Study of knowledge, attitude and anxiety in Kurdistan-region of Iraqi population during the monkeypox outbreak in 2022: An online cross-sectional study

doi:10.21203/rs.3.rs-1961934/v3

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Research Article

Study of knowledge, attitude and anxiety in Kurdistan-region of Iraqi population during the monkeypox outbreak in 2022: An online cross-sectional study

https://doi.org/10.21203/rs.3.rs-1961934/v3

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Background

On July 23, the WHO declared the rapidly spreading monkeypox (MPX) epidemic as a Public Health Emergency of International Concern (PHEIC). This study attempted to assess the knowledge, attitude, and anxiety levels of the general population during the MPX outbreak.

Methods

An online cross-sectional survey was conducted during the period July 27 and July 30, 2022, using a convenience sampling method. The questionnaire was adapted and developed after an in-depth review of the previous studies.

Results

A total of 510 respondents participated in this study. 277 (54.3%) were male, 233 (45.7%) were female. Participants had insufficient knowledge of MPX with a mean and SD deviation 2.096±1.359, 2.576±1.466, having a normal attitude toward MPX 4.031±1.645. Moreover, they had anxiety problems 32.382±10.094. There were significant differences in the mean rank scores of the knowledge of respondents about MPX according to their, religion, level of education, place of residence with p-values>0.001, 0.001, 0.001, respectively and 0.009 for marital status. Also, there were significant differences in the mean rank scores of attitudes of respondents toward MPX according to their gender, level of education, and age, with p-values 0.011, 0.020, 0,029, respectively, and p-value>0.001 for place of residence. Lastly, there were significant differences in the mean rank score of anxiety of respondents toward MPX according to their gender, level of education, religion, and place of residence, with p-values>0.001, 0.001, 0.001, 0.001 respectively, and 0.009 for marital status.

Conclusion

There is an urgent need to raise public awareness and manage people's emotional wellbeing.

Monkeypox

knowledge

attitude

anxiety

mental health disorders

social media

fear

stress

panic

PTSD

Against the backdrop of the ravages of the COVID-19 pandemic, the recent resurgence of the monkeypox (MPX) caused by monkeypox virus (MPXV) has sparked widespread panic about the prospect of another global outbreak [1]. The global spread of MPX in May month of 2022 has provoked widespread public concern. On July 23, the World Health Organization (WHO) declared the rapidly spreading MPX epidemic as a Public Health Emergency of International Concern (PHEIC). As a zoonotic disease, MPX has been documented in several parts of the world, particularly in Western and Central Africa that are endemic for MPXV, and this disease was considered a neglected disease [2–5]. Though the virus was identified in 1958, it was not until 1970, when MPXV was reported from a patient in the Democratic Republic of the Congo who had symptoms of smallpox, that the virus was officially recognized as a separate human infection via zoonosis, and thereafter other human MPX cases with zoonotic infections proved animal spillover of MPXV from animals [6]. The incubation period for MPX is anywhere from 5 days to 21 days, and it spreads by droplets and through contact with skin lesions or contaminated bodily fluids and materials [7]. In addition, MPXV transmission can occur via the vertical pathway (i.e., mother to fetus). The symptoms of human MPX are self-limiting and typically disappear after 14-21 days. It is thought that rodents operate as a reservoir for MPXV, and exposure factors include coming into contact with animals (living or dead) and consuming bush foods [3,8].

Since May 7, 2022, an alarming epidemic of MPX has been occurring across Europe, Australia, and America in people who have no proven travel ties to endemic regions [2–5,9]. However, this was not predicted that MPX cases will rapidly rise and affect several countries in three months, and will pose global public health emergency [10,11]. As of October 14, 2022, in 110 countries, 79.231 cases were laboratory confirmed globally, with 49 deaths. [12]. This rapid rise in MPX cases across many countries suggests that more and more cases will be seen in coming time, and few researchers are opining whether this PHEC due to MPX could turn up and looms into another pandemic? [13,14]. There is a discrepancy between the rate at which MPX is spreading and the fact that we have it, which makes prevention measures more difficult [15].

