Applied Science, Faculty of
Nursing, School of
DSpace
UBCV
Pacis, Jefferson
Master of Science in Nursing - MSN
University of British Columbia
This thesis investigates barriers and facilitators to preventative mpox vaccination among underrepresented gay, bisexual, transgender people, and other men who have sex with men in and around Vancouver, British Columbia, as part of a larger inter-provincial mixed-methods study funded by the Canadian Institutes of Health Research. Using Interpretive Description and Reflexive Thematic Analysis, this qualitative strand foregrounds the lived experiences of participants (n=14) who are racialised, transgender, sex working, or living with HIV. Findings show that vaccine engagement was shaped by the interplay of stigma and trust, where stigma eroded confidence in health systems, yet affirming care, trust, and resilience enabled uptake. Community networks and grassroots-oriented outreach functioned as stabilising forces that countered inequitable conditions. However, mpox-related communications inadvertently reinforced stigma and exclusion. Despite these barriers, participants reframed vaccination as a form of solidarity, turning vulnerability into strength through collective action and peer support. The subsequent application of the Health Stigma and Discrimination Framework highlighted multi-level drivers, manifestations, and outcomes of stigma, while the heuristic use of the kite metaphor offered ways of visualising the complex dynamics of agency and constraint in public health engagement across socio-ecological levels. This study advances health equity scholarship by amplifying underrepresented perspectives and demonstrating that vaccine uptake reflects both systemic inequities and community strength. It calls for stigma-sensitive communication, affirming care, and sustained investment in community-led initiatives as structural imperatives for public health.
TETHERED FLIGHT: WEATHERING AGENCY AND CONSTRAINT IN MPOX VACCINATION AMONG UNDERREPRESENTED GAY, BISEXUAL, TRANS, AND OTHER MEN WHO HAVE SEX WITH MEN THROUGH INTERPRETIVE DESCRIPTION by Jefferson Pacis BScN, British Columbia Institute of Technology, 2020 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2025 © Jefferson Pacis, 2025ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis entitled: TETHERED FLIGHT: WEATHERING AGENCY AND CONSTRAINT IN MPOX VACCINATION AMONG UNDERREPRESENTED GAY, BISEXUAL, TRANS, AND OTHER MEN WHO HAVE SEX WITH MEN THROUGH INTERPRETIVE DESCRIPTION submitted by Jefferson Pacis in partial fulfillment of the requirements for the degree of Master of Science in Nursing in Nursing Examining Committee: Dr. Elizabeth Saewyc, School of Nursing, UBC Vancouver Supervisor Dr. Devon Greyson, School of Population and Public Health, UBC Vancouver Co-supervisor Dr. Vicky Bungay, School of Nursing, UBC Vancouver Supervisory Committee Member iii Abstract This thesis investigates barriers and facilitators to preventative mpox vaccination among underrepresented gay, bisexual, transgender people, and other men who have sex with men in and around Vancouver, British Columbia, as part of a larger inter-provincial mixed-methods study funded by the Canadian Institutes of Health Research. Using Interpretive Description and Reflexive Thematic Analysis, this qualitative strand foregrounds the lived experiences of participants (n=14) who are racialised, transgender, sex working, or living with HIV. Findings show that vaccine engagement was shaped by the interplay of stigma and trust, where stigma eroded confidence in health systems, yet affirming care, trust, and resilience enabled uptake. Community networks and grassroots-oriented outreach functioned as stabilising forces that countered inequitable conditions. However, mpox-related communications inadvertently reinforced stigma and exclusion. Despite these barriers, participants reframed vaccination as a form of solidarity, turning vulnerability into strength through collective action and peer support. The subsequent application of the Health Stigma and Discrimination Framework highlighted multi-level drivers, manifestations, and outcomes of stigma, while the heuristic use of the kite metaphor offered ways of visualising the complex dynamics of agency and constraint in public health engagement across socio-ecological levels. This study advances health equity scholarship by amplifying underrepresented perspectives and demonstrating that vaccine uptake reflects both systemic inequities and community strength. It calls for stigma-sensitive communication, affirming care, and sustained investment in community-led initiatives as structural imperatives for public health. iv Lay Summary The mpox (formerly called “monkeypox”) outbreak in Canada exposed significant gaps in vaccine access for men who have sex with men and related communities, especially those who are racialised, trans, living with HIV, or engaged in sex work. This thesis analyses the experiences of people in and around Vancouver who were eligible for the mpox vaccine in the 2022–2023 outbreak. Through interviews, the study examined why some received the vaccine while others did not. Participants described exclusion and caution toward the healthcare system, shaped by both past experiences and institutional responses that deepened stigma during the outbreak. At the same time, many found support through trusted providers, community organisations, and peer-led outreach. The findings show that improving vaccine access and uptake requires listening to those most affected and building public health initiatives that are equity-centred, stigma-sensitive, and rooted in trust. v Preface This thesis is the original, unpublished work of the author, Jefferson Pacis, completed under the supervision of Dr. Elizabeth Saewyc, Dr. Devon Greyson, and Dr. Vicky Bungay. The research forms part of a larger mixed-methods study funded by the Canadian Institutes of Health Research and the Canadian Immunization Research Network, which examined mpox vaccine communication strategies targeting gay, bisexual, trans, and other men who have sex with men communities across British Columbia, Ontario, and Quebec. The broader project emphasised the inclusion of underserved groups, including people living with HIV, transgender individuals, and sex workers. This thesis presents a primary qualitative analysis focused on the British Columbia component, drawing on in-depth interviews within the key populations eligible for preventative mpox vaccination. The interpretive process was supported by ongoing consultation with the supervisory committee. The author completed all writing and revisions in accordance with committee feedback. The research team obtained ethical approval for the overarching study from the UBC Behavioural Research Ethics Board (Ref#: H23-00897) and submitted a separate application for this thesis (Ref#: H24-00889) in accordance with the University of British Columbia’s guidelines for the primary use of research data. Generative artificial intelligence was not used at any stage of this thesis. Content Note on Explicit Language & Terminology This thesis includes direct quotations from participants containing explicit, stigmatising, or distressing language related to sexuality, gender identity, and health. These terms have been preserved verbatim to honour the authenticity and emotional resonance of participants’ narratives. Their inclusion is intentional and ethically framed to reflect lived experiences of vi marginalisation, and readers are advised accordingly. In addition, I use the epidemiological term gay, bisexual, trans, and other men who have sex with men and associated identities to generally reflect the language adopted in public health messaging during the 2022–23 mpox outbreak. While this terminology shaped the conditions of participation and recruitment during the outbreak, I employ it here critically, aware of its limitations in flattening sexual and gender diversity. The “+” acknowledges both the contested and expansive nature of the category, extending to those made visible through public health classification rather than self-identification. This positioning reflects intersectional critiques that caution against framing identities as fixed or monolithic, thereby highlighting their relational and interlocking character. vii Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface ............................................................................................................................................ v Table of Contents ........................................................................................................................ vii List of Abbreviations .................................................................................................................... x Acknowledgements ..................................................................................................................... xii Dedication ................................................................................................................................... xiv Chapter 1: Introduction ............................................................................................................... 1 1.1 Overview ............................................................................................................................... 1 1.1.1 Mpox in Global Context ................................................................................................. 2 1.1.2 Mpox in Canada ............................................................................................................. 3 1.2 Problem Statement ................................................................................................................ 5 1.3 Purpose of Study ................................................................................................................... 6 1.4 Research Questions ............................................................................................................... 7 1.5 Significance of the Study ...................................................................................................... 7 Chapter 2: Literature Review ...................................................................................................... 9 2.1 Overview ............................................................................................................................... 9 2.2 Search Strategy ...................................................................................................................... 9 2.3 Barriers to and Facilitators of Vaccination ......................................................................... 11 2.4 Stigma, Discrimination, and Structural Marginalisation ..................................................... 13 2.5 IBPOC, Trans, Sex Workers, and PLWH in Mpox Research and Care ............................. 16 2.6 Literature Gaps and Justification......................................................................................... 18 Chapter 3: Research Methods ................................................................................................... 20 3.1 Overview ............................................................................................................................. 20 3.2 Methodological Framework: Interpretive Description ........................................................ 20 3.3 Analytical Approach: Reflexive Thematic Analysis ........................................................... 22 3.4 Theoretical Lens: Health Stigma and Discrimination Framework..................................... 24 3.5 Study Context ...................................................................................................................... 25 3.6 Participant Recruitment ....................................................................................................... 26 3.7 Data Collection .................................................................................................................... 29 3.7.1 Transcription and Verification .................................................................................... 31 viii 3.8 Data Analysis Process ......................................................................................................... 32 3.9 Ethical Considerations......................................................................................................... 34 3.10 Researcher Positionality and Reflexivity .......................................................................... 35 3.11 Knowledge Translation ..................................................................................................... 37 Chapter 4: Findings .................................................................................................................... 40 4.1 Overview ............................................................................................................................. 40 4.2 Sample Population............................................................................................................... 41 4.3 Eroded Trust: Systemic Neglect and Social Apathy ........................................................... 42 4.4 Building Trust: Confidence, Collective Action, and Care Ethics ....................................... 45 4.4.1 Positive Attitudes Towards Mpox Vaccination ............................................................. 46 4.4.2 Community’s Proactive & Justice-Oriented Approach to Health Decision-Making ... 49 4.5 Facilitating Uptake: Agency, Networks, & Grassroots Outreach ....................................... 52 4.5.1 Individual and Grassroots Motivators Bolstering Vaccine Uptake ............................. 52 4.5.2 Peer Influence & Community-Informed Outreach Supporting Vaccine Uptake .......... 57 4.6 Deterring Uptake: Constraints, Confusion, & Harm ........................................................... 62 4.6.1 Psychosocial Deterrents Impeding Vaccine Uptake .................................................... 63 4.6.2 Structural & Communication Deterrents Disrupting Vaccine Uptake ........................ 68 4.7 Stigma and Strength: Navigating Risk and Resistance ....................................................... 74 4.7.1 Stigma as Turbulence: Impacting Race, Occupation, Health, & Community .............. 74 4.7.2 Stigma Destabilised by Resistance and Resilience ....................................................... 83 4.8 Tracing the Wind: Synthesis of Findings Through the Kite Metaphor ............................... 87 4.8.1 Tracing the Metaphor’s Conceptual Origin ................................................................. 87 Chapter 5: Discussion ................................................................................................................. 91 5.1 Overview ............................................................................................................................. 91 5.2 Navigating Winds of Trust and Erosion .............................................................................. 93 5.2.3 Micro-Level Navigation ................................................................................................ 93 5.2.2 Meso-level Navigation .................................................................................................. 94 5.2.1 Macro-level Navigation ................................................................................................ 97 5.3 Weathering Winds of Uptake and Constraint ..................................................................... 99 5.3.1 Micro-level Weathering ................................................................................................ 99 5.3.2 Meso-level Weathering ............................................................................................... 101 5.3.3 Macro-level Weathering ............................................................................................. 102 ix 5.4 The Tethered Flight as Relational Analytic ...................................................................... 105 5.5 Implications for Public Health Practice & Policy ............................................................. 107 5.6 Recommendations for Future Research ............................................................................ 109 5.7 Reflexivity & Positionality ............................................................................................... 111 5.8 Limitations ........................................................................................................................ 112 Chapter 6: Conclusion .............................................................................................................. 114 References .................................................................................................................................. 116 Appendix A: Tethered Flight: Agency and Constraint in Public Health Engagement ...... 127 x List of Abbreviations 2S/LGBTQIA+: Two-Spirit and lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, and other identities AIDS: Acquired Immunodeficiency Syndrome BC: British Columbia BCCDC: British Columbia Centre for Disease Control and Prevention CBRC: Community-Based Research Centre CDC: Centers for Disease Control and Prevention CIHR: Canadian Institutes of Health Research CINAHL: Cumulative Index to Nursing and Allied Health Literature GBTMSM+: Gay, Bisexual, Trans, and Other Men who have Sex with Men GTA: Greater Toronto Area HIM: Health Initiatives for Men HSDF: Health Stigma and Discrimination Framework HIV: Human Immunodeficiency Virus ICD: International Classification of Diseases ID: Interpretive Description JSTOR: Journal Storage KFF: Kaiser Family Foundation KTE: Knowledge Translation and Exchange MSM+: Men who have Sex with Men and other identities NACI: National Advisory Committee on Immunization ON: Ontario xi PAHO: Pan American Health Organization PEP: Post-Exposure Prophylaxis PHAC: Public Health Agency of Canada PLWH: People Living with HIV PrEP: Pre-Exposure Prophylaxis QC: Quebec RTA: Reflexive Thematic Analysis STBBI: Sexually Transmitted and Blood-Borne Infections STI: Sexually Transmitted Infection TCBC: Trans Care BC WHO: World Health Organization xii Acknowledgements This thesis would not have been possible without the guidance, support, and care of many individuals and communities. I am deeply grateful to my supervisory committee: Dr. Elizabeth Saewyc, Dr. Devon Greyson, and Dr. Vicky Bungay. Each of you brought invaluable insight, rigour, and encouragement to this work. Your shared commitment to equity, ethics, and community-engaged research has not only shaped the direction of this thesis, but also the researcher I am becoming. The way you brought your distinct expertise into dialogue, collaborating with generosity, intellectual curiosity, and mutual respect, was both grounding and inspiring. I thank you for your mentorship, your critical reflections, and the collective care you extended throughout this journey. Special thanks to Gerry Goh and Caroline Mniszak from the Greyson Lab team, whose guidance and coordination during participant recruitment and data collection were essential to the success of this research. And to our community partners, HIM, Ribbon Community, and TCBC, thank you for your collaboration and for serving as trusted hubs in carrying out this crucial research. I am also profoundly grateful to the Canadian Institutes of Health Research and the Canadian Immunization Research Network, whose support for the broader mpox project made this thesis possible. Their investment in this work created the conditions for inquiry, collaboration, and reflection that shaped this research. To my partner, Fernando, your steadfast love and faith in me kept me grounded through the most challenging moments of this journey. To my mom and grandparents, your sacrifices, strength, and unwavering support are the foundation upon which this work stands, I am forever grateful. To my brother, Jayson, and best friend, Marc: this is for you, too. xiii To my chosen family in the 2S/LGBTQIA+ community and to our allies, your support, fierceness, and everyday acts of resistance continue to inspire me. To the participants who generously shared their time, stories, and truth: I am deeply thankful. Your lived realities and textured experiences are the heart of this thesis. xiv Dedication To those who continue to live, love, and resist at the margins, this work is for you. To those, like me, who entered research without a traditional background and questioned whether their voice belonged: know that it does. I grew up in the remote mountains of the northern Philippines, never imagining that one day I would walk such a privileged path. Those beginnings continue to ground me and drive me forward. May this work stand as a reminder that knowledge arises from many origins and forms, and that gratitude, when paired with care rooted in lived experience, holds the power to transform. I honour my roots by closing this dedication in my native tongue, Ilocano: aglaplapusana ken pudpudno nga panagyaman, panangirambak, ken kinaragsak iti marikriknak para kadaguiti pamilyak, gagayyem, ken kakailyan!1 Chapter 1: Introduction 1.1 Overview The unprecedented mpox outbreak in 2022 and 2023 not only crossed intercontinental borders, but also generated valuable data that offered critical insights into emergency response tactics and equity in global public health. For decades, mpox (previously referred to as monkeypox) has remained endemic in several West and Central African countries, where it posed a recurrent but geographically contained public health threat (Gilbert et al., 2023). However, a significant global shift began in May 2022, when the mpox virus rapidly transcended its historical boundaries and spread to over 100 non-endemic countries, including Canada (World Health Organization [WHO], 2025). This swift and widespread transmission challenged long-standing assumptions about zoonotic containment and exposed critical gaps in global and national preparedness systems (Zumla et al., 2024). The outbreak disproportionately impacted key populations, particularly gay, bisexual, transgender folks, other men who have sex with men, and adjacent identities (GBTMSM+), those living with Human Immunodeficiency Virus (HIV), and sex workers who may face occupational exposure (PHAC, 2025b). Contrary to common belief in non-endemic countries, mpox is not classified solely as a sexually transmitted infection (STI); transmission can also occur through close contact with infected humans or animals, respiratory droplets, and contaminated objects or fomites (WHO, 2023b). While the GBTMSM+ population is disproportionately affected by the mpox outbreak, its spread further extends beyond this key group as it can also be transmitted via transplacental transmission in pregnant people (Centers for Disease Control and Prevention [CDC], 2023; Thornhill et al., 2023). In turn, pregnant individuals may face an increased risk of the debilitating 2 repercussions of mpox, which may potentially cause severe maternal illness or adverse outcomes for their unborn children (Thornhill et al., 2023). For example, the virus can even result in stillbirth or preterm birth as well as miscarriage, thereby amplifying the suffering of expectant parents and their families, and jeopardising the health and survival of their babies (Thornhill et al., 2023). 1.1.1 Mpox in Global Context As of August 2025, the WHO (2025) has reported 162,785 confirmed mpox cases and 424 deaths across 140 countries since the beginning of the 2022 outbreaks, marking a historic expansion in scope and demographic reach. As of November 2024, the United States has reported over 34,349 cases (Johns Hopkins University, 2025). In contrast, Mexico has reported 4,192 Mpox cases and 35 deaths as of November 2024, with 113 cases and one death occurring in 2024 (Pan American Health Organization [PAHO], 2024). In Canada, a total of 2,142 cumulative mpox cases were reported from May 2022 to July 2025, with the epidemic peaking in July and August 2022 (PHAC, 2025b). Ontario (ON) reported the highest number of mpox cases, followed by Quebec (QC), particularly in early clusters linked to Montréal, whereas British Columbia (BC) experienced a smaller but still significant number of cases (PHAC, 2025b). In the United Kingdom, cases peaked at about 350 per week in July 2022 before declining to zero by mid-December (WHO, 2023a). In South America, countries such as Argentina, Brazil, Chile, Colombia, and Peru reported a combined total of 25,503 mpox cases and 71 deaths from 2022 to 2024 (PAHO, 2024). As of November 2024, the South American subregion accounted for a substantial proportion of the 66,806 confirmed mpox cases reported in the Americas, second only to the North American subregion (PAHO, 2024). These figures and 3 developments underscore the evolving nature of the outbreak and the importance of sustained surveillance and public health preparedness. Further, in the U.S. mpox outbreak, severe inequities were evident, with O’Shea et al. (2023) underscoring that of 38 mpox-associated deaths by March 2023, 87% occurred among non-Hispanic Black individuals, most of whom were also living with HIV, underscoring the amplified impact of systemic racism and structural barriers to care. Similarly, Schildhauer et al. (2025) reported that prolonged mpox infections (>28 days) occurred in 1.3% of cases, disproportionately affecting Black individuals (20.7% vs. 11.6%) and those with HIV (61.0% vs. 39.9%), with durations reaching up to 345 days and over a quarter lasting 50 days or more. Indeed, the 2022–2023 mpox outbreak represents a transformative public health event internationally, which is notable for its wide-reaching impact, multiple transmission pathways, and exposure of pre-existing health inequities. 1.1.2 Mpox in Canada The outbreak in Canada originated in Montréal and the Greater Toronto Area (GTA), prompting the National Advisory Committee on Immunization (NACI) to quickly issue guidelines for targeted vaccination among at-risk groups (Bhuiya et al., 2022). Canada was recognised internationally for pioneering preventative vaccination efforts during the early stages of the outbreak (Bhuiya et al., 2022; Tam, 2024; The Globe & Mail, 2023). BC’s response demonstrated a robust public education, surveillance, and vaccine campaigns, particularly emphasising outreach to the GBTMSM+ community (CBC News, 2023; Gilbert et al., 2023). These efforts paralleled those seen in ON and QC and contributed to the overall containment of the outbreak within Canada. 4 During the early stages of Canada’s mpox response, Gilbert et al. (2023) conducted a foundational study examining mpox vaccine uptake among participants attending STI clinics in Vancouver, BC. The majority of confirmed cases have been observed among the GBTMSM+ community, with environments conducive to close interpersonal contact, such as bathhouses, park plays, and contact sports, serving as potential hotspots for mpox transmission within social and sexual networks (Gilbert et al., 2023). Their findings also revealed high levels of first-dose vaccine acceptance, particularly when outreach was done in a competent and affirming approach addressing health concerns of the Two-Spirit and lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other identities (2S/LGBTQIA+). Clinics that emphasised privacy, community inclusion, and peer-led communication saw higher engagement (Gilbert et al., 2023). This early success coincided with a strategic pivot from post-exposure prophylaxis (PEP) to pre-exposure prophylaxis (PrEP) in mid-2022 (Bhuiya et al., 2022). PrEP or preventative mpox vaccination was directed at key populations identified by public health as at-risk, including sexually active GBTMSM+ individuals. Public health units, in partnership with community-based organisations in Vancouver and Toronto, led the rollout using local sexual health clinics and mobile pop-up sites during major events, such as Pride festivals, which increased visibility and access (Gilbert et al., 2023; Tan et al., 2024). A 2024 surveillance update from the PHAC highlighted disparities in vaccine uptake across regions by acknowledging that vaccine receipt has been lower in rural regions and among underserved sexual and gender minority communities (Tam, 2024). To address these gaps, PHAC launched targeted outreach programs, emphasising peer-based vaccine promotion, mobile clinics, and partnerships with Indigenous and newcomer health organisations (Tam, 2024). Further, the 5 Chief Public Health Officer’s 2024 annual report emphasises that equity-focused outreach is a national priority in vaccination efforts, shaped by lessons from mpox and guided by intersectionality and social justice principles (Tam, 2024). In summary, Canada’s mpox vaccination efforts offer a critical lens into the broader strengths and shortcomings of equity in public health practice. While the rollout was rapid and relatively efficient in reaching White, cisgender MSM+ populations in urban centres, an emerging but consistent body of evidence reveals that this success did not extend uniformly to all members of the GBTMSM+ community (Gilbert et al., 2023; Tam, 2024). This pattern reflects more than a shortfall in logistics; it represents systemic issues in the ways public health frameworks identify, prioritise, and communicate with key populations. 