Abstract
Since 2022, a global mpox outbreak in non-endemic countries, including Canada, has spread rapidly, mainly affecting gay, bisexual, and queer men (GBQM). With mpox primarily transmitted through sexual and close physical contact, concerns emerged over the replication of early responses to HIV/AIDS, which was initially labeled as a “gay disease,” perpetuating ongoing negative stereotypes and discrimination against GBQM. To prevent potential social and health-related stigmatization, institutional actors, including public health authorities, community-based organizations (CBOs), and clinical bodies, collaborated to provide guidance and promote culturally informed responses. We aimed to examine how health institutional collaborations were formed and maintained as challenges emerged during Canada’s mpox outbreak response. We conducted 30 online individual interviews and six small focus groups with 48 CBO practitioners, public health personnel, and clinical providers across Canada. Data were analyzed using institutional ethnography and actor–network theory, through indexing, which involves categorizing and consolidating categories. We mapped four interrelated networks of coordination: assembling the network through existing HIV infrastructures; co-developing public health messaging to increase cultural sensitivity to GBQM’s lived experiences; negotiating vaccine eligibility criteria to reflect community realities; and mobilizing networks to deliver vaccines in GBQM community–friendly settings. Regional differences in public health infrastructure influenced the development of coordination, messaging, and access to care. Findings highlight how relational infrastructures developed for HIV were reactivated and repurposed during the mpox response. Investing in and maintaining strong community and public health relationships outside of crisis periods can improve future responses to health emergencies affecting GBQM communities and other marginalized populations.
Keywords
Introduction
Since May 2022, mpox has spread globally in countries without previously documented transmission, including Canada (World Health Organization, 2025). Mpox has two main clades: clade I (subclades Ia and Ib) is linked to higher mortality rates (up to 10%), while clade II (subclades IIa and IIb) has a mortality rate of about 1% (Americo et al., 2023). The 2022–2023 outbreak was primarily associated with clade IIb and disproportionately impacted gay, bisexual, and queer men (GBQM), who accounted for nearly 90% of cases worldwide (World Health Organization, 2025). This pattern was also observed in Canada, where 96% of cases occurred among GBQM, rising from two in April 2022 to 533 in July 2022 (Public Health Agency of Canada, 2024). Likewise, in the United Kingdom, 96% of over 2,200 cases documented in July 2022 were among GBQM (Biesty et al., 2024; Garcia Iglesias et al., 2023). Similarly, in the United States, 95% of over 600 cases reported in August 2022 occurred among GBQM (CDC, 2025). In response, the World Health Organization (WHO) declared the outbreak a public health emergency of international concern (PHEIC) in July 2022, which ended in May 2023 (World Health Organization, 2025). In August 2024, the WHO issued a second PHEIC following a surge of clade Ib cases in Central and East Africa (World Health Organization, 2025). As clade IIb was mainly transmitted through sexual and close physical contact among GBQM, these communities faced stigmatization and blame, echoing responses to HIV/AIDS in the 1980s when it was labeled a “gay disease” (Logie, 2022).
Public health agencies acknowledged the potential stigmatization of mpox and emphasized engaging affected communities to reduce discrimination and transmission (Freckelton & Wolf, 2022; World Health Organization, 2004). In Canada, the Federal, Provincial and Territorial Public Health Response Plan for the Management of Monkeypox engaged GBQM communities in containment efforts (Freckelton & Wolf, 2022). Canada also established a Special Advisory Committee (SAC) in June 2022 to provide recommendations from public health agencies and stakeholders, including community-based organizations (CBOs) (Public Health Agency of Canada, 2022). The SAC was deactivated in December 2022 as the number of cases decreased. These approaches align with the WHO guidance to involve affected communities for effective mpox response (World Health Organization, 2004).
Canada’s healthcare model, where the federal government provides funding while provinces and territories deliver services, has shaped the response to mpox. Each jurisdiction features varying governance infrastructures. Some have regional health authorities (e.g., British Columbia [BC]) or local public health units (e.g., Ontario), while others have a centralized health authority (e.g., Alberta and Quebec) (Manns et al., 2024). In Ontario, CBOs involved in HIV and GBQM health mobilized a community response early in the local outbreak, convening weekly community mobilization meetings with public health actors and clinicians. These meetings enabled CBOs to provide advice to public health agencies, facilitating a tailored response for GBQM communities (Tan et al., 2024).
International research has revealed that CBOs played critical roles in shaping effective mpox interventions. In the United Kingdom, while the UK Health Security Agency failed to engage affected communities, CBOs developed communication products that resonated better with GBQM (Biesty et al., 2024; Garcia Iglesias et al., 2023). In Australia, a National Mpox Taskforce comprising national and local public health agencies, as well as key clinical, laboratory, and CBOs, was established, responsible for creating messaging and strategies to address barriers to GBQM’s healthcare engagement (Cornelisse et al., 2023). In Japan, a formalized partnership among academia, community, and government increased disease awareness among GBQM communities (Kato et al., 2024). The WHO European Regional Office also co-developed messaging campaigns with affected communities (Palumbo et al., 2024). Although these studies highlight successful collaborations between CBOs, public health, and clinicians, there remains limited research on the perspectives and experiences of diverse stakeholders involved in Canada’s mpox response and on how complex institutional relations shaped a coordinated intervention.
