Restoring public trust in COVID-19 vaccine among Africans, Caribbean, and Black Canadians Community based participatory research (CBPR)

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ACB people experienced higher infection and recovery rates, greater health risks, and access to care. Public mistrust, due to anti-Black racism and historical trauma contributed to low vaccine uptake among ACB populations. Our study examined multi-level and intersectional issues impacting vaccine uptake and acceptance in Ottawa. This paper will focus on the themes of agency and community resilience. Methods A mixed methods research (MMR) approach guided this study using the socio-ecological model (SEM), intersectionality lens, and community-based participatory research principles to generate the qualitative results. The sample included 49 ACB participants involved in focus group discussions (FGDs). The sample population included service providers (20), social workers (15), doctors (3), and nurses (3) and others (8) who were predominantly Black African (70%), mostly female (80%), age range was 35–44 (33%) with high school diplomas (40%). Data were recorded digitally, transcribed verbatim, analyzed inductively. Data analysis methods were thematic analysis including inductive coding using NVivo software and rigor methods were member-checking and external audits. Ethical approval retrieved from affiliated institutions and measures taken to ensure trustworthiness of data. Results Our data showed rebuilding public trust is possible by bridging knowledge gaps on vaccine information, increasing service providers’ cultural competence capacity, and providing governance/leadership opportunities for ACB communities. Conclusion Restoring public trust will require dismantling racism by prioritizing ACB community’ needs, proactive and accessible culturally appropriate messages, and opportunities to develop policies to improve health outcomes. Agency Community resilience low COVID-19 vaccine uptake public health mistrust ACB people socio-ecological model lens Community based participatory Research (CBPR) SEM Intersectionality lens Figures Figure 1 Background Public mistrust predates the COVID-19 pandemic and was further amplified with the rapidity of the COVID-19 immunization rollout in Canada. Public mistrust within health institutions is deeply rooted in anti-Black violence, racism, experimentation observed among African, Caribbean and Black Canadians (ACB) and other racial groups and a strong predictor for vaccine hesitancy (VH) [ 1 , 2 ]. VH is a common term that is currently used in the literature to capture the varying reasons for low uptake of COVID-19 vaccine among various populations. Nacimento et al defines it as VH as existing on a continuum ranging between complete adherence and complete refusal due to doubts or concerns within a heterogeneous group of individuals who may be influenced by a combination of cognitive, emotional, cultural, social, spiritual, and political factors [ 3 , p. 2] The key difference with VH during the COVID-19 pandemic was the rapidity of immunization roll-out across Canada and worldwide, politicization of vaccines among major pharmaceutical companies (i.e. Pfizer, Moderna, Astra Zeneca), and racial reckoning in the murders of George Floyd, Breanna Taylor, Ahmaud Ahbery and countless others. The collision of these highly political and racially tense events exacerbated vaccine hesitancy during the pandemic. High income countries such as the United Kingdom, United States, United Arab Emirates (UAE) ran rapid vaccine rollout programs and encountered low uptake of COVID-19 vaccine among various minority groups (Black, Arabs, Asians, Hispanic/Latino and a small percentage of American Indians and Alaskan natives) [ 4 ]. Challenges with vaccine hesitancy among minority groups do not stem from their innate vulnerabilities, instead the key drivers are socio-economic factors such as social status, access to social goods, housing, employment, and healthcare services [ 4 , 5 , 6 ]. Within the Canadian context, one key study found that vaccine hesitancy among Black Canadians primarily stemmed from “the denial of their rights and feeling that decisions were being made for members of the Black community and hesitancy related to medical distrust” [ 3 ] (p. 9) The selection of the most effective vaccine companies, primarily between Pfizer and Moderna, became another source of vaccine hesitancy among minority groups. During the pandemic the World Health Organization recommended a vaccine with 70% effectiveness; Pfizer reported 90% effectiveness in preventing COVID-19, while Moderna reported 94.5% effectiveness [ 1 ]. Accompanying these reports were miscommunication lacking in cultural and linguistic approaches from both government and public health agencies on COVID-19 vaccine effectiveness [ 7 ]. Additionally, vaccine clinical trials experienced difficulty recruiting Black participants due to the historical dehumanisation and experimentation done withing Black communities, inflexible clinic hours, lack of translation services and transportation costs [ 1 ]. The racial tensions during the pandemic that resulted from the murders of George Floyd and others reinforced systemic racism within our social justice, political and healthcare systems. There is a growing body of research to show the linkages between social determinants, COVID-19 infections and racialization. These social determinants places vulnerable ACB individuals a greater risk of disease and psychological stress (3, 5, 8). In Canada, heavy policing and social distancing rules were enforced on minority groups, particularly within Black communities reinforcing the mistrust within our social and health systems [ 1 ]. Several studies have highlighted the impact of public mistrust among various racialized populations in Canada and its impact on vaccine uptake. One recent study coined the term vaccine mistrust ( a sub-theme of public mistrust used in reference to Black individuals) defined it as “a lack of confidence in the healthcare system, providers, treatments, and immunizations because of failure to them ” [ 6 , p. 1]. The findings showed vaccine mistrust was highest among Black Canadians compared to other racialized groups such as Arab and Indigenous communities due to higher rates of racial discrimination in healthcare services and conspiracy theories [ 3 ]. Additionally, Black Francophones tend to have higher rates of vaccine mistrust compared to Black Anglophones due to language barrier impacting access to health services. Another report revealed 57% of ACB individuals were less likely to intend to be vaccinated compared to White individuals due to pre-existing chronic conditions, high level of COVID-19 risk perceptions, skepticism towards COVID-19 vaccination and difficulty identifying trusted sources of information [ 4 ] Additional studies have also shown worse outcomes due to the COVID-19 virus for Black communities in both Canada and the US [ 3 , 8 ]. Large city hubs revealed that ACB people in Ottawa reported 37% of confirmed COVID-19 cases although they represent 7% of the population; while 33% of cases in Toronto although they represent 9% of the population. Additionally, the mortality rate for COVID-19 infection is 2.2 times higher in Black compared to White communities [ 3 ]. Similarly in the US, COVID-19 hospitalization rates and death were higher among African Americans due to the linkages between economic factors and physical health [ 8 ]. Despite the successful efforts of public health institutions across Canada to achieve high vaccination coverage, there is growing concern among government officials, public health leaders, and policy makers that more targeted approaches are needed to restore public trust with COVID-19 vaccines among racialized communities [ 7 ]. Study Aim The ACB Vaccine Acceptance study (AVA) led by the University of Ottawa and its partners, and funded by Public Health Agency of Canada (PHAC) collaborated to address the unique barriers, and lived experience of ACB communities due to low vaccine uptake. The study aimed to meaningfully engage with ACB community members and service providers to facilitate vaccine uptake and to strengthen communities’ confidence in and acceptance of COVID-19 vaccines in Ottawa and the national capital region. Two main research questions were addressed during this study: How do ACB people understand their vulnerability to COVID-19 infection, especially in relation to vaccination? What are the individual, community and structural barriers/facilitators that promote vaccine uptake and access to inclusive services? This study utilizes the socio-ecological model (SEM) to explore the issues surrounding vaccine uptake including challenges, and provide community-driven evidence-based approaches to rebuild trust among ACB communities within Canadian healthcare institutions. Methods Study Design and Participants This mixed method study used the socio-ecological model (SEM), intersectionality lens and the tenets of community-based participatory research (CBPR) to guide the research process including collect data from participants. The focus group discussions (FGDs) data set is the focus of this paper. The socio-ecological model (SEM) is a framework that has five interacting levels of health behaviour to help unravel complex societal issues [ 9 ]. Intersectionality lens helps to illuminate issues resulting