'It was something that I let slip by the wayside': a qualitative study of challenges to equitable mpox vaccination in the UK outbreak response.

BACKGROUND: During the mpox outbreak in 2022-2023, inequities in vaccine access and uptake were highlighted in several countries. We present an intersectionality-informed, equity-focused approach to understand how the intersection of several characteristics, practices, and circumstances created unique and specific barriers to accessing the mpox vaccine in the UK. METHODS: The study was co-produced with community co-researchers. Between April and July 2023, semi-structured in-depth interviews and focus group discussions were conducted online with 35 UK-based people of diverse ethnicity, sexual identity and orientation with risk factors for mpox. Interviews and focus groups were audio-recorded and transcribed. Transcripts and codes were analysed applying an equity lens focused on understanding how the intersection of demographics, practices and circumstances might lead to exclusion from the mpox vaccination public health campaign. Combining data from all participants, we designed four composite fictional personas who correspond to representative profiles of people that found themselves at the margins of the UK mpox vaccination campaign. RESULTS: The thirty-five participants were diverse in terms of gender (28 cisgender men, 7 transgender or non-binary) and ethnicity (including White, Black, Asian, Latino/x and Arab individuals). We identified six circumstances leading to the exclusion of the UK mpox vaccination campaign: i) not being connected to sexual health services or community organisations and advocates; ii) feeling that the vaccine criteria are too restrictive; iii) lacking trust in institution, often because of structural racism; iv) experiencing feasibility barriers; v) living outside of London; vi) being in a relationship with someone with more risk factors. Our four fictional personas combine these circumstances and represent the characteristics of someone on the margins, either geographically or socially. CONCLUSION: Our findings highlight the need to design more inclusive vaccine campaigns during evolving public health emergencies that consider how the intersection of stigma, characteristics, practices, and circumstances might lead to exclusion and inhibit vaccine uptake. Our persona approach further highlights the need to consider whether shared barriers to engagement (which can span multiple identities and positionalities) require tailored solutions. Guidelines should be co-designed with affected communities and include stigma-reduction interventions to ensure equitable provision and access to vaccine programmes.