Knowledge, attitudes, and practices toward Mpox among laboratory professionals in Zambia: A cross-sectional study

David Chisompola; John Nzobokela; Elijah Chinyante; Nanjela Chidima; Allen Chipipa; Charlotte Nyirenda; Edward Phiri; Lucky Kalyapu; Sepiso K Masenga

doi:10.1371/journal.pone.0335365

. 2025 Nov 3;20(11):e0335365. doi: 10.1371/journal.pone.0335365

Knowledge, attitudes, and practices toward Mpox among laboratory professionals in Zambia: A cross-sectional study

David Chisompola ^1,^*, John Nzobokela ², Elijah Chinyante ², Nanjela Chidima ², Allen Chipipa ², Charlotte Nyirenda ², Edward Phiri ², Lucky Kalyapu ³, Sepiso K Masenga ^4,^5,^*

Editor: Muhammad Abbas Abid,⁶

PMCID: PMC12582439 PMID: 41183077

Abstract

Introduction

Monkeypox (Mpox), caused by the Mpox virus, is an emerging zoonotic disease of global public health significance. In Zambia, limited data exist on laboratory professionals’ (LPs) preparedness to manage and prevent Mpox outbreaks. This study aimed to assess knowledge, attitudes, and practices (KAP) regarding Mpox among LPs in Zambia.

Methods

A cross-sectional online survey was conducted among 293 LPs across Zambia from April to August 2025. A structured, validated questionnaire assessed socio-demographic data and KAP toward Mpox. Descriptive statistics, chi-square tests, and logistic regression analyses were performed using Stata version 15.

Results

Of the 293 respondents, 52.2% demonstrated good knowledge, 47.4% had a positive attitude, and 7.5% exhibited good Mpox-related practices. Significant knowledge gaps were observed, including limited awareness of Mpox transmission (62.5%), complications (76.1%). Additionally, 72% of LPs expressed willingness or support for mandatory Mpox vaccination. LPs working in health centres/clinics (AOR = 0.07; 95% CI: 0.009–0.54; p = 0.11), private hospitals (AOR = 0.05; 95% CI: 0.003–0.74; p = 0.030), public hospitals (AOR = 0.06; 95% CI: 0.011–0.39; p = 0.003), and research or academic institutions (AOR = 0.10; 95% CI: 0.01–0.77; p = 0.027) were significantly less likely to report good Mpox-related practices compared to those working in district or provincial health offices.

Conclusion

The study highlights a low knowledge, a relatively low positive attitude, and poor practices toward Mpox among Zambian LPs. Identified gaps underscore the important need for targeted education and capacity-building initiatives to enhance Mpox preparedness and response.

Introduction

Monkeypox (Mpox) is a viral zoonotic disease caused by the Mpox virus, a member of the Orthopoxvirus genus in the Poxviridae family, which also includes variola (smallpox), cowpox, and vaccinia viruses [1,2]. Human infections occur through animal spillover or direct contact with lesions, body fluids, or respiratory droplets of an infected person, presenting with fever, lymphadenopathy, and a progressive rash that can lead to complications such as secondary infections, sepsis, or corneal scarring [3]. Historically, Clade I Mpox infections have been linked to a higher case fatality rate, ranging from 1.4% to 11%, compared to Clade II Mpox infections [4]. The 2022 global outbreak underscored its potential for human-to-human spread via close contact, necessitating rapid diagnosis, isolation, and vaccination for containment [5,6].

Globally, notable outbreaks have been reported to include the 2003 U.S. outbreak linked to imported prairie dogs [7], as well as travel-associated cases in the UK and Israel in 2018 [8,9]. As of November 2023, over 91,000 cases and 166 deaths had been reported across 116 countries [10]. The African continent has borne the heaviest burden, with the Africa CDC reporting a 160% increase in cases and a 19% rise in deaths, predominantly in the DRC [11]. By 2024, Africa had recorded over 14,000 cases and 524 fatalities, surpassing previous years’ figures, with new outbreaks emerging in Burundi, Kenya, Rwanda, and Uganda [12]. Mpox has been endemic to the rainforest regions of Central and West Africa, with sporadic outbreaks outside the continent linked to travel or animal trade [1,3]. The global health importance of Mpox was highlighted when the World Health Organization (WHO) declared it a Public Health Emergency of International Concern (PHEIC) on August 14, 2024 [13]. This decision followed a surge in cases in the Democratic Republic of the Congo (DRC) and the virus’s spread to previously unaffected African countries, placing neighbouring Zambia at heightened risk. If left unaddressed, Mpox can lead to severe complications such as secondary bacterial infections, respiratory distress, encephalitis, and, in some cases, death [14].

Zambia reported its first Mpox case in October 2024 [15], signalling an urgent need to evaluate healthcare professionals’ (HCPs) such as laboratory professionals’ (LPs) preparedness in managing potential outbreaks. HCPs play a critical role in outbreak containment and are regarded as being at elevated risk of acquiring severe infectious diseases while caring for patients [16]. Recent studies conducted across different countries have highlighted that HCPs generally exhibit low levels of knowledge about Mpox, along with a lack of positive attitudes and suboptimal practices related to its prevention and management [17–19]. Yet there is limited data on their knowledge, attitudes, and practices (KAP) regarding Mpox in Zambia. Addressing this gap is essential for tailoring effective public health interventions, improving health education, and strengthening outbreak response strategies.

This study aimed to assess KAP related to Mpox among Zambian healthcare workers, identifying key gaps in awareness and behavioural practices. The findings will inform targeted measures to enhance Zambia’s capacity to mitigate the spread and impact of Mpox.

