Factors related to nursing students’ behavior for personal protection against Monkeypox at Western University, Buriram Campus, Thailand

Abstract

BACKGROUND:

Mpox, previously known as Monkeypox, is a viral infection transmitted from animals to humans. It has symptoms similar to smallpox or cowpox, which has been severely epidemic and claimed many lives. In July 2022, the World Health Organization declared monkeypox a public health emergency of international concern.

MATERIALS AND METHODS:

This study aimed to explore the relationship between personal factors, knowledge about monkeypox, attitude toward monkeypox prevention, and behavior to prevent monkeypox among nursing students at Western University, Buriram Campus, Thailand. This cross-sectional descriptive study consisted of 430 nursing students selected by purposive sampling. Data were collected by using a questionnaire on personal data, knowledge about monkeypox, attitude toward monkeypox prevention, and behavior to prevent monkeypox. Statistics were used, while Chi-Square and Pearson’s product-moment correlation coefficient were used to identify factors related to monkeypox self-protective behavior.

RESULTS:

The results of the study found that the sample group knew about monkeypox, attitude toward monkeypox prevention, and monkeypox self-protective behavior at high levels of 56.3, 6, 6.7, and 81.2, respectively. Factors that were significantly related to monkeypox self-protective behavior among nursing students at Western University, Buriram Campus, included knowledge about monkeypox and attitude toward monkeypox prevention (r = 0.099, 0.309), respectively (P < 0.001).

CONCLUSIONS:

The results of the study concluded that knowledge about monkeypox and attitude toward monkeypox prevention in nursing students are important for effective monkeypox prevention. In addition, stricter monkeypox prevention should be implemented because the number of monkeypox infections reported in various media has decreased, causing the general public to be less aware of self-protection.

Introduction

Monkeypox is a disease of global importance in terms of public health and affects countries around the world. Monkeypox is a viral disease transmitted from animals to humans with symptoms similar to smallpox, which historically had severe outbreaks and killed many people. Monkeypox in humans was first found in the 1970s in the Democratic Republic of the Congo. The outbreak was suppressed by vaccination in the 1980s. It has been found in Central and West Africa until it became endemic in tropical forests before spreading to urban areas. The vectors are rodents and mammals.[1] In July 2022, the World Health Organization declared monkeypox a public health emergency of international concern.[2] The global monkeypox situation in 2022–2024 involved a total of 99,176 confirmed cases and 208 deaths. As for the situation in Africa in 2022–2024, there are a total of 14,250 cases and 456 deaths. In Thailand, the first monkeypox patient was found in a Nigerian tourist in Phuket Province in May 2022.[2] The current monkeypox infection situation in Thailand has revealed a total of 862 cases, divided into 841 cases (97.56%) of males and another 21 cases (2.44%) of females, with those aged between 30 and 39 years accounting for 361 cases (41.88%). Buriram Province found two monkeypox patients.[3]

Transmission from animals to humans can occur through direct contact with the blood, body fluids, or skin or mucous membranes of infected animals and from person-to-person transmission. It can result from contact with respiratory secretions, from skin lesions of an infected person, or from hugging and touching bodies with boils or touching boils that occur near the vagina, anus, and genitals, including kissing and exchanging breaths during sexual intercourse, which may contain droplets of germs mixed with breath. The incubation period of monkeypox is 6 to 13 days but can range from 5 to 21 days.[1,2] Patients usually suffer from fever, muscle aches, and headaches. Fatigue and swollen lymph nodes, sore throat, stuffy nose, and coughing are also seen. Pus or blood in the stool, pain in the anus, or blood in the stool are possible as Mpox can be transmitted through the anus. Skin symptoms usually occur within 1–3 days. After the onset of fever or after the fever subsides, lesions usually appear on the genitals and may also appear on the mouth, face, or trunk and spread throughout the body within 14–21 days. The lesions appear as macular, popular, vesicles, umbilications, and pustules form 5 to 7 days before scabs form. The number of lesions can range from 1 to 2 to more than 100. After the scabs have fallen off, pitted scars may appear. When the rash has completely scabbed off and new lesions have formed, the patient is no longer contagious.[4]

From the literature review, it was found that knowledge about monkeypox among health massage service providers in Bangkok is at a low level.[5] Attitudes toward monkeypox among disease screening officers and personnel at international entry points in Thailand is at a moderate level.[6] Healthcare workers in Saudi Arabia have low levels of knowledge,[7] and university students in Bangladesh mostly have moderate knowledge, low attitudes, and moderate practices on monkeypox prevention.[8] For Thailand, there have been studies on monkeypox in terms of incidence surveys and attitude surveys, but no studies have been found on factors related to monkeypox. Therefore, to effectively control monkeypox, healthcare providers must have adequate knowledge, attitudes, and good practices to prevent the spread of the disease. Therefore, it is necessary to support medical personnel to understand the methods used for the prevention and treatment of monkeypox.[7]

Currently, there is no standard treatment for monkeypox infection, but there is supportive treatment for its symptoms. In addition, the number of monkeypox infections reported in various media has decreased, causing the public to be less aware of self-protection. A decrease in self-protection behaviors increases the chance and risk of monkeypox infection.[2] Nursing students are the medical personnel who will have to go out to take care of people’s health in the future. Nursing students learn the importance of health education during their study period and receive practical training.[9] Therefore, empathetic participation is an important component in building the nurse–patient relationship, which leads to more appropriate patient care. Empathetic participation is one of the important professional values that nurses have.[10] Therefore, they must know about health care, disease prevention, and health promotion for the public. Thus, the researcher aimed to study the factors related to self-protection behaviors from monkeypox of nursing students at Western University, Buriram Campus, to be beneficial in taking care of their health and the public’s health in preventing monkeypox infection. The results of the study can be used as a guideline for designing effective monkeypox prevention methods.