from the interaction of factors such as gender, race, socioeconomic status, etc. to influence health outcomes [ 10 ]. CBPR centers the ACB community at the core of the study to address their lived experiences with health inequity, embolden them to codesign the implementation of interventions, practices, and policy tools [ 11 ]. The eligibility criteria for participants were: self-identify as African, Caribbean or Black; be at least 16 years old; able to communicate in either English or French; reside in Ottawa and the National Capital Region. Participants were recruited using a peer-led approach from specific agencies such as Canadians of African Descent Health Organization (CADHO), South-East Ottawa Community Health Centre (SEOCHC), Ottawa Public Health (OPH), Somerset West Community Health Centre (SWCHC), Restore Medical Clinic, AIDS Committee of Ottawa (ACO), River Jordan Ministry, Men of Honor Ministry, African, Caribbean, and Black Community Wellness Resource Centre-Ottawa, International Pastors and Leaders Forum (IPLF). All focus group discussions (FGDs) used an interview guide, were held virtually via Zoom due to COVID-19 restrictions, audio-recorded, and transcribed verbatim. The sample size was 49 ACB community participants involved in the FGDs. The sample population comprised of service providers community workers (20), social workers (15), doctors (3), and nurses (3) and others (8) who were predominantly Black African (70%), mostly female (80%), age range was 35–44 (33%), and held high school diploma (40%). Consenting participants answered interview questions about their knowledge, experiences and barriers to accessing COVID-19 vaccines. Sessions lasted for 60 minutes and a gift card of $ 30 was provided at the end. The study was approved by the University of Ottawa Research and Ethics Board (REB) (H-12-21-7558). Analysis We used Braun & Clark (2006) ‘s six steps thematic analysis framework to make sense of the data and guide data interpretation (Braun & Clark, 2006). This process began with the development of a coding framework informed by questions from the interview guides and a systematic approach that involves the six steps: (1) familiarizing with the data; (2) generating initial codes; (3) developing a coding tree to guide the coding of transcripts; (4) identifying themes; (5) reviewing, defining and naming themes; 6) interpreting the narratives and stories; and ( 7 ) producing the report – a concise, coherent, logical, and non-repetitive account supported by vivid examples. We used Nvivo computer software for data management and storage. A theme is a pattern in the information that describes and organizes the possible observations, or interpretations of phenomena identified in the data. This process involved participatory data analysis team meetings to review and discuss codes and preliminary themes generated by the data analysts. During these meetings we renamed codes and collapsed them under broader themes and sub-themes. Once the themes were obtained from the FGD data, the SEM was used to further categorize the themes and quotes into the five levels. This process was repeated as more transcripts were coded to ensure comprehensive interrogation and interpretation of the data until saturation was reached [ 12 ]. The participatory data analysis team meetings also helped clarify discrepancy, unexpected or unclear coding and to improve the level of abstraction of major themes [ 13 ]. Trustworthiness of data was established using Lincoln and Guba (1985) qualitative research evaluation criteria; credibility, confirmability, dependability, transferability. Specific data validation strategies employed include external audit, member-checking and peer debriefing (14). Results Six major themes were generated from our study findings, this paper will focus on one; agency and community resilience. Agency refers to “enabling people to command their own unique or tailored interventions to fit their own perceptions of need and their own circumstances, and to develop their own capabilities” [ 15 , p. 3]. Community resilience is defined in the literature as “ an ongoing process of change and adaptation” and the “ capability (or process) of a community adapting and functioning in the face of disturbance [ 16 , p.7]. Together these two concepts refer to a theme that describes how ACB community collectively mobilized resources to handle the devasting COVID-19 pandemic circumstances. This theme had three sub-themes, which will be used to organize the results section below. These subthemes are: i) vaccine information, ii) cultural competence and safety, and iii) experts of their bodies and experiences. Theme 1: Vaccine information Agency as it relates to vaccine information is described as having both an empowering and disempowering impact based on the accuracy of health messages provided to the public. In our study, participants expressed the positive impact accurate vaccine information had on their beliefs and ability to make an informed decision to become vaccinated. While, misinformation had the opposite effect creating more doubt in the vaccine rollout process. One participant shared, I was concerned about the side effects, that was my main issue– not side effects, but long-term effects. And until I spoke to a friend who works in labs and a scientist and kind of explained how the vaccine worked, then I was able to have a better sense and also when Health Canada started to publish more information on the vaccine, how they evaluate it and things like that. So at first it was kind of… I was reluctant to take the vaccine because I was not sure of like the type of vaccine and there wasn’t that much information out there. But once information started to trickle down and then I felt more comfortable F4 FGD 5 Another participant shared: I think it’s very important for the healthcare to give us accurate information. Like right now they have stopped talking about giving…, I think for me it is important. We have to know, it is the reality, this is what is going on. By you keeping quiet, people are dying in silence without us knowing. We are thinking that, oh, okay, now things are cooling down. Everything, you know, it’s because we don’t have that information. They have to give it to us F2 FGD 4 Vaccine information that came from public health institutions changed rapidly over the course of COVID-19 rollout and participants shared their concerns about their trust in the healthcare system and the need for more transparency. This participant shared: In Ottawa at the beginning and even the World Health Organization, like people did not know and things kept changing. And people were like, well, can we trust them? Can we believe them? And so, just, yes, being more transparent and explaining, you know what, we don’t know, and it’s evolving and we will… this is today, based on the information we have today this is the best course of action, type of thing. F6 FGD 5 Theme 2: Cultural Competence and safety Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency, or those professions to work effectively in cross-cultural settings and interactions” [17, slide 20]. Cultural safety is the transformative element of cultural competence that “involves the experience of the patient. It requires creating a healthcare environment that acknowledges and addresses power imbalances, ensuring it is free from racism and discrimination, thereby allowing individuals to feel secure when accessing health services” (17, slide 37). Our results showed cultural competence on a continuum spanning from interactions with service providers to changes needed within health organizations. First, participants shared strategies for service providers to engage and empower ACB participants with health literacy on COVID-19 vaccines with compassion, and utilize culturally safe approaches. One participant shared this unique quality about the Black community: Black people we are different. We don’t like to be rushed, and we don’t like somebody to come and just interfere like that. So, you have to kind of be friendly and introduce yourself and tell them we are here to talk about the COVID, we are here to talk about the vaccine. And talk them on… don’t laugh them when you talk F1 FGD 4 Second, the Black community is comprised of very diverse communities enmeshed within dominant cultures. Thus, it is imperative that communication messages be culturally specific depending on the group being targeted. Several participants shared key strategies that were used in the ACB community from various perspectives within the community. Outlined in the quotes below are examples from the Ghanian, Congolese and Caribbean communities. It is important to note that each of these strategies may not be limited to that particular group alone. Strategies suggested by Ghanaian participants Strategies suggested by Congolese participants Strategies suggested by Caribbean participants Yeah, I think that you have to target to identify African groups, African organizations. We have for example, we are very soon, summer is coming, we have many outdoor events. And that’s our period to, we have people from Ghana, meetings for, meeting somewhere, from Uganda, meeting somewhere. You have to identify those groups and now try to be in touch with them and see if we can give them more information about the vaccine. M3 FGD 4 Each country has got his own community. Where there is some, preferably, like