key: cord-0984668-pvj1c9j0 authors: Sides, E.; Jones, L. F.; Kamal, A.; Thomas, A.; Syeda, R.; Kaissi, A.; Lecky, D.; Patel, M.; Nellums, L.; Greenway, J.; Campos-Matos, I.; Shukla, R.; Brown, C.; Pareek, M.; Sollars, L.; Pawson, E.; McNulty, C. title: Attitudes Towards Coronavirus (COVID-19) Vaccine and Sources of Information Across Diverse Ethnic Groups in the UK: a Qualitative Study date: 2022-02-06 journal: nan DOI: 10.1101/2022.02.04.22270456 sha: fa8b5e6829d574193eececf0759455c83e7d5926 doc_id: 984668 cord_uid: pvj1c9j0 Objectives To explore attitudes and intentions towards COVID-19 vaccination, and influences and sources of information about COVID-19 across diverse ethnic groups (EGs) in the UK. Design Remote qualitative interviews and focus groups (FGs) conducted June-October 2020 before UK COVID-19 vaccine approval. Data were transcribed and analysed through inductive thematic analysis. Setting General public in the community across England and Wales. Participants 100 participants from 19 self-identified EGs with spoken English or Punjabi. Results Mistrust and doubt were common themes across all EGs including white British and minority EGs, but more pronounced amongst Bangladeshi, Pakistani, Black ethnicities and Travellers. Many participants shared concerns about perceived lack of information about COVID-19 vaccine safety, efficacy and potential unknown adverse effects. Across EGs participants stated occupations with public contact, older adults and vulnerable groups should be prioritised for vaccination. Perceived risk, social influences, occupation, age, co-morbidities and engagement with healthcare influenced participant intentions to accept vaccination once available; all Jewish FG participants intended to accept, while all Traveller FG participants indicated they probably would not. Facilitators to COVID-19 vaccine uptake across all EGs included: desire to return to normality and protect health and wellbeing; perceived higher risk of infection; evidence of vaccine safety and efficacy; vaccine availability and accessibility. COVID-19 information sources were influenced by social factors, culture and religion and included: friends, family; media and news outlets; and research literature. Participants across most different EGs were concerned about misinformation or had negative attitudes towards the media. Conclusions During vaccination programme roll-out, including boosters, commissioners and vaccine providers should provide accurate information, authentic community outreach, and use appropriate channels to disseminate information and counter misinformation. Adopting a context-specific approach to vaccine resources, interventions and policies and empowering communities has potential to increase trust in the programme. • This is amongst the largest qualitative studies on attitudes to the COVID-19 pandemic in the UK general public across ethnic groups (EGs), ages and religions, adding insights from a broader range of participants. • Qualitative methodology enabled discussion of participants' responses around vaccination, probing to collect rich data to inform recommendations across EGs. • Most data collection was undertaken in English, possibly excluding sectors of the population who may access COVID-19 information through different sources due to language. • Data collection was June-October 2020 before COVID-19 vaccines were licensed. Attitudes are highly responsive to current information around a COVID-19 vaccine, as well as the state of the pandemic and perceived risk. Data were collected prior to much of the intervention work, putting the attitudes and intentions expressed in this study in a context of minimal community engagement and support. This provides a baseline snapshot of attitudes, providing the option to explore and assess the impact of such interventions. • Socioeconomic data and index of multiple deprivation were not collected, limiting the ability to determine a possible accumulative effect of factors such as socioeconomic status, ethnicity and age. 56247121-file00.14 3 Introduction 274 words The coronavirus (COVID-19) pandemic has had a striking impact on global health with five million reported deaths worldwide by December 2021 [1] .The UK has seen more COVID-19 cases per capita than many other countries with over 13 million cumulative cases up to January 2022, over 172,000 deaths and much associated morbidity including 'long COVID-19' [2] . Increased COVID-19 morbidity and mortality have been associated with increasing age, gender, comorbidities, deprivation, occupations with greater face to face contact, and certain minority ethnic groups (EGs) [3] [4] [5] . Vaccination programmes are one of the key strategies used to limit the societal impact of infections [6] so vaccine acceptability and uptake is crucial to COVID-19 control [7] . Public vaccine safety concerns and doubts have contributed to reductions in uptake of non-COVID-19 vaccines which has led in increase in these infections [8, 9] . Modelling suggests 10,400 deaths and much long-term morbidity had been avoided by March 2021 through the English COVID-19 vaccination programme introduced in December 2020 [10] . Positive COVID-19 vaccine attitudes reportedly increased from 78% in December 2020 to 96% in May to June 2021 [11, 12] . Evidence indicates there were differences in COVID-19 vaccine uptake based on demographic and socioeconomic factors. Black or Black British adults and those living in the most deprived areas were more likely to report COVID-19 vaccine hesitancy [11] [12] [13] [14] . However, there is a lack of in-depth qualitative literature exploring attitudes towards the COVID-19 vaccine across a broad cross-section of the UK population with balanced representation of ethnicities, ages, genders and religions. This qualitative study aims to explore the general public's acceptability and uptake of a COVID-19 vaccine prior to its roll out and attitudes towards sources of COVID-19 information, with representation across EGs. Methods 826 words This paper forms part of a wider qualitative study that explored the attitudes, behaviours and needs of diverse EGs in Wales and England during the COVID-19 pandemic. Focus group and interview