Keywords
hMPX
knowledge attitudes practices
general public
Philippines
Abstract
Introduction.
In the Philippines, research on knowledge, attitudes, and practices (KAP) regarding human mpox (hMPX) remains limited, despite rising case numbers. While hMPX vaccines are unavailable locally, enhancing community awareness and promoting non-pharmaceutical interventions are crucial for reducing transmission risks.
Methods.
This cross-sectional study utilized an anonymized online data collection tool to explore the general public’s hMPX KAP and their relationships, and identify sociodemographic groups linked to low hMPX knowledge; 502 respondents were included in the analysis.
Results.
Knowledge about hMPX was evenly distributed across low, moderate, and high levels. Higher knowledge was associated with being female (b = 0.130, p = 0.004), having higher education (b = 0.134, p = 0.006), and smaller household size (b = –0.098, p = 0.028). Knowledge was not significantly associated with perceived disease susceptibility or severity; however, it strongly predicted perceived effectiveness of preventive measures, which in turn emerged as the most consistent and influential predictor of preventive practices. Full mediation of the effect of knowledge by perceived effectiveness was observed with protective sexual practices and avoiding crowded places, but only partial with proper hand hygiene and disinfection of fomites/high-touch surfaces.
Conclusion.
This study highlights the complex interplay between knowledge, attitudes, and practices in shaping public health behavior toward hMPX in the Philippines. Significant knowledge gaps and the mediating role of attitudes in influencing preventive practices underscore the need for targeted, stigma-free health communication strategies. Strengthening public understanding and perception through tailored interventions will be critical in mitigating hMPX transmission.
References
International Committee on Taxonomy of Viruses. Poxviridae. Available at: https://ictv.global/report_9th/dsDNA/poxviridae. Accessed on 28 September 2024.
Khodakevich L, Jezek Z, Messinger D. Monkeypox virus: ecology and public health significance. Bull World Health Organ 1988;66(6):747-752.
Adler H, Gould S, Hine P, Snell LB, Wong W, Houlihan CF, Osborne JC, Rampling T, Beadsworth MB, Duncan CJ, Dunning J, Fletcher TE, Hunter ER, Jacobs M, Khoo SH, Newsholme W, Porter D, Porter RJ, Ratcliffe L, Schmid ML, Semple MG, Tunbridge AJ, Wingfield T, Price NM; NHS England High Consequence Infectious Diseases (Airborne) Network. Clinical features and management of human monkeypox: a retrospective observational study in the UK. Lancet Infect Dis 2022;22(8):1153-1162. doi: 10.1016/S1473-3099(22)00228-6.
Ramnarayan P, Mitting R, Whittaker E, Marcolin M, O'Regan C, Sinha R, Bennett A, Moustafa M, Tickner N, Gilchrist M, Kershaw A, Rampling T, NHS England High Consequence Infectious Diseases (Airborne) Network. Neonatal monkeypox virus infection. N Engl J Med 2022;387(17):1618-1620. doi: 10.1056/NEJMc2210828.
Viedma-Martinez M, Dominguez-Tosso FR, Jimenez-Gallo D, Garcia-Palacios J, Riera-Tur L, Montiel-Quezel N, Linares-Barrios M. MPXV Transmission at a tattoo parlor. N Engl J Med 2023;388(1):92-94. doi: 10.1056/NEJMc2210823.
Chen N, Li G, Liszewski MK, Atkinson JP, Jahrling PB, Feng Z, Schriewer J, Buck C, Wang C, Lefkowitz EJ, Esposito JJ, Harms T, Damon IK, Roper RL, Upton C, Buller RM. Virulence differences between monkeypox virus isolates from West Africa and the Congo basin. Virology 2005;340(1):46-63. doi: 10.1016/j.virol.2005.05.030.
World Health Organization: Mpox. 26 August 2024. Available at: https://www.who.int/news-room/fact-sheets/detail/mpox. Accessed on 28 September 2024.
Parker S, Buller RM. A review of experimental and natural infections of animals with monkeypox virus between 1958 and 2012. Future Virol 2013;8(2):129-157. doi: 10.2217/fvl.12.130.