Methods

Study settings and participants

We conducted a cross-sectional descriptive study in Zambia using an open online self-administered survey designed with Google Forms (see Table 2). This study was carried out from 29th April to 24th May 2025. A combination of convenience and simplified snowball sampling was employed to recruit participants. LPs were invited through emails and social media platforms such as WhatsApp, Facebook and LinkedIn. The study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [20], checklist to guide reporting, supplementary file S3 File. The study was a nationwide survey conducted in Zambia, targeting LPs from a wide range of facilities and practice settings.

Table 2. Healthcare professionals Responses to Knowledge, Attitude and Practices Questions about Monkeypox in Zambia.

		N (%)
	Knowledge Questions	Correct Answers	Incorrect Answers
Q1	Have you heard of Monkeypox (Mpox) before?	288 (98.3)	5 (1.7)
Q2	What is the causative agent of Monkeypox?	290 (99.0)	3 (1.0)
Q3	What are the common modes of Monkeypox transmission? (Select all that apply)	110 (37.5)	183 (62.5)
Q4	What are the common symptoms of Monkeypox? (Select all that apply)	110 (37.5)	183 (62.5)
Q5	Is Monkeypox a zoonotic disease?	278 (94.9)	15 (5.1)
Q6	What is the incubation period of Monkeypox?	182 (62.1)	111 (37.9)
Q7	Is there an effective vaccine available for Monkeypox?	135 (46.1)	158 (53.9)
Q8	What are the potential complications of Monkeypox? (Select all that apply)	70 (23.9)	223 (76.1)
Q9	Can Monkeypox be diagnosed through laboratory testing?	290 (99.3)	2 (0.7)
Q10	Which of the following groups are considered at high risk for severe complications from mpox? (Select all that apply.)	186 (63.5)	107 (36.5)
Q11	Which of the following sample types is most appropriate for the diagnosis of Mpox?	233 (79.5)	60 (20.5)
Q12	Which of the following is the most appropriate laboratory test for confirming a Mpox diagnosis?	250 (85.9)	41 (14.1)
	Attitude Questions
Q1	Do you believe Monkeypox is a serious public health threat in Zambia?	268 (91.5)	25 (8.5)
Q2	How concerned are you about the risk of Monkeypox infection in healthcare settings?	236 (80.6)	57 (19.4)
Q3	Do you think healthcare professionals should receive specialized training on Monkeypox management?	288 (98.3)	5 (1.7)
Q4	Do you believe the Hospitals are adequately prepared to handle a Monkeypox outbreak?	232 (79.2)	61 (20.8)
Q5	How confident are you in your ability to diagnose and manage Monkeypox cases?	57 (19.5)	236 (80.5)
Q6	Do you support the mandatory vaccination of healthcare workers against Monkeypox if a vaccine is available?	211 (72.0)	82 (28.0)
Q7	Do you think people with Monkeypox should be isolated to prevent the spread of the disease?	272 (92.8)	21 (7.2)
Q8	How do you feel about the stigma associated with Monkeypox?	182 (62.1)	111 (37.9)
Q9	Do you believe Monkeypox can be effectively controlled through public health interventions?	284 (96.9)	9 (3.1)
Q10	Should Monkeypox surveillance and reporting systems be strengthened in Zambia?	287 (98.0)	6 (2.0)
	Practices Questions
Q1	Have you ever attended a training or workshop on Monkeypox?	18 (6.1)	275 (93.9)
Q2	How often do you use personal protective equipment (PPE) when handling patients with suspected infectious diseases?	258 (93.1)	19 (6.9)
Q3	Do you regularly update yourself on emerging infectious diseases like Monkeypox?	200 (68.3)	93 (31.7)
Q4	Have you ever encountered a suspected Monkeypox case in your healthcare facility?	83 (29.3)	200 (70.7)
Q5	If you suspect a Monkeypox case, what would be your first step?	78 (26.6)	215 (73.4)
Q6	Do you follow infection prevention and control (IPC) guidelines when managing patients with infectious diseases?	259 (94.5)	15 (5.5)
Q7	How frequently do you educate patients and colleagues about Monkeypox prevention?	33 (11.3)	260 (88.7)
Q8	Have you ever participated in Monkeypox surveillance or research?	18 (6.1)	275 (93.9)
Q9	Do you know the reporting procedure if you identify a suspected Monkeypox case?	88 (30.0)	205 (70.0)
Q10	If a Monkeypox outbreak occurs in your facility, do you feel prepared to handle cases?	78 (26.6)	215 (73.4)

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The principal investigator and co-investigators of the study initiated recruitment through simplified snowball sampling [21]. This was done beginning with conveniently selected seed participants representing diverse healthcare professions, workplace settings, and geographic regions. To mitigate recruitment bias inherent in chain-referral methods, we implemented three safeguards: (1) limiting each participant to referring a maximum of three colleagues to prevent network clustering, (2) verifying professional credentials of all referred participants to maintain sample quality, and (3) supplementing with various professional groups to reach HCPs beyond referral networks. This approach balanced the efficiency of snowball sampling with intentional diversity preservation across key demographic and professional strata, while the referral cap and verification process specifically addressed potential overrepresentation of certain subgroups that could skew results.

Inclusion and exclusion criteria

We included participants who were LPs and residents of Zambia at the time of the study, aged 18 years or older, able to understand and read the English language used in the questionnaire, provided informed consent to participate, and had access to the internet to complete the online questionnaire. Participants were excluded if they were under 18 years of age, not residing in Zambia, unable to provide informed consent due to cognitive or communication impairments.

Sample size determination

The sample size was calculated using the sample proportion formula provided by the OpenAI online statistical tool. We employed an estimated prevalence of Mpox-related knowledge among HCPs, which is reported to be 26% [17], the confidence level was set at 95%, and the margin of error, set at 0.05. Under these assumptions, the minimum required sample size to ensure statistical robustness was calculated to be at least 296 participants. A total of 293 participants were recruited.

