Co‐designing a theory‐informed, multicomponent intervention to increase vaccine uptake with Congolese migrants: A qualitative, community‐based participatory research study (LISOLO MALAMU)

Abstract Introduction Disparities in the uptake of routine and COVID‐19 vaccinations have been observed in migrant populations, and attributed to issues of mistrust, access and low vaccine confidence. Participatory research approaches and behaviour change theory hold the potential for developing tailored vaccination interventions that address these complex barriers in partnership with communities and should be explored further. Methods This study used a theory‐informed, community‐based participatory research approach to co‐design a culturally tailored behaviour change intervention aimed at increasing COVID‐19 vaccine uptake among Congolese migrants in London, United Kingdom (2021–2022). It was designed and led by a community‐academic partnership in response to unmet needs in the Congolese community as the COVID‐19 pandemic started. Barriers and facilitators to COVID‐19 vaccination, information and communication preferences, and intervention suggestions were explored through qualitative in‐depth interviews with Congolese migrants, thematically analysed, and mapped to the theoretical domains framework (TDF) and the capability, opportunity, motivation, behaviour model to identify target behaviours and strategies to include in interventions. Interventions were co‐designed and tailored in workshops involving Congolese migrants. Results Thirty‐two Congolese adult migrants (24 (75%) women, mean 14.3 (SD: 7.5) years in the United Kingdom, mean age 52.6 (SD: 11.0) years) took part in in‐depth interviews and 16 (same sample) took part in co‐design workshops. Fourteen barriers and 10 facilitators to COVID‐19 vaccination were identified; most barrier data related to four TDF domains (beliefs about consequences; emotion; social influences and environmental context and resources), and the behavioural diagnosis concluded interventions should target improving psychological capability, reflective and automatic motivations and social opportunities. Strategies included culturally tailored behaviour change techniques based on education, persuasion, modelling, enablement and environmental restructuring, which resulted in a co‐designed intervention comprising community‐led workshops, plays and posters. Findings and interventions were disseminated through a community celebration event. Conclusions Our study demonstrates how behavioural theory can be applied to co‐designing tailored interventions with underserved migrant communities through a participatory research paradigm to address a range of health issues and inequalities. Future research should build on this empowering approach, with the goal of developing more sensitive vaccination services and interventions which respond to migrant communities' unique cultural needs and realities. Patient or Public Contribution Patient and public involvement (PPI) were embedded in the participatory study design and approach, with community members co‐producing all stages of the study and co‐authoring this paper. An independent PPI board (St George's Migrant Health Research Group Patient and Public Involvement Advisory Board) comprising five adult migrants with lived experience of accessing healthcare in the United Kingdom were also consulted at significant points over the course of the study.