Our objectives are twofold. First, we map how collaborations between CBOs, public health, and clinicians were formed and navigated during the 2022 mpox outbreak. Second, we analyze the structural and relational challenges that emerged. The research was initially conceived as an institutional ethnography (IE) study (D. E. Smith, 2005, 2006), exploring how institutional forces organized and constrained a coordinated response. During analysis, it became apparent that the dynamics between CBOs, public health, and clinical organizations involved complex institutional relations. This prompted us to incorporate actor–network theory (ANT) as a complementary framework (Frimpong et al., 2022). This enabled us to trace the discourses and practices that structured the response, as well as the heterogeneous assemblages of humans and nonhumans, including institutions themselves, that made these efforts possible.
We argue that relational infrastructures between CBOs, public health institutions, and clinical organizations, developed over decades of sexual health work, were reactivated and repurposed for outbreak response across Canada to meet the needs of GBQM communities. Together with public health and clinical actors, CBOs mobilized networks, co-developed messaging, and adapted service delivery models. These relational networks also exposed tensions around funding, power dynamics, and institutional inflexibility, which shaped the possibilities and constraints of Canada’s mpox response.
Complementing IE With ANT
Pioneered by Dorothy Smith (2005, 2006), IE maps how people’s everyday actions are coordinated, organized, and regulated across time and space through ruling relations (Grace, 2019). IE emphasizes “the interface of embodied individuals and institutional relations” when analyzing how people engage in and navigate social worlds (Mykhalovskiy, 2008, p. 140). IE has been widely applied in healthcare, emphasizing how access is institutionally organized. For example, Mykhalovskiy (2008) explored how the decision-making of people living with HIV around antiretrovirals is shaped by biomedical and healthcare systems instead of individual choices. DeVault and McCoy (2006) similarly describe healthcare as a complex coordination network across multiple activities and sites, where institutional and administrative power regulate care delivery and uptake.
ANT builds on IE’s concern with coordination by analyzing how relational networks are assembled, negotiated, and stabilized and make actions possible (Tummons, 2010). While IE focuses on how ruling relations organize people’s work, ANT focuses on how coordination is the outcome of a heterogeneous network. Consequently, ANT contributes to a more complex analysis of how CBOs and other stakeholders mediated responses during the mpox outbreak, foregrounding the institutional relations shaping a coordinated action (Frimpong et al., 2022).
ANT provides a framework for analyzing complex relations and their effects (Latour, 2005). From an ANT perspective, relations are not pre-existent but emergent through networks (Bilodeau & Potvin, 2018). ANT has been influential in health research, particularly in public health interventions, recognizing them as networks involving human and nonhuman actors (Bilodeau & Potvin, 2018). Actors have converging and diverging interests, and ANT’s objective is to trace the works of various entities to make networks functional (Bilodeau & Potvin, 2018; Potvin & Clavier, 2013). By situating humans alongside nonhumans, ANT emphasizes a relational view of action, which resonates with the concept of assemblages (Bilodeau & Potvin, 2018; Rhodes & Lancaster, 2020). Assemblage thinking considers all actors to have equal agency within networks (Rhodes & Lancaster, 2020). This echoes IE’s concern for coordinating people’s activities while extending the analysis to include institutions, infrastructures, and multiple actors that enable coordination (Tummons, 2010).
Deploying IE and ANT foregrounds how institutions, as relational assemblages, are mobilized to respond to emerging public health emergencies. Both approaches begin with identifying a problem. In IE, the problematic refers to a poorly understood issue or a “disjuncture” in people’s experiences (McLiesh et al., 2024). In ANT, this involves problematization, requiring researchers to identify connections between various entities relevant to the event. ANT further emphasizes negotiation of roles and interests, known as interessement. Successful interessement entails enrollment, which is the acceptance of different roles. Finally, mobilization demands the coordination of action by various entities within a network (Bilodeau & Potvin, 2018). Such principles allow for a comprehensive analysis of how networks coordinate, operate, and produce solutions (Bilodeau & Potvin, 2018).
ANT’s focus on network formation, conflict navigation, role negotiation, and action coordination provides a framework for analyzing collaborative responses to public health emergencies. For instance, Frimpong et al.’s (2022) ANT analysis of CBOs in Sierra Leone traced how institutions and relational assemblages mediated responses to COVID-19 (Frimpong et al., 2022). Their study revealed that various CBOs utilized their experiences with health disasters to problematize COVID-19 as urgent and mobilize a community-level response. Considering COVID-19 as a serious community threat compelled CBOs to create networks to promote health literacy. However, coordination was marred by disagreements over roles and tasks, resulting in inefficient resource utilization. Building on these insights, we integrate ANT and IE to analyze how CBOs, public health agencies, and clinical organizations shaped coordination and response to the 2022 mpox outbreak in Canada.
Methods
Data were derived from the Learning from Mpox Study, a mixed-methods project aimed at improving the well-being of diverse GBQM across Canada during the mpox outbreak and informing future pandemic preparedness. The qualitative component involved three streams: (1) interviews with individual GBQM; (2) interviews and focus groups with health system stakeholders, including community-based practitioners, clinicians, and public health personnel; and (3) textual analysis examining key texts, including directives to health professionals and prevention messaging. This paper draws exclusively on the second stream, which offered the richest insights for mapping institutional coordination and relational processes.
Data collection for the second stream occurred in two phases. The first phase, conducted in English between September 2023 and March 2024, involved participants across Canada. A second phase was conducted in French and English with stakeholders exclusively based in Quebec between February and March 2025, gathering insights from the province where the first outbreak in Canada was reported. Recruitment of participants leveraged our extensive network of stakeholders with direct outbreak response experience. Purposive recruitment was supplemented by snowball sampling. Data collection continued until analytic saturation was achieved, where no new insights emerged in subsequent interviews or focus groups. The study received ethical approval from the University of Toronto Human Research Ethics Board (Protocol #44777) and the University of Montreal Research Ethics Board (Protocol #2023-4970).