Data collection instrument and data collection procedures

The data collection tool used in this study was a structured questionnaire adopted from validated instruments in previous studies [20,22,23], modified and developed using Google Forms. The questionnaire was designed in English and included essential components such as an introduction to the study, a confidentiality statement, and a clear indication that participation was voluntary. It comprised four main sections: (1) socio-demographic information, including gender, age, education level, years of professional experience, type of institution and region of residence; (2) knowledge-based questions; (3) attitude-based questions; and (4) practice-based questions related to Mpox.

Prior to the main data collection, a pilot study was conducted with ten healthcare professionals to assess the content reliability and clarity of the questionnaire. Following this, the finalized survey was disseminated through WhatsApp Messenger, Facebook, LinkedIn, and email, with periodic reminders sent to enhance response rates. The Google Form was configured to accept only one response per participant using its built-in “limit to one response” feature, which prevents duplicate responses without collecting identifying information. No email addresses or identifying information were collected, ensuring participant anonymity. Participants were able to access and complete the questionnaire using either a computer or mobile device. The dependent variable in this study was the participants’ level of knowledge, attitude and practices regarding Mpox. The independent variables included various sociodemographic characteristics such as age group, gender, level of education, healthcare professional, years of experience, current working setting, and Province of residence.

The data collection form had four sections with a total of 42 questions (Supplementary form S1 File). The first section consisted of nine (9) questions which addressed participants’ sociodemographic and descriptive characteristics. These included age group, gender, level of education, healthcare professional, years of experience, current working setting, region of residence, province of practice and the name of the institution.

Each section of the questionnaire was scored to enable quantitative assessment. For the knowledge section, which included 12 questions, each correct answer was awarded one point, while incorrect or “not sure” responses received zero points. The total possible score ranged from 0 to 12. Based on the modified Bloom’s cut-off point [24], the total score for each question, respondents were categorized into two groups: those with “good knowledge” scoring ≥80%, and those with “poor knowledge” scoring <80% Similarly, In the attitude section, the total attitude score ranged from 0 to 10. Attitude levels were categorized into two groups: “positive attitude” for scores ≥90% and “negative attitude” for scores <90%. In addition to the knowledge and attitude section, the preventive practice section, had a total practice score ranging from 0 to 10. Scores were categorized into two levels: “good practice” for scores ≥75% and “poor practice” for scores <75% [24]. The overall knowledge score was interpreted according to Bloom’s cut-off point as high (80–100%), moderate (60–79%), and low (≤59%) [25].

Data analysis

The dataset was first cleaned, tabulated, and assessed for consistency and completeness using Microsoft Excel, and subsequently analysed using Stata version 15. Data collected during the pilot study were excluded from the final analysis to preserve the validity and reliability of the results. The Shapiro-Wilk test (P < 0.05) was conducted to assess whether the data were normally distributed. Both descriptive and inferential statistical analyses were performed. Descriptive analysis covered demographic characteristics and responses related to healthcare professionals’ KAP regarding Mpox. Categorical variables were summarized using frequencies and percentages. Inferential statistical analyses were conducted to assess associations between KAP levels and selected sociodemographic variables such as sex, profession, level of education, and workplace setting. Chi-square tests (χ²) were used to evaluate the relationship between categorical variables, such as good and poor knowledge and practices and positive and negative attitude. Logistic regression was used for multivariate analysis to determine factors associated with good knowledge, positive attitudes, and good practices related to Monkeypox. Statistical significance was set at p < 0.05.

Ethical approval

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants were fully informed about the purpose, objectives, and scope of the study and provided digital written informed consent prior to participation. Participation was entirely voluntary, and all responses were collected anonymously to ensure confidentiality. Ethical approval for the study was granted by the Mulungushi University School of Medicine Research Committee and the National Health Research Authority on April 22^nd and 29th, 2025, under reference numbers SMHS-MU2-2025-10 and NHRA8653/21/04/2025.

Results

Basic characteristics of the participants

A total of 293 participants completed the questionnaire. The majority were male (n = 158, 53.9%) and aged between 25 and 34 years (n = 184, 62.8%). Most respondents resided in urban areas (n = 219, 74.7%) and held a diploma qualification (n = 133, 45.4%). Regarding work experience, the majority of participants (n = 113, 38.6%) had 6–10 years of experience. Additionally, most participants were employed in public health hospitals (n = 194, 66.2%) and were primarily based in the Copperbelt Province (n = 115, 39.2%). The full demographic characteristics are presented in Table 1.

Table 1. Characteristics of the study population.

