Abstract
Introduction
Mpox (formerly monkeypox), a zoonotic disease, was identified predominantly in the Democratic Republic of the Congo (DRC) in 1970 (Ladnyj et al., 1972). Following the global eradication of smallpox, mpox has become the most prevalent orthopoxvirus infection in humans (McCollum & Damon, 2014). During the last decade, mpox cases have been reported primarily in Central and West Africa, but multiple cases have occurred sporadically in Nigeria and outside the African continent, including the United States (Beer & Rao, 2019; Ilic et al., 2022; Reed et al., 2004). Recently, the majority of mpox cases and chains of transmission have surged in nations beyond the endemic areas, prompting the World Health Organization (WHO) to declare mpox a public health emergency of international concern (Thornhill et al., 2022; World Health Organization, 2022f). As of February 23, 2024, more than 93,921 confirmed cases and 179 deaths have been identified in more than 117 countries across all six WHO regions (World Health Organization, 2022a). The distribution of disease was observed mainly in the European region and the United States (World Health Organization, 2022d). Previous reports showed a remarkable rate of healthcare-associated transmission of mpox from Central and West African countries (Nakoune et al., 2017; Yinka-Ogunleye et al., 2019). Although the case fatality rate was initially estimated at approximately 3%–6%, the number of cases is increasing globally. This is a concern for global health security because infections were initially limited to endemic regions, with rare cases spreading to non-endemic areas (World Health Organization, 2022b). A specific plan must be released to control the outbreak when transmission of the mpox virus occurs through either large respiratory droplets, close or direct contact with skin lesions, or contaminated fomites (GOV.UK, 2022). After an incubation period ranging from 5 to 21 days, the illness begins with flu-like symptoms, followed by the development of multiple popular, vesiculopustular, and ulcerative lesions on the face and body, and prominent lymphadenopathy (McCollum & Damon, 2014). The overall clinical presentation of mpox is similar to that of smallpox but less severe (Nalca et al., 2005). The disease can be considered a self-limited infection; possible complications include pneumonitis, encephalitis, keratitis, and secondary bacterial infections (Sheeran et al., 2016).
The rise in the incidence of human mpox, especially in non-endemic countries, emphasizes the importance of implementing preventive measures and early screening and detection. Even though the likelihood of mpox virus transmission is limited compared to COVID-19, a coordinated multidisciplinary effort is required to prevent further global spread. The WHO released a recommendation to control the human-to-human spread of mpox, requiring healthcare providers (HCPs) to have sufficient knowledge for the early diagnosis and treatment of the disease (Sklenovska & Van Ranst, 2018; World Health Organization, 2022e). Moreover, HCPs are also considered to be at high risk of contracting serious infectious diseases when they provide care for patients (Selvaraj et al., 2018; Zachary & Shenoy, 2022). A WHO report showed that one of the challenges to preventing the re-emergence of mpox was a lack of knowledge about the disease (World Health Organization, 2022g). Several studies conducted in different countries have found low levels of knowledge about mpox, and unsatisfactory awareness and lack of a positive attitude among HCPs (Alkalash et al., 2023; Bates & Grijalva, 2022; Jahromi et al., 2023; Lounis, et al., 2023; Malaeb et al., 2023; Miraglia Del Giudice et al., 2023; Peng et al., 2023; Sobaikhi et al., 2023; Swed, Bohsas, et al., 2023; World Health Organization, 2018). Some of the factors associated with knowledge and attitude included young age, higher education level, and occupation (Alkalash et al., 2023; Hasan et al., 2023; Peng et al., 2023; Sobaikhi et al., 2023). Perceptions, awareness, and basic knowledge about mpox must be improved among HCPs to provide support for early screening and detection of mpox patients, as well as to improve their preventive measures.
