The Role of Religions in the COVID-19 Pandemic: A Narrative Review

Culture, religion and health are closely intertwined, profoundly affecting people’s attitudes and behaviors as well as their conception and experience of illness and disease. In order to analyze the impact of religion in the current COVID-19 pandemic, we performed a literature review investigating both the scientific and grey literature on the topic. COVID-19 outbreaks reported in pilgrimages and religious ceremonies around the world—especially in the first wave of the pandemic wave—and the role played by religion in conveying culturally sensitive information about COVID-19 are some of the evidence we reviewed. Our research highlights how religions have represented, on the one hand, a risk for the spread of the virus and, on the other, a precious opportunity to engage people, and in particular minorities, in fighting the pandemic. To overcome this pandemic and to be prepared for similar ones in the future, scientists, politicians and health professionals should acknowledge the role that culture and religion play in people’s lives and how it can assist in tackling complex health challenges.


Introduction
The COVID-19 pandemic has disrupted the global economic, health and social scenario. Such a challenge cannot be tackled without considering the role that the cultural and social dimensions play in influencing pandemic resilience, compliance with public health measures, and the global commitment needed to overcome this unprecedented crisis.
Among cultural dimensions, religion undoubtedly covers a prominent role. The concepts of health and disease are deeply rooted in religious beliefs and people's beliefs and behaviors may positively or negatively influence both individual and public health. It is the case of a diverse propensity to individual lifestyle habits, namely smoking, alcohol consumption, physical activity, dietary patterns [1,2], anti-conservative behaviors [3], or the risk of infection spreading due to religious and traditional rituals (e.g., ritualistic bathing and mortuary rituals) [4].
Moreover, historically, infectious diseases have assumed relevant religious connotations, for instance, those of divine punishment in leprosy and Ebola outbreaks [5,6]. Especially during the first pandemic wave, religious gatherings went under the spotlight as a relevant source of the virus spread [7]. Several worship ceremonies were canceled [8] or offered through livestream by churches, synagogues, mosques, and temples [9]. However, some worship ministers and religious groups ignored the restrictions on physical distancing, claiming exemptions for faith ceremonies [10], and questioned government guidance on SARS-CoV-2 prevention measures. Some religious houses also provided the faithful with disinfection supplies, personal protective equipment and free COVID-19 testing [11] or offered themselves as vaccination sites [12,13]. Nevertheless, some faith communities embraced conspiracy theories serving as promoters of COVID-19 misinformation [14].
Literature has also flourished on the role of religion, and more widely of spirituality, in coping strategies decreasing stress and promoting psychological well-being during the pandemic period [15,16]. The faithful's concerns in the shift from embodied to disembodied religious practices impacting not only the religious rituals per se but also the social networks entrenched in religious meetings have been pointed out [17,18].
In this scenario, we aimed to capture relevant insights about the role held by religions in the COVID-19 pandemic, focusing on how religious habits and leaders have interplayed with the SARS-CoV-2 infection and its spread from the beginning of the pandemic to late 2021.

Materials and Methods
We performed a narrative review investigating both scientific and grey literature published on the topic from March 2020 to the 30th of September 2021. A search string was built using the keywords "COVID-19", "SARS-CoV-2", "Religion", "religious confession", "faith" and synonyms and variants. PubMed, Web of Science and Google Scholar were investigated and a hand-search on Google was also performed. Two researchers independently assessed all the records retrieved for their relevance to the research topic based on the abstract and the full text in two different consequential stages. Inclusion criteria were primary studies, short communications, perspectives articles and newspaper articles whose content dealt with the interplay between religion and COVID-19. Only literature published in English was considered for inclusion. Discrepancies in the selection process were solved through a consensus discussion among the two researchers.

Results
Sixty-one scientific articles, grey literature reports and newspaper articles were deemed relevant and narratively summarized according to the topics that emerged.