Simpson K, Heymann D, Brown CS, Edmunds WJ, Elsgaard J, Fine P, Hochrein H, Hoff NA, Green A, Ihekweazu C, Jones TC, Lule S, Maclennan J, McCollum A, Mühlemann B, Nightingale E, Ogoina D, Ogunleye A, Petersen B, Powell J, Quantick O, Rimoin AW, Ulaeato D, Wapling A. Human monkeypox–After 40 years, an unintended consequence of smallpox eradication. Vaccine 2020;38(33):5077-5081. doi: 10.1016/j.vaccine.2020.04.062.
Centers for Disease Control and Prevention. Multistate outbreak of monkeypox¬¬–Illinois, Indiana, and Wisconsin, 2003. MMWR Morb Mortal Wkly Rep 2003;52(23):537-40.
Rimoin AW, Mulembakani PM, Johnston SC, Lloyd Smith JO, Kisalu NK, Kinkela TL, Blumberg S, Thomassen HA, Pike BL, Fair JN, Wolfe ND, Shongo RL, Graham BS, Formenty P, Okitolonda E, Hensley LE, Meyer H, Wright LL, Muyembe JJ. Major increase in human monkeypox incidence 30 years after smallpox vaccination campaigns cease in the Democratic Republic of Congo. Proc Natl Acad Sci U S A. 2010;107(37):16262-16267. doi: 10.1073/pnas.1005769107.
Yinka-Ogunleye A, Aruna O, Dalhat M, Ogoina D, McCollum A, Disu Y, Mamadu I, Akinpelu A, Ahmad A, Burga J, Ndoreraho A, Nkunzimana E, Manneh L, Mohammed A, Adeoye O, Tom-Aba D, Silenou B, Ipadeola O, Saleh M, Adeyemo A, Nwadiutor I, Aworabhi N, Uke P, John D, Wakama P, Reynolds M, Mauldin MR, Doty J, Wilkins K, Musa J, Khalakdina A, Adedeji A, Mba N, Ojo O, Krause G, Ihekweazu C; CDC Monkeypox Outbreak Team. Outbreak of human monkeypox in Nigeria in 2017-18: a clinical and epidemiological report. Lancet Infect Dis. 2019;19(8):872-879. doi: 10.1016/S1473-3099(19)30294-4.
European Centers for Disease Control. Monkeypox cases reported in UK and Portugal. 19 May 2022. Available at: https://www.ecdc.europa.eu/en/news-events/monkeypox-cases-reported-uk-and-portugal. Accessed on 6 October 2024.
World Health Organization: WHO Director-General declares the ongoing monkeypox outbreak a public health emergency of international concern. 23 July 2022. Available at: https://www.who.int/europe/news/item/23-07-2022-who-director-general-declares-the-ongoing-monkeypox-outbreak-a-public-health-event-of-international-concern. Accessed on 6 October 2024.
Pollock ED, Clay PA, Keen A, Currie DW, Carter RJ, Quilter LAS, Gundlapalli AV, Mermin J, Spicknall IH. Potential for recurrent mpox outbreaks in gay, bisexual, and other men who have sex with men–United States, 2023. MMWR Morb Mortal Wkly Rep 2023;72(21):568–573. doi: 10.15585/mmwr.mm7221a1.
Low N, Bachmann LH, Ogoina D, McDonald R, Ipekci AM, Quilter LAS, Cevik M. Mpox virus and transmission through sexual contact: Defining the research agenda. PLoS Med 2023;20(1):e1004163. doi: 10.1371/journal.pmed.1004163.
Brosius I, Van Dijck C, Coppens J, Vandenhove L, Bangwen E, Vanroye F, Verschueren J; ITM MPOX Study Group; Zange S, Bugert J, Michiels J, Bottieau E, Soentjens P, van Griensven J, Kenyon C, Ariën KK, Van Esbroeck M, Vercauteren K, Liesenborghs L. Presymptomatic viral shedding in high-risk mpox contacts: A prospective cohort study. J Med Virol 2023;95(5):e28769. doi: 10.1002/jmv.28769.
