Understanding Mpox Knowledge, Communication, and Care Engagement Among Black and Latino Gay and Bisexual Men

Abstract

The monkeypox (Mpox) disproportionately impacted gay and bisexual men (GBM), particularly Black and Latino communities, yet limited research has examined how these populations understood and navigated Mpox-related information and care during the outbreak. This qualitative study explored health communication, trust, and structural factors influencing Mpox knowledge and health care engagement among Black and Latino GBM. Between November 2023 and May 2024, we conducted 30 semi-structured interviews with Black and Latino GBM recruited from a clinic-based sample in San Diego, California. Interviews explored participants’ Mpox knowledge, information sources, communication practices, and health care experiences. Data were analyzed using a rapid qualitative analysis approach informed by inductive and deductive coding strategies. Participants described limited and evolving knowledge of Mpox, with information obtained primarily through social media, peer networks, and news media. Mpox messaging was frequently perceived as stigmatizing and identity-based, shaping perceptions of susceptibility and contributing to concerns about discrimination. Peer networks emerged as critical sources of information exchange, normalization, and support related to prevention and care. Participants reported stronger engagement in care and vaccine uptake when interacting with providers perceived as affirming, trustworthy, and knowledgeable about LGBTQ+ health. Limited provider competency in LGBTQ+ care undermined trust and willingness to engage health care systems. Structural inequities, including racism, stigma, and barriers to health care access, further shaped participants’ experiences with Mpox prevention. Findings underscore the importance of culturally responsive public health communication, affirming clinical care, and community-informed strategies that leverage peer networks to support equitable Mpox prevention and health care engagement among Black and Latino GBM.

Introduction

The monkeypox (Mpox) outbreak in the US emerged in May 2022 with 68–75% of reported cases affecting white gay and bisexual men (GBM).^1,2 Over time, the proportion of cases decreased among white GBM to 24–38% and increased among Black (21–47%) and Latino (23–34%) GBM.^1,2 While the factors underlying this shift remain unclear, the trajectory of Mpox parallels that of HIV, which initially predominantly affected white GBM but now disproportionately impacts Black and Latino GBM.^1,2

Significant overlaps among HIV, Mpox, substance use, and other sexually transmitted infections (STIs) exist. Notably, between May and July 2022, 61% of individuals diagnosed with Mpox had either HIV (38%) or a recent STI.² People with HIV (PWH) with unsuppressed viral loads or low CD4 counts were more likely to experience severe Mpox outcomes.^3–9 In GBM, sexualized substance use increases Mpox transmission risk behaviors.^1,7

A disproportionate share of the two available Mpox vaccines were administered to white individuals,¹ mirroring broader health disparities shaped by socio-structural determinants, (e.g., limited health care access, economic inequality, intersecting oppressions).^8,10–15 The disproportionate impact of Mpox on Black and Latino GBM clearly highlights the need for culturally appropriate strategies and interventions.

Understanding how Mpox-related information is communicated, interpreted, and acted upon remains critical. This study seeks to examine how Black and Latino GBM navigate Mpox-related knowledge, communication, and care.

Methods

A qualitative research design utilizing semi-structured interviews was employed to explore health communication strategies and barriers to accessing care among GBM. This study was approved by the Institutional Review Board (IRB# HS-2023–0043) at San Diego State University. Participants provided informed consent, and confidentiality was ensured through de-identification of transcripts and secure data storage. Participants were compensated $75, via cash or Amazon gift card.

Recruitment

Between November 2023 and May 2024, we conducted 30 semi-structured, in-depth interviews with a clinic-based sample of Black and Latino GBM in San Diego, California (Table 1). Eligible participants: (1) age 18 or older, (2) self-identified as GBM, (3) could read and understand English or Spanish, (4) provided informed consent, and (5) provided confirmation of at least two doses of the COVID-19 vaccine for in-person interviews. Recruitment occurred through community-based clinic partnerships, social networks, and direct outreach within health care settings. Most interviews took place online, some were conducted in person when preferred by the participant.

Table 1.

Participant Characteristics

Characteristic, n (%)	Study group (n = 30)
Gender Identity
Male	28 (94%)
Genderqueer/Nonbinary	2 (7%)
Age (years)
Mean (SD)	39.3 (10.6)
Race
Latine/Hispanic	20 (66%)
Black/African American	10 (33%)
Sexual Identity
Gay/Homosexual	25 (83%)
Bisexual	5 (17%)
HIV Status
Positive	23 (77%)
Negative	7 (23%)

Percentages may not total 100% due to missing responses. Data are self-reported.

