Table 3 Subthemes of approaches to address hesitancy and under-vaccination factors for newcomer refugees and immigrants in Calgary and area (2021-2022) with verbatim quotes

Vaccinations in evolving conditions

"We updated paperwork almost weekly…guidelines, paperwork…we had weekly meetings [to discuss] what was new, this is what's changed… ‘Okay, now ages 12 to 17 is approved for this’. ‘Now this one only counts’ …’now Moderna is only half dose for this age group’. ‘Oh, now we don't give Moderna under 30, unless they really want it because of myocarditis’. Like the information avalanche was unreal, like nothing I've ever worked in. But it was always updated, always communicated. Trying to make sure we were all using the most up-to-date information.” (Key informant 03)

Information mobilization and cultural interpretation

“By then, we were approaching the religious leaders, we're sending the message […] that this is not something bad it has nothing to do with their religion. […] [W]e were trying to do that with the help of the […] traditional religious leaders, so we were and most of the time we were conducting these vaccination processes at home and at the mosque, which is a holy place in the people, faster. So we will go into the mosques, […] using their loudspeaker using the sound of the Mullah or the religious person and talking with the people that there is a vaccine.” (Key informant 08)

Targeted community outreach

“Our system […], the health system in Alberta is not set up well to serve this population. So…having [an immigrant service agency partner] there, helping [refugees and newcomers] navigate the system and helping coordinate clinics and, you know, where to go and how to access it, and how to get a health number. You know, without an organization like that or a partnership like that, I would imagine it would be extremely difficult to be able to navigate the system.” (Key Informant 03)

Low barrier, community-based, culturally responsive clinic design

“We had extremely good partnerships [for specific population groups]. They called, they advertised… they found volunteers everywhere, went to houses, went to community, the churches, the yard sales. All those kinds of things and had signs and advertising. And so we had a ton of partners that did that work […] like we just had so many partners that did the work for us and got them in the door for us.” (Key informant 02)

Referring to community partners: “I don't know how they organized it, but they would arrange groups or families and they would come with them, they would from start to finish. They would come to the door with them. We would get them registered. Lots of them, we had to create Unique Lifetime Identifier’s (ULI) for them if they hadn't had one created yet… their team would help support in terms of translation, all that stuff. And then we would help, we would funnel them through the clinic right and get them registered and vaccinated and aftercare.” (Key informant 02)

Partnerships with NGOs

“We had extremely good partnerships [for specific population groups]. They called, they advertised… they found volunteers everywhere, went to houses, went to community, the churches, the yard sales. All those kinds of things and had signs and advertising. And so we had a ton of partners that did that work […] like we just had so many partners that did the work for us and got them in the door for us.” (Key informant 02)

Referring to community partners: “I don't know how they organized it, but they would arrange groups or families and they would come with them, they would from start to finish. They would come to the door with them. We would get them registered. Lots of them, we had to create Unique Lifetime Identifier’s (ULI) for them if they hadn't had one created yet… their team would help support in terms of translation, all that stuff. And then we would help, we would funnel them through the clinic right and get them registered and vaccinated and aftercare.” (Key informant 02)

Flexible funding

“There's a shared complexity in even accessing emergency funding that we knew could support people. There are the bureaucrats that are involved, and then, of course, the challenges of the inaccessibility of this funding, just because of how things have been structured, and particularly, for newcomers and refugees because that is always an issue. If you see how resources flow, you realize that they don't necessarily flow very well to newcomer and issues.” (Key informant 10)

Other factors to address

“If we are not compassionate enough, and we are unable to understand them… vaccination probably is only taking a few minutes to be done, but in long term we are going to lose that trust. These groups of people are very traumatized. Their mental well-being is not really the best, and if we are unable as a health care provider, we are unable to detect that, and address that.. they wouldn't be very enthusiastic to get the vaccine. Not only the [COVID-19] vaccine, it could be for anything else in the future.” (Key informant 08)

“It is helping people where they're at but also helping them understand what we can do to help them get better health outcomes. So, [refugees are] a really marginalized population generally, and this is where public health really adds a lot of value, I think, and helps people navigate the healthcare system and engages them in healthcare and develops trust with this population because they've been through a lot often. So establishing trust with health authorities sometimes takes a long time, but they're very appreciative and it helps them trust in our system basically.” (Key informant 12)

"How fun or engaging or comfortable something is matters too right. At the end of it.. you can watch like [SPO] staff just talking to people all the time, all the stuff …that's high intensity work right?” (Key informant 13)

“[…] to get them engaged and get them to understand how the system works in Calgary and then working towards them coming to our routine clinics, so that we can support them where they live in the community. Initially they're kind of centralized in one area, but then they spread throughout the zone and other parts of the province, and so we want to kind of start that model of getting them to connect with supports in the community and support accessing health services within the way it's normally done within Alberta.” (Key informant 12)

“They already went through [so] much. They went through a lot, so we just want to make their life easier here [by explaining what COVID-19 vaccination or no COVID-19 vaccination means]. Sometimes very small, tiny things make a huge difference, yeah?” (Key informant 01)

“Alberta was relatively limited in its deployment of community-based vaccination clinics compared to other provinces right. You know the vaccine role in Alberta is primarily driven initially by pharmacies and public health. Later on primary care like family doctors are giving them permission to get vaccines and then later, later on, like we are able to do these mobile vaccination clinics through a medical [provider] all over the province, but we are much lower than the other provinces in terms of just like I guess like vaccine deployment.” (Key informant 13)

"We can be available after hours… that's what we should target if people are working in bigger factories or institutions, hospitals or other places. We can go there and do vaccination…With the kids' vaccination, it was such a low rate because nobody wants to do anything differently… No approval came through for schools [even though these] are good places for vaccination.” (Key informant 11)

“There are lots of wastage of vaccines which can be prevented, if we have a central kind of approach. Or we have different facilities, who are vaccinating that can talk to each other, or they can have a centralized approach…. why [are we] wasting when the rest of the world doesn't have it and there's so much shortage everywhere.” (Key informant 11)