Topics identified were (1) religious pilgrimages and rituals worldwide being relevant to COVID-19 outbreaks, especially in the first pandemic wave (2) difficulties to engage the Closed Religious Communities (e.g., Haredi, Amish, etc.) in which community way of life, restrictions in using media and resistance to comply with preventive measures were identified as a significant COVID-19 risk (3) COVID-19 unofficial treatments (4) vaccine hesitancy also supported by concerns about the religious acceptability of vaccine composition or a firm interpretation of the Ramadan fasting (5) fuel of religious discrimination (6) religious communities and leaders strongly trusted in conveying COVID-19 information (7) religions playing a crucial role in coping stress and promoting mental (but also physical) well-being during the pandemic.
Literature review findings are presented and discussed here by categorizing them as risks and opportunities. The key characteristics of scientific articles and reports contributing to the different topics are reported in Table 1. Main results: Amish/Mennonite excess death rates globally similar to the national trends. Excess death rate spiked with a 125% increase in November 2020 when many governmental restrictions relaxed and many of the Amish and Mennonite groups were engaging in face-to-face interactions. According to authors, the importance of face-to-face rituals among CRCs indicates the spread of COVID-19 could be especially problematic within these groups, particularly for those that restrict technology. Anti-vaccine misinformation promoted by leaders of different religions. Homosexuality, control of the mind, conspiracy to "feed cow's blood to Hindus", manufacturing based on slaughtered fetuses, "mark of the devil" are some of the arguments used.
Seale H [45] 2020 Newspaper article Australia Religious concerns over vaccine production methods and the importance to engage religious leaders to ensure they are equipped with accurate information about the potential COVID-19 vaccine, its development process and the rationale for its use. isolation, mental health, meditation and other coping strategies among the topics discussed. Information received has been shared throughout the community. Additional community calls were requested with particular regard to mental health. Distribution of food and facemasks was also achieved at three congregations. The calls also served to identify and correct any potentially harmful misinformation circulating among the communities and to prepare religious leaders for the safe re-opening of religious services. Main results: Religion and spiritual beliefs and practices were positively associated with coping and coping was inversely related to psychological distress. Note: n.a.-not applicable; HCW-healthcare workers. References reported do not follow numerical order but are clustered for topics. Other topics that emerged were: concern regarding the possible role of fasting in influencing the severity of the SARS-CoV-2 infection [73][74][75]; how religious worship adapted to gathering restrictions (e.g., online ceremonies etc.) and how faithful perceived this shift [76][77][78][79].

Religious Events and COVID-19 Spread
Religious events are traditionally characterized by large numbers of people meeting in dedicated places to pray or meditate, often for several days. Some rituals include also physical contact, such as shaking hands in the "sign of peace" in Catholic churches. Thus, such events can pose a relevant risk for the spread of respiratory viruses-including SARS-CoV-2-within the community. Previous respiratory disease outbreaks have shown that this risk is real. During the 2009 H1N1 influenza A and the Middle East respiratory syndrome coronavirus (MERS-CoV) outbreaks, face-mask use was low among Muslim pilgrims and, interestingly, the outbreaks coincided with the Hajj pilgrimage [19]. COVID-19 outbreaks associated with religious events were confirmed early in the pandemic, as early as February 2020 and the risk of large-scale religious events being pandemic triggers was also highlighted in The Lancet [19].