topic guide development The interview guide (Supplementary 1) was informed by Public Health England's (PHE) 2020 review of disparities in risks and outcomes for COVID-19 [4] and the Theoretical Domains Framework (TDF) [15] . Eight of the fourteen TDF domains were mapped to the following topics explored in the interviews and FGs: knowledge, beliefs about consequences of COVID-19 infection and vaccination; optimism that a vaccine would help solve the pandemic (optimism); feelings about being offered a COVID-19 vaccine (emotion, memory, attention and decision-making); reasons for or against accepting a COVID-19 vaccine (intentions, reinforcement); influences on decision-making (memory, attention and decision making); groups to be prioritised (professional role and identity); and where to receive the vaccine if willing (environmental context and resources). Recruitment Individuals were recruited between June and October 2020 with the aim of selecting a diverse crosssection of the UK population across regions, including minority EGs, religions, and occupations. Ethnic minority varies by country and context and is defined as "a group of people who differ in race or colour or national, religious, or cultural origin from the majority population of the country in which they live" [16] . They also inputted into the design and methodology, as well as data collection tools and recruitment strategy. The study was internally reviewed by the PHE Research Ethics and Governance Group (REGG) (Reference: NR0215). All participants involved in the study provided informed consent, including the use of anonymised transcript quotes in reporting and publications. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) There were some differences of opinion on whether children should be prioritised; some thought children should be prioritised as they were carriers of the virus, while others raised concerns about possible unknown side effects on developing immune systems. More detailed findings by ethnic group are reported in Table 3 . There were also differences within EGs, with factors such as frontline occupation and perceived health status influencing their intention to accept a vaccine once made available. Having a health condition led to higher risk perception while positive health status caused lower risk perception, thus influencing intention to accept a vaccine. There was a belief amongst some that alternative methods of prevention such as practicing good hygiene, maintaining a good diet and exercise, were equally, if not more, important to vaccination. Some believed that there were other ways to build immunity rather than vaccination or had a belief that vaccination was unnecessary due to their perception that they were healthy. Some participants were optimistic that a working vaccine would become available while others were aware it might take time. Some believed a vaccine to be important and recognised its role in herd immunity. Barriers to vaccination Mistrust and doubt were common themes across EGs and many shared concerns about perceived lack of information about COVID-19 vaccine safety, efficacy and potential unknown adverse effects. Mistrust in government advice and recommendations were identified as the greatest potential barriers to vaccine acceptability. This was due to perceptions of the government's handling of the pandemic, perceived unclear messaging and frequently changing guidance at various stages of the pandemic which resulted in confusion. Disengagement with pharmaceuticals, medicine and healthcare services was a barrier to vaccine uptake which was mainly due to mistrust. Some participants raised concerns about their friends and family being susceptible to misinformation, for example that the vaccine included chemicals or microchips. A few participants had negative views around vaccination imposed by their relatives. A minority of participants stated that they would definitely not accept the vaccine, which was primarily due to being opposed to vaccines in general. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 6, 2022. ; 56247121-file00.14 7 Facilitators for vaccination There was general agreement across EGs on places to receive the vaccine, including community healthcare settings and settings perceived as low risk, e.g. a space with less people. Many participants stated that they would accept the vaccine either to enable return to normal life, to continue working, or to protect themselves and others due to existing health conditions. However, several of these participants stated that they would wait until others in the population received the vaccine first in order to observe potential side effects. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 6, 2022. ; https://doi.org/10.1101/2022.02.04.22270456 doi: medRxiv preprint 56247121-file00.14 8 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. 10 Attitudes and intentions by ethnic group Caution and wariness to accept a COVID-19 vaccine, including concerns about vaccine safety was reported amongst all EGs including White and non-White groups. Although themes of mistrust and doubt arose across most EGs, they were more pronounced amongst the following: Bangladeshi (mistrust of government guidance surrounding vaccines); Pakistani (mistrust of COVID-19 vaccine due to government and Public Health England handling of pandemic); Black ethnicities and Travellers (mistrust of authorities, pharmaceuticals or pharmaceutical companies developing vaccines). Arabic and Traveller FG participants suggested that vaccines might not be necessary for those with a strong enough immune system. Some participants in all EGs indicated they probably would accept a vaccine once it became available. There were no other notable differences between EGs. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. Contrasting views: • Caution and concern about vaccine safety. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. 