Examining factors impacting acceptance of COVID-19 countermeasures among structurally marginalised Canadians

ABSTRACT The COVID-19 pandemic highlighted and exacerbated inequities in health for structurally marginalised Canadians. Their location on society's hierarchies constrained their ability to access healthcare and follow recommended health behaviours. The aim of this article is to identify, from the perspective of marginalised populations, factors influencing the acceptance or rejection of COVID-19 countermeasures by structurally marginalised Canadians. Interviews were conducted with Canadians 18 + who identified as Black (n = 8), First Nations, Métis, or Inuit (n = 7) and low-income (<40,000 annual household income) (n = 8) between August and December 2021. Measures were said to impact well-being and interfere with revenue generating activities. Longstanding unfavourable living and environmental conditions as they relate to structural marginalisation was said to fuel anger toward the government and lead to a greater reluctance to accept countermeasures. Participants described concerns about government decisions being made without considering their unique contexts, or knowledge of the experiences of the population for whom these decisions were being made. Effective proactive action from government is important to foster trust with marginalised populations to support acceptance of health information and address growing inequities. Action that demonstrates government competence and commitment to the interests of marginalised populations is critical.


Introduction
Canada is a culturally diverse and inclusive country, with a population comprised of 22% foreignborn individuals, 22% visible-minority citizens, 23% French-speakers, and 5% Indigenous Peoples (Statistics Canada, 2017a, 2022).Despite celebrating diversity, many individuals identifying as diverse in Canada are marginalised members of society, with poor access to resources and disproportionate rates of illness and poorer health outcomes.For example, Indigenous Peoples experience inadequate infrastructure funding, and discriminatory policies that limit their access to loans or mortgages as compared to non-Indigenous people in Canada (Government of Canada, 2018;Statistics Canada, 2017b).Additionally, working poverty is reportedly higher for Canadians without a high school degree, First Nations living off reserve, newcomers to Canada, and racial minorities (Government of Canada, 2018); moreover, unemployed adults and those of lower income or lower education level are more likely to experience disproportionate levels of chronic diseases, as compared to their employed or of higher socioeconomic status counterparts (Government of Canada, 2018).Structurally marginalised persons report reduced access to health services, perpetuation and exacerbation of pre-existing health conditions, poor housing conditions, and lower earning power (Bailey et al., 2017;Berkowitz et al., 2021;Braithwaite & Warren, 2020;Cupertino et al., 2020;Kovich, 2020).
One way in which Canadians face health inequities and adversity is through marginalisation.The Ontario Marginalisation Index (ON-Marg) defines marginalisation as 'the process by which individuals and groups are prevented from fully participating in society' (Ontario Community Health Profiles Partnership (OCHPP), 2023).Marginalisation can be conceptualised through four dimensions: households and dwellings, material resources, age and labour force, and immigration and visible minorities (OCHPP, 2022).Marginalised populations can thereby experience various barriers to accessing meaningful employment, adequate housing, education, recreation, clean water, health services and other social determinants of health (OCHPP, 2023;Public Health Ontario, 2018).The concept of structural marginalisation considers how social, economic, and political hierarchies and policies produce and pattern negative health outcomes (Bourgois & Hart, 2011;Holmes, 2011).More recently, researchers have opined that people are structurally marginalised when their location in their society's hierarchies (such as socioeconomic, racial, cultural) and their institutional status (such as immigration status, labour force participation) constrain their ability to access healthcare and pursue healthy lifestyles (Bourgois et al., 2017;Lasser et al., 2006;Pollock et al., 2011;Wang & Hu, 2013).Consequently, structurally marginalised individuals are more likely to live in neighbourhoods with fewer resources, less government investment, have a greater likelihood of exposure to harmful pollutants and stressful circumstances (Williams & Collins, 1974), and to experience greater health inequities compared to individuals not experiencing structural marginalisation (Diez Roux & Mair, 2010).