Participants were given the option to participate in a one-on-one interview or a focus group, depending on their availability and preferred format. Interviews provided a confidential space for personal reflection, while most focus groups, composed of colleagues from the same organization or cross-organizational CBOs, facilitated discussions of shared institutional experiences and broader perspectives on the mpox response. Focus groups ranged from two to five participants. All sessions were conducted virtually through Zoom using a semi-structured interview guide and were recorded. Participants provided written consent before the interviews. No honorarium was offered, unless participants self-identified as belonging to and serving marginalized groups (e.g., Black, Indigenous, or racialized communities, 2SLGBTQ+ people, or those with low income) and requested a $50 honorarium.
The interview guide included eight overarching and interconnected domains: stakeholder roles and initial reactions to the 2022 mpox outbreak; sources of information and key texts influencing response; mpox messaging and common client/patient questions and concerns; health systems’ response effectiveness; mental health and well-being of providers; learning from previous pandemics; addressing stigma and ethical issues; and effective partnerships and collaborative practices. We transcribed, reviewed, and de-identified interviews using Otter.ai and Microsoft Word. French transcriptions were translated into English for analysis. Transcripts were entered into NVivo 14 and coded deductively and inductively by the first five co-authors through line-by-line coding (Bradley et al., 2007).
Our coding and analysis involved indexing by consolidating semantic and latent categories (Nguyen et al., 2024; Rankin, 2017). Our analysis was informed by IE’s focus on how policies and guidelines coordinated stakeholders’ responses to mpox. Additionally, ANT guided us in highlighting the roles of both human (e.g., providers, CBO staff, and public health workers) and nonhuman elements (e.g., directives, Zoom, and protocols) in assembling the response network. First, a core sub-group of nine authors, with expertise in qualitative research, contributed to the broader analytic synthesis. Each member gained familiarity with the interviews by independently reading transcripts, and then compared and discussed the coding. Second, broader categories were applied, allowing this sub-group of authors to organize key components into manageable sections. Third, key categories were reviewed, refined, named, and explained through regular discussions with the research team and key community stakeholders. In case of disagreements, a consensus was reached through discussions among a sub-group of authors and subsequently presented to the research team. Several team members identify as 2SLGBTQ+, some hold clinical roles, and many maintain longstanding partnerships with CBOs and public health agencies. These positionalities facilitated access and rapport but also required team members to critically reflect on emerging findings.
Results
Fourteen public health personnel, 27 community-based practitioners, and seven healthcare providers participated in the study. Geographically, 28 came from Central Canada (Ontario and Quebec), 13 from Western Canada (BC and Alberta), and seven from other regions. We completed 30 individual interviews and six focus groups, with median durations of 49 and 80 min, respectively. Participants worked in diverse institutional settings, including CBOs focused on advocacy and service delivery for 2SLGBTQ+ communities, public health agencies responsible for outbreak management, and clinicians providing patient care.
Our analysis mapped four interrelated institutional practices showing how CBOs, public health agencies, and clinical organizations functioned as relational networks in coordinating the mpox response. Within these networks, CBOs emerged as primary mediators by (1) assembling multisectoral networks through leveraging longstanding relationships with public health and clinical partners; (2) co-developing public health messaging through translating community knowledge into non-stigmatizing messaging institutionalized by public health; (3) negotiating vaccine eligibility criteria through shaping or adapting criteria to align institutional policies with community access needs; and (4) mobilizing networks for vaccine delivery through activating institutional relations to deliver equitable access in trusted community spaces. Network coordination evolved through continuous negotiations between CBOs, public health authorities, clinics, and other organizations. Regional differences in public health infrastructure and institutional arrangements significantly influenced the success or failure of coordination, messaging, and vaccine access.
Assembling Multisectoral Networks
CBOs, public health agencies, and clinical organizations as institutional actants assembled multisectoral networks in response to early local mpox outbreaks. Infrastructural arrangements and longstanding partnerships developed over years of queer health work between AIDS Services Organizations (ASOs), public health agencies, and clinical organizations were rapidly mobilized and expanded. In this context, CBOs serving GBQM communities from Ontario and BC assumed coordinating roles after they were invited or endorsed by other institutional actors, including public health authorities or clinical partners. Response coordination varied across geographical contexts, where differences in public health governance shaped how networks were assembled.
One staff member at a large Ontario-based CBO shared that his organization was bringing stakeholders together by activating established partnerships and infrastructures. He noted that a clinician contacted them first, initiating the assembly of a community mobilization table. Importantly, this clinician was already part of an extensive network of key stakeholders, which he brought together, and the CBO stepped forward to organize meetings formally: So [a clinician] contacted us and was like, I’ve been paying attention to these [mpox] cases […], and there needs to be some level of coordination. So, he invited us. He basically pulled together a number of stakeholders. And I think that was really key because he has the clout to say, I’m intimately connected with the outbreak […], which I think was a draw to get people in the room or on the Zoom call. And he was like […], if there are people missing, invite them.
Here, clinical institutional actors recognized the importance of deploying a community response. Clinical actors initially problematized mpox as a community concern and engaged key community and public health institutions to initiate coordinated interventions. Subsequently, the CBO was enrolled in the network and assumed the coordinating role, bringing in additional partners, which further expanded the network. The same participant explained: [We took] the reins on the coordinating role […]. We have resources; everybody else is strapped for time. So, we’ll take on the responsibility of coordinating these meetings, setting out an agenda, putting the Zoom link, just like the administration of that […]. And then that became our regular, weekly meetings […]. And that was the venue for us to have a relationship with [public health agencies], other community agencies in our network, community health centers, and non-health-related community people, including staff from [a local bathhouse].