Variable	Frequency (%)	Knowledge Score N (%)			Attitude Score N (%)
Variable	Frequency (%)	Good = 153 (52.2)	Poor = 140 (47.8)	P value	Positive = 139 (47.4)	Negative = 154 (52.6)	P value	Good = 22 (7.5)	Poor = 271 (92.5)	P value
Age
18–24 years	30 (10.2)	12 (40)	18 (60)	0.142	13 (43.3)	17 (56.7)	0.077	0 (0.0)	30 (100)	0.043
25–34 years	184 (62.8)	97 (52.7)	87 (47.3)		96 (52.2)	88 (47.8)		12 (6.5)	172 (93.5)
35–44 years	60 (20.5)	30 (50.0)	30 (50.0)		20 (33.3)	40 (66.7)		6 (10.0)	54 (90.0)
> 45 years	19 (6.5)	14 (73.7)	5 (26.3)		10 (52.6)	9 (47.4)		4 (21.1)	15 (78.9)
Sex
Male	158 (53.9)	79 (50.0)	79 (50.0)	0.411	75 (47.5)	83 (52.5)	0.992	11 (7.0)	147 (93.0)	0.701
Female	135 (46.1)	74 (54.8)	61 (45.2)		64 (47.4)	71 (52.6)		11 (8.1)	124 (91.9)
Location
Urban	219 (74.7)	113 (51.6)	106 (48.4)	0.715	106 (48.4)	113 (51.6)	0.571	15 (6.9)	204 (93.1)	0.461
Rural	74 (25.3)	40 (54.0)	34 (46.0)		33 (44.6)	41 (55.4)		7 (9.5)	67 (90.5)
Education level
Diploma	133 (45.4)	77 (57.9)	56 (42.1)	0.161	73 (54.9)	60 (45.1)	0.054	12 (9.0)	121 (91.0)	0.411
Degree	132 (45.0)	61 (46.2)	71 (53.8)		56 (42.4)	76 (57.6)		7 (5.3)	125 (94.7)
Masters	28 (9.6)	15 (53.6)	13 (46.4)		10 (35.7)	18 (64.3)		3 (10.7)	25 (89.3)
Years of experience
< 1 year	30 (10.2)	13 (43.3)	17 (56.7)	0.311	16 (53.3)	14 (46.7)	0.266	1 (3.3)	29 (96.7)	0.045
1–5 years	97 (33.1)	46 (47.4)	51 (52.6)		46 (47.4)	51 (52.6)		7 (7.2)	90 (92.8)
6–10 years	113 (38.6)	62 (54.9)	51 (45.1)		58 (51.3)	55 (48.7)		5 (4.4)	108 (95.6)
> 11 years	53 (18.1)	32 (60.4)	21 (39.6)		34 (64.1)	19 (35.9)		9 (17.0)	44 (83.0)
Workplace Setting
District/ Provincial Health office	7 (2.4)	7 (100)	0 (0.0)	0.127	2 (28.6)	5 (71.4)	0.168	4 (57.1)	3 (42.9)	0.003
Health Centre/Clinic	46 (15.7)	23 (50.0)	23 (50.0)		28 (60.9)	18 (39.1)		3 (6.5)	43 (93.5)
Private Hospital	18 (6.1)	10 (55.6)	8 (44.4)		6 (33.3)	12 (66.7)		1 (5.6)	17 (94.4)
Public Hospital	194 (66.2)	99 (51.0)	95 (49.0)		92 (47.4)	102 (52.6)		11 (5.7)	183 (94.3)
Research or Academic institution	28 (9.6)	14 (50.0)	14 (50.0)		11 (39.3)	17 (60.7)		3 (10.7)	25 (89.3)
Province of Practice
Central Province	21 (7.2)	8 (38.1)	13 (61.9)	0.863	11 (52.4)	10 (47.6)	0.329	5 (23.8)	16 (76.2)	0.086
Copperbelt Province	115 (39.2)	60 (52.2)	55 (47.8)		56 (48.7)	59 (51.3)		8 (7.0)	107 (93.0)
Eastern Province	18 (6.1)	10 (55.6)	8 (44.4)		7 (38.9)	11 (61.1)		1 (5.6)	17 (94.4)
Luapula Province	12 (4.1)	7 (58.3)	5 (41.7)		4 (33.3)	8 (66.7)		0 (0)	12 (100)
Lusaka Province	33 (11.3)	17 (51.5)	16 (48.5)		17 (51.5)	16 (48.5)		1 (3.0)	32 (97.0)
Muchinga Province	9 (3.1)	5 (55.6)	4 (44.4)		4 (44.4)	5 (55.6)		1 (11.1)	8 (88.9)
North-Western Province	15 (5.1)	9 (60.0)	6 (40.0)		3 (20.0)	12 (80.0)		3 (20.0)	12 (80.0)
Northern Province	6 (2.1)	4 (66.7)	2 (33.3)		5 (83.3)	1 (16.7)		0 (0)	6 (100.0)
Southern Province	56 (19.1)	27 (48.2)	29 (51.8)		29 (51.8)	27 (48.2)		2 (3.6)	54 (96.4)
Western Province	8 (2.7)	6 (75.0)	2 (25.0)		3 (37.5)	5 (62.5)		1 (12.5)	7 (87.5)

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Data are presented as frequency (percentage). Knowledge, attitude, and practice outcomes were dichotomized into good/poor or positive/negative based on predetermined cut-off scores. P-values were obtained using the Chi-square test of independence; Fisher’s exact test was applied where expected cell counts were < 5; Bold represented statistical significance which was set at p < 0.05. N = number of respondents. % = percentage.

Knowledge, attitude and practices of laboratory professionals about human Monkeypox

Among the survey respondents, 52.2% demonstrated low knowledge of Mpox (using Bloom’s cut-off point of ≤59%), 47.4% exhibited a positive attitude, and 7.5% reported good preventive practices (Table 2). Despite a low level of knowledge, significant knowledge gaps were observed: 62.5% were unaware of Mpox transmission modes, 76.1% did not know its potential complications, 53.9% were unsure whether an effective vaccine exists, and 36.5% could not identify the groups at higher risk of severe Mpox disease (Table 2).

