Knowledge, concerns, and vaccine acceptance related to Mpox (Monkeypox) among university students in North and Northeast China: An online cross-sectional study

ABSTRACT

The growing number of Mpox cases in China has posed a challenge to public health. The prevalence of men who have sex with men behaviors among students has been consistently increasing each year in China, accompanied by a high frequency of unprotected anal sex. As crowded places, schools are highly likely to cause an Mpox outbreak among students through long-term close contact. Understanding university students’ perceptions about Mpox and willingness to vaccinate play a vital role in implementing preventive measures in schools. This study aimed to assess knowledge, concerns, and vaccine acceptance toward Mpox among university students in North and Northeast China. A cross-sectional study was conducted among 3831 university students from seven universities in North and Northeast China between September 10 and September 25, 2023. This study found a relative insufficiency in Mpox knowledge among university students (71.60%), with less than half expressing concern about the Mpox outbreak (39.57%), and the majority exhibiting a positive attitude to vaccination (76.30%). Multivariate regression analysis revealed that a good knowledge level was associated with age, study discipline, education level, and a high level of concern about Mpox. Male, elderly, or highly educated participants had a low level of concern about Mpox. Participants with a high level of knowledge toward Mpox were more likely to have the vaccination willingness. This study might help governments and schools to understand students’ Mpox perceptions and vaccination intentions, enabling them to implement effective measures in addressing the issue of inadequate understanding regarding Mpox among university students.

KEYWORDS:

• Mpox
• knowledge
• concerns
• vaccine acceptance
• students
• North and Northeast China

Introduction

Monkeypox disease (Mpox) was a zoonotic infectious disease caused by the Mpox virus, which belonged to members of the genus Orthopoxviral.¹ The Mpox virus was first discovered in monkeys in 1958, and the first Mpox case was detected in a nine-month-old boy from the Democratic Republic of the Congo in 1970.¹ Mpox was mainly endemic in Central and West Africa, and had since spread to many nonendemic countries, including the United States, the United Kingdom, and others.² The World Health Organization (WHO) has reported a total of 91,123 confirmed Mpox cases and 663 probable cases, including 157 deaths as of September 30, 2023.³

The common clinical manifestations of Mpox contained fever, muscle and headache pain, rash, and lymphadenopathy.^4–6 The increase in international travel, the popularity of new pets, and the decline in smallpox vaccination protection all contribute to increase the risk of Mpox transmission.^7,8 Mpox virus could spread by animal-to-human transmission or human-to-human transmission.^6,9 The routes of Mpox human-to-human transmission included intimate or sexual contact, contaminated surfaces or skin-to-skin contact, and respiratory droplets contact.¹⁰ Sexual contact (especially sex between men) was the most important way of transmission.^11,12

On September 16, 2022, the first imported case of Mpox in the mainland of China was found in Chongqing Municipality, China.¹³ Between June and August 2023, 1098 Mpox cases were detected in China in just 3 months.¹⁴ This implies that China continues to face the public health challenges posed by Mpox. Moreover, as a populous country, China cannot effectively control local transmission, which could potentially exacerbate risk of global transmission.^15,16 The incidence of Mpox in North and Northeast China was significantly high.¹⁴ Especially in Beijing, the most Mpox cases were reported in North China, where 180 Mpox cases were reported between June and August 2023.¹⁴ And a high number of men who have sex with men (MSM) exist in North and Northeast China, among which Beijing, Hebei, Jilin, Heilongjiang, and other regions are the high concentration areas of MSM population.¹⁷ And the average number of online MSM numbers in a social networking MSM app could be over 60,000 per day in Beijing.¹⁸ In addition, the prevalence of men who have sex with men (MSM) behaviors among students has been consistently increasing each year in China,¹⁹ accompanied by a high frequency of unprotected anal sex.^20,21 MSM students were more than three times more likely to have had sexual contact with casual or commercial sex partners compared with non-MSM students, which makes it easier to spread Mpox.¹⁹ What’s more, prolonged frequent physical contact between students might lead to the occurrence of Mpox cluster.²² Although students are not the main infected group, the above characteristics might have a high risk of Mpox transmission in the student population. Therefore, before the Mpox outbreak occurred in schools, understanding university students’ perception about Mpox and willingness to vaccinate played a vital role in implementing preventive measures in schools.

