Good knowledge about the MPX virus and associated disease is paramount for helping communities to better prepare and properly respond to a possible MPX outbreak. Lack of awareness can impede the capability of the community to prevent and limit the transmission of the infection; therefore, it is important that the Lebanese population have an adequate understanding of the MPX, in terms of early identification, routes of transmission, and precautionary measures. To date, there’s no information regarding knowledge regarding MPX in the Lebanese community. Hence, this study provides an overall picture of the public awareness of MPX and offers a unique perspective on knowledge gaps in the early phase of the MPX in Lebanon. Unveiling knowledge gaps is essential to implement preventive measures, especially regarding primary prevention, and to orient communications campaigns and lead to better outcomes, in terms of preparedness and reducing morbidity and mortality. and explores the influencing factors of knowledge.
Main findings:
The main finding of this study was that a poor level of knowledge regarding MPX was found among the majority (66.96%) of the Lebanese population. Knowledge gaps and substantial uncertainties were also revealed in the majority of MPX knowledge domains, especially in those related to the routes of transmission, clinical presentation, treatment, and the severity of the disease. On the contrary, participants have a good knowledge level of the precautionary measures and the response to a suspected infection. Female gender, increased age, and living in rural areas were found negatively associated with a good level of knowledge. However, participants with higher educational levels, those working in the medical field, those suffering from chronic disease/immunodeficiency, and participants with moderate/high economic situations were more likely to have a good knowledge score compared to their counterparts.
Some explanations for such gaps and uncertainties in the knowledge of MPX are quite forthright. Firstly, MPX is neither endemic in Lebanon nor in its neighboring countries. The recency of the disease, not in terms of its origin, but rather in terms of its appearance in non-endemic locations could explain the poor knowledge level revealed in this study. Given the rarity of MPX cases in the country (only four sporadic travel-related cases), these findings in terms of poor knowledge level were expected. In fact, the Lebanese population is not familiar with this infection, since the disease originates from central Africa and usually spread in the tropical rainforest region. Secondly, the majority of the participants were aged less than 50 years old, therefore, they were born in a “Variola-free” world and did not have previous information regarding the disease . Another explanation is that the Lebanese population is currently stranded amid a multi-layered, overlapping shock that led the country into a nationwide socio-economic crisis. In addition, the majority of Lebanese people (82%) live in multidimensional poverty, which takes into account factors other than income, such as access to health, education, and public utilities. (“Multidimensional Poverty in Lebanon: Painful Reality and Uncertain Prospects”). In this regard, several studies highlighted a potential link between low knowledge levels on diseases and low economic situation. Although there is no doubt that the resilience of the Lebanese people has shown again in these crises, the truth is: that we are facing an exhausted population in one of the most complicated years since the civil war. People were overwhelmed by preserving their basic needs as well as their access to essential healthcare and medications. This shift in their priorities could restrain their proactivity in seeking information about a potential disease such as MPX. Lastly, it should be mentioned that the coverage of this topic by local media has been sluggish and timid compared to what was shown during the COVID-19 pandemic. However, such a dearth of knowledge concerning the transmission, treatment, and symptoms can negatively affect the control of the disease. Aside from many others, the so-called ‘exotic’ agents, in particular, are a threat to our public health systems due to limited experience in case management and a lack of appropriate resources. Therefore, raising the population's level of knowledge and awareness is suggested to successfully prevent the disease from spreading across the world.
Interestingly, a common aspect of poor knowledge and uncertainties was found in several studies conducted previously about uncommon outbreaks in the study areas (60-62). For example, a number of studies conducted in Indonesia revealed that healthcare workers had high knowledge about Indonesia’s endemic outbreaks and a low level of knowledge regarding other rare outbreaks . In regards to MPX, a similar pattern of uncertainty and dearth of knowledge was reported in recent studies tackling MPX knowledge either among the general population or among healthcare workers which aligns with our findings. For example, a study conducted among the general population in Saudi Arabia showed that more than half (52%) of participants had low knowledge about MPX infection. Another study conducted in Iraq showed that most of the surveyed subjects have insufficient knowledge of this infection. Although healthcare workers and medical students are supposed to be more knowledgeable in this subject, several knowledge gaps were revealed. For example, a study conducted in Indonesia showed that only 10% of general practitioners could correctly answer 80% of questions about monkeypox (45). Another recent study conducted in Italy found that medical professionals’ knowledge of monkeypox was relatively unsatisfactory, with significant knowledge gaps in this subject (33). Similar results were found in a recent study conducted among medical students Jordanian medical, nursing, dentistry, and pharmacy students, and Saudi physicians (16, 42).