Conceptual framework

From the literature review, the researcher applied the conceptual framework of Bloom as cited in Khumsaen[11] to this study, which stated that knowledge, attitude, and behavior are processes that are linked step by step to create the desired behavior, which has three components: Knowledge, Attitude, Practice 9 is a physical expression that requires knowledge and attitude to lead to practice. The research conceptual framework is shown in Figure 1 as follows:

Figure 1.

Conceptual framework

Materials and Methods

Study design and setting

This study was a cross-sectional descriptive study that collected data from 430 first- to fourth-year nursing students at Western University, Buriram Campus, Thailand, in the academic year 2023.

Study participants and sampling

The population in this study consisted of 430 nursing students at Western University, Buriram Campus, Thailand. The sample group was selected by purposive sampling, which met the criteria: nursing students at Western University, Buriram Campus, 1^st–4^th year, academic year 2023, who had given consent and were willing to participate in the research project.

Data collection tool and technique

The instruments used in this study were questionnaires on knowledge about monkeypox, attitudes toward monkeypox prevention, and behaviors for self-protection from monkeypox by people in Mueang District, Buriram Province.[11] The researcher used the questionnaire to find reliability and tested it (Tryout) with a sample group of 30 people who had similar characteristics and environment to the sample group studied. The questionnaire was then analyzed for reliability using KR-20 and Cronbach’s alpha coefficient, with reliability values of 0.89, 0.92, and 0.99, respectively. The questionnaire was divided into four parts, consisting of:

Part 1: General information – This includes age, gender, grade point average, education level, income, and receipt of information about monkeypox prevention.

Part 2: Knowledge about monkeypox – There are[11] True/False questions. A correct answer is worth 1 point, and an incorrect answer is worth 0 points. The interpretation criteria are divided into three levels as follows: An average score between 2.34 and 3.00 means a great deal of knowledge, while an average score between 1.68 and 2.33 means moderate knowledge, and an average score between 1.00 and 1.67 means little knowledge.[11]

Part 3: Attitudes toward prevention of Monkeypox – There are ten questions in the form of multiple choice questions with a scale format. Likert scales are divided into four levels: strongly agree, agree, disagree, and strongly disagree. The interpretation criteria are divided into three levels as follows: An average score between 2.34 and 3.00 means having a very good attitude. An average score between 1.68 and 2.33 means having a moderate attitude, and an average score between 1.00 and 1.67 means having a low attitude.[11]

Part 4: Behavior to protect oneself from monkeypox – There are 14 questions in the form of multiple choice questions using Likert scales divided into five levels ranging from every time, often, sometimes, rarely, and not practiced. The interpretation criteria are divided into three levels as follows: An average score between 2.34 and 3.00 indicates good preventive behavior. An average score between 1.68 and 2.33 indicates moderate defensive behavior. An average score between 1.00 and 1.67 means low defensive behavior.[11]

Data collection takes time from May to July 2024. The obtained data will be recorded and analyzed statistically.

Ethical consideration

This study was approved by the Research Ethics Committee of the Buriram Provincial Public Health Office Thailand, No. BRO2024-043 Certification Date: 23 April 2024. In addition, this study will be conducted in accordance with the Helsinki Code of Ethics only if the subjects voluntarily consent and sign a study contract before participating in the research.

Data analysis

Descriptive statistics were calculated, including frequency distribution, percentage, mean, and standard deviation, and the relationship between the studied factors was analyzed using Chi-square and Pearson’s product-moment correlation coefficient at a statistical significance level of 0.05.

Results

It was found that the majority of the sample group was female (92.1%), aged between 21 and 25 years (60.0%), Grade point average between 2.01 and 4.00 (98.8%), and had a monthly income from parents of 1000–10,000 baht (96.0%). The average monthly income was 6155.09 baht (SD = 3887.956). Most had sufficient income to spend (61.6%), and most of the sample had previously received information about monkeypox prevention (95.1%), mostly from social media at 88.5%.

Table 1 shows it was found that nursing students had knowledge about monkeypox at a high level (56.3%), a moderate level (39.5%), and a low level (4.2%). Attitudes toward monkeypox prevention were at a high level (66.7%), a moderate level (32.1%), and a low level (1.2%). Self-protective behaviors against monkeypox were at a high level (81.2%), a moderate level (11.9%), and a low level (7.0%), respectively.