In Albany (Georgia, USA), the SARS-CoV-2 virus infected more than 100 people who went to a funeral in February 2020, fueling an outbreak in the surrounding rural county [20]. In Arkansas, a pastor infected more than 30 attendees in a religious ceremony, leading to three related deaths and the infection of 26 other people, one of whom died [20,21]. In Saudi Arabia, returning Saudi pilgrims visiting pilgrimage sites in Iran and Iraq were suspected to be the initial source of the spreading of SARS-CoV-2 in the community [22]. Luckily, for the first time in the eight decades of the history of Muslim pilgrimage, as soon as the pandemic began to worsen, the Kingdom of Saudi Arabia, on 27 February 2020, placed restrictions on the inbound Umrah pilgrimage [23]. Conversely, Pakistan did not stop religious travelers at first. On 24 March 2020, Pakistan reported 990 cases, sixty percent of which being pilgrims returning from Iran [24]. The same happened in Iran, where several cases within the country and a dozen in neighboring countries were linked to large pilgrimage events [25,26]. In Greece, 48 out of 53 (90.6%) pilgrims who visited Jerusalem on 19 February 2020, tested positive [27]. In Guangzhou (China), SARS-CoV-2 infection was diagnosed in six passengers returning from a pilgrimage in Pakistan. These pilgrims had spent the previous weeks in close contact with thousands of pilgrims gathered in a masjid, without wearing facemasks, thus potentially infecting a large number of people [28]. In Malaysia, in early March 2020, about 16,000-19,000 people of different nationalities attended the Sri Petaling gathering organized by a Muslim missionary movement and held in Kuala Lumpur [29,30]. One thousand seven hundred people tested positive and, later, 35% of new COVID-19 cases reported in the country were linked to this gathering [30]. This apparently acted as the source of infection for the next two gatherings in Pakistan and India as several infected Malaysians attended those meetings [31]. Moreover, in late February 2020, another COVID-19 cluster in Malaysia originated from a Christian leadership seminar in Kuching, Sarawak (a Malaysian state in Borneo). The event has been identified as the source of 117 of the 371 COVID-19 cases in Kuching [29]. In India, as of 4 April 2020, 1023 people related to this congregation had tested positive [32]. Another outbreak in the northwestern Indian state of Punjab was linked to a 70-year-old Sikh priest who, after returning from Italy and Germany, refused self-quarantine and attended several religious meetings, including a Sikh festival attracting 300,000 people daily [33]. In the Eastern Cape Province, South Africa, as of 7 May 2020, about 80% of the infections in the province resulted from three burial ceremonies in Port St. Johns, Port Elizabeth and Mthatha. In the Free State province (still in South Africa), a single religious event attended by three COVID-19-positive church leaders led to the infection of more than 80 people and the further tracing of 1600 people who may have been exposed to the virus [34].
In Italy, the high number of priests who have died of COVID-19 in the first pandemic waves (269 as of April 2021) [80] and the resulting shortage of hospital chaplains, led to nurses and doctors being appointed to give the blessing [81].
Especially in the first phases of the pandemic, COVID-19 infection rates among the ultra-orthodox Jews of Israel have been reported to be significantly high, considering the size of this group population in Israel [82]. Even if large families and crowded living conditions have been called upon for explaining this finding, participation in daily communal religious prayers (and the Jewish holiday of Purim on 9 March 2020) may also have contributed [35]. In London, about a thousand devotees of the International Society for Krishna Consciousness attended a funeral in its temple on 21 March 2020. Twenty-one of them tested positive and five died [36]. A similar outbreak occurred in Italy, in the Molise Region, after a Roma funeral [37].
A further example of the importance-for health-of a full understanding of religious and cultural contexts is offered by the ultra-orthodox community in the US who, due to cultural and social rules preventing them from using technological devices and media, was not promptly updated on the severity of the first pandemic wave of COVID-19 [38]. Similar considerations have been made for other closed religious communities (CRCs), such as the Amish/Mennonites, for whom technological restrictions, regular face-to-face worship rituals, and resistance to preventive measures (including vaccination) have raised concern about COVID-19 spread [39].

COVID-19 Unofficial Treatments and Vaccine Hesitancy
Another potential risk linked to religious beliefs lies in the resistance to adopting COVID-19 preventive measures (including vaccination) due to the persuasion that God's protection is the only effective resource and in the use of unofficial treatments tied to religious beliefs. About the latter, Lebanese Christians have been described as drinking a mixture of water and sacred soil found at the grave of Maronite monk Mar Charbel (Mount Lebanon); Hindu groups have been reported hosting cow-urine drinking parties to cure COVID-19 [40].
