Toxoplasmosis awareness among women: a cross-sectional study on knowledge, attitudes, perceptions, and risk factors

Abstract

Toxoplasmosis, a prevalent zoonotic infection caused by Toxoplasma gondii, poses significant risks for pregnant women. Despite its global prevalence, awareness remains inconsistent, particularly in endemic regions like Pakistan. A cross-sectional study evaluated knowledge, attitudes, and perceptions of 612 women in Khyber Pakhtunkhwa, Pakistan, using a validated questionnaire. Descriptive statistics, chi-square tests (χ²), Spearman’s correlation, and logistic regression were employed to examine demographic and behavioral associations. The dependent variable investigated in this study was high-risk status for toxoplasmosis exposure, based on various demographic and behavioral factors such as dietary habits, hand hygiene, and environmental exposure. The study revealed that while 66.8% of participants had a high level of knowledge, significant gaps persisted. Notably, 37.1% were unaware that cat feces can be a source of transmission, 41.8% did not associate the consumption of raw meat with the risk of infection, 28.8% were unaware of the importance of screening during pregnancy, and 25% did not recognize Toxoplasma as a protozoan. Attitudes were moderately positive (56.9%), yet 45.9% underestimated the severity of toxoplasmosis. High-risk practices included the occasional consumption of raw meat (6.93%; χ² = 388.94, p < 0.001) and poor hand hygiene (4.57% never washed hands after meat handling). Logistic regression identified younger women and unmarried women as being at high risk; education significantly predicted knowledge but not safer practices. Despite moderate awareness, persistent gaps between knowledge and Risk factor exposure demand targeted interventions in high-risk groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-25286-4.

Introduction

Toxoplasmosis is a worldwide prevalent zoonotic infection caused by the obligate intracellular protozoan parasite Toxoplasma gondii (T. gondii), which infects nearly one-third of the world’s human population [1–4]. The seroprevalence of toxoplasmosis exhibits significant regional variations, ranging from low in North America, Southeast Asia, Northern Europe, and Saharan Africa (10%–30%), to moderate in Southern and Central Europe (30%–50%), and high in Latin America and tropical Africa [5]. Toxoplasmosis, predominantly congenital toxoplasmosis, is a significant concern for pregnant women. The prevalence of congenital toxoplasmosis is terrifyingly high in endemic areas, with substantial regional variations. Studies from countries such as Brazil, Mexico, and Pakistan report a higher prevalence of congenital toxoplasmosis among pregnant women [3].

In Pakistan, the incidence of T. gondii infection among women of reproductive age is 40.6%, and studies from Southern Punjab have reported similarly high rates [4]. In Pakistan, studies have reported alarming seroprevalence rates of 29.45% and 40.6% among women with poor obstetric history in Southern Punjab and Khyber Pakhtunkhwa, respectively [6]. In another community-based study from Bahawalpur District involving married women of reproductive age (n = 500), a 38.2% IgG seroprevalence was observed [7]. Several studies from South Asia have shown varying seroprevalence rates of T. gondii infection among women of reproductive age and pregnant women. In a rural cohort of pregnant women in Bangladesh (n = 208), the overall seroprevalence (IgG and/or IgM) detected by chemiluminescent immunoassay was 25.0% [8]. An earlier hospital-based study from Dhaka reported 38.5% IgG and 1.1% IgM positivity among pregnant women [9]. In North India, a prospective cohort of women in early pregnancy (first four months; n = 180) showed a 45.2% IgG seropositivity rate [10]. Meanwhile, a large Indian series including mixed female cohorts (with pregnant women) reported a comparatively lower prevalence of 22.4% IgG in 2014, providing a proper lower contemporary estimate [11]. In Nepal, a classic series from Kathmandu documented 55.4% overall seroprevalence among pregnant women [12]. In Sri Lanka, a cross-sectional study at the Peradeniya antenatal clinic (n = 486) found a prevalence of 29.9% [13], while another Sri Lankan study (n = 293; mean age 27 years) reported 12.3% IgG seropositivity and no IgM positivity among pregnant women [14].

These statistics highlight a substantial disease burden, especially among women of reproductive age. Several factors contribute to T. gondii transmission in humans, including eating raw or undercooked meat, ingesting oocysts from contaminated soil, water, or cat litter, vertical transmission from mother to fetus, blood transfusions, and organ transplants [15]. This protozoan exists in three infectious stages: oocysts (which release sporozoites), tachyzoites (a rapidly multiplying form), and tissue cysts (containing bradyzoites). Oocysts are produced only in the intestines of cats, which serve as the definitive hosts, and are excreted into the environment via feces [3]. After sporulation, these oocysts become infectious and can contaminate soil, water, and vegetables, presenting a significant route of infection for both animals and humans [16]. Parasitic tissue cysts and tachyzoites can also infect intermediate hosts, including humans, as well as various warm-blooded animals [17–20].