Many groups of individuals in Canada may be considered marginalised; including but not limited to, people of lower socioeconomic standing, minority race, gender or sexual orientation, religion, and experiencing displacement, conflict, or disability (Government of Canada, 2020).Though disparities and inequities exist among different groups of people, structurally marginalised people have been found to have a lower life expectancy, higher rates of mental illness, poorer health, and higher rates of preventable death (Government of Canada, 2018).Central to the present work are experiences of structural marginalisation among individuals who identify as First Nations, Metis, or Inuit, Black, or low income.For example, Indigenous Peoples in Canada have historically been impacted by colonialism, forced displacement, cultural genocide, oppression, and discrimination (Mosby & Swidrovich, 2021).Structural forces in the form of laws and legislation, such as the Indian Act, have played a role in oppression and marginalisation of this population subgroup (Erin, 2023).The structural marginalisation of Indigenous population is prevalent to this day, with Indigenous Peoples experiencing housing insecurity (homelessness or overcrowding), disproportionately having higher levels of incarceration than the general population, as well as experiencing barriers to adequate health care, affordable healthy food, and clean water supply (Mosby & Swidrovich, 2021).Similarly, to this day, Black people living in Canada are subjugated to forms of prejudice, discrimination, and hatred due to unconscious bias, hate crimes, and violence (Government of Canada, 2023).A consequence of this, among many others, is the overrepresentation of Black individuals in the criminal justice system in Canada, which has yet to be resolved (Government of Canada, 2023).Lastly, Canada currently faces marginalisation related to low-income status, with reports estimating a minimum of 35,000 individuals experiencing homelessness on any given night (Homeless Hub, 2023).Evidence of structural marginalisation among these populations was highlighted and exacerbated by COVID-19.

COVID-19 and marginalised populations
As a response to the COVID-19 pandemic, Canada adopted several public health measures, including social distancing, self-isolation, travel bans and lockdowns, at different levels of governance, and provided social and financial supports to those eligible (Canadian Public Health Association, 2021;Urrutia et al., 2021).To combat the viral threat, Canada's response also involved vaccination programs, with the first two COVID-19 vaccines, Pfizer-BioNTech and Moderna Spikevax, being authorised in September of 2021 (Government of Canada, 2021).
Despite great efforts, the COVID-19 pandemic exacerbated inequities in health (Cooper, 2021;Public Health Agency of Canada, 2021), continues to have a disproportionate impact on structurally marginalised populations in Canada (i.e.Indigenous peoples, low-income people, and visible minorities), with higher reported risk of COVID-19 infection and higher rates of morbidity and mortality compared to the general population (St-Denis, 2020;Etowa et al., 2020).More specifically, across different racialized populations, Black Canadians were found to have the highest age-standardised COVID-19 mortality rate (49 deaths per 100,000 population), as compared to non-racialized and non-Indigenous population (Gupta & Aitken, 2022).The risk of dying from COVID-19 was further increased for Black Canadians who also identified as low-income (Gupta & Aitken, 2022).These data are consistent with those reported for ethnic minorities outside of Canada (Greenaway et al., 2020).
The disproportionate health impact of COVID-19 on subpopulations in Canada can be explained by structural marginalisation, including crowded housing, poorer access to healthcare, and working as front-line employees (Chiodo et al., 2021;van Ingen et al., 2021).Measures to mitigate COVID-19 spread worked under the assumption that all Canadians had equal capacity to follow recommendations, such as stay-at-home orders, social distancing, and isolating when ill.However, following countermeasures such as 'social distancing' or 'self-isolation' was not feasible for many marginalised individuals often in low-wage roles, who might be experiencing homelessness, or in general did not have the resources to follow mandates (Bresge, 2020).This assumption may have led to a lack of tailored countermeasure campaigns, which instead had unintended negative impacts on the lives of marginalised individuals.Measures also worked under the assumption that the public trusted the government and would therefore accept government recommendations.However, structurally marginalised individuals may be less likely to trust health institutions (Hermesh Id et al., 2020), which can help to explain why marginalised individuals may be less likely to follow measures (Aw et al., 2021;Block et al., 2020;Fridman et al., 2020;Van Scoy et al., 2021).For example, a survey conducted in 2021 found that Black Canadians had lower vaccination rates than the Canadian average (Innovative Research Group, 2021).Indeed, marginalised individuals were found to have hesitations regarding measures put in place across the country to contain the spread of COVID-19 (Brankston et al., 2021), placing them at further risk of infection.It is crucial that measures put in place by public health moving forward are informed by research documenting the structural factors shaping hesitancy to trust and accept government interventions.