Mild to severe manifestations of MPX include fever, widespread headache, lethargy, lymphadenopathy, back pain, and myalgia in addition to the itchy to painful skin lesions that are the disease's hallmark [15]. The skin rash that might occur up to three days after the fever has subsided is the most prominent clinical symptom [16]. It typically starts off looking like maculopapules, then turns into vesicles, then pustules, and finally crusts. It first manifests on the face, then spreads rapidly to the rest of the body, especially the face and extremities, and can eventually affect the entire body in extreme cases. When compared to smallpox, the most notable distinction is that MPX leads to lymphadenopathy. In certain cases, the skin lesions might remain for up to four weeks [17,18].

The rising incidence of human MPX highlights the need for vigilant surveillance for the disease, prompt diagnosis, and finding out effective vaccines, drugs and treatment options [19,20]. Primary prevention of MPX is achieved by public awareness campaigns that highlight the risk factors for the disease and the preventative steps that can be taken to lessen those risks [15,21]. However, a report by the World Health Organization (WHO) revealed that lack of knowledge regarding MPX, especially among healthcare providers, was one of the obstacles faced in preventing the re-emergence of MPX [22]. The knowledge level about MPX is relatively low among Jordanian health students, general practitioners in Indonesia and physicians in Saudi Arabia [23–25]. In the first month following the WHO alert, public concern over COVID-19 outpaced that of MPX in some countries outside of Africa. Predictors of agreement with MPX vaccination included fear of catching the disease, a strong commitment to infection preventative measures, and the belief that the disease is severe and virulent. Those who are older and more educated are less likely to agree with vaccine mandates [17,19]. Myocarditis is a potentially fatal consequence that has been described in people who have had monkeypox or who have taken the mRNA COVID-19 vaccination [26–28].

Anxiety and stress are common responses to disease outbreaks like MPX [29] and other public health emergencies. The public's uncertainty, concern, panic, and fear are understandable given that MPX is a re-emerging disease with severe consequences worldwide [30]. MPX research is ongoing, therefore many of the known facts are evolving, and many beliefs about the disease and its treatment persist. These misconceptions and false information about MPX are spreading rapidly in the era of broad social media use [29,31]. As a result, they can be quite disturbing for some people. Authorities worldwide are warning the public against forwarding such messages without first verifying their legitimacy. As a result, everyone is feeling the effects of widespread anxiety and worry to varying degrees. The public's awareness and attitude are hypothesized to have a significant impact on the final mental and clinical outcomes. For this reason, researching these facets of the Kurdish population in Iraq is crucial. Another important health risk that is projected to grow steadily worse during this epidemic is that of mental disorders. Despite the public's widespread fear and panic during the MPX outbreak, patients, survivors, and their families face significant stigma and social isolation [32,33]. The resurgence and global spread of MPX represents a significant risk to human health and safety, particularly in non-endemic countries such as Iraq. Because there is a dearth of studies assessing MPX knowledge in Iraq, this study sought to assess such knowledge among a representative cross-section of the community [34]. Given the importance of the aforementioned factors, it was decided to assess and analyze the general population's knowledge, attitudes, and anxiety about MPX viral infection in the Kurdistan region of Iraq.

2.1. Study design, setting, period, and sample size

This was an online cross-sectional observational study carried out in all provinces of Kurdistan, the home province of the Iraqi population. Participants living in the Kurdistan-region of Iraq, aged 18 years or older, and understanding the content of the questionnaires were prompted to fill out the survey. The convenience sampling method was used to collect the data. The data was collected between July 27, 2022 and July 30, 2022. The sample size was computed, keeping the confidence interval at 95%, with an estimated 50% response distribution and a margin of error of 5%. The required minimum sample size was determined to be 382 individuals, with a total population of 5.2 million.