Factors associated with practices towards Monkeypox

Age, years of experience, and workplace setting were included in both univariate and multivariate logistic regression analyses due to their statistical significance (p < 0.05). In the multivariate analysis for age, laboratory professionals (LPs) aged 25–34 years (AOR = 0.95; 95% CI: 0.10–9.27; p = 0.971) and 35–44 years (AOR = 1.01; 95% CI: 0.19–5.40; p = 0.985) demonstrated no significant differences in Mpox-related practices compared to those aged >45 years. Similarly, for years of experience, LPs with 1–5 years (AOR = 1.02; 95% CI: 0.10–9.86; p = 0.981), 6–10 years (AOR = 0.46; 95% CI: 0.04–4.88; p = 0.522), and more than 11 years (AOR = 1.42; 95% CI: 0.08–23.4; p = 0.804) did not differ significantly in their Mpox-related practices compared to those with less than 1 year of experience. In contrast, workplace setting was a significant predictor. LPs working in health centres/clinics (AOR = 0.07; 95% CI: 0.009–0.54; p = 0.11), private hospitals (AOR = 0.05; 95% CI: 0.003–0.74; p = 0.030), public hospitals (AOR = 0.06; 95% CI: 0.011–0.39; p = 0.003), and research or academic institutions (AOR = 0.10; 95% CI: 0.01–0.77; p = 0.027) were significantly less likely to report good Mpox-related practices compared to those working in district or provincial health offices (Table 3).

Table 3. Factors associated with practices in logistic regression.

Variable	Univariate analysis		Multivariate analysis
	OR (95% CI)	P value	AOR (95% CI)	P value
Age
> 45 years	Ref		Ref
18–24 years	(Empty)	(Empty)	(Empty)	(Empty)
25–34 years	0.26 (0.07, 0.91)	0.035	0.95 (0.099, 9.27)	0.971
35–44 years	0.41 (0.10, 1.67)	0.217	1.01 (0.19, 5.40)	0.985
Years of experience
< 1 year	Ref		Ref
1–5 years	2.25 (0.26, 19.1)	0.456	1.02 (0.10, 9.86)	0.981
6–10 years	1.34 (0.15, 11.9)	0.792	0.46 (0.04, 4.88)	0.522
> 11 years	5.93 (0.71, 49.3)	0.100	1.42 (0.08, 23.4)	0.804
Workplace Setting
District/ Provincial Health office	Ref		Ref
Health Centre/Clinic	0.05 (0.007, 0.34)	0.002	0.07 (0.009, 0.54)	0.011
Private Hospital	0.04 (0.003, 0.54)	0.015	0.05 (0.003, 0.74)	0.030
Public Hospital	0.04 (0.008, 0.22)	<0.0001	0.06 (0.011, 0.39)	0.003
Research or Academic institution	0.09 (0.01, 0.61)	0.014	0.10 (0.01, 0.77)	0.027

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OR = Odds Ratio; AOR = Adjusted Odds Ratio; CI = Confidence Interval; Ref = Reference category. Variables with p < 0.05 in the multivariate analysis were considered statistically significant.

Discussion

To our knowledge, this is the first study to investigate the knowledge, attitudes, and practices of LPs regarding monkeypox in Zambia, thereby providing a foundation for evidence-based management strategies and policy formulation. This study assessed the KAP of 293 LPs and identified key factors influencing their responses toward monkeypox. Our findings reveal critical gaps in preparedness among Zambian laboratory professionals. 52.2% of respondents showed good knowledge, only 47.4% reported a positive attitude, and 7.5% reported good preventive practices.

Our study finding showed an overall knowledge score of 52.2%, which is classified as low according to Bloom’s cut-off point. This was consistent with the 50% reported in Vietnam [22], 55.3% in Egypt [26], and 55% in Saudi Arabia [27]. The low knowledge score likely reflects a lack of targeted, continuing education on emerging infectious diseases like Mpox for laboratory professionals in Zambia. It may also indicate a reliance on informal information sources which may not be comprehensive or accurate. In contrast, other studies reported lower levels of knowledge compared to our findings, with knowledge scores of 33.3% in Jordan [28], 36.5% in Indonesia [29], 38.5% in Ethiopia [30] and 48% in Saudi Arabia [31]. These variations may be attributed to differences in study settings, sample size, timeframes, perceptions of Mpox infection, sources of information, and whether participants had received relevant training, all of which could contribute to the observed discrepancies.

Our study revealed that 47.4% of laboratory professionals exhibited a positive attitude towards Mpox. This is lower than the 51.7% reported across 27 countries [26], 62% reported in Ethiopia [30] and 85% observed in Saudi Arabia [27]. This difference is likely to be attributed to variations in sample size, study design, geographical context, and the categories of healthcare professionals included in each study.

In our survey, Mpox preventive practices included regular participation in training sessions and workshops focused on emerging infectious diseases, as well as the consistent use of personal protective equipment such as gloves, gowns, masks, and eye protection when managing patients with suspected infections [32]. Our survey revealed a 68.3% of respondents actively keeping themselves informed on current public health threats through credible sources and demonstrated awareness of the early signs and symptoms of Mpox. In Mpox suspected cases, 26.6% LPs indicated that they would promptly isolate the patient and report the case to relevant public health authorities in accordance with established guidelines. Furthermore, 94.5% reported strict adherence to infection prevention and control protocols, including proper hand hygiene, environmental sanitation, and biomedical waste management. Finally, 26.6% of HCPs expressed confidence in their ability to respond to a potential Mpox outbreak within their facilities, citing the presence of outbreak preparedness plans and routine staff training. These findings highlight a generally high level of awareness and adherence to Mpox prevention practices among qualified LPs in the public health sector. Our study revealed an extremely poor overall level of Mpox preventive practices of 7.5%. This is lower than 51.8% reported in Vietnam [22].

Our study found that 72% of LPs expressed willingness or support for mandatory Mpox vaccination, a rate slightly similar with the 67.7% reported by Kumar et al. (2022) among HCPs in Pakistan [20]. However, our findings were higher than those from a global systematic review and meta-analysis (58%) [33] and the 58.6% acceptance rate documented by Ricco et al. (2022) in Italy [34]. These variations may reflect differences in study populations, regional vaccination policies, or levels of Mpox awareness at the time of data collection.