Focusing on vaccination, even before the spread of the pandemic, several studies have shown how religion can influence vaccine hesitancy, intended as a delay in accepting or refusing vaccines despite the availability of vaccination services [83]. A case study on measles and rubella vaccine hesitancy in Zimbabwe highlighted how religious teachings that emphasize prayers as alternatives to medicines, and the lack of privacy in a religiously controlled community can reinforce the hesitancy generated by poor knowledge of vaccine safety and effectiveness among members of the Apostolic Church [84]. Regarding COVID-19 vaccination campaigns, a national survey covering 638 Arab Americans-more than half foreign-born-between May 2020 and September 2020 highlighted that only 56.7% of respondents reported an intention to be vaccinated and that 7.5% stated being frankly unlikely to receive a vaccine. Of those, 85.4% self-reported a moderate to high religiosity and women were five times more unlikely to receive the vaccine than men, suggesting that relying on religion as a coping mechanism in facing the COVID-19 pandemic, coupled with possible misinformation about COVID-19 vaccines, informally spread throughout religious communities and posed additional barriers in vaccine literacy among Arab American women [41]. In the US, the "Religion and the Vaccine Survey", conducted in March 2021 underlined that Protestants (Black, Hispanic, White evangelical and "other Protestant of color") and Mormons were the least vaccine-receptive religious groups (share of accepters equal/less than 50%). Among these, White evangelical Protestants reported the higher share of vaccine refusers at 26%, whereas Hispanic Protestants were the most vaccinehesitant (42%). An increase in acceptance has been observed in June 2021 [42].
Conspiracy narratives against COVID-19 vaccines tied to religious beliefs have been highlighted in Pakistan [43], but unscientific theories and COVID-19 vaccination misinformation promoted by religious leaders appeared to spare no religious belief, according to Galang [44].
Moreover, concerns about the acceptability of vaccine composition and manufacturing processes, such as porcine gelatin for Muslims and Hindus or cell lines from aborted fetuses for Christian communities, have also been expressed [45].
In addition, a firm interpretation of the practice of fasting during Ramadan, intended as "refraining from anything entering the body cavities," has been feared to promote some reluctance to receive vaccinations during the holy month [46]. Attention has also been paid to the role of fasting in influencing the severity of SARS-CoV-2 infection, highlighting the need for future studies to better address the topic [73][74][75].
Furthermore, the pandemic may also fuel religious discrimination [47], in particular towards Muslims and Jews [48]. Beliefs that Jews developed the virus to later gain credit and profit from the vaccine they would develop or that the pandemic is a punishment for Jewish denial of Jesus are classic examples of observed anti-Semitic attitudes [48].

COVID-19 and Religions: Opportunities
Religious meetings represent meaningful moments for believers and may be particularly important for minorities. For example, Black churches have a well-known role in promoting spiritual renewal and mental resilience and in addressing racism, especially for older African Americans [59]. A proactive engagement of religious communities and leaders may ensure both significant relief during pandemic times and proper and trusted communication on how to appropriately deal with the pandemic, also considering the increase and the strengthening in religiosity that some studies have detectedduring the pandemic [60,61].
In this regard, proactive activities have been developed in some contexts. In São Paulo, a spiritual hotline was developed in May 2020, and, during the first two weeks, 108 appointments were requested, and calls were made from Brazilian states and from Portugal [62], highlighting the resonance of the project. In the Philippines, Catholic congregations organized online ceremonies providing online counseling and guidance, and distributed free protective equipment and food to the poor and homeless people [63]. Similar support services have also been set up in Detroit [49].
An online survey conducted in March 2020 in the first quarantined community in the US, a Modern Orthodox Jewish community, showed that community organizations were more trusted than any other source of COVID-19-related information by offering concrete support, such as food delivery, social support, virtual religious services, and dissemination of COVID-19-related information [50]. Religion can be used in disseminating precautionary measures and evidence-based practices against COVID-19 [51,52], as we have already learned in defeating the Ebola epidemic in West Africa [85].