1.2 Problem Statement Despite the global mobilisation of public health resources to address the mpox outbreak in 2022 and 2023, stark disparities in vaccine access and uptake have persisted, particularly among under-acknowledged members of the key group, including racialised individuals, transgender folks, sex workers, and people living with HIV (PLWH). While national and international health bodies, such as the NACI, PHAC, and WHO, have issued timely guidelines and deployed vaccination campaigns, these efforts have largely prioritised more visible and socioeconomically advantaged communities, often overlooking the intersecting vulnerabilities of adjacent subpopulations. Existing literature has extensively documented mpox transmission patterns and clinical outcomes. However, there remains a critical gap in understanding the ways stigma, systemic discrimination, and intersecting identities or realities impact vaccine acceptance and uptake. Preliminary research reveals that structural barriers, including healthcare-linked stigma, lack of 6 affirming care approaches, and mistrust stemming from historical medical neglect, significantly hinder vaccination efforts for these affected individuals. These factors, nonetheless, are seldom disaggregated or explored in sufficient detail within public health frameworks or intervention strategies and, in some instances, may require intensive qualitative approaches to uncover. These gaps pose a serious challenge to affirming, equitable outbreak response and public health preparedness. Without a nuanced understanding of the sociocultural and structural barriers and facilitators affecting vaccine uptake among key individuals and their communities, efforts to achieve comprehensive mpox control and prevent future outbreaks remain insufficient. 1.3 Purpose of Study Mpox outbreaks pose significant public health challenges due to their potential for rapid spread and severe health consequences, including painful lesions and complications that can lead to hospitalisation and even death. These difficulties are further exacerbated for overlooked subgroups, who often face precarious living conditions and systemic barriers to healthcare access, thereby amplifying their vulnerability during infectious outbreaks (Ju et al., 2023; Liu et al., 2025). Although vaccination is a crucial tool for curbing the risks, morbidity, and mortality associated with mpox, the receipt of vaccines appears to be inequitable (May et al., 2023; Rajkhowa et al., 2023). It is therefore essential for health equity to understand the deterrents and enablers to vaccine acceptance and uptake among the underserved GBTMSM+ members. Addressing these inequities is vital, and this study aims to contribute to efforts advocating for equitable access to mpox vaccines and healthcare interventions, as there remains a pressing need to understand the complex factors shaping vaccine-related decisions across individual, interpersonal, and structural spheres. 7 1.4 Research Questions The analysis focuses on the barriers and facilitators to receiving preventative mpox vaccinations among Indigenous, Black, and other People of Colour (IBPOC), sex workers, trans individuals, and PLWH within the GBTMSM+ community in and around Vancouver, BC. This population includes individuals who are often inadvertently neglected by the healthcare system due to intersecting positions and face unique healthcare challenges and disparities. This primary analysis aims to address the following research questions: 1. What are the attitudes and beliefs of underrepresented members of the GBTMSM+ community in and around Vancouver, BC, regarding preventative mpox vaccinations? 2. What barriers and facilitators shape preventative mpox vaccine acceptance and uptake? 3. How do their experiences of stigma related to race, occupation, sexual orientation, gender, and HIV/AIDS status impact the receipt of preventative mpox vaccination? 1.5 Significance of the Study The significance of this study lies in its focus on a highly underserved segment of the key population, who are at an elevated risk of health disparities during infectious disease outbreaks, such as mpox. While global and national public health responses have largely focused on the dominant GBTMSM+ group, this study intentionally shifts the lens to examine subpopulations within this community. These subgroups frequently encounter multiple, intersecting forms of stigma, structural marginalisation, and healthcare inaccessibility, which exacerbate their vulnerability during public health emergencies (May et al., 2023; Rajkhowa et al., 2023; Ramnarine, 2024; Rodriguez-Diaz et al., 2022). By centring their lived experiences and perspectives, this research addresses critical gaps in mpox-related literature and contributes to the growing discourse on health equity. This work’s 8 findings aim to foreground GBTMSM+ competent and affirming care, as well as stigma-sensitive public health strategies that prioritise trust-building, vaccine accessibility, and community engagement. Moreover, this study supports the global call for decolonising public health by amplifying the voices and needs of those who have historically been excluded from healthcare decision-making and research design. 9 Chapter 2: Literature Review 2.1 Overview This chapter presents a narrative review of the existing literature relevant to the current study, aiming to situate the research within a broader academic and public health context. The purpose of the review is threefold: to contextualise the mpox outbreak as a public health issue marked by socio-structural inequities; to identify gaps in the current body of knowledge, particularly around the experiences of underrepresented members of the population of interest; and to frame the study’s specific focus on the impact of stigma and discrimination on healthcare access and outcomes for these subgroups. While there has been a growing attention to mpox in public health discourse, much of the existing research remains limited in scope and demographic representation. This has resulted in a narrow understanding of risk, vulnerability, strength, and access to care, particularly for affected individuals who are often excluded from mainstream research and intervention efforts. This literature review aims to highlight these limitations, draw attention to key themes and patterns in the literature, and build a case for why a more stigma-sensitive, equity-based, and intersectional approach is necessary in addressing mpox and related public health challenges. To ensure a comprehensive and methodologically sound understanding of existing literature, I employed a structured and transparent search strategy. The following section outlines the specific databases, keywords, and selection criteria used to identify and analyse the scholarly sources reviewed in this chapter. 2.2 Search Strategy Grounded in an Interpretive Description (ID) methodology (Thorne, 2016), I employed a narrative review of the literature rather than a systematic or scoping assessment. This approach 10 aligned with the study’s qualitative aim to identify conceptual gaps and contextual patterns related to stigma, discrimination, and mpox vaccination within GBTMSM+ communities. I did not aim to exhaustively synthesise all available literature; instead, I examined the ways current knowledge frames the issue, where gaps persist, and the insights that inform and support the focus of my thesis. Following Ferrari’s (2015) guidance on narrative reviews as a way of mapping and synthesising relevant evidence, I conducted searches across four academic databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Journal Storage (JSTOR), and Google Scholar. I chose them for their coverage of public health, social science, nursing, and interdisciplinary fields relevant to the study’s inquiry. Foundational works on stigma (Goffman, 1963), intersectionality (Crenshaw, 1991), and metaphor (Lakoff & Johnson, 1980) were also included to ground the study in focal theoretical perspectives. I placed particular emphasis on literature published from 2016 onward to capture contemporary debates and empirical evidence on mpox and comparable infectious disease outbreaks. I paid close attention to studies addressing sexual and gender minority populations, vaccination uptake, stigma, resilience, health disparities, and access to care. In addition to peer-reviewed scholarship, I incorporated institutional reports and grey literature from organisations such as the WHO, CDC, and PHAC. I strategically selected keyword combinations to reflect the study’s core concepts, drawing on both free-text terms and controlled subject headings such as MeSH (PubMed) and Main Headings (CINAHL). Keywords included “monkeypox,” “mpox,” “vaccine,” “stigma,” “barriers,” “facilitators,” “prevention,” “epidemiology,” “men who have sex with men,” “BIPOC,” “IBPOC,” “homosexual,” “homosexuals,” “gays,” “gay men,” “bisexual,” 11 “bisexuals,” “transgender,” “transgender people,” “sex workers,” “people living with HIV,” “healthcare disparities,” and “Canada.” Searches were conducted iteratively, with articles screened for alignment with the research questions and conceptual focus. I also prioritised peer-reviewed studies, critical commentaries, and public health reports examining social or behavioural dimensions of mpox and comparable infectious disease responses. I used backward and forward citation tracking to capture foundational works and recent studies not retrieved in the initial search. To uphold scholarly rigour, I excluded sources from predatory journals and unverified grey literature. This narrative approach provided conceptual grounding for the study, enabling deeper engagement with existing knowledge and underscoring persistent gaps in the literature. 2.3 Barriers to and Facilitators of Vaccination Barriers to mpox vaccination uptake are multifaceted and can be broadly categorised as structural, social, and individual. A comprehensive understanding of these impediments is essential for informing targeted public health interventions and ensuring equitable access to vaccination during outbreaks, such as mpox. Access to vaccines is often constrained by broader structural challenges, including economic and financial costs, as well as limited availability of facilities, particularly in resource-limited contexts (Bragazzi et al., 2022). Digital inequities further exacerbate access issues, as individuals lacking reliable internet access or digital literacy may be unable to schedule appointments or access critical health information (Rajkhowa et al., 2023). Privacy concerns and the inability to navigate complex healthcare systems also present barriers, particularly for individuals seeking discreet care due to stigma (Gilbert et al., 2023). 12 Social dynamics significantly shape vaccine acceptance. A prevailing lack of trust in health systems rooted in systemic discrimination and historical mistreatment continues to affect vaccine confidence among racialised 2S/LGBTQIA+ folks (Grey et al., 2023). Compounding this is the widespread circulation of inaccurate information, particularly through social media platforms, which can undermine trust in vaccine safety and efficacy (Rajkhowa et al., 2023). The stigmatisation of mpox as a “gay disease” has also dissuaded some individuals from seeking vaccination for fear of social labelling or discrimination (Takenaka et al., 2024). Individual-level determinants, such as perceived susceptibility to infection, also influence vaccination decisions. Some individuals may not perceive themselves as being at risk if they do not belong to groups prominently featured in public health messaging (Gilbert et al., 2023; León-Figueroa et al., 2024). Further, personal experiences, including previous negative interactions with healthcare providers, fears regarding vaccine side effects, or a lack of competent and affirming care, can contribute to hesitancy. Intersectional factors such as race, gender identity, sexual orientation, and socioeconomic status further shape health-seeking behaviours, often placing individuals at the crossroads of multiple vulnerabilities (Crenshaw, 1991; Nadarzynski et al., 2021). Although the existing literature heavily emphasises barriers to mpox vaccine uptake affecting underserved members of the 2S/LGBTQIA+ communities, several studies have begun to identify strength-based facilitators that could inform future interventions. High vaccine acceptability has been linked to targeted outreach through trusted community networks and clinics (Gilbert et al., 2023; León-Figueroa et al., 2024). The presence of competent and affirming healthcare providers, peer education, and inclusive public health messaging has also been shown to increase vaccine confidence and uptake (Nadarzynski et al., 2021). 13 While often a vector for incorrect information, social media has also served as a useful tool for real-time outreach and myth debunking when used by credible public health spaces or organisations (Rajkhowa et al., 2023). These emerging facilitators point toward opportunities to enhance vaccine delivery and engagement, particularly when interventions are community-informed and equity-oriented. 2.4 Stigma, Discrimination, and Structural Marginalisation According to Erving Goffman (1972), stigma is a social label or characteristic that marks individuals as deviating from prevailing societal norms, resulting in their marginalisation or devaluation, both in self-perception and social interactions. Goffman (1972) argues that stigma influences the ways individuals manage their identities to navigate social expectations and prejudices, thereby shaping their opportunities and psychological well-being. Within Goffman's (1972) framework, discrimination is seen as the conduct and actions that arise from stigmatisation, resulting in unfair and inequitable treatment of individuals due to their stigmatised traits, often leading to social exclusion, marginalisation, and the denial of opportunities. Bergman et al. (2022) also describe stigma as a complex societal process entailing social discrimination and marginalisation, posing a threat to individuals’ mental, physical, and emotional well-being. Stigma has also been linked to many detrimental health consequences, encompassing both immediate and lasting impacts on affected individuals (Banjar & Alqueel, 2023; Ju et al., 2023). This association exacerbates the pre-existing inter- and intrapersonal difficulties experienced by affected individuals due to their increased likelihood of facing greater invisibility, vulnerability, and discrimination (Bergman et al., 2022; Banjar & Alaqeel, 2023; Ju et al., 2023). 14 Health disparities associated with sexual orientations and gender identities have been linked to homo-, bi-, and transphobic stances perpetuated by the public and even some healthcare professionals, negatively affecting these groups’ health-seeking behaviours (Bergman et al., 2022; Gilbert et al., 2023; Nadarzynski et al., 2021). Similarly, they often struggle with a multitude of intersecting factors, such as substance misuse, encounters with violence, and mental health concerns, resulting in the occurrence of syndemicity among infectious disease outbreaks, thereby complicating the already convoluted real-world struggles of these individuals (Bergman et al., 2022; Gilbert et al., 2023; Nadarzynski et al., 2021). Like other types of biases, anti-GBTMSM+ beliefs and attitudes amplify the debilitating effects of stigma, precluding effective public health communication strategies and generating barriers to seeking available healthcare services (Ju et al., 2023). By fostering alienation and fear, stigma may drive impacted folks away from seeking available healthcare services and honestly disclosing their symptoms, inducing the silent spread of the mpox virus (Ju et al., 2023; Nadarzynski et al., 2021). In this work, I use the Health Stigma and Discrimination Framework (HSDF) by Stangl et al. (2019) as a subsequent analytical lens, as it is a pivotal tool for understanding the pervasive impact of health-related stigmas. There are also striking similarities between the HIV/AIDS epidemic in the 80’s and 90’s, and this mpox outbreak as these health conditions are significantly linked to highly stigmatised sexual minorities, primarily framed by media channels or anti-GBTMSM+ groups as a “gay disease,” and initially dealt with disintegrated public health response (Ju et al., 2023; Takenaka et al., 2024). The HIV epidemic and mpox outbreaks also overlap in a lethal dance of increased mortality rates, specifically in geographical locations where both diseases are endemic (Banjar & Alaqeel, 2023; Bergman et al., 2022). 15 In the same way, underserved PLWH are more susceptible to severe complications if infected with mpox due to their immunocompromised status (O’Shea et al., 2023; Schildhauer et al., 2025). This dangerous synergy emphasises the immediate need for efficient and comprehensive public health tactics addressing the intersectionality of HIV and other emerging infections like mpox by bolstering early detection and fostering equitable access to life-saving health services (O’Shea et al., 2023; Schildhauer et al., 2025). Apart from the health disparities rooted in stigma and discrimination, racism is also an evident repercussion of the recent mpox outbreak. According to Crenshaw (1991), racism cannot be reduced to individual prejudice; it is also embedded in systemic and institutional structures that sustain unequal treatment and oppression based on race. It involves perpetuating harmful stereotypes and social exclusion, which intersect with other forms of discrimination, such as gender, class, and health status (Crenshaw, 1991). Crenshaw’s (1991) work also emphasises that intersectionality is not merely the sum of multiple marginalisations, but a distinct analytical lens for understanding how overlapping structures of oppression create unique forms of exclusion. Her foundational example of Black women’s workplace discrimination cases, which were dismissed when race and gender were considered separately. This illustrates that intersecting identities cannot be meaningfully addressed in isolation, a point directly relevant to the compounded inequities faced by Black communities during the mpox outbreak (O’Shea et al., 2023; Schildhauer et al., 2025). For example, due to the selective use of photos depicting people from the West and Central African nations on mpox information across media channels and platforms in the early stages of the outbreak, Black people and other individuals of African descent have had become victims of harmful stereotypes and dehumanising associations with the mpox virus (Bergman et 16 al., 2022; Bragazzi et al., 2023; Ju et al., 2023). To mitigate the racialised and stigmatising connotations historically associated with the term “monkeypox,” particularly its disproportionate impact on Black communities, the WHO (2022) officially adopted “mpox” as the name of the disease. Anti-Black racism takes on an intersectional dimension when it converges with other forms of marginalisation, such as anti-sex work prejudice, homophobia, transphobia, and HIV-related stigma. Therefore, public health authorities and policymakers must adopt stigma-sensitive and trauma-informed approaches when disseminating health information to the public and address misleading and incorrect information about infectious outbreaks (Bergman et al., 2022; Bragazzi et al., 2023; Ju et al., 2023). 2.5 IBPOC, Trans, Sex Workers, and PLWH in Mpox Research and Care Throughout the years, studies and discussions around STIs and infectious disease prevention have centred predominantly on affluent and White cisgender MSM (Gilbert et al., 2023; Nadarzynski et al., 2021; Owen-Smith et al., 2016). For instance, in Gilbert et al.’s (2023) study on mpox vaccine uptake, most participants were White, reflecting a demographic pattern that mirrors earlier research on GBTMSM+ populations and highlighting how Canadian mpox research, and likely that of other Western contexts, has reproduced the same disparities long evident in sexually transmitted and blood-borne infections (STBBI) studies. Like other studies, these predominant research participants are characterised by their high access to healthcare services and university-level education (Gilbert et al., 2023; Nadarzynski et al., 2021; Owen-Smith et al., 2016). In turn, the experiences and health needs of underserved members are often decentred in research and healthcare settings (Gilbert et al., 2023; Owen-Smith et al., 2016; Strathdee et al., 2023). 17 Despite existing research highlighting the increased risk of mpox among GBTMSM+ populations, there is a paucity of data specifically addressing the experiences of the underserved members in the context of disease outbreaks (Gilbert et al., 2023; Nadarzynski et al., 2021; Owen-Smith et al., 2016). For example, during infectious outbreaks, transgender individuals often encounter barriers to accessing competent and gender-affirming care services, which can exacerbate health disparities and contribute to their marginalisation within healthcare systems (Gahagan & Subirana-Malaret, 2018; Owen-Smith et al., 2016; Ramnarine, 2024). Individuals who provide sexual services as their line of work represent another under-recognised pool within this key group, facing poorer health outcomes due to reduced health-seeking behaviours associated with stigma, thus increasing their susceptibility to acquiring other STIs and other infections (Ramnarine, 2024; Strathdee et al., 2023). Despite their heightened risks, vaccination campaigns have historically ignored gender-diverse sex workers in most global and national settings (Ramnarine, 2024; Strathdee et al., 2023). These systemic barriers exacerbate disparities in vaccine accessibility, thereby hindering efforts to mitigate the spread of infectious diseases. PLWH within the GBTMSM+ community are also insufficiently represented in research studies (O’Shea et al., 2023; Ramnarine, 2025; Stangl et al., 2013). PLWH face an inequitable convergence of marginalisation in healthcare and research contexts, exacerbated by systemic neglect and stigma (Earnshaw & Chaudoir, 2009; Stangl et al., 2013). Despite bearing a disproportionate burden during health crises, such as the recent mpox outbreak, their needs are often inadvertently disregarded and abandoned (Earnshaw & Chaudoir, 2009; Ramnarine, 2025; Stangl et al., 2013). This neglect deepens disparities in healthcare access and impedes the development of essential tailored interventions to improve their health outcomes (Earnshaw & 18 Chaudoir, 2009). Further, Nadarzynski et al. (2023) emphasise that the insufficient inclusion of minority groups can obscure important differences in vaccination acceptance and uptake, a common limitation in studies of the GBTMSM+ community (as cited in Gilbert et al., 2023). Current evidence indicates an overrepresentation of affluent, cisgender, White gay men in research on global health crises, such as mpox and comparable outbreaks, reflecting structural inequities in healthcare access and representation. This skewed focus perpetuates inequalities and undermines efforts to address the fuller scope of health risks and challenges faced by the insufficiently served subpopulation. By considering their individualised standpoints and addressing the complex socio-structural dimensions and exposures they face, healthcare interventions can be structured to better meet their needs and minimise the disproportionate impact of infectious outbreaks. 2.6 Literature Gaps and Justification. Although research on mpox vaccination uptake is expanding, significant gaps remain at the intersections of stigma, identity, and accessibility. While barriers and facilitators have been documented, stigma-informed scholarship that explicitly examines the ways intersecting stigmas shape vaccine acceptance and health-seeking behaviours is limited. Much of the current evidence is quantitative and epidemiological, leaving a critical gap in qualitative, experiential insights that centre the voices of those most affected by structural and social exclusion. Inadequate representation of GBTMSM+ subgroups continues to undermine the development of stigma-sensitive and equitable public health responses. The geographic and contextual scope of current research is also narrow, with most studies concentrated in clinical or urban settings. Few explore rural areas, community-based contexts, or non-clinical environments where access barriers may be particularly acute. These underexamined settings are crucial to 19 understanding the real-world challenges to mpox vaccine delivery and receipt, especially for ambient populations in hard-to-reach areas. Critically addressing these gaps ensures that public health interventions are evidence-based and grounded in the lived realities of those disproportionately affected by stigma, exclusion, and structural inequity. This study responds by employing a stigma-informed, equity-driven lens to investigate mpox vaccine uptake among GBTMSM+ individuals, particularly those at the margins of visibility in current research. 20 Chapter 3: Research Methods 3.1 Overview This chapter outlines the methodological approach used to investigate the barriers and facilitators influencing the uptake of preventative mpox vaccination among underserved key subpopulations. Grounded in a qualitative research paradigm, I drew on Thorne’s (2016) Interpretive Description (ID) as the study’s methodological framework to generate rich, contextualised understandings of participants’ lived experiences. I gathered data through semi-structured interviews, allowing for in-depth exploration of participants’ attitudes, beliefs, and interactions with healthcare systems and public health messaging. To guide the analytic process, I utilised Braun and Clarke’s (2021) Reflexive Thematic Analysis (RTA): a flexible and iterative approach that supported the identification of complex patterns and development of themes within the data. I also applied Stangl et al.’s (2019) Health Stigma and Discrimination Framework (HSDF) as a subsequent theoretical lens to guide the interpretation of stigma-related dynamics across individual, community, organisational, and policy levels. These methodological and conceptual tools enabled a textured and contextually grounded exploration of mpox-related vaccine decisions. 3.2 Methodological Framework: Interpretive Description I selected Thorne’s (2016) ID for its capacity to generate clinically relevant knowledge grounded in the lived realities of individuals, making it particularly well-suited for applied health research. Originating within the discipline of nursing, ID is intentionally designed to bridge the gap between theoretical knowledge and practice, offering a flexible, contextually responsive, and methodologically sound approach (Thorne, 2016). 21 Philosophically, ID is grounded in a constructivist paradigm, which posits that reality is multiple and constructed through relational and contextual interactions (Thorne et al., 2004; Thorne, 2016). Lincoln et al. (2011) situate constructivism as a central qualitative paradigm, one that assumes multiple socially constructed realities and emphasises knowledge as co-created through researcher–participant interaction. This orientation was especially relevant for a study seeking to explore the ways participants navigated vaccine uptake within the complex landscapes of health inequity, stigma, and systemic marginalisation. Instead of striving to uncover objective truths, I aimed to engage in a shared process of meaning-making with participants, situating their lived realities within broader socio-structural frameworks. While rooted in a constructivist stance, ID also draws from interpretivist influences and traditions, particularly in its analytical emphasis on subjective interpretation, contextual nuance, and meaning-making (Thorne et al., 2004; Thorne, 2016). Interpretivism is evident in ID’s methodological flexibility, which resists rigid coding templates in favour of a fluid, recursive analytic process that remains open to developing insights (Thorne et al., 2004). Thus, ID’s capacity to blend constructivist epistemology with interpretive sensibilities offers a strong foundation for examining deeply personal and socially embedded phenomena, such as the emotional, interpersonal, and systemic influences shaping mpox vaccine behaviours. Thorne’s (2016) work also emphasises the power of “disciplinary orientation” shaping the researcher’s thinking and the ways insights and themes are developed. Rather than bracketing this influence out, ID encourages critical reflexivity that harnesses disciplinary perspectives to generate actionable, practice-relevant insights. As both a member of the GBTMSM+ community and a practitioner in the nursing field, I occupied a dual positionality, bringing insider knowledge and outsider lens informed by clinical training and applied health research expertise. My dual 22 perspective enabled me to employ a layered form of reflexivity, thereby strengthening the study’s epistemological rigour while promoting the kind of practice-sensitive interpretation that Thorne’s (2016) ID is designed to support. Throughout the research process, I drew on Thorne's (2016) relational and reflexive orientation in ID to critically examine the ways my personal and professional standpoints influenced data collection, interpretation, and meaning-making. My insider knowledge helped me build rapport and develop a community-grounded understanding, while my outsider lens prompted analytical distance and clinical sensitivity. I experienced this dynamic interplay as central to the process, consistent with ID’s positioning of reflexivity as an ethical and epistemological imperative rather than a procedural step (Thorne, 2016). In summary, Thorne’s (2016) ID provided a philosophically coherent, methodologically rigorous, and practically oriented framework for exploring the complex interplay of identity, stigma, and health decision-making within the context of mpox vaccination. By integrating constructivist and interpretivist perspectives, and remaining grounded in its disciplinary roots, ID facilitated an in-depth examination of the key group’s lived realities, thereby enabling findings that are both analytically robust and meaningfully translatable to practice and policy. 