The aim of this research was to identify, from the perspective of marginalised populations, factors influencing the acceptance or rejection of COVID-19 countermeasures by structurally marginalised Canadians; specifically, individuals who identify as Black, low-income, First Nations, Metis or Inuit (FNMI) (Government of Canada, 2022c).Although at the time of writing COVID-19 countermeasures have largely been lifted in Canada (Government of Canada, 2022a;Office of the Premier, 2022), this work highlights ways that we might practice making future public health measures work for all Canadians, and particularly those at greatest risk.

Methods
Qualitative interviews were conducted as part of a larger project exploring the role of trust in Canadian's acceptance of COVID-19 countermeasures.The data presented herein stemmed from interviews conducted with people who self-identified as Black and First Nations, Métis or Inuit, or low income.Interviews provided a mechanism for exploring the unique perspectives of participants, including results discussed herein regarding the role of structural marginalisation in the acceptance or rejection of COVID-19 countermeasures.Data representing the perspectives of other subgroups in larger study are presented elsewhere (Koshy et al., 2023;Herati et al., 2023).

Participant recruitment
Participants (N = 23) were purposely recruited via Leger, a large research marketing firm that has a panel of over 400,000 members.Leger recruited a purposive sample of Canadians over the age of 18 who identified as Black (n = 8), First Nations, Métis, or Inuit (n = 7) and low-income (<40,000 annual household income) (n = 8) via their panel.Recruitment occurred between August and December 2021, coinciding with the period of data collection.Leger recruited potential participants and provided contact information to the research team to obtain consent to participate and schedule interviews.All participants received an information letter that outlined the aim of the research in advance of participation.Interviews were roughly one hour in length, at a time convenient for participants.Participants received $75 CAD in remuneration to compensate for their time.

Data collection
We adopted an interview-based approach for this study to understand the logic behind decisions to accept or reject measures.More specifically, we used a convergent interviewing technique (Dick, 2017) which is characterised by a structured process and unstructured content.Interviews were embedded within a process of design and analysis so that subsequent interviews could build on reflective opportunities from former interviews.Recruitment and data collection continued until we reached saturation of themes, whereby no new themes were emerging from the data (Braun & Clarke, 2021;Charmaz, 2014).Memos served as a record of the researcher's initial thoughts on each interview for the purpose of communicating the analytic progress.Data were collected by three researchers: one per population of focus.There was racial congruence with the interviewer and participants from the Black Canadian subgroup but not for the FNMI interviews, nor were interviews conducted by low-income researchers.Interviews were conducted by telephone or via a virtual platform (Cisco Webex, Zoom or Microsoft Teams), depending on the participant's choice and were audio recorded and human-transcribed by a professional agency abiding by a confidentiality agreement.Participants provided written or oral consent for the audio recording and the use of quotes in publications.Codes instead of names have been used to maintain anonymity.Ethics approval was obtained from the University of Waterloo Research Ethics Board (#42486).
To meet the aim of the present article, participants were asked questions related to their perceptions of, and compliance with, government measures to reduce the spread of COVID-19.For example, participants were asked to discuss how COVID-19 has impacted their lives; what measures they followed or did not and rationale behind their actions; how their identity (as Black, FMNI or low income) shaped their experiences during COVID-19 (if at all) and acceptance of measures.A final interview guide modified based on early analyses is presented in Appendix 1.