In order to guarantee a large-scale distribution and recruitment of participants, the questionnaire was administered in an online format. The online survey was administered via Google forms and was distributed via Facebook, WhatsApp, Twitter, and email lists. The questionnaire was adapted from prior published studies on MPX and COVID-19 [35–37], and modified to suit the current study (Supplementary File 1). Various adjustments were made according to the suggestions made by the specialists. To guarantee accurate results, the tool was translated from English to Kurdish by some bilinguals using a forward-backwards method. A total of five minutes was needed to finish the questionnaire. Specialists on the study team confirmed that the final survey was accurate, comprehensible, and valid in terms of its content. The present research was written in accordance with the STROCSS 2021 guideline for cross-sectional studies [38].

2.2. Study tool and measures

The questionnaire was divided into four main parts. The first part of the questionnaire gathered information about the sociodemographic characteristics of respondents, including age, gender, marital status, religion, level of education, and geographic distribution. For the sociodemographic variables, age was divided into four categories (18-27, 28-37, 38-47, and 48-57). The gender was coded as one for men and two for women, and the religion was coded as one for Muslims, two for Christians, and three for others. The marital status was recorded as a binary variable, with a value of one indicating single and two indicating married. The level of education was categorized into being able to read and write, middle and/or high school, bachelor's degrees, and postgraduate degrees.

The second section assessed respondents’ knowledge of MPX related to modes of transmission, isolation, prevention, treatment, main symptoms of the disease, source information, having heard the word "MPX" before 2022, and having attended lectures/discussions about MPXV infection. This section consists of nine items: Three questions were yes or no, with 1 for yes and 0 for no selection; two questions were on a Likert-point scale (true, false, I don’t know); 2 for yes; 1 for I don’t know; and 0 for no selection; and four questions were checkboxes to choose the correct answers. During the analysis, the scores are added, and the total score is between 0 and 11 for the knowledge. A higher score indicates better knowledge.

The third part of the questionnaire consists of four questions related to the attitude of participants towards the MPX outbreak. This section included four items. Participants were asked to rate attitude items as either true or false with an additional (I don’t know) option, 2 for true, 1 for I don’t know, and 0 for false selection. If the total score is between 0 and 8, getting a higher score indicates a better attitude. The fourth part included questions related to the anxiety of participants about MPX viral infection. This part included nine items with a five-point Likert scale ranging from never, rarely, sometimes, often, and always, 5 for always, 4 for often, 3 for sometimes, 2 for rarely, and 1 for never selection. The total score is between 5 and 45. Getting a higher score indicates severe anxiety.

2.3. Ethical approval and inform consent

This study followed all guidelines set forth by the Institutional Research Ethics Board and the Declaration of Helsinki. The Ethical Review Committee of the University of Raparin College of Nursing formally approved this study (Ref = 7/29/408). Electronic informed consent was obtained from the participants before filling out the questionnaires. On the first page of the survey, the study aims were explained to all participants, and privacy and confidentiality of the information were also ensured.

2.4. Statistical analysis

Statistical analysis of the data was performed using SPSS 25.0 (Chicago, Illinois). Cronbach's alpha was used to calculate the internal consistency of the items. The test's reliability, as measured by Cronbach's alpha, was 0.80. The Shapiro-Wilk test was used to evaluate the normal distribution of the distance variables studied in this research, but none of the variables followed the normal distribution. Therefore, in the present study, non-parametric tests were used by Mann-Whitney U in the case of two groups, the Kruskal-Wallis test was used in the case of three groups or more, and the Spearman correlation test was used for quantitative variables. Percentages and frequencies were used to describe categorical data, whereas mean rank, mean, standard deviation, and p-value were used to characterize continuous variables.

