Exploring key informants’ perceptions of Covid-19 vaccine hesitancy in a low-SES urban community in Ireland: emergence of a ‘5Cs’ model

Aim: The aim of this study was to explore key informants’ views on and experiences with Covid-19 vaccine hesitancy in a Dublin community of low socioeconomic status (SES) and to identify feasible, community-centred solutions for improving vaccination acceptance and uptake. Methods: Qualitative, semi-structured interviews were carried out at a local community-centre and a central hair salon. Twelve key informants from the target community were selected based on their professional experience with vulnerable population groups: the unemployed, adults in recovery from addiction, the elderly, and Irish Travellers. Inductive thematic framework analysis was conducted to identify emergent themes and sub-themes. Results: Drivers of vaccine hesitancy identied by key informants largely fell under the WHO ‘3Cs’ model of hesitancy: lack of condence in the vaccine and its providers, complacency towards the health risks of Covid-19, and inconvenient access conditions. Covid-19 Communications emerged as a fourth ‘C’ whereby unclear and negative messages, confusing public health measures, and unmet expectations of the vaccine’s effectiveness exacerbated anti-authority sentiments and vaccine scepticism during the pandemic. Community-specic recommendations involved the provision of accurate and accessible information, collaborating with community-based organizations to build trust in the vaccine through relationship building and ongoing dialogue, and ensuring acceptable access conditions. Conclusions: A Condence, Complacency, Convenience, Communications, Community-centred Solutions (‘5Cs’) model of vaccine hesitancy emerged through inductive analysis of key informant interviews in a low-SES urban community. The model and in-depth key informants’ perspectives can be used to compliment equitable vaccination efforts currently underway by Health Services Executive Ireland and non-governmental organizations.


Introduction
Vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services [1]. It can be deadly. Covid-19 mortality over a 2-year period is up to eight times higher in populations with high vaccine hesitancy compared to those with an ideal vaccination uptake [2]. An individual who is fully vaccinated with a messenger RNA (mRNA) vaccine is up to 90% less likely to get infected [3], 94% less likely to be hospitalized [4], and 90% less likely to die from Covid-19 [5].
Low socioeconomic status (SES) communities, despite experiencing disproportionately high Covid-19 morbidity and mortality due to environmental and social inequities [6], have lower rates of vaccination uptake [7]. SES-related factors such as diminished trust in governmental institutions, poorer health literacy, and logistical di culties simultaneously increase ones' likelihood of being vaccine hesitant [7,8] and ones' vulnerability to Covid-19 if unvaccinated. Experts have called for the prioritisation of densely populated deprived areas during vaccination rollout to capture people at increased risk of infection and hospitalisation [9]. However, ensuring equitable vaccination requires understanding and addressing community-speci c challenges associated with vaccination willingness and uptake [10].
In the Republic of Ireland, 91% of the eligible population were fully vaccinated for Covid-19 as of January 2022, and 56% had received a booster vaccine [11]. Nevertheless, an estimated third of the adult population had experienced some Covid-19 vaccine hesitancy, and 9% were opposed to the vaccine, with trends in resistance steadily increasing as the pandemic progressed [12,13]. As reported internationally, adults in Ireland who are vaccine hesitant are more likely to live-in urban settings and be in a lower income bracket [12], the same areas at increased risk for Covid-19 incidence and comorbidities [9].
Interventions to address vaccine hesitancy are most successful if they are based on empirical data and situational assessment, and adapted to a speci c target group in a culturally sensitive manner [14]. Preliminary ndings on the drivers of Covid-19 vaccine hesitancy in Ireland show that national trends match those found internationally [12,14]: vaccine hesitant individuals in Ireland are more likely to have conspiracy beliefs; lower levels of trust in scientists, health care professionals, and the state; and to consume signi cantly less information from formal information sources and more from social media [12]. Still, target groups must be consulted on community-speci c drivers of vaccine hesitancy in order to tailor the design and rollout of interventions to address local reasons for declining a highly effective vaccine [15].
The aim of this study was to explore key informants' views on and experiences with vaccine hesitancy in a Dublin community of historically concentrated disadvantage and to identify feasible, community-centred solutions for improving Covid-19 vaccination acceptance and uptake. Key informants were individuals from the target community working with population groups identi ed as disproportionately vulnerable to Covid-19: the socioeconomically disadvantaged and/or unemployed, adults in recovery from addiction, the elderly, and Irish Travellers, an indigenous ethnic minority group [16].