Toxoplasmosis is often clinically asymptomatic in immunocompetent individuals [15]. But in pregnancy, it can cause congenital infection with severe outcomes such as stillbirth, fetal death, intracranial calcifications, hydrocephalus, and chorioretinitis. The risk of vertical transmission rises in the third trimester, though infections in the first trimester cause the most severe damage [16]. In an immunocompromised patient, latent infections may reactivate, leading to seizures, encephalitis, and other neurological complications [17]. Additionally, toxoplasmosis has been linked to neuropsychiatric disorders, including epilepsy, schizophrenia, and bipolar disorder [18, 19]. Diagnosis relies on serological tests, while molecular techniques [20], like polymerase chain reaction (PCR), offer higher specificity and sensitivity, particularly for congenital cases. Immunochromatographic tests and Western blotting also contribute to confirming the diagnosis [21, 22].

Toxoplasmosis treatment typically combines sulfadiazine and pyrimethamine, with folinic acid or an alternative such as lincosamides and macrolides. Spiramycin is preferred in early pregnancy to reduce the chances of T. gondii fetal transmission, particularly in the first trimester when the risks like hydrocephalus and intracranial calcifications are highest [4, 23]. Recent studies highlight natural products such as ginger (Zingiber officinale) and date palm (Phoenix dactylifera), for their promising antiparasitic effects with minimal side effects [24, 25]. Despite available treatment, prevention remains the key approach, especially in pregnancy, through safe food handling, proper cooking, hand hygiene, and health education provided by maternity care professionals [26, 27].

Toxoplasmosis remains a neglected parasitic disease in many developing countries, including Pakistan, despite its significant health and economic impacts. Awareness campaigns and community-based surveys are crucial for identifying knowledge, attitudes, and practices that reveal existing knowledge gaps and inform the development of effective control strategies. A study conducted among university students in Islamabad and Rawalpindi assessed their awareness, understanding, and behaviors concerning toxoplasmosis, highlighting the urgent need for focused, educational efforts [28]. Overall, toxoplasmosis poses a critical one-health concern, impacting both humans and animals worldwide. Due to its diverse transmission routes, broad spectrum of clinical outcomes, and considerable public health burden, a multidisciplinary approach is necessary, integrating education, public health initiatives, veterinary interventions, and community engagement. Enhancing preventive strategies and raising awareness, especially among high-risk groups such as pregnant women, can substantially reduce the incidence, prevalence, and severity of the disease. In our study, we focused on women to assess their KAP regarding toxoplasmosis and identify areas needing targeted intervention. Therefore, Public health initiatives should focus on educating at-risk groups, especially pregnant women, about the modes and sources of T. gondii transmission. Studies from several countries emphasize the critical role of education in raising awareness and changing behaviors to prevent infection [29–32]. The study aimed to assess the knowledge, attitudes, practices, and risk factors for toxoplasmosis among women in Khyber Pakhtunkhwa, Pakistan, to identify critical awareness gaps and inform the development of targeted, effective control strategies.

Materials and methods

Study design and settings

A structured questionnaire was used in this cross-sectional study to evaluate toxoplasmosis risk factor exposure among women in Khyber Pakhtunkhwa, Pakistan, from January to March 2025. The study was conducted across multiple urban and rural community locations within the province, with a focus on districts surrounding major educational institutions. We calculated a sample size of 385 women using a 95% confidence interval, a 5% margin of error, and a 50% response rate by using the following formula as described by [33, 34].

Where

• n is the sample size needed.

• Z is the Z-value (1.96 for 95% confidence).

• p is the estimated proportion (0.5 if unknown).

• e is the margin of error (0.05).

• N is the population size.

Now putting the values in the above equation.

By Finite Population Correction (FPC), the desired sample size will be calculated by considering the scope of the study throughout the province, which is given by:

A Response distribution was considered for estimation of the sample, with a margin of error of 5% and a 95% level (z = 1.96).

However, to enhance the statistical power and generalizability of the findings, we expanded the sample size. We collected questionnaires from 700 participants, of which only 612 were included for further analysis, yielding an overall response rate of 87.4%. The inclusion criterion for validity was a minimum completion rate of 75% of the questionnaire. To maintain the integrity and reliability of the study findings, only those participants who completed at least 75% of the questionnaire were included in the final analysis. This threshold was set to ensure sufficient data for accurate and valid statistical analysis, while minimizing potential biases from incomplete responses. A stratified random sampling technique was used to select participants representing diverse demographic categories, including age, marital status, educational levels, employment status, and residential backgrounds (urban versus rural).