However, studies are scarce on university students’ perception about Mpox and willingness to vaccinate in China. Only one study examined the high prevalence of vaccine hesitancy among university students in southwest China, but there was no assessment conducted regarding the students’ perception of Mpox.²³ Several other studies in China focused on healthcare workers,^24,25 the general public,^26–28 or MSM.^29–33 These findings indicated that the general population^26,27 and MSM population^29–32 in China had limited knowledge level of Mpox, while the knowledge level of Mpox was high in healthcare workers.²⁴ Moreover, Chinese individuals had a relatively strong willingness to vaccinate against Mpox.^{24–26,28,29} Only one study reported a high knowledge level of Mpox among the Chinese population, which might be due to large selection bias resulting from a small sample size (N = 521).²⁸ At present, there were few studies on the level of concern about Mpox in the Chinese population, the rates of which varied from 37.1% to 62.7%.^24,26,27,30 Several studies found a correlation between major factors, such as level of education,^27,28,32 age,^24,32 and Mpox knowledge in China. A low knowledge level of Mpox was associated with a low willingness to vaccinate.^{23,24,26,28–30} Therefore, considering the potential lack of perception among university students regarding Mpox and the limited research in the current studies, it is necessary to investigate their level of knowledge, concerns, and vaccine acceptance toward Mpox. In addition, the analysis of factors influencing knowledge, concerns, and vaccine acceptance toward Mpox will facilitate the development of targeted strategies for future interventions in schools. Thus, this study aimed to evaluate knowledge, concerns, and vaccine acceptance toward Mpox, and their influencing factors among university students in North and Northeast China.

Materials and methods

Study setting, design, and sampling

This was a cross-sectional study which was carried out through a self-administered online questionnaire designed using an online survey platform (called Wenjuanxing). The data were collected between September 10 and September 25, 2023. A convenience sampling method was used to collect the questionnaire. This study randomly selected among students at seven universities in North and Northeast China, including three universities in Beijing (Beijing University of Technology, the Capital University of Economics and Business, and Capital Medical University); Jilin University in Jilin Province; Harbin Medical University in Heilongjiang Province; Hebei Medical University in Hebei Province; and Baotou Medical College in Inner Mongolia. Questionnaires are voluntarily distributed to students through online platforms with the assistance of counselors or school medical professionals in schools. Participants under the age of 18 and those who declined to participate were not eligible to be included in this study. All participants were provided with online informed consent. Meanwhile, participants were acquired to answer two common-sense questions unrelated to this study, “Where is the capital of China? (Shanghai/Beijing/Nanjing/Wuhan)” and “In which direction does the sun rise in the morning? (West/East/South/North),” to eliminate participants who did not answer the questions seriously.

The questionnaire has been employed in a previous study.²⁶ The questionnaire was modified by a team of six infectious disease staff members from Chaoyang District Center for Disease Prevention and Control of Beijing, along with a professor from Fudan University, to enhance its applicability to the university student population. Additionally, an assessment of its surface validity was conducted to ensure coherence, accuracy, and comprehensibility. Prior to official distribution, a pilot study involving approximately ten samples was carried out. The results indicated the clarity and comprehensibility of these questions.

The sample size was computed by using the single sample proportion formula, n = [(Z_α/2)²P (1-P)/d²], where n is the number of sample size, Z_α/2 is 1.96 at a 95% confidence interval, d is a 5% margin of error. Referring to a previous survey of the public in China, 54.5% of the participants learned about Mpox information before the survey.²⁶ This value was applied as an estimated response distribution (P). Thus, a minimum sample size of 382 was determined.

Demographic characteristics

Participants’ demographic information was asked to provide, which included age (<20 and ≥20 y), gender (Male or Female), major (Medical or Non-medical), study level (Undergraduate and below, Postgraduate and above), living area (Rural or Urban), relationship status (Single or Unsingle), sexual behavior in the last 3 months (Yes or No), chronic disease (Yes or No). Age was categorized into two groups based on the median age of 20 y in the study. Chronic diseases included hypertension, diabetes, gout/hyperuricemia, chronic pain, chronic respiratory disease, immunodeficiency disease, malignant tumor, and others.