| INTRODUCTION
Vaccination is one of the world's most cost-effective and successful public health interventions and is essential to reducing mortality and morbidity caused by serious infectious diseases.6][7] Many of these same populations also suffered disproportionately worse health and economic outcomes because of the pandemic. 8,9Faced with the COVID-19 pandemic, scientists and governments rapidly set about developing and distributing safe and effective vaccines for COVID-19 to help bring the pandemic under control and protect populations.However, the success of vaccine-based protection measures hinges on high population uptake and coverage.[12][13][14][15][16] Health inequalities can be linked to wider social inequalities, including broader environmental, social and economic factors.
Globally, COVID-19 exacerbated inequalities experienced by some migrants and ethnically minoritised groups and highlighted the structural violence embedded within society. 17,18Along with hostile immigration policies, institutional racism and xenophobia, the medical establishment has a long history of exploiting and mistreating black and some ethnically minoritised populations. 19,20This is reflected in their poorer health outcomes compared to white groups.For example, rates of infant and maternal mortality, cardiovascular disease and diabetes are higher among Black and South Asian groups.The effects of this wider context on trust were also evident in widely reported conspiracy theories about population control and concerns of being used as 'guinea pigs' in the COVID-19 vaccination drive, posing major barriers to vaccine uptake. 10,21,22Muddled and inconsistent messaging and a lack of leadership from Heads of State during acute phases of the pandemic also likely contributed to lower trust in the health system and allowed misinformation to thrive, 23 particularly among migrant and ethnically minoritised groups.There were also clear information barriers for those with limited English language proficiency and the failure of governments to adequately adapt and disseminate essential messaging to diverse populations. 24though governments later took steps to physically widen access to COVID-19 vaccination for excluded groups, 25,26 these actions were not enough to repair their already eroded trust in public institutions and authorities.As we now begin to move from the pandemic to the endemic stages of COVID-19, it is essential that we do not lose sight of the inequities highlighted or the momentum needed to tackle them.This is important not only to improve COVID-19 vaccine equity but to improve the reach of routine vaccination programmes and improve health outcomes more broadly.The King's Fund recently stated that 'a cross-government strategy for reducing health inequalities and addressing the diverse health needs of all groups at risk of poor health and high mortality has never been more urgent'. 27is must be done sensitively, considering pre-existing structures of oppression and mistrust and adequately accounting for populations' unique realities, lived experiences and diversity.
Various approaches based on behavioural insights theory have been used to increase the uptake of routine and other more established vaccinations.The World Health Organization's (WHO) Tailoring Immunisations Programme (TIP) 28 employs the capability, opportunity, motivation and behaviour (COM-B) model of behaviour change, the theoretical domains framework (TDF) and the behaviour change wheel (BCW) [29][30][31] to understand and address vaccination behaviours.While TIP fosters in-depth, mutual understanding among stakeholders recognises the complexity of vaccination behaviour and facilitates the implementation of interventions supporting change, it operates within a traditional research paradigm, where studies are designed and implemented by academics and research is done 'on' rather than 'with' communities.This approach may perpetuate inequities and hinder authentic participation, leading to underrepresentation of these groups in research. 32 contrast, a participatory research paradigm directly considers power asymmetries and histories of oppression, gives value to the subjectivity of lived experience and actively involves individuals affected by the issue being studied as equal partners in the research process.Participatory research leads to knowledge that is locally situated and context-specific, which is important for generating workable solutions to existing problems. 33In addition to enhancing community empowerment, it is argued that engaging communities in this way can advance the rigour, relevance and reach of research. 34 date, there have been shortcomings in the meaningful involvement of migrants in health research, 35   were conducted with Congolese migrants (see Table 1) and the CBPR approach was evaluated through participant feedback.Further context about the study, population, sampling, recruitment and data collection methods are described in a published protocol. 36All study resources and expenses were paid for by grants awarded to the St George's research team.Participants were financially compensated for participation using vouchers (1-h interviews-£20; 2-h workshops T A B L E 1 Inclusion and exclusion criteria of study participants.

Inclusion criteria Exclusion criteria
• Born in the Democratic Republic of Congo (DRC).• Aged 18 or above.
• Currently residing in the United Kingdom.
• Willing and able to give informed consent.
• Not migrant as per earlier definition.
• Not born in the DRC.
• Below the age of 18.
• Temporarily in the United Kingdom for holidays, visiting friends/relatives or other reasons.• Lacking the capacity to consent, as determined by the Mental Capacity Act framework.
-£40) and reimbursed in cash for travel costs.Nonacademic coalition members were paid for their time (according to rates set out by NIHR INVOLVE guidance 37 ) and Hackney Congolese Women Support Group and Hackney Refugee and Migrant Forum received financial donations to support their running, in addition to nonfinancial contributions (e.g., skills-based training). 36A community celebration and presentation of key findings was held in July 2022.

| Study costs
This study cost approximately £17,500 to conduct, not including academic staff time.This included £7000 on general project spend (coalition member payments and expenses, participant vouchers and expenses, venue hire, catering and entertainment for end-of-study celebration event, stationery and other materials, professional artist hire), £4500 in one-off donations to nonacademic partners and £6000 on translation and transcription costs, using a professional translator from the London Congolese community.