Our finding that 62.5% of participants could not correctly identify Mpox transmission modes is particularly concerning. This significant gap may be attributed to systemic issues such as limited access to structured training programs and updates on emerging pathogens. Furthermore, in the digital age, health professionals increasingly turn to online sources for information, which can be a double-edged sword, providing rapid updates but also potentially exposing them to misinformation or inconsistent messaging [35]. This underscores the need for institutional efforts to provide regular, evidence-based updates and perhaps even training on digital health literacy to ensure laboratory professionals can critically appraise information sources.

In the multivariate logistic regression analysis workplace setting a significant predictors of Mpox-related practices among LPs. LPs working in health centres/clinics, private hospitals, and research or academic institutions were significantly less likely to report good Mpox-related practices compared to those working in district or provincial health offices. This may be due to reduced access to formal training, and updated guidelines, which can limit opportunities for LPs to adopt and maintain optimal Mpox-related practices.

Strengths and limitations

This study has several limitations that should be acknowledged. First, the survey was conducted in English, which may have introduced a selection bias, as only participants with sufficient English proficiency could complete the questionnaire. This requirement may imply a higher formative capacity among respondents, potentially overestimating knowledge and attitudes compared to the broader population of laboratory professionals. Secondly, we did not assess participants’ sources of information. The influence of online health content and misinformation was not captured, yet digital platforms are a primary source of information and can significantly affect Mpox-related knowledge and practices through exposure to misinformation and variable quality content [35]. Thirdly, the exclusive use of an online survey format inherently excluded LPs lacking reliable internet access, likely underrepresenting practitioners in rural or resource-constrained settings. Finally, the reliance on self-reported data may have introduced social desirability and recall biases. Despite these limitations, the study possesses several notable strengths. To the best of our knowledge, this is the first study in Zambia to assess laboratory professionals’ KAP regarding Mpox. The use of a structured questionnaire enhanced reliability, and the diverse provincial coverage of participants adds to the generalizability of the findings within the Zambian laboratory professional community.

Despite these limitations, the study possesses several notable strengths. To the best of our knowledge, this is the first study in Zambia to assess laboratory professionals’ KAP regarding Mpox. As such, it provides valuable baseline data that can guide the development of targeted training initiatives, awareness campaigns, and evidence-informed policy interventions. The use of a structured and standardized questionnaire enabled consistent data collection across participants, enhancing the reliability of the findings. Furthermore, the inclusion of a diverse sample of LPs from multiple provinces contributes to the breadth and contextual relevance of the results, offering a more comprehensive understanding of the current KAP landscape among laboratory workers in Zambia.

Importantly, these findings offer a broader reflection of the country’s overall readiness or lack thereof, to respond to emerging infectious disease outbreaks. The study highlights significant gaps in outbreak preparedness, underscoring the urgent need for coordinated action by the Ministry of Health and key stakeholders. To strengthen the resilience of the health system, we propose priority interventions: including investment in health education, surveillance systems, and the development of responsive and proactive policies. Such measures are essential to ensure that healthcare professionals are adequately equipped to manage and mitigate the impact of future outbreaks like Mpox.

Conclusion

We assessed the knowledge, attitudes, and practices related to Mpox among laboratory professionals in Zambia, identifying key gaps in awareness and behavioural practices. The findings revealed a low knowledge level, a low positive attitude, and poor practices towards Mpox. These insights are important for informing targeted education and training programs aimed at improving Mpox-related preparedness and response among healthcare workers. By addressing the identified gaps, Zambia can strengthen its capacity to prevent, detect, and mitigate the spread and impact of Mpox, especially in the face of emerging global health threats. This study provides foundational evidence to support policy development, resource allocation, and capacity-building initiatives to enhance outbreak preparedness and public health resilience in Zambia.

Supporting information

S1 File. Questionnaire form.

(PDF)

pone.0335365.s001.pdf^{(300.9KB, pdf)}

S2 File. Data.

(XLSX)

pone.0335365.s002.xlsx^{(82.9KB, xlsx)}

S3 File. Strobe checklist.

(DOCX)

pone.0335365.s003.docx^{(32.5KB, docx)}

Data Availability

The raw data underlying the results presented in the study have been uploaded as a Supporting information file.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0335365.r001

Decision Letter 0

Muhammad Abbas Abid

29 Jul 2025

Dear Dr. Chisompola,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Satff Editor comments: Please correct the term monkeypox into Mpox in the title.

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Additional Editor Comments:

Even though it is a KAP study, the study is important as knowledge about mpox is still limited. Yet, there are a number of changes required before it becomes a holistic and interesting read.

The study results cannot be generalized to all healthcare professionals as most of the included participants technologists.

The limitations section should be added upon and the reviewer comments incorporated to make it a more comprehensive read.

Good luck to the authors!

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: 1. The manuscript labels 46.5% knowledge accuracy as “moderate” without establishing any theoretical or empirical justification for that classification. There is no engagement with literature that defines meaningful thresholds for knowledge adequacy in healthcare preparedness contexts. This subjective categorization reduces the interpretive clarity of the findings. The authors should support their classifications using references to similar KAP studies or global health benchmarks to ensure their descriptors have an objective basis and allow readers to assess the severity of the observed gaps with greater precision.

2. The finding that 76.4% of participants could not correctly identify Mpox transmission modes is significant, yet the paper does not probe the reasons for this widespread misconception. There is no exploration of the sources participants rely on for infectious disease information or whether misinformation might play a role. As a result, the implications of this gap are left underdeveloped. The discussion could be improved by analyzing potential systemic contributors to poor knowledge, such as lack of access to continuing education or the influence of low-quality digital health content, especially in low-resource environments.