Table 1.

Knowledge level about monkeypox, attitude toward monkeypox prevention, and self-protective behavior from monkeypox of nursing students at Western University, Buriram Campus (n=430)

Factor		Quantity		Percentage
Knowledge about monkeypox
A little		18		4.2
Moderate		170		39.5
A lot		242		56.3
Attitudes toward monkeypox prevention
A little		5		1.2
Moderate		138		32.1
A lot		287		66.7
Preventive behaviors against monkeypox
A little		30		7.0
Moderate		51		11.9
A lot		349		81.2

Table 2 shows the factors significantly associated with monkeypox prevention behavior among nursing students, including knowledge about monkeypox (r = 0.099) and attitude toward monkeypox prevention (r = 0.309) (P < 0.001). Gender, age, grade point average, income, and receipt of information about monkeypox prevention were not significantly associated with monkeypox prevention behavior.

Table 2.

Factors associated with monkeypox protective behavior among nursing students (n=430)

Factors		Chi-square		Pearson correlation		P
Sex		2.700		-		0.259
Age		2.726		-		0.605
Grade point average		4.009		-		0.135
Income		2.053		-		0.358
Obtaining information about monkeypox prevention		1.184		-		0.553
Knowledge about monkeypox				0.099		<0.001**
Attitudes toward monkeypox prevention				0.309		<0.001**

**P<0.001

Discussion

The results of the study found that nursing students knew about monkeypox, attitudes toward the prevention of monkeypox, and behaviors to protect themselves from monkeypox at a high level, which may be because searching for information and news nowadays can easily be done through various online media and the nursing curriculum has organized teaching in preventing various health problems, whether it is preventing chronic diseases or preventing new diseases, which may allow students to gain more knowledge. When students have more knowledge, it results in good attitudes and behaviors to prevent monkeypox, which is consistent with the study that found that the knowledge, attitudes, and practices of medical students with monkeypox are at a good level.[12] Nursing students had a good level of overall knowledge concerning monkeypox.[13] This was consistent with a study that found that public health officers had a good attitude toward monkeypox prevention measures.[7] It was also consistent with a study that found that health care providers’ practices toward monkeypox were at a good level.[14] The factors that are related to the self-protective behavior from monkeypox of nursing students at Western University, Buriram Campus, are knowledge about monkeypox and attitude toward monkeypox prevention, which are in accordance with the objectives and hypotheses of the study. They can be explained in detail as follows:

Knowledge about monkeypox may be because the majority of the sample group received information about monkeypox prevention at a level of up to 95.1%, and nursing students must study subjects related to health, which may allow students to gain more knowledge and be able to prevent monkeypox. This is consistent with a study that found that factors significantly related to the intention to have behaviors to prevent monkeypox included having good knowledge about monkeypox and transmission.[15] It is also consistent with a study that found that knowledge has a statistically significant relationship with behavior to prevent the spread of monkeypox.[11] This is consistent with a study that found that knowledge was associated with healthcare providers’ practices regarding monkeypox prevention in Vietnam.[14] and consistent with studies that found that knowledge has a statistically significant relationship with behaviors to prevent COVID-19.[16,17,18,19,20]

Attitude toward monkeypox prevention may be because most of the sample group had an attitude toward monkeypox prevention at a high level of 66.7%, which may cause nursing students to have a good view of the benefits of monkeypox prevention since monkeypox is dangerous to health and may cause death. Nursing students will also have good behaviors to prevent monkeypox. This is consistent with a study that found that attitudes were significantly related to the practices of healthcare providers regarding monkeypox prevention in Vietnam[14] and 30% of the studied nursing students had positive total attitude level toward monkeypox[13] and Consistent with attitudes having a positive relationship with self-protective behaviors from COVID-19 infection of people in U Thong District, Suphan Buri Province.[16] Consistent with attitudes having a relationship with preventive behaviors of coronavirus disease 2019 of restaurant operators in Suphan Buri Province.[19] and Consistent with attitudes having a relationship with preventive behaviors of coronavirus disease 2019 (COVID-19) of monks and novices in Chum Phae District, Khon Kaen Province.[20]

Conclusion

The current research study emphasizes the important results, that is, nursing students still lack knowledge about monkeypox, attitudes toward monkeypox prevention, and behaviors to protect themselves from monkeypox, which are still at low and moderate levels, although the overall level is at a high level. The important factors related to behaviors to protect themselves from monkeypox are knowledge about monkeypox and attitudes toward monkeypox prevention. It is necessary to organize teaching and learning for nursing students to have a better understanding of knowledge about monkeypox and behaviors to protect themselves from monkeypox, which will help enhance awareness and health awareness in preventing monkeypox.

Limitations and recommendation

The limitation is the cross-sectional design of the study, so the results do not indicate a causal relationship. Therefore, a longitudinal study is recommended to better explain the possible causal relationship between the factors. In addition, the sampling was limited to a single school and was not based on random sampling. Therefore, future studies should use more reliable sampling methods. The results may not be directly generalizable to other populations with different sociocultural contexts and health care systems.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Western University has funded this project.