Interview content

Authors MTE and CKC conducted all interviews (30–45 mins on average) and were conducted in English. Interview domains included: participants’ knowledge and understanding of Mpox; sources of Mpox information; access to vaccination; perceptions of public health and media messaging; changes in sexual behavior during the Mpox outbreak; the impact of the COVID-19 pandemic on participants’ responses to Mpox; trust and mistrust in health care providers and institutions; and preferred communication strategies for receiving health information. Given the intersectional nature of health, the guide incorporated discussions of substance use, mental health, and overlapping health concerns that influence risk and care engagement.

Analysis

We analyzed interview data using a rapid qualitative analysis (RQA) approach, which maintains rigor while producing results comparable to traditional qualitative coding methods.^16–18 RQA was the most appropriate approach given that our research questions were applied and descriptive. We aimed to understand how Black and Latino GBM gained, navigated, and understood Mpox-related information across very specific, pre-identified domains rather than to generate novel theories or inductive concepts. Furthermore, the interview guide was structured around those domains, making the structured analysis of RQA consistent with how data were collected. Our data analysis was guided by critical realism, which adopts an ontological realism—there is a real world that exists independent of our thoughts and perceptions—alongside an epistemological constructivism– our understanding of reality is constructed by interactions, language, and standpoint.^19,20 Thus, we accept participant narratives as evidence of real social and structural conditions (e.g., stigma, racism, and health care inequities exist), while acknowledging that those narratives are shaped by social positions and experiences. This epistemological stance aligned with RQA, a well-suited method for identifying structural and relational patterns without the deeper interpretive depth of constructionist approaches, as deductive analyses are most appropriate when taking a critical realism approach.²¹

Five members of the team (M.T.E., K.E.P., B.K., G.G., and C.K.C.) conducted the data analysis. Following the steps of RQA, first, we divided the interview transcripts among the analysts, and the team read and developed a summary of each interview organized by the interview domains (e.g., Mpox Knowledge, vaccine access, preferred communication strategies). Summaries were written to capture the substance of each narrative, preserving the participant’s language and meaning. We then used the summaries to fill a data matrix with rows labeled with participant IDs and columns labeled with interview domains, which allowed the team to review data from all participants by domain simultaneously. Next, domain by domain, four members of the team (M.T.E., K.E.P., B.K., and G.G.) reviewed the data domain by domain to identify patterns, variations, and notable quotes. The full analyst team met regularly to discuss emerging findings, resolve discrepancies in how data were entered or interpreted across domains, and to reach consensus on key themes. Our team-based review process allowed us to resolve any challenges (e.g., entering data that could span more than one domain; analytical and interpretive disagreements) and ensured that we came to decisions that were agreed upon by all members of the team.

Results

Participants’ mean age was 39.3 (SD: 10.6), 30% identified as Black or African American, and 66% identified as Hispanic or Latino. Results related to GBM perspectives are categorized in three key areas:(1) General Mpox Knowledge, (2) Preferred Methods for Health Communication, and (3) Patient-Provider Trust Amid Medical System Untrustworthiness.

General Mpox knowledge

Participants demonstrated fragmented and limited knowledge of Mpox, with understanding shaped by incomplete and inconsistent information derived largely from informal sources. Many participants described a basic or surface-level understanding of Mpox, often emphasizing uncertainty about key aspects of the disease. For example, one participant shared,

“… all of a sudden it’s a thing… but I mean… I still don’t feel like I am [an expert]… I just know the basics of things.” (PPT 2; 31yo; Latino; PWH).

Another stated, “I really don’t even know that much about monkeypox. … It didn’t affect me at all…something about, like pox, I guess, like little bumps or bumps on their skin-rash, like bumps, blistering. Just very vaguely.” (PPT 22; 29yo; Black; PWH)

Participants cited social media, news, and interpersonal networks as their primary sources of information. One participant explained, “I would see TikTok about people explaining their experience… that was … my initial exposure to it… the first place I actually heard about it was Tik Tok.” (PPT 6; 55yo; Black; PWH), while another noted, “I would hear on TV… I really don’t exactly know what it is.” (PPT 30; 43yo; Latino; PWH). Others described relying on informal conversations with peers or individuals in the medical field rather than structured health messaging.