Data analysis
Data analysis began with a bottom-up or inductive thematic analysis of interview transcripts using the software NVivo.Initial coding required researchers to work systematically through the entire dataset, giving full and equal attention to every data point.For this exploratory phase, we were open to coding all data before determining what was or was not significant to the analysis (Braun & Clarke, 2006).In vivo codes (the participants' own words) were used to help preserve participants' meanings of their views and actions.We then approached the data using focused coding involved taking earlier codes that continually reappeared and using them to organise large amounts of data into meaningful themes.During focused coding, the analyst built and clarified themes relevant to the dataset; what it covered that was relevant to the aim.Building on themes in the data, the final stage of coding involved consideration of the data through a lens of marginalisation.We asked of the data, how might we understand resistance to accept measures as they relate to historical and ongoing marginalisation for these populations?Inductive coding was completed by one of the three interviewers solely on the data for which they were responsible.Subsequent stages of analysis were conducted by a single analyst who was responsible for Black Canadian interviews.To manage the researchers' perspectives and expectations in the analytical process, our team with diversity in social identities met weekly to discuss ongoing analyses and themes (initial and focused coding) for a period of four months.At least two members of the team reviewed transcripts, and during the interview process, memos were shared with the larger team.All coding for the interviews were completed using NVIVO coding software.

Results
The following section is organised into two parts; factors related to low acceptance of countermeasures and low acceptance as it relates to marginalisation.Participant codes are used in place of names and are in Table 1 alongside participant province of residence, age range, and gender.

Factors related to low acceptance of countermeasures
Though most participants were accepting, measures were described as impacting one's livelihood and their right to bodily autonomy.Lockdowns, capacity limits and limits on social gatherings were described as challenging to accept.
When they had closed a lot of things like the restaurants, the gyms and all of that, I wasn't a fan of those restrictions.Reason being is because we were already in the house so much and so we kind of needed to at least breathe a bit.And I felt like being in the house all the time felt a bit suffocating, so I was not on board with those restrictions, and I was kind of unhappy with the level it got to.Because it was extremely limiting us from actually living.(BC4) A participant in the low-income interviews discussed the harms of lockdown in relation to financial security.
I'm following all the protocols, and we do at work as well, the masks and the gloves, and the shields and stuff on the counter … but when that first announcement of lockdown came, I'm not going to lie, I was pretty scared thinking okay, I don't have a lot of savings, how am I going to survive staying indoors?(LI2) Participants' refusal of measures was explaining in relation to criticisms of the government's lack of transparency in communicating the severity of the virus.They acknowledged the novelty and uncertainty of COVID-19 but faulted the government for presenting information as facts and not acknowledging the limitations of their knowledge, which negatively impacted their trust in the government.Participants inferred that if the government could not acknowledge those limitations, they might also not acknowledge other pandemic misinformation.
Well, I would really love to see a doctor or a research scientist or whoever, actually come on the public media, TV or a paper and say, 'You know what?This is new.I know I'm a doctor.I know I'm supposed to know all this, but I really don't.We are experiencing something brand new that we've never had before, and not only us, but the world is troubled by this, but let's work together.I apologize that I gave you not sound advice.'I would love to hear that, for someone in charge apologizing they made a mistake.That would make that person more trustworthy instead of always ignoring their changed stories every single day … .whenthey made a mistake, they were never humble enough to admit it and say, Participants cited conflicting pandemic messaging between the provincial, federal and at times municipal governments as a reason for not fully accepting countermeasures.They discussed examples such as the lifting of some countermeasures at the federal level while some provinces did the opposite, which created uncertainty regarding the countermeasures that should be accepted, and casted doubt on which level of government was giving the correct information.
Well, at the beginning, it was a little touch and go.I mean, like the prime minister would say one thing, the premier would say another thing.And the mayor, he would say something else.I don't think all the people involved were really talking to each other.… They would say the wrong message and not really paying attention to what the other person was going to say.I was just paying attention to what was happening in my proximity.(LI3) I'd say people seem to have ignored what's being said at federal level, because they just thought whichever province they reside in says, is what they should follow.So, if it's Alberta, for example saying we're going to work towards the pandemic and they're saying things like, we no longer even have to wear masks in schools, then people are like okay, this is sensible because the Alberta Health Minister or the Alberta Head doctor said it.So, they accept things at face value without really thinking about the wider implications of what's been said by, maybe, the federal top doctors.(BC2)

Low acceptance as it relates to marginalisation
Participants discussed feeling excluded in the development of provincial and federal countermeasure policies, which negatively impacted their acceptance of these policies.They opined that the policies were going to impact Canadians (e.g.their finances), yet their opinions were not considered, leading to their general unacceptance of some countermeasures.
