BackgroundThe 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.MethodsWe 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.ResultsMean 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.ConclusionAs 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.

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The Netherlands is part of the historic Northwest-Southeast multi-confessional culture belt according to the comparative framework of churchstate relations in Europe as recently developed by Madeley on the basis of Rokkan's conceptual map. The aim of this paper is to describe the development of the church-state relations in the Netherlands within this historic framework of state-formation and nationbuilding, and to interpret recent challenges of its historic state-church model, such as secularisation, the rise of immigrant religions, and general 'de-and re-territorialisation' tendencies. The Netherlands developed from a relatively very tolerant polity dominated by the Calvinist Church to a 'pillarised' society, in which the Rome-Reformation divide (which also had a strong geographical dimension) was institutionalised in the political system. After the 1960s, very strong secularisation put this 'pillarised' system under severe pressure, but the remnants of this system offered a favourable opportunity structure for religious newcomers (Muslims in particular), who could establish their mosques and Muslim schools relatively easily. However, while the main Protestant churches, and even Catholic and Protestant political parties have merged, failing integration of these newcomers in Dutch society and terrorist attacks at the global level as well as in the Netherlands encouraged a new divide between Muslims and non-Muslims. The metropolitan areas in particular became the scene of this new divide.

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