| Intervention development procedure
Michie et al. 29  knowledge.'How Might We' questions (a design thinking approach 40 ) were used to aid creativity and problem-solving.Three intervention components were agreed upon to take forward to co-design workshops, which were felt to blend community desires with effective and contextually feasible approaches to change behaviour.the influenza vaccine, which some perceived to be more effective.
One participant said, "I prefer flu vaccine because that one will protect you" (P21, female).
Issues relating to information and communications were another important barrier.Many participants highlighted how language and literacy barriers had directly influenced their vaccination decisions, for example, not having access to an interpreter, or through exposure to misinformation and rumours in their social networks, causing fear and distress.Participants voiced concerns that they might be being exploited and used as 'guinea pigs' by the NHS and government and alluded to present-day racism and historical events involving the exploitation of black and African populations by white Europeans.Some also commented that they felt bombarded by instructions and rules from the government and NHS about how to behave but these instructions lacked the information to help them feel safe or understand the rationale.S1).The mapping and behavioural diagnosis exercise 31 identified that psychological capability (specifically: knowledge; decision processes), reflective motivation (intentions; beliefs about consequences; optimism), automatic motivation (emotions/ fear) and social opportunity (social influences) needed to be addressed through the intervention design.Five (of nine) corresponding intervention functions were selected (for practical reasons) for the intervention development: education, persuasion, modelling, enablement and environmental restructuring (the relationships between these are shown in Supporting Information: Table S2).
Possible intervention components (behaviour change techniques and mode of delivery) linked to these intervention functions that were generated by the coalition are summarised in Table 3.
Three broad intervention components were then selected by

| Results part 3: Outputs of co-design workshops
Participants customised and tailored the intervention components in the co-design workshops, resulting in a final intervention comprising community-led workshops, plays and posters.Table 4 shows how the intervention components addressed the intervention functions identified in the behavioural diagnosis.

| Intervention component 1: Community-led workshops
Both participant groups co-designed a community-led workshop plan (Supporting Information: Table S3).Key tailoring needs included local, in-person meetings, Lingala language (with interpreters if possible) and regular, scheduled sessions (favoured over pop-ups for

| Artist's impression of workshops and intervention components (visual minutes)
The visual minutes from the co-design workshops (Figure 2) have been reproduced to support funding applications and share the study findings and process with a range of stakeholders.

| Feedback on the participatory process
We received 38 completed feedback forms from the interviews and co-design workshops.Feedback was positive: participants said they felt welcomed and valued in the community, could express opinions honestly, and found the discussion important.They said they found the workshops fun and enjoyed the participatory and sociable nature.