Study design and setting
Qualitative, semi-structured interviews were carried out in collaboration with (1) a community partnership organization that addresses long-term unemployment and poverty through education and social inclusion initiatives, and (2) a long-standing hair salon located on the target community's main road. These speci c collaborations were formed to enhance understanding of vaccine hesitancy through community-based organizational representatives' knowledge of local social and cultural dynamics [17], and the fact that clients regularly disclose information about health and identity to hairdressers [18]. A semi-structured interview format was selected to allow participants to freely express themselves while providing reliable, comparable data [19]. The study's qualitative methodology was preregistered on the Open Science Framework (https://osf.io/n5jch).

Sample and recruitment
A non-probability purposive sampling method was used to identify potential key informants from the two partnering organizations that met the following criteria: knowledge of and experience with community vaccine hesitancy based on their professional role and having lived and/or grown up in the target community; ability to communicate that knowledge to the researchers; and willingness to take part in the study [20,21]. To ensure diversity of opinion, key informants of various ages, genders, and occupational roles were selected.
Prior to participant recruitment, the researchers met with managers of the respective establishments to introduce themselves and explain the study objectives. After agreeing to the research collaboration, managers identi ed and invited eligible staff members to participate in semi-structured interviews. A rst round of twelve interviews were scheduled and completed, at which point the researchers found that no new information relevant to the study objectives was emerging and data saturation was achieved [22].

Data collection
Semi-structured interviews were conducted at the hair salon on 17 September 2021, and at the community partnership on 19 November 2021, in private rooms provided by management. Interviewers had formal qualitative research training (CI, MR) and were accompanied by an undergraduate research intern from the local community acting as a liaison between the researchers and collaborating organizations (LP). Participants were presented with an information sheet and gave informed oral consent in the full knowledge that interviews would be audio recorded, transcribed, and anonymized as approved by the researchers' institutional Human Research Ethics Committee (UCD-HREC-LS-E-21-222). Interviews lasted around 20 minutes and followed a set of research questions developed through consultation with community representatives and review of existing literature on Covid-19 vaccine hesitancy in Ireland [12,16]. Both individual and community perspectives were sought on (1) attitudes towards the vaccine, (2) thoughts on the current pandemic situation given widespread rst-round vaccinations, and (3) attitudes towards the booster (Fig. 1).

Data analysis
Data were coded and analysed using an inductive thematic framework method according to the following recommended stages of trustworthy, thematic analysis [23,24]: Transcription: Audio recordings were transcribed verbatim by two researchers (CI, VD).
Familiarisation: Two researchers (CI,VD) familiarized themselves with the data by re-listening to audio recordings and re-reading the transcripts. Each researcher recorded analytical notes, thoughts, and impressions in the transcript margins.
Initial coding: The same researchers independently coded three transcripts line by line, identifying potential themes and subthemes relating to vaccine hesitancy through an 'open coding' process. Once results were compared and an initial coding framework constructed, CI completed line by line open coding of the remaining nine transcripts. This allowed for further revision before the research team met to discuss, re ne, and agree to a working thematic framework. During peer debrie ng, researchers recognized that key themes largely fell under the World Health Organization's (WHO) "3Cs" model of vaccine hesitancy [14]. Thus, determinants of hesitancy were re-categorized under Con dence, Complacency, Convenience and -unique from the WHO model -Covid-19 Communications and Community-Centred Solutions, as de ned in Fig. 2.
Applying the thematic framework: The working thematic framework was systematically applied to all transcripts by CI using Nvivo software V.11. Overlapping themes were combined, and necessary re nements made until three layers of distinct themes were nalized and approved by all researchers.
Charting and interpreting the data: A matrix was used to summarize data for each participant, code, and theme. Connections within and between codes and cases were made in order to ful l the original research objectives and highlight ndings generated through inductive analysis.