“I have a really good friend who’s in a health field… so I always like to talk to them about it… versus getting some… word of mouth …, that you can’t even tell if it’s true or not.” (PPT 4; 38yo; Latino; Not living with HIV)

Participants’ knowledge of Mpox was also shaped by how information was framed within social and identity-based narratives. Several participants described Mpox as being communicated primarily as affecting gay men, which influenced their understanding of transmission and perceived relevance. For example, one participant noted,

“I heard …, it was mostly among sex among gay men. So that I especially wasn’t worried about it then…if it were like, … COVID that it’s just like you walk … into the grocery store and then, … you might get it. With monkeypox, … you have to … have sex with someone presumably to get it or, you know, someone infected to get it. So I thought that would be a lot easier to avoid. (PPT 1; 26yo; Latino; PWH)

In some cases, participants explicitly connected Mpox messaging to broader patterns of stigma and blame, particularly in relation to HIV. As one participant described, “I was like, oh what is this? And then my … primary doctor goes-excuse my language, but another excuse to blame the homosexual he says, first its AIDS, now it’s monkeypox that we’re going to be paying for.” (PPT 15; 60yo; Black; PWH) Participants also reported exposure to messaging that conveyed moral judgment or behavioral expectations, which further shaped how information was interpreted. One participant explained,

“They [HOPWA Case Managers] just kept saying, like, you can get it for being nasty or for being just whatever, like just behave, … they were saying first off stay your ass home. Don’t be out there, being nasty… just behave, don’t be nasty, and take your meds and all the other shit.” (PPT 18; 42yo; Latino; PWH)

Despite exposure to multiple information sources, participants highlighted gaps in communication from health care providers that contributed to ongoing confusion. One participant described their provider interaction as minimal, stating, “He basically—kept it very vague… He said that monkeypox was a sexually transmitted disease… and that’s pretty much about it… if I’m not being sexually active…there was no need for it [the vaccine].” (PPT 13; 60yo; Latino; PWH).

Participants’ understanding of Mpox prevention also reflected varying levels of awareness regarding vaccination. Many participants were aware that a vaccine was available and generally expressed confidence in its safety, often relying on health care providers to guide vaccination decisions. As one participant explained,

“I thought it was fine. I, you know, based on what my doctor had said, it was a technology that had already been around and it wasn’t, you know, brand spanking new so I didn’t have any particular qualms about it.” (PPT 1; 26yo; Latino; PWH)

Although participants generally expressed favorable attitudes toward vaccination and awareness of its availability, this knowledge did not necessarily translate into timely access because of eligibility restrictions, limited vaccine supply, and appointment availability during the early stages of the outbreak. Participants frequently described challenges obtaining the vaccine during the initial rollout, including long waiting lists, limited appointment availability, eligibility restrictions, and constrained vaccine supply. One participant shared,

“I tried to get the vaccine and it was very difficult at that time. Everywhere I went was a dead end and you had to sign up and go on waiting lists and it just wasn’t readily available.” (PPT 10; 54yo; Latino; PWH)

Others similarly described repeated efforts to obtain vaccination but encountered screening criteria that limited access despite actively seeking protection.

“I had been trying to get it for months, just as a precaution… I called probably about 8 or 9 times [and] I was told I wasn’t really a candidate at that time and that there weren’t enough vaccines. So, if I wasn’t considered a higher risk, they weren’t going to give it to me… I was calling back-to-back, I was calling over and over, and I called different sites, and they all had the same guidelines, and if I didn’t meet that criteria, then they were just, you know, well, it’s okay for you to wait in the meantime. And I was just kind of like, well, what’s the point of that…” (PPT 26; 34yo; Latino; Not living with HIV)

Others expressed uncertainty about the seriousness or relevance of Mpox, with one participant reflecting,

“… I just thought it was going to be just like sensationalism. Like, people are just putting dubs on the story. … I personally didn’t know anybody who actually had it, but friends of friends, you know … so I just… It didn’t bother me.” (PPT 22; 29yo; Black; PWH)

Overall, these findings suggest that participants’ knowledge of Mpox was often fragmented and shaped by incomplete information, stigmatizing and identity-based messaging, and inconsistent communication from trusted health care providers. These factors influenced not only how participants understood Mpox transmission and personal risk, but also how they perceived preventive strategies, including the role of vaccination and their ability to access it during the early stages of the outbreak.