3. The sample is heavily skewed, with 63.6% of respondents being laboratory technologists or scientists. Despite this imbalance, the authors generalize their findings across all healthcare professionals in Zambia. Such overrepresentation introduces substantial bias, especially in measuring practices and attitudes, as lab personnel may differ in their patient interaction frequency. A more appropriate approach would involve stratified results or a weighting mechanism to ensure that the findings reflect Zambia’s broader healthcare workforce demographics more accurately.

4. A key limitation of this study is its omission of the influence that online health content and misinformation may have on healthcare professionals' Mpox-related knowledge and practices. The findings are discussed in isolation from the digital information environment that increasingly shapes professional awareness and response to emerging diseases. This narrows the scope of the analysis and limits its utility for training design. To address this, it is suggested that the authors review recent works such as https://doi.org/10.1109/CCWC62904.2025.10903713 and https://doi.org/10.1109/AiDAS63860.2024.10730443, which show how exposure to sentiment and toxicity in online platforms affects health discourse, and can inform how preparedness programs should adapt to the realities of information ecosystems.

5. There are unresolved concerns about participant anonymity and data integrity. The paper claims that duplicate responses were prevented via email verification, yet also states that all data were collected anonymously. This contradiction raises questions about how the research balanced verification with participant privacy, especially given the use of a Google Form. The authors need to clarify the process, explicitly stating how identity verification was managed without violating ethical principles of anonymity, particularly in light of the sensitive nature of self-reported practices.

Reviewer #2: The study is well formatted and methodologically sound and provides interesting insights into the levels of preparedness of health workers in Zambia, so that training resources can be improved.

MAJOR COMMENTS:

1. Line 52: The mode of transmission described as ‘direct transmission’ is unclear, it would be better described as something along the following lines: ‘direct contact with a person with the virus’, and maybe with the addition that this occurs through skin lesions, body fluids....

2. Discussion: You could introduce more commentary on the results than simply comparing data from other studies but try to give some kind of explanation for the findings based on the literature.

3. Strengths and limitations: Mention a possible bias of selection related to people responding, with the language, cause participants should understand English and this could imply a greater formative capacity and overestimate some values.

MINOR COMMENTS:

1. Line 15: error in the correspondent's e-mail address (p.2): Should correct “gmai.com” to “gmail.com.”

2. Line 50: Orthopoxvirus, all together, instead Ortho poxvirus

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Reviewer #1: No

Reviewer #2: Yes: Inés Armenteros-Yeguas

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PLoS One. 2025 Nov 3;20(11):e0335365. doi: 10.1371/journal.pone.0335365.r002

Author response to Decision Letter 1

15 Sep 2025

Response to Reviewers

We thank the Editor for handling our manuscript (PONE-D-25-30146), titled "Knowledge, Attitudes, and Practices Toward Mpox Among Laboratory Professionals in Zambia: A Cross-Sectional Study," and the Reviewers for their insightful comments. Their feedback has been invaluable in significantly improving our manuscript. We have refined our analysis to focus exclusively on laboratory professionals and have incorporated new discussions and limitations as suggested. We believe these revisions have substantially strengthened the manuscript.

We have provided our point-to-point answers to the reviewers’ comments below.

Editor and Reviewers comments

Staff Editor comments: Please correct the term monkeypox into Mpox in the title.

Response: We thank the editorial team for this comment. We have updated the title as requested. It now reads “Knowledge, Attitudes, and Practices Toward Mpox Among Laboratory Professionals in Zambia: A Cross-Sectional Study”.

Additional Editor Comments:

Even though it is a KAP study, the study is important as knowledge about mpox is still limited. Yet, there are a number of changes required before it becomes a holistic and interesting read.

The study results cannot be generalized to all healthcare professionals as most of the included participants technologists.

Response: We thank the editorial team for this critical observation. We agree with this limitation. Consequently, we have revised the entire manuscript to focus solely on laboratory professionals (technologists and scientists). All analyses, results, and discussions now specifically pertain to this group, and we have adjusted the title, abstract, introduction, methods, and discussion to reflect this focused scope. Generalizations to other healthcare professionals have been removed.

The limitations section should be added upon and the reviewer comments incorporated to make it a more comprehensive read.

Response: We thank the editorial team for this suggestion. We have substantially expanded the 'Strengths and Limitations' section to incorporate all points raised by the reviewers, including the potential for selection bias due to the English-language survey, the influence of online information and misinformation, and the limitations of the sampling method.

Reviewer #1:

1. The manuscript labels 46.5% knowledge accuracy as “moderate” without establishing any theoretical or empirical justification for that classification. There is no engagement with literature that defines meaningful thresholds for knowledge adequacy in healthcare preparedness contexts. This subjective categorization reduces the interpretive clarity of the findings. The authors should support their classifications using references to similar KAP studies or global health benchmarks to ensure their descriptors have an objective basis and allow readers to assess the severity of the observed gaps with greater precision.

Response: We thank the reviewer for this crucial feedback. We have revised our interpretation to use the standard Bloom's cut-off point, which categorizes a score of ≤59% as low, 60-79% as moderate, and 80-100% as high. Our mean knowledge score of 52.2% therefore falls into the 'low' category, not 'moderate'. We have corrected this throughout the manuscript (Abstract, Results, Discussion) and have cited the use of this established benchmark (Ref 25: Halboup et al., 2023) to provide an objective basis for our interpretation.

Response: We agree with the reviewer that this is a critical point. We have revised the Discussion section to delve deeper into the potential reasons for these significant knowledge gaps. We now explicitly mention the likely role of limited access to structured continuing education and the potential reliance on informal digital sources, which may expose professionals to misinformation. We have also expanded the Limitations section to formally acknowledge that our study did not assess information sources, which is a key area for future research.