Questionnaire design and distribution

We developed a structured questionnaire in English (as attached supplementary file) with input from epidemiologists and public health experts. It consisted of four sections: demographic (5 items), knowledge (8 questions), attitudes and perceptions (5 items), and risk factors (6 items). The tool demonstrated good reliability, with Cronbach’s alpha values of 0.80, 0.76, and 0.73 for knowledge, attitudes and perceptions, and risk factors, respectively, all exceeding the standard threshold for internal consistency.

Data collection procedure

The data were collected through face-to-face interviews using structured questionnaires by trained research assistants in community settings across Khyber Pakhtunkhwa, Pakistan. Confidentiality was ensured by excluding personal identifiers, and informed consent was obtained, explaining study objectives and participant rights. Quality control measures included mandatory responses, standardized clarifications, on-site checks for completeness, and a double data entry in Microsoft Excel to reduce errors. This rigorous approach maintained data integrity while adhering to ethical research principles, particularly regarding respondent autonomy and data protection protocols. The combination of trained personnel, standardized administration, and systematic quality checks guaranteed the collection of reliable and valid data for analysis.

Study variables

The study revealed toxoplasmosis risk factor exposure through 24 questions, assessing three key domains: knowledge, attitudes, perceptions, and risk factors. Demographic variables included age group (20–30, 31–40, or ≥ 41 years), marital status (single or married), education level (secondary, bachelor, or master), employment status (employed, unemployed, or student), and place of residence (rural or urban).

For the assessment of knowledge regarding toxoplasmosis, there were nine questions. Each correct answer was scored 1 point, and an incorrect answer was scored 0 points, yielding a total score ranging from 0 to 9. Median scores ≥ 6 was set as the threshold for higher knowledge. In comparison, lower scores (5 or below) showed a low level of knowledge, revealing participants’ limited understanding of disease transmission, prevention, and symptoms. The cut-off points were determined based on previous KAP studies [32, 37] and the median score distribution in our sample. For attitude/perception assessment, we included five questions, each scored from 0 to 1, resulting in a total possible score range from 0 to 5. We then further categorized the overall attitude based on the total possible score. A median score of 4 or above indicates a positive attitude, while scores below 4 were classified as indicating a negative attitude. There were six questions to assess the risk factor exposure. We assessed exposure to risk by assigning scores to optimal/no-risk responses (0 points) and high-risk responses (1 point), resulting in a total possible score of 0 to 6. A score of 3 or above was classified as “high-risk exposure”, whereas a score below 3 was classified as “low-risk exposure” using the median score as the threshold. Using a median threshold of 3 or above as higher potential risk exposures, and vice versa.

Statistical analysis

Data analysis was performed using SPSS version 2023 (IBM Corp.). Initial data cleaning included an analysis of missing values to identify and address any incomplete responses; however, no imputation was required, as all questions were compulsory. Descriptive statistics (frequencies, percentages) characterized demographic variables and the overall distribution of knowledge, attitudes, practices, and risk factors. Chi-square (χ²) tests were used to assess associations between demographic characteristics and related knowledge, attitude, and risk outcomes. Spearman’s rank correlation (ρ) was used to evaluate the relationships between knowledge scores, attitudes, and risk factors. Binary logistic regression was employed to recognize predictors of high-risk status (dependent variable: risk level [low/high]), with odds ratios (ORs) and 95% confidence intervals (CIs). The dependent variable was the risk level, categorized as low or high based on a median split of the total risk factor exposure score (low risk: score < 3; high risk: score ≥ 3), as well-defined in the “Study Variables” section. All tests utilized two-tailed significance thresholds (α = 0.05). For the multiple chi-square tests in Table 5, a Bonferroni correction was considered; however, as the analyses were exploratory and aimed to identify potential associations for further investigation, we reported the uncorrected P-values, acknowledging that some findings should be interpreted with caution.

Table 5.

