Heterogeneity in vaccination attitudes and behavior within an outwardly homogenous religious group: a cross-sectional study of the Ultra-Orthodox Jewish population in Safed, Israel

Background: Ultra-Orthodox Jewish (UO) communities often show suboptimal and delayed vaccine uptake, leading to recurrent outbreaks. Health equity efforts often treat minorities as uniform, overlooking internal diversity. The UO population comprises distinct subgroups with varying social norms; how this impact on vaccination is not described. We use Safed, a UO-majority city with low vaccination coverage as a case study to examine subgroup differences in vaccination behavior and attitudes. Methods: In 2023–24, a cross-sectional survey was conducted among parents of children aged 0–10. Respondents were categorized as Litvish, Hasidic, Sephardic, non-mainstream UO, or non-UO. The survey assessed DTP and MMR vaccination status, vaccination attitudes using a validated hesitancy index, sources of information and trust. subgroups were compared using chi-square tests, t-tests, and ANOVA. Results: 318 parents participated (201 UO). MMR coverage ranged from 100% (Litvish) to 60% (non-mainstream, p < 0.001); DTP showed a similar gap (100% vs. 65.9%, p < 0.01). Significant differences in vaccine attitudes were found among UO subgroups (p < 0.001), with the Litvish showing the least hesitancy and non-mainstream groups the most. Information from healthcare professionals was sought by 36.8% of Litvish vs. 24.6% of non-mainstream. Religious authorities were the primary source of information for 68.8% of Litvish vs. 36.2% of non-mainstream respondents (p = 0.007). Trust in rabbis and healthcare professionals varied significantly between UO subgroups. Conclusions: Significant intra-UO variation in vaccination attitudes and behavior challenges the assumption of community uniformity. Local health services should identify and consider the particulars of their population to deliver equitable and effective vaccine programmes.