Awareness about Mpox

The awareness of Mpox was evaluated by asking, “Did you learn about Mpox before this survey? (Yes or No).” If participants who selected “Yes,” how to get Mpox information (Internet sources, traditional media, publicity by schools and other organizational units, communicate with friends or others, etc.) and how much they were about Mpox (Often, occasionally, rarely, and unconcerned) were further asked to recall.

Knowledge of Mpox

The knowledge of Mpox was measured by 12 knowledge items. The scale was adopted from a survey of 1028 Chinese community residents regarding the awareness, knowledge, and concerns about Mpox.²⁷

The Mpox knowledge scale was as follows: (1) Mpox is an infectious disease, (2) Mpox is caused by a virus, (3) People can get Mpox by close contact with an infected person or animal, (4) People are generally susceptible to Mpox, (5) There are currently no specific treatments for Mpox, (6) There is a vaccine that protects against Mpox. (7) Mpox can cause fever, (8) Mpox can cause headache, (9) Mpox can cause fatigue or exhaustion, (10) Mpox can cause swollen lymph nodes, (11) Mpox can cause a body rash, (12) Mpox can cause back and muscle aches. Participants were acquired to choose one of the three answers (Yes/No/Don’t know) for each question. The answer “don’t know” was considered wrong. Having a high level of common or clinical knowledge about Mpox was defined as answering more than seven questions correctly.

The 7-item generalized anxiety disorder-7 (GAD-7)

The GAD-7 with seven validated questions was used to assess anxiety symptoms of participants toward the Mpox (Supplementary Table S1).³⁴ Participants with 5–21 scores were identified as having anxiety.²⁹

Concerns about Mpox

All participants were asked, “Are you concerned about the Mpox epidemic? (Yes/No),” aiming to measure participants’ concerns about Mpox.^24,26 If selected yes, we further asked the reason why there was concern about the Mpox pandemic.

Attitudes toward Mpox

This section contains five questions designed to measure the attitude toward Mpox according to the previous study,³⁵ with three-point Likert scale possible responses (disagree/undecided/agree) (Supplementary Table S2). Different responses to the score were as follows: disagree = 0, undecided = 1, agree = 2. A positive attitude was defined as having a score exceeding or equal to the average value of the participants’ scores, while a negative attitude was lower than the average.

Willingness to adopt preventive measures and Mpox vaccine

Willingness to adopt preventive measures was collected by a single question “How do you think you should avoid Mpox infection?.” The preventive measures were divided into three categories (hygiene practices/social distancing/travel avoidance) according to the previous study.^26,36 Willingness to adopt the Mpox vaccine was measured by asking participants “Whether they were willing to get the Mpox vaccine?,” with 3-Likert scale possible responses (disagree = 1, neutral = 2, agree = 3). The answers of neutral and disagree were both defined as unwillingness. In addition, participants who refused to be vaccinated were required to select specific reasons.

Statistical analyses

Continuous variables were expressed with Mean and Standard Deviations, while categorical data were given with frequencies and percentages. The Chi-square test was used to compare the differences of characteristics between groups. The Crude and adjusted odds ratio (OR) and the 95% confidence interval (95% CI) were estimated. Binary logistic regression was used to assess the association between possible influencing factors and Mpox knowledge, concerns about Mpox, and vaccine acceptance toward Mpox among students. All variables in the univariable analysis were also included in the multivariable logistic regression model. To establish the optimal model and address potential multicollinearity, backward stepwise regression was used to select variables and identify the final model in the multivariable logistic model. Data analyzes were examined using R software (Version 4.3.1). Statistical significance was defined as a p value of <.05.

Results

A total of 3831 students participated in this study, excluding 89 students who declined to participate, 83 students who answered common-sense questions incorrectly, 143 students who were under the age of 18 and 7 students whose data were abnormal. The mean age of the participants was 20.62 ± 2.58 y. Most of the participants were female (66.98%), were single (79.12%), were undergraduate and below (68.10%), majored in non-medical specialty (94.13%), lived in urban (77.84%), having no sexual behavior (90.16%) and no history of chronic disease (95.77%) (Table 1).

Table 1. Demographic characteristics of the study participants (N = 3831).