Toxoplasma-related comparison of knowledge, attitude, perception, and its risk factors scores amongst different groups

Variable	Knowledge		Attitude/Perception		Exposure to Risk
	Low	High	Negative	Positive	High	Low
Age (Years)
20–30	125	248	160	213	59	314
31–40	56	105	76	85	37	124
≥41	22	56	28	50	16	62
	χ² = 1.08		χ² = 2.76		χ² = 4.15
	p-value = 0.58		p-value = 0.25		p-value = 0.13
Marital status
Married	153	319	207	265	87	385
Single	50	90	57	83	25	115
	χ² = 0.53		χ² = 0.43		χ² = 0.02
	p-value = 0.47		p-value = 0.51		p-value = 0.88
Education
Secondary	56	82	82	56	22	116
Bachelor	79	198	69	208	65	212
Master	68	128	113	84	25	172
	χ² = 6.281		χ² = 68.683		χ² = 9.603
	p-value = 0.04		p-value = < 0.001		p-value = 0.01
Occupation
Employed	66	125	92	99	41	150
Unemployed	112	222	140	194	52	282
Student	25	62	32	55	19	68
	χ² = 0.96		χ² = 3.61		χ² = 3.68
	p-value = 0.62		p-value = 0.17		p-value = 0.16
Residence
Rural	79	160	112	127	41	198
Urban	124	249	152	221
	χ² = <0.001		χ² = 2.22		χ² = 0.34
	p-value = 0.96		p-value = 0.14		p-value = 0.56

χ² Chi-Square test, P Probability value, P < 0.05 was considered statistically significant

Results

Socio-demographic variables of participants

As shown in Table 1, most respondents were young adults (20–30 years), most were married, and a significant portion had higher education (bachelor’s or master’s degree). More than half of the participants were unemployed, and most lived in urban areas. These socio-demographic characteristics reflect the diverse backgrounds of the study population, which may influence their knowledge, attitude, and exposure to risk factors related to toxoplasmosis.

Table 1.

Frequencies of Socio-demographic variables among participants (N = 612)

Variable	Category	Frequency (%)
Age	20–30 years	373 (60.9)
	31–40 years	161 (26.3)
	41 years and above	78 (12.7)
Marital Status	Married	472 (77.1)
	Single	140 (22.9)
Education	Secondary	138 (22.5)
	Bachelor	277 (45.3)
	Master	197 (32.2)
Occupation	Employed	191 (31.2)
	Unemployed	334 (54.6)
	Student	87 (14.2)
Residence	Rural	239 (39.1)
	Urban	373 (60.9)

n (%) number (percentage)

Descriptive analysis

The assessment of toxoplasmosis-related knowledge, attitudes, and risk factor exposure is summarized in Table 2. Participants obtained a mean knowledge score of 4.19 (SD = 1.62), indicating moderate levels of understanding of the disease. The mean attitude scores were 3.13 (SD = 1.76), reflecting participants’ responses to items assessing perceptions and attitudes toward toxoplasmosis prevention and control. The mean score for risk factor exposure was 8.48 (SD = 2.26), representing reported practices and behaviours associated with potential transmission routes. The standard deviations observed across the three domains suggest variation in responses among participants.

Table 2.

Descriptive analysis of toxoplasmosis-related knowledge, attitudes, and risk factors exposure

Variable	Mean	Standard Deviation
Knowledge	4.19	1.62
Attitude	3.13	1.76
Risk Factors	8.48	2.26

SD Standard Deviation

Correlation

Spearman correlation coefficient (ρ) was computed to assess the strength and direction of the associations between the independent variables (knowledge, attitude, and risk factors), as shown in Table 3.

Table 3.

Correlation between knowledge, attitudes, and risk factors

Association	(ρ)	p-value	Direction
Knowledge and Attitude	0.18	< 0.01**	Positive Correlation
Knowledge and Risk factors	-0.09	0.04	Negative Correlation
Attitude and Risk factors	-0.03	0.49	Negative Correlation

P Probability value, (ρ) Spearman’s correlation coefficient

*indicates statistical significance at the 0.01 level

A statistically significant but weak positive correlation was observed between knowledge and attitudes (ρ = 0.18, p < 0.01), suggesting that increased knowledge was associated with more positive attitudes toward toxoplasmosis prevention. In contrast, a weak but significant negative correlation was observed between knowledge and risk factors (ρ = -0.09, p = 0.04), indicating that increased knowledge was correlated with decreased exposure to risk factors. No statistically significant association was observed between attitudes and risk factors (ρ = -0.03, p = 0.49).

Overall score of knowledge, attitude, perception, and risk factors level

As summarized in Table 4, most women demonstrated adequate knowledge of toxoplasmosis, although a significant proportion still showed limited awareness. Attitudes toward prevention were generally positive, yet misconceptions persisted among some participants. While most respondents were classified as having low-risk exposure, nearly one-fifth fell into the high-risk category, highlighting the need for targeted educational and preventive measures.

Table 4.