3.1. Sociodemographic characteristics

The Kurdish population of Iraq was surveyed through an online questionnaire about their knowledge, attitudes, and levels of anxiety during the MPX outbreak. There was a total of 510 responses collected. The participants who took part in the study were 18–57 years old and originally from the Kurdistan region of Iraq. The participants in the study were limited to only those individuals who had access to the internet. According to the results of this study, even those with the lowest levels of education were able to read and understand the questions being asked. Approximately 40% of participants were holders of bachelor's degrees, with a mean age of 31.13 ± 8.59. There were 54.3% males and 45.7% were females. In the current study, the participants come from four different provinces in the Kurdistan-region of Iraq, with the most participants from Sulaymaniyah (50%), followed by Erbil, Duhok, and Halabja. Approximately 94.5% of participants were Muslim (Table 1).

3.2. Knowledge about the MPX outbreak

The results of Figure 1 show that 70% of participants believe that MPX is a viral infectious disease; 81% of them have never heard of MPX, 92% of them have never attended a lecture or discussion about MPX, and 56% of the participants believe that isolating people with symptoms of the disease will stop the spread of the epidemic. On the other hand, 54% of participants believed that the virus would be transmitted in more than one way. Around 26.7% of the participants chose more than one item as a symptom of the disease. About 62.2% of the participants selected social media as a source of their knowledge of the disease.

As shown in Table 2, there were significant differences between the mean rank scores of knowledge respondents about MPX according to their, religion, level of education, and place of residence with p-values >0.001, 0.001, 0.001, 0.001 respectively and 0.035 for marital status. However, the Spearman correlation coefficient test showed that there was a significant and indirect relationship between the mean scores of knowledge and their age, with a p-value of 0.009.

3.3. Attitude towards the MPX outbreak

As shown in Figure 2, 44.3% of the participants didn’t have any idea about whether a patient infected by MPX should stay at home or not. While 42.5% of them mentioned that they will refuse vaccination for MPX, 36.3% of the participants didn’t agree with travelling, whereas 36.3% didn’t show any attitude toward travelling, and 42.9% of the participants agreed with the idea that the MPX epidemic will be controlled.

As shown in Table 2, there were significant differences between the mean rank scores of attitudes of respondents toward MPX according to their gender and level of education with p-values of 0.011, 0.020, respectively, and p-value>0.001 for and place of residence. In addition, the Spearman correlation coefficient test showed that there was a significant and indirect relationship between the mean scores of attitudes and their age, with a p-value of 0.029.

3.4. Anxiety towards the MPX outbreak

The data presented in Figure 3 shows the anxiety level of participants about the current MPX outbreak. In the preceding two weeks, over half of the participants had been preoccupied by the MPX outbreak, ranging from sometimes to always. The fear of contracting the MPXV was paranoid in 43% of the respondents. Among those who took part in our study, 41% admitted to feeling terrified when a friend or afamily member became sick, ranging from "sometimes" to "always". However, 11% of the participants reported having difficulty sleeping in the past two weeks owing to worry about the current outbreak. The frequency of these difficulties ranged from "often" to "always". 50% of the respondents had restricted social connections, and 42% never discussed the outbreak with their friends. It was discovered that approximately 16% of participants engaged in inappropriate social behavior due to their fear of contracting the virus. The frequency of these behaviors ranged from "often" to "always". Almost 26% of participants never posted on social media about the MPX outbreak.

Drawing from the data given in Table 2, there were significant differences in the mean rank score of anxiety of respondents toward MPX according to their gender, religion, level of education, and place of residence, with p-values>0.001, 0.001, 0.001, 0.001, respectively, and 0.009 for marital status. However, the Spearman correlation coefficient test showed that there was a non-significant and indirect relationship between the mean scores of knowledge and their age, with a p-value of 0.147. Moreover, Table 3 showed that the participants' knowledge of MPX in both parts is low, with mean scores of 2.096±1.359, and 2.576±1.466, respectively. Participants' attitudes toward MPX were normal, with mean scores of 4.031±1.645. Finally, the results show that the present study participants have anxiety problems with MPX, with mean scores of 32.382±10.094.

