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Research Article

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

[version 1; peer review: 1 approved with reservations, 1 not approved]
PUBLISHED 12 Jun 2024
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This article is included in the Emerging Diseases and Outbreaks gateway.

Abstract

Objective

This study aimed to establish the factor structure and reliability of the evaluation instrument measuring monkeypox (Mpox) knowledge, perception and beliefs of health threat in students of the health area in two universities of Peru during 2022.

Methods

The methodology used was psychometric in nature. The study variable on knowledge of monkeypox was based on the instrument made by Ricco et al., carried out with health professionals, adjusted to Peru and administered to 416 students.

Results

The results showed adequate goodness-of-fit indicators with RMSEA and SRMR coefficients lower than 0.08 and a TLI lower than 0.90 and adequate reliability values for knowledge of monkeypox (KR20=0.70 and α=0.73), with the perception of health threats being the one with the highest reliability (α=0.88 and Ω=0.89).

Conclusions

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.

Keywords

Monkeypox; Knowledge; Perception; Beliefs

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 compared 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 monkeypox (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.

The stated situation added to the Peruvian context in contrast to the literature review carried out allows us to identify the small number of studies related to the degree of knowledge, attitudes and perceptions in health students concerning Mpox, a situation that motivated this study to establish the factor structure and reliability of the evaluation of knowledge, perceptions, and beliefs of health threats in students of the health area in regard to monkeypox (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 emerging health challenges, such as monkeypox and other epidemiological threats.

2. Methods

2.1 Study design and scope

This research is a psychometric study carried out in two universities in the capital of Peru during the months of August to December 2022.

2.2 Population

A total of 436 students enrolled in the universities during the period of interest for this research were surveyed using non-probability convenience sampling. The exclusion criteria were as follows: not being enrolled at the time of administration of the instruments; being under 18 years of age; not accepting informed consent; and not having completed more than 50% of the questionnaires. Twenty of these students (4.5%) did not answer more than 50% of the questionnaires; for this reason, they were excluded from the study, which meant a final sample of 416 students.

2.3 Variables and instruments

The study variable on knowledge of monkeypox was taken from the instrument created by Ricco et al.18 and carried out with health professionals. From the original instrument, 17 items on knowledge of monkeypox were extracted, organized into three response categories: “True”, “False” and “Don’t know”. The questions have a correct and incorrect question structure; for this reason, after collection, they were transformed into dichotomous items (correct answer=1 point and incorrect answer=0 points). The total score of the questionnaire ranges from 0 to 17 points. Following the recommendations of Lira and Caballero,19 the instrument was translated by professionals and evaluated by expert judgment to maintain agreement and coherence with the Peruvian social context.

Regarding the variable of perception and belief of health threats, the instrument from Ricco et al.’s study18 was also used. It comprised 11 items presented on a Likert scale with five response categories (1=strongly disagree, 5=strongly agree), while the items of threat to health due to other diseases transmitted through the virus used a threat perception magnitude scale with ten response categories reduced to five (1=least threat perception, 2=maximum threat perception), with a total score between 11 and 55 points.

2.4 Procedure

The instrument was validated by Ricco et al. (2022) and adjusted to Peru through a pilot test that allowed impertinent practices to be excluded. The collection of information received the approval of the university authorities and the informed consent of the students. The students were invited to participate voluntarily and contacted by email and WhatsApp to access the instrument through a Google form.

2.5 Data analysis

The psychometric analysis of the study was exploratory, using the weighted least squares means and variance-adjusted estimation (WLMSV) and polychoric matrix, as well as oblique rotation (quatrimin) to obtain the factor loadings of the dimensions of the study instruments. Additionally, it included the calculation of explained variance to understand the total variation in the data explained by the factors identified in the exploratory factor analysis. Bartlett ’s sphericity was also evaluated to determine if there is sufficient correlation between the variables and the Kaiser-Meyer-Olkin (KMO) adequacy index, which provides a measure of the adequacy of the data for factor analysis.