3.3 Analytical Approach: Reflexive Thematic Analysis To analyse the qualitative data, I employed RTA as outlined by Braun and Clarke (2021). I selected this analytic approach for its compatibility with Thorne’s (2016) ID methodology, offering a flexible yet rigorous method for exploring participants’ nuanced experiences. Braun and Clarke’s (2021) RTA supported my identification of patterns in the ways the key population perceived and navigated stigma, health communication, and access to mpox vaccination. It also 23 provided me with a lens to examine the broader social, structural, and intersectional forces that shaped vaccine attitudes and decision-making processes. Situated within an ID framework, RTA allowed for a reflexive, iterative, and contextually grounded approach to thematic development. Instead of adhering to a linear coding protocol or striving for “theme saturation,” RTA also embraces the inherently constructivist and interpretive nature of qualitative inquiry (Braun & Clarke, 2021; Thorne, 2016). My stance aligns with the philosophical foundations of this study, as I view knowledge as co-constructed and situated within historical, cultural, and relational contexts. The reflexive component of RTA guided me to maintain critical self-awareness throughout the analytical process. This was essential given my dual positionality as both an insider within the community and an outsider through my professional training as a nurse. I also found that RTA’s (Braun & Clarke, 2021) emphasis on shared and patterned meaning-making aligned with ID’s (Thorne, 2016) goal of generating insights relevant to clinical and public health contexts. That said, I did not treat themes as objective truths waiting to be discovered; instead, I viewed them as interpretive constructs shaped by participant narratives, my active role as a researcher, and the theoretical sensitivities that guided, but did not predetermine, my analysis. I explored concepts such as stigma, trust, resilience, and other forces influencing vaccine uptake through the perspective of lived experience and situated knowledge. This analytical approach allowed me to incorporate principles from frameworks like intersectionality (Crenshaw, 1991) and monolithic representation (Collins & Bilge, 2016; Collins et al., 2021) during the writing and discussion stages. I did not use these concepts as strict frameworks; instead, I regarded them as interpretive tools to enhance the findings and explore tensions within the analysis. For instance, while coding and developing themes, I encountered 24 narratives that challenged simple categorisation, particularly regarding gender-diverse identities and experiences with public health messaging. Intersectionality provided the language to articulate these tensions, while RTA, and by extension ID, offered the systematic openness to integrate them in a meaningful way. In other words, I found RTA (Braun & Clarke, 2021) to be an interpretively rich, epistemologically and ontologically coherent, and ethically grounded method for analysing the complex dynamics shaping mpox vaccination decisions. In alignment with Thorne’s (2016) ID, I employed RTA to guide a flexible yet thorough analytical process that honoured the depth of participant experience, responded to contextual nuances, and maintained a critical awareness of my positional influence throughout. 3.4 Theoretical Lens: Health Stigma and Discrimination Framework I employed the HSDF, developed by Stangl et al. (2019), as a later-applied theoretical lens to guide interpretation and deepen analysis. The framework proved analytically appropriate for contextualising the multi-level manifestations of stigma shaping participants’ attitudes and behaviours around mpox vaccination. By conceptualising stigma as a dynamic process operating across socio-ecological levels, such as individual, interpersonal, organisational, community, and policy, the HSDF enabled me to develop a layered understanding of the complex ways affected individuals experience, internalise, and resist stigma within public health contexts (Stangl et al., 2019). Stangl et al.’s (2019) framework also provided a structure for identifying thematic echoes across drivers, facilitators, intersections, manifestations, and outcomes of health-related stigma. In this study, it illuminated instances when stigma tied to sexual orientation, gender identity, race, HIV status, and sex work intersected and shaped the ways GBTMSM+ folks engaged with 25 mpox-related campaigns. Although I did not incorporate the HSDF into the initial analytic phases, I drew on it as an interpretive anchor during the writing of the Findings and Discussion chapters, which provided me with the theoretical vocabulary to articulate patterns of stigmatisation and resistance within the participant narratives. Rooted in a socio-ecological perspective and reflecting Crenshaw’s (1991) Intersectionality, the HSDF posits that stigma is not merely individual prejudice but is produced and maintained through interactions among people, institutions, policies, and systems (Stangl et al., 2019). This framework guided the development of survey tools and analytic categories in the parent study and influenced my interpretive approach in the qualitative analysis. Its usefulness extended beyond personal stories, enabling a thorough examination of the structural and institutional factors affecting vaccine uptake. 3.5 Study Context This thesis is part of a larger mixed-methods research initiative funded by the Canadian Institutes of Health Research (CIHR) and led by Dr. Devon Greyson at the University of British Columbia’s (UBC) School of Population and Public Health. The broader project investigates mpox vaccine communication campaigns targeting members of the GBTMSM+ community across BC, ON, and QC. It aims to assess (a) the communication strategies utilised by community partners and public health authorities, (b) campaign elements that either improved or hindered vaccine acceptance and uptake, and (c) the potential for novel vaccine safety surveillance strategies to inform future public health engagement. This thesis specifically focuses on the BC-based qualitative component of the overarching study. Using ID methodology (Thorne, 2016), I explore the lived experiences of underserved community members eligible for preventative mpox vaccination in BC during the 26 2022–2023 vaccine rollout. This work investigates the ways participants navigated the intrapersonal, interpersonal, structural, and informational dynamics of the mpox vaccination campaign, with a particular focus on the barriers and facilitators that influenced their vaccine-related decision-making. My thesis contributes to the qualitative strand of a broader research design that includes both quantitative and qualitative elements, including document analysis, community interviews, and worker interviews. The quantitative arm of the larger study draws from the Sex Now Survey (2022 and 2023). This thesis provides deeper insight into the lived, contextually embedded narratives of vaccine uptake among BC participants. By focusing on this specific provincial and population context, I engage directly with questions of equity, stigma, and vaccine access in public health initiatives. The partnership with CIHR underscores the national relevance and rigour of this research, while the community-collaborative approach reflects a commitment to centering the voices of those most affected. This primary analysis not only fills a critical gap in understanding vaccine behaviours within key populations, but also aims to generate findings that are translatable to public health practice, advancing more equity-based and stigma-aware interventions for comparable health crises in the future. 3.6 Participant Recruitment Participants for this study were recruited in collaboration with local community-based organisations, including Health Initiatives for Men (HIM), Trans Care BC (TCBC), and Ribbon Community (formerly AIDS Vancouver). Recruitment strategies were multi-modal, involving outreach through social media platforms, organisational newsletters and bulletin boards, and in-person presentations at community-based events. In addition to digital and event-based outreach, 27 physical posters promoting the study were also distributed across key community-based venues, including pubs, nightclubs, bathhouses, sex shops, and café stores along Davie Street, a well-known hub for 2S/LGBTQIA+ communities located in Downtown Vancouver. These highly localised outreach efforts were designed to reach under-recognised GBTMSM+ individuals who may not be connected through traditional health promotion channels but are active within trusted community spaces. In-person interviews were conducted at one of our community partner sites, facilitated with the support of staff and volunteers who assisted with scheduling and helped create a welcoming and safe environment for participants. These combined strategies reflect a comprehensive and community-embedded approach to recruitment. They formed part of a broader engagement strategy within the parent study, which sought to reach diverse GBTMSM+ folks eligible for mpox vaccination in BC, ON, and QC, in accordance with eligibility guidelines set by the NACI and provincial public health authorities. The parent study also sought to include participants representing different stages of vaccination: (a) individuals who had completed the two-dose preventative mpox vaccination series, (b) those who had received only one dose, and (c) those who had not received any dose. By including participants across these categories, the goal was to explore the ways various communication strategies and structural factors influenced their vaccine-related decision-making. This thesis focused specifically on underrepresented groups in the BC-based qualitative component, engaging fourteen participants: a number deemed sufficient to achieve information power based on the specificity of the research aim, the depth of data gathered, and the richness of participant narratives (Malterud et al., 2016). Recruitment targeted underreported groups within 28 the GBTMSM+ community, including IBPOC, transpeople, sex workers, and PLWH. Participants were eligible if they were 18 years or older, fluent in English, and met the mpox vaccination criteria outlined by the PHAC (2025a). According to PHAC’s (2025a) updated mpox vaccine guidelines, eligibility now includes gay, bisexual, and other men who have sex with men, transgender individuals, and others within the 2S/LGBTQIA+ spectrum who are at higher risk of exposure. Risk criteria include having multiple sexual partners, being in relationships with partners who have other partners, receiving a recent STI diagnosis, engaging in sexual activity in sex-on-premises venues, or participating in sex work regardless of gender identity. Staff and volunteers in such venues may also be eligible if their roles involve potential contact with bodily fluids or contaminated surfaces without appropriate protection. Eligibility further covers sexual partners of individuals meeting these criteria, close contacts of confirmed cases, individuals anticipating high-risk encounters (including during travel to areas with active transmission), and those with immunocompromising conditions or other health risks as defined by provincial guidelines (PHAC, 2025a). A theoretical sampling strategy was employed to guide participant selection. Unlike predetermined sampling methods, theoretical sampling involves selecting participants and data sources based on emerging patterns or conceptual needs identified during data collection and analysis (Corbin & Strauss, 1990). This approach facilitated the iterative refinement of themes, ensuring that the developing analysis remained grounded in the data while being responsive to theoretical concepts, such as stigma and intersectionality. Corbin and Strauss (1990) present theoretical sampling as a central canon of grounded theory, emphasising the iterative interplay between data collection and analysis. I interpret this principle as resonating with the constructivist and interpretive foundations of this work’s philosophical and paradigmatic 29 underpinnings, particularly in its reflexive and recursive orientation to knowledge co-construction. The recruitment process was indeed carefully designed to ensure both methodological rigour and equity, prioritising depth and contextual relevance over breadth. The integration of community collaboration, targeted inclusion criteria, and theoretical sampling enabled the study to explore the intersections of identity, access, and stigma in a way that honoured the complexity of participants’ lived experiences while contributing meaningfully to public health knowledge and vaccine equity strategies. 3.7 Data Collection Data were collected through semi-structured interviews conducted via secure UBC Zoom from 2024 to 2025, as well as in-person interviews at a drop-in group site. These interviews formed part of the BC-specific qualitative component of the broader CIHR-funded parent study. The interview guide was developed in alignment with the overarching study’s research questions and was reviewed and approved by the institutional ethics committee. The guide incorporated domains from the HSDF by Stangl et al. (2019), allowing participants to reflect on their experiences with stigma, access to health services, and vaccine-related decision-making in relation to preventative mpox vaccination. Prior to participation, demographic information was collected using encrypted online UBC software REDCap. In most cases, individuals interested in participating in the study self-identified themselves by following a QR code or link to an informational document and a screening questionnaire hosted on the UBC ARC REDCap platform. Those who were recruited in person at one of our community partners’ group sites were presented with information about the study and screened for eligibility in a face-to-face setting. 30 Participants recruited online were screened for eligibility based on inclusion criteria and were then sent a secure, individualised link to complete the online informed consent form. Once consent was obtained, participants were invited to schedule an interview by email or telephone. Before beginning each interview session, the interviewer reviewed the informed consent process again using slides and answered any participant questions to ensure clarity. Verbal consent was reaffirmed prior to audio-recording the interview. To uphold confidentiality, pseudonyms were also used during the interview. The interviews were conducted in English, audio-recorded with the participant’s permission, and typically lasted around 60 minutes. Eligible participants received a $50 honorarium upon completing their interview. A list of 2S/LGBTQIA+-focused resources in BC was also provided to each participant after the interview. While the majority of interviews were conducted via secure UBC Zoom, four were held in person at one of our community partners’ group sites, with the support of staff and volunteers who assisted with scheduling and provided a private, safe, and welcoming environment for participants. During the interviews, especially the in-person sessions, I was specifically attentive to non-verbal cues and body language. In alignment with ethical qualitative research practices and commitments to creating a trauma-informed and stigma-sensitive interview space, I chose not to pursue follow-up questions when participants appeared visibly uncomfortable or hesitant. Rather than press for responses, I prioritised participants’ emotional safety and agency, allowing the conversation to move organically according to their comfort level. This decision reflects my reflexive awareness as a researcher and the relational sensitivity foundational to this work and the broader study. 31 Most interviews, both virtual and in-person, adhered to the standard time frame, with one notable exception. An interview with a highly knowledgeable participant, who was both a community member and a healthcare provider, lasted approximately two hours after a technical interruption midway through the virtual session, necessitating completion in two separate segments. This participant voluntarily chose to continue and elaborated on experiences related to stigma, access, and decision-making regarding mpox vaccination, providing rich insights that went beyond the scope of the original interview questions. To complement the audio recordings, interviewers also took fieldnotes following each interview, documenting contextual observations such as setting, tone, and notable interactions. Audio-recordings were transcribed verbatim by a designated transcription team. Each transcript was de-identified and checked for accuracy. Relevant notes were stored securely by Greyson Lab’s authorised team members, and all data were managed in accordance with UBC’s ethical standards and data retention policies. This multi-faceted approach to data collection ensured the depth, trustworthiness, and contextual richness necessary for a nuanced understanding of the context and phenomenon under study. 3.7.1 Transcription and Verification During transcription, each transcript was de-identified and assigned a unique identifier to protect participant confidentiality. The transcription process served as the foundational step in preparing the qualitative data for comprehensive analysis, converting spoken dialogue into a written format suitable for iterative coding and interpretation (Braun & Clarke, 2021; Byrne, 2022). Following transcription, participant-checking was offered as an option. Some participants chose to review their transcripts, while others declined. In a few cases, participants who initially 32 agreed were unable to complete the review but granted permission for the research team to use the transcript as is. This practice involved offering participants the opportunity to review their transcripts for accuracy and contextual fidelity, ensuring that their contributions were faithfully captured and represented. In some instances, participants chose not to engage in transcript review; in these cases, verification was conducted by cross-referencing fieldnotes, clarifying context with the interviewer, and listening closely to audio segments to ensure accuracy. All identifying information was removed from the transcripts during this phase, and only de-identified data were retained for analysis. Participant-checking served not only as a quality assurance measure, but also as a form of collaborative engagement, consistent with both the ethical principles of this study’s methods and broader standards of rigour in qualitative research (Braun & Clarke, 2021). By inviting participants to confirm or clarify their statements, particularly where meanings may be ambiguous or where sensitive content was discussed, the process enhanced the credibility and trustworthiness of the dataset. 3.8 Data Analysis Process Data were analysed using Braun and Clarke’s (2021) RTA, which aligns with Thorne’s (2016) ID methodology, offering a flexible, recursive, and reflexively engaged analytic process. Braun and Clarke’s (2021) RTA, along with Thorne’s (2016) ID, emphasises the researcher’s active role in meaning-making and acknowledges the influence of positionality, theoretical sensibilities, and prior knowledge on theme development. In contrast to more prescriptive coding methods, RTA supports a dynamic, evolving analysis that prioritises depth and nuance over formulaic saturation (Braun & Clarke, 2021; Byrne, 2022; Thorne, 2016). 33 I began coding inductively in NVivo, exported the data to Excel, and then manually organised the codes and further developed and fine-tuned the themes in Word, developing these directly from participants’ narratives without imposing a predetermined structure. This non-linear nature of qualitative analysis allowed me to re-engage with data through recursive movement between coding, interpretation, and theme refinement. The final themes represent the patterns within the data and outcome of an iterative and reflexively engaged process that foregrounds contextual complexity, power, and identity, which are core principles within both RTA (Braun & Clarke, 2021) and ID (Thorne, 2016). As the analysis progressed, I engaged with sensitising concepts from Stangl et al.’s (2019) HSDF, which I applied subsequently as an analytical lens. This application of the chosen framework provided a scaffold for interpreting the drivers, manifestations, and outcomes of stigma across socio-ecological levels. While participants’ meaning-making remained central, Stangl et al.’s (2019) HSDF supported a deeper interrogation of the structural dynamics shaping vaccine decision-making in the context of layered marginalisation. Reflexivity also guided the analytic process, as I kept a detailed reflexive journal throughout data analysis to document my analytic decisions and interpretive assumptions. This practice supported transparency and epistemological accountability consistent with both ID and RTA. Reflexivity was also practiced in the writing of my fieldnotes and in conversations during our regular team meetings, where we debriefed on data collection. As the analysis advanced, I encountered tensions that initial coding did not fully capture, which prompted the subsequent integration of theoretical concepts such as additive thinking (Crenshaw, 1991) and monolithic representation (Collins & Bilge, 2016; Collins et al., 2021). 34 These concepts clarified the layered and intersectional forms of exclusion described by participants. 3.9 Ethical Considerations Ethical approval for the overarching study was obtained through the UBC Behavioural Research Ethics Board (Ref#: H23-00897). A separate application (Ref#: H24-00889) for ethics clearance specific to this thesis was prepared and submitted in accordance with UBC’s guidelines for the primary use of research data. All research activities were conducted in accordance with established ethical standards for research involving human participants, with particular attention to obtaining informed consent, maintaining confidentiality, and respecting participant autonomy. Prior to participation, individuals completed an online informed consent form hosted on UBC ARC REDCap. This consent was reaffirmed verbally immediately before the start of each interview, whether conducted in person or via video conference. Participants were informed of their right to decline any question or to withdraw from the study at any point without consequence. These procedures ensured that participants clearly understood their rights and the voluntary nature of their involvement throughout the research process. As part of the consent process, participants were invited to provide a pseudonym to protect their identity. In cases where no pseudonym was provided, one was assigned by the research team. Researchers retained the discretion to modify pseudonyms when necessary and informed participants that this might occur; for example, if a name closely resembled another participant’s or risked inadvertently identifying the individual or others in their community. These steps were implemented to maintain both participant confidentiality and the integrity of the dataset. 35 The transcripts were de-identified and assigned unique identification codes, with all personally identifiable information removed. Participants were given the opportunity to review their transcripts, allowing them to verify the accuracy and contextual fidelity of their contributions. Although not all participants opted to review their transcripts, the offer was part of a broader commitment to relational ethics and participant agency. In line with UBC’s data management policies, all research materials were securely retained and will be stored for a period of five years. Electronic files, including audio recordings and transcripts, were encrypted and saved on password-protected servers. Documents, such as consent forms and handwritten or electronic notes, were securely stored, accessible only to authorised research personnel. These procedures underscored a strong commitment to ensuring the privacy, safety, and ethical stewardship of participant data throughout the study. 3.10 Researcher Positionality and Reflexivity As an underrepresented member of the GBTMSM+ community, I brought a deeply personal commitment to this research, shaped by my lived experience and ongoing engagement with community-based health equity work. My positionality as an insider allowed me to approach this study with cultural competency and a sense of ethical responsibility, ensuring that participants’ voices were authentically represented. At the same time, I recognised that my role as a nursing professional and academic researcher positioned me as a partial outsider: one informed by disciplinary training and institutional context. In this project, I occupied multiple roles, including interviewer, data coder or analyst, and author of this primary analysis. I personally conducted the majority of the interviews of my thesis participants. I also collaborated with my colleagues to accuracy-check the interview transcripts, further ensuring the trustworthiness and fidelity of the data. These responsibilities 36 afforded me close engagement with the data and deepened my reflexive awareness throughout the research process. Throughout the data collection and analytic process, I engaged in continuous reflexive practice, primarily through maintaining personal journals after each interview. These journals became a space for critically reflecting on my interactions with participants, my emotional responses, and the nuanced interpersonal dynamics that shaped the research encounter. While I also took observational fieldnotes, I ultimately chose not to include them in the analysis, as they were more descriptive than interpretive. Instead, my reflexive journaling provided the most valuable lens for examining how my identity, assumptions, and evolving interpretations influenced the research process. This commitment to reflexivity became particularly significant during the analytic and writing phases, when I began to recognise conceptual tensions within the data, especially surrounding identity, marginalisation, and classification. Although I had structured patterns from participants’ narratives, I lacked the theoretical vocabulary to fully name or interrogate them. I treated this not as a limitation but as a generative moment in the analytic journey, consistent with the focal sensibilities of ID (Thorne, 2016) and RTA (Braun & Clarke, 2021). Through deeper engagement with relevant literature as my analysis evolved, I also encountered additive thinking (Crenshaw, 1991) and monolithic representation (Collins & Bilge, 2016; Collins et al., 2021), which helped illuminate the ways participants’ experiences were not merely shaped by multiple forms of exclusion, but by intersecting systems of reductive classification. Further, I am acutely aware of the limitations of terms like “MSM+,” particularly in how they flatten complex, diverse gender and sexual identities. During the 2022–2023 mpox outbreak, public health messaging often relied on the epidemiological term “MSM+” as a 37 primary risk category. While this framing may have been epidemiologically justified, it often erased the lived realities of gender-diverse individuals, especially transwomen and non-binary people, who were grouped under a term that did not reflect their self-identification or individualised experiences. In this thesis, I use the term “GBTMSM+” to reflect the language adopted by public health authorities during the aforementioned outbreak period, while signalling a critical stance toward its limitations. The “+” is used intentionally to acknowledge those whose identities, practices, and risks placed them within the scope of public health response, but who may not identify with the label “MSM.” Participants in this study themselves raised these concerns, with some challenging the reductive nature of this classification and describing the ways it erased their identities and contexts. My goal in using “GBTMSM+” is not to reinforce this terminology, but rather to engage with it critically, make its limitations visible, and, where possible, support shifts toward a more non-monolithic, community-informed language in public health and research. Reflexivity in this study was not treated as a discrete step but as a continuous, relational, and epistemological commitment. It shaped the interpretation of data, the construction of themes, and the navigation of dualities between belonging to the community under study and remaining accountable to academic and research standards. This layered positionality enriched the research process, strengthening the analytic integrity and contextual sensitivity of the findings. 