The CBO took an active role in coordinating a response by managing administrative tasks and facilitating connections among human and nonhuman actors (including personnel from various agencies and organizations, digital platforms, and community venues) to come together and participate in the network. This illustrates interessement by aligning the interests and priorities of different actors around the shared goal of addressing the outbreak. Another Ontario CBO staff member described this process: We talk about collaboration, partnership. The way I experienced it or seen is that the partnership was with the [ASOs]. Because we don’t have to convince them […]. Like they all say, okay, let’s get together and figure this out.
The alignment of interests enabled the enrollment of diverse organizational actors to the community mobilization table. This interessement was significant in bringing influential people and institutions into the network. The same participant described how the network became the primary venue for engagement to advance community health outcomes: The collaboration partners are very useful to get the big players to work with us […]. You know, when the medical officer joins your call, this is important. They’re paying attention to what you’re saying. So, we knew also this was an opportunity to do something bigger, more profound, more beneficial for the community.
In addition to activating pre-existing relationships to enroll various institutions and organizational actors into the network, funding relationships also functioned as mediators, which enabled some CBOs to sustain coordinated responses. A public health worker from Ontario explained that they allowed CBOs to “use funding for [mpox] that may have already been geared to HIV work.” While this funding flexibility facilitated network mobilization, it also created tensions within existing sexual health programming. As one Ontario CBO staff member reported, it “just kind of added work for you, but no additional money came in.” This suggests that funding reallocation stretched many CBOs beyond their capacity.
In Ontario, problematization was driven by clinical actors, and CBOs assumed responsibility for network enrollment and mobilization. This contrasts with the approach in BC, where the provincial public health authority initiated problematization. A staff member from a large CBO explained: The biggest benefit for us has been our partnership with the [provincial public health agency]. So, once they were sort of responsible for the [mpox] file, we were quickly asked to co-host a provincial working group […] that has representatives from each of the [regional] health authorities, as well as community representatives.
This suggests that BC’s provincial public health authority invited the CBO to lead the coordination of institutions into a network. Their longstanding partnership with the province’s public health and established partnerships, along with credibility gained from previous collaborations, positioned the CBO as a trusted partner. As the participant above continued, “So the partnership with [regional public health units] from the get-go position[ed] us, alongside them, as the authority around accessing [the] queer community.” He also attributed these successes to governance infrastructure differences, noting that BC’s regional health authorities made coordination more manageable compared to CBOs in other provinces: Just geographically, [BC] is split into five or six different health regions. [Unlike] other provinces […], you know, counterparts like Ontario, they have 26 health authorities. So, just like the ability to, you know, only manage six different regions […], it’s just a benefit of where we are.
Geographic and governance infrastructures actively configured the possibilities for network assembly. Despite differences in public health governance, these CBOs’ extensive and longstanding network with other institutions enabled them to actively shape local responses.
Many public health actors acknowledged the effective collaboration with CBOs. For example, an Ontario public health officer described: I think the relationship we had with [CBO] […] was absolutely instrumental in helping us be extremely effective […]. I think they were the ones who brought in other organizations and community partners serving the GBMSM community.
Similarly, a regional public health personnel in BC noted: I think that the collaboration between the [CBOs] and the ability to hear directly from those groups, that population around what was needed, was hugely beneficial […].
These responses suggest that public health units recognized CBOs’ localized expertise and community networks, which were instrumental in ensuring that outbreak initiatives met GBQM communities’ needs. Public health agencies acknowledged CBOs as important institutional partners in the mpox response rather than exercising control over them.
In this section, we showed that public health and clinical institutional actors actively initiated the problematization of the outbreak by defining mpox as an urgent public health issue requiring coordination and community expertise. This framing positioned CBOs as key mediators, responsible for enrolling other partners and mobilizing a response network.
Co-Developing Public Health Messaging
CBOs also acted as institutional mediators in co-developing public health messaging for GBQM communities. This involved drawing on CBOs’ community knowledge by translating and reframing moralizing discourses that accompanied HIV and mpox messaging for GBQM. While public health messaging typically involves institutional processes that limit content and hinder timely dissemination, CBOs activated pre-existing multisectoral organizational relationships to circumvent bureaucratic constraints, enabling faster creation, approval, and dissemination of non-stigmatizing and culturally relevant messaging. Differences in provincial governance infrastructures influenced how public health institutions engaged CBOs and other partners in messaging processes, ranging from co-creation to more informal or top-down models. Public health institutions recognized the institutional legitimacy of CBOs, acknowledging them as crucial partners in the co-creation and legitimation of messaging, which institutionalized multisectoral trust.
CBOs exercised agency by problematizing historically pathologizing discourses that positioned GBQM communities as responsible for contagion (Logie, 2022). Through this reframing, CBOs initiated interessement by aligning public health institutions with community-informed approaches to messaging. As one CBO worker from Ontario explained: We were giving messages about how to reduce stigma […], especially for gay men because, historically, it’s seen as, “oh, you brought this upon yourself.” So, our job was to remove that. And the good thing is that [public health authorities] understood the value of that.
CBOs and public health agencies recognized the importance of medically accurate and culturally appropriate messaging. CBOs translated complex public health information into a language accessible to GBQM communities, which public health units could not have achieved due to institutional constraints. Another Ontario CBO worker said: The biggest piece around our relationship with public health units […] was that we were able to produce communications products at a speed and in a tone that they could never match because of their approval processes and because of constraints around the language that they could or couldn’t use […]. It meant that we could use language that people actually use in the community […]. And it didn’t feel like a public health advert.