| Dissemination
The findings and intervention were shared through a community celebration event in July 2022, attended by 45 Congolese community members and participants, a local councillor, and live streamed by an African YouTube channel with 18,000 subscribers.Academics and policymakers were informed at two international conferences.A project brief will be shared with local and national stakeholders.heritage.These barriers and preferences were addressed through co-designed workshops, plays and posters.This study effectively demonstrates how behavioural theory can be adapted to a participatory approach to co-design a vaccination intervention.
The key barriers to COVID-19 vaccination identified in our study population were concerns about the vaccine's safety, effectiveness, and side effects, information and communication issues (such as language barriers, exposure to misinformation, inadequate or confusing official messaging) and general mistrust of the COVID-19 vaccination programme.Concerns about the vaccine were mostly attributed to its novelty and perceived insufficient testing time.
Similar barriers have been reported among other migrant populations, 10,23,[41][42][43][44][45] suggesting a need for a more nuanced and responsive approach that addresses the specific concerns and worldviews of diverse communities and builds trust.A key aspect of fostering vaccine acceptance lies in enhancing institutional and interpersonal trust and trust in vaccines, 46,47 which may be achieved by actively listening to the concerns of various groups and prioritising transparent and clear communication, especially during emergencies.Surprisingly, access to vaccines was not a major barrier in our study, suggesting that government efforts to widen access to vaccination for marginalised groups during the pandemic were largely successful.
Nevertheless, the limited impact of these efforts on increasing uptake in this population due to other prevailing barriers emphasises the need for contextually-tailored initiatives, rather than a one-size-fitsall approach.
Participants indicated a preference for visual, oral, dialoguebased and face-to-face forms of communication and put trust in healthcare professionals and community leaders and members.
Interestingly, despite all participants being registered with a GP, they still reported barriers to vaccine uptake.This suggests that contact with a healthcare professional alone may not be sufficient to facilitate uptake and indicates potential shortcomings in primary care services' provision of culturally competent care for this population.to influence the health decision-making process. 48 Our findings align with other research which highlights preferences for face-to-face 58,59 and oral communication 60,61 among migrant populations, as well as strategies that build or reinforce trust. 59,62,63They also align with systematic reviews that have indicated that culturally adapted interventions may be effective in community settings. 64,65However, our use of sociocultural elements and community members to facilitate engagement with the intervention went beyond the surface-level cultural adaptations common to behavioural interventions, such as language translation or reading level adjustments, 65 representing an advancement on current literature.Other studies have indicated limitations in culturally competent care for refugees and migrants, 66,67 which our findings allude to, including the need for greater refugee participation and perspectives in the practice of cultural competence and recognition of structural barriers. 68,69This emphasises the need for a wholesystem approach to creating a more enabling environment to facilitate vaccine uptake.Future interventions may be strengthened by incorporating multi-level intervention components and identifying policy categories that support their delivery.
A key strength of our study was its community-centred, participatory approach.Participatory research aims to reinforce local capacity and solutions and promote transformative change. 34,69,70wever, existing participatory health research with migrants has been criticised for inadequately including migrants in developing health interventions. 35In our study, we enhanced community capacity through a partnership approach that shared power, recognised and celebrated community assets and expertise and provided skills-based training and leadership opportunities for community partners.Several studies involving marginalised populations have demonstrated the benefits of involving community members as health promoters or advocates to build trust and facilitate the uptake of interventions, 59,62,63 including targeted initiatives to increase COVID-19 vaccine uptake with refugees and migrants 52 and COVID-19 'Community Champions' schemes implemented in local authorities. 71However, our study went beyond these, by actively involving community members in designing and leading the study.Our Congolese partners played a vital role in building relationships and establishing trust, providing valuable cultural and experiential knowledge to tailor activities and ensure participants felt valued and heard.This was reflected in the high attendance of participants in research and dissemination activities and overwhelmingly positive feedback received during the evaluation.Our focus on community assets and the resourcefulness of underserved communities like migrants challenges deficit models which often underpin behaviour change models and solely attribute barriers to language difficulties and issues related to access and trust.
Using participatory methods, we demonstrated that underserved communities are resilient and can find real-world solutions to their health needs.
Future studies and initiatives should build on this communitycentred, participatory approach.Collaborative partnerships with people and communities are now considered critical in healthcare, and recent legislation in England 72 aims to address health inequalities highlighted by the pandemic and provide more tailored care to diverse communities.However, there is still relatively limited guidance on how to do this well in research or practice.We provided details of our budget and participatory process for transparency and to highlight challenges and costs for others working in this space.
While the increased attention on collaborative approaches is positive, funders, authorities and researchers must be cognisant of how inherent biases and systemic racism may serve to widen inequalities despite their good intentions and proactively address this.For instance, they should be sensitive to how their actions to address inequity may be perceived and how they may inadvertently heighten the sense of exclusion felt by other underserved groups, particularly migrants.It will be crucial to recognise and support migrant communities and smaller organisations that informally support their communities by creating accessible local funding and capacitybuilding mechanisms.Our study funded a black-led organisation to lead community-based research addressing issues important to their community and provided personal development opportunities to build community capacity.[75][76][77] As such, our study contributes to understanding how community engagement and participatory research can promote equity in migrant health and help dismantle power structures hindering vaccine uptake and perpetuating harm among these communities.

| Limitations
Our study's primary limitation is the lack of implementation or evaluation of the intervention due to time and budget constraints.As a result, we cannot draw conclusions on the intervention's feasibility, effectiveness, or acceptability.However, we are pleased to report that our community partner has successfully obtained further fundraising and capacity-building support locally to enable them to continue building on this work.Challenges of conducting participatory research in the current academic funding environment have been noted. 69,78,79Our study underscores the need to restructure which we see as an opportunity for improvement.The resurgence of interest in participatory research offers an opportunity to rethink approaches for addressing vaccine inequities and involving migrant populations in research.Adopting an inclusive, collaborative and communitycentred approach may advance efforts to close the global immunisation gap.We therefore constructed this community-based participatory research (CBPR) study with Congolese migrants in the United Kingdom to understand the complex mechanisms influencing their COVID-19 vaccination attitudes, beliefs and behaviours, and use behavioural theory and participatory co-design methods to translate these findings into a tailored intervention to strengthen their COVID-19 vaccine uptake.