The first case of mpox in Vietnam was reported on October 3, 2022, in Ho Chi Minh City, by an individual who had traveled from Dubai (CDC, 2022a). Approximately 10 days later, a second mpox case was detected and linked to the first, requiring urgent control and preventive measures. Vietnam has ranked one of top 10 countries reported mpox cases over the world (World Health Organization, 2024). The Ministry of Health released guidelines for managing the disease; once a case is suspected, contact identification or tracing should be conducted immediately (Ministry of Health, 2022). The recent increase in the incidence of human mpox requires prevention, early detection, prompt response, and management by HCPs who are knowledgeable about mpox. Research on HCPs in non-epidemic infection such as Vietnam is lacking. Understanding HCPs’ awareness and knowledge of non-epidemic infections and treatment practices could help identify existing gaps and enhance occupational safety and viral surveillance. Adoption of preventive measures, especially in the context of emerging infectious diseases, is largely determined by knowledge about diseases and attitudes toward practice (Akinyinka et al., 2019; Wahed et al., 2013). This study aims to investigate knowledge, attitude, and practice (KAP) toward prevention of mpox among HCPs in Vietnam using a self-reported questionnaire based on the literature and the theoretical framework of the Health Belief Model (HBM). We hypothesize that knowledge, attitude, and associated factors regarding mpox will be positively related to practice. Findings from our study could potentially inform the design of effective health education and implement necessary prevention to control mpox in the context of its re-emergence. The study findings also provide a baseline reference database for future assessments of the effectiveness of health education activities in improving health behaviors. The HBM, developed by M H Becker and L A Maiman, is a conceptual framework focused on disease prevention behaviors and is used to explain health behaviors and appropriate interventions to change behaviors (Becker, 1974; Champion, 1984). As several studies have shown the positive impacts of the HBM on modifying health behaviors (Chaboksavar et al., 2022; Goruntla et al., 2021; G. Huynh, M. Q. Nguyen, et al., 2020). The HBM was used as the theoretical framework in the present study.
Methods
Participants and Survey Design
A cross-sectional study was conducted among HCPs working at four community health centers and two hospitals in Ho Chi Minh City, Vietnam between August and October 2022. Sample size was calculated using the single population proportion formula, assuming the rate of good practice was 50% because there was no published data evaluating mpox practice among HCPs in Vietnam. A 5% margin of error and 95% confidence level were used. The minimum sample size was 385.
Inclusion and Exclusion Criteria
Eligible participants included HCPs, who were working at the time of the survey and had agreed to participate in the study. Participants were excluded if they did not complete the questionnaire, or missed any questions that measured their KAP or took part in the pilot survey.
Questionnaire Development
The survey questionnaire was developed according to the frequently asked questions regarding mpox from the WHO and CDC websites, the Ministry of Health guidelines, and references from previously published articles (Alshahrani et al., 2022; CDC, 2022b; World Health Organization, 2022b). Attitudes about mpox were based on the domains of the HBM framework, which was a good fit for predicting behaviors in previous studies (Huynh et al., 2021; Shitu et al., 2022). The draft questionnaire was sent to experts specializing in multidisciplinary areas such as infectious diseases, epidemiology, and community medicine. They assessed the questionnaire for face validity, relevance, clarity, and comprehensiveness of each section, and some details were modified according to their feedback. A pilot survey was then conducted among 30 HCPs to gather feedback on the instrument’s comprehensibility. Based on participants’ responses, minor changes were made to the questionnaire, including the replacement of ambiguous words. Furthermore, the Cronbach’s alpha values for the KAP scale were 0.72, 0.79, and 0.70, respectively, indicating that the scale had good reliability.
The final survey questionnaire included four parts (Supplemental Appendix):
Data Collection
The list of the survey participants was determined using a convenience sampling strategy and was based on the list of HCPs from health facilities. Eligible participants were invited to take part in the survey using a self-administered questionnaire that assessed KAP regarding mpox. All participants were guaranteed anonymity and they provided written informed consent. The survey required approximately 10–15 min to be completed. A total of 612 suitable respondents were included in the final statistical analysis.
Ethics Approval
This study complied with the Declaration of Helsinki. All participants were informed of the aims and scope of the study and signed a consent form before taking part in the survey. All participants in this survey took park voluntarily, and all the information from the study was anonymous. The Ethical Committee of Le Van Thinh Hospital reviewed and approved the protocol of this study on August 11, 2022, with reference number 21/LVT-BOARD).
Data Analysis
Statistical analyses were performed using the STATA 14 software (StataCorp. LLC, College Station, TX, USA). Descriptive analysis was presented as frequencies and percentages of variables to assess socio-demographics and KAP items. Chi-square tests or
Results
A total of 612 participants who met the inclusion criteria were included in the final statistical analysis. The characteristics of the surveyed HCPs are presented in Table 1. Over two-thirds of participants were female and less than 40 years old (81.5%). Nearly 40% of HCPs were nurses and had experience of less than 5 years (80.6%). The majority of participants had heard about the global mpox outbreak (97.4%). Among them, 79.1% received information about mpox from the website of their hospital or the Ministry of Health. Only 14.7% of HCPs admitted learning information on mpox through training.
