Open Access Open Badges Research article

Religious subgroups influencing vaccination coverage in the Dutch Bible belt: an ecological study

Wilhelmina LM Ruijs12*, Jeannine LA Hautvast1, Koos van der Velden1, Sjoerd de Vos3, Hans Knippenberg3 and Marlies EJL Hulscher4

Author Affiliations

1 Academic Collaborative Centre AMPHI, Dpt of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands

2 Municipal Health Service GGD Rivierenland, Teisterbantlaan 1b, 4001 TJ Tiel, The Netherlands

3 Dpt of Human Geography, Planning and Development Studies, University of Amsterdam, Nieuwe Prinsengracht 130, 1018 VZ Amsterdam, The Netherlands

4 Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525EZ Nijmegen, The Netherlands

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BMC Public Health 2011, 11:102  doi:10.1186/1471-2458-11-102

Published: 14 February 2011



The Netherlands has experienced epidemics of vaccine preventable diseases largely confined to the Bible belt, an area where -among others- orthodox protestant groups are living. Lacking information on the vaccination coverage in this minority, and its various subgroups, control of vaccine preventable diseases is focused on the geographical area of the Bible belt. However, the adequacy of this strategy is questionable. This study assesses the influence of presence of various orthodox protestant subgroups (orthodox protestant denominations, OPDs) on municipal vaccination coverage in the Bible belt.


We performed an ecological study at municipality level. Data on number of inhabitants, urbanization level, socio-economical status, immigration and vaccination coverage were obtained from national databases. As religion is not registered in the Netherlands, membership numbers of the OPDs had to be obtained from church year books and via church offices. For all municipalities in the Netherlands, the effect of presence or absence of OPDs on vaccination coverage was assessed by comparing mean vaccination coverage. For municipalities where OPDs were present, the effect of each of them (measured as membership ratio, the number of members proportional to total number of inhabitants) on vaccination coverage was assessed by bivariate correlation and multiple regression analysis in a model containing the determinants immigration, socio-economical status and urbanization as well.


Mean vaccination coverage (93.5% ± 4.7) in municipalities with OPDs (n = 135) was significantly lower (p < 0.001) than in 297 municipalities without OPDs (96.9% ± 2.1). Multiple regression analyses showed that in municipalities with OPDs 84% of the variance in vaccination coverage was explained by the presence of these OPDs. Immigration had a significant, but small explanatory effect as well. Membership ratios of all OPDs were negatively related to vaccination coverage; this relationship was strongest for two very conservative OPDs.


As variance in municipal vaccination coverage in the Bible belt is largely explained by membership ratios of the various OPDs, control of vaccine preventable diseases should be focused on these specific risk groups. In current policy part of the orthodox protestant risk group is missed.