3.5. Determining predictive factors of knowledge and attitude of the participants:

In table 4, the regression analysis results showed that the "level of education" significantly (p-value 0.001) had predictive capabilities for predicting knowledge in the present study. This means that if one unit is to be added to the participant’s knowledge, 0.474 percent of their level of education must be increased. The "place of residence" significantly (p-value 0.001) had predictive capabilities for predicting knowledge in the present study, which means that if one unit is to be added to the participant’s knowledge, 0.216 percent of their level of education must be reduced. The "gender, level of education and place of residence" significantly (p-value=0.012, 0.042 and 0.001) respectively, had predictive capabilities for predicting attitude in the present study, this means that if one unit is to be added to the participants’ attitude 0.382 and 0.233 per cent of their gender and place of residence must be reduced and 0.134 per cent of their level of education must be increased. The other variables did not have the capability of predicting participants’ knowledge and attitude.

The global burden of the COVID-19 pandemic has been felt over the past two years. The fact that it occurred during an era of widespread transportation networks and intercontinental contact and fast travelling means, in tandem with significant advancements in infection prevention measures compared to previous pandemics. Sophisticated levels of information technology and telecommunication, gave it a unique quality that set it apart from other pandemics in modern history [17]. Aside from the obvious devastating health effects, the pandemic also had widespread economic repercussions. Therefore, the announcement of the re-emergence of MPX as well as its declaration of global health emergency along with currently continuously rising cases could have detrimental effects on the societies regarding worry and anxiety, especially given the recent recovery of the international systems from the pandemic consequences and the loosening of the strict measures that were applied on travelling and personal communications. This worry and anxiety could be related to the recent COVID-19 pandemic and the experiences people associate with it [35,39].

Epidemics and pandemics tend to occur at periodic intervals, i.e., they appear every now and then. Society encounters many challenges during these times. The lack of awareness frequently leads to a careless attitude, which can have an adverse effect on one's capability to respond appropriately to these challenges [37]. The mental health of a community might be negatively influenced by the widespread effects of outbreaks and pandemics. Individuals in a community are influenced behaviourally as well as emotionally by the fear and anxiety that are associated with pandemics and epidemics [37]. As a result, the researchers here endeavoured to assess people's levels of knowledge, attitudes, and anxiety in Kurdish society.

The results of the knowledge assessment questionnaire revealed participants’ knowledge gaps concerning MPXV infections. Put another way, the respondents were not informed about the disease, its symptoms, causes, transmission, and treatment, as well as about how to handle people with the disease. The reason why people have this relatively limited amount of information regarding the disease can be associated with the fact that the disease has not yet been reported in the Middle East, apart from a few rare cases in Lebanon and the United Arab Emirates [25] and in the context of question. Additionally, the participants do not have experience with the disease and their knowledge is limited as knowledge of something can partially or partly stem from experience [23]. Based on previous research [24], the disease is a re-emerging disease in the world; that is, it emerges here and there every now and then. Although the pandemic seems to be recent, knowledge of the disease by ordinary people can help prevent its development. Our results coincide with previous research not only among ordinary people, but among Jordanian medical, nursing, dentistry, and pharmacy students [23], Indonesian general practitioners [24], Saudi physicians with medical students [25], and Italian physicians [36].These groups of the human population are considered to be knowledgeable as they belong to the health sciences and should possess information at least regarding health-related topics. This highlights the recency of the disease, not in terms of its origin, but rather in terms of its reappearance. A dearth of knowledge concerning the transmission, treatment, and symptoms can negatively affect the control of the disease. Therefore, raising the population's level of knowledge and awareness is suggested to successfully prevent the disease from spreading across the world.