Characteristics	n (%)
Age
<20	1721 (44.92)
≥20	2110 (55.08)
Gender
Female	2566 (66.98)
Male	1265 (33.02)
Major
Non-medical^a	3606 (94.13)
Medical	225 (5.87)
Study level
Undergraduate and below	2609 (68.10)
Postgraduate and above	1222 (31.90)
Living area
Rural	849 (22.16)
Urban	2982 (77.84)
Relationship status
Single	3031 (79.12)
Unsingle	800 (20.88)
Sexual behavior
No	3454 (90.16)
Yes	377 (9.84)
Chronic disease^b
No	3669 (95.77)
Yes	162 (4.23)

^aNon-medical include philosophy, economics, pedagogy, literature, history, Science, engineering, agronomy, Management, Art Studies, etc. ^bChronic diseases included hypertension, diabetes, gout/hyperuricemia, chronic pain, chronic respiratory disease, immunodeficiency disease, malignant tumor, and others.

In this study, 64.84% of participants learned about Mpox before the survey (Table 2). The two main ways to acquire Mpox information included the Internet (such as Wechat, Weibo, etc.) and traditional media (such as TV, newspapers, radio, etc.) (Figure 1). About 71.60% of the participants had a high level of knowledge about Mpox. More than half of the participants did not understand that there was a vaccine to prevent Mpox (54.71%), no specific drugs to treat Mpox (50.07%), and the general susceptibility of the population (51.21%) (Figure 2).

Figure 1. Source of Mpox information among university students who attention about Mpox.

Figure 2. Answer each Mpox knowledge question correctly among university students.

Table 2. Knowledge, concerns, and vaccine acceptance related to Mpox of all participants (N = 3831).

Characteristics	n (%)
Awareness of Mpox
No	1347 (35.16)
Yes	2484 (64.84)
Knowledge level of Mpox^a
Low	1088 (28.40)
High	2743 (71.60)
GAD-7^b
No	3371 (87.99)
Yes	460 (12.01)
Concerns about Mpox
No	2315 (60.43)
Yes	1516 (39.57)
Attitudes toward Mpox^c
Negative	2174 (56.75)
Positive	1657 (43.25)
Willingness to adopt Mpox vaccine
No	908 (23.70)
Yes	2923 (76.30)

^aA correct answer more out of 7 questions was considered a high level of Mpox knowledge. ^bParticipants with 5–21 scores were identified as having anxiety when answering the GAD-7. ^cA positive attitude was defined as having a score exceeding or equal to the average value of the participants’ scores.

Part of participants (39.57%) were concerned about the Mpox outbreak (Table 2). Worrying about infection in self or family (89.45%) was the leading cause of concern about the Mpox outbreak (Figure 3). And 56.75% of the participants expressed a negative attitude toward Mpox. Few participants (12.01%) were anxious about the Mpox (Table 2). The majority of participants (76.30%) were willing to adopt the Mpox vaccine. Concerns about the adverse effects (80.84%) or protective effects (46.48%) of the vaccine were the main reasons for reluctance to vaccinate (Figure 4). Participants choose social distancing, travel avoidance, and vaccination as the main means of preventing Mpox (data not shown).

Figure 3. The reasons among university students who worried about Mpox.

Figure 4. The reasons why university students were not willing to get the Mpox vaccine.

Table 3 shows multivariate regression analysis of Mpox knowledge level and its influencing factors. Medical students were more likely to have a higher knowledge level about Mpox compared to non-medical students (adjusted OR: 1.58; 95% CI: 1.12–2.21). Participants with high knowledge levels were likely to be young (adjusted OR: 0.60; 95% CI: 0.50–0.72), have a high education level (adjusted OR: 1.24; 95% CI: 1.02–1.50), a good awareness to Mpox (adjusted OR: 1.66; 95% CI: 1.43–1.92), a good attitude about Mpox (adjusted OR: 1.64; 95% CI: 1.41–1.90), and a high level of concern toward Mpox (adjusted OR: 1.26; 95% CI: 1.09–1.47).

Table 3. Factors associated with Mpox knowledge level among university students in North and Northeast China.