World Health Organization. Multi-country outbreak of mpox, external situation report#34. 28 June 2024. Available at: https://www.who.int/publications/m/item/multi-country-outbreak-of-mpox--external-situation-report-34--28-june-2024. Accessed on 13 October 2024.
World Health Organization. WHO Director-General declares mpox outbreak a public health emergency of international concern. 14 August 2024. Available at: https://www.who.int/news/item/14-08-2024-who-director-general-declares-mpox-outbreak-a-public-health-emergency-of-international-concern. Accessed on 13 October 2024.
Vakaniaki EH, Kacita C, Kinganda-Lusamaki E, O'Toole Á, Wawina-Bokalanga T, Mukadi-Bamuleka D, Amuri-Aziza A, Malyamungu-Bubala N, Mweshi-Kumbana F, Mutimbwa-Mambo L, Belesi-Siangoli F, Mujula Y, Parker E, Muswamba-Kayembe PC, Nundu SS, Lushima RS, Makangara-Cigolo JC, Mulopo-Mukanya N, Pukuta-Simbu E, Akil-Bandali P, Kavunga H, Abdramane O, Brosius I, Bangwen E, Vercauteren K, Sam-Agudu NA, Mills EJ, Tshiani-Mbaya O, Hoff NA, Rimoin AW, Hensley LE, Kindrachuk J, Baxter C, de Oliveira T, Ayouba A, Peeters M, Delaporte E, Ahuka-Mundeke S, Mohr EL, Sullivan NJ, Muyembe-Tamfum JJ, Nachega JB, Rambaut A, Liesenborghs L, Mbala-Kingebeni P. Sustained human outbreak of a new MPXV clade I lineage in eastern Democratic Republic of the Congo. Nat Med 2024. doi: 10.1038/s41591-024-03130-3.
Philippine Daily Inquirer. First case of monkeypox detected in PH. 29 July 2022. Available at: https://newsinfo.inquirer.net/1637227/first-case-of-monkeypox-detected-in-ph. Accessed on 20 October 2024.
Ylaya EM, Grande PG, Dancel LL, Nicolasora AD, Polotan FG, Pantoni RA, Melo E, Ortia SP, Manalo JI, Abulencia MF, Chu MYJ, Dizon TJ, Bucoy-Sy MC, Adasa G, Gianan-Gascon A and Roman AD. Case report: A comprehensive report on the first confirmed mpox case in the Philippines during the 2022 mpox global outbreak: from clinical presentation to shotgun metagenomic sequencing analysis. Front Med 2024;11:1387407. doi: 10.3389/fmed.2024.1387407.
Cordero DA Jr. The threat of monkeypox in the Philippines: another problematic preparation and management for the healthcare system? Clin Exp Vaccine Res 2023;12(1):77-79. doi: 10.7774/cevr.2023.12.1.77.
GMA News. DOH detects 1 new mpox case. 19 August 2024. Available at: https://www.gmanetwork.com/news/topstories/nation/917530/doh-mpox-case/story/. Accessed on 20 October 2024.
GMA News. PH detects 2 more mpox cases, both in NCR. 26 August 2024. Available at: https://www.gmanetwork.com/news/topstories/nation/918239/philippines-mpox-ncr/story/. Accessed on 20 October 2024.
GMA News. DOH: Mpox cases actually dipped in May 2025; total cases 911 since 2024. 31 May 2025. Available at: https://www.gmanetwork.com/news/topstories/nation/947931/doh-more-mpox-cases-in-april-2025-than-in-may-total-cases-911-since-2024/story/. Accessed on 2 June 2025.
Anadolu Ajansi. Philippines confirms 1 death from mpox, another in hospital. 18 April 2025. Available at: https://www.aa.com.tr/en/asia-pacific/philippines-confirms-1-death-from-mpox-another-in-hospital/. Accessed on 2 June 2025.