Of note, less than 10% of surveyed adults declared to have heard of MPX before the ongoing outbreak. Such a result could affect our positive findings in terms of good knowledge in the precaution measures and response domains. Participants may have chosen the precautions measures and the appropriate response based on their previous experience with COVID-19. Therefore, their answers to the knowledge items in these domains may have been based on “common sense” rather than on their actual knowledge of the disease.
Focusing on MPX routes of transmission knowledge gaps, only 59.0% of participants were aware that MPX is not a sexually transmitted disease. This could be explained by the fact that the majority of surveyed adults rely on social media to get information about MPX. However, social media could be flooded with misinformation, especially in terms of considering MPX as a gay disease. Of note, other plausible routes of transmission such as respiratory droplets(31.9%) and vertical transmission (19.2%) were not well recognized by the respondents. These findings stressed the importance of raising knowledge in this area to prevent the transmission of the infection.
In terms of unveiled knowledge gaps, only 11.2% declared that clinical manifestation of HPMX is not usually severe and only half of them acknowledged that MPX is not a deadly disease. In addition, only 25% of participants were aware that MPX doesn’t spread easily between people. Such item-related lack of knowledge will affect the Lebanese population's risk perception in terms of the severity of the disease and will increase their anxiety toward a potential infection. Hence, the MPX risk should be communicated effectively among the Lebanese population. In addition, only 14.6% of participants were aware that antibiotics should not be used to treat MPX. This issue is concerning as Lebanon is characterized by high levels of antibiotic misuse, as almost half of the population self-medicates with antibiotics and over 30% of the antibiotics are dispensed without a prescription. Another gap of knowledge was revealed in terms of the availability of a specific vaccine. This could affect MPX vaccine acceptance once recommended. However, the 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.
In terms of socio-demographic factors associated with the overall knowledge level, female gender, increased age, and living in rural areas were found negatively associated with a good level of knowledge. A higher knowledge level about MPX among males was also reported by a study conducted recently in Iraq among the general population. However, our results in this matter are inconsistent with those reported in previous research conducted recently in other countries such as Jordan, Saudi Arabia, and Indonesia. (16, 42, 45). Although the infection could affect anyone, the majority of MPX cases in this outbreak were recorded among men. Based on this evidence, males could consider themself more concerned about the disease and amplify their risk perception of possible infection by MPX. The latter would instigate fears and concerns. Therefore, in an attempt to relieve their worries, they will seek more information about the subject which in turn will improve their knowledge.
This study showed that participants aged 50 years and above had higher odds of having a poor knowledge score compared to young participants. In fact, the new media and mass media play an increasingly prominent role in health information. In addition, the internet represents the main source to seek information about MPX. Hence, the familiarity of the younger population with internet service compared to the older population offer them better access to information regarding MPX, which in turn raises their awareness of this subject. Of note, older people usually rely on traditional sources to get health information. Our results were consistent with the finding of a study conducted in Indonesia. Furthermore, living in rural areas.
In regards to the residential location, our results showed its potential to affect knowledge level as participants living in rural areas have a higher odds of poor knowledge regarding MPX compared to those residing in urban areas. At the present time, the internet is the main driver of information. Rural areas were less developed suffering usually from limited access and a weak internet connection. This will in turn limit the access of people residing in rural areas to information which could lead to a poor knowledge level. Although that previous research reported no significant differences by place of residence, several studies regarding knowledge of diseases detected low knowledge levels in rural areas such as the recent study conducted in Saudi Arabia (16, 63). Our results highlight the necessity to develop rural publicity and education methods based on the characteristics of rural populations.