Variables	Knowledge level of Mpox		P^a	Univariable OR (95% CI)	P	Multivariable OR (95% CI)^b	P
	Low, n (%)	High, n (%)
Age
<20	427 (39.25)	1294 (47.17)	<.001	Ref		Ref
≥20	661 (60.75)	1449 (52.83)		0.72 (0.63–0.83)	<.001	0.60 (0.50–0.72)	<.001
Gender
Female	733 (67.37)	1833 (66.82)	.775	Ref		/	/
Male	355 (32.63)	910 (33.18)		1.03 (0.88–1.19)	.746
Major
Non-medical	1041 (95.68)	2565 (93.51)	.012	Ref		Ref
Medical	47 (4.32)	178 (6.49)		1.54 (1.11–2.14)	.010	1.58 (1.12–2.21)	.008
Study level
Undergraduate and below	732 (67.28)	1877 (68.43)	.516	Ref		Ref
Postgraduate and above	356 (32.72)	866 (31.57)		0.95 (0.82–1.10)	.491	1.24 (1.02–1.50)	.028
Living area
Rural	259 (23.81)	590 (21.51)	.134	Ref		/	/
Urban	829 (76.19)	2153 (78.49)		1.14 (0.97–1.35)	.123
Relationship status
Single	864 (79.41)	2167 (79.00)	.812	Ref		/	/
Unsingle	224 (20.59)	576 (21.00)		1.03 (0.86–1.22)	.778
Sexual behavior
No	971 (89.25)	2483 (90.52)	.257	Ref		/	/
Yes	117 (10.75)	260 (9.48)		0.87 (0.69–1.09)	.233
Chronic disease
No	1045 (96.05)	2624 (95.66)	.655	Ref		/	/
Yes	43 (3.95)	119 (4.34)		1.10 (0.77–1.57)	.592
Awareness of Mpox
No	484 (44.49)	863 (31.46)	<.001	Ref		Ref
Yes	604 (55.51)	1880 (68.54)		1.75 (1.51–2.02)	<.001	1.66 (1.43–1.92)	<.001
GAD_7
No	957 (87.96)	2414 (88.01)	1.000	Ref		/	/
Yes	131 (12.04)	329 (11.99)		1.00 (0.80–1.24)	.968
Attitudes toward Mpox
Negative	704 (64.71)	1470 (53.59)	<.001	Ref		Ref
Positive	384 (35.29)	1273 (46.41)		1.59 (1.37–1.84)	<.001	1.64 (1.41–1.90)	<.001
Concerns about Mpox
No	696 (63.97)	1619 (59.02)	.005	Ref		Ref
Yes	392 (36.03)	1124 (40.98)		1.23 (1.07–1.43)	.005	1.26 (1.09–1.47)	.002

^aP-values are from the Chi-square test. ^bAll variables as independent variables in the univariable analysis were included in the multivariable analysis. Backward stepwise regression was used to identify associated factors in the multivariable logistic model. Bold values indicate statistical significance (p < .05).

The association between related influencing factors and concerns about Mpox is presented in Table 4. Participants aged 20 y or older also had a negative concern about Mpox than those who were younger than 20 y old (adjusted OR: 0.77; 95% CI: 0.64–0.92). Compared to female participants, male participants expressed a lower level of concern about Mpox (adjusted OR: 0.54; 95% CI: 0.46–0.63). Furthermore, a low level of concern about Mpox was associated with having high education level (adjusted OR: 0.69; 95% CI: 0.57–0.84), living in urban (adjusted OR: 0.76; 95% CI: 0.64–0.91), existing sexual behavior (adjusted OR: 0.79; 95% CI: 0.61–1.02), having a positive attitude (adjusted OR: 0.65; 95% CI: 0.56–0.75). On the contrary, anxiety about Mpox (adjusted OR: 8.14; 95% CI: 6.30–10.52) had a positive association with concerns about Mpox.

Table 4. Factors associated with concerns about Mpox among university students in North and Northeast China.

