15 February, 2025

A word from our Director: The HPRU is proud to support the MSc module on Disaster Response: Mental Health, Communication and Behaviour, as part of the MSc Mental Health Studies at King’s College London. Each year, students on the module are given the chance to write blogs about papers produced by the Unit. We are delighted to present this recent submission by Thea Dyson that is based on a paper that we co-produced with the HPRU in Behavioural Science and Evaluation:

 

Stigma is a key barrier to mpox health measures in gay and bisexual men

In May 2022, cases of mpox (a virus normally found in west and central Africa) started to appear internationally. By December 2022 there were 3,732 confirmed and highly probable cases in the UK. The mpox outbreak disproportionately affected gay, bisexual and other men who have sex with men (GBMSM) and it was essential that information on the outbreak got to these groups without generating stigma.

In response to the outbreak, the UK Health Security Agency (UKHSA) encouraged people to adopt mitigation measures such as vaccination, self-isolation and contact tracing. Most were able to stick to the guidance, but some groups found it harder to participate. Why was this and how can we address it?

Qualitative research can be used to understand why people may not follow health guidelines. At the time, no qualitative research had examined GBMSM views of the mpox outbreak and mitigation measures. A study by May and colleagues (2023), led by the HPRUs in Emergency Preparedness and Response, and Behavioural Science and Evaluation, addressed this gap by interviewing GBMSM on their views of mpox, the health guidelines and UKHSA public health messaging. 

The study

Forty-four GBMSM participants living in the UK were recruited to complete semi-structured interviews over telephone or video call. Recruitment took place offline and online to increase diversity within the sample. The researchers reached out to under-represented groups to make sure that the study included the views of those whose first language was not English, minoritised ethnic groups and those engaging in sexual practices seen as high-risk. Interviews took place in May to December 2022.

There were two parts to the interviews:

1. The researchers interviewed GBMSM on their views of mpox and mitigation measures using a flexible topic guide and open-ended questions so that participants could talk about what was most important to them.
2. Participants were then shown a UKHSA mpox poster and asked for their opinions.

The data were analysed by ‘reflexive thematic analysis,’ a research technique which helps us to spot common themes in participant’s views. Opinions on ways to improve the poster were summarised and put into a ‘Table of Changes’.

Participants were mostly white British, highly educated and between the ages of 20 and 56. This study’s sample also included people from a broad range of ethnicities including Black, Asian and Latin American. However, numbers of participants from each ethnic minority group were a lot smaller than the white British group.

Views towards mpox and mitigation measures

Two key themes were identified in interviews on attitudes towards mpox and mitigation measures:

Perceived risk and severity.

Interviewees who felt they were at higher risk of mpox or who thought that mpox was a severe illness were more likely to engage with protective behaviours. Interestingly, younger participants and some PrEP users (a medication used to reduce the risk of getting HIV) often viewed mpox as less threatening as they saw it as curable and not as bad compared to other illnesses.

Perceptions of mitigation measures.

Three main barriers to measures were identified. First, some participants were concerned that groups without access to social media may find it harder to engage in measures due to exclusion from mpox information shared online. Second, concerns about stigma made it harder to engage in mitigation measures (particularly measures involving disclosure). Stigma particularly affected racially minoritised groups and participants from geographical areas with smaller GBMSM communities. Third, some participants felt a need to maintain sexual connections and intimacy during the outbreak. This was partly to avoid feelings of isolation they experienced during the COVID-19 pandemic.

Views on the health poster

Three themes were identified in how people viewed the UKHSA poster. First, some participants were concerned that messaging that linked transmission to gay sex could reinforce harmful homophobic beliefs. Others felt that not highlighting this link meant information would not reach at-risk groups. Second, participants felt there was a need for more accurate information in the earlier stages of the outbreak. Third, and perhaps most importantly, most of the interviewees had never seen the UKHSA poster before. Most participants got mpox information from social media or from peers. Some participants were concerned that social media could spread misinformation and felt there was a need for more official sources of information online.

Study limitations

All research has limitations that we have to consider when thinking about the results. For this study, one of the limitations is that an online sign-up was required which may have been off-putting to potential participants. The UK’s digital divide means some groups are less likely to engage online due to lack of skills, motivation and concerns about personal data. The digital divide disproportionately affects older adults which could partly explain lack of participants over 56. Crucially, groups who don’t use technology could be excluded from online mpox information, so research should examine these groups’ views to make sure that mpox information is available in places that they would see it.

Another limitation is that the study was conducted only three months after COVID-19 restrictions were lifted. Pandemic experiences could have impacted views around mpox so results may not be generalisable outside of this context.

Finally, although the study recruited participants from a wide range of ethnicities, the small number of participants from each non-white group meant comparisons could not be made between marginalised ethnicities. This is important considering people from Black ethnic groups were less likely to intend to accept a vaccine to prevent them from getting mpox if they were exposed.

Future interventions

This research identified stigma as a barrier to adopting protective behaviours during the 2022 mpox outbreak, especially for measures that involved disclosure. This was particularly true for ethnic minority groups and participants from areas with smaller GBMSM communities. This could be because these groups face greater discrimination which discourages disclosure. In comparison, participants more involved with GBMSM communities were less concerned about stigma and were therefore more likely to engage with the health measures. Future interventions could focus on GBMSM community outreach to groups at greater risk of discrimination.

Stigma also impacted participants’ views of targeted approaches to health messaging. Whilst some participants felt that targeted approaches were more accurate, others felt that they risked increasing harmful homophobic views. In the past, targeted health messaging, such as PrEP4LOVE (a campaign in Chicago that targeted stigma as a barrier to treatment for HIV) received homophobic responses from the public. Therefore, future interventions should be cautious when deciding whether to use targeted approaches and should consider the impacts on local GBMSM communities. Interventions should be co-designed with local GBMSM communities to account for differences in views. For example, during the 2022 mpox outbreak in Liverpool, public health messaging was created with support from GBMSM communities and sexual health clinics that had experience creating non-stigmatising messaging.

Findings from this research also suggest that groups excluded from social media and GBMSM networks may have found it harder to access information on mpox. Interventions that use these platforms need to consider factors that limit access such as stigma as well as practical factors such as lack of internet access and language barriers. Those with weaker ties to communities are less likely to have access to accurate knowledge. Therefore, GBMSM communities and UKHSA initiatives could reach out to those at greater risk of exclusion.

Additionally, some participants were concerned about misinformation online and felt that it was hard to access accurate information on symptoms. This shows a need for more reliable and well-timed information from official sources. This view has been highlighted in other studies on the UKHSA response and should be considered in future viral outbreaks.