Moving on to the variation of knowledge based on the socio-demographic characteristics, our study demonstrated that there were highly statistically significant differences for all of them, namely age, gender, marital status, religion, level of education, and place of residence on the knowledge scale that included questions about transmission, prevention, isolation, treatment, major symptoms, and source of information. Inconsistent with previous research [23–25], male participants in our study reported a higher level of knowledge compared to females. One explanation for this can be attributed to the dominant role that men have in society and that they are more or less responsible for the fatal issues facing the community. Furthermore, females frequently devote time and attention to make-up and cosmetics, as well as beauty gadgets, based on the researchers’ observation in the Kurdish society. Additionally, married participants reported a higher level of knowledge compared to unmarried participants, which seems both logical and reasonable. Since married people have more concerns about health issues, and have more responsibility in society; as a result, they endeavour to acquire more knowledge. Muslims also reported higher levels of knowledge regarding MPX in comparison with Christians and other religions. That can be more or less related to Muslims being more committed to the rules of their unaltered religion [40]. As for the level of education, people with bachelor's degrees showed the highest amount of knowledge, followed by those with master's and doctoral degrees, those with diploma degrees, those who were able to read and write, and then those who had a secondary school certificate. This result is rather confusing because the ranking order does not determine whether people with higher certificates show more knowledge or those with a lower level of education. Therefore, more research is needed to tackle the effect of education level on the amount of knowledge possessed by a certain population. Place of residence also produced expected results; people living in the culturally and socially more developed province of Sulaimanyah demonstrated a higher level of knowledge, followed by Erbil, Duhok, and Halabja provinces. Contrary to our findings, previous research [23,25] detected no significant differences by place of residence. The distinction between the findings is related to the division of the variables into their components. For instance, place of residence in our study includes the different provinces, while in [23], place of residence includes the division of the variable into someone being from the country or outside the country. Finally, age could also predict the amount of knowledge regarding MPX, with older people having less knowledge about MPX owing to the easier access that younger people have to the Internet. This result is supported in the literature by several studies [24,25]. Nevertheless, the concerning knowledge showed no significant difference with any of the socio-demographic variables.

The second principal variable of the present study involved participants’ attitudes towards MPX, particularly towards vaccination, control of the disease, and travel safety within the country. The results showed that participants held neutral attitudes towards MPX. Although MPX has not spread among people, the attitudes were not reported to be positive. The rather low attitude of the participants indicates the adverse and preconceived effects of COVID-19 on this portion of the population. As Yoo [41] states, "the wounds that the COVID-19 pandemic has inflicted on us are very deep and seemingly long-lasting and still affect us". Such attitudes revealed in this study contradict previous research [25,36] reporting positive attitudes because, unlike the participants of our study, these studies were conducted among physicians. Importantly, the limited knowledge of these study participants might be one reason behind the neutral attitudes expressed.

Participants’ attitudes towards MPX did not vary according to each of the demographic variables: religion and marital status, i.e., participants showed similar attitudes towards MPX regardless of their religion and marital status. However, their attitudes changed according to gender, education level, place of residence, and age. Males’ attitudes were more positive compared to females' in terms of accepting people with the disease after recovery, receiving vaccination, travelling across the country, and controlling the disease. This finding supports and buttresses previous research that found males were more positive in their attitudes [23]. Despite the fact that [36] demonstrated the contrary, i.e., insignificant results. Furthermore, education level showed that people with a bachelor's degree held more positive attitudes while people with diplomas recorded the lowest mean score. The results for attitude, similar to the knowledge domain, produced confusing results. As for place of residence, the results indicated that people from Sulaymaniyah province showed significantly more positive attitudes, followed by people from Halabja, Erbil, and Duhok. This might be associated with the adverse repercussions of COVID-19 that were more severe in Erbil, creating a sense of negativity towards pandemics. Again, age showed significant results, with younger people showing more positive attitudes. This might reflect the fact that people who have gone through old age could have more fear of death [42].

Yet, another last variable of the study involves anxiety that coincided with the knowledge domain and the attitude domain, i.e., participants reported anxiety problems regarding MPX in terms of thinking about the disease, feeling paranoid, avoiding social contact, speaking about MPX, having difficulties with sleeping, being affected by posts on social media about the pandemic, and related ideas. One source of anxiety about the pandemic originates from the media, which keeps people informed and has been reporting bad news. This creates lots of concern and fear for ordinary people, particularly those who have already been affected by COVID-19 [37]. As for the impact of the socio-demographic variables, the results showed significant differences for all of them, except for age. In other words, male participants were, to a greater degree, preoccupied with MPX. Furthermore, Muslims and people who had a bachelor's degree as well as people who belonged to Sulaymaniyah governorate were more anxious when compared to non-Muslims, and people who had other degrees as well as people who belonged to other governorates, respectively.