Variables	Concern about Mpox		P^a	Univariable OR (95% CI)	P	Multivariable OR (95% CI)^b	P
	No, n (%)	Yes, n (%)
Age
<20	929 (40.13)	792 (52.24)	<.001	Ref		Ref
≥20	1386 (59.87)	724 (47.76)		0.61 (0.54–0.70)	<.001	0.77 (0.64–0.92)	.004
Gender
Female	1394 (60.22)	1172 (77.31)	<.001	Ref		Ref
Male	921 (39.78)	344 (22.69)		0.44 (0.38–0.51)	<.001	0.54 (0.46–0.63)	<.001
Major
Non-medical	2181 (94.21)	1425 (94.00)	.837	Ref		/	/
Medical	134 (5.79)	91 (6.00)		1.04 (0.79–1.37)	.783
Study level
Undergraduate and below	1459 (63.02)	1150 (75.86)	<.001	Ref		Ref
Postgraduate and above	856 (36.98)	366 (24.14)		0.54 (0.47–0.63)	<.001	0.69 (0.57–0.84)	<.001
Living area
Rural	490 (21.17)	359 (23.68)	.073	Ref		Ref
Urban	1825 (78.83)	1157 (76.32)		0.87 (0.74–1.01)	.067	0.76 (0.64–0.91)	.002
Relationship status
Single	1801 (77.80)	1230 (81.13)	.014	Ref		/	/
Unsingle	514 (22.20)	286 (18.87)		0.81 (0.69–0.96)	.013
Sexual behavior
No	2046 (88.38)	1408 (92.88)	<.001	Ref		Ref
Yes	269 (11.62)	108 (7.12)		0.58 (0.46–0.74)	<.001	0.79 (0.61–1.02)	.068
Chronic disease
No	2210 (95.46)	1459 (96.24)	.278	Ref		/	/
Yes	105 (4.54)	57 (3.76)		0.82 (0.59–1.14)	.244
Awareness of Mpox
No	852 (36.80)	495 (32.65)	.009	Ref		Ref
Yes	1463 (63.20)	1021 (67.35)		1.20 (1.05–1.38)	.008	1.15 (1.00–1.34)	.058
GAD_7
No	2234 (96.50)	1137 (75.00)	<.001	Ref		Ref
Yes	81 (3.50)	379 (25.00)		9.19 (7.16–11.81)	<.001	8.14 (6.30–10.52)	<.001
Attitudes toward Mpox
Negative	1175 (50.76)	999 (65.90)	<.001	Ref		Ref
Positive	1140 (49.24)	517 (34.10)		0.53 (0.47–0.61)	<.001	0.65 (0.56–0.75)	<.001

^aP-values are from the Chi-square test. ^bAll variables as independent variables in the univariable analysis were included in the multivariable analysis. Backward stepwise regression was used to identify associated factors in the multivariable logistic model. Bold values indicate statistical significance (p < .05).

Table 5 displays the association between influencing factors and willingness to adopt the Mpox vaccine using by multivariate regression analysis. Older than younger (adjusted OR: 0.67; 95% CI: 0.58–0.79), male compared with female (adjusted OR: 0.65; 95% CI: 0.56–0.77), participants who learned about Mpox compared with participants who did not (adjusted OR: 0.82; 95% CI: 0.70–0.97) had a lower willingness to be vaccinated. Inversely, compared with participants who had a lower knowledge level or a more negative attitude, participants with a higher knowledge level (adjusted OR:1.39; 95% CI: 1.18–1.64) or a more positive attitude (adjusted OR:1.35; 95% CI: 1.15–1.58) had a higher willingness to be vaccinated. Anxiety (adjusted OR:1.53; 95% CI: 1.16–2.02) or concerns (adjusted OR:1.21; 95% CI: 1.02–1.43) about Mpox were more likely to make participants willing to get vaccinated.

Table 5. Factors associated with willingness to adopt the Mpox vaccine among university students in North and Northeast China.