After that, the confirmatory factor analysis was obtained to show the goodness-of-fit indicators. The indicators considered were the Tucker-Lewis index (TLI), appropriate when it is greater than or equal to 0.9020; the standardized root mean squared residual index (SRMR) and the root mean square errors of approximation (RMSEA), appropriate when they are lower than or equal to 0.08.20

Finally, the reliability of the instrument was obtained through the KR-20, Cronbach’s Alpha and Omega indicators, with values greater than 0.50, which are acceptable. R Studio software was used for the analyses of psychometric properties, along with the“lavaan”,“semTools” and “semPlot” packages (Rstudio®, Boston, MA, USA). whose license belongs to the Universidad del Cauca.

2.6 Ethical principles

The students who participated in the study did so voluntarily and gave their informed consent in the research instrument form (questionnaire).

The research considered the Declaration of Helsinki and the protocol was approved by the ethics committee of the Norbert Wiener University, file 1787-2022. dated October 2022 where the investigation has been considered a minimal risk investigation.

3. Results

Of the 416 participants, the majority were women (78.61%), belonging to the age group of 18 to 20 years (39.90%), students in the second year of studies (48.32%), nursing professionals (61.78%), and belonging to a private university (90.87%) (Table 1).

Table 1. Characteristics of the study sample.

Variablesn%
Gender
Female32778.61
Male8921.39
Age
18-2016639.9
21-2513031.25
over 2512028.85
Profession
Medicine6014.42
Nursing25761.78
Dentistry9923.8
Type of University
Private37890.87
Public389.13
Year of study
1184.33
220148.32
3378.89
46515.63
5 and 69522.83

Regarding the exploratory analysis of the study questionnaires, the polychoric matrix was used, and the weighted least squares means and variance adjusted (WLMSV) was applied. Each of the items in the questionnaires is based on the dimensions, given that the factor loadings are greater than 0.40. The items that best respond to the knowledge instrument are: yes, they know that monkeypox can be transmitted through direct contact (0.76) and respiratory secretions (0.73), in addition to knowing that monkeypox infections are mainly associated with typical skin lesions (0.75). While for the questionnaire on perception and beliefs about health threats of monkeypox and other diseases transmitted through viruses, it was shown that the items that responded best were the following: perception of monkeypox infection according to its severity (0.93); perception that monkeypox will occur and affect their daily activities (0.87). Likewise, the explained variance for the variables of knowledge and perception and beliefs about monkeypox was reported at 84.6% and 87.1%. The Kaiser-Meyer- Olkin index for the variables of knowledge and perception and beliefs in regard to monkeypox reported 0.93 and 0.95, respectively, taking into account that the appropriate limit is 0.60 and Bartlett ’s sphericity index turned out to be significant (p<0.05) for both variables (Table 2).

Table 2. Factor Loadings of the exploratory analysis for the instruments of knowledge, perception and beliefs about monkeypox and diseases transmitted through viruses.

KnowledgePerception and beliefs
D1(λ)D1(λ)D2(λ)D3(λ)
Variable 1
Monkeypox (MPXV) is caused by a newly discovered virus.0.72
The MPXV virus circulates only among primates, including humans.0.68
In most cases, the MPXV virus evolves into an influenza-like illness without complications.0.62
MPXV infections are associated with typical skin lesions.0.75
Until recently, cases of MPXV have been mainly associated with traveling abroad.0.71
There is no effective vaccine against MPXV available to date.0.67
Effective drugs against MPXV are not available to date.0.58
MPXV can be transmitted through respiratory secretions.0.73
MPXV can be transmitted through saliva droplets.0.7
MPXV can be transmitted by direct contact.0.76
MPXV can be transmitted through body fluids.0.74
MPXV infection is associated with a high rate of systemic complications.0.69
MPXV causes less severe disease in children (age < iiv years) than in adults.0.6
The skin rash associated with MPXV is usually asymptomatic.0.67
Standard preventive measures are effective in preventing MPXV infection.0.55
Surface tension and the profusion of skin lesions associated with MPXV have prognostic value.0.66
MPXV is capable of surviving for several days on contaminated surfaces.0.68
Variable 2
Based on your current understanding, how do you perceive MPXV infection in the country? Regarding its severity0.93
Based on your current understanding, how do you perceive MPXV infection in the country? [Regarding its frequency]0.82
How would you rate the health threat posed by the following diseases? [monkeypox virus]0.81
How would you rate the health threat posed by the following diseases? [SARS-COv-1]0.87
How would you rate the health threat posed by the following diseases? [Tuberculosis]0.83
How would you rate the health threat posed by the following diseases? [Seasonal flu]0.62
How would you rate the health threat posed by the following diseases? [Hepatitis B virus]0.84
How would you rate the health threat posed by the following diseases? [Human immunodeficiency virus (HIV)]0.80
From your point of view, in the next 12 months, will the MPXV be a likely occurrence during daily activities?0.87
From your point of view, in the next 12 months, will the MPXV significantly affect your daily activities?0.87
From your point of view, in the next 12 months, are you confident you can recognize cases of monkeypox during your academic activity?0.64
Explained Variance (%)84.687.1
KMO0.930.95
Bartlett sphericity (p-value)0.0370.021