2 | METHODS 2 . 1 |
Study aim, design and settingThis CBPR study aimed to co-design a culturally tailored behaviour change intervention with Congolese migrants (non-UK born) to strengthen their COVID-19 vaccine uptake.It was conducted by a community-academic coalition (including Congolese migrants, community, and academic stakeholders) from November 2021 to November 2022 in Hackney, United Kingdom, a diverse London borough.Community days (involving peer-led qualitative in-depth interviews and interactive poster walls) and co-design workshops recommend several steps to design a behavioural change intervention, starting with defining the problem in behavioural terms and selecting a target behaviour the intervention should increase in the population.We defined our target behaviour as 'getting a COVID-19 vaccination'.The four stages of intervention development are outlined in Figure 1.First, data collected through indepth interviews and poster walls with Congolese migrants were thematically analysed 38 collaboratively by the coalition to identify barriers and facilitators to vaccination, communication preferences, sociocultural values and suggestions for improving vaccination services.Barriers were mapped to the 14-domain TDF, 30,39 COM-B model and BCW 31 and a behavioural diagnosis was made following Michie et al., 29 generating possible intervention functions (functions likely to be effective in achieving behaviour change) which represented a starting point for intervention development.The coalition brainstormed ideas for possible intervention components, reflecting on the qualitative findings and their specific sociocultural and local F I G U R E 1 The four stages of the theory-informed intervention co-development procedure: gather and analyse insights; map to theoretical framework; define intervention components and co-design intervention.The target behaviour was getting a COVID-19 vaccination.COM-B, capability, opportunity, motivation and behaviour; TDF, theoretical domains framework.

| 5 of 16 3. 1 . 1 |
BarriersVaccine safety concerns included uncertainty about the COVID-19 vaccine development process and speed, beliefs about consequences due to personal risk factors (e.g., blood clots), a negative experience (e.g., side effects from an earlier dose), knowledge of vaccine scares and historical events (e.g., contracting vaccine-derived poliomyelitis) or belief in rumours and conspiracy theories about the vaccine's effects.My issue was on the blood clot side because when I had my kid, I was bleeding a lot, I lost 1 litre plus.So, when I heard on the news that people were having blood clots I said, my God, it makes me feel really scared.(P5, female) Yes, some children have become disabled after receiving polio vaccine.[…] [They are afraid] because the side effects of vaccine have caused to their children to become disabled, and they don't want again to take the risk.(P2, female) There were also concerns around the vaccine's effectiveness and the need for multiple doses or boosters.Participants questioned the necessity of the vaccine when it doesn't necessarily prevent infection and contrasted the COVID-19 vaccine with other vaccines such as

I
refused [the vaccine] the first time… Because I came recently in the country, and I was not sick.I just came and I couldn't speak English.I refused.No, I wanted to have an interpreter to explain to me… (P28, female) It was not easy for me [to get the vaccine] because there was so many rumours and I was questioned myself if do I have to take it or not.We came in this country to seek protection.(P4, female) A few participants also said they felt confused and overwhelmed by the official information and public health messaging, which had been complicated and at times contradictory.For example, I was scared and reluctant about the vaccines because I was confused with the information from research….I was not sure because scientists were not clear in their language.(P6, female) Widespread exposure to misinformation and rumours also made it difficult for participants to know what to believe and enhanced mistrust towards authorities and public institutions.Our data suggest that many participants felt the official public health communications used by the government and NHS were coercive, and this increased their scepticism of the response, including the vaccine.Many participants said they felt they were being 'forced' or 'imposed' to take the vaccine, that freedom of choice had been taken away, and this had made them question the government's motives behind the vaccination programme.For example, I have been constantly receiving letter pushing me to receive vaccine.[…] I would do it voluntarily but not by force.Now they are forcing people and I don't know what is hidden behind this vaccine?(P16, male)

3. 2 |
Results part 2: Behavioural mapping exercise and selection of interventions Most of the barrier data related to four TDF domains: beliefs about consequences, emotion, social influences and environmental context and resources, with smaller clusters of data related to optimism, decision-making processes and deficits in knowledge (Supporting Information: Table consensus.The first component was centred around workshops, as there was a strong demand for this type of activity within the community.The second component focused on creative performance-based activities like dance, songs and plays.The third component focused on visual media such as posters and GIFs.These components were chosen because the participants emphasised the significance of creative expression in their culture.Additionally, they expressed a preference for visual and oral forms of communication.