This rapid messaging was made possible by the CBOs’ embeddedness within GBQM communities. CBOs in BC described playing similar roles, co-creating messaging, and gaining legitimacy with public health institutions by being positioned as authoritative in the mpox response. For example: We created a number of one-pagers for community in terms of how to reduce the spread of mpox. And then […] because we were sort of positioned alongside the [provincial public health agency] as sort of like the authority […], it really made it very streamlined for the rest of the health authorities to approach […].
In contrast to the more formalized collaboration between public health institutions and CBOs in Ontario and BC, Quebec’s approach relied on direct institutional enrollments rather than structured mobilization tables or working groups. A Quebec CBO worker described how interpersonal networks were activated to co-create messaging: I send suggestions on how to say things […]. They cut and paste my text that I sent to them by email. Of course, they have to validate things […], but at the end of the day, like 90% of what we ask, it’s been there […]. I think it was our way of ensuring that the information was adapted and respectful.
Although a structured forum was absent, institutional relationships and trust between public health agencies and CBOs remained strong, facilitating community-informed messaging. However, a participant from another Quebec CBO noted that, while public health institutions were careful about developing non-stigmatizing language, CBOs were responsible for translating this messaging and adapting it to meet the specific needs of their clients before sharing it: The goal also, was to really avoid stigmatizing the community […] on the ground. There was a lot of thoughtfulness about this […] when someone came to us with a question, you knew to prioritize some messages over others to not disinterest the person or create a micro-aggression or anything like this.
Public health officials acknowledged CBOs as legitimate translators and mediators of public health messaging, recognizing their deep connections within affected communities. For example, a public health officer from Ontario noted: A lot of continuous conversations with organizations […] to evolve those messages […]. And also, adapting the content to the reality of people’s lives. Like, you know, they gave very specific feedback on what words would resonate.
Echoing similar sentiments, a public health officer in Quebec articulated: Communicating directly in this community was part of the strategy to have direct channels of communication. We worked a lot with the community organization […] because of pre-established relationships before the outbreak.
Co-creating messaging with CBOs was critical for many public health institutions. In Alberta, the local public health unit activated their partnerships with CBOs to retranslate provincial communications, which one health officer described as “very formal, structured, just non-friendly.” He continued: So, we worked with them [CBOs] to say, what are you hearing? What are questions you’re getting? So we set that and then we had working relationships […] [with] a lot of community groups with the question […] what are you hearing? So, what are pieces that we could have FAQs that you’re hearing from your folks, and then run some of our draft messaging, does this resonate with your community?
Alberta’s centralized institutional messaging was challenging for local adoption, as the language produced was not reflective of the experiences of GBQM communities. Some local public health units were compelled to enroll CBOs and work with them to adapt messaging from the province, suggesting that mpox information across Alberta was variable.
CBOs in some provinces problematized stigmatizing public health messaging directed at GBQM communities from previous and historic outbreaks, including HIV. CBOs aligned their goal of producing non-stigmatizing messaging with the broader public health institutional aim of disseminating practical information. This alignment enabled the co-development of medically accurate and culturally appropriate communication products, which legitimized the role of CBOs as authoritative institutional partners in the mpox response.
Negotiating Vaccine Eligibility Criteria
In addition, some CBOs, mainly from Central Canada, acted as institutional mediators in shaping and negotiating eligibility criteria for the mpox vaccine. CBOs collaborated with public health authorities to refine the vaccine eligibility frameworks, ensuring that they are responsive to the community’s needs. However, CBOs’ capacity to influence official guidelines was inconsistent across the country due to differences in institutional infrastructures, including formal and informal CBO–public health partnerships, health system structure, and history of HIV organizing. These institutional configurations shaped stakeholders’ capacity for engagement, affecting GBQM’s access to vaccines.
Public health agencies engaged with CBOs to define who should be prioritized in the vaccination campaign. One public health staffer explained that a representative from the National Advisory Committee on Immunization (NACI) self-enrolled in Ontario’s community mobilization table to seek feedback from community sources about the eligibility criteria: NACI […] came to the new community mobilization table twice, maybe three times, to bring questions about vaccination to the community. Like, what’s the community’s readiness for vaccination? How are they going to receive this information? What’s the best way to talk about it?
He added that public health actors were responsive to the community feedback: Public health provincially brought the draft criteria for who should get the vaccine to the community and then heard the feedback […], and they adopted the community’s language […]. Later, we realized […] that it was phrased in a way that was really not accessible to trans people […]. As soon as the community raised that […] they updated the language.
This response illustrates how CBOs problematized the initial proposals by public health authorities, contributing to a reconfiguration of vaccine eligibility criteria that better aligned with the lived realities of GBQM communities. It also suggests that public health actors collaboratively shaped and refined the criteria. Importantly, CBOs further problematized the criteria by advising public health authorities to focus less on identity and more on sexual practices. One CBO worker from Ontario articulated: We had to shift the messaging relatively early on […]. Because it doesn’t matter if you’re a gay man, it matters if you’re intimately connected to the sexual networks of these people.
In advocating for criteria grounded in sexual practices, CBOs played a mediating role in aligning their knowledge and interests with public health’s priority of vaccine delivery.
Meanwhile, in Quebec, a participant working in a CBO described how their organization informally collaborated with their local public health unit to inform the establishment of eligibility criteria: So we worked together again about inclusion criteria, like if it was okay. It all started from science […] and then they also changed the criteria two, three times, to include more people, and because they saw that nobody was … like it was not a massive [amount of] people that were trying to get a vaccine.