3.11 Knowledge Translation The findings of this study will be disseminated through a multifaceted Knowledge Translation and Exchange (KTE) strategy developed in close collaboration with key community partners and public health stakeholders. Distribution will include presentations, online platforms, 38 printed materials, and community-led events, with the goal of reaching both GBTMSM+ community members and healthcare professionals, particularly those who may not be well-versed in 2S/LGBTQIA+ competent and affirming care. Partnerships with organisations such as HIM, TCBC, and the Ribbon Community, as well as institutional stakeholders like the British Columbia Centre for Disease Control and Prevention (BCCDC) and vaccine researchers, will be central to shaping and implementing the dissemination plan. These focal collaborators will support the translation of findings into practical, accessible formats that reach immunisers, public health personnel, and community members across various channels. Dissemination will also be facilitated through the Community-Based Research Centre (CBRC) and HIM, whose networks and outreach infrastructure can amplify reach within the broader GBTMSM+ community. Physical materials such as posters and pamphlets will be distributed at major events, including Pride festivals, where stalls or booths can serve as accessible points for sharing findings with engaged audiences. In addition, clinics serving 2S/LGBTQIA+ populations will be targeted as strategic venues for further dissemination, ensuring access for individuals who may not be as engaged online. Beyond physical venues, dissemination will leverage the social media platforms operated by community partners, allowing for targeted, interactive messaging and broader audience engagement. These digital strategies will help ensure that research findings remain visible, accessible, and relevant, thereby supporting community engagement even beyond in-person events. Recognising that community partners are experts within their own contexts, dissemination efforts will remain collaborative and responsive. All knowledge exchange 39 activities and materials will be tailored to meet the specific needs and requests of these organisations, including the possibility of co-developing messaging, translating findings into plain language, and hosting educational workshops to address topics of concern raised by the study. These workshops will be opportunities to share findings and foster community-led dialogue around stigma, vaccine access, and public health messaging. For larger-scale KTE projects that extend beyond the initial project's scope, additional funding may be sought through sources such as Health Research BC grants. These efforts will be grounded in the understanding that effective KTE relies on reciprocal relationships and prioritises accessibility, accountability, and actionable outcomes. Most importantly, this KTE strategy aims to ensure that study findings are shared and actively used to inform community-led initiatives and interventions, promoting equity, amplifying the voices of underrepresented individuals, and supporting improvements in public health practice. 40 Chapter 4: Findings 4.1 Overview In this chapter, I weave a nuanced narrative of trust, stigma, constraint, and agency as experienced by underserved key groups navigating the mpox vaccine landscape. Central to this account are the tensions between eroded trust due to systemic neglect and efforts to rebuild it through community action and care ethics. Participants’ stories also surface the structural and communicative forces that both facilitated and deterred vaccine uptake, alongside the intersecting stigmas faced by those living at the margins, whether as IBPOC, sex workers, trans-individuals, or people living with HIV/AIDS. This analysis incorporated the HSDF (Stangl et al., 2019) as a subsequent analytical lens, applying it to examine multi-level stigma processes intersecting with race, gender, sexuality, HIV status, and sex work in shaping mpox vaccine-related decision-making and healthcare engagement. Its relevance is most apparent in the final theme, where the framework highlights the complex and layered nature of these intersections. The HSDF is introduced here in broad terms, setting the stage for the Discussion chapter, where its analytic contribution and resonance with the findings are explored in greater depth. Through this analytic process, I developed a thematic interpretation that examines the interplay of agency, constraint, and relationality across individual, community, and systemic levels. These insights are synthesised in a visual conceptualisation presented at the close of this chapter. The Tethered Flight metaphor (Appendix A) serves as a heuristic device, capturing the wind-like forces that shape public health engagement among underrepresented GBTMSM+ individuals, referred to here as Tethered Flyers, in the context of mpox vaccination. Its utility 41 threads through the findings, with imagery of turbulence, shifting flight paths, and taut or frayed tethers reflecting the varying conditions that shape vaccine engagement. Five core themes and eight subthemes, developed through Braun & Clarke’s (2021) RTA and grounded in Thorne’s (2016) ID, guide the presentation of findings. These themes are expressed through narrative arcs that illustrate how personal experiences intersect with social and systemic structures. Each theme includes illustrative participant quotes, attention to embedded subthemes, and interpretive bridges that highlight the interconnectedness of the findings. Some excerpts appear across multiple themes, reflecting the ways lived realities often cut across domains of healthcare access, stigma, trust, and community resistance. These findings offer insight into the complex, intersectional conditions that shape mpox prevention. 4.2 Sample Population This study engaged fourteen participants. Each is represented by a pseudonym to honour and humanise their voices while protecting their confidentiality. Participant ages ranged from the early 20s to the early 70s, with the majority in their 30s and 50s. While most participants were based in Vancouver, others lived in nearby regions, including inner and outer suburbs, Victoria, Richmond, Burnaby, Delta, and islands off the BC mainland. One participant was a community member who also works in the healthcare field. Participants identified across a spectrum of sexual orientations and gender identities within the GBTMSM+ umbrella. Self-described sexualities included gay or homosexual, bisexual, pansexual, asexual, and curious or questioning. Many participants identified as cisgender men and binary transmen, whereas others used more expansive or fluid terms, such as genderfluid or non-binary, to describe their gender identities. 42 The sample reflected considerable racial and ethnic diversity. Participants self-identified as Indigenous, Latino, English-Chinese, Chinese, Indo-Fijian, Filipino (including those of mixed Filipino descent), Jewish, Middle Eastern, Japanese, and Caucasian or White. This diversity across race, gender, and sexuality provided a rich and layered foundation for exploring varied perspectives and experiences related to mpox vaccination. Experiences with transactional sex were disclosed by several participants, including those currently engaged in online adult entertainment work or in-person sexual commerce. One participant described a history of in-person sexual labour. Three participants disclosed living with HIV/AIDS. The sample consisted of diverse participants across spectrums of sexuality, gender identity, race, and occupation, offering a nuanced understanding of the vaccine experience in context. A commitment to honouring lived experiences guided the analytic process, making visible the dynamic forces that shape them. 4.3 Eroded Trust: Systemic Neglect and Social Apathy Participants explicitly expressed deep concerns about historic and ongoing systemic failures in healthcare, shaping the theme of trust erosion rooted in perceived neglect and indifference toward the community. As River reflected: “I feel like if it doesn’t affect a certain demographic with people, they don’t really care […] Okay, this is affecting the gays. It’s not up to us. […] But I mean, are we surprised? Gay people are erased from history all the time!” This remark evokes a collective fatigue rooted in historical patterns of erasure, reinforcing ways that participants understood the mpox outbreak not as an isolated health crisis, but as part of a longer continuum of marginalisation. Echoing this, Minion questioned the inequities in public health response: “How come people […] can ask for a proof to enter a restaurant […] that we are vaccinated for COVID, but 43 no one is caring about monkeypox?” This contrast highlights a sense of disposability felt by participants, as the protections extended to the broader public during the COVID-19 pandemic were perceived as conspicuously absent in the face of a virus that disproportionately affected their community. Building on perceived neglect and apathy rooted in perceptions of urgency, Carey voiced a fear that the mpox outbreak might mirror the early days of the HIV/AIDS crisis: “Oh, my God, are we going to have another like HIV/AIDS thing […] because it seems to mostly quote-unquote ‘target’ […] [MSM]. Are they just going to ignore this and everything?” This sense of historical repetition, where queer lives are again rendered peripheral in times of public health emergency, surfaced repeatedly across participant narratives. Those with lived experience in healthcare delivery and queer communities described deep disillusionment with institutional responses: “How can we work in a healthcare system that refuses to provide care for us, as queer people? […] Decisions not based on ethics but based on convenience” (Cedar). A morally distressing incident, where a local clinic discontinued mpox testing due to bureaucratic delays and logistical inefficiencies, rather than clinical constraints, fueled Cedar’s disillusionment. Cedar’s attempts to escalate concerns to public health institutions were met with indifference: “I’ve mentioned this to people at [the organisation] and they were, like, ‘Oh, I didn’t know that happened.’” The emotional toll was profound: “This is the only time I’ve walked out of my job in my career […] Perhaps because I was on the verge of a panic attack.” These accounts reveal that systemic failures are experienced by those seeking care and community members working within the system, particularly when bureaucratic vaccine-related decision-making is perceived as prioritising convenience over ethical obligation. Such failures 44 can erode the already fragile trust and amplify both burnout and moral injury for individuals positioned within overlapping roles of marginalisation and responsibility. This sense of abandonment extended beyond formal institutions into participants’ social and professional environments, where silence or ignorance about mpox contributed to deep feelings of isolation. As Kai described, “In my […] places of occupation […] there was this wave of blissful ignorance […] I had to sort of be the vehicle of carrying [mpox-related] information.” Jordan echoed the same dynamics: “Well, because most of my friends are not gay […] I don’t remember discussing [the mpox or its vaccine] with anybody […] other than my partner.” Curious or questioning folks also emphasised this disconnect: “[Mpox] wasn’t discussed at all between [non-GBTMSM+] friends, family, [and] close friends.” (Michael). These stories reveal instances where the perceived irrelevance of mpox to non-community members shaped a silence that participants had to navigate largely on their own. In turn, participants navigated inadequate systems while acting as informal health educators, translating, contextualising, and advocating for information in spaces where institutional responses had failed and social support was lacking. Some participants described perceived neglect and indifference as extending beyond institutional inaction during the outbreak’s onset, persisting into the aftermath, particularly when post-vaccine and safety follow-up failed to occur. As Carey reflected, “It just feels so bad that they didn’t think to do that […] or that they chose not to. It really felt like, ‘Well, have fun with that.’ It felt pointed that they chose not to do that.” River paralleled this frustration: “I do find it a little funny that [Laughs] it was because it’s […] the gays’ getting it, that they weren’t like, ‘Oh, we should probably do this too,’ even though they do it for everything else.” These reflections suggest that institutional neglect was not merely a relic of past epidemics, but an active 45 destabilising force that shaped the ways participants experienced and interpreted public health decisions in real time. In moments when care was most needed — or more pointedly, withheld — some institutions appeared to deliberately erode trust rather than foster it. These narratives point to more than a failure of outreach or logistics; they reveal a patterned exclusion from the logics of care, where urgency, visibility, and action remain conditional. In this context, trust could not be assumed or gradually repaired; community members had to actively reclaim it. Much like the tension of a tether attached to a kite (Appendix A), trust determined the strength and stability of one’s connection to care; when frayed by neglect or apathy, the ability to stay aloft amidst systemic turbulence became increasingly precarious. 4.4 Building Trust: Confidence, Collective Action, and Care Ethics Despite widespread accounts of eroded trust, many participants described moments where trust was actively rebuilt, particularly in response to public health actions that felt timely, inclusive, and affirming. Coco, for instance, described being “quite impressed at the rapidity and [support toward] the whole vaccination, […] bringing the care to the people who needed it.” Rather than being overlooked or deprioritised, Carey expressed feeling genuinely seen: “The queer community was super like ‘awesome’ […] they’re actually taking steps now. […] ‘Oh my God, they got the vaccine out so fast. This is amazing!’” Benjamin reiterated: “The vaccination programs were being rolled out so quickly […] the government was looking after us this time!” For folks living with HIV/AIDS and navigating care across provincial boundaries, consistent follow-up affirmed their dignity and saved their life: “[The healthcare team] just wanted to make sure that I was taking care of myself […] I probably wouldn’t be standing here today if I didn’t have such good follow-up” (Marc). Having received two doses of the mpox 46 vaccine through outreach initiatives, Marc expressed profound gratitude: “[B.C.’s mpox vaccination rollout tactics] were wonderful. They kept me alive. I’m really grateful to the Province of B.C. […] We’re very lucky to be here.” These reflections underscore that trust in public health can be rekindled through sustained engagement, visibility, and tangible expressions of care that affirm the lives of those who have been historically overlooked. Other participants illustrated that trust in the mpox vaccine did not need to be rebuilt, as it was already embedded in a broader, long-standing commitment to public health and preventive care. For example, Carey reflected on their lifelong belief in vaccine value: “[…] so through my whole life, I’ve just [gotten] my flu shot every year […] because you didn’t want to get sick, and you didn’t want other people to get sick.” This habitual practice reflects a deeply internalised ethic of care that extended beyond personal protection to encompass a sense of responsibility for the health of others. This internalised orientation toward vaccination also mirrored broader shifts in the reception and discussion of mpox within the community. Instead of being marked by fear, shame, or silence, these responses reflected a stabilising force (Appendix A) — akin to favourable winds that enable a kite to rise with balance and direction. 4.4.1 Positive Attitudes Towards Mpox Vaccination This subtheme of positive attitudes accentuated elements beyond institutional trust as participants shared evolving personal and community attitudes toward the mpox vaccine. As Coco observed, “It wasn’t shameful or anything like that […] It was talked about very, very openly, like any other vaccine should be.” This openness represented a shift from hesitancy to collective affirmation, where vaccination became normalised as an act of shared responsibility. 47 This positive shift carried a sense of urgency and pragmatism, as people actively embraced the vaccine as a straightforward way to protect themselves and others: “Like once [the mpox vaccine is] available, you just got to get it” (River). Social influence also played a key role in reinforcing positive attitudes toward mpox vaccination: “[…] it was nice to see that a lot of people were getting vaccinated” (Jordan). This points to the subtle yet powerful impact of witnessing peers take part in preventative care. For Carey, this direct and affirming influence became a stabilising force: “I definitely talked about [the vaccine] with some friends […] because they know [I’m a sex worker] and […] they were super supportive.” These accounts underscore the importance of peer networks in shaping vaccine acceptance by normalising participation and emotionally validating health-seeking behaviours. A strong belief in medical science and an enduring trust in Canada’s public health infrastructure further reinforced this positive shift in vaccine attitudes: “I’m totally comfortable with the safety of vaccines in Canada. […] I’m fully on board with the safety and the necessity of being vaccinated” (Benjamin). This signals a deep-seated trust in biomedical interventions and the broader regulatory and health governance systems responsible for ensuring public safety. Kai offered a similar reflection: “In hindsight, I’m thinking I might have gone into [receiving the mpox vaccine] a little bit more ignorantly, if you will, but I was just happy that there was a vaccine. […] I just sort of trusted the process.” Here, trust functioned as a bridge, allowing for immediate vaccine uptake even in the absence of full information: an account echoed by others who described faith in both past experiences and established public health protocols. Coco emphatically expressed his trust in the scientific foundations of the mpox vaccine: “I trust science! [Laughs] I trust science that […] built or put the vaccine together to be effective 48 to help us.” This sentiment reflects an underlying confidence in both the institutional processes and technical expertise behind vaccine development, suggesting that scientific credibility itself served as a stabilising force amid uncertainty. Jordan also remarked, “I trust that a lot of precautions are taken, you know, before [a vaccine] is made available.” The placement of trust in the regulatory safeguards and protocols that precede public access to vaccines indicates an awareness of and confidence in the ethical and procedural diligence of the healthcare system. In this regard, science itself became a trusted actor, reinforcing confidence in the mpox vaccine as both a safe and necessary intervention. Kai developed positive attitudes toward the mpox vaccine through active reinforcement of affirming professional and social environments: “I had surrounded myself with […] social workers, nurses, epidemiologists […] I was very much insulated in that sphere. […] Because of that normalisation, it was easy for me to then go [get vaccinated].” Here, Kai’s proximity to credible, values-aligned sources who helped normalise preventative care solidified his trust in the vaccine. Kai went on to describe his own vaccination decision as part of a broader ripple effect, stating, “I had thought that if I can model just how this is just a normal thing […] then my other friends and family members would go and do the same.” This reflection illustrates the ways positive health behaviours can diffuse through trusted social channels, especially when modelled by community members who straddle multiple spheres of influence. For PLWH, they regarded the receipt of the mpox vaccine as both a logical health decision and an essential act of self-preservation: “I’m always pro-vaccine, because I want to live. […] If the doctors are offering me something to help me, I’m always willing to [take them]” (Marc). This statement speaks to more than just biomedical compliance, as it reflects a learned vigilance: an instinctive calibration of risk and resilience. Rainor highlighted the same sentiment: 49 “[My doctor], […] not that he’s God, but […] I listen to what he says, because I trust that he has my best interests in his hands.” This sense of relational trust served as a counterweight to the historical betrayals experienced by many PLWH in clinical settings. Experiences of health vulnerability and caregiving also shaped vaccine acceptance among those without direct histories of medical marginalisation. Carey reflected: “[Having grown up with] all three adults [who are] immunocompromised […],” the decision to vaccinate carried both practical and emotional significance. Despite Carey’s tone remaining lighthearted: “Just because you grew up not getting [vaccinated] doesn’t mean you shouldn’t […] you want to visit Grandma without getting Grandma sick? How about you do that? [Laughs],” the underlying message conveyed a serious point: preventative action is a moral imperative. These reflections illustrate that accumulated lived experiences and deeply held commitments to familial well-being shaped the trust in the mpox vaccine. These accounts of positive vaccine orientation reflect not only satisfaction with the vaccine itself, but also participants’ experiences of supportive and affirming encounters with public health. They point to a fundamental shift from marginalisation toward meaningful recognition, where participants felt seen, heard, and cared for in ways that disrupted long-standing patterns of exclusion. As many participants framed their decisions as relational and community-driven, the next subtheme highlights the importance of collective action in building and reclaiming trust amidst structural headwinds: winds that blow directly against the intended path of travel, reducing speed and increasing resistance (Skybrary Aviation Safety, n.d.). 4.4.2 Community’s Proactive & Justice-Oriented Approach to Health Decision-Making This subtheme highlights the strength of peer networks, collective knowledge, and an insider-outsider perspective in shaping proactive health behaviours and advocating for ethics-50 driven institutional decisions. Participants described mpox vaccine uptake as an intentional, relational act grounded in care for themselves and their communities. As Coco expressed, “It wasn’t a question of getting vaccinated or not. It was just something you do. You take care of yourself. You take care of your friends and others […] it’s part of the common good to society today.” This framing reveals a moral clarity where vaccination is embedded within broader social obligations. Carey reinforced the same thought: “I don’t want to hurt other people around me […] even if I don’t actually have myself at risk of an exposure, I’m still helping overall by getting [vaccinated].” River echoed this standpoint decisively: “Get this vaccine [so] we can kind of stop this from getting much worse. You know what? Just jab it into my arm and we’re good!” These reflections underscore a shared ethic of relational care through outbreak containment, where vaccination was not framed through an individual risk-benefit lens, but through a responsibility to protect one another. Kai noted that queer communities have long relied on each other amid institutional inaction: “Queer folks […] are very aware of how certain epidemics or pandemics disproportionately impact them […] so I would [strongly encourage] people that were in my closest circles […] to go get the vaccine where it was available.” In this regard, people made health decisions not simply as individuals but through relational practices, grounded in shared memory and collective care. Benjamin highlighted this collective care as seen on digital platforms: “It was all on the gay social media, and friends, and everybody saying […] ‘Did you get your vaccine?’ […] it was like, we’re all in this together!” This framing reveals that the normalisation of vaccine uptake became a source of pride, solidarity, and mutual accountability. 51 Neil recalled a communal enthusiasm: “I think we were quite relieved when we did get [the mpox vaccine] […] Pride was coming up […] and we could possibly get infected, so it was important [to get vaccinated].” Neil added, “All my friends got it! When I went to get my shots, it was packed. It was like the hottest place in the city. [Laughs] I feel like we really turned up for that.” These stories depict a broader ethic of shared responsibility, framing vaccination as both a protective measure and a celebratory moment. For PLWH, vaccination carried additional moral weight: “I think [vaccines] should be mandatory […] because you don’t know what other people’s immunity’s like, or what they’re already fighting” (Marc). These accounts emphasise that public health engagement within layered GBTMSM+ communities grew from deeply relational motivations, as driven by responsibility and a commitment to communal well-being. Cedar described tensions that emerged when institutional directives conflicted with community needs, recalling being instructed to discard unused vaccines nearing expiration despite awareness of at-risk individuals just outside formal eligibility criteria. As Cedar stated, “We’re not [going to] throw out vaccines. That’s ridiculous!’ […] To throw it out versus give it to someone [who needs it].” Instead, the care team notified gender-diverse individuals and others facing heightened risk, offering remaining doses. Cedar further reflected, “[…] If we’re [going to] literally throw [vaccines] out and a second dose is recommended, but it’s restricted due to shortage of supply, I don’t feel like it’s ethical to throw out vaccines, […] which we were instructed to do.” This account illustrates how rigid and insufficiently community-informed policies can erode trust, whereas community-rooted decision-making fosters more ethical, responsive, and justice-oriented public health practices. In addition, Cedar raised concerns about the lack of racial representation and equitable outreach. Reflecting on patterns observed at Cedar’s occupational setting: “At [my workplace] 52 we would see [a] fairly large number of men of colour, Southeast Asian, South Asian […] men. And not many, but some Black men.” However, Cedar described a vaccination session held around that same area and expressed frustration at the visible lack of diversity: “[…] but at this particular vaccine session […] I could see [the] lack of diversity in the room. It was very frustrating.” This observation highlights a significant disconnect between the demographic realities of the GBTMSM+ population accessing care and the more limited representation noted within the vaccine rollout. These stories depict a community not merely reacting to public health initiatives, but actively shaping its own health outcomes, drawing on a deep-rooted culture of care, informed action, and ethics-based advocacy. In both practice and principle, this communal orientation reflects a justice-oriented ethic of advocacy and care, propelling health engagement and providing an updraft that counters the destabilising forces of systemic exclusion. 4.5 Facilitating Uptake: Agency, Networks, & Grassroots Outreach Mpox vaccination decision-making reflected a series of direct and indirect interactions across individual, community, and systemic levels, resembling wind conditions that could accelerate, redirect, or ground community members’ flight towards vaccine uptake (Appendix A). This theme explores the multi-level forces that facilitated vaccine uptake, highlighting the crucial roles of individual motivators, social influence, and community-based efforts. 4.5.1 Individual and Grassroots Motivators Bolstering Vaccine Uptake Rather than being passively guided by institutional messaging, this subtheme unpacks what many participants described as a proactive orientation toward receipt of mpox vaccine, marked by individual conviction and community-rooted values. 