I’m Congolese, there is a community for Congolese here in Ontario. So if they go through those organizations, they will get a lot of people because those people will be connected with their communities. M3 FGD 4 But we have Caribbean radio station in the country, in Ottawa, go to a Caribbean radio station, get the word out there. We have the multicultural station right on the market. They would love to accommodate people with multicultural things, to go and talk about all of these things. So, somebody have to go and you know, talk to those people and come on the air and spread the word. You know because lots of people from all walks of life listen to that Caribbean station. They have on Saturdays one in the morning, one in the evening, one at night. So you can go there and reach the community who listen to that Caribbean station. F3 FGD 5 Lastly, there is a need for culturally competent and safe programs within our healthcare system that target the improvement of Black health outcomes. This participant shared “they should support the initiative that is really targeting this population. Healthcare, whatever the system is, this… [ Institution name] should be able to support any Black clinics or programs that would target that population of BlacksF3 FGD 2 Theme 3: Experts of their bodies and experiences The theme of agency was amplified in this sub-theme of ACB participants acknowledging their expertise in themselves and lived experiences. One participant expressed that agency for ACB participants need to have this foundational element within health service delivery, communication, and policy development “ This is an African reality and I believe that we have knowledge that Westerners, unfortunately, do not have, but as they are the ones who have the infused science, they always tend to simply ignore it. Then, I believe that medicine, research would have a lot to gain by getting closer to our traditions.” M FGD 6 Discussion Our study has shown the challenges for increased mistrust within the ACB population due to historical mistreatment, and anti-Black racist programs and policies. Considering these atrocities, ACB populations have remained resilient as a means of survival for their families and the next generation with limited resources and support from public health institutions. Our results have added to the literature by providing strategic ways agency can be better integrated within vaccination and other health-related programs to build trust among ACB populations across Canda. As evident in the results, agency and community resilience have been identified as resources to strengthen ACB voices in health care. According to Shankar et al, the approach to agency within health interventions was often missing the individual component. This approach to agency [advances] “human resource capacity at the most basic level, through shifting individual mindsets, to cultivate resilient people and communities that can adapt to diverse and changing environments” [ 18 , p.165]. Thus, health interventions should adopt an agency-based framework to build individual and collective capacity of the participants and improve health outcomes. The agency-based framework takes into consideration four key components: 1) an individual’s culture, context, and local population, 2) safe spaces for reflection and identification, 3) connecting goals with resources, and 4) building agency-based interventions within networks [ 18 ]. Additionally, community resilience is also part of the continuum of agency and has similar components described in the literature as: local knowledge, social network, communication, health, governance/leadership, resources, economic investment, preparedness, and economic outlook [ 16 ]. In addition, while many studies have focused on the social determinants that have been exacerbated during the pandemic among racialized groups, our study adds to the literature by providing key strategies to amplify the ACB community’s voice as an agent to rebuild trust in our healthcare system Agency and community resilience can be used as approaches to rebuild public trust among ACB community members on an individual, interpersonal and structural levels. Bridging the Knowledge Gap Since the pandemic, there has been a burgeoning body of literature showing the local, national and global impacts on people’s lives particularly those populations that have been rendered vulnerable due to social, political and economic determinants. Public health institutions worldwide faced immense challenges in equitable, vaccine distribution, human and economic resources further weaking an already overtaxed system [ 19 ]. Our study that was conducted in the nation’s capital of Ottawa is booming with immigrants from diverse places, particularly those from the ACB communities. Utilizing the health systems resilience conceptual framework, we integrated the complex challenges with low vaccine uptake among ACB communities within the SEM (see Fig. 1 ). On an individual level, ACB participants held varying knowledge, risk perspectives and attitudes about COVID-19 vaccine effectiveness. For participants who received accurate information from a trusted source were more likely to get vaccinated compared to those who were misinformed. This aligned well with other studies that found individuals who received vaccine information from healthcare providers had a positive attitude towards the vaccine [ 19 ]. Therefore, bridging the knowledge gap with the intent to build an ACB client’s health literacy has positive implications for vaccine uptake and action toward healthier decision making. Cultural Competence of Service Providers On an interpersonal level, participants shared their challenges communicating with service providers and engagement with vaccine rollout programs due to a lack of cultural sensitivity and targeted interventions. There is evidence to show the impact of engagement and empowerment when health programs are designed with a critical health literacy lens that incorporate cultural safety and address language barriers [ 19 – 21 ]. This will help foster better patient satisfaction and positive relationships between ACB community members and service providers. On a community level participants expressed the need for targeted public health messages that are culturally informed which is a viable tool to re-engage ACB community members to get vaccinated. Mobilizing ACB-led organizations through peer support is an effective tool that can be used to empower ACB communities [ 7 , 23 ]. This strategy can help foster more social networks within the diverse ACB communities. On an institutional level, our participants shared the need to access appropriate services at local hospitals in Ottawa tailored to meet their needs. Low racial health literacy, lack of access to care and inequities in services are the reasons ACB have problems with vaccine uptake. These similar challenges were evident in a US study that examined the preparedness of African Americans and Latinos who also lacked access to care, social and economic resources, health and safety materials (i.e. protective personal equipment – PPE) and funding within the school system [ 19 ]. By prioritizing the needs and health disparities of ACB community members can help shift the negative perspectives some have of the healthcare system [ 8 ]. Governance and Leadership Opportunities A history of systemic and Anti-Black racism and the pathologizing of Black bodies, policies and practices within the healthcare system rarely support traditional practices leaving ACB members with a low level of agency [ 1 ]. To rebuild trust, collective action is needed by both service providers and healthcare institutions to first acknowledge the individual agency within ACB people as experts in themselves and ability to solve complex problems when granted access to appropriate resources. Additionally, providing opportunities for ACB community members to disseminate health-related information to their communities will address multiple barriers with communication and trust. In order for ACB communities to thrive in another pandemic, it is imperative for health systems to participate in meaningful community engagement. Using the health systems resilience framework supported by the World Health organization, community engagement is at the core, that impacts health service delivery, governance and financing, workforce, medical products and public health functions [ 19 , 22 – 25 ]. Our study participants shared these key elements of community engagement strategies in keeping with the framework to include engaging with ACB communities, building partnerships, tailoring messages to inform service delivery, policy and practice decisions and governance. Ensuring ACB community members are involved in policy decisions, hired to be key gatekeepers like primary care physicians, have access to health services and medication will help to improve their overall physical and mental health outcomes [ 19 , 22 – 25 ] Limitations of the Study There are limitations with the study. The focus group data had a significant percentage of African participants which may only showcase some of the unique ethnocultural experiences of members of African communities, as opposed to more diverse Caribbean and Black communities within the Ottawa and national capital regions. There is also an over-representation of females in the study which could also skew the data