In this context, adaptations to eligibility criteria were driven by practical considerations, including low uptake, rather than direct advocacy from mobilization tables. This was echoed by a Quebec-based public health official, who explained that the limited initial vaccine supply prompted narrow eligibility criteria, restricting vaccines to individuals only after they had been exposed to mpox. Likewise, a CBO staff member from Quebec described how these criteria remained restrictive even as cases and vaccine supplies increased: Since we work with organizations that serve vulnerable populations […], we wanted to share information about vaccination, but at the same time, they didn’t necessarily tick all the boxes to get the vaccination, despite the real risk that individuals had.
In contrast, public health authorities in some jurisdictions followed a centralized institutional model in establishing eligibility criteria without CBO input. A community-based practitioner from Alberta articulated: I believe [the criteria] were all established out of [the province]. We certainly had no say in it […]. It pretty much all came directly out of [the provincial public health agency]. Here’s the criteria, here’s the number […]. They put it up on their webpage. They shared it with all of us through our [provincial] community council on HIV […]. So, we all got the same information, the same way, at the same time.
Reflecting on this centralized approach, one public health officer from Alberta acknowledged that the guidelines did not reflect community realities. While the criteria were “permissive enough,” there were some challenges with using identity categories rather than behaviors: “I didn’t love the language, they used GBMSM […], which we really disliked […]. We said, you know, talk about what the behaviors are.” These concerns led to a shift toward practice-based criteria, challenging the authority of the central public health unit by realigning response with the lived realities of affected communities.
In BC, CBOs were also not actively engaged by public health authorities, who relied on identity categories rather than sexual practices when establishing eligibility criteria. A participant working in a BC-based CBO described, “I think that they were a little bit too reliant on identity […] over practices or behaviors […], so that was a big failing.”
In the early days of the mpox outbreak, when Ontario and Quebec were the first provinces to report cases, public health agencies self-enrolled in community mobilization tables or activated partnerships with CBOs to establish vaccine eligibility criteria. However, the collaborative approaches appeared weaker in Western Canada, leading to the establishment of top-down criteria based on identity, which may have reinforced stigmatizing discourses marking GBQM communities as “risky.” In contrast, where CBOs actively exercised institutional agency, they problematized identity-based factors and advocated for behavior-based eligibility, better reflecting the realities of mpox exposure. This enabled the development of non-stigmatizing eligibility criteria, which were adapted and adopted by public health authorities.
Mobilizing Networks for Vaccine Delivery
CBOs and public health agencies coordinated and mobilized networks to ensure equitable access and promote uptake of mpox vaccines. Public health and CBOs mutually benefited from their relationship, with the former recognizing CBOs’ community knowledge and networks, while the latter needed public health resources. CBOs in many jurisdictions hosted vaccine clinics to make them available to GBQM communities. This required leveraging public health and community networks, including bathhouses and bars. However, in Alberta, vaccine access was more centralized, creating access barriers. These differences reflect how institutional structures influenced the provision of and access to mpox vaccines.
Some Ontario-based CBOs, especially in major urban centers, activated their pre-existing relationships with local public health units to assemble vaccination clinics in trusted spaces. For example, a CBO worker described how their non-clinic office was transformed into a vaccination site, and the local public health department mobilized resources to provide equitable vaccine access: I recognized the need to host a vaccine clinic once it was advised by [local public health] and Health Canada […]. We’re not a clinic at all. But this was like an ad hoc response to emergencies kind of situation, where we aligned with [local public health] and had public health nurses come in and administer vaccines to people.
In cases where CBOs also offered clinical services, these organizations coordinated with their local public health units to provide vaccines. A community-based practitioner from an Atlantic province shared: So, we ended up meeting with the medical officer of health […] and we had happened to end up talking about mpox. And it turns out that he had the file on that […]. And then we took on the role of actually giving any sort of vaccines and doing response in-house here in our clinical setting because we had been a mainstay in [city] for over 50 years.
In smaller provinces, community organizations leveraged their longstanding partnerships with public health to deliver vaccinations. In these contexts, vaccine provision relied on personal connections with public health institutions. A participant from one of the Territories explained how they coordinated with their local health unit to provide vaccines to their clinic: The chief medical officer […] that we were speaking directly with […] they were a lot more prompt, which was good. Because I think that they met us in what we felt to be like […] the urgency of setting up a vaccination clinic as soon as possible, as access can be challenging at the best of times […]. And at the end of the day, ultimately, other than them providing publicly available information and making that accessible, they also made sure that we had a supply of vaccines to distribute.
Public health personnel also recognized the vital role of CBOs and other organizations in bringing mpox vaccinations closer to the communities that needed them. A local public health officer in Ontario said, “We worked with the community, we also ran mobile clinics, directly in bathhouses, in nonprofits in the [gay] village, as well as we worked with some medical clinics who served the community.” A local public health officer in Quebec described similar interventions “in some bars and saunas.” These responses highlight how the interests of public health and CBOs to deliver vaccines aligned, prompting a collective response by gathering diverse actors (clinicians, vaccines, organizations, and clinics). In some cases, partnerships with CBOs enabled public health agencies to deliver vaccines locally. In other cases, health agencies leveraged their personal relationships with organizations, such as businesses, to make vaccines available in their venues. However, it should be noted that these successes often occurred in major urban centers with higher concentrations of CBOs and existing infrastructures.
