Psychometric properties of an instrument measuring monkeypox knowledge, perception, and beliefs of health threat in health science students in a middle-income country

1. Introduction

The disease caused by the monkeypox (Mpox) is considered, after the eradication of smallpox in 1979, the most important infection caused by a virus of the Poxviridae family of the Orthopoxvirus genus.^1,2 During the period 2017–2021, outbreaks of cases were reported in Nigeria and other regions that received travelers from this origin. The last outbreak of cases recorded occurred in May 2022 in the United Kingdom, during the COVID-19 virus pandemic.³ In July 2022, Mpox was declared a public health emergency of international concern by the World Health Organization due to the simultaneous record of cases in more than 70 countries.⁴

Manifestations of the disease range from fever, lymphadenopathy, and a typical skin rash to systemic symptoms or even death,⁵ which is self-limiting in most cases. However, there are more severe forms associated with immunosuppressed populations and vulnerable groups of children, pregnant women, and older men.^6,7 Mpox was initially considered a zoonotic disease; however, it currently incorporates contagion through human-human contact, where the main transmission route is direct contact between mucous membranes and skin in sexual activity,⁸ and secondary routes are respiratory droplets and vertical transmission.^8,9

There have been 86,173 cases and 89 deaths confirmed in the world until February 24, 2023. The Americas accounts for 86% of the cases and includes six of the ten countries with the highest number of confirmed cases globally.¹⁰ In the case of Peru, it is in the fourth place and accounts for 17% of the deaths caused by Mpox.^11,12 Compared to 2022, a significant decrease in cases was observed in 2023 in Latin America, in contrast to other regions of the world. In Latin America, concern about Mpox remains latent since, in addition to the frequency of cases, there are barriers such as social inequality, misinformation, a shortage of human and health resources, and political crises.¹³

One aspect of interest is related to the level of knowledge of health personnel concerning Mpox,¹⁴ where health professionals in training become relevant in outbreak contexts. For example, we can mention similar cases such as what occurred with the COVID-19 pandemic, which has highlighted the role of learning during university life, proposing strategies for a preventive approach to the healthcare profession, and providing bases for managing the perception of possible contagion.¹⁵

The re-emergence of the disease caused by the Mpox generated epidemiological alerts worldwide and required health services to implement effective responses that guarantee effective prevention strategies based on mastering the conditions that led to the current state of this problem.^16,17 This situation invites us to explore the degree of knowledge as well as the characteristics, attitudes, perceptions and beliefs that influence the practices present during the interaction with users of health services.

Previous research has shown that health students have insufficient knowledge and inadequate attitudes towards Mpox.^18–20 A multicentric study conducted at three universities in the United Arab Emirates, Egypt, and Iraq evaluated the knowledge, attitudes, concerns, and mental health needs regarding Mpox among nursing students. Using a questionnaire with acceptable internal consistency (Cronbach’s alpha of 0.85), it was found that students, particularly in Egypt, have significant gaps in their knowledge and generally neutral or negative attitudes towards Mpox. Many experience moderate anxiety and perceive a considerable need for mental health support. Additionally, a positive correlation was observed between knowledge and attitudes, with significant variations based on nationality, educational level, and exposure to information, highlighting the need for personalized educational and support programs.¹⁹ This underscores the importance of having appropriate tools to measure students’ knowledge, attitudes, and perceptions to promote quality health education and strengthen students’ skills in facing emerging health challenges.²¹

The stated situation added to the Peruvian context in contrast to the literature review, reveals a limited number of psychometric studies on instruments that evaluate the knowledge, attitudes, and perceptions of health students regarding Mpox.²² This motivated the study to establish the factor structure and reliability of evaluating knowledge, perceptions, and beliefs about health threats among health students concerning Mpox infection. Through the review and validation of the psychometric properties of this instrument, the aim is to promote high-quality education in health sciences that not only stays current with medical knowledge but also accurately reflects students’ perceptions and readiness to address health challenges, such as Mpox and other epidemiological threats.

2. Methods

3. Results

The main characteristics of the 416 study participants were identified, showing that the majority were women (78.61%), belonging to the age group of 18 to 20 years (39.90%), second-year students (48.32%), nursing professionals (61.78%), and attending a private university (90.87%) ( Table 1).