Although MPX has not been reported in the current context and little is known about its adverse effects, not only general practitioners’ and physicians’ information about it can be useful, but ordinary people’s information about it can help prevent the disease from spreading through different regions. Additionally, having obtained information about MPX can enhance people’s attitudes, and this, in turn, might cause them to eliminate their anxiety about the disease.

5. Limitation

Despite the fact that the present study includes a large portion of Kurdish population, it is restricted to people who have access to the Internet. People without Internet access may have significantly different knowledge, attitudes, and anxiety than those who do. Therefore, the present study’s findings cannot be generalized to the whole population.

In the current MPX outbreak, most educated people have insufficient knowledge of this infection. There is an urgent need to raise public awareness and manage people's emotional wellbeing. There has been no research conducted to date that assesses how the MPX epidemic affected people's mental health. Researching the effects of MPX on people's mental health in different groups, including the general public, pregnant and lactating mothers, healthcare providers, immunocompromised patients, individuals infected with the virus, their close contacts, gay, bisexual people, and people with pre-existing psychiatric and medical problems who are at increased risk for adverse psychosocial outcomes, is crucial for developing efficient interventions for those affected. Health officials in Italy are urged to act in the face of a global expansion of MPX by introducing preventative and control measures, such as the MVA-BN vaccination for vulnerable populations and tecovirimat drug for treating confirmed cases. Since MPX can be transmitted from animals-to-humans, it is imperative that animal health officials also be involved in any and all prevention efforts, and one health approach to be strengthened and implemented widely to tackle zoonotic concerns of monkeypox. Considering the continuous rapid rise in MPX cases in several countries, and taking into mind any feasible pandemic probability of this disease amid the already ongoing COVID-19 pandemic, proactive control measures, adequate disease prevention strategies and preparedness plans need to be formulated and immediately implemented to tackle the appearance of fears and psychological disturbances among people, and safeguard the mental health of the general public. For this purpose, there is an urgent requirement to adopt suitable policies and recommendations to effectively prevent and control MPXV spread as well as disseminate perfect scientific information related to public health concerns of this virus so as to explicitly counteract the infodemic's misinformation and disinformations that could create confusion and unwanted panic, and protect the mental health disturbances of the public.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Research Registration Unique Identifying Number (UIN)

1. Name of the registry: Not applicable

2. Unique Identifying number or registration ID: Not applicable

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not applicable

Author Agreement Statement

We declare that this manuscript is original, has not been published before, and is not currently being considered for publication elsewhere. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We confirm that all have agreed with the order of authors listed in our manuscript. We understand that the Corresponding Author is the sole contact for the Editorial process. He is responsible for communicating with the other authors about progress, submissions of revisions, and final approval of proofs.

Data availability Statement

The datasets used and analyzed in the current study are not publicly available due to condition on ethical restrictions. The raw data that supports the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgments

Not applicable

Provenance and peer review

Not commissioned, externally peer-reviewed

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Table 1: Sociodemographic characteristics of the study sample (N= 510)

Variables	Items	N	%
Age	18-27	204	40
	28-37	186	36.5
	38-47	84	16.5
	48-57	36	7.1
Gender	Male	277	54.3
Gender	Female	233	45.7
Marital status	Single	240	47.1
Marital status	Married	270	52.9
Religion	Islam	482	94.5
	Christian	23	4.5
	Other	5	1
Level of education	Able to read and write	31	6.1
	Secondary and high school	87	17.1
	Diploma	104	20.4
	Bachelor	204	40
	Master and doctoral	84	16.5
Residence area	Sulaymaniyah	255	50
	Erbil	118	23.1
	Duhok	70	13.7
	Halabja	67	13.1