Key informant demographics and personal views on the vaccine
The study sample (n = 12) was made up of three key informants from a central hair salon and nine from a local community centre including: two guidance counsellors for adults in recovery from addiction, three working with job seekers and/or those on social welfare, one community health o cer working with the local Irish Traveller population, two administrators, and one centre manager. Key informants' characteristics and their personal stances on COVID-19 vaccination and booster shots are described in Table 1. Five key informants were completely accepting of COVID-19 vaccines, citing motivators such as personal safety and that of loved ones, returning to normalcy and going on holidays, and being adequately informed. Of the seven key informants who experienced little to great vaccine hesitancy, fear of side effects, especially in the case of underlying health conditions, and guilt at receiving the vaccine before those more vulnerable were the most-cited barriers. Only two key informants were entirely accepting of the booster shot. Those who were resistant (n = 5) were largely discouraged by unmet expectations of vaccine e cacy. Community context Key informants believed community Covid-19 vaccination rates to be in line with national rates at the time of data collection (~ 90% of the eligible population). Though the local population was broadly accepting of the vaccine, participants noted "very strong anti-vaccination feelings in a small number of people" (Management 1). Two participants commented on a pattern of resistance whereby 'anti-vaxxers' tended to be 'anti-maskers' and harbour conspiracy beliefs.
Stances on the vaccine varied by population group. Middle-aged and older clients of the hair salon were "very happy to get it done [and] get back out" (Hair Salon 2 and 3). Attitudes of unemployed community centre clients met "an absolute extreme on both sides, and in the middle" (Employment Services 3), though Employment Services 2 found that many clients who "moaned" about the vaccine still got it eventually. A genuine resistance was noted amongst community centre clients in recovery from addiction; whereas in the Traveller community, vaccine acceptance was possible under the right conditions (e.g., P zer instead of Johnson and Johnson vaccine, seeing others be vaccinated rst, increased convenience for everyday life, the disease being "on the doorstep").

The 5Cs
In the following sections, we focus on four main themes explaining Covid-19 vaccine hesitancy in the low-SES Dublin community. The rst three -Con dence, Complacency, Convenience -are in line with the WHO 3Cs model of Vaccine Hesitancy [14]. A separate theme of Covid-19 Communications emerged through inductive analysis to explain local hesitancy, as did Community-Centred strategies for improving vaccination willingness and uptake. Sample quotes for each theme and sub-theme are presented in Table 2. Because key informants are themselves members of the target community, reported results integrate their insights into community perceptions of the vaccine with their own vaccination experiences. Underlying health conditions "My daughter wasn't going to get it because she was a bit concerned 'cause she's epileptic." (Hair Salon 2) "I have asthma and obviously we're all aware of the di culty of respiratory illness or whatever, so, I wanted to kind of see would that impact me in any way." (Adults in Recovery 1) Close proximity to negative vaccination experience "I mean the odds were so low. But I suppose it's been such an unusual couple of years that I think anxiety levels are probably heightened anyway. Then a good few had very bad side effects the day after so that didn't help matters either." (Management 1, speaking on Ireland's pause of the AstraZeneca jab in March 2021 following reporting of blood clots) Cultural norms "For Traveller women, being infertile was a huge concern because a Traveller woman sees her life made when she's married and has children. There's a lot of women in the local Traveller community that aren't vaccinated as a result and trying to talk them out of that is very di cult. Very, very di cult." (Community Health O cer 1)

Distrust in government and health services
Feeling like the world is against you "They just think it's all a big scam. You know, we work in a disadvantaged area and there's a lot of people that have grown up feeling that the world is against them, that the government is against them. So, they already have that kind of mentality and mindset and are very easily swayed as to go against the grain while they're living in disadvantage and poverty." (Employment Services 3) Fear of conspiracy "An article came out from the government saying that they're gonna vaccinate homeless people and Travellers with Johnson & Johnson vaccine because it's more practical for people that move around. Very common sense, but this was seen as an ethnic cleansing. That's basically the way they saw it. Then a public gure came out and said 'they're trying to get rid of us Travellers' and it was a nightmare trying to debunk that. "I wasn't really able to make an informed decision when I was getting the vaccine. I just went for it." (Adults in Recovery 1) "I had a lot of questions that I wanted answered and they weren't answered, so I wasn't going to actually go and have something that I didn't know what I was dealing with." (Admin 1) "I contacted my GP who was very unwilling to give me information and directed me to the HSE website… but speci c information around my asthma was not there. I actually had to go on Google the NHS website and nd out more information." (Adults in Recovery 1) Lack of accurate information (GP) "I was having a conversation with people yesterday who were asking 'Why would we have to get a third, like that's ridiculous.' I was just saying it wears off, it's probably not as effective, you know. That's the only reason I can give people at the minute as a healthcare worker because I really don't know myself to be honest." (Community Health O cer 1) "I don't know why my GP was reluctant to give information. My own opinion is that there's a lack of knowledge on their end as well. I don't think they had the answers." (Adults in Recovery 1) "I think they've managed it very poorly with the Covid passports. I mean, there's a 2-tier society going on, you know, and I think that pisses people off more than brings people with. You need to bring people with you, rather than get two sides kind of ghting against each other." (Employment Services 3)