Regarding the exploratory analysis of the study questionnaires, the polychoric matrix and the weighted least squares means and variance adjusted (WLMSV) method were used, adjusting the data for a robust interpretation of the relationships between the questionnaire items. It was observed that the factor loadings for all items exceeded the 0.40 threshold, ensuring reliable representativeness of each dimension within the evaluated constructs. For the Mpox knowledge questionnaire, the items with the highest factor loadings were: knowledge of Mpox transmission through direct contact (0.76) and respiratory secretions (0.73), as well as knowledge that infections are commonly associated with typical skin lesions (0.75). This indicates that these aspects best reflect the knowledge construct of Mpox. In terms of the perception and beliefs questionnaire, the items that most accurately captured the construct were: perception of the severity of Mpox infection (0.93) and the belief that an infection would affect one’s daily activities (0.87). These results suggest that participants tend to associate Mpox with significant impacts on daily life and perceive it as a serious threat. Additionally, the explained variance for the knowledge and perception and beliefs questionnaires on Mpox was high, reaching 84.6% and 87.1%, respectively, indicating that the items adequately represent each construct’s dimensions. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for both questionnaires was excellent, with values of 0.93 and 0.95, exceeding the recommended limit of 0.60. Furthermore, Bartlett’s test of sphericity was significant (p<0.05), confirming that the correlation matrix is suitable for factor analysis ( Table 2).

Regarding the confirmatory factor analysis, goodness-of-fit indicators were evaluated for each of the study questionnaires to determine how well the data fit the proposed model structures. Appropriate thresholds for these indicators were set as follows: RMSEA and SRMR values below 0.08 indicate a good model fit, while TLI values of 0.90 or above are also indicative of a well-fitting model. For the Mpox knowledge questionnaire, the goodness-of-fit indicators met these standards, with RMSEA and SRMR values of 0.065 and 0.075, respectively, both comfortably below the threshold. The TLI value of 0.92 further confirmed that the model fit was acceptable. These results suggest that the questionnaire reliably captures the knowledge dimension as designed. Similarly, the questionnaire assessing perceptions and beliefs about health threats, specifically those posed by Mpox and other viral diseases, demonstrated strong goodness-of-fit indicators. Both RMSEA and SRMR values were below 0.08, and the TLI was exceptionally high at 0.97. This indicates that the model is particularly robust and aligns closely with the theoretical structure of perceived health threats and beliefs.

Finally, Table 3 shows that the reliability results were adequate, taking into account that they are reliable with values greater than 0.50. The reliability of the Mpox knowledge questionnaire was adequate (KR20=0.70 and α=0.73). The reliability of the questionnaire on Mpox was adequate for each of the dimensions of the instrument, with the perception of threat to health from other contagious viral diseases being the one with the greatest response (α=0.88 and Ω=0.89).

4. Discussion

The second decade of the 21st century has been characterized by the challenge of offering efficient health responses to emerging conditions that involve changes in lifestyles. In the face of infectious conditions such as Mpox, there is a growing need for tools that account for underlying factors that allow us to understand the complexity of the phenomenon and thus guide decision-making in areas such as public health and clinical practice. This perspective, according to the National Institute of Health of Peru, requires coordinated actions that link surveillance and risk assessment approaches and involve actors from society, the media, and academia.²⁵

Based on formative strategies in the Latin American context, the reemergence of infectious conditions leads to the implementation of expected learning outcomes that link epidemiological surveillance processes, the incorporation of sociocultural characteristics analysis in formal research processes in clinical and public health settings. It is crucial that these formative strategies include the development of competencies in data management and interdisciplinary response, allowing health professionals to adapt to the changing dynamics of emerging and reemerging infectious diseases.²⁵

Furthermore, it is essential to promote innovative pedagogical approaches that integrate research with practice, facilitating the creation of solutions adapted to the available resources and the sociocultural particularities of the region. Collaboration between educational institutions, health organizations, and local communities is essential to strengthen the response capacity to health emergencies, thereby improving the resilience of health systems in Latin America. Previous studies have discussed the importance of emerging infectious diseases and their impact on public health, highlighting the need for robust epidemiological surveillance and the adaptation of public health strategies,²⁶ evidencing the challenges these diseases represent in the region and the importance of interdisciplinary research and response.²⁷

The research allowed us to establish that the instrument subjected to the validation process in a sample of Peruvian students retains a similar factor structure based on the characteristics of the original instrument used by Ricco et al. (2018; 2022) in a sample of Italian physicians.²⁰ The two factors incorporated in the instrument were characterized by offering information related to knowledge through a unidimensional configuration, while in the second factor it was possible to identify a configuration based on three dimensions.^28–30 In both cases, when performing the reliability analysis using Cronbach’s alpha, Omega and KR 20 criteria, it was evident that the factors were highly reliable with values greater than 0.70.^28,30

In the local context, no similar studies were identified that used this instrument; however, in a validation experience carried out by Yupari-Azabache et al., where knowledge, attitudes and practices were measured, a factor structure comprised of four dimensions was reported for knowledge, three dimensions for attitudes and two dimensions for practices, with optimal reliability criteria (Cronbach α between 0.81 and 0.91; McDonald ω between 0.82 and 0.92), similar to those of the present one.²²