3 . 3 . 3 |
dependability and frequency) on Friday and Saturday.Participants preferred for workshops to be delivered by the local community organisation (HCWSG) with specialists and health professionals as speakers.They highlighted a desire for two-way communication, with opportunities to ask questions and discuss experiences.There was a demand for covering wider health topics in addition to COVID-19 vaccination information.3.3.2 | Intervention component 2: Short playsParticipants co-designed short plays (Figure2) using storyboards.Plays utilised storytelling to highlight common barriers, concerns and fears about vaccination in the community identified during the interviews and used culturally adapted behaviour change techniques, such as modelling positive vaccination experiences/behaviour and positively framing messages through relatable characters, local settings, cultural references, customs and humour to encourage vaccine uptake.Intervention component 3: Posters and flyers Participants co-designed campaign-like posters about COVID-19 vaccination and invitational flyers for the workshops (Figure 2).They preferred to use rich, eye-catching colours (by contrast, black was felt to signify death), culturally relevant imagery (e.g., Congolese scenery, ways of life), photos of local people to convey credibility and Lingala language.They wanted printed and digital versions to share through a range of channels.T A B L E 3 Intervention functions and potential behaviour change techniques, modes of delivery and types of content ideated during coalition workshop.

4 |
DISCUSSIONThis study describes how co-design and CBPR approaches were used to develop a culturally tailored behaviour change intervention to strengthen COVID-19 vaccination uptake in a Congolese migrant population in the United Kingdom.Congolese migrants were found to experience similar barriers to COVID-19 vaccination as identified in T A B L E 3 (Continued) other migrant and ethnic minority groups.Participants indicated a preference for oral and visual communications and receiving vaccination information via a trusted intermediary.They were also keen for interventions to reflect their Congolese customs and These findings underscore the urgent need for interventions and service adaptations that better cater to the linguistic needs and cultural diversity of migrant populations.The critical role of community connectors in facilitating vaccination opportunities must also be recognised and integrated into intervention strategies.Participants emphasised a sense of pride in their heritage, customs and community, and wanted to design interventions that reflected their cultural identity.They specifically highlighted the significance of storytelling, rich colours, and illustrations depicting their homeland.Identifying and incorporating these cultural elements into interventions may ensure they are more representative and relatable to the target population.Such culturally sensitive approaches may help to effectively engage with marginalised groups and foster a sense of belonging and inclusion, which has been shown F I G U R E 2 Examples of the co-designed plays and posters for intervention components 2 and 3. Bottom left: The artist's live drawing of the workshops and final intervention comprising workshops, plays and posters.
These unique findings emphasise the value of actively involving communities in codesigning and tailoring interventions.A participatory approach not only ensures interventions are culturally appropriate but also promotes a sense of ownership and investment within the community, which may enhance interventions' effectiveness and impact.Previous literature highlights gaps in understanding around how to develop tailored and targeted health interventions involving migrants, beyond engaging with community-based organisations and using culturally appropriate messaging.49There are also limited examples of participatory, co-designed vaccination interventions involving migrant populations.[50][51][52][53][54][55]Our study addresses this gap and offers a valuable example of a community-engaged approach to co-designing a vaccination intervention for an underserved migrant community.Our study builds on previous work which used WHO TIP methodology to develop a tailored intervention to increase vaccine acceptance in a Somali community,56 by showing how behavioural theory can be employed in a participatory study design.It also complements a study in New Zealand that used behavioural theory and cultural insights to co-design a lifestyle support mobile health intervention with Maori/Pasifika populations.57A strength of the New Zealand study was its use of ethnic-specific models of health alongside the TDF, representing the worldviews of Maori and Pasifika populations.Future studies seeking to use behavioural theory in the development of interventions with migrant populations could explore developing migrant-specific models of health with communities, as a means of ensuring culturally specific beliefs, values and worldviews are more robustly translated into behaviour change techniques while equally valuing Western and migrant worldviews.
