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.

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).

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).

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).

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. ^{22 – 24} 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 life ²⁵ 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 characteristics ²⁸ ; 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 , 29 – 34}

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.

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.