based on their unique gendered experiences. To address these issues, our study hosted a World Café with a diverse multicultural group of stakeholders to include ACB community members, researchers, students, policy makers, faculty members and research staff. Their feedback provided a breadth of innovative strategies to rebuild trust among ACB community members that have been integrated in our study results. Conclusion The present study illustrated the decay in public mistrust among ACB communities due to past and present systemic barriers within our healthcare system. Currently, there are limited Canadian studies focusing on solutions to restore public trust among Black and other racialized communities. Thus, more studies are needed from various racialized communities to provide more robust solutions for vaccine hesitancy. Our study explored key themes of agency and community resilience as key strategies to rebuild public trust among ACB community members by bridging knowledge-action gaps, improve cultural competence among service providers, and governance and leadership opportunities for ACB communities. These are key drivers to restoring public trust among ACB communities is possible and will require dismantling racism and other forms of discrimination to better prioritize the needs of this vulnerable group. This paradigm shift in our current public health system will require significant collaborative efforts between government agencies and ACB communities, proactive, accessible and culturally sensitive messaging, more ACB leaders in policy positions to re-establish a health structure that enables them to thrive and have better health outcomes. Declarations Author Contribution Conceptualization, JE, CD, EE.; methodology, SS.; formal analysis, JE, SS, AJ; investigation, JE, LM, SS..; writing—original draft preparation, AJ..; writing—review and editing, AJ, JE.; visualization, supervision, JE.; project administration, JE, SS, AJ..; funding acquisition, JE. All authors have read and agreed to the published version of the manuscript. Acknowledgement Dr. Etowa (corresponding author) would like to thank the ACB community members, authors, and community partners who made participated in this project. 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In: Leal Filho, W., Azul, A.M., Brandli, L., Özuyar, P.G., Wall, T. (eds) Quality Education. Husbands W, Etowa J, Oakes W, Omorodion F, Luginaah I, Etowa E, Ghose B, Wong JP. Advancing research for HIV prevention among African, Caribbean and Black men: Protocol for a multisite cross-sectional study in Ontario (weSpeak study). Medicine (Baltimore). 2021 May 7;100(18):e25662. doi: 10.1097/MD.0000000000025662 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4572095","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":328083875,"identity":"be46c118-aca0-41cd-9bc5-5de11969c698","order_by":0,"name":"Josephine Etowa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYBACxgYwIQEXkCNJC5htzMDADGYQoQ9KJTYQ0sLc3v7wceEOizx+BubjDz622aVvON5//MHPNjsG/vYD2C3oOWNsPPOMRLFkA1ti48y25NwNZw4zNva2JTNInEnArmVGDps0b5tE4oYDPIbNvNuYczfcSGZsADIYDBhwaUl//hukZf8B/o9ALfXpBkAtjX+31TMY8D/AoSXBjBlsCwMPI1DL4QSQFhCDwUAChy1Av0jPBGqZcZjNcObMf8cNZ545bDhb9t9xHokb2G0xBIbY58K2usT+9uYHHz6cqZbnO9744OObM9Vy/P3YbTFsAAY0mMWMJsODVT0QyGNRPApGwSgYBaMAFQAA9mNjItSPFBAAAAAASUVORK5CYII=","orcid":"","institution":"University of Ottawa","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Josephine","middleName":"","lastName":"Etowa","suffix":""},{"id":328083877,"identity":"f28a23cb-6db4-4289-9de1-3dfa468cd453","order_by":1,"name":"Amoy Jacques","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Amoy","middleName":"","lastName":"Jacques","suffix":""},{"id":328083880,"identity":"96e6cc0f-92bd-4acb-a662-427522dd0b7d","order_by":2,"name":"Dr. Luc Malemo","email":"","orcid":"","institution":"Ottawa Public Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"Dr.","firstName":"Luc","middleName":"","lastName":"Malemo","suffix":""},{"id":328083881,"identity":"7600db54-d3b7-44ff-a1c7-3d94e77e4550","order_by":3,"name":"Dr. Bishwajit Ghose","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"submittingAuthor":false,"prefix":"Dr.","firstName":"Bishwajit","middleName":"","lastName":"Ghose","suffix":""},{"id":328083882,"identity":"d8500924-0fd4-49e7-a8e7-1cf38fa92c16","order_by":4,"name":"Dr. Egbe Etowa","email":"","orcid":"","institution":"Toronto Metropolitan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"Dr.","firstName":"Egbe","middleName":"","lastName":"Etowa","suffix":""},{"id":328083883,"identity":"e87bf90b-81fa-4027-bff6-05ebc1cd92fa","order_by":5,"name":"Dr. Charles Dabone","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"submittingAuthor":false,"prefix":"Dr.","firstName":"Charles","middleName":"","lastName":"Dabone","suffix":""},{"id":328083884,"identity":"c811a0da-c637-4d41-9d36-3edcf2496818","order_by":6,"name":"Sylvia Sangwa","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sylvia","middleName":"","lastName":"Sangwa","suffix":""}],"badges":[],"createdAt":"2024-06-12 18:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4572095/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4572095/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12982-025-00520-x","type":"published","date":"2025-05-20T15:57:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60635086,"identity":"ae906993-cec9-44e0-99d5-8040818ae4b6","added_by":"auto","created_at":"2024-07-19 01:57:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":602383,"visible":true,"origin":"","legend":"\u003cp\u003eSocio-ecological model (SEM) adapted to the ACB community vaccine acceptance (AVA) developed by Dr. Josephine Etowa\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4572095/v1/f1b84d018363a6b5479cb4ab.png"},{"id":83460003,"identity":"07f7317d-0505-4d9c-a84d-ae7a6b2c13bc","added_by":"auto","created_at":"2025-05-26 16:08:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1367533,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4572095/v1/57af4d1f-57e9-4248-988b-b07c36c14315.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRestoring public trust in COVID-19 vaccine among Africans, Caribbean, and Black Canadians Community based participatory research (CBPR)\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePublic mistrust predates the COVID-19 pandemic and was further amplified with the rapidity of the COVID-19 immunization rollout in Canada. Public mistrust within health institutions is deeply rooted in anti-Black violence, racism, experimentation observed among African, Caribbean and Black Canadians (ACB) and other racial groups and a strong predictor for vaccine hesitancy (VH) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. VH is a common term that is currently used in the literature to capture the varying reasons for low uptake of COVID-19 vaccine among various populations. Nacimento et al defines it as\u003c/p\u003e \u003cp\u003eVH as existing on a continuum ranging between complete adherence and complete refusal due to doubts\u003c/p\u003e \u003cp\u003eor concerns within a heterogeneous group of individuals who may be influenced by a combination of cognitive, emotional, cultural, social, spiritual, and political factors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, p. 2]\u003c/p\u003e \u003cp\u003eThe key difference with VH during the COVID-19 pandemic was the rapidity of immunization roll-out across Canada and worldwide, politicization of vaccines among major pharmaceutical companies (i.e. Pfizer, Moderna, Astra Zeneca), and racial reckoning in the murders of George Floyd, Breanna Taylor, Ahmaud Ahbery and countless others. The collision of these highly political and racially tense events exacerbated vaccine hesitancy during the pandemic.\u003c/p\u003e \u003cp\u003eHigh income countries such as the United Kingdom, United States, United Arab Emirates (UAE) ran rapid vaccine rollout programs and encountered low uptake of COVID-19 vaccine among various minority groups (Black, Arabs, Asians, Hispanic/Latino and a small percentage of American Indians and Alaskan natives) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Challenges with vaccine hesitancy among minority groups do not stem from their innate vulnerabilities, instead the key drivers are socio-economic factors such as social status, access to social goods, housing, employment, and healthcare services [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Within the Canadian context, one key study found that vaccine hesitancy among Black Canadians primarily stemmed from \u0026ldquo;the denial of their rights and feeling that decisions were being made for members of the Black community and hesitancy related to medical distrust\u0026rdquo; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] (p. 9)\u003c/p\u003e \u003cp\u003eThe selection of the most effective vaccine companies, primarily between Pfizer and Moderna, became another source of vaccine hesitancy among minority groups. During the pandemic the World Health Organization recommended a vaccine with 70% effectiveness; Pfizer reported 90% effectiveness in preventing COVID-19, while Moderna reported 94.5% effectiveness [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Accompanying these reports were miscommunication lacking in cultural and linguistic approaches from both government and public health agencies on COVID-19 vaccine effectiveness [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, vaccine