Convenience
Access barriers Transport/ nancial barriers "My mother is a family support worker with the HSE. One of the families she goes to is a lady that is on her own with four or ve children, so she wouldn't have the means for a car or anything like that. And one of her children actually had symptoms of Covid and the GP had suggested that they get her to go to [the HSE testing and vaccination centre] to have the child tested. Now, rst of all, she has children that she couldn't get minded. Her only means of getting to [the centre] was through a taxi. You know, she didn't have the money for that." (Admin 1) Lack of access to preferred vaccine "I know within this population there was a lot of like discourse over the right vaccine to get. One individual didn't want the Astra Zeneca, just straight up refused to get vaccinated up until a couple weeks ago where he could actually go in and get P zer." (Adults in Recovery 1) Lack of IT/literary skills "I see a lot of clients that don't have good literacy or IT skills, so they might not have the skills to go online and register on the vaccine portal, like a lot of older members of the community." (Employment Services 1)

Communications breakdown
Mixed messages "There's too many leaders saying too many different things. If they got one person to speak... I nd they were saying different things throughout Covid, and that was confusing, especially a lot of the older people were very confused." (Hair Salon 3) Confusing statistics "You know, NPHET is supposed to be the backbone of the pandemic. And I'm sorry but the muppet show... And I don't mean to be smart, I know they're well-educated men but, you know, the statistics and stuff they put up, a lot of people wouldn't get what that means." (Admin 1) Overreporting of case numbers "People do watch the news and have radios on and all they're hearing is case numbers. And I think that's a massive problem because they're not seeing any improvement. They're just saying, 'What's the point?' and I don't blame them." (Employment Services 2) Lack of encouragement "You ask any old person what they do on a daily basis. Sit down with their cup of tea and watch the 6 o'clock news, and they've been like that for 40-50 years. And there was all this information that didn't necessarily need to be [communicated] to them. Where information on how well people were doing on the vaccine, or how the vaccine was going to help people, or you know the bene ts of it, didn't happen, unfortunately." (Admin 1)

Illogical rules and regulations
Public health measures without explanation "Closing nightclubs at 12:00 o'clock when they only open at 11. Does Covid only come out at 12:01? All this stuff drives me bloody crazy. Like all these rules make no sense. You could go to a pub last year and you could stay there if you bought a meal because the meal saved you from COVID. Like it's just crazy, none of it makes sense." (Admin 2) *HSE = Health Service Executive Ireland. NHS = National Health Service England.
Theme/Sub-theme Sample Quote(s) Disjointed approach "You've so many different stakeholders, my impression of it is that they're trying to please everyone and achieving nothing, you know, and I think that comes out in the communications. I just don't think there is a singular vision for how we're going to get out of this. Or perhaps there is, but it's just not coming across, you know, so I think that's really damaging...I think if we do get it to a point where we have to reintroduce restrictions or anything like that, I think they'll really struggle with it this time around." (Management 1)

Unmet expectations
Sense that the vaccine doesn't work "I suppose they've always been telling us 'get as many people vaccinated as possible' and now, I think over 90% the population over 16 is vaccinated and obviously the case numbers are spiking again. So, it's frustrating and I think probably for the people that were hesitant about getting a vaccine in the rst place, it's maybe adding to their suspicions or concerns about it now that they see that all these people are vaccinated but they're still getting Covid, and the case numbers are still going up." (Employment Services 1) Being sold the wrong story "I just think that perceptions were kind of wrong. People thought that the vaccine was going to stop people getting the virus, which it actually doesn't. It just stops people getting really sick from the virus and I'm not sure that message was put across properly." (Employment Services 2) Scepticism stemming from false hope "How many times were we told, 'two weeks to atten the curve'? And, 'just another two weeks'? It's been a while now at this stage and it's hasn't attened. So, I think there is probably a sense that maybe people don't know what they're doing at government level... I think it's harder to convince people to make sacri ces in their own lives when they don't actually feel like it's really going to have an impact." (Management 1)