I have none (no trust) in Justin Trudeau's party, and I have none (no trust) in Doug Ford's party.I don't.Well, Justin Trudeau just gave down $4 billion dollars to implement a vaccine passport.A billion [expletive]taxpayer's dollars!Where did we get the say?We didn't.It was just decided for us and that was a good thing for us?A billion[expletive] dollars is not something to screw around with. (FNMI7) The following quote speaks to the impact of racism on the decision-making of a participants who identified as FNMI.This participant argues that they should not be forced to follow rules imposed by the government (defiance of the COVID-19 vaccines), given that they are in unceded territory, and thus, not within Canadian jurisdiction.Some participants also expressed criticism regarding the government's lateness or reluctance in taking some decisions and actions during the pandemic.This added to their reluctance to fully accept the countermeasure policies.A lack of trust resulting from perceived delays in decision-making that benefited the interest of the government and for-profit companies can be understood to influence how supportive the participants in our study were of the measures.
Overall it [government relations with population] wasn't overly great, not even just with COVID, but with our public sector … .justhis [Premier] plain stubbornness and complete ignorance of the wellbeing of the general public.So, they were holding off to save themselves rather than to actually benefit the general public by allowing the services to get back to normal.(LI7) Particularly, the quote below speaks to criticism regarding whose interests were being served by measures, with concerns that the government were putting themselves ahead of Canadians.
It's been difficult to trust the government in Alberta when it has not seemed like they've been prioritising the collective health of the public, it's definitely been more focused on the profit of pharmaceutical industry as well as businesses.At this point, the Alberta government doesn't seem to really care about the health of individuals, instead it seems more focused on, let's say, profits.(BC2) Participants indicated that the development of policy did not consider their individual needs.Their unique living situations, for example, were cited as a factor limiting their ability to accept the pandemic countermeasures.For example, FMNI4 discussed the inability to follow measures (like distancing or bubbles) given living conditions.
There's not much access to resources here, and there's not enough housing.I mean, you can't even get a house because you're not employed and all that stuff.I think the issue is when one person gets it and they're going back to a house of 10-15 people, everyone gets it.So, it's not like the communities aren't taking it (countermeasures) seriously, because I know that the ones that I've been to, have.(FNMI4) Participants felt that if the government considered their contexts, they would either amend some of the measures, or ensure that living environments were conducive for people to comply with the measures.
I would encourage that governments in Canada have interviews be conducted with Black Canadians that have experienced COVID-19 themselves, or also those who are caregivers.(…) It would also be a good idea to use surveys or do focus groups.And then from those focus groups, try to find a variety of different age groups and people from different socioeconomic backgrounds and what not.(BC2) The following provides an example of structural marginalisation as a barrier to countermeasure acceptance.In this case, overcrowding experienced by Indigenous communities as a barrier to social distancing.
The places where the outbreaks are the highest right now are in places like Iqaluit, where you have five in a three-bedroom, small house, no basement.You've got five families.There's one grocery store, one small grocery store there in that community.And you've got nurses, mostly non-Inuit.They're flying in and out on government expense.They're the ones that are bringing it in.They might have private housing maybe or two nurses are living together but for the most part, the entire community is living in very small quarters where they cannot (social) distance at all.(FNMI6) The following quote showcases how living conditions, in this case a small apartment, meant that the acceptance of measures led to mental health risks.
I couldn't hang out now I'm in an apartment.If I had been in my own house, I could have been going out, at least in the backyard … One day I was so scared that I called my girlfriend and I said, I feel like jumping off the balcony.She told me to have breakfast.It's funny now, but it wasn't funny at the time.(LI5) Participants inferred that their (non)acceptance of the pandemic countermeasures was linked to their unique circumstances including their living conditions, geographical location, and socioeconomic status.Other participants recounted historical subjugation and oppression as examples of why they will not wholly accept every countermeasure (such as vaccination).