clinical trials experienced difficulty recruiting Black participants due to the historical dehumanisation and experimentation done withing Black communities, inflexible clinic hours, lack of translation services and transportation costs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe racial tensions during the pandemic that resulted from the murders of George Floyd and others reinforced systemic racism within our social justice, political and healthcare systems. There is a growing body of research to show the linkages between social determinants, COVID-19 infections and racialization. These social determinants places vulnerable ACB individuals a greater risk of disease and psychological stress (3, 5, 8). In Canada, heavy policing and social distancing rules were enforced on minority groups, particularly within Black communities reinforcing the mistrust within our social and health systems [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies have highlighted the impact of public mistrust among various racialized populations in Canada and its impact on vaccine uptake. One recent study coined the term vaccine mistrust ( a sub-theme of public mistrust used in reference to Black individuals) defined it as \u0026ldquo;a lack of confidence in the healthcare system, providers, treatments, and immunizations because of failure to them\u003csup\u003e\u0026rdquo;\u003c/sup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, p. 1]. The findings showed vaccine mistrust was highest among Black Canadians compared to other racialized groups such as Arab and Indigenous communities due to higher rates of racial discrimination in healthcare services and conspiracy theories [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Additionally, Black Francophones tend to have higher rates of vaccine mistrust compared to Black Anglophones due to language barrier impacting access to health services. Another report revealed 57% of ACB individuals were less likely to intend to be vaccinated compared to White individuals due to pre-existing chronic conditions, high level of COVID-19 risk perceptions, skepticism towards COVID-19 vaccination and difficulty identifying trusted sources of information [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Additional studies have also shown worse outcomes due to the COVID-19 virus for Black communities in both Canada and the US [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Large city hubs revealed that ACB people in Ottawa reported 37% of confirmed COVID-19 cases although they represent 7% of the population; while 33% of cases in Toronto although they represent 9% of the population. Additionally, the mortality rate for COVID-19 infection is 2.2 times higher in Black compared to White communities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Similarly in the US, COVID-19 hospitalization rates and death were higher among African Americans due to the linkages between economic factors and physical health [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the successful efforts of public health institutions across Canada to achieve high vaccination coverage, there is growing concern among government officials, public health leaders, and policy makers that more targeted approaches are needed to restore public trust with COVID-19 vaccines among racialized communities [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStudy Aim\u003c/h2\u003e \u003cp\u003eThe ACB Vaccine Acceptance study (AVA) led by the University of Ottawa and its partners, and funded by Public Health Agency of Canada (PHAC) collaborated to address the unique barriers, and lived experience of ACB communities due to low vaccine uptake. The study aimed to meaningfully engage with ACB community members and service providers to facilitate vaccine uptake and to strengthen communities\u0026rsquo; confidence in and acceptance of COVID-19 vaccines in Ottawa and the national capital region. Two main research questions were addressed during this study: How do ACB people understand their vulnerability to COVID-19 infection, especially in relation to vaccination? What are the individual, community and structural barriers/facilitators that promote vaccine uptake and access to inclusive services? This study utilizes the socio-ecological model (SEM) to explore the issues surrounding vaccine uptake including challenges, and provide community-driven evidence-based approaches to rebuild trust among ACB communities within Canadian healthcare institutions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eThis mixed method study used the socio-ecological model (SEM), intersectionality lens and the tenets of community-based participatory research (CBPR) to guide the research process including collect data from participants. The focus group discussions (FGDs) data set is the focus of this paper. The socio-ecological model (SEM) is a framework that has five interacting levels of health behaviour to help unravel complex societal issues [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Intersectionality lens helps to illuminate issues resulting from the interaction of factors such as gender, race, socioeconomic status, etc. to influence health outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. CBPR centers the ACB community at the core of the study to address their lived experiences with health inequity, embolden them to codesign the implementation of interventions, practices, and policy tools [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The eligibility criteria for participants were: self-identify as African, Caribbean or Black; be at least 16 years old; able to communicate in either English or French; reside in Ottawa and the National Capital Region. Participants were recruited using a peer-led approach from specific agencies such as Canadians of African Descent Health Organization (CADHO), South-East Ottawa Community Health Centre (SEOCHC), Ottawa Public Health (OPH), Somerset West Community Health Centre (SWCHC), Restore Medical Clinic, AIDS Committee of Ottawa (ACO), River Jordan Ministry, Men of Honor Ministry, African, Caribbean, and Black Community Wellness Resource Centre-Ottawa, International Pastors and Leaders Forum (IPLF). All focus group discussions (FGDs) used an interview guide, were held virtually via Zoom due to COVID-19 restrictions, audio-recorded, and transcribed verbatim. The sample size was 49 ACB community participants involved in the FGDs. The sample population comprised of service providers community workers (20), social workers (15), doctors (3), and nurses (3) and others (8) who were predominantly Black African (70%), mostly female (80%), age range was 35\u0026ndash;44 (33%), and held high school diploma (40%). Consenting participants answered interview questions about their knowledge, experiences and barriers to accessing COVID-19 vaccines. Sessions lasted for 60 minutes and a gift card of \u003cspan\u003e$\u003c/span\u003e30 was provided at the end. The study was approved by the University of Ottawa Research and Ethics Board (REB) (H-12-21-7558).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eWe used Braun \u0026amp; Clark (2006) \u0026lsquo;s six steps thematic analysis framework to make sense of the data and guide data interpretation (Braun \u0026amp; Clark, 2006). This process began with the development of a coding framework informed by questions from the interview guides and a systematic approach that involves the six steps: (1) familiarizing with the data; (2) generating initial codes; (3) developing a coding tree to guide the coding of transcripts; (4) identifying themes; (5) reviewing, defining and naming themes; 6) interpreting the narratives and stories; and (\u003csup\u003e7\u003c/sup\u003e) producing the report \u0026ndash; a concise, coherent, logical, and non-repetitive account supported by vivid examples. We used Nvivo computer software for data management and storage. A theme is a pattern in the information that describes and organizes the possible observations, or interpretations of phenomena identified in the data. This process involved participatory data analysis team meetings to review and discuss codes and preliminary themes generated by the data analysts. During these meetings we renamed codes and collapsed them under broader themes and sub-themes. Once the themes were obtained from the FGD data, the SEM was used to further categorize the themes and quotes into the five levels. This process was repeated as more transcripts were coded to ensure comprehensive interrogation and interpretation of the data until saturation was reached [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The participatory data analysis team meetings also helped clarify discrepancy, unexpected or unclear coding and to improve the level of abstraction of major themes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Trustworthiness of data was established using Lincoln and Guba (1985) qualitative research evaluation criteria; credibility, confirmability, dependability, transferability. Specific data validation strategies employed include external audit, member-checking and peer debriefing (14).