Moreover, important religious ceremonies, such as the Jewish holiday of Pesach (or Passover), Ramadan, Easter, and funerals, were organized through online platforms [76,77], underlining how religion was able to adapt to the pandemic and reinforcing the relevance of complying with public health measures in the faithful. However, this shift has not been painless. The literature highlights that the forced digitization of religious worship disrupted religious habits and practices requiring the faithful to accept not physically participating in fundamental liturgical rituals, such as the Eucharist, the passing of the peace, the burning of incense for the Christians [18,78], and the holy chants. Besides the missing of physical participation in rituals, the faithful also expressed how the impossibility to meet in religious rituals (e.g., group prayers, pilgrimages) affected their social networks, often deeply rooted in religious belonging, being only partially relieved by online worship and meetings [18]. This is even more crucial within the context of religious and ethnic minorities, for which physical participation in rituals and meetings maintains and provides a transnational source of identification, constituting an essential factor in their social network [79]. The value of physical participation also emerges in a survey performed in the United Kingdom (UK), soon after the easing of restrictive measures (July 2020). The survey, covering 939 participants of different religious backgrounds, reported on the global compliance of worship places with social distancing and the use of face masks with a general acceptance of this latter. Face masks, even if perceived as uncomfortable and reducing the singing and chanting volume, were globally tolerated, since this meant resuming the singing and chanting during communal worship [53].
Furthermore, the role of religious coping-intended as the use of "cognitive or behavioral techniques, in the face of stressful life events, which arise out of one's religion or spirituality" [86]-in easing COVID-19 anxiety and supporting psychological well-being during the pandemic has strongly come to the fore. During the early months of the pandemic, Google searches for prayer relative to all major religions collected for 107 countries rose by 30%, reaching the highest level ever recorded and remaining 10% higher than previously throughout the entire 2020 [61]. According to the author, this finding seems to indicate more than just the mere replacing of physical churchgoing with online worship but a global, increasing demand for religion as a means to cope with adversity. An online survey covering 1250 adults in Italy underlined that the participants, and in particular women, were perceived to have poorer mental health than in the pre-pandemic period, and that spirituality and religious practices play a protective role in psychological and mental health but also for physical health [64]. In a cross-sectional study on a sample of 419 American Orthodox Jews, negative religious coping and mistrust in God have resulted to correlate strongly with higher levels of COVID-19-related negative impacts in different areas of life (e.g., sleep, diet, family, relationships, enjoying life) versus a global and better resilience of individuals with intrinsic religiosity and positive religious coping [65]. In a sample of 970 Americans between 20 and 79 years of age, negative religious coping resulted in the likelihood of being more associated with COVID-19 anxiety than positive religious coping [66]. In a survey performed on 543 residents of the United Arab Emirates, in the early stages of the pandemic, Muslims reported significantly higher levels of positive religious coping compared to their Christian counterparts, and in this group, positive religious coping was found to be inversely related to depressive symptoms and having a history of psychological disorders [67].
In this regard, particular attention is paid to the elderly, who are usually the most religious in communities [87]. Geriatric psychiatrists believe that faith may support older patients in relieving anxiety during the COVID-19 pandemic [68] and female older adults have been found to have higher levels of religious coping, and lower levels of death anxiety during the COVID-19 pandemic than male older adults [69]. Moreover, in older homebound adults, positive religious coping has been reported to be associated with a less suicide risk [70]. The positive impact of religion and spirituality on mental health has also been highlighted in a cross-sectional study on a sample of 200 Malaysian healthcare workers involved in the assistance of COVID-19 patients, in which positive coping was predictive of a reduction in anxiety and depression scores [71]. The lowering of psychological distress has also been reported in a more recent study on a sample of 549 caregivers (parents and other adults in childrearing roles) across Canada, United States, United Kingdom, and Australia [72]. Thus, besides the role of religions in favoring compliance with COVID-19 preventive measures, also its role in coping strategies should be further valorized by governments and institutions, as scientists and researchers advocate [30,88]. The World Health Organization is moving in this direction by recognizing the importance of chaplaincy interventions in supporting the healing process of religious patients [89].