13 Sources of COVID-19 information Themes around COVID-19 information included: (1) sourcing information from friends, family and social media, media and news outlets and the research literature (2) concerns about misinformation; and (3) cultural and religious influences (Table 4) . Many participants across all EGs reported comparing stories with friends and family, often via WhatsApp and other social media channels. A number of participants stated that they received information from traditional UK media channels such as British Broadcasting Company (BBC) news and their websites. Some participants reported watching the BBC government daily COVID-19 briefings while others used websites to obtain information and reported that they were aware of the minority ethnic COVID-19 statistics through the news. A small number reported that some relatives obtained information through non-UK based news outlets (e.g. American and Asian), which may have promoted different information, behaviours, and attitudes. In most focus groups or interviews across a range of EGs, one or more participants had negative attitudes towards the media. Such attitudes included a belief that media: had its own agenda; should present more balanced stories; caused confusion; gave inconsistent messaging, and participants reported wariness or uncertainty surrounding the credibility of the information. It was reported that media coverage had negative implications on the mental health and wellbeing of some participants, sometimes causing fear and distress. A minority reported directly using government guidance. Some had public facing roles and they therefore followed the guidance from their workplace. A minority reported researching the topic themselves through research literature. Concerns around misinformation were mentioned across all EGs. Some raised their concerns surrounding the spread of misinformation amongst their WhatsApp and social media networks, for example that the vaccine contained a microchip to monitor people. As a result, some reported taking on the role of dispelling misinformation circulating among friends and family, particularly for older family and community members. Some cultural and religious sources of information were identified. A participant suggested that their parents believed in traditional remedies (Bangladeshi FG) while another reported obtaining information from the mosque (South East Asian FG). . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. "…So every time you had a WhatsApp in the morning, people were scared, who's passed away, and things like that. So I think that actually did not help. Too much negative WhatsApp calls going around, messages, and I said to people, try to stay positive…" [Unknown, FG18] Media and news outlets Traditional media a source of information e.g. news, BBC, newspaper. "…at the end of the day like come to 5 to 6 o'clock, I just go onto the BBC news website and quickly just have a look at what's, what they've published…" [Unknown, FG2] Participants or their family watched news from non-UK based media outlets. "…I mean most of the information I've had on it has come from America… I learnt first from listening to the American news and speaking to my cousin who works for the government in Washington…" [M, FG3] Government daily COVID-19 press conferences or briefings were a source of information. "…because I have a degree in Applied Biology, I understood a lot of the briefings and how these things spread…" [Unknown, FG16] Websites such as BBC a source of information. "…from websites mainly, like the BBC website, what's been on the internet…I don't really follow closely let's say, but it's, from time to time or when there is a major change…" [F, FG13] Awareness of the minority ethnic COVID-19 statistics through the news. "…Then that started hitting the news, the headlines, I think that's when it started, how would I put it, that's when it started affecting a lot of people in our background…" [M, FG5] Perception that the media had its own agenda. "…To me, you should be trying to find out, more informative for the public rather than their media outlets and to score points against the government and, that's how I saw it…" [M, FG18] Belief that the media should show more balanced stories. "…They have to think of presenting a true reflection of what is happening. So good and bad, both." [M, FG9] Media and news caused fear among some participants. "…I was watching ITV this morning and it's like the arguments are still ongoing about all of the negative news that's out there, which is really scaremongering and really starting to affect peoples' mental health …" [F, FG20] Confusion at inconsistent messaging and policies. "…Some of the things he told were confusing, but others were not. They did one thing wrong. Participants concerned about the spread of misinformation through WhatsApp and social media. "The funeral one was massive because … there was all these groups being started, different Facebook, WhatsApp type groups, talking about whatever and it was actually quite upsetting, I think, to be honest, because I think people were somewhat misinformed…" [F, FG5] Taking on the role of dispelling misinformation amongst network. "The amount of viral things that were going around in and amongst my extended family and friends and, I've just got this thing where I'm like, guys, it's fake news..." [F, FG5] Volunteering for a local community radio station to help dispel misinformation. "I also sort of voluntarily basis, oversee a local community radio station…So getting those messages out was important, and try and dispel those conspiracy theories. It was quite difficult, but we eventually got there …" [M, FG19] . It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. 