Study Participants

During August 2–4, 2022, we conducted in-depth interviews with CCJ residents and staff. Among 57 potentially exposed residents who had shared a dormitory-style housing unit with the mpox case-patient, 19 were still residing in CCJ at the time of the investigation. We invited all 19 residents to participate, in addition to a purposeful convenience sample of 13 staff member who worked in various roles at CCJ during our investigation. Staff provided verbal consent; residents provided written consent by making a nonidentifying mark on a document that included details of the interview process, voluntary nature of participation, and confidentiality protections. This investigation was part of a public health response to an ongoing outbreak. It was reviewed and approved by CDC and conducted consistent with applicable federal law and CDC policy (13–17).

Data Collection

We developed a semistructured interview guide with questions on knowledge, attitudes, and practices regarding mpox and postexposure prophylaxis, hygiene and cleaning practices, and behaviors in jail that could lead to mpox transmission. Resident interviews were conducted in semiprivate spaces, far enough away from other residents and staff to provide audio privacy. A custody officer remained nearby, maintaining visual contact. Staff interviews were conducted in private spaces. All resident interviews were conducted by 2 interviewers, 1 leading the interview and 1 taking detailed notes. Some staff interviews were conducted by a single interviewer because of time constraints. All interviewers were trained on in-depth interview techniques, and interviews lasted ≈30–45 minutes.

Data Analysis

We analyzed data in 2 phases. First, we developed an a priori matrix to organize and analyze findings (18–20) to make evidence-based recommendations to improve immediate mpox response activities (12). Columns included predetermined topics aligned with interview questions. We entered participant responses into each row and summarized responses across row and topic, enabling rapid identification of findings. Key themes were compiled by reviewing the matrix entries, interview notes and summaries, and organizing findings and common themes. The study team discussed themes to summarize and reach consensus.

We later reassessed those data using the health belief model, a framework used to understand health behaviors and develop strategies to motivate behavior change (21,22). The model includes predictors for human behavior, such as perceived susceptibility to a disease or condition, perceived severity of illness, perceived benefits to taking action, perceived barriers to action, cues to action, and self-efficacy (21,22). Organizing the data around that framework further informed health promotion efforts in CCJ and similar settings.

Perceived Susceptibility to Mpox

Residents reported varied levels of concern about mpox, from not concerned at all to very concerned, and felt that residing in CCJ heightened their risk. Some residents reported keeping to themselves and therefore felt their risk was low. However, most residents were concerned about factors outside their control, such as communal housing, that could increase their risk. For some residents, their heightened sense of susceptibility led to more conservative behaviors, such as frequent handwashing and avoiding social interactions or recreational activities.

Similarly, although staff thought their risk for MPXV infection was low, they perceived working in a jail inherently increased their risk for contracting infectious diseases. Some staff expressed confidence in their knowledge of infection prevention and control practices, such as using personal protective equipment, but others understood those tools might not guarantee protection.

Perceived Severity of Potential Mpox Illness

Residents and staff were unsure how severe illness would be if they contracted mpox. However, some drew connections to COVID-19 and wondered if persons with weakened immune systems or underlying conditions would have more severe illness.

Perceived Benefits of Behavior Change to Prevent Mpox

Residents and staff described several benefits to mpox prevention behaviors, including preventing transmission to their families. Residents were concerned that quarantining or isolating because of mpox exposure or MPXV infection could delay their release from jail. Those concerns motivated residents to want to protect themselves, but they felt they did not have sufficient knowledge about prevention options. Several residents felt they did not receive adequate information about the vaccine when it was offered, including information on safety and side effects (12). However, some residents reported they chose to get vaccinated, relying on previous knowledge that vaccination reduces risk for other illnesses.

Perceived Barriers to Mpox Preventive Actions

Cues to Action to Engage in Mpox Prevention

The mpox case within CCJ was the cue to action for residents and staff to protect themselves; however, many residents and nonhealthcare staff did not feel they had the information or resources to do so. Participants desired timely, clear communication about possible mpox exposure and prevention options, which they felt they had not received. Participants felt clear communication would help quell rumors, enable persons to better protect themselves and others, and improve relationships among staff in different roles and between staff and residents.

Self-Efficacy to Engage in Mpox Preventive Actions

Self-efficacy to engage in mpox preventive actions varied. Many residents expressed low self-efficacy because of limited mpox knowledge, perceived limited access to healthcare and cleaning and hygiene supplies, perceived insufficient communication about their risk, and facility factors such as communal living. Healthcare staff reported greater self-efficacy because of medical training, knowledge and availability of personal protective equipment, and experience caring for patients with other infectious diseases. However, staff in other roles described limited self-efficacy because of more extended physical proximity to residents, including contact that was unpredictable and outside their control, limited knowledge of mpox and prevention methods, and perceived insufficient communication about their risk.