We [Black Canadians] as a whole, we've been suffering for hundreds of years.Though now there's some change, but it's still not the way it should be or probably will ever be.But when it comes to certain things like the pandemic countermeasures, someone can't put themselves in your shoes if they don't know what you're experiencing and going through.So, the message from a racialized person would be accepted by racialized communities.It doesn't matter their skin colour because they have felt what other racialized communities have felt.(BC3) The participant above, who identified as Black, discussed the importance of representation in government and oversight of measures.In this case, acceptance of measures was less about the message and more about who was communicating it.Similarly, on behalf of low-income Canadians, one participant spoke of the failure of social systems in meeting the needs of citizens, suggesting that the experience of failure in government programs in the past would naturally play a role in the future acceptance of government initiatives.
So, this isn't a situation that I've been in, but I just feel like, if I was on Ontario Works or whatever, and the system failed me as far as being able to get money or find housing or whatever, then maybe I would be disgruntled enough to think, 'Okay, well, nobody's going to help me.I'm not going to listen to any of them, because they don't have my best interests at heart', or whatever.(LI2)

Discussion
The extent of acceptance of COVID-19 countermeasures differs across individuals, or groups of individuals, within the same population.The aim of this article was to identify, from the perspective of marginalised populations, factors influencing the acceptance or rejection of COVID-19 countermeasures by structurally marginalised Canadians via interviews with First Nations, Métis or Inuit Peoples, Black Canadians, or low-income Canadians.
Participants unaccepting of measures spoke of lockdowns and associated isolation as impacting their well-being; a finding that is consistent with criticisms of countermeasures at large.For example, the Organisation for Economic Co-operation and Development (OECD, 2020) data suggest that social distancing and mandatory confinement policies greatly impacted the ability of individuals to maintain their social life (i.e.being away from friends and family) beyond those within their household.While not diminishing the role of isolation in managing the spread of infectious disease, researchers have weighed the psychological risks, particularly for those already marginalised, as it relates to quarantining (Brooks et al., 2020).For instance, the separation of loved ones, loss of freedom, uncertainty over disease status, boredom, and in extreme cases even leading to suicide, as consequences of implementing a quarantine (Brooks et al., 2020), may be a more probable outcome for marginalised Canadians already experiencing disparities and inequities.
The ability to continue with or seek revenue generating activities as it relates to countermeasure acceptance was another concern among participants.This aligns with findings from previous literature, which states how COVID-19 countermeasures, namely, social distancing, stores closing, transportation, restaurants, hotels, and other service industries, will impact low-paid and insecure workers the most, as compared to the general population (Kantamneni, 2020;Lund, 2021;Newman Id et al., 2022;OECD, 2020).The need to work and fulfil their financial needs has indeed been cited as a barrier to social distancing (Bodas & Peleg, 2020;Jay et al., 2020;Weill et al., 2020).This was particularly so in low-income neighbourhoods; and indeed, individuals living in wealthier neighbourhoods increased their days at home substantially more compared to those from less affluent neighbourhoods (Jay et al., 2020).This finding is not surprising given that marginalised individuals are more likely to be constrained in their capacity to work from home, take paid or unpaid time off work, or draw on savings to meet basic needs (Atchison et al., 2021;Orhun & Palazzolo, 2019).
Across all three subgroups, responses to pandemic countermeasures were dependent on the extent to which they perceived the source of the countermeasure information as trustworthy, legitimate, or fair.For some, conflicting messaging from the federal and provincial governments impacted their perception of government competence in managing the COVID-19 pandemic, which in turn challenged their level of countermeasure acceptance.Within Canada, provinces often dictate the implementation and administration of health-related policies under federal guidance.In addition, the seeming lack of transparency in pandemic messaging from government institutions elicited doubts about the intentions of the government and consequently led to doubts about the efficacy of some countermeasures.Consistent with other work, concerns regarding whose interests were being served in the development of measures was also found to erode trust or prevent trust from developing or being repaired.Indeed, trust in institutions of governance is important for the acceptance of government policies (Algan & Cahuc, 2014;Meyer et al., 2013;Ward et al., 2016).For example, institutional trust is linked with health behaviours such as vaccine acceptance (Attwell et al., 2017;Marlow et al., 2007;Wang et al., 2021) and adherence to COVID-19 countermeasures (Gotanda et al., 2021;Han et al., 2023;Shanka & Menebo, 2022).Both the governments' competence and care for citizens were called into question; the first related to inconsistent messaging, and the latter related to questions of interests being served.Trust in the government is driven by both care and competence, where trust is influenced by the government's values and ability to respond to the needs of all citizens and to manage all aspects of uncertainty, including social, economic, and political situations (Murtin et al., 2018).