Variables	Items	Number	Knowledge			Attitude			Anxiety
			Mean rank	Z\df	P-value	Mean rank	Z\df	P-value	Mean rank	Z\df	P-value
Gender	Male	277	266.89	-1.926^a	0.054^e	270.40	-2.545^a	0.011^d	286.19	-5.136^a	>0.001^d
	Female	233	241.95			237.79			219.01
Marital status	Single	240	241.4	-2.113^a	0.035^d	255.30	-0.029^a	0.977^e	237.51	-2.602^a	0.009^d
	Married	270	268.35			255.70			271.49
Religion	Islam	482	252.64	2.00^b	0.005^d	257.96	2.00^b	0.104^e	263.97	2.00^b	>0.001^d
	Christian	23	338.98			195.26			76.57
	Other	5	146.50			295.30			262.40
Level of education	Able to read and write	31	188.58	4.00^b	>0.001^d	242.45	4.00^b	0.020^d	218.79	4.00^b	>0.001^d
	Secondary and high school	87	199.57			255.65			213.66
	Diploma	104	228.30			216.49			237.18
	Bachelor D.	204	279.91			274.93			287.95
	Master and doctoral	84	312.52			261.27			256.25
Place of residence	Sulaymaniyah	255	278.58	3.00^b	0.004^d	288.23	3.00^b	>0.001^d	328.28	3.00^b	>0.001^d
	Erbil	118	232.88			235.00			228.29
	Duhok	70	223.71			186.94			145.11
	Halabja	67	240.70			236.56			141.75
Age		31.13±8.59	R= -0.116^c		0.009^d	R= -0.088^c		0.029^d	R= -0.096^c		0.147^e
a = Mann-Whitney Test, b = Kruskal-Wallis Test, c = Spearman correlation test, d = significant, e = non-significant

Table 2: The relationship between knowledge, attitude and anxiety with sociodemographic characteristics (N= 510).

Variables	Minimum	Maximum	Mean	Standard deviation	Results
Knowledge	0.00	11.00	4.672	2.025	Having insufficient knowledge toward MPX
Attitude	0.00	8.00	4.031	1.645	Normal attitude toward MPX
Anxiety	9.00	45.00	32.382	10.094	Having anxiety problems

Table 3: Identifying knowledge, attitude and anxiety of the participants toward MPX epidemic (N=510).

MPX= monkeypox

Table 4: The regression analysis results for determining predictive factors of knowledge and attitude of the participants.

		Knowledge							Attitude
		Unstandardized coefficients		Standardized coefficients			95.0% Confidence Interval for B		Unstandardized coefficients		standardized coefficients			95.0% Confidence Interval for B
No.	Variables	B	Std. Error	Beta	t	P. value			B	Std. Error	Beta	t	P. value
1	Age	0.076	0.115	0.034	0.662	0.508	-0.150	0.302	-.0166	0.096	-0.093	-1.738	0.083	-0.354	0.022
2	Gender	-0.328	0.182	-0.081	-1.807	0.071	-0.685	0.029	-0.382	0.151	-0.116	-2.529	0.012	-0.680	-0.085
3	Marital status	-0.019	0.215	-0.005	-0.091	0.928	-.0441	0.402	-0.089	0.179	-0.027	-0.501	0.617	-0.440	0.261
4	Religion	0.355	0.310	0.050	1.145	0.253	-0.254	0.965	-0.136	0.258	-0.023	-0.528	0.598	-0.644	0.371
5	Level of education	0.474	0.079	0.265	5.995	>0.001	0.319	0.629	0.134	0.066	0.092	2.036	0.042	0.005	0.263
6	Place of residence	-0.216	0.083	-0.115	-2.612	>0.001	-0.378	-0.054	-0.233	0.069	-0.152	-3.385	0.001	-0.368	-0.098

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Study of knowledge, attitude and anxiety in Kurdistan-region of Iraqi population during the monkeypox outbreak in 2022: An online cross-sectional study

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