53 4.5.1.1 Individual Enablers. Participants repeatedly identified sexual health, social connectivity, and the desire to return to pre-outbreak routines as key motivators: “[…] It wasn’t even the campaigns that got people to get their vaccinations. […] It was people wanting to get back to hooking up that, […] like, ‘Okay, I need to get my vaccine so that I can get back to it’” (River). This sentiment captures the intricate interplay of desire, risk, and personal responsibility, highlighting the ways vaccine uptake often serves as a means of balancing safety and pleasure simultaneously. Coco distilled the vaccination decision-making process into something remarkably intuitive: “Well, the vaccine was something you wanted to get [Laughs], and mpox was something you didn’t want to get!” Beneath the light-hearted delivery lies a pragmatic stance informed by lived experience and an embodied awareness of risk. Coco’s framing speaks to the clarity that can emerge when public health messaging aligns with lived realities: where the perceived benefit of action (mpox vaccination) clearly outweighs the risk of inaction (potentially contracting mpox). Within this logic, vaccine acceptance emerges as a natural extension of one’s commitment to community and self-care, reinforcing the idea that preventative health behaviours can feel instinctive rather than complicated. Instead of relying on general online searches or informal social media discourse, participants prioritised public health authorities’ sources and evidence-based platforms: “I would usually […] look at BCCDC website or something like WebMD […] where they would have hopefully trusted medical facts” (Coco). Paralleling this, Jordan described a pragmatic, efficiency-driven approach to online information seeking, relying on search engines like Google not as a source in itself, but as a tool to access credible, locally anchored information: “It was literally just Google ‘Mpox vaccine’ […] and I do remember it being a very official, […] a local 54 or Canadian source.” These testimonies reflect a selective trust in digital infrastructure, dependent not on the platform’s popularity, but on its capacity to deliver reputable content linked to public health organisations. Benjamin emphasised a similar desire for factual clarity devoid of personal commentary or ideological spin, stating, “I don’t want anybody’s opinion. I want facts.” Jordan added, “Social media [was avoided], for sure, […] [as] it’s hard to know what’s real and what isn’t,” reinforcing the idea that these platforms were not designed to handle the nuance or credibility required during a public health crisis. These accounts illustrate a consistent pattern of avoiding emotionally charged or speculative discourse, particularly that which proliferates in algorithm-driven digital information sources, where content is amplified based on engagement metrics rather than credibility. However, the valuation of official sources did not preclude a recognition of their limitations. Kai actively sought to balance high-level information with insights from grassroots or community-specific channels: “I really had to pay attention to some more grassroots organisations […] to fact check […] not just looking at macro-organisations.” Such an approach speaks to a sophisticated form of media literacy: one that resists over-reliance on any single channel and, instead, assembles a more holistic and context-responsive understanding of vaccine access and eligibility. For some, the lessons drawn from COVID-19 became part of a personal health ethic: “I’d like to consider myself as someone who’s very proactive when it comes to vaccines, in the same way that I sort of dealt with the COVID-19 pandemic vaccines” (Kai). Jordan echoed this orientation, emphasising the pace at which communities mobilised: “[…] [In getting the] COVID [vaccines], […] [we were] […] the first one to jump on it. […] It was the same with [the mpox 55 vaccine].” Benjamin mirrored the same sentiment with a mix of humour and urgency: “It was the same kind of thing with COVID […] Like once you hear that […] there’s a vaccine available […] ‘Okay, now what? When and where [Laughs]?’” These narratives show that COVID-19 not only formed the backdrop, but also actively shaped experiences, both behaviourally and structurally. Participants’ prior experiences equipped them with the tools to navigate mpox-related risk with increased vigilance and trust. The pandemic fostered a new normal wherein rapid vaccination campaigns, public health messaging, and peer discourse around vaccines were expected and familiar. In essence, the mpox vaccine did not feel novel or disruptive; it felt continuous with a broader public health trajectory already tethered to the collective consciousness of many GBTMSM+ individuals. 4.5.1.2 Grassroots Enablers. Participants frequently cited organisations such as Health Initiative for Men (HIM) and the Community-Based Research Centre (CBRC), a 2S/LGBTQIA+-focused health organisation known for community-driven research and advocacy, for delivering culturally attuned and strategically targeted communication. Carey reflected: “I remember like the HIM clinic, and was it CBRC? […] the health organisations were pushing [mpox vaccine campaigns] on Instagram, Twitter, and Facebook.” This emphasis on multi-platform visibility underscores the moments that community-rooted institutions were familiar to participants and seen as legitimate vehicles of health information. Their online presence mirrored the digital landscapes in which many GBTMSM+ individuals engage, allowing the dissemination of vaccine messaging to align with community norms and habits. Jordan recounted: “[…] Seeing the [mpox campaigns] on the Instagram, I mean, obviously […] it’s Health Initiative for Men, so it was pretty clear from there.” This suggests that the message’s effectiveness hinged on its messenger, precisely because it came 56 from community-rooted organisations with longstanding reputations for GBTMSM+ competent and affirming care. Neil also underscored the tangible outcomes of these campaigns: “I guess they did a good job because it got a lot of people out and got their vaccines for it. […] It was definitely visible, and I think [the outbreak] [was] kept at bay.” In this context, the phrase “kept at bay” conveyed that the outbreak remained effectively contained, thanks in part to the high visibility and accessibility of the vaccination campaigns within trusted spaces. Beyond digital platforms, the physical environment emerged as a crucial vehicle for vaccine promotion: an embodied space where information could be encountered organically in the rhythm of daily life. As Michael described, “Mainly at health centres […] like signs [of mpox vaccine] along the street [and] ads, […] when I go to HIM […] they have […] signs up there as well.” Such strategic placement of signage and messaging reflects a low-barrier and deliberate attempt to weave vaccine promotion into the fabric of the GBTMSM+ community life, subtly reinforcing preventative norms while helping to normalise uptake. Joey described the absence of coercive imposition: “They didn’t force people; they just recommended [the mpox vaccine]. That’s the difference, okay? When it’s forced, people don’t want to get it.” Joey’s emphasis on voluntariness and respectful engagement underscores the importance of preserving individual agency in public health efforts. For PLWH, the Dr. Peter Centre, a specialised HIV care and harm reduction facility, and the Ribbon Community, a peer- and community-led support organisation, were critical: “[I heard about the mpox vaccine] here at the […] Ribbon Community [and at] the Dr. Peter Centre. […] The community around them is of most importance, especially […] because a lot of us have compromised immune systems” (Rainor). This highlights that centralised vaccine messaging, when interwoven with routine and community-based care, gained traction by being embedded in 57 trusted and responsive spaces. These HIV/AIDS-focused hubs carried an emotional resonance that proved equally impactful: “I love it here [the Ribbon Community]. I love the volunteers. I think they’re amazing. I […] honestly can say that […] from the bottom of my heart,” Rainor reflected. Such expressions underscore the importance of familiarity, compassion, and continuity in shaping vaccine uptake, as expressions of trust cultivated over time. These accounts suggest that personally meaningful and grassroots-based motivators worked in synergy to enable vaccine uptake. The interplay between personal resolve and community-informed action enabled flight paths toward mpox vaccine uptake (Appendix A), ensuring that decisions were not simply reactive but rooted in intention and belonging. 4.5.2 Peer Influence & Community-Informed Outreach Supporting Vaccine Uptake This subtheme explores the ways that GBTMSM+ individuals leveraged the strength of their social ties and community connections to advocate for mpox vaccination within interwoven circles of friends, chosen families, and peer networks. Rather than waiting for direction from institutional sources, participants often assumed the role of trusted messengers, circulating timely information, sharing personal testimonies, and encouraging others to access preventative care. Within these interconnected social networks, information travelled quickly and persuasively, often spurring immediate action. 4.5.2.1 Peer-Fueled Vaccine Information Mobilisation. Community members’ engagement with social media platforms and offline channels played a pivotal role in vaccine-related communication, functioning as swift and responsive information dissemination webs. Instagram functioned as a key source of real-time updates regarding vaccine availability: “I believe it was actually Instagram […] saying that they had the first doses available […] so I immediately just asked my spouse, ‘Let’s go get this’” (Jordan). This immediacy of action 58 underscores instances when digital networks enabled rapid mobilisation within personal circles, particularly when formal institutional outreach remained less visible. Carey emphasised the heightened effectiveness of informal peer communication over official campaigns: “I definitely saw more of a push from actual friends and community members talking about [the mpox vaccine],” highlighting the trust and resonance embedded in peer-led dialogue. For Neil, the amplification of 2S/LGBTQIA+ voices and values reverberated within a curated digital environment offering both motivation and immediacy to support vaccine uptake. “I’m in this like bubble where other 2S/LGBTQIA+-inclusive accounts […] on my feed […] talked about […] [community] concern, safety, and health” (Neil). In some cases, these personal and digital networks transcended the role of passive information conduits and became active mobilisers. As Coco described: “One friend sent me a text message that there was a pop-up clinic at the top of Trail Seven at Wreck Beach, so I sent messages to a couple other friends […] and […] some of us had it done there.” Chris, who noted challenges with English communication, shared a similar experience: “So [we have this] group [chat, where my peers] exchange […] vaccination [information and] […] where it’s free [to get it].” This reflection highlights the role of linguistically inclusive peer networks in functioning as informal yet vital information hubs, enabling individuals to share resources, clarify access points, and collectively reduce barriers to vaccination. Interpersonal trust extended the reach of peer-based advocacy by anchoring it within structured yet affirming environments that were both physically accessible and culturally attuned. As the socio-symbolic air currents of interpersonal trust carried individuals aloft, community organisations bolstered their tethers (Appendix A), offering timely information and tangible pathways to vaccination that respected identity, autonomy, and lived experience. 59 4.5.2.2 Community-Powered Vaccine Outreach. Participants consistently credited the HIM organisation as one of the most trusted and frequently cited sources of mpox vaccine information and access, recognising it for its leading communication and outreach efforts tailored to the GBTMSM+ community throughout this period. As Chris recounted, “I went [to HIM Clinic] for [an] STI test, and […] the nurse [suggested to get the mpox vaccine],” illustrating preventative care as seamlessly integrated into routine clinical interactions. Jordan reiterated this by turning to HIM’s digital platforms as a reliable source of up-to-date vaccine information: “Because I was checking on the HIM online […] they had the first doses available, and there was an online booking [system].” Benjamin paralleled this, noting, “I think the only one I remember is notifications from HIM […] that continued to remind people that we should be vaccinated,” emphasising that consistent digital nudges helped sustain awareness over time. Participants also highlighted the consistent presence of visual messaging within HIM’s physical clinic spaces: “When I go to HIM, the Health Initiative for Men, […] I’d always [see the campaigns] while I’m like waiting” (Michael). Such visibility created an environment where information was available and woven into the clinic experience itself, normalising prevention through repetition and familiarity. In addition to its fixed sites, HIM’s presence extended into the broader community through mobile units and pop-up clinics, which brought services directly to where people gathered. As Cedar explained: “HIM really mobilised with Vancouver Coastal Health well, doing really significant outreach […] in Stanley Park […] bath houses, at gay bars, […] at Wreck Beach, […] [reaching] people that traditionally wouldn’t go into the clinic.” During the initial phases of outbreak, participants recognised HIM as the only organisation conducting sustained and visible public-facing campaigns tailored to GBTMSM+ individuals: “Well, the only campaigns I was seeing […] was by HIM. I didn’t see campaigns 60 from the Provincial Health or other health organisations” (Minion). This observation points to a significant gap in broader public health messaging and highlights the critical role of community-based organisations in filling that void. The Ribbon Community, formerly AIDS Vancouver, also earned recognition for its Corner Program and, alongside the Dr. Peter Centre, provided trusted spaces that delivered quality care through competent and affirming interactions. Rainor recounted: “They’re just kind of like the health of the community around them is of most importance […] because a lot of us have compromised immune systems.” Rainor added, “For people in the know […] places like the Corner, […] I feel [that] they were very educated in helping us decide […] what we wanted to do about [the mpox vaccine].” These reflections illustrate that these community-based organisations acted as anchors of health literacy and affirming support, particularly for individuals who might otherwise fall through institutional cracks. Community-led efforts further extended beyond visibility within urban centres to include mobile and outreach-based services tailored to those living outside major metropolitan areas: “In Kelowna, the outreach clinics, like Urban Health Outreach […] [and] Living Positive, […] had some advertisement […] where it’s affiliated with HIV and whatnot” (Marc). These HIV-oriented local organisations functioned as accessible points of entry for broader vaccine education and delivery. For Marc, these community efforts are seen as critical: “Living Positive in Kelowna is an outreach program […] where they help [PLWH]. […] I was like homeless, but they came to me in the park. […] I got my pneumovax, my mpox, and my flu shot.” This model of direct engagement circumvented common access barriers, such as unstable housing, transportation limitations, and rigid service gatekeeping. 61 Having lived with AIDS for years, Marc further reflected on the significance of follow-up care: “Basically, […] the voicemail would just be like an outreach team calling me and just saying, you know, in a kind manner […] ‘Would you like to come talk to us?’ or […] ‘Have you gotten [the vaccine]?’” These seemingly simple inquiries carried emotional weight, offered as respectful invitations that conveyed care, dignity, and genuine concern for Marc’s well-being. Instead of perceiving such contact as intrusive or clinical, Marc interpreted it as life-affirming: “Because sometimes as a homeless person, or a drug user, we forget, […] so you know, I probably wouldn’t be standing here today if I didn’t have such good follow-up.” These stories illustrate the power of low-barrier, person-centred care models that reach out rather than wait for individuals to seek services, meeting people where they are, both geographically and psychosocially. 4.5.2.3 Affirming Interactions in Vaccine Delivery Settings. The quality of interpersonal interactions and environmental conditions at vaccination sites acted as a recurring enabler of mpox vaccine receipt. These experiences played a critical role in building trust, reducing anxiety, and normalising the vaccination process. As River shared, “The […] nurses were great. They were knowledgeable.” Another added, “[…] [the immunisers were] helpful, and they had answered the questions that I asked” (Coco). In several cases, the clarity and affirming tone used by health professionals helped reduce fear and fostered a sense of comfort: “I appreciated […] just the compassion. I always find nurses very compassionate, and very reassuring in a way […] particularly for monkeypox” (Jordan). Michael noted the valuation of autonomy, describing the approach as informative and supportive: “They weren’t […] forceful on it […] but they’re like, ‘We do recommend it and yeah, you know, it’s free to get!’” 62 The emotional tone of clinics also mattered. Benjamin described the environments as positive and communal: “It seemed the people were very efficient and welcoming. […] It wasn’t traumatic at all. […] There was sort of some camaraderie with the people waiting. […] We’re all in this together!” Another highlighted: “It was smooth, and then it was very friendly […] [the nurse] offered a hand if she wants to carry my jacket […] they asked me to stay a little bit […] and then we chitchatted a little bit” (Minion). These relaxed and friendly encounters helped reframe vaccination as something informal, social, and approachable. Friendly reminders and competent follow-up also supported continued uptake: “[The nurses] were great at answering. I think they were quite friendly. And they probably were the ones that told me I have to come back for a second shot” (Neil). These narratives demonstrate that the affective quality of the vaccination experience, marked by compassion, clarity, and casual friendliness, functioned as a crucial facilitator in participants’ willingness to engage with mpox vaccination efforts. In these moments, the transactional nature of vaccine delivery felt tethered to care, dignity, and relational trust. Even as some experienced moments of ethical clarity and collective alignment, others saw their trajectories disrupted, their paths to mpox vaccination snagging on the very structures meant to support them, a dynamic explored in the following theme. 4.6 Deterring Uptake: Constraints, Confusion, & Harm Alongside the many factors that enabled vaccination, participants identified a range of deterrents that complicated or delayed mpox vaccine access and uptake. This theme unpacks these barriers by tackling the complex interplay of personal, social, and structural dynamics, often shaped by exhaustion, uncertainty, and fractured communication pathways. Doubts about vaccination did not signal opposition to vaccination; rather, they reflected a careful and often 63 burdensome negotiation of perceived risk, community context, and the emotional toll of navigating overlapping public health crises. 4.6.1 Psychosocial Deterrents Impeding Vaccine Uptake This subtheme unravels the recurring narrative among participants centred on the salient psychosocial impediments that undermined motivation to pursue mpox vaccination. These deterrents extended beyond logistical constraints to encompass emotional, interpersonal, and identity-based tensions. These factors contributed to the grounding of the flight toward vaccine uptake, stalling the momentum that might have otherwise lifted individuals into action (Appendix A). 4.6.1.1 Exhaustion Undermining Vaccine Readiness. In contrast to the earlier account of COVID-19 priming some folks for vaccine readiness, a subset of participants described the pandemic as an exhausting headwind: emotionally and psychologically depleting the very energy required to consider yet another round of prevention. Neil recalled: “I think fatigue, because we were still dealing with COVID […] and now [mpox]. […] Frustration […] [on] how much longer do we have to constantly isolate and not be able to […] do things and see people.” Minion described moments when evolving demands of pandemic-era vaccination, particularly changing eligibility criteria and shifting booster timelines, created confusion and wore down initial motivation: “So when the [COVID] vaccine came out, I couldn’t wait until like my turn is to get the first [dose].” However, Minion’s tone shifted: “When they started to say, ‘Oh, you need another shot,’ and then, ‘Oh, you need another booster,’ my opinions [started to change]. […] I stopped with the second shot for COVID. I did not get a booster.” This sense of burnout reverberated socially, echoed in the hesitations of peers and chosen families. 64 Minion described a close friend who “wasn’t an anti-vaccine person,” but who, upon hearing about the mpox vaccine, had “a very hard no to it.” Their shared sentiment — “Enough. Enough vaccines!” — depicts a standpoint not rooted in vaccine resistance, but rather in a palpable exhaustion from the emotional weight of back-to-back health threats. Minion reflected, “Is it [ever] going to be over [?] or […] [Will there] be another thing coming? Like is it a series of viruses and vaccine[s]? Is it going to be a lifestyle for us?” These questions illustrate that the lift required for engagement had vanished, weighed down by the relentless demands of surviving successive crosswinds of uncertainty (Appendix A). 4.6.1.2 Risk of Unwanted Disclosure. One of the more unique deterrents centred on the intradermal route of mpox injection: “[…] People knew that this big welt on your arm was an mpox vaccine. […] Some gay men who were healthcare providers […] had colleagues approach them and be, like, ‘Oh, I thought you were married. Does your husband know?’” (Cedar). In this context, the vaccine mark became more than a routine side effect; it was a visible marker of vulnerability, potentially inviting speculation, judgment, or exposure in both professional and social settings. Cedar further observed that some people actively sought to avoid this form of visibility: “There were some people I vaccinated that explicitly asked not to have this method […] because they didn’t want everyone knowing they had received the [mpox] vaccine.” This form of deterrent reveals a layered convergence of stigma, embodiment, and public health infrastructure, revealing that the decision to get vaccinated became complicated when systems failed to anticipate the risk of misreading, outing, or further marginalising people. Though clinically sound, the vaccine rollout missed key opportunities to implement GBTMSM+-affirming care by overlooking the complexity of socio-political and socio-sexual 65 meanings that bodies carry in public spaces. These textured stories underscore that the delivery of preventative care must extend beyond the point of administration, encompassing stigma-sensitive support and equitable follow-up. 4.6.1.3 Muted & Sensationalised Dialogues. Across participant narratives, a telling silence within social and familial networks underscored the lack of interpersonal lift needed to support vaccine decision-making. As Michael reflected: “[…] One of the main factors why I’ve never gotten [the vaccine] is because […] mpox [was] not discussed at all.” Jordan shared the same sentiment: “Well […] because most of my friends are not gay, or not homosexual […] I don’t remember discussing [the mpox vaccine] with anybody […] other than my partner.” These gaps in conversation downplayed the perceived severity of the outbreak and contributed to a widespread normalisation of inaction, implying that mpox, and by extension its vaccine, was not a public or personal priority. Michael, a curious and questioning participant, added that sexual inactivity with the GBTMSM+ population during the outbreak led to the belief that he was outside the scope of risk: “I haven’t gotten [the vaccine] because I [was not] really like sexually active.” Others, like Carey, referenced peer norms that appeared unconcerned: “Part of my reason for not getting [vaccinated] for a bit was because it seemed like other sex workers and other people weren’t that worried about it.” Rainor also described the trivialisation of the virus in casual conversation: “People were like, ‘Oh, now what? Like, oh, monkeypox, pfft!’ That’s kind of how I remember people on the street discussing it. […] I mean, like [what’s next?] elephantpox? […] snakepox?” These accounts illustrate that psychosocial disengagement, whether due to muted social discourse, perceived irrelevance, or peer ambivalence, functioned as a quiet deterrent. Unlike 66 overt structural barriers, these forces operated subtly, below the surface, yet still carried enough weight to ground individual action. Social silence extended into familial contexts, shaped by a confluence of discomfort, privacy concerns, and fear of judgment: “We didn’t really talk about it in my family much […] I kind of avoided talking about it, just because I didn’t want the whole questions of like, ‘Why do you feel like you need [the vaccine]?’” (Carey). Minion mirrored this testimony: “[…] I’m not out to my family, so I couldn’t share that I’m getting [the mpox] vaccine.” These narratives reveal that without affirmation or acknowledgement, individuals were left to navigate their decisions in isolation, with limited support from their immediate social environments. In contrast to the quiet disconnection experienced within intimate circles, many participants described the media landscape as saturated with alarmist tones. This shift from muted immediacy to heightened spectacle further disoriented community members: “I felt that it was kind of being used partially as a social media ploy. […] Stirring fear […] like it’s going to be the next big shutdown” (Michael). Rather than offering guidance, these messages contributed to an atmosphere of looming crisis, lacking context and clarity. Neil also recalled the fear-inducing tone of online narratives: “[…] There were […] some details of like the symptoms, and what would happen if you contracted it. […] Bumps on your skin, […] easily contractable, and contagious. […] It sounded scary.” Kai spoke directly to this disconnect between lived risk and mediated representation: “This was actually a real risk, versus […] what’s being sensationalised [online].” Kai added, “Even though there were those acts of resistances, […] there was also just a lot of imminent fear [due to] the fear-mongering that was going on […] that created the self-fulfilling prophecy amongst queer members.” 67 In this layered media context, even routine health promotion materials became fraught: “People were even afraid to pick up the brochures, because it’s like they wouldn’t want people to think that they had mpox too […] that was really scary then” (Marc). These reflections demonstrate that the absence of trustworthy conversations and the proliferation of alarmist messaging have unsettled the communication environment. In turn, despite the availability of information, messages were rarely empowering and instead allowed silence, stigma, and fear to collide. Unlike COVID-19 vaccine-related messaging tactics, participants repeatedly pointed to poor institutional communication around potential side effects and interactions with other medications, critical information that could have supported informed consent and trust. “Side effects weren’t really talked about […] because that’s a deterrent for people to get vaccinated,” River noted. Jordan mirrored this by noting that “[…] the possible side effects, and maybe just […] reactions with other medications […] was probably the most concerning.” These accounts reveal a lapse in centralised communication, where absent transparency fuelled hesitation and left participants’ willingness to vaccinate suspended in uncertainty rather than supported by informed trust. In contrast to the omnipresence of COVID-19 vaccine campaigns, mpox repeatedly appeared as an afterthought: “COVID was still the main talk of the town. [Mpox] was kind of like the ugly stepsister in Cinderella […] the one nobody talked about. […] [So], I didn’t really care to look into it at all” (Michael). Rainor reiterated the same thought: “I think that […] the COVID overshadowed a lot of things at that time. It really did. […] [Mpox] was like this dark shadow over all of us for a little bit, it seemed.” These testimonies underscore serious 68 communication and outreach gaps, driven by the perception that mpox was eclipsed by COVID-19 and denied the weight and urgency it required. 4.6.2 Structural & Communication Deterrents Disrupting Vaccine Uptake This subtheme presents the multi-layered barriers that participants encountered when navigating mpox vaccine access within public health systems, which were often experienced as disjointed, unresponsive, or exclusionary. In other words, harm often took subtle forms, manifesting through delays, dismissals, and opaque booking systems that implicitly signalled to participants, particularly those from underrepresented groups, that their needs were peripheral to the design and delivery of mpox vaccination efforts. 4.6.2.1 Structural & Outreach Lapses. While many areas of Vancouver benefited from community-informed strategies, such as mobile clinics and outreach in non-traditional settings, the province of BC did not apply these interventions uniformly. What may have been framed as operational efficiency often failed to account for the complexity of diverse contexts, inadvertently reinforcing existing inequities in who could navigate these systems with ease. Cedar reflected: “There’s only one [person] […] [doing] the [street] outreach to sex worker communities. […] [This staff] was the only person in the room that had experience working in […] the target populations.” This account points to a critical limitation: the outreach infrastructure, while well-intentioned, was constrained by staffing shortages and a lack of personnel with established rapport and skills in delivering GBTMSM+ competent and affirming care. Neil also reported a lack of cohesive inter-regional planning and a scarcity of vaccines outside major urban centres: “[…] People were only able to get the vaccines in big cities,” drawing attention to the geographic disparities across Canada that left community members in 69 rural or smaller urban areas without meaningful access to prevention. Neil elaborated, “I had a friend […] from […] Nova Scotia, and maybe their gay community isn’t as large there, so maybe they didn’t see [the outbreak] as an issue.” Here, decision-makers used the absence of perceived community density to justify the limited rollout, revealing that risk and visibility assumptions may have shaped access in inequitable ways. Neil added, “[My friend] goes to the leather events [in Canadian urban centres] […] he’s like, ‘Where do I get [the mpox] vaccine shot from?’ So, […] he was here visiting in Vancouver, and was able to get a shot.” This testimony highlights the inequitable distribution of vaccines across provinces, with prevention efforts disproportionately concentrated in large metropolitan areas, resulting in a patchwork of access that fails to reflect a national, coordinated approach to equity. This underrepresentation undermines the realities of mobile and networked lives of GBTMSM+ individuals. For Carey, booking a vaccination appointment through the regional health authority (the publicly funded body delivering services in and around Metro Vancouver) proved so difficult that it ultimately led to disengagement: “I tried calling […] Fraser Health and booking [the mpox] vaccine. […] I remember just not being able to book an appointment through Fraser Health, so I gave up on that entirely, and just went, ‘Oh, fuck it!’” For participants like Carey, who disclosed being involved in sex work, these barriers were not abstract; they posed real, time-sensitive risks. Carey eventually accessed the vaccine through another health authority (i.e., Vancouver Coastal Health) but shared that this required a strategic reframing of their eligibility: “I technically fall under the criteria and everything, or I can phrase things in a way, so it sounds more like I fall under the criteria, if it really gets to that point.” Carey felt further confused during the booking process: “My next step would have also been like trying the Sex Sense 70 hotline […] but they also basically said […], ‘Try the local health authority’ [Laughs].” These reflections highlight a broader issue of system opacity, in which eligibility criteria were either unclear, inconsistently communicated, or difficult to navigate. As a result, participants were often forced to engage in forms of self-advocacy that bordered on self-editing, managing their risk and the language they used to be recognised within bureaucratic systems. Beyond questions of physical access and booking designs, participants described critical gaps in infrastructure, provider competency, and institutional preparedness that collectively impeded both vaccine delivery and diagnostic efforts. As Kai noted, “[My family doctor] was not able to answer any of the questions, and I don’t think they were very knowledgeable […] they […] come from more of that old school, traditional mentality of just routine checkup.” This absence of basic awareness among primary care providers created subtle but consequential barriers, where clinical silence or misalignment threatened to stall vaccine uptake at the very point of contact. Concerns extended beyond individual providers and into the structure of clinical teams: “Our clinical team […] lacks people with lived experience. So, I was the only [experiential] person” (Cedar). In turn, this lack of community-rooted insight weakened the capacity to respond effectively to community needs, as Cedar’s “[colleagues] didn’t really understand the relationship between this incoming […] infectious disease in Eastern Canada and the fact that Vancouver Pride was in four weeks.” 4.6.2.2 Communicative Lapses. Participants acknowledged the usefulness of targeted digital platforms and in-clinic messaging, but many described the centralised communication approach as lacking resonance, marked by narrow language framing that induced stigma and confusion. River remembered encountering campaigns that lacked a compelling sense of 71 urgency: “There were definitely […] posters, […] generally, but not a lot of it was pushed. […] They’re not like talked about all the time.” Neil added, “[…] maybe some better branding. […] I honestly can’t picture [any mpox vaccination campaigns] when you asked me about [them].” This dulled sense of immediacy extended into digital outreach through social media: “It was there, but it almost felt like it was more like […] rumbles versus, ‘You need to go get this, and this is important’” (Kai). Michael echoed this sentiment: “[The campaigns] were there. I noticed them. […] But I feel like they […] were easy to ignore […] because [there were] other bigger issues out there.” These accounts accentuate a deeper systemic inertia: a reluctance to deliver messaging with the urgency needed to capture attention and prompt timely action. Coco further unpacked this inertia by highlighting missed opportunities in the promotion of local pop-up clinics: “I think maybe the only thing that could have been done better would be better advertisement of pop-up clinics. […] It can’t be so much on the spur of the moment.” This reflection highlights a failure not of intention, but of communicative execution, where grounded efforts lacked the promotional updraft necessary to carry them across the community. Despite being ostensibly grounded in epidemiologically sound intent to prioritise those most at risk, the targeted language used in outreach materials appeared to unravel in practice, yielding unintended consequences. Participants described feeling boxed in by reductive categorisations that failed to reflect the complexity and fluidity of queer and trans lives. River recalled: “Okay, it’s gay men who need to get it, like gay men and sex workers, and [those] who are having […] various sexual encounters.” Such wording, while intended to identify heightened vulnerability, inadvertently placed the onus of outbreak containment, and even the subtext of blame, on the very communities it sought to serve. 72 Joey critiqued the approach more explicitly: “They should stop! […] They’re so narrowminded! […] Okay, it affects the people that are [MSM], but because you point it on the news, […] how many [eligible] people will avoid […] getting the vaccine?” Joey warns that narrow eligibility can stigmatise the GBTMSM+ communities and deter others, at risk or in solidarity, from seeking vaccination for fear of mislabelling or exclusion. Chris also highlighted that such rigid language categories fail to hold space for those living at the intersections of gender, sexuality, and risk: “Maybe [they should try] to expand the category to [other at] risk [population]. Usually, gay people [are the target of the vaccine], but not […] lesbians or transmasculine.” This reflection illuminates the complexities that fall outside neatly demarcated eligibility boxes. Another salient repercussion of the narrow language framing through institutional risk communication emerged among participants whose identities, practices, or social locations lay beyond the conventional boundaries of the “MSM+” category: “Because it’s so geared towards […] the sort of catch-all group of […] [MSM], […] I’ve always kind of thought of myself like on the edge with that” (Carey). The notion of being “on the edge” speaks to more than just misalignment, as it points to the quiet but persistent dissonance experienced when dominant narratives flatten the nuanced contours of gender-diverse lives. Carey further critiqued the framing: “If you’re acknowledging that some of the people in this umbrella are bisexual, you’re going to have to acknowledge that [there are] people […] engaging with those bisexual men [who] are going to fall outside of the [MSM] category.” Even when well-intentioned or epidemiologically justified, such framing risks reinforcing institutional blind spots that further obscure the ambient social networks and relational dynamics that shape real-world exposure. 73 Cedar echoed this issue, noting, “We saw […] another transwoman and we weren’t exactly sure if she qualified. But she came in, and she was, like, ‘I think this is relevant for me. I don’t like that the marketing is all about gay men. […] I have partners who are X, Y, Z genders.’” Benjamin offered a similar reflection: “[Wasn’t] it a danger to other people too? […] They could have sex with women too, so were other people at risk as well? […] But the part I remember is […] that [term], MSM.” These narratives critically dissect the assumptions embedded in public health eligibility criteria, illustrating that narrowly defined risk categories are medically reductive and harmfully exclusionary. More troublingly, PLWH reported receiving inaccurate or misleading clinical guidance from trusted providers: “I did not get a vaccination, with my doctor’s recommendation, because […] I was detectable HIV-positive. […] I could get [the infection] even more so […] if I did [get vaccinated]” (Rainor). This concern reflects genuine apprehension about immune vulnerability and exposes a critical knowledge gap among care providers, where misinformation discouraged vaccination and reinforced fears about HIV status and susceptibility. This is particularly concerning given that Imvamune®, the vaccine used during Canada’s mpox outbreak, is considered safe for immunocompromised individuals, including people living with HIV, regardless of viral load status (PHAC, 2025a). These accounts reveal that inconsistent messaging, whether stemming from public health campaigns or clinical encounters, can sever the communicative threads meant to tether structurally vulnerable individuals to trustworthy sources of information and care. What follows is an exploration of how stigma shaped the contours of risk perception, community belonging, and preventative health action. 74 4.7 Stigma and Strength: Navigating Risk and Resistance This theme traces the complex socio-symbolic air currents of stigma encountered by the Tethered Flyers (Appendix A) in their pursuit of preventative mpox vaccination. Participants spoke to the ways race, occupation, HIV status, and gender identity intersected to shape distinct experiences of stigmatisation. To contextualise these experiences, stigma is broadly understood here as a social process that devalues individuals or groups based on perceived difference or deviation from normative standards (Stangl et al., 2019). Although a full analytic engagement with the HSDF by Stangl et al. (2019) will be taken up in the Discussion chapter, it is important to acknowledge that participants’ experiences pointed to multiple, intersecting forms of stigma that shaped their experiences around mpox-related communications and vaccination decisions. As a result, individuals and communities engaged with preventative mpox vaccination as a form of health promotion, tethered in the active choice to navigate complex and dynamic forces. 4.7.1 Stigma as Turbulence: Impacting Race, Occupation, Health, & Community This subtheme examines the emotional and psychosocial conditions shaped by stigma, better described here as a form of turbulence, faced by participants in the context of mpox-related public health responses. Narratives involving racialised communities, sex work, and HIV cast individuals into hyper-visibility and, at the same time, reduced them to symbols of risk, while stigma coursed through individual, social, and institutional channels, reinforcing long-standing hierarchies of blame and exclusion. 4.7.1.1 Racialisation of Mpox. Participants observed that the language and imagery in early communications often activated longstanding racialised assumptions, particularly those 75 linking Blackness and African heritage to contagion, and that the original term monkeypox carried historical baggage with a visceral tone that evoked racialised imaginaries. Neil illustrated this when he remarked, “I notice you calling it mpox and not monkeypox, which is how originally […] it came out as. […] That’s how it started, as monkeypox, so that was a scary sounding kind of name for it.” He continued, “[…] And I don’t know if there was like racist things attached to that, but I guess that might have been some reasons why […] the branding or name of […] mpox [was changed].” Chris expressed it more succinctly: “[…] The name [Monkeypox] is discriminative!” These accounts highlight the ways language can perpetuate stigma, with “monkeypox” reinforcing racist and dehumanising associations. The eventual shift to mpox, though delayed, signified an intentional break from colonial logics and the racialised associations that circulated in the early stages of the outbreak (WHO, 2022). Cedar’s critique of language also extended into visual representation, particularly in public health campaigns responding to mpox. While acknowledging the importance of featuring racial and gender diversity, Cedar noted that some campaigns appeared to “swing too far” by relying almost exclusively on images of people of colour. This overcorrection, even if well-intentioned, risked reinforcing stigma rather than countering it. The concern became sharper when mpox outreach relied on highly racialised imagery, such as lesion photographs largely drawn from repositories of African cases or campaign models who did not reflect the broader diversity of those affected. For Cedar, such strategies underscored the need for balance, warning that “you have to have a diversity of […] individuals pictured” to avoid reinscribing the very inequities campaigns seek to address. Within this textured context, Cedar perceived the choice to centre White-presenting figures in visual materials not as an act of erasure, but as a deliberate anti-stigma strategy: “So, 76 HIM actually used more White people cartoons, which I think was appropriate in this instance because of the stigma associated with mpox and people from the African diaspora.” Cedar concluded, “[…] It was the right choice because we’re trying to decrease the stigma.” This interpretation suggests a deeper orientation toward harm reduction, which in turn prioritises the ways representation functions within a specific sociopolitical climate rather than adhering to abstract ideals of inclusion. 4.7.1.2 Stigma Surrounding Sex Work. Many sex working participants interpreted the rollout as filtered through a narrow, moralising lens, further reinscribing longstanding social hierarchies and moral judgements. River remarked, “There’s already a stigma against […] the sex worker population.” Carey expanded on this sentiment: “[The messaging] felt […] judgy […] [and] […] more shaming of people who engaged in [survival sex work] and didn’t really address [the reality that there are] people who […] couldn’t avoid that.” This critique unravels the absence of structural nuance in messaging; specifically, the failure to acknowledge moments when precarity and constrained agency shape decision-making for those engaged in survival sex labour. Carey elaborated on the nuanced manifestations of stigma becoming a consequential barrier: “I didn’t want to try to deal with the hassle of […] trying to prove I was eligible or potentially at risk.” Here, the burden of proving one’s legitimacy — of justifying need through disclosure — unravelled the deeper inequities at play. “I probably didn’t want to have to […] disclose and be like, ‘Oh, yeah, this is all the reasons why I should have to,’ instead of just being able to turn up, check ‘yes’ on a form and then just sit-down and get a poke in the arm” (Carey). Stigma operated here as both gatekeeper and silencer, restricting access, suppressing disclosure, 77 and making the right to care conditional on erasing or concealing sex work, thereby enabling constraints and discouraging vaccine uptake. Some clinical teams sought to recalibrate their approach by grounding their work in affirming, stigma-sensitive communication and outreach strategies: “We […] really worked on the language […] to really help destigmatise the language […] so that […] targeting a specific population or populations [does not] lead to increased stigma” (Cedar). This intentionality speaks to the responsibility of public health not just to extend services, but to do so in a way that does not reinscribe marginalisation through its messaging or delivery. 4.7.1.3 Remnants of HIV/AIDS Stigma. This section illustrates mpox as more than a biomedical event, as it emerged as a socio-political flashpoint that reignited collective memories and social scripts rooted in the HIV/AIDS crisis during the ‘80s and ‘90s. Participants’ reflections on the mpox outbreak revealed a powerful and unsettling sense of historical return, framing queer and trans lives as risky, deviant, or disposable. “There was a lot of parallel between […] mpox and the HIV pandemic that occurred […] It was like, ‘Oh, it’s a them issue,’” River recalled, invoking the legacy of ‘othering’ that marked early responses to HIV/AIDS. Coco observed that media coverage mirrored these exclusionary logics: “I think there were some news agencies […] that may have compared it to […] the beginning of the AIDS epidemic in the ‘80s,” highlighting the instances wherein past crises were invoked in ways that often obscured more than they clarified. For Carey, the public silence around mpox intensified a familiar sense of abandonment: “Oh, my God, are we going to have another like HIV/AIDS thing? […] because it seems to mostly quote-unquote ‘target’[MSM]. Are they just going to ignore this and everything?” In this regard, the perception of invisibility, coupled with the weight 78 of historical neglect, contributed to a haunting sense that the social valuation of GBTMSM+ lives had not meaningfully shifted. Kai explained that deeper cultural logics linking queerness with disease persisted beneath the surface of public messaging: “To the effect similar to AIDS […] gay men are dirty, queer people in general are dirty, and […] they’re sort of the ones who are bringing this negativity to different communities.” This sentiment was echoed by Cedar, “This is really like AIDS 2.0,” noting the recurrence of framing GBTMSM+ individuals as epidemiological threats. “This reaction everyone is having, you know, gay men as a vector. This is all very AIDS-like,” Cedar added. Such narratives, whether explicitly stated or subtly encoded, perpetuate structural stigma, reinforcing the myth that queer bodies are inherently dangerous or contaminating. For Joey, who was an adult when the AIDS crisis fully emerged, the emotional toll was especially pronounced: “It’s always been stigma, always! Since I got [HIV], […] we were told that we probably wouldn’t live […] more than 18 months.” This recollection depicts the instances when the mpox outbreak reopened wounds that were long thought to be scarred over. However, Cedar emphasised that these experiences were not monolithic: “Some transpeople identify or have relationships to that HIV stigma of the ‘80s, ‘90s, 2000s and some do not […] But […] when we think of HIV stigma, typically we go to gay men. There is also an association with transwomen.” These sentiments reveal that the impact of stigma cannot be untethered from the sociopolitical forces that define who is seen, who is protected, and who is left to weather the turbulence of crisis alone (Appendix A). While Benjamin noted that society may have “learned from the AIDS epidemic,” the recurrence of stigmatising responses to mpox suggests that such lessons have not been fully absorbed into the core of public health or media infrastructures. Despite decades of advocacy and 79 community education, stigma continues to be reproduced through the very systems meant to protect. “Basically, HIV has […] a huge stigma. So yeah, that [does] matter” (Chris). These reflections underscore that the symbolic and structural echoes of HIV/AIDS continue to shape the landscape of queer health, requiring responses that are not just factual, but trauma-informed, equity-oriented, and community-driven. 4.7.1.4 Community in the Face of Stigma. The mpox-related official communications aimed to promote awareness and safety. However, participants consistently recounted moments when the targeted framing of language, tone, and imagery in campaigns inadvertently reactivated enduring narratives of deviance and contagion. 4.7.1.4.1 Stigma in Risk Communication. For Minion, the timing and framing of the vaccination campaign generated unease: “Because [the campaigns were] very focused on the LGBTQ group, and just especially a month before the Pride [celebration], […] I felt like, ‘Okay, so only gay people can get this virus?’ [Laughs].” Although delivered with humour, this reflection reveals a serious concern that highly targeted messaging may unintentionally reinforce harmful misconceptions and stigma. Kai paralleled this perception of over-targeting: “Mpox was being portrayed as something that was only impacting the queer communities, and in particular gay men. […] ‘Oh, this isn’t going to impact a person who’s straight.’” In this account, the campaign’s focus both alienated queer individuals and reinforced the false dichotomy that mpox posed no relevance to heterosexual populations. Cedar noted that transwomen were either forcibly lumped into the MSM umbrella or rendered invisible altogether: “One of the barriers was […] reaching transwomen without grouping them in with gay, bi, queer men all the time. […] Doing this […] that is both gender affirming and acknowledges the long history of stigma.” Cedar critically examined this 80 oversimplification of trans lives: “How do we talk about […] how transpeople fit and intersect with the gay, bi, queer men’s community?” This query underscores the importance of recognising the fluid and intersecting lived realities in relation to risk exposure and community engagement. Cedar concluded, “Because obviously this is not a circle. This is a Venn diagram,” illustrating the inadequacy of unidimensional classifications and the need for models that reflect the relational and overlapping nature of queer and trans social worlds. Most importantly, Cedar critiqued the repeated use of the phrase “the general population is not at risk,” drawing attention to its exclusionary implications: “Who the fuck is the general population? Are gay, bi and queer men and transpeople not in the general population? Who are we, aliens? Like, come on!” This community advocate found the messaging stigmatising and profoundly alienating: “The whole thing was very othering,” Cedar explained. Although such language may have been intended to manage public panic or streamline messaging, its effects were divisive. It demarcated an artificial boundary between those considered ‘at-risk’ and a presumed, protected majority. This points to an unequivocal takeaway: “Language is critical. Messaging is critical” (Cedar). These narratives expose the emotional, social, and institutional burdens that accompany stigmatising communication, particularly when it activates longstanding fault lines of exclusion within health discourse. Participants did not simply call for visibility in health campaigns; they urged for messaging that affirms, respects, and reflects the dignity and complexity of queer and trans lives. 4.7.1.4.2 Stigma Turning Inward. Participants’ narratives revealed the profound emotional burden imposed by mpox-related stigma, not only in its external manifestations but in the internal landscapes it shaped. As River expressed plainly, “I guess generally, [there is] a lot of 81 shame towards gay men and […] their sexual choices.” This statement distills the core of internalised stigma, revealing instances when societal shame toward gay men and their sexual choices can seep inward, shaping self-perception and eroding self-worth. Joey felt this stigma viscerally and across generations: “Well, naturally, [the mpox outbreak was] always a ‘faggot’ thing,” invoking the crude and enduring associations between queerness and disease. In naming this connection, Joey surfaces a cultural lineage of homophobic slurs and stereotypes that framed the outbreak in ways both damaging and familiar. Personal histories of rejection and concealment compounded the emotional weight of internalised stigma: “I come from a very small village […] and to be gay, well, they call you a ‘dickie licker’ or whatever, but it’s hidden, and it’s always hidden” (Joey). The consequences, as Joey recalled, were harrowing: “I was thrown out of […] my town where I came from. And the funny thing is, my father kicked me out when I was [a teenager because of my sexuality].” Carey explained that their gender expression often draws unwelcome attention: “I always worry about turning up to the spaces that are dominated by […] queer men,” signalling the subtle and ongoing internal negotiations prompted by stigma. “I don’t want to feel like I’m intruding,” Carey continued, “even though […] I know, I [have all the right] to be there.” Carey elaborated: “Because […] a concern for me […] was […] the fact that […] my gender identity and expression aren’t […] the most telling of the group or doesn’t exactly fit into the group that is supposed to be getting these shots.” These reflections demonstrate the internalisation of stigma and the anticipatory monitoring that occurs when one’s legitimacy within queer health spaces feels tenuous, manifesting even before an interaction takes place. Frustration emerged around the strong association between mpox and queer sexual identity, particularly gay men: “I just thought, ‘Oh, here’s another disease that I need to get a 82 vaccination for. […] Feeling a little […] irritated or frustrated. […] Another gay disease that we have to protect ourselves from” (Benjamin). Neil echoed: “It was mainly gay men. […] Maybe they’re more sexually active. […] Stigma, I guess, is maybe the word.” He later added, “[…] people […] say [that] gay men [are] Promiscuous.” Kai offered a parallel reflection, stating, “You know, gay men are dirty, queer people in general are dirty, and you know, they’re sort of the ones who are bringing this negativity to different communities.” These sentiments speak to the weariness of navigating yet another wave of pathologising discourse, where protection is necessary, but accompanied by the fatigue of being repeatedly framed as the problem. Apart from revealing the inward turn of stigma and its enduring imprint on self-perception, these narratives also gesture outward: toward the institutional landscapes in which such stigma is perpetuated. Other participants’ narratives underscore the personal toll of internalised shame, while Cedar extended this inward turn to the professional setting, interpreting colleagues’ actions, such as inappropriately donning full PPE, as practices that reinforced stigma and intensified its internal impact. For instance, Cedar described that “[…] it didn’t really occur to my colleagues, who were cisgender, heterosexual clinicians, how much stigma was going to be associated with this [outbreak].” Cedar added, “They were running around wearing […] full airborne PPE precautions. […] In the hall, outside the room. […] It didn’t really occur to them that this might increase stigma.” Practices intended to uphold infection control became entangled with behaviours that publicly marked individuals as vectors of infection. Cedar further pointed to the unintended harms created by institutional signage and protocols amidst an outbreak: “PPE is great […] But how do we [use PPE] that’s less stigmatising?” 83 However, within these systemic fractures and the emotional labour of navigating care, participants offered glimpses of resistance, carried not by force, but by resolve. What follows is a shift in narrative focus: from the turbulence of stigma to the steady lift of resilience and strength through resistance. 4.7.2 Stigma Destabilised by Resistance and Resilience In contrast to dominant narratives that framed GBTMSM+ communities primarily through the lenses of risk and vulnerability, many participants articulated their vaccine choices as expressions of strength, autonomy, and cultural pride. Resilience, described by Masten (2001) as “ordinary magic,” refers to adaptive systems that enable individuals and communities to withstand and navigate adversity. This form of psychological endurance has been shown to buffer the negative effects of chronic stress and promote emotional well-being, acting as a protective factor against anxiety and depression (Johnson et al., 2011; Surwill & Pharr, 2025). In this study, participants forged their resilience through daily decisions, the quiet strength of community care, and the defiant refusal to be pathologised. 4.7.2.1 Embodied Stance against Stigma. Older PLWH shared powerful accounts of resilience that challenged deficit-based assumptions about ageing, illness, and identity: “I’ve been HIV [positive] for [many years]. Do you know how many people [have been living with HIV for as long as I have]? Not many! […] And I’m still around, and I still have a better attitude than half the people here” (Joey). They continued, “I live my life according to a very basic principle, that love is more important than being deceiving or being angry, or being, ‘Poor me, poor me, poor me.’ No time for that! Life is too short.” This reflection resists the notion that chronic illness confines people to narratives of decline, instead offering a model of strength that 84 is embodied and earned. It is in these expressions — clear-eyed, love-bound, and fiercely self-defined — that strength catches wind and lifts. Such empowerment, nonetheless, is often built through early encounters with loss, abandonment, and systemic marginalisation. Joey further reflected on the challenges they faced while growing up on a reserve1 and within foster care, describing themself as “the sum of all the people that crossed my path, and the lessons I left behind.” Their story interwove experiences of Indigenous displacement, childhood institutionalisation, and intergenerational trauma with a deeply rooted ethic of self-knowing: “A teacher […] taught me to look inside, and know thyself […] and I got lucky and every day I’m thankful for the life I have.” This reframing of past adversity as a site of wisdom, rather than burden, reflects what resilience literature recognises as the transformative potential of meaning-making in the face of cumulative threat (Smith & Hayslip, 2012). For Rainor, empowerment grew from resisting stigma through knowledge-sharing and intentional visibility: “Instead of […] feeling like a victim, or I was stigmatised, I decided […] to educate people that still were living in ‘90s [HIV] propaganda.” Rainor kept medical articles on hand to counter misinformation and shared that they would do the same for mpox if needed, highlighting a sense of personal responsibility to counter stigma with evidence. However, this commitment to advocacy did not preclude Rainor’s moments of profound vulnerability with HIV: “At one point during that time, I thought, ‘I might not make it. My body might not pull through this!’ I was really scared. But I knew […] I’m going to be okay.” This 1 Growing up on a reserve does not inherently involve intergenerational violence. It is widely understood that colonial disruption of cultural norms and relationships has contributed to harms in many communities, yet experiences vary and must not be assumed. Alongside these realities, communities continue to sustain resilience, kinship, Indigeneity, and cultural continuity. 85 reflection captures the emotional texture of resilience, not the absence of fear, but the capacity to persist in its midst. It is this interplay between fear and fortitude, visibility and care, that shapes a more nuanced portrait of what it means to endure and resist. 4.7.2.2 Collective Stance against Stigma. Participants described looking out for one another, circulating information, encouraging vaccine uptake, and reframing participation in public health measures as an expression of solidarity and community pride, rather than passive compliance. As Chris shared: “Yeah, stigma is stigma! [But] […] it’s not the reason to avoid [mpox] vaccination.” Their words reflect a critical stance in acknowledging the persistence of systemic biases while refusing to allow it to dictate health choices. For Chris, empowerment also came from within the community itself. “[In our group chat, I] post the link and suggest […] to exchange communication [and] empower [each other].” This account depicts a salient portrait of empowerment that is neither individualistic nor abstract. It is grounded in practical solidarity through the sharing of resources, encouraging access, and building resilience through reciprocal action. Coco echoed this stance: “[the mpox vaccine] was discussed in a very positive manner, and a very positive light. It […] wasn’t shameful. […] It was talked about very, very openly, like any other vaccine should be spoken about.” Coco further reflected, “It influenced [our group] very positively, because I think we were all kind of on the same boat, following the same train of thought, ‘This is that we should be vaccinated.’” The metaphor of being on the same boat captures the alignment of values across Coco’s network, revealing a coordinated response in the face of social precarity, where solidarity outweighed stigma. Carey’s affirmation captured this collective care ethic grounded in mutual protection and public good: “I care about myself and other people around me. […] I don’t really know how else 86 to phrase it, other than like, ‘I don’t want to hurt other people around me.’” Mirroring this shared ethic of resistance, Coco expressed: “You take care of yourself. You take care of your friends and others, whoever you meet or don’t meet.” These reflections depict that the act of vaccination became a gesture of community responsibility, affirming that resistance to stigma is often enacted not through grand declarations, but through quiet, daily decisions to protect oneself and others. Benjamin echoed this sense of solidarity: “We’re all in this together. Isn’t this great? […] Give me the shot and we’ll be safe!’ […] I want to reduce or eliminate any risk there is from my behaviour.” His enthusiastic comment reveals that peer encouragement and accountability were not imposed by institutions but exchanged organically among their closest circles. Neil reinforced this stance with both clarity and humour: “[…] We all just wanted to be safe and be protected. […] I don’t know anyone who refused to get it.” Recalling the energy of the vaccine rollout, he added, “When I went to get my shots, it was packed! It was like the hottest place in the city. [Laughs] That was our joke. […] I feel like we […] did what we had to do to — […] prevent [mpox] from spreading!” These memories convey more than enthusiasm, as they reflect a community mobilising under pressure, transforming fear into action, and isolation into shared purpose. This collective resistance also surfaced in the ways participants made meaning of their social and sexual networks, reframing them as sources of strength and pride rather than risk or shame. Cedar articulated this tension with coherence: “We have strong networks of support. We have strong community ties […] Sometimes we have sex with our friends […] This is not a bad thing!” Cedar’s statement resists the pathologising gaze often imposed on queer intimacy, particularly in times of public health crisis. 87 Indeed, as participants made clear, resilience is not passive endurance: it is a practiced defiance. It is found in the daily work of confronting stigma, honouring one’s life and history, and choosing, again and again, to live with community-tethered pride and purpose. These narratives reveal more than a reaction to crisis; they map a shared trajectory from constraint toward agency and care. To convey this interplay of vulnerability and strength, the analysis turns to a guiding metaphor that has quietly shaped the interpretation throughout: the image of a tethered flyer with a kite in flight. 4.8 Tracing the Wind: Synthesis of Findings Through the Kite Metaphor Metaphors are not merely rhetorical devices; they are central to how we understand experience and construct meaning. As Lakoff & Johnson (1980) assert, “our ordinary conceptual system, in terms of which we both think and act, is fundamentally metaphorical in nature” (p. 3). In the context of public health research, this insight is particularly resonant, as metaphors offer a means of grasping complex, often intangible dynamics such as stigma, trust, resilience, and strength. They help bridge the personal and the systemic, rendering visible the emotional and contextual layers that shape engagement with care. From a qualitative standpoint, ID also recognises the role of metaphor as a heuristic tool: one that helps distil experiential knowledge and surface patterns of meaning within applied settings (Thorne, 2016). In this analysis, the Tethered Flight metaphor (Appendix A) is used not as sheer decoration but as a conceptual scaffold: a dynamic and relational lens for interpreting mpox vaccine engagement among underserved GBTMSM+ individuals. 4.8.1 Tracing the Metaphor’s Conceptual Origin In developing a visual representation to convey the layered complexity of the findings, I explored common symbolic depictions of marginalised communities. I considered familiar 88 images such as trees, rainbows, waterfalls, and umbrellas, each visually appealing yet ultimately insufficient. Although beautiful, these symbols felt overly familiar or reductive, lacking the dynamism needed to reflect the nuanced, multifaceted realities at the heart of this thesis. I remained cautious of choosing a metaphor that might unintentionally obscure the complexities or uniqueness of the findings. This pause prompted me to turn inward and reflect on my personal experience. In turn, a memory rooted in my early life in Maliplipit, a remote mountain village in Pilar, northern Philippines, surfaced rather than an abstract academic concept. Growing up in a community with limited resources, I relied on creativity and resourcefulness as the foundation for play and learning. I vividly remember making and flying kites by crafting frames from fresh coconut leaf spines, unravelling used rice sacks to make string, reusing sardine cans as spools, and assembling the kite body from old newspapers or plastic bags, adhering with leftover cooked rice for paper kites, or by repeatedly and gently pressing plastic against a concrete platform with stones until the friction caused the material to bind. These practices did not emerge from formal instruction in educational spaces that taught the principles of aerodynamics or the physics of kite construction and flight. Instead, they were passed down through generations as an embodied, communal form of knowledge that fostered profound joy and pride, even in conditions of material scarcity. Revisiting this memory illuminated the kite as a compelling metaphorical tether that not only represents flight, but also embodies the negotiated balance between agency, constraint, and relational force. Its symbolic resonance extends beyond play, evoking a dynamic process of being held, lifted, and redirected by powerful forces. A kite cannot fly on its own; it requires 89 wind, and the character of that wind is crucial. Excessive force can destabilise flight, and insufficient lift can prevent takeoff altogether. This dynamic interaction with the environment reflects the multi-level forces influencing vaccine uptake among the key population, where structural stigma, social apathy, systemic neglect, community care, resistance through resilience, and affirming support all operate as varying winds that shape one’s flight path. For me, this metaphor struck a deep chord, offering a vital and evocative way to honour the data and the complex lived experiences that gave it life. The kite metaphor, employed throughout this chapter, serves as a heuristic for understanding the layered dynamics of trust, stigma, and resilience in mpox vaccine decision-making. Trust functioned as the tether: when taut, it anchored community members to care and created stability; when frayed by neglect, inconsistent messaging, or exclusionary policies, it left individuals vulnerable to turbulence. The winds represented the intrapersonal, social, and structural currents that carried, redirected, or obstructed uptake. At times, these wind-like forces stabilised flight, as favourable breezes of peer encouragement, culturally attuned communication, and affirming encounters that bolstered engagement. At other moments, headwinds of stigma, systemic apathy and neglect, or rigid administrative directives slowed or destabilised trajectories, underscoring the precarity of staying aloft within inequity-prone health systems. Yet participants also demonstrated the capacity to navigate and redirect these currents. Community-driven outreach, relational advocacy, and peer-based trust acted as steady updrafts, reframing vaccination as an act tethered to dignity, ethics, and collective care. Even in the face of turbulence, resilience emerged not as passive endurance but as practiced defiance: a refusal to be grounded by stigma or exclusion. The kite metaphor, thus, crystallises the findings: mpox vaccination unfolded not as a linear transaction but as a flight within a shifting atmosphere of 90 multi-level forces, where the community tethered itself to trust, sought balance in the midst of turbulence, and harnessed resilience to forge a path of agency and collective strength amid constraint. 91 Chapter 5: Discussion 5.1 Overview This chapter critically interprets the findings, advancing beyond description to examine their meaning, significance, and implications. Guided by Thorne’s (2016) ID, Braun and Clarke’s (2021) RTA, and informed by the subsequent application of Stangl et al.’s (2019) HSDF, the analysis situates participants’ narratives within the sociopolitical, cultural, and institutional contexts that shape mpox vaccination experiences among underrepresented GBTMSM+ individuals in and around Vancouver, BC, and where appropriate, within the growing body of empirical knowledge associated with health care access generally and vaccine uptake specifically. The sociodemographic diversity of participants shaped both the depth and direction of the interviews. Many occupied multiple marginalised positions, including racialisation, trans identities, sex work, and HIV/AIDS, which influenced their experiences with mpox vaccination and their articulation of trust, stigma, and health engagement. These intersecting identities also determined what participants disclosed, the ways they interpreted public health messaging, and the extent to which they felt recognised or excluded by institutions. Participants noted the lack of diversity at vaccination sites and the racialisation of mpox, while gender-diverse participants spoke with particular intensity about the inadequacy of MSM-based eligibility criteria. Participants engaged in sex work contributed nuanced perspectives on how discretion and invisibility function as barriers to care, while PLWH navigating socioeconomic precarity highlighted the importance of affirming outreach that met them where they were, both geographically and psychosocially. 92 A less diverse sample, or one composed primarily of individuals with normative social privilege (e.g., White, cisgender, securely housed, steadily employed, or not living with stigmatised health conditions), would likely have left many of these layered critiques unspoken. In this sense, the sociodemographic composition shaped the contours of the data, deepened the analysis, and amplified voices often absent from mainstream public health discourse. The Tethered Flight metaphor (Appendix A) introduced in the Findings section remains central in this chapter. It animates the synthesis of five core themes and frames health engagement as a dynamic interplay between agency and constraint, in which the “kite” of mpox vaccine uptake depends on structural winds, relational tethers, and the skills needed to navigate turbulent or absent socio-symbolic air currents, spanning across micro-, meso-, and macro-level forces shaping preventative mpox vaccination. The following sections revisit the themes distilled through the metaphor, deepened through their resonance with the HSDF (Stangl et al., 2019) and Intersectionality (Crenshaw, 1991), and connected to relevant literature. The HSDF conceptualises stigma processes across socio-ecological levels (Stangl et al., 2019), while Crenshaw’s (1991) intersectionality sharpens the discussion by drawing attention to overlapping systems of race, gender, sexuality, occupation, and health status. To establish a post-hoc resonance with the findings, I frame “stigma and strength” not as a separate section but as turbulence and resilience — recurring air currents threaded through each discussion (Appendix A). This synthesis reflects the structural inequities, shifting forms of acknowledgement and legitimacy, and the negotiated practices of care illuminated in participants’ accounts. The chapter closes with reflections on practice, policy, and research directions, alongside methodological and positional considerations that shaped this thesis. 93 5.2 Navigating Winds of Trust and Erosion One of the unique contributions of this work is the way confidence was undermined both subtly and overtly by stigma, while strength countered its effects. Participants did not experience trust and mistrust as opposites, but rather as intertwined forces that shaped their engagement with public health responses to the mpox outbreak. At times, affirming encounters with providers and networks stabilised confidence; at other times, neglect and indifference eroded trust and reinforced exclusion and stigma. These dynamics resonate with the HSDF’s (Stangl et al., 2019) multi-level framing, where intra- and interpersonal negotiations around trust intersect with organisational dynamics and structural inequities. 5.2.3 Micro-Level Navigation For many participants, stigma turned inward as internalised doubt and anticipated rejection, eroding trust in public health. However, these individuals embodied a counter-movement: they refused to live as victims, confronting stigma head-on with clear-eyed defiance and fiercely self-defined agency. PLWH, for instance, resiliently resisted pathologisation by transforming defiance into a philosophical stance grounded in survival across years of marginalisation. They often anchored their trust in the vaccine within self-preserving action, drawing on the embodied wisdom of navigating health vulnerability across time. For some, trust deepened through enduring ties with care providers whose guidance had already proven life-preserving in the context of HIV management. This relational grounding supports broader findings that affirming provider relationships often function as stabilising anchors against stigma, enabling health-promoting action rather than hesitation-fueled inaction (Logie et al., 2011; Gahagan & Subirana-Malaret, 2018). 94 Logie et al. (2011), for example, describe parallel strategies among PLWH negotiating intersecting stigmas of gender, race, sexual orientation, and sex work, while Liu et al. (2025) show that MSM facing mpox-related stigma sustained engagement with care by cultivating resilience against institutional exclusion. Resilience, described by Masten (2001) as an “ordinary magic,” arises from adaptive systems that enable individuals and communities to withstand and navigate adversity. These accounts affirm that resilience buffered stigma, emerging as an active refusal that reconstituted it into a steadfast ground for self-definition and endurance. Trust in Canadian vaccines and biomedical infrastructures surfaced as a powerful micro-level countercurrent. Participants invoked a sense of institutional reliability rooted in the collective memory of successful vaccination programs. This work supports those of Gilbert et al. (2023), who demonstrated that when mpox vaccine information was visible and coming from persuasive channels (e.g., peers or reputable clinic messaging), mpox vaccine uptake was higher, thereby suggesting that trust embedded in those communication pathways likely enhanced vaccine confidence and action. These stigma-countering accounts align closely with Stangl et al.’s (2019) HSDF, as participants reframed potential stigma or vulnerability as grounds for action rather than inaction. By drawing on histories of affirming clinical relationships and individual uptake motivators, community members transformed vaccination into a resource for agency. This rechannelled trust countered the destabilising winds of uncertainty and stigma, allowing individuals to re-orient their kites along steadier currents. 5.2.2 Meso-level Navigation Participants who occupied overlapping roles as care providers and community members noted how colleagues’ behaviours eroded trust; for instance, feeling treated with suspicion in 95 clinical spaces by donning unnecessary protective equipment in their presence. This supports documented patterns in other studies of the HIV/AIDS era in the ‘80s and ‘90s, where stigma permeated healthcare interactions and reinforced hierarchies of contamination (Bergman et al., 2022), and more recently, where mpox-related stigma risked replicating past tendencies to associate disease with marginalised identities (Banjar & Alaqeel, 2024). The findings also illustrated how participants’ workplaces and social environments remained indifferent to the mpox outbreak, creating conditions where stigma thrived through these muted undercurrents and amplifying trust erosion. As has been reported elsewhere (Grey et al., 2023), the findings reinforce evidence that institutional practices and discourses can reproduce inequities when they overlook the lived realities of racialised and queer communities, placing the onus on communities to mitigate harm. A lack of racial diversity at vaccination sites and experiences of systemic erasure resonate with those of Grey et al. (2023), who documented such experiences among racialised gay, bisexual, and queer men during COVID-19. Rodriguez-Diaz et al. (2022) similarly warn that unheeded lessons from COVID-19 in the mpox response create conditions that risk compounding mistrust, particularly for Black and Latino MSM, including those living with HIV. As organisations rendered underserved participants invisible and withdrew support, the labour of care shifted unevenly onto those already marginalised, reinforcing what Ramnarine (2024) identifies as the structural displacement of responsibility onto communities situated at what Crenshaw (1991) describes as multiple fault lines of inequity. Stangl et al.’s (2019) HSDF conceptualises these dynamics as stigma practices, where silence, neglect, and unequal distribution of responsibility reproduce inequities under the guise of organisational neutrality. Hence, apathy in workplaces and social spaces amplified silence, diminished awareness, and 96 further destabilised trust, showing that meso-level environments can either steady or unsettle the currents that shape collective response. Countering these trust-eroding conditions, participants consistently situated community hubs as central tethers of confidence and support during the outbreak. Trusted spaces such as HIM, the Ribbon Community, the Dr. Peter Centre, CBRC, and the Living Positive Resource Centre provided affirming care during the peak of the outbreak. In partnership with healthcare institutions, these community-rooted organisations extended outreach by meeting people where they were, creating accessible points of entry that reduced trust erosion. Many noted encounters at vaccine sites, marked by affirming interactions with staff, transformed what could have been an othering process into an affirming act, reinforcing belonging within GBTMSM+ communities. Although research has highlighted the importance of community co-creation in mpox elimination campaigns (Palumbo et al., 2024), participants in this study emphasised the equally critical role of affirming encounters with care stewards. Experiences at vaccine sites, where staff demonstrated respect and affirmation, transformed potentially alienating processes into acts of belonging. This finding aligns with other studies that highlight the importance of trust-building interactions with providers for equitable vaccine uptake (Biesty et al., 2024; Gilbert et al., 2023). Participants described these initiatives as moments when the winds steadied and flight felt possible, underscoring the power of familiar, accessible, and affirming care. Stangl et al. (2019) frame these kinds of trust-inducing practices as organisational or community-level facilitators of stigma reduction, including community dialogues that shift harmful norms and leadership advocacy that signals visible commitment. Read through this lens, responsive and affirming interventions did more than provide services; they generated positive outcomes by 97 mitigating the reach of stigma, rebuilding trust, and fostering greater engagement with prevention. 5.2.1 Macro-level Navigation Many accounts in this study illustrated moments where trust could stabilise. The early and rapid vaccine rollout through sexual health clinics and mobile services in partnership with community-based organisations reflected what Gilbert et al. (2023) identified as visible and affirming investments in community well-being, signalling that institutions could act responsively when they worked in partnership with trusted sites of care. These interventions resonated with evidence that community-centred health promotion actively rebuilds trust by aligning services with the contexts and needs of those most affected (Biesty et al., 2024). However, structural risk communication compounded the erosion of trust, as shame towards gay men’s sexual practices framed a subtext of blame that saturated institutional messaging. Participants recognised echoes of HIV/AIDS-era discourses, where promiscuity became shorthand for irresponsibility and contagion. Such framings have long structured stigma against MSM, resonating with studies that highlight the reduction of sexual health to a matter of moral failure rather than systemic inequity (Banjar & Alaqeel, 2024; Blockley, 2024). Bergman et al. (2022) caution that mpox responses risked repeating these patterns, as public health narratives seemed to have cast gay men as both victims and vectors of disease. Institutional communications intensified these dynamics through repeated assurances that “the general population is not at risk.” While framed as reassurance, this phrase operated as an exclusionary marker, positioning GBTMSM+ as the implicit risk-bearing “other.” Mainstream media often mirrored these cues. Rodriguez-Diaz et al. (2022) describe similar dynamics across COVID-19 and mpox, where official framings reproduced racialised and sexualised hierarchies 98 of vulnerability. Ju et al. (2023) demonstrate that media coverage reproduced associations between mpox and sexual minority communities, reinscribing the moral undertones of risk. Participants interpreted these discourses as reminders of conditional belonging. Strathdee et al. (2023) argue that such conditional belonging reflects the failure of rights-based public health, where protection is unevenly distributed along lines of sexuality, race, and class. In this context, institutional messaging around mpox did not merely inform; it reanimated historical scripts of stigma, shaping vaccine uptake by inadvertently inducing shame and exclusion within public health communication itself. These dynamics also illustrate HSDF’s (Stangl et al., 2019) focus on structural pathways of stigma and the need to confront communication that reproduces blame and inequity. For participants who straddle the dual roles of healthcare workers and community members, trust eroded sharply when they witnessed the very institutions they served halt mpox testing at the height of the outbreak. Under rigid directives from institutional authorities, these suspensions fractured an already fragile confidence, exposing the dissonance between professional obligation and community solidarity. Participants also highlighted the absence of post-vaccine safety follow-up, a standard in prior pandemic, as further evidence of systemic neglect that deepened mistrust. What may have appeared as a bureaucratic adjustment to manage structural strain revealed itself in practice as an inequitable withdrawal of care, felt most acutely by those already navigating intersecting vulnerabilities. These accounts underscore that bureaucratic practices, though framed as pragmatic, often carry uneven consequences that destabilise institutional legitimacy. Grey et al. (2023) illustrate a parallel dynamic during the COVID-19 pandemic, where rigid protocols embedded in Canadian health systems reproduced structural racism and exclusion. These patterns reveal the insidious 99 ways that administrative rationality can reinscribe inequity when detached from lived experience. Takenaka and colleagues (2024) also depict that queer men perceived public health interventions during mpox as filtered through historical patterns of dismissal, reinforcing the sense that institutions prioritise containment over a community-anchored approach. Strathdee et al. (2023) further caution that when public health responses neglect the rights-based needs of marginalised groups, they inadvertently deepen mistrust rather than mitigate it. From the HSDF lens (Stangl et al., 2019), the stoppage of mpox testing during a critical window of need and the absence of large-scale post-vaccine safety surveillance exemplify stigma-enforcing mechanisms. Withholding services at moments of heightened vulnerability signalled devaluation and fuelled anticipation of neglect, eroding confidence in formal systems. These withdrawals weakened institutional protections and diminished service quality, creating conditions where trust could no longer be tethered to institutional anchors. 5.3 Weathering Winds of Uptake and Constraint Another key contribution of this work is its demonstration that, although stigma seeped into participants’ lives and delayed or deterred vaccination, their resistance through resilience facilitated vaccine uptake. Vaccine decision-making emerged through the interplay of individual motivations, community networks, and institutional structures. These dynamics generated lift when peer support, agency, and grassroots outreach sustained momentum, but created drag when communication failures, systemic barriers, and inequitable policies restricted access and uptake. 