Living and environmental conditions also emerged from the data as an important factor related to the acceptance of measures.This was most notable when described in relation to living conditions for participants who identify as FMNI.Statistics Canada reports that in 2016, an estimated 18.3% of the FNMI population were living in housing that was considered not suitable for the number of people in residence (Statistics Canada, 2017b).This physical inability to observe the required social distance from fellow residents is seen as a major hindrance to accepting the COVID-19 countermeasures for participants that identified as FMNI.Relatedly, there was a general perception presented that the longstanding unfavourable living and environmental conditions that made acceptance of measures a challenge relate to structural marginalisation, which in turn fuelled anger toward the government and a greater reluctance to accept countermeasures.Some of this perception may be explained through consideration of the collective trauma of marginalised populations in Canada and systems of oppression.We operationalise collective trauma to be a cataclysmic event(s) that affects not only direct victims, but society as a whole (such as the study sample), and whose effects can transcend from one generation to the other.According to Hirschberger (2018), it can transform the way survivors and future generations perceive the world and understand the relationship between their group and other groups, even people who are unrelated to the initial victimisation (Hirschberger, 2018).Although we did not assess participants' experiences of trauma, racism, or oppression, it may be that some participants have such experiences, perhaps from collective historical trauma which spans multiple generations, and may have led to a reluctance or hesitancy to believe and accept government policies, and particularly health policies (Mohatt et al., 2014).Thus, this perception that the government failed to consider and ameliorate their circumstances may have led to not fully accepting the countermeasure directives during the pandemic.
The (non)acceptance of the COVID-19 countermeasures is also related to the notion of transactional trust.The transactional attribute of trust was explained by Bornstein and Tomkins (2015) as a relational construct that is characterised by the trustor's willingness to be vulnerable to a trusteeon the condition of a mutual 'give and take' relationship.For example, one participant questioned why they should follow government directives when it seems the government is not listening to them.Another participant complained of overcrowded living conditions of residents in the community, while visiting health professionals had better accommodation.These examples speak to how their transactional trust is linked to their acceptance of the COVID-19 countermeasures, as well as linked to their structural marginalisation.Marginalised groups such as Indigenous Peoples and racialized groups, were being asked to follow government measures while their material resources, largely controlled by the government, leave them in a place of greater risk of poverty, overcrowded housing, poorly regulated care homes, and vulnerability to COVID-19 infection (Cooper, 2021).Our participants described government (in)action and policy as not reflecting consideration of the inequities and social exclusion experienced by low-income, FNMI and Black Canadians.Our data suggest that participants were not fully accepting of government directives if they did not perceive anything to be gained in return.To foster trust, measures to consider the structural inequities experienced by marginalised groups would involve listening to the needs of these populations and ensuring decisions are made with individuals representing these populations at the table.
Additionally, participants described concerns about government decisions being made without considering the unique contexts, or knowledge of the experiences of the population for whom these decisions were being made.This exclusion and inadequate attention given to their unique issues may have come up due to the under-representation of marginalised Canadians in provincial and federal government.For instance, visible minority candidates remain significantly under-represented considering that in 2021, visible minority groups represented just 18.2% of all the candidates from the six main parties in Canada (Black & Grifth, 2022).Most marginalised groups are frequently excluded from decision-making, public institutions, basic services, and even citizenship (Government of Canada, 2022b).It has been shown that systemic racism, as well as mistreatment and discrimination of racialized communities within the health system, leads to a significant decrease in trust from these communities in the health care system and other institutions (i.e.government) (Public Health Agency of Canada, 2021).Research supports the need for greater meaningful engagement with community leaders to learn how Canadian social institutions might work to be more trustworthy and work with, and for, the communities they serve.