Pandemic fatigue
Wanting to move on "I think it's a lot more di cult this time with the boosters, 'cause we were sold a story that we'd be grand once we're all vaccinated, and we're not. So, it is going to be harder. People are Covidfatigued, and just tired after the last few years. I think it will be hard enough to hit the numbers that we need. But, I mean, just keep a consistent message I think would be a good way forward." (Management 1) *HSE = Health Service Executive Ireland. NHS = National Health Service England. Table 2. Key informants' perceptions on drivers of Covid-19 vaccine hesitancy in a low SES Dublin community 1.1 Con dence "There's probably two reasons why people are hesitant. One: being genuinely afraid of putting something into their body, and two: being anti-establishment." (Employment Services 2)

Fear of side effects
Participants acknowledged that lack of trust in the effectiveness and safety of vaccines, and lack of trust in the system and authorities that deliver them were primary drivers of hesitancy in the community. Fear surrounding the vaccine's safety stemmed from how "fast" (Adults in Recovery 1, Employment Services 1) it was rolled out, and its perceived "trial" status (Hair Salon 1). Safety concerns were heightened in individuals with underlying health conditions and those who witnessed and/or heard reports of serious side effects. In the Traveller community, fear of infertility was a concern amongst women due to the cultural weight placed on having a family.

Distrust in government and health services
Anti-establishment sentiments and distrust in government and health services stemming from economic disadvantage further impeded Covid-19 vaccine uptake. Key informants working in employment services noted that clients felt "left behind", "angry" (Employment Services 2), "poorly treated by government departments", and that "the government doesn't care" (Employment Services 3). Though some clients simply needed space to "rant" (Employment Services 2) before getting vaccinated, for others, the consequences of "paranoia" and "lack of trust in the government" (Adults in Recovery 2) were further reaching. Some would not engage with health services as a result or did not have a good relationship with their general practitioner (GP). A history of social inequities and poor community health outcomes left clients feeling that a vaccine wasn't "gonna change much" (Employment Services 3).
Combining anecdotes from Adults in Recovery 1 and 2, a picture emerges of how a history of being let down by health services compiled with lack of information on Covid-19 has created distrust towards the vaccine and its providers amongst former drug users (Fig. 3). , was believed to be a means of ethnic cleansing.

Social pressure
When describing fears circulating in the Traveller community, Community Health O cer 1 noted how di cult it can be to go against a "mob mentality". The phenomenon of "jumping on the bandwagon" to be "outwardly against something" was also observed by Employment Services 3, crediting the tendency for negative stories to gather more weight than positive stories. This type of social pressure affected families. Three participants mentioned instances of a parent discouraging their adolescent child to be vaccinated: two participants heard of adult children discouraging elderly parents.

Inadequate information
Five participants emphasized the role that misinformation spread via social media and word-of-mouth played in fuelling fears of side effects and conspiracy. They noted that community members may lack the resources to challenge misinformation shared by trusted personal contacts. Participants themselves found it di cult to debunk rumours and make informed decisions due to a lack of accessible, accurate information. Adults in Recovery 1 and Admin 1 found no information on the Health Service Executive Ireland (HSE) website on how the vaccine would react with their underlying health conditions and turned to their GPs for answers. Adults in Recovery 1 never got an appointment: Admin 1 paid 60€ for one. Participants wondered how more vulnerable community members would have fared in similar situations.
"Can you imagine an elderly person sitting at home with no one to ring? No one to talk to, to say, 'Well, you know, I don't feel well after having this.' It's the most vulnerable they should have took into consideration." (Admin 1) Even healthcare professionals lacked adequate information. Community Health O cer 1 never received speci c training on Covid-19 as part of their healthcare role, relying on independent research and, in some instances, "literally just assuming."