However, married participants with higher educational levels, those working in the medical field, those suffering from chronic disease/immunodeficiency, and participants with moderate/high economic situations were more likely to have a good knowledge score compared to their counterparts. In addition, highly educated individuals frequently hold better-paying positions and are employed, giving them access to authoritative information from scientists and other experts. People who fall into this category also frequently participate in and read scientific journals, as well as better educate themselves. As for marital status, the higher odds of better knowledge among married participants compared to unmarried ones was expected. In fact, married people usually exhibited a higher responsibility sense, and bear the role of protecting their family members and ensuring their wellbeing. Furthermore, our results concerning the better level of knowledge among participants with chronic disease or immunodeficiency compared to those without could be explained that people with chronic diseases were more concerned about their health status. Therefore, they experienced preventive treatment of the disease in the early stage. In addition, they may have a regular checkup with their healthcare provider who could sensitize them regarding the MPX.
In terms of occupation, it was presumed that participants working in the medical field were a knowledgeable group, particularly in health-related topics compared with other groups of the population. However, several studies reported that even healthcare providers in non-endemic countries lacked knowledge regarding MPX (16, 42, 45). Hence, a study exploring the current level of knowledge among Lebanese healthcare workers is recommended.
The study showed that higher education and economic situation play important and positive roles in the knowledge of MPX among Lebanese people. Similar findings in terms of education were found in a recent study conducted in Iraq (64). Although some studies about knowledge showed that education was unrelated to knowledge (65), our finding was consistent with findings of previous studies on communicable and noncommunicable diseases, which demonstrated that high educational status was correlated with improved disease prevention knowledge (66). In accordance with our findings, a study assessing knowledge of dengue fever infection among the general population disclosed that high income and high education levels were associated with up to two times better knowledge.
It should be mentioned that highly educated individuals frequently hold better-paying positions which give them better access to reliable information from scientists and other experts (67). Of note, this difference in knowledge based on the socioeconomic situation emphasized the health inequalities among different socioeconomic groups. This could be explained that participants with poor economic conditions may not pay much attention to health care and may not have the motivation to actively master knowledge (68). Our results highlighted the need for paying more attention to the public with low education and/or low income and improving their knowledge regarding the disease.
In respect of the MPX source of information, this study highlighted the influence of these sources on the MPX level of knowledge. The majority of participants with a good knowledge level reported scientific journals/research articles on health websites, health authorities, and healthcare providers. Social media and mass media play an increasingly prominent role in health information. However, social media were flooded with misinformation and rumors about MPX. Moreover, health information via the Internet should not be a substitute for healthcare professional experts in emerging infectious diseases. Taken together, the combination of traditional media, new media, and healthcare professional experts would be a better choice to improve the knowledge about emerging and reemerging infectious diseases in the public.
Significant variability in terms of gender, age, geographical areas, socioeconomic situation, and occupation were recorded for the various knowledge domain tackled in this study. Factors such as female gender increased in age and living in rural areas were found negatively associated with a good knowledge level in the majority of domains. On the contrary, working in the medical field, having a good socioeconomic status(moderate/high), and having a higher educational level were associated with a good knowledge level in these domains. Of note, these aforementioned variabilities were also revealed upon comparing the overall level of knowledge level.
Strengths and Limitations
This is the first study to explore the baseline level of information among Lebanese people in the early phase of the emerging MPX outbreak and to disclose knowledge gaps. However, our findings should be interpreted while taking into consideration the timing of the survey. This study can be helpful to tailor well-informed educational and awareness programs aiming to improve the knowledge of MPX emergence among the population based on the disclosed knowledge gaps. However, several limitations of this study should be acknowledged in this study such as the cross-sectional design which does not allow us to deduce causality. This study was prone to selection bias due to its being online and with convenience sampling which limits the generalizability of the findings. For example, this study only included people having internet literacy and those who have access to the internet. Face-to-face interviews and longitudinal studies with randomization would be suggested in the future to confirm our results.
Implications:
As more and more cases of MPX are snowballing in different countries, the Lebanese government and population should be prepared for containing a possible outbreak. The findings of this study implied that health authorities should communicate the health information for the MPX disease with a risk of imported infection. Of note, the dissemination of health information prior to the MPX outbreak had a crucial role in preventing the emergence of infectious diseases including MPX. Moreover, the public's sense of social responsibility should be deepened by focusing health information on preparedness, confidence, comprehensive prevention measures, and mitigation techniques. Although media coverage of epidemics frequently serves as the public's primary source of information on MPX, it is insufficient for fostering awareness and beneficial health behaviors and should not be a substitute for trustworthy sources of information such as healthcare professional experts in emerging infectious diseases.