Baseline Characteristics of Healthcare Providers (
More than half of all HCPs had sufficient knowledge about mpox (54.4%). The vast majority of HCPs knew that mpox is caused by a virus (98.4%), has similar signs and symptoms to smallpox (90.9%), and that it can be prevented by limiting contact with suspected cases (91.2%) and washing hands (91.9%). However, only 13.4% of participants stated that mpox had been previously reported in some African countries, and about 60%–70% of participants had good knowledge about the onset of mpox symptoms, transmission, treatment, and vaccine and that certain groups of people have a higher risk of infection (Table 2).
Knowledge of Healthcare Providers Toward Mpox (
Regarding attitude, over a third of the participants showed a positive attitude (36.8%). Most of them agreed to isolate if they became infected with mpox (81.2%). Over half of the participants showed positive attitudes toward the likelihood of them and their family members becoming infected with mpox (Table 3).
Attitude of Healthcare Providers Toward Mpox (
Regarding practices for managing mpox, most of the respondents indicated good preventive measures, such as wearing masks (93.1%), avoiding close contact with individuals who have suspected or confirmed cases of mpox (85.5%), and following the mpox guidelines of the Ministry of Health (80.9%). More than half of participants protect themselves against mpox when traveling (55.6%) and seek medical advice and isolate from others when they have a suspected or confirmed illness (51.9%). Over two-thirds of participants washed their hands frequently with soap and water or alcohol hand sanitizer. Considering the cut-off score of 6 points, 51.8% of participants were categorized as having good practices (Table 4).
Practice of Healthcare Providers Toward Mpox (
Univariate logistic regression analysis indicated that participants’ sex, the source of mpox information on social media, websites of hospitals or the Ministry of Health, friends, relatives, and training were significantly associated with practices for managing mpox. Participants who had sufficient knowledge and a positive attitude were more likely to have good practices regarding mpox. In multivariate logistic regression analysis, participants who were female showed higher good practices compared to those who were male (AOR 1.6, 95% CI [1.1, 2.4],
Results of Logistic Regression Factors Associated with Practice Regarding Mpox (
Discussion
Two years after the COVID-19 pandemic outbreak, the new zoonotic mpox disease has been reported in multiple non-endemic nations, raising concerns in the health sector. Even though mpox is a self-limiting infection and generally milder than past smallpox outbreaks, early discovery and attempts to control the disease are essential. To combat this outbreak effectively, the Ministry of Health released a comprehensive preventive plan requiring all HCPs to be informed about disease treatment, risk factors, and preventive measures (Ministry of Health, 2022; World Health Organization, 2022c). HCPs are considered front-line workers for the early identification, differential diagnosis, and management of suspected or confirmed cases in healthcare facilities. Therefore, they need to be educated on handling cases as well as protecting themselves (World Health Organization, 2018). This study investigated the situation before the mpox cases were reported in Vietnam, but after the global outbreak had occurred. These findings will contribute to the development of innovative solutions to mitigate the further spread of the virus.
It seems likely that HCPs have gaps in their knowledge about mpox. The study findings revealed that over 50% of participants had sufficient knowledge, which is consistent with previous studies that found approximately 52% of Italian practitioners, 55.3% of Egyptian healthcare workers, and 55% of Saudi physicians had correct knowledge (Alshahrani et al., 2022; Amer et al., 2024; Ricco et al., 2022). By contrast, studies conducted among general practitioners in Indonesia, 11 Arabic countries, and medical doctors in Bangladesh showed inadequate knowledge of mpox (Harapan et al., 2020; Hasan et al., 2023; Swed, Alibrahim, et al., 2023). Moreover, a previous Jordan’s finding indicated that healthcare workers possessed a limited knowledge and lacked confidence to diagnose and treat mpox infected patients (Sallam et al., 2022). A possible explanation for these findings might be differences in the questionnaires used and the cut-off point for defining good knowledge. Findings from the present study identified gaps in mpox knowledge that affect HCPs’ abilities to diagnose and treat the disease. Only two-thirds of participants had good knowledge about the onset of illness, transmission, treatment, and vaccine, and who has a higher risk of infection. In contrast to earlier findings, the level of knowledge about COVID-19 is high and most HCPs are well-versed in the disease (G. Huynh, T. N. H. Nguyen, et al., 2020). A possible explanation for the discrepancy might be that mpox is considered a re-emerging infectious disease that has not been previously reported in Vietnam, thus education about the disease may have been neglected. Because the global mpox outbreak is rapidly evolving, our findings suggest that continuing medical education and create clear communication for all HCPs because they play an critical role in prevention and treatment for communities.