Regarding the confirmatory factor analysis, the goodness-of-fit indicators were evaluated for each of the study questionnaires. It is important to mention that the appropriate values for indicators such as RMSEA and SRMR must be lower than 0.08 and TLI must be lower than 0.90. For this reason, the goodness-of-fit indicators for knowledge about monkeypox were adequate given that RMSEA and SRMR were 0.065 and 0.075, respectively, while TLI reported a value equal to 0.92. Additionally, the questionnaire on perceptions and beliefs of health threats posed by monkeypox and other diseases transmitted through viruses reported adequate goodness-of-fit indicators, with RMSEA and SRMR less than 0.08 and the TLI reporting 0.97.

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 monkeypox knowledge questionnaire was adequate (KR20=0.70 and α=0.73). The reliability of the questionnaire on monkeypox 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).

Table 3. Indicators of goodness of fit of the confirmatory factor analysis and reliability for the instruments of knowledge, perception and beliefs about monkeypox and diseases transmitted through viruses.

KnowledgePerception and beliefs
D1D1D2D3
Chi-square of Adjustment (χ2)45.21366.66
TLI0.920.97
RMSEA0.065 [0.045-00.077 [0.065-0.091]
SRMR0.0750.074
α0.730.830.880.81
KR-200.7NANANA
ΩNA0.830.890.8

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 monkeypox, 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.21

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.18 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.2224 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 0.70.22,24

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.25

The study carried out by Caycho -Rodríguez et al., established a strategy for the development and initial validation of a scale of fear of monkeypox, 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]).26

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.17,27

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 life25 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 characteristics28; 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.21,2934

The results of the present study should be analyzed with caution, considering the sampling method, a condition that limits the ability to generalize the findings. 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.

5. Conclusions

The evaluation of knowledge, perceptions and beliefs about the health threats of infectious diseases such as monkeypox, 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.

Ethics and consent

The students who participated in the study did so voluntarily and gave informed consent. The research considered the Declaration of Helsinki, and the protocol was approved by the ethics committee of the Norbert Wiener University, file 1787-2022 dated October 2022 and where it has been considered as a minimum risk research.

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Rivera-Lozada O, Ipanaqué-Zapata M, Rivera-Lozada IC et al. Psychometric properties of an instrument measuring monkeypox knowledge, perception, and beliefs of health threat in health science students in a middle-income country [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:627 (https://doi.org/10.12688/f1000research.145169.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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PUBLISHED 12 Jun 2024
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Reviewer Report 14 Nov 2024
Mona Gamal Mohamed, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates 
Not Approved
VIEWS 5
Introduction:

The introduction lacks a comprehensive discussion of the psychometric framework and the significance of the study. While the disease context is briefly mentioned, the foundational importance of this work in advancing measurement science is not adequately ... Continue reading
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Mohamed MG. Reviewer Report For: Psychometric properties of an instrument measuring monkeypox knowledge, perception, and beliefs of health threat in health science students in a middle-income country [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:627 (https://doi.org/10.5256/f1000research.159078.r338479)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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7
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Reviewer Report 09 Oct 2024
Alysa Pomer, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA 
Approved with Reservations
VIEWS 7
Summary:
In this study, the authors seek to validate a psychometric instrument measuring mpox knowledge, perceptions, and beliefs of health threats in a new context—namely, among healthcare students at two universities in Peru. This is a valuable contribution in ... Continue reading
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Pomer A. Reviewer Report For: Psychometric properties of an instrument measuring monkeypox knowledge, perception, and beliefs of health threat in health science students in a middle-income country [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:627 (https://doi.org/10.5256/f1000research.159078.r323813)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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