Implications
Our data demonstrate that longstanding structural marginalisation fuels anger toward the government and leads to a greater reluctance to follow government health recommendations.As such, the acceptance of government interventions moving forward will require listening to the needs of these populations and ensuring that their interests are heard and acted upon.This may involve greater transparency on the part of government to acknowledge their faults and limitations in knowledge, and to be accountable to actions that aim to redress ongoing inequities stemming from systems of oppression.The data also suggest a need for greater representation of marginalised subgroups and people who understand the unique contexts of marginalised Canadians among decision-makers developing public health interventions.This may involve creating policies that ensure greater diversity in representation among leadership and individuals making decisions for a diverse population.

Limitations
While we present data on three marginalised groups in Canada, we acknowledge that resistance to accept countermeasures may have occurred across many other population groups beyond those represented in this study.Our recruitment via Leger limited us from obtaining perspectives of marginalised groups of individuals based on language (non-English or French speaking), those with the inability to be recruited or participate due to literacy or access to technology, or from Indigenous Peoples living on reserve.Furthermore, in this study we did not explore the intersectionality of multiple demographic characteristics for our participants (e.g. both Black and low-income), which may create unique challenges and barriers impacting one's ability to comply or accept COVID-19 countermeasures.We were also unable to obtain representation from all provinces and territories.Lastly, while there was racial congruence with the interviewer and the interviewee for our interviews with Black Canadians, this was not the case for FMNI individuals or those identifying as low income.We acknowledge this is the limitation in both the collection, analysis, and interpretation of data.Though our diverse team did meet regularly to discuss interpretation of our data from various social positions, our team will prioritise representation of marginalised populations, who understand the unique contexts of these communities in Canada, in future research.

Conclusion
The aim of our research was to identify, from the perspective of marginalised populations, the factors that played a role in the rejection of COVID-19 countermeasures by structurally marginalised Canadians.Our data identify that the rejection of measures relates to historical and ongoing experiences of marginalisation in Canada.Participants described concerns of government decisions being made without considering their unique contexts, or knowledge of the experiences of the populations for whom these decisions were being made.Our data suggest that decision-makers need to engage members of marginalised sub-groups and facilitate greater representation of people who understand the unique contexts of marginalised Canadians among decision-makers when developing public health initiatives.Ultimately, this may help to foster support for government intervention in communities that have been marginalised.Our insights lend support for the notion that government competency and demonstrated commitment to the interests of marginalised populations is critical to mitigate the unintended harms of policies that put these subgroups of Canadians at a higher risk of morbidity and mortality compared to the rest of the population.
'You know what, I'm sorry.(FNMI2) I feel like the government is not necessarily working against people, but I think they have an obligation to tell the community, society, what they need to know and what they want to hear.Not necessarily actual facts … it's like they [government] mask information certain ways, certain things they say, messages … kind of like smoke and mirrors.Just like you're talking about one thing to avoid another thing.(BC3) And then the inconsistencies with every bit of information that's being thrown out from every direction, constant changes.Constant backtracking.No real information to back most of it up.Again, the consistent changes for what information there was seemed to not add up.(LI7) I don't believe the government.No.You know the pandemic (is) not going away, and you're not telling people that.You're letting it open a little bit to see how far it goes.The numbers are rising and I'm watching it.It's not going away.How about you own up and tell people it's not going away?So, we're going to have to find ways to deal with it.(FNMI6)More specifically, the participant below spoke to the importance of government connecting with the public, and for leaders to show humility and transparency.So, I think politicians are lacking that and even health officials when they're making statements, it's very polished.It's almost drone-Like, catatonic.They don't speak from the gut, and that kind of causes you to … I don't trust that.When you're just stating the facts and droning on and on and on about it, I'd rather you talk to me like we're sitting down having dinner or something.Tell me what your shortfalls are as well as what your strengths are.(FNMI3)
So, [not receiving] the booster would be out of defiance.It's up to me.It's not up to you whether I get it.It's I don't want to put it on a piece of paper and hand it to border security going across the border.It's not right.It's not my border.(…) That's the Canadian border.It's not my border.So, I have different views on some things.-55-64, Woman, FNMI6