15 Use of websites to identify 'fake news'. "…there are a few really good websites that tell you whether it's fake news or not, like reputable …" [F, FG5] Cultural and religious influences Perception that some people believe in natural remedies. "…I might tell them stuff and they would just be like, they will just talk about some kind of folk cures to take or drink and you'll be fine…" [M, FG10] Information from the mosque. "I think we are doing everything OK now from our point of view, we've got the radio and the messages going on a regular basis. Also, from the Mosque and from community…" is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. This study adds findings about COVID-19 vaccinations, some of which differ from attitudes towards other vaccinations. Mistrust and doubt surrounding COVID-19 vaccination were common themes that arose across white British and minority EGs but they were more pronounced in Bangladeshi, Pakistani, Black ethnicities and Travellers. Across EGs, many were cautious and shared concerns about COVID-19 vaccine safety and efficacy. There were differences within EGs, with factors such as occupation and perceived health status influencing their intention to accept a vaccine once made available. Attitudes and intentions sometimes differed between EGs, for example all participants in the Jewish FG reported that they probably would accept a vaccine while all participants in the Traveller FG probably would not accept one. Although many received their information from trusted sources such as mainstream television, many also reported negative attitudes towards the government, media and news outlets. Table 5 provides an overview of practical intervention and policy recommendations based on the findings of this study. Comparison with existing literature Low trust in government advice and recommendations due to its perceived handling of the pandemic and changing COVID-19 messaging was identified as a potential barrier to vaccine acceptability and uptake in our study and others [21] [22] . The link between mistrust in a COVID-19 vaccine and mistrust in government was found to be more pronounced among some minority ethnic participants in a small qualitative study amongst UK HCPs, particularly Black African, Black Caribbean and other Black groups [23] . Such differences were observed to an extent in our study, where mistrust was reported in not only Black ethnicities (authorities and pharmaceutical companies developing vaccines), but Bangladeshi (mistrust of government guidance surrounding vaccines) and Pakistani (mistrust of COVID-19 vaccine due to government and Public Health England handling of pandemic) groups too. It is important to recognise that mistrust can stem from wider inequalities beyond COVID-19 [23] . In our study, similar barriers and facilitators towards the COVID-19 vaccination were often reported across EGs. However, surveillance data demonstrates that COVID-19 vaccination rates in the UK and Israel were lowest amongst certain minority EGs [24] [25] . For UK healthcare workers between December 2020 and February 2021, studies found that some minority EGs were more likely to be COVID-19 vaccine hesitant in comparison to White British groups [13] , and that COVID-19 vaccine uptake was lower amongst some ethnic minority groups compared to White [26] . In a US youth survey, Black participants were less likely and Asian participants more likely to accept a COVID-19 vaccine compared to White participants [27] . A UK survey found that certain demographic characteristics (age, sex, ethnicity, religion, qualifications, employment status, key worker, extremely clinically vulnerable, extremely clinical vulnerable household member) explained only 4% of the variance in vaccination intention, beliefs about the value of vaccines explained 35% of the variance, and positive COVID-19 vaccination beliefs and attitudes explained 28% [28] . This suggests, in line with our findings, that being from a minority EG alone is unlikely to account for vaccine uptake differences and implies that attitudes and intentions vary depending on an interaction between multiple factors such as location, time and socioeconomic, cultural and political context. Locally appropriate outreach settings are needed with flexible appointments to overcome vaccine access issues. Migrants with precarious immigration status suggested walk-in centres in trusted locations such as foodbanks, community centres and charities would facilitate vaccine access and uptake [29] . Additionally, allowing vaccination without documentation or general practice registration should be considered and publicised to facilitate equitable access, for example for the estimated 600,000 undocumented migrants living in the UK, [30] the homeless and other vulnerable populations. In most focus groups or interviews across a range of EGs, one or more participants had negative attitudes towards the media and its impact on them. In our study, participants raised concerns about the impact of social media misinformation and stress the importance of disseminating clear, consistent vaccination messages covering safety, effectiveness, as well as empowering the public to address misinformation in their networks and being active on social media to combat misinformation (Table 5 ). Negative attitudes towards the media, government, medicine and healthcare could be overcome by messaging and vaccine delivery from trusted figures [31] . Other studies have found a strong correlation between a trusted healthcare professional or physician's recommendation of a vaccine and higher uptake [32] [33] . However, this may not be adequate for those who are disengaged with medicine and healthcare. Many participants expressed concerns about receiving a COVID-19 vaccine or wanted more information, particularly around safety and efficacy. Large UK questionnaire surveys support this, demonstrating a significant positive association between confidence in the importance, safety and effectiveness of a COVID-19 vaccine, and vaccine acceptance [21, 34] . A small qualitative UK parental study and larger survey completed in May 2020 found that COVID-19 vaccine safety and efficacy concerns were the greatest barrier to definite vaccine acceptance, which in the larger parallel survey was 56% [21] . There was a belief that COVID-19 vaccine development had been rushed amongst most participants in our study and other small qualitative studies amongst UK HCPs [23] . Some of our participants stated that they would wait until "it is deemed safe and effective," or others in the population received the vaccine first before accepting it themselves. This was echoed in UK qualitative studies exploring COVID-19 vaccination in pregnant women [35] and recent migrants [29] , a Canadian qualitative study in a diverse sample of the population [36] and a US quantitative study of attitudes towards COVID-19 vaccination in 14 to 24 year olds [27] . Previous research indicates that people deem older vaccines safer than newer ones [37, 38] . Main reasons for hesitancy were concerns about unforeseen future side effects of vaccines, and general mistrust in the benefits and safety of vaccines [34] , and a few thought that they should rely on their own strong immune systems. A large UK parental survey found that lower income, or ethnic minority participants were at least twice as likely to reject COVID vaccination [34] and although we found no apparent differences by minority ethnicity, our sample size of 100 and its . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. ; qualitative methodology were not designed to determine this. In a qualitative study on experiences of participation in COVID-19 vaccine trials, minority ethnic participants highlighted the importance of diverse representativeness in trials [39] , which was also mentioned by one of our participants. Similar barriers and facilitators to ours were found in a systematic review exploring parents' acceptance of childhood vaccinations in general [40] . We found that participants' perception of risk of COVID-19 infection and severe illness to themselves, and their family, through occupation, age or comorbidity, and protection through vaccination were strong facilitators for COVID-19 vaccination acceptance. This has been found in several other studies of the general population, healthcare workers, immunocompromised and parents [7, 21] [32] . In contrast, Travellers in our study and others perceived themselves at lower risk of infection through their lower contact with other population groups. [32] Easy access will be important to facilitate vaccination uptake for those with risk due to occupation or comorbidity [24] . Our study and others certainly indicated that many would prefer a local, low risk community healthcare setting with convenience of booking appointments [29, 41, 42] . However, a key difference to note is that at the time of data collection, access to vaccines was not a tangible issue as they had not yet been approved. The importance of differentiating between vaccine hesitancy, which has less variation in different EGs [43] , and under-vaccination related to environmental context and access have been raised by others [29, 44] . In Israel, low uptake in certain groups has been increased by well-tailored outreach efforts [25, 45] . Many participants across EGs reported comparing stories with friends and family, often via channels such as WhatsApp and other social media. Concerns about misinformation were raised across all groups. People with more of a reliance on social media and social networks for COVID-19 information are more likely to trust it [46] , and be exposed to misinformation [47] ; these tend to be those of younger age, lower education levels, and lower income. [48] There is evidence of social media outlets circulating COVID-19 misinformation. [46, [49] [50] [51] [52] . COVID-19 vaccine messaging must be appropriate for both the 'influencers' and the 'influenced' to facilitate the dissemination of trusted information amongst networks. Strengths and limitations of the study This is amongst the largest qualitative studies on attitudes to vaccination in the UK general public and, importantly in contrast to others, incorporates most UK minority EGs, the COVID-19 pandemic and perceived risk. [7, 21, 24, 25, 28, 34, 43, 48, [53] [54] [55] Although intention does not necessarily directly translate to actual vaccine uptake in the future it is a good predictor and surveys demonstrate a steady increase in vaccine acceptance since 2020 [53] . Most data collection was undertaken in English, possibly excluding sectors of the population who may access COVID-19 information through different sources due to language. Similar themes were identified from the English FGs and Punjabi interviews, with exception of some religious views, indicating consistency of results. Much of the data collection and analysis was conducted by White British researchers which could have impacted interpretation of findings, however FGs and interviews were held remotely which may have reduced this and also acquiescence bias. The first five FGs included a range of ethnicities while others mainly comprised participants of the same ethnicity; the latter allowed greater reflexivity between participants. Both focus group type yielded similar data. Data collection was June-October 2020 before COVID-19 vaccines were licensed. Attitudes to vaccine are not static and are highly responsive to current information around a COVID-19 vaccine, as well as the state of the pandemic and perceived risk. Data were also collected prior to much of the intervention work, putting the attitudes and intentions expressed in this study in a context of minimal community engagement and support. This is a strength as it provides a baseline snapshot of attitudes, providing the option to explore and assess the impact of such interventions. To avoid exclusion of typically underrepresented groups, recruitment involved approaching charities that aim to empower and advocate for minority ethnic communities and improve their access to services. The data may be subject to selection bias, as those with a greater interest in COVID-19 may have volunteered and we did not reach every minority EG in the UK. Socioeconomic data and index of multiple deprivation were not collected, limiting the ability to determine a possible accumulative effect of factors such as socioeconomic status, ethnicity and age. Attitudes and intentions by EG were presented for the FGs and interviews that included participants of the same or similar ethnicities i.e. FGs 4, 6-24 and Interviews 1-3, as transcription did not allow for differentiation between ethnicities of each participant (Table 3) . Table 1 and Supplementary 3 demonstrate FG characteristics. Interventions and policies must be appropriate and effective for diverse populations where vaccine acceptability and uptake are low, to reduce inequalities and increase vaccine equity. This study's findings have local and national implications for clinicians and policymakers, as presented in Table 5 , which fall under three overarching areas: providing information that addresses specific concerns of communities; authentic community outreach; and using the right channels to disseminate credible information and counteract misinformation. Unanswered questions, future research and implications Since this work was completed the results and recommendations have been presented to government bodies. Faithbased and EG communities are now more actively involved in local and more tailored COVID-19 communications in the UK [56] . There are efforts to locate vaccination clinics in more accepted local assets, such as places of worship, including mosques and churches [56] . Local COVID-19 vaccine community champions and influencers in minority groups are being identified and encouraged [56] [57] [58] . Further detailed guidance from the UK Race Disparities Unit encourages targeted local action and engagement with support from community champions and other local leadership [59, 60] . . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. ; Nonetheless, more high-quality research and evaluation is needed to demonstrate the effects of different interventions on COVID-19 vaccine uptake [5] . Future locally led outreach should engage marginalised groups and explore the attitudes and behaviours where there is low vaccine uptake to mitigate barriers [14] . Future research must gain further understanding of similarities and differences within groups to adopt a context-specific approach to vaccine resources, interventions and policies, and proactively involve diverse patient and public groups. Such interventions should provide access, equity, and knowledge, and empower and engage local communities. Surveillance should continue to monitor vaccine uptake, with both quantitative and qualitative studies to explore any ongoing disparities in uptake and whether they continue to be related to concerns in vaccine safety or low perception of COVID-19 risk. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. ; Table 5 . COVID-19 vaccination attitudes and COVID-19 sources of information: implications and recommendations for clinicians and policymakers Topic Subtheme Implication/ Recommendation Attitudes towards COVID-19 and a COVID-19 vaccine • A degree of optimism that a COVID-19 vaccine would become available while some were aware it might take time. • Some understood the importance of a COVID-19 vaccine. • Different beliefs surrounding who should receive the vaccine. • Belief that people should have the choice. • Some believed that other health behaviours were equally, if not more important to maintain. • Public health messages should continue to inform the public about vaccines and how to access them. • Rationale for and order of priority groups for COVID-19 vaccination should be clearly stated • Public health messaging should continue to encourage positive health behaviours in addition to getting vaccinated. • More research is needed to explore the attitude towards compulsory vaccination in different groups or settings. • Recognition of importance of clinical trials. • Continue to quote the emerging evidence from vaccine trials. • Actively recruit more diverse participants to clinical trials. • Many would wait until others had tried the vaccine until accepting it themselves. • Positive 'success' stories of vaccination should be developed and disseminated by individuals and organisations authentically representing diverse groups in terms of age, gender, ethnicity, region, occupations. • People were concerned about COVID-19 vaccine safety and efficacy, which linked closely to concerns about vaccine development. • Perception of health and risk meant that some may not accept a vaccine immediately. • Concerns should be addressed by providing clear, accessible information about COVID-19 vaccine development and safety. • Vaccine information should be presented and disseminated in a relatable and understandable manner, including efficacy against deaths, hospital admission, value in protecting family, long COVID, and side effects. • The development of vaccine messaging should involve collaboration with diverse groups. • Belief that culture and religion had influences on the attitudes of certain groups towards vaccines. • Involve local community and religious groups to understand and address the population's concerns and needs for accessing vaccination. • Desire to return to 'normality' identified as a motivator. • Occupation influenced some participants' intentions of accepting a vaccine. • Protecting the health and wellbeing of themselves and others was a motivator. • Stress the value of vaccination in returning life back to normal e.g. ability to celebrate festivals and to protect vulnerable family members and friends. • Evidence-based, appropriately targeted, context specific COVID-19 vaccine messaging for occupations at risk. • Provision of vaccine in occupational settings or practical support such as paid time off to get vaccinated • Environmental context and resources were identified as facilitators e.g. availability and accessibility. • Policymakers should ensure that vaccines are available at accessible times and locations. • Some would encourage others to accept a vaccine. • Messaging should emphasise the benefits of vaccination in also protecting close family (including those under 18 years) and friends, including those with comorbidity. • Low trust and doubt were identified as barriers to vaccine acceptability. • Public trust should be rebuilt by local and national government by providing consistent, clear, evidence-based messaging and actions and by working with the community as partners, co-designing messages. • Disengagement with medicine and healthcare services was a barrier to • Invest in community groups to help build engagement with formal services, e.g. . It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. Community Champions working with healthcare providers and grassroots organisations to increase engagement. • Misinformation was a concern amongst some participants. • Social influences were identified as a barrier. • Communications should preferably be disseminated via trusted and respected channels and figures on both a local and national level, rather than from the government