CBOs played a crucial role connecting public health agencies to community-friendly venues, bringing vaccines where GBQM gather, including sex-on-premises and cruising venues. A public health staff member from BC articulated: We also delivered vaccines in partnership with community agencies where we would provide the vaccinators, the clinicians, by working through outreach in a variety of settings, sex-on-premises settings, like bathhouses, sex parties, and then outreach into places where we knew people were having sex in in public settings.
Recognizing the impact of community insights, an Ontario public health staffer commended the local health unit for expanding mpox vaccination availability through strategic partnerships with CBOs and diverse community settings: Like [local public health] did a really good job in response, where community told them to make their vaccination clinics low threshold. You know, they went to the bathhouses, they vaccinated the staff, they provided clinics at the bathhouses, they provided them in community organizations, they provided them in ethno-specific organizations.
While many public health units proactively facilitated vaccine access, inconsistencies were found. A clinician from Alberta expressed disappointment about public health’s failure to engage CBOs in vaccine delivery strategies, creating barriers to access: [The provincial health authority] decided there’s going to be one single place serving the entire region. So, like, literally, you had to come to the [facility] in [a major city] and that was the only place you can get the vaccine […], it wasn’t truly accessible.
Disparities between urban and non-urban locations were also evident in other provinces. A participant from a smaller town in Ontario described advising his clients to travel to Toronto to receive vaccinations: The first question, “I want my vaccine, I need my vaccine. Where can I get my vaccine?” To which I knew the answer that we don’t have them here […]. So, I said, “Are you going to Toronto for Pride?” “Yes, I am.” “Okay, get it there […]. Because if you’re gonna go here, you’re gonna have to wait.”
A CBO worker from Quebec also suggested that while vaccine delivery was significantly smoother in major urban centers, it was less efficient in other areas. They described encountering issues communicating with their local public health department office to gain access to vaccines: We needed to create linkages with public health directors just to obtain vaccines. So, this was the first step before being able to organize […] vaccination clinics.
They also noted the lack of community clinics: In the regions where we intervened, they didn’t have these kinds of community clinics. So, it was really a question of organizing vaccination clinics outside of safe spaces that these individuals frequented.
The provision of low-barrier and community-informed vaccination was successful due to strong partnerships between public health and CBOs. Mobilizing partnerships enabled CBOs to coordinate diverse actors, including public health, nurses, venues, communities, and infrastructure, to deliver vaccines in trusted spaces. However, in jurisdictions where such institutional partnerships were underdeveloped, support for equitable vaccine access failed to materialize, creating structural barriers and uneven uptake.
Discussion
We used IE and ANT frameworks to analyze the roles of CBOs, public health agencies, and clinical organizations during Canada’s response to the 2022 mpox outbreak. These institutions acted as relational assemblages, working together to enact collective agency. Our analysis mapped four interrelated institutional practices: assembling multisectoral networks, co-developing public health messaging, negotiating vaccine eligibility criteria, and mobilizing networks to ensure equitable vaccine delivery. CBOs played a mediating role in activating and reconfiguring longstanding partnerships developed over years of sexual health work with public health and clinical actors. These collaborations created response networks adapted for mpox. Previous research has shown that continuous partnerships between CBOs, public health, and other stakeholders, initially established to address infectious diseases, can support rapid, coordinated, and comprehensive responses to new public health emergencies (Cornelisse et al., 2023; Osborne et al., 2021). In our study, these networks were reactivated and adapted to translate community knowledge into action, improving the mpox response for GBQM communities (Cornelisse et al., 2023).
Insights from our analysis suggest that mpox response was built on lessons learned from COVID-19, which revealed longstanding structural challenges that undermine public health responses for marginalized communities (Cénat et al., 2023; Newman et al., 2025). Canada’s HIV institutional networks were tested during the COVID-19 pandemic, becoming a template for addressing emerging outbreaks, such as mpox (Munasinghe et al., 2024; Ryu et al., 2023). Pre-existing CBOs, public health, and clinical infrastructures adapted for rapid service delivery, vaccine administration, and targeted health messaging for COVID-19 enabled the rapid activation of networks to meet the demands of affected communities during mpox (Cornelisse et al., 2023). These interventions were likely more impactful due to the legitimacy and embeddedness of CBOs within GBQM communities, mediating the reduction of mpox transmissions among GBQM and the broader population (Xiu et al., 2025). However, our findings suggest that CBOs’ success relied on reallocating existing funding without additional resources, stretching their capacities to deliver effective sexual health care. This highlights the ongoing funding challenges faced by CBOs. Future pandemic preparedness should prioritize dedicated funding rather than relying on resource allocation.
The productive cross-sectoral institutional partnerships between CBOs, public health, clinical organizations, and other stakeholders in creating an effective mpox response in Canada align with results reported internationally (Biesty et al., 2024; Cornelisse et al., 2023; Garcia Iglesias et al., 2023; Kato et al., 2024) and locally (Tan et al., 2024). However, our study presented unique insights into how coordination was accomplished and how multisectoral stakeholders navigated challenges, and it provided a national perspective on models of collaboration across provinces. We showed how CBOs functioned as institutional mediators, problematizing the dominance of public health frameworks and practices by mobilizing their community expertise. Through ongoing negotiations, CBOs made their situated knowledge visible, contributing to the reconfiguration of public health’s response grounded in the lived realities of GBQM communities.