Complacency
"People have relaxed a little bit and I don't think there's that same sense of life and death that was there very early on." (Management 1)

Low perceived Covid-19 risk
Complacency refers to factors supporting a view that the risks of Covid-19 are low, and vaccination is not considered a necessary preventive action. Employment Services 1 explained that low perceived risk manifested in the community early in the pandemic because most people had experienced and/or witnessed only mild cases of Covid-19. Conversely, participants noted how a rst-hand experience with severe Covid-19 or other illness ampli ed perception of risk and increased vaccination uptake. Four participants thought their personal level of risk did not merit receiving the Covid-19 vaccine before other more vulnerable people, expressing guilt at going before those who needed it more.
Participants felt that fear of Covid-19 had waned over the course of the pandemic, acknowledging that people "weren't scared anymore" (Admin 2), had grown "complacent" (Management 1), and "were just getting on with it" (Admin 2).

Counterproductive vaccination incentives
The theme of complacency emerged indirectly in attitudes towards the vaccine that implied low perceived risk of the virus.
At the time of data collection, a vaccine certi cate (i.e., proof of full vaccination or recovery from Covid-19) was required for indoor hospitality and events, and for most international travel [25]. The restrictions led many community members to be vaccinated out of social or professional convenience rather than as a necessary preventive action.
Participants highlighted potential push back from those who disagreed with restrictions for the unvaccinated, emphasizing people's right to and preference for making their own medical decisions. Of ve participants who mentioned feeling pressurized to get the vaccine either through work or in order to avoid restrictions, none were planning on getting a booster shot at the time of data collection. For many, with fear of Covid-19 waning over time, upholding freedom of choice took precedence over worries about the virus and its health consequences.
Relying on non-health related incentives for Covid-19 vaccination may also inadvertently discourage immunization in disadvantaged community members who are frustrated by divisive social and occupational restrictions.

Convenience
"Her only means of getting to [the vaccination centre] was through a taxi. You know, she didn't have the money for that." (Admin 1)

Access barriers
At the time of data collection, the closest HSE vaccination centre was located approximately 20 minutes on public transport from the local area. This could pose a challenge for elderly people who remained "nervous about getting on a bus" (Hair salon 3), and/or for those without the nancial means for a taxi or to have children minded. Some community members were unable to access their preferred vaccine; others had trouble registering for an appointment online due to limited IT and/or literacy skills.
Community Health O cer 1 spoke of a one-day mass vaccination campaign initiated for the local Traveller community.
Beyond this, participants were unaware of vaccination campaigns being brought to the local area.

Covid-19 Communications
" There's hostility and fear there because of the lack of communication, and lack of support, and a lack of trying to get people to understand what's going on here, why this is happening." (Adults in Recover 1)

Communications breakdown
While identi ed subthemes generally fell under the WHO 3cs framework for vaccine hesitancy, a separate theme emerged relating to government and media communications. Participants shared a view that communication failures reinforced local vaccine hesitancy during the pandemic. A breakdown of communication was described whereby "mixed messages", "lack of clarity" (Employment Services 3), and "contradictions" (Community Health O cer 1) from the government and media led to "hostility", "fear" (Adults in Recovery 1) and "damaged trust" (Management 1) in the community. Contradictory messages from multiple leaders, and the tendency to use big words and statistics were confusing for local community members.
Participants attributed some of the communications breakdown to the pandemic's increasing complexity over time and the dilution of accurate messages due to the quantity of false information on social media. Nevertheless, they felt that unsatisfactory government and media communications, particularly the overreporting of case numbers and lack of encouraging vaccination updates, further deterred vaccine hesitant individuals from seeking out immunization.

Illogical rules and regulations
More than half of participants were frustrated by a sense that some public health measures -for example, a closing time of midnight instead of 2am for all on-licensed premises in November 2021; and a requirement that pubs serve a meal of the value of €9 per customer in order to reopen in June 2020 -"made no sense." (Admin 2). The lack of clarity behind speci c approaches "planted seeds in people's heads" (Admin 1) that they needn't follow restrictions. One participant made a direct connection between diminished trust in the government's ability to lead due to confusing regulations and struggling to get everyone "on board" (Admin 1) with vaccination.