or politicians. • There was opposition to vaccines in general amongst a minority of participants. • Surveillance, surveys and qualitative work on vaccine uptake and acceptability should continue to inform and understand attitudes, beliefs and behaviours. Friends and family, social media • Family was a source of information for some participants, rather than media outlets. • People reported that negative WhatsApp messages spread rapidly amongst their networks. • Information was received via social media amongst some participants. • Positive trustworthy vaccine messages disseminated via social media could be advantageous for rapid dissemination of information and increase vaccine uptake in young people. • Public health messages should be disseminated via multiple channels. • Ensure that community outreach includes range of representatives of different ages and genders to facilitate family conversations. • Traditional media were cited as a source of information e.g. news, BBC, newspaper. • A participant reported directly using government guidance rather than through the media. • Some participants or their family watched news from non-UK based media outlets. • Government daily COVID-19 press conferences or briefings were a source of information. • Websites such as BBC a source of information. • Awareness of minority ethnic COVID-19 statistics through the news. • Both traditional and alternative communication channels should be used to communicate clear messaging and guidance based on behavioural science. • Perception that the media had its own agenda. • Belief that the media should show more balanced stories. • Media and news caused fear among some participants. • Confusion at the media due to inconsistent messaging. • Negative impact of media and news on mental health. • Avoid using fear and instead share positive, supportive communications. • Seeking information on the COVID-19 vaccine and trials themselves. • Reading academic or scientific literature. • This is positive for those who have access to these sources, however could increase disparities for those with limited access to such sources of information. • Increase capacity for science in schools and adult education to improve understanding of science underpinning vaccines. • Participants concerned about the spread of misinformation through WhatsApp and social media. • Some participants took on the role of dispelling misinformation amongst their network. • Volunteering for a local community radio station to help dispel misinformation. • Use of websites to identify 'fake news'. • Public health messages surrounding vaccines should be tailored depending on socio-cultural context. • 'Influencers' should be empowered and provided with the necessary skills and resources to address misinformation amongst their networks. • Different community leaders have different impact, value and reach in different contexts. • Accessibility and equity of correct information is key. Translation of messages is only one aspect of this. . It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 6, 2022. • ES: assisted with data collection; had substantial contributions to the analysis and interpretation of the qualitative data; drafted all versions of the manuscript and critically revised it; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • LJ: project managed from study start to close; led the analysis and interpretation of the qualitative data; had substantial contributions to the design of the study (led on development of protocol, gained ethics approval, drafted interview questions, recruited participants); led the collection of data; had substantial contributions to the analysis and interpretation of the qualitative data; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • AK: had substantial contributions to the design of the study (commented on interview questions, recruited participants); collected data; had substantial contributions to the analysis and interpretation of the qualitative data; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • AT: had substantial contributions to the analysis and interpretation of the qualitative data; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • RBS: had substantial contributions to the design of the study (development of protocol, drafted interview questions); collected data; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • AWK: quality checked data; had contributions to the interpretation of the qualitative data; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • DML: had substantial contributions to the design of the work (helped develop protocol and interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • MGP: had substantial contributions to the design of the study (recruited participants); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • LN: had substantial contributions to the design of the work (reviewed interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • JG: had substantial contributions to the design of the work (reviewed interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • ICM had substantial contributions to the design of the work (reviewed interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 6, 2022. ; • RS: had substantial contributions to the design of the work (reviewed interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • CB: had substantial contributions to the design of the work (reviewed interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • MP: contributed to the design of the work (reviewed interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • LS: contributed to the design of the work (reviewed interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. • EP: contributed to the design of the work (reviewed interview questions); reviewed analysis; critically commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. CAMM: had substantial contributions to the design of the work (helped develop protocol, data collection schedules); reviewed analysis; contributed to drafting the manuscript; commented on versions of the manuscript; gave final approval of the version to be published; and has agreed to be accountable for all aspects of the work. Data Sharing Statement Data available upon reasonable request. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 6, 2022. ; Public Health England. UK Coronavirus Dashboard Build Back Fairer: The COVID-19 Marmot Review COVID-19: review of disparities in risks and outcomes Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study. The Lancet Global health UK immunisation schedule: the green book, chapter 11 Predictors of intention to vaccinate against COVID-19: Results of a nationwide survey Tracking the global spread of vaccine sentiments: the global response to Japan's suspension of its HPV vaccine recommendation Measles outbreaks in a population with declining vaccine uptake Impact of COVID-19 vaccines on mortality in England Ethnic differences in SARS-CoV-2 vaccine hesitancy in United Kingdom healthcare workers: Results from the UK-REACH prospective nationwide cohort study A Rapid Systematic Review of Factors Influencing COVID-19 Vaccination Uptake in Minority Ethnic Groups in the UK. Vaccines (Basel) A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science Ethnic Minorities Maryland Scholastic Summary of Product Characteristics for COVID-19 Vaccine Pfizer/BioNTech Parents' and guardians' views on the acceptability of a future COVID-19 vaccine: A multi-methods study in England. Vaccine Trust in health information sources and its associations with COVID-19 disruptions to social relationships and health services among people living with HIV Race, ethnicity and COVID-19 vaccination: a qualitative study of UK healthcare staff Trends and clinical characteristics of COVID-19 vaccine recipients: a federated analysis of 57.9 million patients' primary care records in situ using OpenSAFELY. b2021. medRxiv preprint A study of ethnic, gender and educational differences in attitudes toward COVID-19 vaccines in Israel -implications for vaccination implementation policies COVID-19 vaccine coverage in health-care workers in England and effectiveness of BNT162b2 mRNA vaccine against infection (SIREN): a prospective, multicentre, cohort study National Study of Youth Opinions on Vaccination for COVID-19 in the U.S COVID-19 vaccination intention in the UK: results from the COVID-19 vaccination acceptability study (CoVAccS), a nationally representative cross-sectional survey Strategies and action points to ensure equitable uptake of COVID-19 vaccinations: A national qualitative interview study to explore the views of undocumented migrants, asylum seekers, and refugees No Way Out, No Way In. Irregular Migrant Children and Families in the UK Using behavioural science to develop public health messages for racial and ethnic minority communities during COVID-19 Determinants of Vaccination Uptake in Risk Populations: A Comprehensive Literature Review. Vaccines (Basel) Acceptability of a Hypothetical Zika Vaccine among Women from Colombia and Spain Exposed to ZIKV: A Qualitative Study. Vaccines Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. Lancet Reg Health Eur Maternal vaccines during the Covid-19 pandemic:A qualitative interview study with UK pregnant women. Midwifery Attitudes, current behaviours and barriers to public health measures that reduce COVID-19 transmission: A qualitative study to inform public health messaging More vaccines for children? Parents' views. Vaccine Parents with doubts about vaccines: Which vaccines and reasons why The social experience of participation in a COVID-19 vaccine trial: Subjects' motivations, others' concerns, and insights for vaccine promotion. Vaccine A systematic review of factors affecting vaccine uptake in young children Efficacy or delivery? An online Discrete Choice Experiment to explore preferences for COVID-19 vaccines in the UK United States COVID-19 Vaccination Preferences (CVP): 2020 Hindsight. Patient Acceptance and Willingness to Pay for the COVID-19 Vaccine among Migrants in Shanghai, China: A Cross-Sectional Study. Vaccines Vaccine hesitancy, refusal and access barriers: The need for clarity in terminology. Vaccine Israel's rapid rollout of vaccinations for COVID-19 Three months in: A timeline of how COVID-19 has unfolded in the US 2020 Associations Between COVID-19 Misinformation Exposure and Belief With COVID-19 Knowledge and Preventive Behaviors: Cross-Sectional Online Study Measuring the impact of COVID-19 vaccine misinformation on vaccination intent in the UK and USA Information and Disinformation: Social Media in the COVID-19 Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Social Media Misinformation"-An Epidemic within the COVID-19 The American journal of tropical medicine and hygiene COVID-19 Related Misinformation on Social Media: A Qualitative Study from Iran COVID-19 vaccine rumors and conspiracy theories: The need for cognitive inoculation against misinformation to improve vaccine adherence Imperial College London's Institute of Global Health Innovation and YouGov. Covid-19: Global attitudes towards a COVID-19 vaccine Exclusive: Fewer black and Filipino NHS staff vaccinated amid 'hesitancy' concern Strategies for addressing vaccine hesitancy -A systematic review The Rt Hon Matt Hancock MP, and The Rt Hon Robert Jenrick MP. Community Champions to give COVID-19 vaccine advice and boost take up The role of Community Champion networks to increase engagement in the context of COVID19: Evidence and best practice Factors influencing COVID-19 vaccine uptake among minority ethnic groups -17 UK Government Vaccines Taskforce. 2020 achievements and future strategy London: UKVTF. 2020 Available from Second quarterly report on progress to address COVID-19 health inequalities We would like to extend our thanks to all public representatives, healthcare professionals, researchers and expert advisors who contributed to this study. Thank you to all participants for providing their time and sharing their views and experiences for FGs and interviews. Conflicts of Interest ATK participates in the UK's Scientific Advisory Group for Emergencies (SAGE) behavioural science sub-group SPI-B. The views expressed are those of the author. LJ and CAMM have been involved in the review of Public Health England/UK Health Security Agency COVID-19 guidance. All other authors have no conflicts of interest to declare. Funding