muslims must be cured when sick in order not to trouble themselves and other people [16]. However, when infected with COVID-19, whether they die naturally or are cured to extend life, according to religious principle, these people were all tested by God. Japakiya and Binlatae, wrote that when Muslims died of COVID-19 or the like, with their endurance of the test, they will be one who die as shahid or a martyr [17,18].

Some Muslims in the study believed the vaccination caused weaken ability. Most of them received information and pictures through online media or mouth to mouth. Online media often showed pictures of impacted people being disabled or paralyzed. There were many symptoms reported, including fatigue, especially for older workers involved in agricultural production, which is common in the border area. Others feared loss of life from the vaccine, especially the elders and children with low immunity. This was according to Daya, Lillahkul and Noin which found that parents of Muslim children often denied vaccinations to increase immunity for children of 0-5 years old because of the side effects of vaccination. Other reasons reported for resisting the vaccine included lack of bargaining power to receive continuous vaccination, receiving incomplete data on the vaccine, lack of confidence that the products were according to Islamic principle, and management of the service system not according to the way of life of the community [19]. This also conformed to the study of Phansuma and Boonsuksa which found that the most important learning of vaccination to prevent COVID-19 for Muslims in three southern border provinces was knowledge and understanding of the vaccine. This led to a positive attitude [12].

Some Muslims who participated in the study did not accept COVID-19 vaccination because they believed VHVs were persuading them to get the vaccine to receive an award from the state. There was rumor that if VHVs invited a villager to have vaccination, they will receive a reward per head. This was consistent with McQuerrey which found that attitudes to VHV’s were both positive and negative. Although a VHV made a sacrifice for society, they were also perceived as self-interested. This reflected the long-lasting conflict and mistrust between the state and the community which was exacerbated by the COVID-19 outbreak [13,20]. Tareh reported that public health workers in the area stated that there were Muslims who did not want doctors involved with their people, which was related to politics [9,21]. Panjor indicated that Muslim movement groups like the Barisan Revolusi Nasional Melayu Patani (BRN) maintained their political ideology against the state in spite of the COVID-19 pandemic. The Barisan Revolusi Nasional Melayu Patani (BRN) used every occasion in their struggle for independence of “occupied” Pattani state, without regard to public health [22].

7. Recommendations

1) Muslim religious leaders have great influence in the southern border area and should be active as VHV’s to disseminate accurate information about health prevention and vaccination. Any information from a trusted person will be easier to accept.

2) There should be a concerted effort by both Thailand and Malaysia to disseminate accurate information about COVID-19 and to block disinformation and misinformation.

3) There should be future research on developing a learning process on epidemics and pandemics that is sensitive to the religious principles of the local population in order to develop a positive attitude in the southern border region

Author Contributions

Conceptualization, all authors; methodology, P.T. and K.L.; formal analysis, all authors; investigation, all authors; writing—original draft preparation, P.T. and K.L.; writing— review and editing, P.T. and K.L. All authors have read and agreed to the published version of the manuscript.

Funding

This study was financially supported by The Office of National Higher Education Science Research and Innovation Policy Council (NXPO).

Institutional Review Board Statement

This study received approval from the Boromarajonani College of Nursing, Nakhon Si Thammarat (BCNNST), Thailand under certificate No. F-02/2564, on 18 November 2021.

Informed Consent Statement

Informed consent was obtained from all the subjects involved in the study.

Data Availability Statement

Data availability is restricted due to privacy reasons. However, data may be available by writing to the correspondence author.

Conflicts of Interest

The authors declare no conflicts of interest.

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