Response: We thank the reviewer for this important critique. We fully agree. Rather than stratifying or weighting the existing data, which was not designed for this purpose, we have chosen to refine the focus of our entire paper. We have revised the manuscript to specifically study and report on Laboratory Professionals only. The title, objectives, participant descriptions, results, and discussion have been updated accordingly. This provides a more accurate and meaningful contribution to the literature on a specific, critical subgroup of healthcare workers.

Response: We thank the reviewer for this insightful suggestion and for the relevant references. We have reviewed the suggested literature and have incorporated this perspective into our revised manuscript. The Limitations section now explicitly discusses this gap in our study and the potential influence of the digital information ecosystem. Furthermore, we have added a sentence to the Discussion suggesting that future training programs should include digital literacy components to help professionals navigate online information critically. The suggested references have been added to the reference list (Ref 35).

Response: We thank the reviewer for highlighting this contradiction and sincerely apologize for the oversight. To clarify: no personal identifying information, including email addresses, was collected. The Google Form was configured to use its built-in "Limit to 1 response" feature, which uses the respondent's Google account to prevent duplicates without transmitting the email address to the collector. This ensures anonymity. We have revised the Methods section to state this clearly: “The Google Form was configured to accept only one response per participant using its built-in “limit to one response” feature, which prevents duplicate responses without collecting identifying information. No email addresses or other personal identifiers were collected, ensuring complete participant anonymity.”

Reviewer #2:

The study is well formatted and methodologically sound and provides interesting insights into the levels of preparedness of health workers in Zambia, so that training resources can be improved.

MAJOR COMMENTS:

Response: We thank the reviewer for this suggestion to improve clarity. We have revised the sentence in the Introduction to read: “Human infections occur through animal spillover or direct contact with lesions, body fluids, or respiratory droplets of an infected person…”

2. Discussion: You could introduce more commentary on the results than simply comparing data from other studies but try to give some kind of explanation for the findings based on the literature.

Response: We thank the reviewer for this suggestion to deepen our discussion. We have significantly revised the Discussion section. Beyond comparing rates, we now provide potential explanations for our findings, particularly the low knowledge scores and the significant differences in practices based on workplace setting. We discuss factors such as access to training, the potential impact of information sources, and the specific roles of laboratory professionals in different settings.

Response: We thank the reviewer for this excellent point. We have added this specific limitation to the 'Strengths and Limitations' section: “First, the survey was conducted in English, which may have introduced a selection bias, as only participants with sufficient English proficiency could complete the questionnaire. This may have excluded laboratory professionals with lower English literacy, potentially leading to an overestimation of knowledge and attitude scores in our sample.”

MINOR COMMENTS:

1. Line 15: error in the correspondent's e-mail address (p.2): Should correct “gmai.com” to “gmail.com.”

Response: We thank the reviewer for spotting this error. We have corrected the corresponding author’s email address to d.chisompola@gmail.com

2. Line 50: Orthopoxvirus, all together, instead Ortho poxvirus

Response: We thank the reviewer for this correction. We have revised "Ortho poxvirus" to "Orthopoxvirus" in the Introduction.

Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response: Thank you spotting this issue. We have added Supplementary files, S1. Questionnaire form, S2. Data and S3. Strobe checklist

Attachment

Submitted filename: Response to Reviewers FINAL.docx

pone.0335365.s005.docx^{(21.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0335365.r003

Decision Letter 1

Muhammad Abbas Abid

10 Oct 2025

Knowledge, Attitudes, and Practices Toward Mpox Among Laboratory Professionals in Zambia: A Cross-Sectional Study

PONE-D-25-30146R1

Dear Dr. Chisompola,

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PLoS One. doi: 10.1371/journal.pone.0335365.r004

Acceptance letter

Muhammad Abbas Abid

PONE-D-25-30146R1

PLOS ONE

Dear Dr. Chisompola,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. Questionnaire form.

(PDF)

pone.0335365.s001.pdf^{(300.9KB, pdf)}

S2 File. Data.

(XLSX)

pone.0335365.s002.xlsx^{(82.9KB, xlsx)}

S3 File. Strobe checklist.

(DOCX)

pone.0335365.s003.docx^{(32.5KB, docx)}

Attachment

Submitted filename: Response to Reviewers FINAL.docx

pone.0335365.s005.docx^{(21.4KB, docx)}

Data Availability Statement

The raw data underlying the results presented in the study have been uploaded as a Supporting information file.

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PERMALINK

Knowledge, attitudes, and practices toward Mpox among laboratory professionals in Zambia: A cross-sectional study

David Chisompola

John Nzobokela

Elijah Chinyante

Nanjela Chidima

Allen Chipipa

Charlotte Nyirenda

Edward Phiri

Lucky Kalyapu

Sepiso K Masenga

Roles

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Methods

Study settings and participants

Table 2. Healthcare professionals Responses to Knowledge, Attitude and Practices Questions about Monkeypox in Zambia.

Inclusion and exclusion criteria

Sample size determination

Data collection instrument and data collection procedures

Data analysis

Ethical approval

Results

Basic characteristics of the participants

Table 1. Characteristics of the study population.

Knowledge, attitude and practices of laboratory professionals about human Monkeypox

Factors associated with practices towards Monkeypox

Table 3. Factors associated with practices in logistic regression.

Discussion

Strengths and limitations

Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Muhammad Abbas Abid

Roles

Author response to Decision Letter 1

Decision Letter 1

Muhammad Abbas Abid

Roles

Acceptance letter

Muhammad Abbas Abid

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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