The study carried out by Caycho -Rodríguez et al., established a strategy for the development and initial validation of a scale of fear of Mpox, a dimension that could be considered a proxy variable for the attitude factor of this study. The authors reported scale reliability criteria based on a psychological dimension (ω McDonald=0.91) and another affective dimension (ω McDonald=0.71). Additionally, they reported high values of goodness of fit, reliability, and invariance when making comparisons between men (CFI=.99; TLI=.99; RMSEA=.066 [90%CI .004–.111]) and women (CFI=.99; TLI=.99; RMSEA=.067 [90% CI.032–.101]).³¹

The approach to this zoonotic disease raises the need to incorporate a complex perspective that links knowledge of aspects such as infection mechanisms, close contact with people with the disease, topical lesions, vulnerable groups and the need for vaccination. The above shows the gap in existing knowledge and the needs of the country when considering the experience of the COVID-19 health emergency and the low levels of knowledge reported in recent studies.^17,32

The items related to attitudes suggest the existence of various manifestations that involve the ability to determine the impact on the reality of the country, which corresponds to a macro-systemic perspective towards a transition that involves daily life²² and includes academic work. The above is based on the need to close gaps in knowledge by health professionals, including those in training, and thus improve communication in care processes with a preventive scope.

A study on the level of advanced knowledge and practices in the general population developed in Peru concluded on the need to guarantee the use of validated instruments that respond to sociodemographic and occupational characteristics³³; however, given the conditions in which the investigations were developed, the results obtained give an account of the criteria to deepen the mechanisms of situational analysis that involve, in addition to the natural history of the disease, the incubation periods, geospatial characteristics of the most frequent regions, and strategies to avoid the national health emergency.¹⁷ Studies in Europe, North America and some in Latin America reported similar needs and raised conditions that require valid mechanisms to approximate a reliable measure in processes of estimating the occurrence of problems associated with the presence of infectious diseases, considering the high emotional burden and the need to promote decision-making based on evidence related to the experience of providing health services, including academic practice settings.^25,34–39

In the last two decades, Latin American universities have incorporated support strategies based on the allocation of their own resources (technical, human, and financial) and the dissemination of external calls for international cooperation to achieve high standards in research indicators framed within faculty development. Countries such as Brazil, Argentina, Chile, and Mexico stand out for the projection of research results in the consolidation of these initiatives. In the case of countries comparable to Peru, such as Ecuador and Colombia, it has been documented that one of the main limitations is financial support, a condition that affects the degree of scientific production.

To improve faculty participation in research, universities can implement incentives such as reducing teaching loads for those who advise students on research projects, granting recognitions and awards for research excellence, and offering continuous professional development opportunities in research methodologies.⁴⁰ Additionally, it is essential to foster a research culture from the early years of university education, integrating research into the curriculum and providing access to resources such as scientific journals and academic databases.⁴¹ In this regard, educational institutions can adopt concrete measures such as creating more research opportunities through internal and external funding programs, improving research infrastructures, and promoting interdisciplinary and international collaborations.⁴²

Considering the results of this research, it is possible to affirm that professionals in medicine and health sciences need to develop capacities for the administration of instruments and protocols that meet criteria of validity, precision, sensitivity, and specificity. This directly impacts decision-making, the improvement of care quality, and the ability to detect variations in conditions based on interventions according to local needs.

Additionally, it is essential for these professionals to stay updated with the latest research and technological advances in the health field, which will allow them to apply diagnostic and therapeutic tools more effectively. Continuous training and evidence-based education are essential to ensure that health professionals can adapt to the changes and challenges presented by emerging and re-emerging infectious diseases.⁴³

The implementation of specific training programs in validation studies and the promotion of a research culture within health institutions are key strategies to strengthen these capacities. This not only improves the quality of care and patient safety but also fosters a collaborative and multidisciplinary work environment where best practices based on scientific evidence are valued and applied.

The results of this study should be analysed with caution. Since variables such as infectious conditions in the last year, socioeconomic status, or ethnic background were not considered, it is not possible to establish the potential confounding effect. Additionally, it is necessary to consider that the analysis plan did not consider criteria of temporal stability and invariance of the factors based on criteria such as gender, age or academic program, conditions that would increase the scope of establishing the psychometric properties of the instrument.

Regarding the way the sample was obtained, there may be an influence of selection and participation biases in the study. However, given the study’s focus on the psychometric characteristics of the instrument, the obtained sample adequacy index (KMO) supports the baseline generated to provide evidence for factor analysis for the Peruvian and Latin American context.

5. Conclusions

The evaluation of knowledge, perceptions and beliefs about the health threats of infectious diseases such as Mpox, becomes relevant in all areas of daily life, including university education. Having instruments that accurately reflect the knowledge, perception and beliefs of health students will make it possible to contribute significantly to the prevention, control and management of this disease and, at the same time, be prepared to address other challenges of public health in the future.

The exploratory scope of this study creates scenarios to consolidate the research line. For future studies, it is expected to estimate indicators of sensitivity to change and determine the concordance between the diagnostic capabilities of students and the criteria of the instructor in clinical settings.