Knowledge, perception, attitude, and risk factor exposure level score among participants (N = 612)

Characteristic	Score level	Frequency (%)
Knowledge	High	409 (66.8)
	Low	203 (33.2)
Perception and Attitude	Negative	264 (43.1)
	Positive	348 (56.9)
Risk Factors for Exposure	Low	500 (81.7)
	High	112 (18.3)

n (%) number (percentage)

Comparison of Toxoplasma-related KAP and risk factor exposure scores between different groups

As shown in Table 5, education level was significantly linked to knowledge, attitudes, and risk factors related to toxoplasmosis. Women with higher education, especially those with a bachelor’s and master’s degree, were more likely to demonstrate better knowledge, positive attitudes, and lower risk of exposure compared to those with secondary education. In contrast, no significant associations were found with age, marital status, occupation, or place of residence. These findings emphasize the role of education in shaping awareness, perceptions, and preventative practices toward toxoplasmosis.

Knowledge about toxoplasmosis among study participants (N = 612)

As shown in Table 6, all participants reported hearing about toxoplasmosis, though only a small number had ever been infected. Most women correctly identified toxoplasmosis as a protozoan infectious disease, but notable gaps in knowledge were still present. For example, over one-third of participants did not know that cat feces and undercooked meat are key ways of disease spreads. Similarly, more than one-third were unaware of its possible negative effects on pregnancy. While most recognized the importance of regular screening during pregnancy, a significant number of women remained uninformed. These results suggest that overall awareness of toxoplasmosis is good, but essential gaps exist that could increase the risk of exposure.

Table 6.

Toxoplasmosis knowledge among participants (N = 612)

Question	Answer	Frequency (%)
Have you heard about Toxoplasma?	Yes	612 (100)
Have you ever been infected with toxoplasmosis?	Yes	31 (5.1)
	No	581 (94.9)
Is Toxoplasma an infectious disease?	Yes	456 (74.5)
	No	156 (25.5)
Do you know that Toxoplasma is a single-celled parasite?	Yes	459 (75)
	No	153 (25)
Is toxoplasmosis transmitted to humans via cat faeces?	Yes	385 (62.9)
	No	227 (37.1)
Is toxoplasmosis transmitted to humans via uncooked or raw meat?	Yes	356 (58.2)
	No	256 (41.8)
Do you know that toxoplasmosis can affect pregnancy outcomes?	Yes	383 (62.6)
	No	229 (37.4)
Are you aware of regular screening for toxoplasmosis during pregnancy?	Yes	436 (71.2)
	No	176 (28.8)

n (%) number (percentage)

Attitude and perception toward Toxoplasma among study participants (N = 612)

As shown in Table 7, most participants reported awareness of preventive measures and recognized the importance of health education and precautionary behaviors during pregnancy. However, perceptions of disease severity varied, with nearly half of the respondents not viewing toxoplasmosis as a serious health concern. Similarly, a significant minority did not value preventive strategies or health education, indicating that misconceptions still exist. Overall, while attitudes toward prevention were generally positive, significant gaps remain that could hinder effective risk reduction, especially among women of reproductive age.

Table 7.

Participant attitude and perception toward Toxoplasma (N = 612)

Question	Answer	Frequency (%)
Do you know how to prevent toxoplasmosis?	Yes	405 (66.2)
	No	207 (33.8)
Do you think toxoplasmosis is a serious disease?	Yes	331 (54.1)
	No	281 (45.9)
Do you believe health education about toxoplasmosis is important?	Yes	390 (63.7)
	No	222 (36.3)
Should pregnant women take extra precautions to prevent toxoplasmosis?	Yes	397 (64.9)
	No	215 (35.1)
Would you encourage others to adopt preventive measures?	Yes	390 (63.7)
	No	222 (36.3)

n (%) number (percentage)

Risk factor exposure of Toxoplasma among study participants (N = 612)

As shown in Table 8, most participants reported practicing safe behaviors such as regularly washing fruits and vegetables, avoiding raw or undercooked meat, and maintaining good hygiene after handling raw meat. However, lapses in these preventive practices were observed among a small but notable portion of respondents. A significant number of women reported keeping cats, and many were directly involved in cleaning litter boxes, which could pose a potential risk of exposure. Similarly, while the majority wore gloves during gardening, a small percentage did not consistently take this precaution. These findings indicate generally good practices but highlight specific behavioral gaps that could increase vulnerability to toxoplasmosis and should be addressed through targeted health education and risk reduction strategies.

Table 8.