Unmet expectations of vaccine effectiveness
Unsatisfactory communications also led to unmet expectations of the vaccine's effectiveness. Ten of twelve participants believed that the pandemic situation would be under control once vaccinations were rolled out and expressed disappointment that case numbers were rising at the time of data collection. Participants described how confusion, frustration, and anger due to perceived lack of effectiveness of the vaccine led to the entrenchment of community scepticism. For those who had been initially accepting of the vaccine, unmet expectations contributed to Covid-19 booster resistance as participants and community members were left with a feeling of, "what's the point?" (Adults in Recovery 2, Examples of miscommunications that led to disillusionment with the vaccine included selling the vaccine as preventive against all Covid-19 infection, rather than severe Covid-19 infection, and creating false hope by continuously reassuring the population that things would improve in "just another few weeks." (Hair salon 1)

Pandemic fatigue
The culmination of unmet expectations, confusing regulations, and a general breakdown of communication was a sense of community-wide fatigue. Participants described a sense of "apathy" (Admin 1), being "fed up" (Employment Services 1), and "wanting to move on" (Admin 2) with the pandemic. These sentiments had negative implications for the local booster campaign. Some community members that had their two vaccinations felt they had "done their duty" (Admin 1) and weren't having any more.

Providing accurate, accessible information
To establish con dence in the vaccine and address complacency, participants underlined the importance of providing communities with "the right information to make an informed choice" (Employment Services 2) through conversation and upscaled Covid-19 information resources.
Recommended information providers varied by population group. Generally, participants found that conversations with health professionals can "put minds at ease" (Hair Salon 3). For the elderly, public health nurses and community registered general nurses providing in-home care were identi ed as effective providers of Covid-19 information. For populations with distrust in health professionals, "it would be useful to appoint someone independent with a scienti c background to a Covid response role where they go around to different community centres and answer peoples' questions." (Adults in Recover 2) Setting up information stands, providing lea ets at the local chemist, implementing a Covid-19 helpline, and -for the digitally literate -conducting informational zoom meetings, webinars, and podcasts in understandable language came up as feasible ways to improve local knowledge and acceptance of the vaccine.

Building trust in the vaccine and its providers
Participants suggested bringing regular Covid-19 question and answer sessions and vaccine campaigns into the community via trusted community-based organizations like youth groups and medical charities. Speci c trust-building techniques emerged through inductive analysis: Ongoing dialogue: "Bringing people together to ask questions and get answers" (Management 1) and "having conversations about initial concerns or reservations in [understandable language]." (Employment Services 1) Relationship building: "Building a rapport with people who may feel backed into a corner and are used to ghting" (Employment Services 3) by "identifying speci c goals", shifting from a "one-size-ts-all" approach to address individual concerns, and "actively listening" (Adults in Recover 1).
Erasing preconceptions: "Becoming familiar with vaccine concerns" (Employment Services 1), "being empathetic", "not talking [down] to people that are not vaccinated" (Management 1), and "understanding it's a process, that you can't ip a switch" (Employment Services 3).
Communicating effectively: "Providing real evidence to debunk misinformation" (Adults in Recovery 1), and "letting [community members] know what you're aiming for, how you're trying to do it, and being honest and upfront" (Employment Services 3).

Improving vaccine access
Along with upscaling local vaccination campaigns and awareness efforts, participants recommended "being more inclusive of communities where general and digital literacy are an issue" (Employment Services 1). Providing marginalized community groups (i.e., Travellers, adults in recovery from addiction) with a choice of vaccine and facilitating private vaccination requests to combat mob mentality and vaccine stigmatization could also improve vaccine uptake.
To help reduce viral transmission and improve perceptions of the vaccine's effectiveness, two participants suggested simultaneously expanding access to affordable antigen tests.