We further contributed to a more nuanced understanding of geography, the structures of public health systems, and the relational history between CBOs and public health, showing how these factors shaped the form and success of the response. For example, in Ontario, network responses were activated through clinical organizations that initiated a community mobilization table. However, in BC, public health actively enrolled CBOs into a coordinated response network, and fewer, more integrated regional public health divisions made coordination smoother. Importantly, while formal partnerships were established in Ontario and BC, Quebec relied more on direct personal relationships, which was also the case in smaller provinces and territories. By contrast, Alberta was characterized by a centralized approach that lacked formalized collaborations with CBOs. Although some localized relationships existed, the lack of formal consultations with CBOs created challenges for local public health practitioners in delivering culturally appropriate responses to GBQM communities in some parts of Alberta. No participants spoke about CBOs providing direct clinical care, and in Alberta, stigmatization of mpox by the media did not appear to affect the ability of CBOs, public health, and clinicians to deliver services. Instead, concerns about stigma prompted proactive efforts to minimize it.
Deploying ANT and IE provided a rich analysis of network formation, resource negotiation, and response coordination. The problematization of mpox as a community health concern was grounded in established partnerships in queer health and HIV advocacy among clinicians, public health, and CBOs. While clinical or public health actors initially problematized mpox, CBOs actively expanded and reconfigured this framing by mobilizing their partnerships and enrolling other stakeholders into the network. Problematization also involved CBOs challenging stigmatizing public health messaging, enabling them to co-produce mpox information, which was later formalized and circulated by public health agencies. The development of community-informed messaging led public health actors to recognize and institutionalize the expertise and authority of CBOs in the response. Previous research established that CBOs are trusted messengers of health information by marginalized groups (Chau et al., 2023). Therefore, public health agencies should further develop relationships with CBOs to enhance trust and improve health outcomes for vulnerable populations. This aligns with WHO guidance recommending collaboration with community networks and recognizing CBOs as essential partners in mpox outbreak preparedness and response (World Health Organization, 2004). However, despite attempts at avoiding stigmatizing messaging, some studies found that GBQM with lived mpox experience reported stigma from providers, suggesting that further efforts are needed to prevent healthcare-based stigma (A. K. J. Smith et al., 2024; Witzel et al., 2024).
Additionally, recognizing the importance of equitable and timely access to mpox vaccinations by CBOs, public health, and other stakeholders created the conditions for interessement, or the alignment of shared problems, such as vaccine inaccessibility and stigma, among different actors in the network. This shared problem enabled the development of formalized collaborations rooted in pre-existing relational and institutional ties. However, in some cases, where relational trust or formal mechanisms for collaborations were absent, institutional assemblages failed to materialize, limiting mobilization and coordination capacities.
Findings suggest that CBOs and public health had common interests in minimizing mpox transmission, addressing stigma, and ensuring access to culturally appropriate care, which likely enhanced response. These shared goals strengthened CBOs’ legitimacy as trustworthy health partners, an outcome of successful enrollment. This institutional legitimacy stemmed from decades of HIV organizing, positioning CBOs as essential partners in public health decision-making (Biesty et al., 2024; Cornelisse et al., 2023; Garcia Iglesias et al., 2023). Enrollment success depended on the quality of partnerships with public health authorities. CBOs were recognized by public health actors for their expertise and their embeddedness within GBQM communities. In some provinces, however, inconsistent collaboration between health authorities and CBOs influenced response effectiveness. This was especially evident in Alberta, where centralized decision-making and the failure to enroll CBOs undermined mpox intervention efficacy and created barriers to vaccine access. Finally, we emphasized how effective mobilization relied on coordinated actions. This included the collaborative delivery of vaccines through partnerships between public health units, nurses, community organizations, and trusted community venues to ensure uptake. By leading and coordinating mpox containment efforts, CBOs earned institutional legitimacy, highlighting the value of community leadership in public health crises.
This study has several limitations. First, data collection began in September 2023, nine months after mpox was declared a public health emergency by the Public Health Agency of Canada. Although this may have affected recall, it allowed for broader reflections. Data collection ended in March 2024, at least three months before another wave of mpox cases emerged in Canada. Nonetheless, a second phase was conducted in Quebec from February to March 2025, and those interviews were incorporated into this manuscript. Subsequent analyses will draw on these two streams of data collection. Second, participants were primarily from major urban centers, which limited the perspectives from rural areas. Further research should focus more on geographic inclusivity. Third, our analysis relied solely on the stakeholder interviews. While this provided a detailed account of institutional work, it did not fully capture how formal policy texts influenced the response. Integrating documentary analyses would help deepen the IE and ANT mapping. Finally, there was no evidence to indicate that CBOs provided direct clinical care beyond vaccine delivery. Future work could explore expanding their role as trusted community spaces for clinical services. Despite these limitations, a key strength is capturing insights from various stakeholders across most Canadian provinces and territories.
Conclusion
Our study emphasized the role of CBOs in coordinating a community-informed response to the 2022 mpox outbreak in Canada that mainly affected GBQM communities. Across jurisdictions, CBOs mobilized their longstanding networks built over decades of HIV work to coordinate effective interventions. Several lessons emerge from these findings that can inform future pandemic preparedness affecting GBQM and potentially other marginalized communities. First, building and maintaining strong relationships before a crisis is crucial. Second, sustained investment in these partnerships during non-emergency periods is necessary for ensuring rapid coordination during future outbreaks. Finally, engaging CBOs early should be prioritized during health outbreaks, which can lead to more effective outcomes. Adopting these lessons could ensure that future pandemic responses are grounded in the experiences and needs of GBQM and other marginalized communities, promoting health equity.
Footnotes
Acknowledgements
The authors wish to thank the research participants and the study community partners.
Ethical Considerations
Our study was approved by the University of Toronto Human Research Ethics Board (Protocol #44777) and the University of Montreal Research Ethics Board (Protocol #2023-4970). All participants provided written informed consent prior to enrollment in the study.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Canadian Institutes of Health Research (grant number 495174).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.