5.3.1 Micro-level Weathering For some, years of living with immunocompromised loved ones, combined with strong support for science, instill a vigilant ethic of protection, reinforcing the view that vaccination safeguards both personal and relational continuity. These affirmations align with evidence that 100 GBTMSM+ often view vaccine uptake as a deliberate expression of responsibility toward their immediate networks (Nadarzynski et al., 2021; Torres et al., 2023). Nevertheless, this lift encountered destabilising headwinds. Participants’ vaccine hesitancy emerged in part from exhaustion with overlapping health crises, as pandemic burnout diminished enthusiasm for yet another urgent vaccination. Complementing this, a global survey by Lazarus et al. (2024) reported a marked decline in booster vaccine willingness across 23 countries, indicating a broader trend of diminishing enthusiasm for vaccination as the pandemic response continues. These findings highlight the ways in which overlapping crises and cumulative burnout can contribute to disengagement from public health initiatives, complicating efforts to maintain vaccine uptake. Fear of unwanted exposure or outing, defined in stigma literature as disclosure concerns, or the fear that others will learn of one’s stigmatised status (Earnshaw & Chaudoir, 2009), intensified this strain, particularly since intradermal mpox vaccine scars could function as unintended markers of sexual identity or presumed risk. Liu et al. (2025) also demonstrate that stigma linked to mpox directly influenced healthcare-seeking among MSM, as anticipated judgment and exposure discouraged clinic attendance. Takenaka and colleagues (2024) also show that young sexual minoritised men experienced vaccination as a heightened marker of visibility, reinforcing fears of surveillance and exclusion. Combined, the findings of this thesis and other studies suggest that vaccination receipt amplifies the weight of stigma, both as an individual burden and a collective constraint on access and uptake. These insights support Stangl et al.’s (2019) HSDF, which highlights the interplay of stigma drivers, facilitators, and manifestations across socio-ecological levels. Individual capacities, including protective ethics, intersect with structural pressures, such as overlapping 101 health burdens, to shape vaccination decisions and health behaviours. Responding to these barriers requires coordinated interventions that reduce stigma, strengthen health information literacy, and build systemic supports capable of alleviating the cumulative impact of successive crises. 5.3.2 Meso-level Weathering Many described a moral responsibility to safeguard partners, families, and social connections by countering misinformation and disinformation through sexual health and media literacy, which enabled them to filter misleading content and engage in cautious information seeking as a form of collective protection. El Mikati and colleagues (2023) define misinformation as health-related content that is false, inaccurate, or misleading, regardless of the intent behind its creation or sharing, whereas disinformation refers to false information that is deliberately produced or circulated with the intention to deceive or cause harm. Participants’ critical information-appraisal skills served as a counterweight to these informational distortions. In line with El Mikati et al.’s (2023) distinction between misinformation and disinformation, participants actively evaluated circulating claims and trusted sources, thereby resisting both unintentional inaccuracies and deliberate attempts to mislead. Participants also resisted the pathologising gaze directed at queer intimacy by reclaiming their close ties to social and sexual networks as affirmations of belonging and care rather than shame, propelling folks to get vaccinated. May et al. (2023) similarly noted that MSM gathered strength from intimate networks to negotiate public health barriers during the mpox outbreak, leveraging strong tethers within circles when institutional guidance lapsed. Nadarzynski et al. (2021) also demonstrate that vaccine uptake among MSM often relies on relational contexts, where collective bonds counteract stigma and encourage protective action. 102 Burkholder et al. (2024) further highlight the role of queer community joy in sustaining mutual care practices that resist narratives of risk and deficit. By situating the reproduction of stigma alongside the creation of collective resistance within organisational and community contexts, these findings affirm HSDF’s (Stangl et al., 2019) meso-level insight that stigma is sustained through structural practices yet can be disrupted through solidarity and mutual care. Further, encouragement from friends, the visibility of peers receiving vaccines, and grassroots digital campaigns helped reconstitute vaccination as a normative and celebratory practice. Evidence from Biesty and co-authors (2024) and Rhodes et al. (2024) further demonstrates that community-led messaging, peer advocacy, and relational trust-building interrupt stigma and increase vaccine uptake. The same networks, however, revealed uneven distributions of labour. Many participants described becoming informal health educators within peer groups, workplaces, and families when institutional communication faltered. This work often fell on those already navigating layered marginalisations, intensifying the emotional and logistical burdens of health engagement. Intersectionality highlights these compounded strains, where inequities converge and amplify vulnerability (Crenshaw, 1991). These findings confirm that meso-level resilience is real but remains delicate: while affirming networks foster uptake, they also conceal the systemic abdications that force marginalised communities to shoulder disproportionate responsibility for public health preventative efforts. 5.3.3 Macro-level Weathering Participants also weathered contradictory winds. The rapid mobilisation of vaccines initially conveyed urgency and recognition, signalling that GBTMSM+ were visible within public health priorities. For many, early access even felt like a departure from prior neglect. 103 However, this momentum quickly dissipated, as eligibility criteria excluded many underserved subgroups, while shifting guidelines disrupted confidence and generated confusion. Sex-working participants emphasised that vaccine communication was filtered through a moralising lens, reinscribing entrenched hierarchies and longstanding judgements. Their interpretations underscored the persistence of structural stigma while also revealing a sharp capacity to name and confront these dynamics in real-time, rather than passively absorbing them. This refusal to be flattened by moral codes resonates with Earnshaw and Chaudoir’s (2009) account of stigma mechanisms as constraints that participants actively resisted. Several participants also described public health messaging as detached from the complex realities of the community or as lacking urgency. Similar dynamics have been observed in media portrayals of mpox, where risk communication obscured rather than clarified vulnerability (Ju et al., 2023). Stangl et al. (2019) describe these disruptions as stigma practices within the HSDF, where systems tasked with protection enact policies and routines that inadvertently reinscribe harm. Trans and non-binary participants described eligibility criteria that collapsed their identities into the rigid MSM category or erased their textured profiles altogether. Similar patterns have been documented elsewhere: Thornhill et al. (2022) observed women and non-binary individuals with mpox excluded from surveillance and communication, while Ramnarine (2024) demonstrates the compounded barriers transgender sex workers of colour face in HIV care. Owen-Smith et al. (2016) offered a parallel depiction by highlighting the pernicious instances when exclusionary research practices render trans health needs invisible, intensifying systemic constraint. Crenshaw’s (1991) account of intersectional marginalisation helps explain 104 why: risk was oversimplified and misclassified, producing structural blind spots that weighed heaviest on those at the edges of normative categories. Inter-provincial disparities compounded these tensions. Community members in non-urban centres often described being overlooked in vaccine rollout, echoing broader critiques of Canadian public health where uneven resource distribution structurally disadvantages queer populations (Grey et al., 2023; Tam, 2024). At the same time, participants reported delays at the first point of contact when general practitioners lacked even basic knowledge of GBTMSM+ care. These lapses resonate with Earnshaw and Chaudoir’s (2009) analysis, which suggests that stigma is encoded in institutional routines, shaping the first points of contact and reinforcing inequitable access. Moreover, the sudden stoppage of mpox testing in the midst of a crisis disoriented community members and further constrained vaccine access, as individuals faced uncertainty in confirming diagnoses when testing was suspended, effectively removing a critical tool for tracing and identifying cases without institutional support. Comparable patterns have been noted in other outbreaks where institutional logics, rather than dismantling inequity, recycled it (Grey et al., 2023; Ju et al., 2023). These insights demonstrate that structural pragmatism cannot take full precedence over individual and collective agency in promoting vaccine access and uptake among marginalised populations during a rapidly evolving crisis. The findings of this study clearly demonstrate that at stake are human lives, whose health and well-being are no less valuable than those often referred to as the “general population.” Prioritising an equity-oriented approach is essential to counteracting the damaging effects of positioning GBTMSM+ communities as outside of, or ‘different’ from, Canada’s population as a 105 whole. Such positioning, as evidenced by participant narratives, reinforces stigma and undermines equity by constraining timely access to preventative care during public health crises. 5.4 The Tethered Flight as Relational Analytic The kite metaphor reanimates the complex and abstract dynamics as ongoing movement, turbulence, and flight. Shifting winds, fragile tethers, and adaptive flyers embody the lived realities behind the abstract intersections, carrying forward the analysis into a metaphorical lens that foregrounds resilience amid constraint. In this metaphor, the kite represents the health outcome: successful vaccine receipt, delayed engagement, or foregone uptake. A steady flight signals receipt of the vaccine, whereas a faltering or grounded kite reflects disrupted or absent uptake. The kite also represents a nuanced outcome — resistance through resilience — where flight persists despite unfavourable structural conditions. Wind represents the multi-level determinants shaping engagement. These forces, situated across micro, meso, and macro contexts, influence the ease, direction, and sustainability of flight. Within the broader category of turbulence and drawing on the language of flight, a headwind refers to a wind that blows directly against the intended path of travel, often reducing speed and increasing resistance (Skybrary Aviation Safety, n.d.). A crosswind describes a lateral force that pushes movement off course, complicating navigation and stability (Grupo One Air, 2023). An updraft denotes a vertical current of rising air that provides lift and sustains altitude, whereas a downdraft is a descending current of air that pushes downward, causing sudden loss of lift and control (National Weather Service, n.d.). Therefore, these aerodynamic forces signify broader social and structural dynamics embodied through the kite metaphor. Headwinds reflect structural stigma that resists and slows vaccine uptake among GBTMSM+ communities. Crosswinds capture intersecting pressures and 106 inequities that push engagement off course. Downdrafts mirror systemic setbacks and harmful exposures that destabilise progress and increase vulnerability, while updrafts represent communal and relational forces that generate lift and resilience. In contrast, ambient or absent winds embody social apathy, fragmented outreach, or institutional neglect. These passive forces, although less visible, still restrict movement and dampen urgency. Internalised stigma acts as a storm within situated at the micro level yet experienced as destabilising and overwhelming. It produces hesitation, delay, or withdrawal from vaccination, showing that personal struggles reflect broader structural and cultural repercussions. Lift arises from enabling conditions. Steady winds or updrafts symbolise supportive relationships, community affirmation, and affirming healthcare interactions. These sources of strength often emerge through meso-level ties, yet are harnessed energy from connections across all levels. Rather than reducing complex experiences to rigid categories, the metaphor highlights the dynamism and interwoven nature of intrapersonal, social, and structural forces that shape public health engagement. The string further grounds the metaphor. The Tethered Flyer embodies the GBTMSM+ community member navigating preventative health decisions. The tether symbolises the quality of their relationship with the healthcare system. A taut, reliable tether conveys supportive and trustworthy care, enabling the flyer to steer with confidence. A frayed or unstable tether reflects tenuous connections to services, constraining agency and leaving the flyer vulnerable to erratic currents. The dynamic interplay between flyer, kite, wind, and tether illustrates the ongoing negotiation between agency and constraint that defines access to preventative health. The metaphor deepens the application of the HSDF by making its multi-level processes visually and relationally graspable. Stangl et al.’s (2019) HSDF identifies drivers, facilitators, 107 manifestations, and consequences of stigma across socio-ecological layers, while resisting the dichotomy of “stigmatised” versus “stigmatisers.” The kite metaphor translates these processes into layered forces of flight, offering a means to illustrate their convergence and relational impact. Most importantly, it also resists deficit-based framings that portray communities only as vulnerable. Instead, it underscores adaptive strategies, resilience, and collective strength, revealing movement, agility, and possibility amid turbulent conditions. 5.5 Implications for Public Health Practice & Policy These findings raise urgent questions for public health practice and policy. Vaccine uptake among this study’s participants reflected structural inequities and conditional trust rather than individual hesitancy. The implications extend beyond technical fixes; they demand system transformation, stigma-sensitive communication, and sustained structural support. A central implication lies in the transformation of the system. Public health infrastructures must embed GBTMSM+ competent and affirming care as a core obligation. Participants described health systems as neglectful or inconsistent, underscoring that affirming care does more than reduce barriers: it generates structural support. When providers with lived experience, or those trained in affirming practices, engaged directly in outbreak responses, participants reported greater confidence and less exposure to anticipated stigma. Grey et al. (2023) and Owen-Smith et al. (2016) emphasise that equity depends on system-level accountability, not isolated efforts by competent providers. The challenge is to weave affirming care into the fabric of response rather than leaving it to chance encounters. Communication also emerged as a decisive force. Messages that claimed neutrality, such as the refrain that “the general population is not at risk,” erased the realities of those most affected and reinforced exclusion. Neutrality, far from harmless, created drag on engagement. By 108 contrast, communication that named inequities, bolstered resilience, and amplified lived experience created affirming moments. Tam (2024) warns that silence in the face of inequity deepens stigma; these findings extend that critique by demonstrating that stigma-sensitive communication can transform engagement itself. Participants highlighted that the targeted framing of mpox-related communication inadvertently flattened complex gender and sexual identities, obscured the lived realities of transwomen and nonbinary individuals, and created real or perceived barriers to vaccination for transmasculine people. Participants in this study expressed discomfort with this reductive classification, highlighting instances where it overlooked aspects of their identities, practices, and unique vulnerabilities. The implication from participant narratives is clear: reliance on “MSM+” or “gbMSM” terminologies risks reinforcing exclusionary practices in public health and scholarship. By critically engaging with these terminologies, this thesis amplifies participants’ concerns and calls for more non-monolithic, community-informed language that better reflects the diversity of those most affected. Equally significant are the community-rooted and peer-led strategies that tethered participants’ trust. These initiatives provided both practical information and relational support, serving as a steady wind against systemic neglect. However, they remain precariously funded, tied to short-term emergency cycles. Rhodes et al. (2024) argue that community-led outreach does not merely fill gaps but reorients the ethos of public health. Sustaining this orientation requires investment that prioritises long-term equity over temporary efficiency. This could take the form of stable funding for community-rooted organisations, integration of peer-led initiatives into formal health systems, and capacity-building that ensures continuity beyond crisis periods. 109 These implications situate mpox vaccination within a broader struggle for health equity. Structural determinants remain the most powerful predictors of engagement for sexual and gender minorities (Banjar & Alaqeel, 2023; Grey et al., 2023; Gergyek, 2023; Liu et al., 2025; Rajkhowa et al., 2023). The findings here echo that evidence while extending it: participants’ resilience is forged through structural conditions shaped and animated by relational dynamics. Therefore, open questions remain: What shifts in funding, training, and governance would follow if public health treated affirming care, stigma-sensitive communication, and community-oriented outreach as structural imperatives? The urgency of this inquiry intensifies as anti-2S/LGBTQIA+ movements escalate globally, eroding rights and narrowing access to care. In turn, public health cannot remain neutral in the face of such forces. The kite metaphor underscores this tension. Without structural shifts, flight remains precarious, destabilised by neglect and political headwinds. With sustained investment and affirming practice, GBTMSM+ communities can sustain flight and redirect winds into collective momentum. Public health must do more than steady a faltering kite at the margins; it must redirect the winds that generate instability in the first place. 5.6 Recommendations for Future Research This study highlights urgent areas that warrant further investigation. The voices of participants reveal gaps that extend beyond the scope of this project but remain vital for advancing equity in vaccine access and broader public health practice. Future research must attend to the experiences of inadequately represented GBTMSM+ individuals who remain least visible in dominant narratives, including racialised people, trans folks, sex workers, and PLWH. These subgroups often experience intersecting stigma that magnifies barriers to care, but their perspectives remain peripheral in the literature (Grey et al., 2023; Logie et al., 2011; Ramnarine, 110 2024; Rodriguez-Diaz et al., 2022; Strathdee et al., 2023; Takenaka et al., 2024; Thornhill et al., 2022). Research that foregrounds these communities can deepen understanding of structural marginalisation while also surfacing strategies of resistance and resilience that may remain otherwise underexplored. The immediate responses to the mpox outbreak demonstrate that stigma-sensitive messaging and peer-led strategies can increase trust and uptake. However, the long-term implications of these approaches remain unclear, prompting critical questions: Do they create sustained confidence in public health systems? Do they reduce the cumulative burden of stigma across other health conditions? Longitudinal studies can illuminate whether stigma-informed interventions leave lasting effects on health equity or whether their influence wanes once urgency fades. Participants repeatedly identified mobile clinics, pop-up sites, and community partnerships as effective interventions. These models reduce barriers of distance, distrust, and bureaucratic delay. Research should examine their durability over time by asking these questions: Do they require constant crisis to be resourced? Can health systems include them as standing infrastructure rather than temporary fixes? Evidence of their sustainability can inform policy decisions that prioritise relational rather than transactional care. The kite metaphor developed in this thesis reveals intersections across micro-, meso-, and macro-levels where forces converge, shaping public health engagement. Future research can map these intersections with greater precision, generating insights that move beyond siloed analysis and toward inclusive strategies for equity. In turn, research that engages underrepresented subgroups, traces long-term effects, examines sustainable delivery, and interrogates neglected intersections can build on this study’s insights. This inquiry does not aim to produce definitive 111 solutions but to extend the dialogue, ensuring that public health scholarship continues to evolve alongside the communities it seeks to serve. 5.7 Reflexivity & Positionality While writing the Findings and Discussion chapters, I realised that the patterns I had identified required sharper conceptual tools than those I initially held. This recognition reflected not failure, but the generative and reflexive nature of analysis within ID (Thorne, 2016) and RTA (Braun & Clarke, 2021). Engaging further with literature during writing provided that precision. Crenshaw’s (1991) critique of additive approaches and Collins and Bilge’s (2016) scrutiny of monolithic representation clarify that participants’ accounts transcended mere descriptions of multiple exclusions. They exposed intersecting systems of classification that constrained identity and agency. Incorporating these concepts mid-analysis was not pre-planned; it became necessary to interpret and represent the data with integrity. Further, while this thesis includes the perspectives of an Indigenous participant, I acknowledge that I am not an Indigenous person on Turtle Island and therefore cannot fully represent Indigenous knowledges. To avoid overreaching, I foreground participants’ own words and resist colonial framings that might otherwise obscure their experiences. I also recognise that while some Indigenous people may identify as Two-Spirit, not all do, and this thesis reflects that diversity without imposing categorical labels. Following Morgensen’s (2011) call to unsettle queer research by addressing the entanglements of settler colonialism, and Kolopenuk’s (2024) reminder that healthcare is deeply implicated in the ongoing violence against Indigenous peoples, I recognise that integrating Indigeneity in this work is crucial to resisting erasure and advancing accountability in public health scholarship. 112 Reflexivity shaped these interpretive choices. Although I detail my positionality in the Methods section, I note here that my proximity to the dynamics of stigma, trust, and institutional exclusion influenced the way I read and structured meaning. The analysis remained co-produced rather than detached, marked by reflection, ethical responsibility, and attentiveness to the political weight carried by participants’ accounts. The kite metaphor was created within this reflexive space: a way to animate forces that might otherwise remain abstract, while acknowledging that my interpretive frame shaped the very contours of its flight. 5.8 Limitations This study offers situated, practice-informed insights rather than claims of broad applicability. Guided by ID (Thorne, 2016) and RTA (Braun & Clarke, 2021), the analysis foregrounds the lived experiences of underrepresented GBTMSM+ communities during the 2022–2023 mpox outbreak in and around Vancouver, BC. These findings are anchored in that sociocultural and temporal context. While they may not reflect experiences in other provinces or countries with different health systems and political climates, they provide transferable insights for equity-oriented vaccine delivery. The findings represent just a snapshot in time, based on data collected during a single phase of the outbreak. They do not account for the complex changes in attitudes, access, or messaging that occur as conditions evolve. The lack of longitudinal follow-up restricts insights into how perspectives change over time, especially among groups whose healthcare access is influenced by unstable structural and political forces. The study also carries the possibility of social desirability bias. Participants may have tempered or framed responses in ways that aligned with perceived community expectations or with my identity as an insider researcher. These dynamics may have influenced accounts of trust, 113 stigma, and vaccine decision-making. Ongoing reflexivity and the emphasis on open-ended, participant-led dialogue sought to mitigate, but could not fully eliminate, these effects. Finally, my positionality as a member of the community shaped both the advantages and challenges of interpretation. Insider knowledge fostered rapport and depth, yet also carried risks of over-identification and assumption. Through sustained reflexive practice, including journalling and critical reflection, I worked to surface these dynamics and to maintain analytic rigour. This thesis resists claims of absolute neutrality, situating its credibility in reflexive accountability and the co-construction of meaning. 114 Chapter 6: Conclusion This thesis presents a nuanced exploration of mpox vaccine uptake among underrepresented GBTMSM+ communities in and around Vancouver, illuminating the complex interplay of stigma, trust, and resilience across micro-, meso-, and macro-level contexts. The findings reveal that vaccine engagement is never simply a matter of individual choice or risk perception; it reflects systemic inequities, relational trust, and community strength. Three overarching insights stand out. First, stigma and strength operate as intertwined forces: stigma eroded trust in public health, yet affirming care and community strength countered its impact. Second, the community served as a stabilising tether, with peer networks, grassroots-oriented outreach, and trusted organisations like HIM, Living Positive Resource Centre, and the Ribbon Community providing accessible and culturally grounded support. Third, structural barriers, reinforced through exclusionary messaging, restrictive eligibility criteria, and uneven vaccine distribution, further marginalised racialised people, trans-individuals, and sex workers, compounding inequities in access. Amid these constraints, participants reframed vaccination as an act of defiance, rather than mere compliance, thereby transforming vulnerability into strength through relational care and collective resilience. This resistance underscores that resilience is not passive endurance but an active refusal to be diminished by inequitable and harmful forces. The analytic use of the Tethered Flight metaphor highlighted these dynamics, offering an innovative way to visualise the complex interplay of stigma, agency, and structural power. The implications for public health are clear: systems must move beyond transactional, deficit-based models to a more relational care approach by embedding stigma-sensitive communication, affirming care, and sustained community-led initiatives at their core. Without 115 structural transformation, fragmented outreach and stigma-enforcing communication will continue to erode trust. With such transformation, public health can begin to rebuild relationships, foster equity, and honour the knowledge and lived realities of those most affected. Most urgently, this study highlights future directions that require attention: deeper engagement with underserved key groups, long-term evaluation of stigma-sensitive interventions, and the development of sustainable models for community-based care that extend beyond crisis response. Pursued together, these efforts can transform conditional trust into relational trust rooted in reciprocity. In closing, this research serves as both evidence and invitation. It underscores the urgent need for equity-oriented, relational approaches to public health, and it invites policymakers, practitioners, and researchers to engage more deeply, keep acting with accountability, and pursue structural change that affirms the full humanity of the communities they seek to support. 116 References Bauer, G. R., & Scheim, A. I. (2019). Methods for analytic intercategorical intersectionality in quantitative research: Discrimination as a mediator of health inequalities. 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A., Ogoina, D., Mbala-Kingebeni, P., Ntoumi, F., Nakouné, E., Njouom, R., Ndembi, N., Mills, E. J., Muyembe-Tamfum, J. J., & Nachega, J. B. (2024). The 2024 Public Health Emergency of International Concern: A Global Failure to Control Mpox. The American journal of tropical medicine and hygiene, 112(1), 17–20. https://doi.org/10.4269/ajtmh.24-0606 127 Appendix A: Tethered Flight: Agency and Constraint in Public Health Engagement KITE (Health Outcome) Vaccine received (Steady flight) Vaccine not received (Grounded) Vaccine delayed (Destabilised) Resistance through Resilience (Keeps kite aloft amid turbulent wind) WIND (Multi-level Forces) Turbulent Wind (Destabilising or damaging) Moderate Wind (Enabling) Mild or Absent Wind (Stagnating) STRING (Health outcomes are tethered to the quality of one’s relationship with the healthcare system) TETHERED FLYER (Underrepresented GBTMSM+ Community Member)
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Saewyc, Elizabeth Marie
Greyson, Devon
Tethered flight : weathering agency and constraint in mpox vaccination among underrepresented gay, bisexual, trans, and other men who have sex with men through interpretive description
Text