Preferred methods for health communication

Participants described navigating health information through a combination of digital platforms, informal networks, and community-based communication, often prioritizing accessibility, immediacy, and relatability. Many reported actively seeking information from multiple sources rather than relying on a single authority, frequently turning to search engines and online content as an initial step. As one participant noted, they would consult “search results… a number of them… probably around three or more,” (PPT 1; 26yo; Latino; PWH) reflecting a pattern of cross-referencing information to assess credibility.

Digital platforms, including social media and online forums, were central to both initial exposure and ongoing learning. Participants described relying on “the front page of Google,” social media, and “random internet forums” as accessible entry points for understanding emerging health concerns. These sources were valued for their speed and breadth of information, particularly for learning about symptoms, transmission, and prevention. However, this reliance also reflected gaps in clear, trusted public health communication, reinforcing the fragmented understanding of MPOX described earlier. Despite the prominence of digital sources, participants emphasized that trust and meaning were often shaped through community and peer-based communication. Word-of-mouth exchanges within social networks were described as essential for validating and contextualizing information. Participants highlighted sharing information within trusted circles, including friends and community members, noting that “I think definitely word of mouth, because they usually, you know, listen to their family and friends.” (PPT 4; 38yo; Latino; Not living with HIV) These exchanges were often informal but highly influential in shaping perceptions of risk and relevance.

Peer-to-peer communication was also described as intentional and relational. Participants shared that when they encountered new or useful information, they would actively disseminate it within their networks. One participant explained, “I started sharing it with people… I shared it with my friends… that’s how peer to peer works for me…”, (PPT 7; 59yo; Black; Not living with HIV) emphasizing how information spreads through trusted relationships. Importantly, these interactions were typically limited to familiar and comfortable social contexts, underscoring the role of trust and shared experience in information exchange.

Participants further highlighted the importance of culturally relevant and representative messengers. Information was perceived as more credible and impactful when delivered by individuals who reflected shared identities and lived experiences. As one participant noted, “If I was trying to get a message out or get the word out to black and minority gay people, you need advocates. You need people who can relay the message to- it’s to people that look like us.” (PPT 9; 54yo; Black; Not living with HIV) emphasizing the role of representation in fostering engagement and trust.

In addition to peer-based communication, participants discussed the importance of targeted, visible, and engaging public health messaging across both digital and physical spaces. Many emphasized that outreach should occur in settings where GBM are already active, including dating applications, social media platforms, clubs, and clinics. Apps such as Grindr, Sniffies, and Scruff were identified as particularly effective channels for reaching communities directly. Participants also noted the importance of repeated exposure across platforms, with one describing the effectiveness of billboard advertisements,

I think billboards work great. That may be old school tech, but, you know, some of the things that I’ve gone to my own doctor and ask questions about are things that I see when driving down the road… I didn’t know what Doxy Prep was and I saw that on the billboard and I was like, Why am I just seeing that all of a sudden? … I felt that the campaign for that was effective, because I saw that, and it made me ask questions. (PPT 6; 55; Black; PWH)

Participants expressed a strong preference for messaging that was concise, visually engaging, and easy to digest. Short, accessible formats were viewed as more effective in capturing attention, particularly in digital environments. At the same time, participants emphasized the need to avoid stigmatizing language, noting that judgmental messaging could deter engagement and limit the effectiveness of public health efforts. These findings highlight a dynamic and multilayered process of health information-seeking, where digital platforms, peer networks, and community relevance intersect. While digital spaces served as key sources of connection, trust was largely constructed through peer relationships and culturally grounded communication. The effectiveness of messaging depended on its visibility, relatability, and ability to inform without reinforcing stigma, stressing the importance of community-informed health communication.