One unanticipated finding was that only over one-third of participants had a positive attitude toward the mpox disease, which contradicts previous studies conducted during the Ebola virus outbreak and the COVID-19 pandemic (Abebe et al., 2016; G. Huynh, T. N. H. Nguyen, et al., 2020). Moreover, Amer FA’s finding found that only 44.5% of healthcare workers had positive attitudes towards mpox (Amer et al., 2024). This inconsistency may be due to the fact that mpox is not reported to be as deadly as other diseases; therefore, awareness about perceived severity and susceptibility is lower than that in previous studies. Although mpox remains relatively rare in Vietnam at the time of study conducted, enhancing positive attitudes toward the disease should be prioritized to help HCPs take the necessary steps to protect themselves and confront the outbreak.
Overall, participants in this study revealed that lower good practices toward mpox were not desirable. More than half of the participants protected themselves against mpox when traveling and sought medical advice and isolated from others when they had a suspected or confirmed case of illness. Over two-thirds of participants washed their hands frequently with soap and water or alcohol hand sanitizer. This finding was reported by prior findings (Amer et al., 2024; Jahromi et al., 2023). These findings also contrast sharply with our previous study which showed a high rate of KAP toward COVID-19 (An et al., 2022). Participants who had sufficient knowledge and a positive attitude were found to have good practices. These results corroborate the previous findings, which emphasized the importance of knowledge and attitude to protect individuals from infectious diseases (Al-Rawajfah et al., 2021). Other important findings showed that female participants who attended training were associated with good practices. Alshahrani et al. also determined that being a female physician and attending training are important factors in improving specific knowledge about mpox (Alshahrani et al., 2022). Besides, using social media as a source of information decreased the likelihood of having good practices. This finding is consistent with that of Bass et al., who found that training was critical to HCPs’ improvement in detecting of mpox cases (Bass et al., 2013). Moreover, previous studies found that media failed to release effective and comprehensive awareness campaigns to the public and the sources of information about the mpox from healthcare providers and officials was the most trusted (Wogu et al., 2020). Although social media plays an important role as a source for seeking or disseminating health information, a variety of misinformation has been released throughout the COVID-19 pandemic (Angawi & Albugmi, 2022). Therefore, educational efforts should be accompanied by greater control over biased information to encourage HCPs’ adherence to preventive practices to control the spread of mpox disease.
Implications
This findings can also be helpful for policy makers and stakeholders to develop strategies and future planning against a potential mpox outbreak, especially since mpox cases have been reported in non-epidemic communities and other viral diseases.
Strengths
To the best of our knowledge, this is the first study to investigate KAP toward mpox in Vietnamese HCPs. The findings could give a rapid finding of KAP gaps and serve as a baseline reference in assessing the effectiveness of health education activities in improving health behaviors.
Limitations
Despite its strengths, this study has some limitations. First, because of its cross-sectional nature, this study could not infer any cause-and-effect relationship between practice and the associated factors. Second, convenience sampling was used to collect data, which might limit the generalizability of the findings. Third, variations in mpox cases may cause a shift in the demand for HCPs to obtain information about the disease. Some of the points required for KAP may vary; therefore, the level of knowledge, attitudes, and preventive practices must be continually assessed to compare the variation in the spread of this disease.
Conclusion
We conducted a cross-sectional study to understand HCP’s level of knowledge about mpox. Survey questionnaires were distributed to HCPs working at four community health centers and two hospitals in Vietnam. The findings showed that only over half of HCPs had adequate mpox knowledge and practices, while just over one-third had positive attitudes. In addition, the identifiable sociodemographic factors associated with practice were sex, social media as the mpox information source and training. Moreover, knowledge and attitude were significantly associated with practice levels. Consequently, continuing health education should be strengthened to not only enhance knowledge, attitude, and preventive practices but also to emphasize the threat that emerging zoonotic diseases pose to community health. It is crucial to recognize that a lack of knowledge, attitude, and preventive practices about the mpox disease could negatively impact adherence to public health intervention strategies; therefore, HCPs should be encouraged to have a positive attitude and maintain appropriate preventive practices to promote the successful prevention and control of emerging diseases.
Footnotes
Author Contributions
Declaration of Conflicting Interests
Funding
Ethical Approval
ORCID iDs
Data Availability Statement
Supplemental Material
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