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSix major themes were generated from our study findings, this paper will focus on one; agency and community resilience. Agency refers to \u0026ldquo;enabling people to command their own unique or tailored interventions to fit their own perceptions of need and their own circumstances, and to develop their own capabilities\u0026rdquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, p. 3]. Community resilience is defined in the literature as \u0026ldquo; an ongoing process of change and adaptation\u0026rdquo; and the \u0026ldquo;\u003cem\u003ecapability (or process) of a community adapting and functioning in the face of disturbance\u003c/em\u003e [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, p.7]. Together these two concepts refer to a theme that describes how ACB community collectively mobilized resources to handle the devasting COVID-19 pandemic circumstances. This theme had three sub-themes, which will be used to organize the results section below. These subthemes are: i) vaccine information, ii) cultural competence and safety, and iii) experts of their bodies and experiences.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Vaccine information\u003c/h2\u003e \u003cp\u003eAgency as it relates to vaccine information is described as having both an empowering and disempowering impact based on the accuracy of health messages provided to the public. In our study, participants expressed the positive impact accurate vaccine information had on their beliefs and ability to make an informed decision to become vaccinated. While, misinformation had the opposite effect creating more doubt in the vaccine rollout process.\u003c/p\u003e \u003cp\u003eOne participant shared,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI was concerned about the side effects, that was my main issue\u0026ndash; not side effects, but long-term effects. And until I spoke to a friend who works in labs and a scientist and kind of explained how the vaccine worked, then I was able to have a better sense and also when Health Canada started to publish more information on the vaccine, how they evaluate it and things like that. So at first it was kind of\u0026hellip; I was reluctant to take the vaccine because I was not sure of like the type of vaccine and there wasn\u0026rsquo;t that much information out there. But once information started to trickle down and then I felt more comfortable F4 FGD 5\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant shared:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think it\u0026rsquo;s very important for the healthcare to give us accurate information. Like right now they have stopped talking about giving\u0026hellip;, I think for me it is important. We have to know, it is the reality, this is what is going on. By you keeping quiet, people are dying in silence without us knowing. We are thinking that, oh, okay, now things are cooling down. Everything, you know, it\u0026rsquo;s because we don\u0026rsquo;t have that information. They have to give it to us F2 FGD 4\u003c/em\u003e \u003c/p\u003e \u003cp\u003eVaccine information that came from public health institutions changed rapidly over the course of COVID-19 rollout and participants shared their concerns about their trust in the healthcare system and the need for more transparency. This participant shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIn Ottawa at the beginning and even the World Health Organization, like people did not know and things kept changing. And people were like, well, can we trust them? Can we believe them? And so, just, yes, being more transparent and explaining, you know what, we don\u0026rsquo;t know, and it\u0026rsquo;s evolving and we will\u0026hellip; this is today, based on the information we have today this is the best course of action, type of thing. F6 FGD 5\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Cultural Competence and safety\u003c/h2\u003e \u003cp\u003eCultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency, or those professions to work effectively in cross-cultural settings and interactions\u0026rdquo; [17, slide 20]. Cultural safety is the transformative element of cultural competence that \u0026ldquo;involves the experience of the patient. It requires creating a healthcare environment that acknowledges and addresses power imbalances, ensuring it is free from racism and discrimination, thereby allowing individuals to feel secure when accessing health services\u0026rdquo; (17, slide 37). Our results showed cultural competence on a continuum spanning from interactions with service providers to changes needed within health organizations. First, participants shared strategies for service providers to engage and empower ACB participants with health literacy on COVID-19 vaccines with compassion, and utilize culturally safe approaches. One participant shared this unique quality about the Black community:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eBlack people we are different. We don\u0026rsquo;t like to be rushed, and we don\u0026rsquo;t like somebody to come and just interfere like that. So, you have to kind of be friendly and introduce yourself and tell them we are here to talk about the COVID, we are here to talk about the vaccine. And talk them on\u0026hellip; don\u0026rsquo;t laugh them when you talk F1 FGD 4\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSecond, the Black community is comprised of very diverse communities enmeshed within dominant cultures. Thus, it is imperative that communication messages be culturally specific depending on the group being targeted. Several participants shared key strategies that were used in the ACB community from various perspectives within the community. Outlined in the quotes below are examples from the Ghanian, Congolese and Caribbean communities. It is important to note that each of these strategies may not be limited to that particular group alone.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategies suggested by Ghanaian participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrategies suggested by Congolese participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrategies suggested by Caribbean participants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYeah, I think that you have to target to identify African groups, African organizations. We have for example, we are very soon, summer is coming, we have many outdoor events. And that\u0026rsquo;s our period to, we have people from Ghana, meetings for, meeting somewhere, from Uganda, meeting somewhere. You have to identify those groups and now try to be in touch with them and see if we can give them more information about the vaccine. M3 FGD 4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eEach country has got his own community. Where there is some, preferably, like I\u0026rsquo;m Congolese, there is a community for Congolese here in Ontario. So if they go through those organizations, they will get a lot of people because those people will be connected with their communities. M3 FGD 4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eBut we have Caribbean radio station in the country, in Ottawa, go to a Caribbean radio station, get the word out there. We have the multicultural station right on the market. They would love to accommodate people with multicultural things, to go and talk about all of these things. So, somebody have to go and you know, talk to those people and come on the air and spread the word. You know because lots of people from all walks of life listen to that Caribbean station. They have on Saturdays one in the morning, one in the evening, one at night. So you can go there and reach the community who listen to that Caribbean station. F3 FGD 5\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLastly, there is a need for culturally competent and safe programs within our healthcare system that target the improvement of Black health outcomes. This participant shared \u0026ldquo;they \u003cem\u003eshould support the initiative that is really targeting this population. Healthcare, whatever the system is, this\u0026hellip; [ Institution name] should be able to support any Black clinics or programs that would target that population of BlacksF3 FGD 2\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Experts of their bodies and experiences\u003c/h2\u003e \u003cp\u003e The theme of agency was amplified in this sub-theme of ACB participants acknowledging their expertise in themselves and lived experiences. One participant expressed that agency for ACB participants need to have this foundational element within health service delivery, communication, and policy development\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThis is an African reality and I believe that we have knowledge that Westerners, unfortunately, do not have, but as they are the ones who have the infused science, they always tend to simply ignore it. Then, I believe that medicine, research would have a lot to gain by getting closer to our traditions.