Risk factor exposure related to toxoplasmosis among participants (N = 612)

Risk factor exposure	Category	Frequency (%)
Do you wash fruits and vegetables before eating?	Never	28 (4.6)
	Sometimes	67 (10.9)
	Always	517 (84.5)
How often you eat undercooked or raw meat?	Sometimes	11 (1.8)
	Rarely	31 (5.1)
	Never	570 (93.1)
Do you wash hands with soap after handling raw meat?	Never	26 (4.2)
	Sometimes	70 (11.4)
	Always	516 (84.3)
Do you wear gloves while gardening?	Never	72 (11.8)
	Sometimes	99 (16.2)
	Always	441 (72.1)
Do you keep cats as pets?	Yes	438 (71.6)
	No	174 (28.4)
Do you clean the litter box?	Yes	419 (68.5)
	No	193 (31.5)

n (%) number (percentage)

Assessment of the associations between toxoplasmosis and age, marital status, residence, and risk factors

As shown in Table 9, a small proportion of women (5.1%) reported having had toxoplasmosis, while most had never been infected. No statistically significant link was found between toxoplasmosis and age, marital status, or place of residence. Although a higher number of infections appeared in the 20–30 age group (23 out of 373), the difference across age groups was not statistically significant. Similarly, no significant differences were observed between married and single women or between urban and rural residents. However, strong associations were evident between infection and several behavioral risk factors. Women who did not regularly wash fruits and vegetables, ate raw or undercooked meat, or failed to practice proper hand hygiene after handling raw meat showed noticeably higher infection rates compared to those who adopted preventive measures. Gardening without gloves and not cleaning litter boxes were also significantly linked to increased infection, emphasizing the role of environmental and household exposures. Overall, while socio-demographic factors did not relate to toxoplasmosis, unsafe dietary habits, poor hygiene practices, and specific ecological exposures significantly increased infection risk. These findings underscore the importance of targeted health education and behavioral interventions to reduce transmission.

Table 9.

Assessment of the associations between toxoplasmosis with age, marital status, residence, and risk factors questions

Variable	Infected (31) n (%)		Uninfected (581) n (%)	Pearson χ²	p-value
Age (years)
20–30	23 (74.2)		350 (60.2)	4.67	0.10
31–40	3 (9.7)		158 (27.2)
≥41	5 (16.1)		78 (13.4)
Marital Status				0.002	0.97
Married	24 (77.4)		448 (77.1)
Single	7 (22.6)		113 (19.4)
Residence
Rural	14 (45.2)		225 (38.7)	0.51	0.47
Urban	17 (54.8)		356 (61.3)
Washing fruits and vegetables before eating
Never	6 (19.4)		22 (3.8)	175.61	< 0.001
Sometimes	24 (77.4)		42 (7.2)
Always	1 (3.2)		517 (89.0)
Eating undercooked or raw meat
Sometimes	9 (29.0)		2 (0.3)	388.95	< 0.001
Rarely	20 (64.5)		11 (1.9)
Never	2 (6.5)		568 (97.8)
Handwash with soap after handling raw meat
Never	4 (12.9)		22 (3.8)	196.71	< 0.001
Sometimes	27 (87.1)		43 (7.4)
Always	0 (0.0)		516 (88.8)
Wearing gloves while gardening
Never	7 (22.6)		65 (11.2)	92.66	< 0.001
Sometimes	23 (74.2)		76 (13.1)
Always	1 (3.2)		440 (75.7)
Have cats as pets
Yes	26 (83.9)		412 (70.9)	2.43	0.12
No	5 (16.1)		169 (29.1)
Clean litter box
Yes	8 (25.8)		411 (70.7)	27.52	< 0.001
No	23 (74.2)		170 (29.3)

n (%) number (percentage), χ² Chi-Square test, P  Probability value

Knowledge, attitude, perception, and risk factor association with toxoplasmosis

As shown in Table 10, Logistic regression analysis identified several key predictors of toxoplasmosis risk. Younger women, especially those aged 20–30 years, had more than three times the odds of being in the high-risk group compared to women aged 41 or older. Single participants were also at higher risk compared to married women, while unemployment more than doubled the odds of high-risk status compared to students. Educational background appeared to have a protective effect, as participants with a bachelor’s degree were less likely to fall into the high-risk category compared with those with higher qualifications. Similarly, lower levels of knowledge significantly increased the odds of risk exposure. In contrast, no significant associations were found for women aged 31–40 years, those with secondary education, rural residents, or participants with negative attitudes toward toxoplasmosis. Overall, the results emphasize that age, marital and occupational status, education level, and knowledge play a key role in risk, while attitude alone does not significantly predict exposure.

Table 10.