With the launch of the COVID-19 vaccination campaigns, the positive role of religion in promoting adherence to COVID-19 vaccination and in elucidating moral issues that can cause vaccine skepticism in their faithful has come powerfully to the fore. The "Religion and the Vaccine Survey" (United States) underlined how faith-based approaches can be effective for hesitant and refusing groups with about 40% of vaccine-hesitant (44% in March 2021 and 38% in June 2021) and 14% (March 2021) and 19% (June 2021)of vaccineresistant Americans who attend religious services at least a few times a year saying that faith-based approaches would make them more likely to vaccinate [42]. The South Dakota COVID-19 Impact Survey (SDSU Poll), performed in April 2021, highlighted as among people who had not received a vaccine, those spurred by a religious leader indicated nearly twice the likelihood of getting vaccinated than those invited by politicians or medical professionals [54].
The Vatican Congregation for the Doctrine of The Faith has reassured Catholics about the moral legitimacy of receiving COVID-19 vaccines that have used cell lines from aborted fetuses in their research and production process in case of a lack of alternatives [55]. The same note also emphasizes that "the morality of vaccination depends not only on the duty to protect one's own health, but also on the duty to pursue the common good", especially with regard to protecting the weakest and most exposed [55]. Some Catholic churches have proposed themselves as vaccination sites [56] and in August 2021, Pope Francis urged people to get vaccinated against COVID-19 [57]. Similarly, appeals to join COVID-19 campaigns and reassurance about the religious acceptance of vaccine composition [58] have come from different religious leaders. Global faith leaders also called for rejecting vaccine nationalisms and embracing a commitment to global vaccine equity [90].

Limitations of the Study and the Way Forward
Our study aimed to investigate and provide an overview of key topics concerning the interplay between religion and the COVID-19 pandemic. As we conducted a narrative review, we cannot rule out that all available evidence on the topic has been considered. Moreover, the timeframe of the research has been confined to September 2021, even if some relevant latest articles have been mentioned.
While taking into account the limitations stated, some considerations arise. First, most of the literature retrieved on the topic does not provide primary data or has not been subject to peer review processes encouraging more scientific and original research to better inform healthcare practitioners and evidence-based policy-making. Further, the screened literature clearly showed a preponderance of studies led in Asian countries and the US and a lack of studies set in European countries, prompting the scientific production attention on the topic in these countries.

Conclusions
Our review findings plainly push for an acknowledgement of the role that religion has in facing complex health challenges and adopting a phenomenological, anthropological, and cultural approach in designing public health strategies. The knowledge of the different cultural and religious specificities and cooperation with religious leaders are crucial to ensure that all the different groups are included in health policies and engaged in health production and protection.
This can be achieved through the establishment of inter-religious and pluricultural collaborative relationships with all representatives of different religious denominations, committed to promoting communication channels providing accurate, accessible, and reliable information to members of religious and belief communities, as also highlighted by a joint Statement of the International Religious Freedom Alliance [91]. Health systems and health policy should become more sensitive to religious and cultural issues, for example, by training the health workforce and structuring cultural and religious-sensitive health pathways. In turn, religious organizations can act as intermediaries to reach out to communities that may have difficulties in accessing health services or are resistant to implementing evidence-based measures.
Such an approach is of the highest priority even in this pandemic phase, which is newly characterized by high virus circulation, especially in some countries, and where the persistence of unequal availability of COVID-19 vaccines continues. Furthermore, our review of the concerns held about vaccine hesitancy and vaccine refusal movements is of significant value when facing possible future pandemic challenges.  Acknowledgments: The authors are grateful to Cristina De Rose for her contribution to the preliminary phases of the manuscript's conceptualization.

Conflicts of Interest:
The authors declare no conflict of interest.