A focus group was used in the context of a church-based measles outbreak to provide a more in-depth understanding of the vaccine attitudes and beliefs of members, as well as their experience with the outbreak. In turn, several of the themes raised in the focus group discussion were reinforced in structured interviews with outbreak and comparison households, including vaccine safety concerns among church members and the role of perceived disease severity in shaping vaccine attitudes and beliefs after an outbreak in the community.
While the results of this study are not generalizable due to the small number of households involved in the outbreak, several of the lessons learned from these families may be useful in future outbreaks among families that refuse vaccination. First, families and church leaders we spoke with in the focus group emphasized the importance of open and clear communication, especially between the church and the state and local health departments. Second, they highlighted the proactive role that the church community took in using its existing social network to help control the spread of measles, for instance by canceling activities involving children and restricting other activities to members who were fully vaccinated. Third, focus group participants also advocated for better education of doctors and hospital staff in considering a measles diagnosis, a suggestion that has been made previously in the context of a measles outbreak in a boarding school.14
While the church was the common link among cases, there was no formal advice regarding vaccination from the church before the outbreak. Instead, vaccine refusal was attributed to a combination of personal religious beliefs and safety concerns among a subgroup of church members; lack of access to health services was not a barrier to vaccination for this population. This suggests an opportunity for health-care providers to proactively address vaccine safety concerns among these families as well as alternatives such as a delayed or modified vaccination schedule or vaccines under special circumstances (i.e., international travel or an active local outbreak).15
This is especially important given that several families involved in the outbreak homeschooled their children or had vaccine exemptions; therefore, they were not subject to laws that require vaccination for school entry. Exemption to vaccination places individuals at increased risk of vaccine-preventable disease.16–18
Vaccine safety concerns and low perceived susceptibility and severity of vaccine-preventable diseases have been associated with nonmedical vaccine exemptions,19
and it has also been suggested that homeschooling families may be more concerned about vaccine safety than non-homeschooling families.20
Few states have a mechanism for tracking immunization rates among their homeschooling families,21
and further research is needed to identify the vaccine beliefs and behaviors, as well as the vaccine education needs, of these families.
It was unexpected that most of the outbreak households said that the experience did not make their opinion of vaccines more positive; however, additional research is needed to confirm and further explain these results. Several of these families were willing to consider certain vaccines in the future, and most reported that they would accept quarantine during any future disease outbreak in the community. This suggests that alternative means of disease control may be successful options for families that are unwilling to vaccinate.
A final objective was to test the methodology of a rapid knowledge, attitude, and belief assessment in the context of a vaccine-preventable disease outbreak. The interview instrument benefited from tailoring after the focus group discussion, and it worked well both in person and on the phone, with outbreak and comparison households, and with both adults and children (with parents answering on their behalf) as the interview subjects. The mixed-method approach also helped with data interpretation; for example, issues like vaccine safety concerns that were raised in the focus group were reinforced by interview data. The methods used can be tailored to be culturally appropriate and done within time and resource constraints.
This study was subject to several limitations. The sample size was small (one focus group and 12 household interviews), so we were limited to a descriptive analysis of the data. Similarly, because of the qualitative nature of the focus group data, the small sample size, and the convenience sampling of comparison households, results were not generalizable beyond the community being studied. However, we included eight of the 11 households involved in the outbreak, which represented 31 of the 34 measles cases in this outbreak. Therefore, despite small numbers, we were able to meet the study objectives, which were to describe the beliefs and experiences of church members involved in the outbreak and test the study's feasibility in the context of a vaccine-preventable disease outbreak. Finally, while we asked about beliefs and behaviors before and after the outbreak, the data were cross-sectional and were gathered several weeks after the outbreak ended.