\u0026rdquo; M FGD 6\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study has shown the challenges for increased mistrust within the ACB population due to historical mistreatment, and anti-Black racist programs and policies. Considering these atrocities, ACB populations have remained resilient as a means of survival for their families and the next generation with limited resources and support from public health institutions. Our results have added to the literature by providing strategic ways agency can be better integrated within vaccination and other health-related programs to build trust among ACB populations across Canda. As evident in the results, agency and community resilience have been identified as resources to strengthen ACB voices in health care. According to Shankar et al, the approach to agency within health interventions was often missing the individual component. This approach to agency [advances] \u0026ldquo;human resource capacity at the most basic level, through shifting individual mindsets, to cultivate resilient people and communities that can adapt to diverse and changing environments\u0026rdquo; [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, p.165]. Thus, health interventions should adopt an agency-based framework to build individual and collective capacity of the participants and improve health outcomes. The agency-based framework takes into consideration four key components: 1) an individual\u0026rsquo;s culture, context, and local population, 2) safe spaces for reflection and identification, 3) connecting goals with resources, and 4) building agency-based interventions within networks [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Additionally, community resilience is also part of the continuum of agency and has similar components described in the literature as: local knowledge, social network, communication, health, governance/leadership, resources, economic investment, preparedness, and economic outlook [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, while many studies have focused on the social determinants that have been exacerbated during the pandemic among racialized groups, our study adds to the literature by providing key strategies to amplify the ACB community\u0026rsquo;s voice as an agent to rebuild trust in our healthcare system Agency and community resilience can be used as approaches to rebuild public trust among ACB community members on an individual, interpersonal and structural levels.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBridging the Knowledge Gap\u003c/h2\u003e \u003cp\u003eSince the pandemic, there has been a burgeoning body of literature showing the local, national and global impacts on people\u0026rsquo;s lives particularly those populations that have been rendered vulnerable due to social, political and economic determinants. Public health institutions worldwide faced immense challenges in equitable, vaccine distribution, human and economic resources further weaking an already overtaxed system [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our study that was conducted in the nation\u0026rsquo;s capital of Ottawa is booming with immigrants from diverse places, particularly those from the ACB communities. Utilizing the health systems resilience conceptual framework, we integrated the complex challenges with low vaccine uptake among ACB communities within the SEM (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). On an individual level, ACB participants held varying knowledge, risk perspectives and attitudes about COVID-19 vaccine effectiveness. For participants who received accurate information from a trusted source were more likely to get vaccinated compared to those who were misinformed. This aligned well with other studies that found individuals who received vaccine information from healthcare providers had a positive attitude towards the vaccine [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, bridging the knowledge gap with the intent to build an ACB client\u0026rsquo;s health literacy has positive implications for vaccine uptake and action toward healthier decision making.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCultural Competence of Service Providers\u003c/h2\u003e \u003cp\u003eOn an interpersonal level, participants shared their challenges communicating with service providers and engagement with vaccine rollout programs due to a lack of cultural sensitivity and targeted interventions. There is evidence to show the impact of engagement and empowerment when health programs are designed with a critical health literacy lens that incorporate cultural safety and address language barriers [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This will help foster better patient satisfaction and positive relationships between ACB community members and service providers. On a community level participants expressed the need for targeted public health messages that are culturally informed which is a viable tool to re-engage ACB community members to get vaccinated. Mobilizing ACB-led organizations through peer support is an effective tool that can be used to empower ACB communities [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This strategy can help foster more social networks within the diverse ACB communities. On an institutional level, our participants shared the need to access appropriate services at local hospitals in Ottawa tailored to meet their needs. Low racial health literacy, lack of access to care and inequities in services are the reasons ACB have problems with vaccine uptake. These similar challenges were evident in a US study that examined the preparedness of African Americans and Latinos who also lacked access to care, social and economic resources, health and safety materials (i.e. protective personal equipment \u0026ndash; PPE) and funding within the school system [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. By prioritizing the needs and health disparities of ACB community members can help shift the negative perspectives some have of the healthcare system [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eGovernance and Leadership Opportunities\u003c/h2\u003e \u003cp\u003eA history of systemic and Anti-Black racism and the pathologizing of Black bodies, policies and practices within the healthcare system rarely support traditional practices leaving ACB members with a low level of agency [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To rebuild trust, collective action is needed by both service providers and healthcare institutions to first acknowledge the individual agency within ACB people as experts in themselves and ability to solve complex problems when granted access to appropriate resources. Additionally, providing opportunities for ACB community members to disseminate health-related information to their communities will address multiple barriers with communication and trust. In order for ACB communities to thrive in another pandemic, it is imperative for health systems to participate in meaningful community engagement. Using the health systems resilience framework supported by the World Health organization, community engagement is at the core, that impacts health service delivery, governance and financing, workforce, medical products and public health functions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Our study participants shared these key elements of community engagement strategies in keeping with the framework to include engaging with ACB communities, building partnerships, tailoring messages to inform service delivery, policy and practice decisions and governance. Ensuring ACB community members are involved in policy decisions, hired to be key gatekeepers like primary care physicians, have access to health services and medication will help to improve their overall physical and mental health outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the Study\u003c/h2\u003e \u003cp\u003eThere are limitations with the study. The focus group data had a significant percentage of African participants which may only showcase some of the unique ethnocultural experiences of members of African communities, as opposed to more diverse Caribbean and Black communities within the Ottawa and national capital regions. There is also an over-representation of females in the study which could also skew the data based on their unique gendered experiences. To address these issues, our study hosted a World Caf\u0026eacute; with a diverse multicultural group of stakeholders to include ACB community members, researchers, students, policy makers, faculty members and research staff. Their feedback provided a breadth of innovative strategies to rebuild trust among ACB community members that have been integrated in our study results.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study illustrated the decay in public mistrust among ACB communities due to past and present systemic barriers within our healthcare system. Currently, there are limited Canadian studies focusing on solutions to restore public trust among Black and other racialized communities. Thus, more studies are needed from various racialized communities to provide more robust solutions for vaccine hesitancy. Our study explored key themes of agency and community resilience as key strategies to rebuild public trust among ACB community members by bridging knowledge-action gaps, improve cultural competence among service providers, and governance and leadership opportunities for ACB communities. These are key drivers to restoring public trust among ACB communities is possible and will require dismantling racism and other forms of discrimination to better prioritize the needs of this vulnerable group. This paradigm shift in our current public health system will require significant collaborative efforts between government agencies and ACB communities, proactive, accessible and culturally sensitive messaging, more ACB leaders in policy positions to re-establish a health structure that enables them to thrive and have better health outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualization, JE, CD, EE.; methodology, SS.; formal analysis, JE, SS, AJ; investigation, JE, LM, SS..; writing\u0026mdash;original draft preparation, AJ..; writing\u0026mdash;review and editing, AJ, JE.; visualization, supervision, JE.; project administration, JE, SS, AJ..; funding acquisition, JE. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eDr. Etowa (corresponding author) would like to thank the ACB community members, authors, and community partners who made participated in this project.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData is provided within the manuscript\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\n\u003cli\u003eKrystal Batelaan . \u0026lsquo;It\u0026rsquo;s not the science we distrust; it\u0026rsquo;s the scientists\u0026rsquo;: Reframing the anti-vaccination movement within Black communities. Global Public Health. 2022. 17:6, 1099-1112, DOI: 10.1080/17441692.2021.1912809\u003c/li\u003e\n\u003cli\u003eChoi, Y., and Fox, A,M. Mistrust in public health institutions is a stronger predictor of vaccine hesitancy and uptake than Trust in Trump. 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Conceptual and design thinking for thematic analysis. \u003cem\u003eQualitative Psychology. \u003c/em\u003e2022\u003cem\u003e 9\u003c/em\u003e(1), 3\u0026ndash;26. https://doi.org/10.1037/qup0000196\u003c/li\u003e\n\u003cli\u003eCreswell, J. W., \u0026amp; Poth, C. N. (2018). \u003cem\u003eQualitative inquiry \u0026amp; research design: Choosing among five approaches\u003c/em\u003e (Fourth edition.). SAGE.\u003c/li\u003e\n\u003cli\u003ePage-Reeves J, Davis S, Romero C, Chrisp E. Understanding \u0026quot;agency\u0026quot; in the translation of a health promotion program. Prev Sci. 2015 Jan;16(1):11-20. doi: 10.1007/s11121-013-0433-3. PMID: 23963625; PMCID: PMC4844179.\u003c/li\u003e\n\u003cli\u003ePatel SS, Rogers MB, Aml\u0026ocirc;t R, Rubin GJ. What Do We Mean by \u0026lsquo;Community Resilience\u0026rsquo;? A Systematic Literature Review of How It Is Defined in the Literature. PLOS Currents Disasters. 2017 Feb 1 . Edition1. doi: 0.1371/currents.dis.db775aff25efc5ac4f0660ad9c9f7db2\u003c/li\u003e\n\u003cli\u003eEtowa, J. Cultural Competence and Safety \u0026ndash; Organizational and Individual Levels; 2024. [updated April 2, 2024; cited April 9, 2024]. Available from: https://co-creath.com/tm/Module%205%20-%20Cultural%20Competence%20and%20Safety/story.html\u003c/li\u003e\n\u003cli\u003eShankar, A, Sundar, S, and Smith, G. Agency-based Empowerment Interventions: Efforts to Enhance Decision-Making and Action in Health and Development. Journal of Behavioural Health Services and Research. 2018. 164-176. DOI: 10.1007/s11414-018-9592-0\u003c/li\u003e\n\u003cli\u003eHaldane, V., De Foo, C., Abdalla, S.M. \u003cem\u003eet al.\u003c/em\u003e Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. \u003cem\u003eNat Med\u003c/em\u003e\u003cstrong\u003e27\u003c/strong\u003e, 964\u0026ndash;980 (2021). https://doi.org/10.1038/s41591-021-01381-y\u003c/li\u003e\n\u003cli\u003eJennifer Cunningham-Erves, Imari Parham, Leah Alexander, Jamal Moss, Iman Barre, Taneisha Gillyard, Jamaine Davis. African Americans and the COVID-19 pandemic: A qualitative inquiry of preparedness, challenges, and strategies on how we can move forward. Social Science \u0026amp; Medicine. 2022. Volume 307, https://doi.org/10.1016/j.socscimed.2022.115185.\u003c/li\u003e\n\u003cli\u003eAl-Jayyousi, G.F.; Sherbash, M.A.M.; Ali, L.A.M.; El-Heneidy, A.; Alhussaini, N.W.Z.; Elhassan, M.E.A.; Nazzal, M.A. Factors Influencing Public Attitudes towards COVID-19 Vaccination: A Scoping Review Informed by the Socio-Ecological Model. Vaccines. \u003cstrong\u003e2021\u003c/strong\u003e, 9, 548. https://doi.org/10.3390/vaccines9060548\u003c/li\u003e\n\u003cli\u003eEtowa, J., Tharao, W., Mbuagbaw, L. \u003cem\u003eet al.\u003c/em\u003e Community perspectives on addressing and responding to HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) among African, Caribbean and Black (ACB) people in Ontario, Canada. \u003cem\u003eBMC Public Health. \u003c/em\u003e2022. \u003cstrong\u003e22\u003c/strong\u003e, 913. https://doi.org/10.1186/s12889-022-13093-0 \u003c/li\u003e\n\u003cli\u003eAl Shamsi H, Almutairi AG, Al Mashrafi S, Al KT. (2020). Implications of language barriers for healthcare: a systematic review.\u003cem\u003e Oman Med J\u003c/em\u003e.;35(2):e122. https://doi.org/10.5001/omj.2020.40\u003c/li\u003e\n\u003cli\u003eJoseph, C., Said, R. Community-Based Education: A Participatory Approach to Achieve the Sustainable Development Goal. 2020. In: Leal Filho, W., Azul, A.M., Brandli, L., \u0026Ouml;zuyar, P.G., Wall, T. (eds) Quality Education.\u003c/li\u003e\n\u003cli\u003eHusbands W, Etowa J, Oakes W, Omorodion F, Luginaah I, Etowa E, Ghose B, Wong JP. Advancing research for HIV prevention among African, Caribbean and Black men: Protocol for a multisite cross-sectional study in Ontario (weSpeak study). Medicine (Baltimore). 2021 May 7;100(18):e25662. doi: 10.1097/MD.0000000000025662\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Agency, Community resilience, low COVID-19 vaccine uptake, public health mistrust, ACB people, socio-ecological model lens, Community based participatory Research (CBPR), SEM, Intersectionality lens","lastPublishedDoi":"10.21203/rs.3.rs-4572095/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4572095/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic had a significant global impact predominantly among Africans, Caribbean and Black (ACB) Canadians. ACB people experienced higher infection and recovery rates, greater health risks, and access to care. Public mistrust, due to anti-Black racism and historical trauma contributed to low vaccine uptake among ACB populations. Our study examined multi-level and intersectional issues impacting vaccine uptake and acceptance in Ottawa. This paper will focus on the themes of agency and community resilience.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A mixed methods research (MMR) approach guided this study using the socio-ecological model (SEM), intersectionality lens, and community-based participatory research principles to generate the qualitative results. The sample included 49 ACB participants involved in focus group discussions (FGDs). The sample population included service providers (20), social workers (15), doctors (3), and nurses (3) and others (8) who were predominantly Black African (70%), mostly female (80%), age range was 35\u0026ndash;44 (33%) with high school diplomas (40%). Data were recorded digitally, transcribed verbatim, analyzed inductively. Data analysis methods were thematic analysis including inductive coding using NVivo software and rigor methods were member-checking and external audits. Ethical approval retrieved from affiliated institutions and measures taken to ensure trustworthiness of data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur data showed rebuilding public trust is possible by bridging knowledge gaps on vaccine information, increasing service providers\u0026rsquo; cultural competence capacity, and providing governance/leadership opportunities for ACB communities.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRestoring public trust will require dismantling racism by prioritizing ACB community\u0026rsquo; needs, proactive and accessible culturally appropriate messages, and opportunities to develop policies to improve health outcomes.\u003c/p\u003e","manuscriptTitle":"Restoring public trust in COVID-19 vaccine among Africans, Caribbean, and Black Canadians Community based participatory research (CBPR)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-19 01:57:50","doi":"10.21203/rs.3.rs-4572095/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-11T15:05:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-11T06:00:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2024-10-08T11:38:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301145045672899419124174082967354853759","date":"2024-07-24T11:29:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-22T00:10:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305650125987381366365958115966062830079","date":"2024-07-12T08:12:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233416319990883801026077423643781934857","date":"2024-07-06T12:18:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-27T09:18:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-26T10:35:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-26T10:01:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2024-06-12T18:42:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8d4cec2d-0b51-4e4f-a87b-13203d46e993","owner":[],"postedDate":"July 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:00:50+00:00","versionOfRecord":{"articleIdentity":"rs-4572095","link":"https://doi.org/10.1186/s12982-025-00520-x","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2025-05-20 15:57:27","publishedOnDateReadable":"May 20th, 2025"},"versionCreatedAt":"2024-07-19 01:57:50","video":"","vorDoi":"10.1186/s12982-025-00520-x","vorDoiUrl":"https://doi.org/10.1186/s12982-025-00520-x","workflowStages":[]},"version":"v1","identity":"rs-4572095","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4572095","identity":"rs-4572095","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}