Patient-Provider trust amid medical system untrustworthiness

Participants described trust in health care as shaped by both affirming provider relationships and experiences of stigma, knowledge gaps, and broader societal inequities. Trust was strongest when providers were perceived as knowledgeable, communicative, and affirming of LGBTQ+ identities. Many participants emphasized feeling supported and confident in their providers’ guidance, with one noting,

“If anything, I think it was the contrary. I think I felt more-like empowered when it comes to it… my doctor has been amazing, so I feel like I am very blessed… she kind of keeps me-in the know and really any little concerns that I probably had she kind of addresses them pretty quickly.” (PPT 2; 31yo; Latino; PWH)

Others described relying heavily on trusted providers for decision-making, stating,

“I just went with whatever my doctor thought was best. I trust her so I was like whatever you think I should take about vaccines that I should get, just let me know and I’ll do it. Yeah, I trust her…if it wasn’t for that, I probably wouldn’t have got any of the vaccines.” (PPT 3; 38yo; Latino; PWH)

Positive relationships were often linked to sustained engagement in care and comfort navigating health systems, particularly when care felt respectful and personalized. For example, one participant reflected, “…Everyone’s treated with respect, and you just don’t feel like you’re out of place… I don’t ever feel like I’ve been like, labeled, mistreated or disrespected.” (PPT 29; 43yo; Latino; PWH)

However, trust was frequently undermined by experiences with providers who lacked knowledge of LGBTQ+ health or communicated in stigmatizing or dismissive ways. Participants described encountering providers unfamiliar with PrEP or sexual health needs, with one explaining,

“… I found out about PrEP, so I wanted to ask my doctor about it and he didn’t know much about it, … I was kind of like a little shocked because, … a medical professional didn’t know about it.” (PPT 4; 38yo; Latino; Not living with HIV)

Others described moralizing or restrictive responses to care requests, including,

“…I had to push him [physician] to do … the Doxy PEP, like asking him what that was. He didn’t really want to talk about it, and so I asked him why. And he said … it’s kind of encouraging a behavior that I would discourage.” (PPT 6; 55yo; Black; PWH)

In some cases, participants felt forced to navigate systems strategically to access care:

“I spent like a year and a half asking for PreP and the only reason why I got that was because I had to lie to the doctors, just like, ‘Yeah, I have a partner who is undetectable.’ Because every single time I would ask this doctor, he’s like, ‘No, you’re not sexually active enough’… I’m not sexually active with men as much as I would like to, because I’m scared. If you give me what I need, then I would be more sexually active…. I had to lie to him for him to … give me PrEP.” (PPT 14; 30yo; Latino; Not living with HIV)

These experiences often led participants to seek out specialized or LGBTQ+-affirming providers, as one participant noted, “I don’t go to any old doctor to talk about PrEP… because they don’t get it.” (PPT 17; 29yo; Latino; Not living with HIV)

Beyond individual encounters, participants’ level of trust in health care systems was shaped by broader experiences of discrimination, stigma, and systemic barriers. Several described being treated differently due to substance use or identity, one participant noted, “the care that I got prior to that was very like lag… and then… it was just like, oh, this is not a patient anymore. This is just a drug user.” (PPT 22; 29yo; Black; PWH) Others described feeling dehumanized or unseen within clinical settings, reflecting, “not feeling like I’m taken seriously… feeling like a statistic more than like a person.” (PPT 23; 37yo; Black; PWH) Systemic inequities, including access to resources and continuity of care, further influenced engagement, with participants highlighting differences in care environments and access across settings. These narratives suggest that trust in health care among GBM varies depending on specific relationships and contexts and is influenced by interactions with affirming and knowledgeable providers, as well as by experiences of stigma, gaps in provider training, and structural inequities.

Discussion

This study provides insight into how Black and Latino GBM navigated Mpox-related knowledge, communication, and care within a broader context shaped by HIV, stigma, and structural inequities. Participants demonstrated a limited and often incomplete understanding of Mpox, with knowledge largely constructed through informal, digital, and peer-based sources rather than consistent engagement with trusted health care systems.^22–24 This gap in knowledge was not simply a lack of information but reflected how Mpox was communicated. Participants frequently described Mpox as framed through identity-based and moralized narratives, often echoing early HIV discourse and reinforcing perceptions of Mpox as a “gay disease.”^2,5,22–27 This framing influenced perceived susceptibility, sometimes leading participants to minimize risk or disengage from prevention messaging.^23,25,26