research funding to better accommodate the unique requirements of participatory, community-based research, including longer timelines and the resource-intensive nature of forming community partnerships and long-term engagement.Despite our efforts to foster full participation, power imbalances still existed in our approach.The study was initiated by academics who had secured funding for research on improving vaccine uptake among migrant communities.The onset of the pandemic made addressing COVID-19 vaccination barriers a pressing concern among migrant communities, aligning our research topic with community needs and facilitating our partnership.However, it may be more challenging to justify co-designing community-based interventions to strengthen routine vaccine uptake if communities do not consider this a research priority.The idea for the behavioural underpinning of the intervention was also put forward by the academic partner and led to an intervention predominantly focused on addressing individual modifiable behaviours.Consideration should be given as to whether the use of this framework may have limited the impact of the participatory approach or impeded engagement with upstream factors such as systemic racism and discrimination, which are recognised to influence ethnic inequities in vaccine hesitancy.80Streuli et al., for example, raised concerns about their use of design thinking and neo-liberal ideologies in designing a vaccination education intervention for Somali refugees, and their potential impact on reinforcing structural inequalities.81Future research should aim to identify the most effective ways of conducting participatory research with communities, being sensitive to their unique needs and context while also addressing broader systemic factors influencing vaccine hesitancy.Evaluating our intervention could help quantify and clarify the relative benefits of a communityengaged and behaviourally informed approach.5| CONCLUSIONS AND NEXT STEPSThe worse health outcomes of adult migrant populations during the COVID-19 pandemic and their widely reported barriers to COVID-19 vaccination have demanded exploration into more tailored interventions to increase vaccine uptake, which consider local context, including personal histories, power dynamics, preferences and needs and are developed and implemented in close collaboration with the target population.They have also highlighted wider inequalities and prompted research into ways of better engaging underserved adult groups specifically in vaccination campaigns, learnings from which can be adapted and used for strengthening routine immunisation programmes.This study reports on the theoryinformed co-design of a tailored COVID-19 vaccination intervention to address these complex challenges in an underserved Congolese migrant population in London.It provides an example of how interventions can be informed by behavioural theory and co-designed with communities, ensuring cultural insights, values and preferences are incorporated.Our participatory approach 36 offers one possible model for engaging with underserved communities in an empowering and equitable way, demonstrating how academic and community partners can better foster mutual exchange of expertise and work effectively together outside of traditional power structures.The next steps will involve refining, implementing and testing the intervention, and potentially adapting and expanding the content to routine vaccinations and wider health needs, as requested by study participants and to address gaps exacerbated by the pandemic.The findings also hold relevance to the co-development and implementation of other health interventions and health promotion activities with migrants and other similar communities.Future research should build on this empowering approach to engaging with underserved migrant communities, with the goal of developing, implementing and evaluating more sensitive vaccination services and interventions which respond to migrant communities' unique needs and realities.Restructuring research funding to better accommodate the requirements of participatory, community-based research will be needed to support such initiatives and promote equitable healthcare for marginalised populations.and Migrant Forum, Halkevi Turkish and Kurdish Community Centre, Community African Network, Clapton Park United Reformed Church and artist Jonny Glover, that championed the project and generously provided spaces and resources to support the work.They would also like to thank St George's National Institute for Health and Care Research (NIHR) PPIE Project Board, particularly Yusuf Ciftci, for their advice and support.This work was funded by the NIHR and seed funding from St George's University of London Public Engagement Network.Sally Hargreaves and Alison F. Crawshaw are additionally funded by the Academy of Medical Sciences (SBF005\1111), the NIHR (NIHR Advanced Fellowship 300072) and the World Health Organization.Sally Hargreaves acknowledges funding from the Novo Nordisk Foundation/La Caixa Foundation (Mobility-Global Medicine and Health Research grant).Anna Deal is funded by the Medical Research Council (MR/N013638/1).
Community role models trained to share key messages, facilitate conversations, show COVID-19/routine vaccination cards, talk about their own vaccination experiences.•Friends, community members and role models to provide examples of the behaviour, so that people have something to aspire to, know what to expect, and have visual proof that it is safe, e.g., through plays, dance, songs, posters, pictures of local people getting vaccinated, campaigns, etc., which can be shared in local settings and on social media.•Use local people and ensure the right people are chosen by speaking to community organisations who know their populationscelebrities will evoke distrust in this community.Trusted advocates and healthcare professionals/experts present feedback on positive outcomes of vaccination in the community/local area, e.g., number of safe vaccinations administered.•Healthcare professionals/experts present examples of negative health consequences that could occur as a result of not getting vaccinated, e.g., long COVID.•Trusted advocates and community members/role models share positive stories, testimonials and persuasive messages about why they got vaccinated, what to expect, and being a COVID-19 Champion.•Peer-led conversations using gentle encouragement, empathetic tone and positive framing of messages.Table summarising how intervention components addressed corresponding intervention functions identified in the behavioural diagnosis.
Abbreviations: ESOL, English for speakers of other languages; PSHE, personal, social, health and economic.T A B L E 4