Association of toxoplasmosis between knowledge, attitudes, and risk factors

Variables	Category	OR (95% CI)	p-value
Age (versus ≥ 41 years)	20–30 years	3.26 (1.91–5.56)	< 0.001
	31–40 years	1.57 (0.88–2.82)	0.13
Marital Status (versus married)	Single	1.77 (1.02–3.06)	0.04
Education (versus Master)	Secondary	0.61 (0.30–1.23)	0.17
	Bachelor	0.61 (0.39–0.98)	0.04
Occupation (versus student)	Employed	1.73 (1.00-2.977)	0.05
	Unemployed	2.25 (1.305–3.880)	0.004
Residence (versus Urban)	Rural	1.20 (0.78–1.83)	0.41
Knowledge (versus High)	Low	1.74 (1.10–2.75)	0.02
Attitude (versus Positive)	Negative	1.032 (0.66–1.61)	0.89

OR Odds Ratio, Cl Confidence Interval

Discussion

Toxoplasmosis remains a significant global zoonotic disease with severe implications, particularly for immunocompromised individuals and pregnant women [35]. This cross-sectional study among women provides a comprehensive assessment of knowledge, attitudes, perceptions, and associated risk factors. The findings offer important insight into both progress and persistent gaps in toxoplasmosis awareness and its prevention across diverse sociodemographic groups. The study found that participants possessed high knowledge (66.8%) about toxoplasmosis, a considerably higher proportion than reports from some countries in Africa (30.1%) and the Middle East [36, 37], but aligning with studies from Latin America and other regions [38, 39]. Respondents demonstrated strong awareness of the fundamental level, with 74.5% correctly identifying toxoplasmosis as infectious and 75% recognizing protozoa as the causative agent, which are higher than those reported in certain endemic regions [40].

Compared with the studies from South and Southeast Asia, our overall knowledge scores are higher than some regional reports, but the same gaps are seen in transmission-related understanding. A large multicounty survey in Malaysia, the Philippines, and Thailand reported low awareness of specific routes (e.g., cat feces, raw meat) despite routine hygiene behaviors among many respondents [40]. Similarly, seroprevalence and awareness studies from Sri Lanka and Bangladesh have documented variable seroprevalence along with detailed knowledge of transmission and pregnancy risks, highlighting comparable public health challenges in the region [14]. Findings from India and Nepal also reported substantial seroprevalence in specific groups and variable KAP levels, supporting our observation that regional burden, awareness, and heterogeneity are context-dependent [41, 42].

Our findings show that pregnancy-related awareness of toxoplasmosis was generally moderate, but notable gaps remain, especially in knowledge about prenatal screening, with 28.8% of women unaware of its importance. These gaps were more common among younger and less-educated participants, highlighting the need for targeted educational efforts. Although 56.9% of respondents had positive attitudes toward prevention and 54.1% saw toxoplasmosis as a serious health concern, nearly half underestimated its risk; these results match the previous studies, which reported 51.4% [41]. A significant positive correlation between knowledge and attitude (ρ = 0.177, p < 0.01) indicates that education can improve awareness; similar results were evidenced from South and Latin America, where education improved prevention advocacy [42]. Encouragingly, 63.7% of respondents supported the introduction of health education, and 64.9% supported special precautions for pregnant women. Nevertheless, 33.8% of participants remained unaware of specific prevention methods, and attitudes alone did not significantly reduce risk behaviors (ρ = -0.028, p = 0.485). This disconnects mirrors findings from Colombia, where improved knowledge failed to alter practices [43].

Our study highlights the multifactorial nature of toxoplasmosis risk, where both behavioral and demographic factors play pivotal roles in shaping exposure and awareness. Meat consumption emerged as the strongest behavioral determinant, with women who occasionally consumed raw or undercooked meat showing markedly higher infection rates as compared to those who abstained (0.4%, χ² = 388.947, p < 0.001). This is strongly consistent with previous research that implicates undercooked meat consumption as a major transmission route [38]. Although the majority of participants reported washing vegetables, a small proportion admitted to never engaging in this practice, echoing findings from Ethiopian cohorts where risky dietary and hygiene behaviour remained prevalent [39].

Environmental exposures were also significant contributors. Gardening without gloves was strongly associated with increased infection risk, underscoring the role of soil contamination in transmission. Likewise, improper cat litter management was positively correlated with an infection rate, reinforcing the importance of zoonotic exposure through felines. The high prevalence of cat ownership (71.57%) and direct litter handling among women in this study mirrors observations from Tanzania [44] and Palestine [45], underscoring the risks of zoonotic exposure.