Simultaneously, participants actively navigated complex information environments, drawing on digital platforms, peer networks, and community spaces to interpret risk and make decisions.^22–24,28 These findings align with prior research demonstrating that GBM communities rapidly adapt to emerging health threats through collective knowledge sharing and behavior change.^23,28 In this study, peer-to-peer communication was not only a source of information, but also a mechanism for validation, contextualization, andtrust-building.^23,24,28 Participants emphasized that information was most meaningful when it was shared within trusted relationships and delivered by individuals with shared lived experience.^23,24,28,29

A key contribution of this study is the identification of a dual dynamic of trust: strong interpersonal trust in affirming providers alongside broader institutional untrustworthiness. Participants described high levels of trust in providers who were knowledgeable, communicative, and experienced in LGBTQ+ and HIV-related care.^29–32 These relationships facilitated openness, adherence to recommendations, and sustained engagement in care.^31,32 Others described experiences with providers who lacked knowledge of PrEP and sexual health, communicated in stigmatizing or moralizing ways, or dismissed patient concerns.^30,33–36 These encounters often resulted in delayed care, self-advocacy, or transitions to specialized clinics perceived as more affirming and competent.^29,30,33,34 Recent studies suggest that targeted assistance following an Mpox diagnosis, including linkage to clinical care, case management, and supportive services, may improve engagement with care and reduce barriers to recovery, highlighting the importance of integrating patient-centered support into Mpox response efforts.³⁷

Participants’ experiences also reflected broader structural and institutional barriers, including stigma related to substance use, racialized experiences within health care, and inequities in access to resources.³⁸ This suggests that trust in health care is relational, context-dependent and shaped by both interpersonal experiences and larger systems of inequity. Additionally, effective Mpox response efforts must address not only information gaps but also the social and structural contexts through which knowledge, trust, and care engagement are produced.

Public health implications

Our findings highlight opportunities to strengthen public health communication and care delivery by drawing on approaches already culturally embedded in GBM communities. Participants described direct, affirming, and respectful ways of discussing sex and risk, offering a non-stigmatizing model for addressing sexual health. Participants’ accounts illustrate existing strengths within GBM communities, including established communication practices, adaptive risk management strategies, and engagement with care.

An important implication of these findings, for both GBM and broader populations, is the promotion of knowledge, confidence, and acceptance of Mpox vaccination. Participants’ experiences suggest that vaccine decision-making is shaped not only by access to information but also by the social contexts in which that information is communicated. Peer communication and trusted social networks appear to play a central role in normalizing Mpox vaccination, facilitating discussion, and reducing uncertainty. These findings are consistent with broader literature demonstrating that social norms and trusted community relationships are important determinants of vaccine uptake.³⁹ Similarly, participants frequently described accepting vaccination based on recommendations from health care providers with whom they had established trusting and long-standing relationships. This underscores the importance of sustained patient-provider relationships and provider recommendations as key facilitators of vaccine confidence and uptake. Public health strategies that leverage both trusted peer networks and affirming health care providers may therefore be particularly effective in increasing Mpox vaccine acceptance and supporting equitable vaccination efforts.

Moreover, participant experiences with affirming providers underscores the value of patient-centered care models that emphasize respect, open communication, and shared decision-making. Provider training in sexual health, PrEP, Mpox and other STIs remains important to enable consistent, nonjudgmental care across settings. Participants’ reliance on specialized and affirming providers suggests a need to extend these practices beyond specific LGBTQ+ clinics or programs. By exploring the interplay between digital information sources, peer networks, and health care experiences, this work identified opportunities to strengthen public health messaging and promote more equitable, patient-centered approaches to care.

This work has several limitations. First, this study was conducted with Black and Latino GBM living in San Diego, a city which has a substantial LGBTQ + population and community. Generalizations to Black and Latino GBM in smaller towns and other US jurisdictions may be limited. Second, men’s experiences of the Mpox outbreak, as well as their access to Mpox information and vaccines are shaped by local and state-level policies. For example, San Diego has abundant health care and other services specifically tailored to the LGBTQ+ community. These data should be understood within their specific geographic context. Despite these limitations, this work supports emerging evidence demonstrating that GBM communities engage in peer-driven communication practices that support harm reduction while preserving sexual autonomy.^6,7 These strategies often occur within trusted social networks and affirming patient-provider relationships, where information is contextualized through shared experience and cultural understanding. Additionally, stigma, inadequate provider knowledge, and medical system untrustworthiness limit ongoing engagement with traditional health care systems.^8,14