Discussion
This qualitative study was the rst to examine drivers of Covid-19 vaccine hesitancy in a low-SES urban community in Ireland through consultation with community representatives. While results con rmed that community drivers of hesitancy largely fell under the WHO Con dence, Complacency, Convenience model [14], the Irish government and media's handling of Covid-19 communications emerged as a novel barrier to vaccination acceptance and uptake. Prior to Covid-19 vaccination roll-out in Ireland, Murphy et al. suggested that public health messaging should be clear, direct, repeated, and positively orientated to target the psychological characteristics of those prone to vaccine hesitance or resistance [12]. Our study outlines how pandemic communications missed these objectives, contributing to the entrenchment of anti-authority sentiments and offering one explanation for increased resistance to Covid-19 vaccination in Ireland during the pandemic [13].
While vaccine-safety related concerns have been identi ed as the main determinant of vaccine hesitancy in Europe and the UK [26,27], key informants identi ed anti-established sentiments stemming from a history of being let down by the government and health services as a primary local challenge. Barriers to vaccination uptake speci c to adults in recovery from addiction were foreshadowed in a 2019 review on methadone treatment protocol in Ireland [28]. Service users described negative program aspects including patient lack of choice, humiliating experiences consuming methadone in a public space, engaging with uncaring service providers, and being treated with a one size ts all approach [28]; all identi ed in this study as drivers of Covid-19 vaccine hesitancy. Complacency may also prevent uptake in this group. The primary barrier to vaccination amongst 872 surveyed people who inject drugs in Australia was lack of perceived vaccine utility [29].
Identi ed barriers to Covid-19 vaccine uptake amongst Irish Travellers (e.g., cultural concerns about vaccines offered during pregnancy, misinformation spread via social media and 'word of mouth') have been cited in relation to other vaccines, as have potential facilitators including su cient understanding of the vaccine and trust in health professionals [30]. The reported negative reaction of the Traveller community towards receiving a single rather than double dose Covid-19 vaccine underlines the importance of applying key informants' recommendations for trust-building (e.g. ongoing dialogue, erasing pre-conceptions) before the implementation of well-intentioned public health measures, as well as after.
Participants expressed negative community sentiments and resistance towards non-health related vaccination incentives and 'being told what to do'. This is in line with ndings from a UK study demonstrating that vaccine passports may induce a lower vaccination inclination in socio-demographic groups that are less con dent in Covid-19 vaccines [31]. Social and professional restrictions make those who already intend to get vaccinated even more inclined to do so, potentially explaining surges in vaccination following implementation of a national vaccine passport policy [31,32]. But research shows, as do our own study ndings, that pressurizing those with doubts about the vaccine to vaccinate reinforces resistance, particularly for those who are economically deprived and/or unemployed [31]. Prioritisation of education and outreach initiatives to combat vaccine scepticism and misinformation emerges as a better-suited strategy for encouraging vaccination in a low SES community. Though it is interesting to note that for injection drug users, monetary incentives may be superior to outreach in achieving adherence to multi-dose vaccine series [33]; and that local Travellers were reportedly accepting of the vaccine when it facilitated international travel.
Encouragingly, results from this study con rm the effectiveness of many strategies already used by the HSE and nongovernmental organizations (NGOs) for ensuring equitable vaccination in Ireland. The HSE's comprehensive vaccine approach for vulnerable groups, including Travellers and those in addiction settings, recommends a hands-on approach using trusted sources within each population group to listen, alleviate individual concerns, and encourage vaccine participation [16]. Our study ndings suggest that this type of 'champion' -or someone with a scienti c background appointed to a Covid response role, as suggested by one key informant -would be of value at the wider community level in low-SES areas. Vaccine communication plans for vulnerable groups are in progress at the HSE, who has called for targeted approaches for meeting information needs [16]. Key informants' perspectives can again be of value: strategies like Q&A sessions with scientists, healthcare professionals and community representatives that facilitate relationship building and ongoing dialogue should be prioritized, as should upscaled Covid-19 vaccine information and training for GPs and community health workers.
Irish NGOs are leading crucial community-level vaccination initiatives in collaboration with the HSE. Pavee Point, an NGO addressing Traveller issues and promoting Traveller rights, has an online 'Travellers Take the Vaccine' page with community member video testimonies addressing many of the vaccine fears and concerns outlined in this research study and linking viewers with the HSE website and vaccine helpline [34]. The medical charity Safetynet's Covid Cluster Rapid Response Figure 2 5Cs Model of Covid-19 Vaccine Hesitancy in a low SES urban community: inductive analysis results from key informant interviews, Dublin, Ireland 2021. *From the WHO SAGE Working Group 3Cs model of Vaccine Hesitancy [14]. Covid-19 Communications emerged through inductive analysis as a separate theme driving hesitancy.