Farahat RA, Rackimuthu S, Umar TP, Siddiqui JA, Shrestha AB, Essar MY. Preparedness of South East Asia countries in view of monkeypox emergence: A call for action. Lancet Reg Health Southeast Asia 2022;6:100074. doi: 10.1016/j.lansea.2022.100074.
Ennab F, Nawaz FA, Narain K, Nchasi G, Essar MY. Rise of monkeypox: Lessons from COVID-19 pandemic to mitigate global health crises. Ann Med Surg (Lond) 2022;79:104049. doi: 10.1016/j.amsu.2022.104049.
León-Figueroa DA, Barboza JJ, Siddiq A, Sah R, Valladares-Garrido MJ, Rodriguez-Morales AJ. Knowledge and attitude towards mpox: Systematic review and meta-analysis. PLoS One 2024;19(8):e0308478. doi: 10.1371/journal.pone.0308478.
Jahromi AS, Jokar M, Sharifi N, Kashkooli S, Rahmanian K, Rahmanian V. Global knowledge and attitudes towards mpox (monkeypox) among healthcare workers: a systematic review and meta-analysis. Int Health 2024;16(5):487-498. doi: 10.1093/inthealth/ihad094.
Berdida DJE. Population-based survey of human monkeypox disease knowledge in the Philippines: An online cross-sectional study. J Adv Nurs 2023;79(7):2684-2694. doi: 10.1111/jan.15635.
Edinger A, Valdez D, Walsh-Buhi E, Trueblood JS, Lorenzo-Luaces L, Rutter LA, Bollen J. Misinformation and public health messaging in the early stages of the mpox outbreak: Mapping the Twitter narrative with deep learning. J Med Internet Res 2023;25:e43841. doi: 10.2196/43841.
World Health Organization. WHO recommends new name for monkeypox disease. 28 November 2022. Available at: https://www.who.int/news/item/28-11-2022-who-recommends-new-name-for-monkeypox-disease. Accessed on 27 October 2024.
Farahat RA, Head MG, Tharwat S, Alabdallat Y, Essar MY, Abdelazeem B, Ould Setti M. Infodemic and the fear of monkeypox: call for action. Trop Med Health 2022;50(1):63. doi: 10.1186/s41182-022-00459-8.
Ju W, Sannusi SN, Mohamad E. Stigmatizing monkeypox and COVID-19: A comparative framing study of The Washington Post's online news. Int J Environ Res Public Health 2023;20(4):3347. doi: 10.3390/ijerph20043347.
Liu R, Chen C. How news reporting exacerbated the monkeypox pandemic in Spain and the US: A corpus-based news values analysis. Glob Public Health 2024;19(1):2320422. doi: 10.1080/17441692.2024.2320422.
El Dine FB, Gebreal A, Samhouri D, Estifanos H, Kourampi I, Abdelrhem H, Mostafa HA, Elshaar AG, Suvvari TK, Ghazy RM. Ethical considerations during mpox outbreak: a scoping review. BMC Med Ethics 2024;25(1):79. doi: 10.1186/s12910-024-01078-0.
Kenyon C. Is monkeypox being underdiagnosed in countries with more stigmatizing attitudes towards men who have sex with men? A simple ecological analysis. Epidemiologia (Basel) 2022;3(3):363-368. doi: 10.3390/epidemiologia3030028.
Dalton AF, Diallo AO, Chard AN, Moulia DL, Deputy NP, Fothergill A, Kracalik I, Wegner CW, Markus TM, Pathela P, Still WL, Hawkins S, Mangla AT, Ravi N, Licherdell E, Britton A, Lynfield R, Sutton M, Hansen AP, Betancourt GS, Rowlands JV, Chai SJ, Fisher R, Danza P, Farley M, Zipprich J, Prahl G, Wendel KA, Niccolai L, Castilho JL, Payne DC, Cohn AC, Feldstein LR; CDC Multijurisdictional Mpox Case-Control Study Group; CDC Multijurisdictional Mpox Case Control Study Group. Estimated effectiveness of JYNNEOS vaccine in preventing mpox: A multijurisdictional case-control study - United States, August 19, 2022-March 31, 2023. MMWR Morb Mortal Wkly Rep 2023;72(20):553-558. doi: 10.15585/mmwr.mm7220a3.