Demographic factors significantly influenced both knowledge and risk profiles. Education was the strongest predictor (χ² = 68.683, p < 0.001). Post-hoc analysis confirmed that bachelor’s degree holders had significantly higher knowledge than those with master’s or secondary education (P < 0.05), supporting trends observed in other studies [46]. However, this educational advantage did not consistently translate into safer practices, reinforcing the idea that knowledge alone is not enough to change behavior. Age was another key factor: younger women had greater baseline knowledge, yet paradoxically faced a higher infection risk, possibly due to risk-taking behaviors or inconsistent use of preventive measures. Marital status modestly affected perceptions of disease severity, while socioeconomic differences further stratified exposure risk, with unemployed respondents showing significantly higher odds of engaging in high-risk practices compared to students, likely reflecting disparities in health literacy or access to resources. Urban-rural differences were notable in knowledge (urban residents better understood cat-related transmission) but not in actual preventive practices, as seen in Algeria [47].

The findings recommend three key priorities for intervention: First, targeted education should focus on high-risk groups (young, single, less-educated women) and address specific misconceptions (e.g., waterborne transmission [48], blood transfusion risks [40]). Second, behavioral interventions must emphasize practical measures, such as consistent hand-washing after gardening (87.3% in our study vs. 77.6% in Ethiopia [39] and safe meat preparation, modeled after successful Brazilian prenatal programs [49]. Third, prenatal screening awareness (71.2%) should be leveraged to expand compliance, addressing gaps seen in Colombia [43], where self-reported adherence surpassed actual follow-up rates. The study emphasizes that while urban populations may have better access to information, both rural and urban communities require culturally tailored interventions to bridge knowledge-practice gaps.

Knowledge-Practice gap

The gap between knowledge and practice observed in this study may arise from behavioral and cultural factors. Knowledge alone often cannot override ingrained habits, perceived low risk, or cultural norms related to food preparation and contact with animals. Behavioral psychology theories show that abstract health risks are often overlooked in favor of convenient or traditional practices. Therefore, interventions need to go beyond education and include practical, culturally appropriate strategies that address these barriers, such as demonstrating safe food handling or providing affordable protective tools like gloves.

Study strengths and limitations

A key strength is the diverse sample of participants from several demographic backgrounds, which augments the representativeness of the findings across the region. The use of a validated, culturally adapted questionnaire with robust internal consistency (Cronbach’s alpha > 0.70 across all domains) and administration by skilled research assistants through face-to-face interviews guaranteed high data reliability and minimized errors. The multidimensional assessment encompasses knowledge, attitudes, perceptions, and risk factors, providing a comprehensive understanding of awareness levels. Moreover, ethical protocols were strictly adhered to, ensuring the confidentiality of participants’ data and obtaining informed consent. However, the study also presents limitations. The geographical focus of data collection in Khyber Pakhtunkhwa may limit the generalizability of results to other provinces, introducing a potential regional bias. Security issues and strict cultural norms restrict women’s participation in Khyber Pakhtunkhwa, posing challenges to broader recruitment, which may affect generalizability. The cross-sectional design limits causal inferences and the ability to assess changes over time. Although efforts were made to include a broad demographic, women outside academic or community networks may have been underrepresented. Lastly, relying on self-reported data carries the risk of recall and social desirability bias, which could affect the validity of the findings.

Conclusion

This study reveals moderate awareness of toxoplasmosis among women in Khyber Pakhtunkhwa, with significant gaps in understanding key transmission pathways. Strong links between specific behaviours and infection risk identify clear targets for public health efforts. Tailored education and prevention strategies, especially for high-risk groups, are vital to lowering transmission and adverse health outcomes.

Authors’ contributions

“Conceptualization, M.H.W, I.A., and C.C.C.; methodology, A.Q. H.Y.A; software, M.A.; validation, F.M.A., K.J.A., and K.F.A.; formal analysis, A.Q. H.Y.A; investigation, A.Q, HY.A; resources, C.C.C.; data curation, I.Q.; writing—original draft preparation, A.Q. H. Y.A. S.H; writing—review and editing, M.H.W, I.A., and C.C.C.; visualization, M.A.; supervision, M.H.W, I.A., and C.C.C.;; project administration, C.C.C.; funding acquisition, C.C.C, M.A. All authors have read and agreed to the published version of the manuscript.”

Funding

The Deanship of Scientific Research funded this work at King Khalid University for funding this work through the large research group program under grant number (R.G.P.02/709/46).

Data availability

The data sets used or analyzed during the current study are available from First author on reasonable request. Email: qadeerktk848@yahoo.com.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Ethics Committee of Kohsar University, Muree, which conformed to the ethical guidelines outlined in the Declaration of Helsinki. The respondents provided electronic informed consent, presented at the beginning of the survey, by selecting either “Yes” or “No” for the statement: “I voluntarily participate in this study after understanding its objectives, and I provide my responses willingly and truthfully,” before proceeding to the online self-administered questionnaire.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.