Philippine News Agency. DOH warns public vs supposedly imported mpox vax. 13 September 2024. Available at: https://www.pna.gov.ph/articles/1233305. Accessed on 17 June 2025.
Lee M, Kang BA, You M. Knowledge, attitudes, and practices (KAP) toward COVID-19: a cross-sectional study in South Korea. BMC Public Health 2021;21(1):295. doi: 10.1186/s12889-021-10285-y.
Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis, 7th ed. Pearson Education Limited; 2009.
Kepios Pte. Ltd. Digital 2023: The Philippines—DataReportal. 9 February 2023. Available at: https://datareportal.com/reports/digital-2023-philippines. Accessed on 23 June 2025.
Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39(2):175-91. doi: 10.3758/bf03193146.
Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 2009;41(4):1149-60. doi: 10.3758/BRM.41.4.1149.
Malaeb D, Sallam M, Salim NA, Dabbous M, Younes S, Nasrallah Y, Iskandar K, Matta M, Obeid S, Hallit S, Hallit R. Knowledge, attitude and conspiracy beliefs of healthcare workers in Lebanon towards monkeypox. Trop Med Infect Dis 2023;8(2):81. doi: 10.3390/tropicalmed8020081.
Alshahrani NZ, Algethami MR, Alarifi AM, Alzahrani F, Alshehri EA, Alshehri AM, Sheerah HA, Abdelaal A, Sah R, Rodriguez-Morales AJ. Knowledge and attitude regarding monkeypox virus among physicians in Saudi Arabia: A cross-sectional study. Vaccines (Basel) 2022;10(12):2099. doi: 10.3390/vaccines10122099.
Kumar N, Ahmed F, Raza MS, Rajpoot PL, Rehman W, Khatri SA, Mohammed M, Muhammad S, Ahmad R. Monkeypox cross-sectional survey of knowledge, attitudes, practices, and willingness to vaccinate among university students in Pakistan. Vaccines (Basel) 2022;11(1):97. doi: 10.3390/vaccines11010097.
Isaacs SN, Mitjà O. Epidemiology, clinical manifestations, and diagnosis of mpox (formerly monkeypox). Updated 26 November 2024. Available at: https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-mpox-formerly-monkeypox. Accessed on 30 June 2025.
Isaacs SN, Shenoy ES, Goldfarb IT. Treatment and prevention of mpox (formerly monkeypox). Updated 10 October 2024. Available at: https://www.uptodate.com/contents/treatment-and-prevention-of-mpox-formerly-monkeypox. Accessed on 30 June 2025.
Rimal RN, Real K. Perceived risk and efficacy beliefs as motivators of change. Hum Commun Res 2003;29(3):370-399. doi: 10.1111/j.1468-2958.2003.tb00844.x.
Bloom BS. Learning for mastery. Instruction and curriculum. Regional Education Laboratory for the Carolinas and Virginia, Topical Papers and Reprints, Number 1. Eval Comment 1968;1(2):12.
Mehmetoglu M. medsem: a Stata package for statistical mediation analysis. Inj J Comput Econ Ec 2018;8(1):63-78.
Zhao X, Lynch JG Jr, Chen Q. Reconsidering Baron and Kenny: myths and truths about mediation analysis. J Consum Res 2010;37(2):197-206. doi: 10.1086/651257.
Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach, 3rd ed. The Guilford Press; 2022.
Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND. Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol 2007;26(2):136-45. doi: 10.1037/0278-6133.26.2.136.
Dayapera LZA, Sy JCY, Valenzuela S, Eala SJL, Del Rosario CMIP, Buensuceso KNC, Dy AS, Morales DA, Gibson AG, Apostol GLC. One health in the Philippines: A review and situational analysis. One Health 2024;18:100758. doi: 10.1016/j.onehlt.2024.100758.
Spring H. Health literacy and COVID-19. Health Info Libr J. 2020;37(3):171-172. doi: 10.1111/hir.12322.
Malecki KMC, Keating JA, Safdar N. Crisis communication and public perception of COVID-19 risk in the era of social media. Clin Infect Dis 2021;72(4):697-702. doi: 10.1093/cid/ciaa758.
Buckell J, Jones J, Matthews PC, Diamond SI, Rourke E, Studley R, Cook D, Walker AS, Pouwels KB; COVID-19 Infection Survey Team. COVID-19 vaccination, risk-compensatory behaviours, and contacts in the UK. Sci Rep 2023;13(1):8441. doi: 10.1038/s41598-023-34244-2.
Fatima K, Syed NI. Dengvaxia controversy: impact on vaccine hesitancy. J Glob Health 2018;8(2):010312. doi: 10.7189/jogh.08.020312.
Mendoza RU, Dayrit MM, Alfonso CR, Ong MMA. Public trust and the COVID-19 vaccination campaign: lessons from the Philippines as it emerges from the Dengvaxia controversy. Int J Health Plann Manage 2021;36(6):2048-2055. doi: 10.1002/hpm.3297.
Siddiquea BN, Shetty A, Bhattacharya O, Afroz A, Billah B. Global epidemiology of COVID-19 knowledge, attitude and practice: a systematic review and meta-analysis. BMJ Open 2021;11(9):e051447. doi: 10.1136/bmjopen-2021-051447.
Rakotosamimanana S, Mangahasimbola RT, Ratovoson R, Randremanana RV. Determinants of COVID-19-related knowledge and disrupted habits during epidemic waves among women of childbearing age in urban and rural areas of the Malagasy Middle East. BMC Public Health 2023;23(1):1990. doi: 10.1186/s12889-023-16931-x.
Kim S, Kim S. Analysis of the impact of health beliefs and resource factors on preventive behaviors against the COVID-19 Pandemic. Int J Environ Res Public Health 2020;17(22):8666. doi: 10.3390/ijerph17228666.
Holroyd TA, Oloko OK, Salmon DA, Omer SB, Limaye RJ. Communicating recommendations in public health emergencies: the role of public health authorities. Health Secur;18(1):21-28. doi: 10.1089/hs.2019.0073.
Zhang C, Adriaanse MA, Potgieter R, Tummers L, de Wit J, Broersen J, de Bruin M, Aarts H. Habit formation of preventive behaviours during the COVID-19 pandemic: a longitudinal study of physical distancing and hand washing. BMC Public Health 2022;22(1):1588. doi: 10.1186/s12889-022-13977-1.
den Daas C, Dixon D, Hubbard G, Allan J, Johnston M. Habits and reflective processes in COVID-19 transmission-reducing behaviors: examining theoretical predictions in a representative sample of the population of Scotland. Ann Behav Med 2023;57(11):910-920. doi: 10.1093/abm/kaad025.
Short SE, Mollborn S. Social determinants and health behaviors: conceptual frames and empirical advances. Curr Opin Psychol 2015;5:78-84. doi: 10.1016/j.copsyc.2015.05.002.
Michaelsen MM, Esch T. Understanding health behavior change by motivation and reward mechanisms: a review of the literature. Front Behav Neurosci 2023;17:1151918. doi: 10.3389/fnbeh.2023.1151918.
Xiang M, Guan T, Lin M, Xie Y, Luo X, Han M, Lv K. Configuration path study of influencing factors on health information-sharing behavior among users of online health communities: based on SEM and fsQCA methods. Healthcare (Basel) 2023;11(12):1789. doi: 10.3390/healthcare11121789.
Branch-Elliman W, Elwy AR, Chambers DA. Embracing dynamic public health policy impacts in infectious diseases responses: leveraging implementation science to improve practice. Front Public Health 2023;11:1207679. doi: 10.3389/fpubh.2023.1207679.
Stover J, Avadhanula L, Sood S. A review of strategies and levels of community engagement in strengths-based and needs-based health communication interventions. Front Public Health 2024;12:1231827. doi: 10.3389/fpubh.2024.1231827.