Variables	Willingness to be vaccinated		P^a	Univariable OR (95% CI)	P	Multivariable OR (95% CI)^b	P
	No, n (%)	Yes, n (%)
Age
<20	339 (37.33)	1382 (47.28)	<.001	Ref		Ref
≥20	569 (62.67)	1541 (52.72)		0.66 (0.57–0.77)	<.001	0.67 (0.58–0.79)	<.001
Gender
Female	540 (59.47)	2026 (69.31)	<.001	Ref		Ref
Male	368 (40.53)	897 (30.69)		0.65 (0.56–0.76)	<.001	0.65 (0.56–0.77)	<.001
Major
Non-medical	861 (94.82)	2745 (93.91)	.346	Ref		/	/
Medical	47 (5.18)	178 (6.09)		1.19 (0.85–1.65)	.307
Study level
Undergraduate and below	563 (62.00)	2046 (70.00)	<.001	Ref		/	/
Postgraduate and above	345 (38.00)	877 (30.00)		0.70 (0.60–0.82)	<.001
Living area
Rural	195 (21.48)	654 (22.37)	.601	Ref		/	/
Urban	713 (78.52)	2269 (77.63)		0.95 (0.79–1.14)	.569
Relationship status
Single	721 (79.41)	2310 (79.03)	.844	Ref		/	/
Unsingle	187 (20.59)	613 (20.97)		1.02 (0.85–1.23)	.807
Sexual behavior
No	819 (90.20)	2635 (90.15)	1.000	Ref		Ref
Yes	89 (9.80)	288 (9.85)		1.01 (0.78–1.29)	.964	1.25 (0.97–1.63)	.086
Chronic disease
No	868 (95.59)	2801 (95.83)	.835	Ref		/	/
Yes	40 (4.41)	122 (4.17)		0.95 (0.66–1.36)	.762
Awareness of Mpox
No	306 (33.70)	1041 (35.61)	.310	Ref		Ref
Yes	602 (66.30)	1882 (64.39)		0.92 (0.79–1.08)	.291	0.82 (0.70–0.97)	.018
GAD_7
No	833 (91.74)	2538 (86.83)	<.001	Ref		Ref
Yes	75 (8.26)	385 (13.17)		1.68 (1.30–2.18)	<.001	1.53 (1.16–2.02)	.002
Concerns toward Mpox
No	604 (66.52)	1711 (58.54)	<.001	Ref		Ref
Yes	304 (33.48)	1212 (41.46)		1.41 (1.20–1.65)	<.001	1.21 (1.02–1.43)	.029
Knowledge level of Mpox
Low	311 (34.25)	777 (26.58)	<.001	Ref		Ref
High	597 (65.75)	2146 (73.42)		1.44 (1.23–1.69)	<.001	1.39 (1.18–1.64)	<.001
Attitude toward Mpox
Negative	544 (59.91)	1630 (55.76)	.030	Ref		Ref
Positive	364 (40.09)	1293 (44.24)		1.19 (1.02–1.38)	.028	1.35 (1.15–1.58)	<.001

^aP-values are from the Chi-square test. ^bAll variables as independent variables in the univariable analysis were included in the multivariable analysis. Backward stepwise regression was used to identify associated factors in the multivariable logistic model. Bold values indicate statistical significance (p < .05).

Discussion

This study found that university students in North and Northeast China had a relatively low knowledge level of Mpox, were less concerned about the Mpox epidemic and willing to get the Mpox vaccine. The study showed that participants with high knowledge levels were likely to be young, majored in medicine, highly educated, have a good awareness of Mpox, have a positive attitude toward Mpox, and have a high level of concern about Mpox. A high level of concern about Mpox was associated with young, female, having a low education level, living in rural areas, and having a negative attitude, and feeling anxiety about Mpox. Younger than older, female compared with male, lower awareness of Mpox than higher awareness of Mpox, higher knowledge level than lower knowledge level, and more positive attitude than more negative and had better willingness to be vaccinated.

This study demonstrated that 71.60% of the students had a high level of Mpox knowledge. The result was similar with the previous studies showing inadequate knowledge of Mpox among students from different countries.^37–40 A community-based study in China reported that 43.5% and 50.3% of 1028 residents had low knowledge regarding Mpox and related symptoms, respectively (correct answers ≥4 out of 6 items).²⁷ Another study in China also found that getting knowledge of Mpox was insufficient in the general public.²⁶ Whereas, 91.1% healthcare workers in China had satisfactory knowledge levels of Mpox common knowledge (≥4 out of 7 questions).²⁴ The possible speculation between the differences that the media coverage of the first imported Mpox cases in Hong Kong and Chongqing during the study period might have improved healthcare workers’ perceptions of Mpox.²⁴ The limited knowledge of Mpox among students might be attributed to its low prevalence in schools, resulting in inadequate attention from students. Insufficient knowledge regarding Mpox could exert a detrimental influence on disease control efforts.⁴¹ A study has demonstrated that illness perceptions had significant direct effect on their adherence to precautionary measures.⁴² Therefore, reinforcing students’ knowledge of Mpox is of paramount importance.

Social media was an important way to spread knowledge about Mpox among students. Previous research has demonstrated that social media is a powerful tool for spreading awareness in infection prevention, helping people make the right decisions and changing their behavior patterns, especially during pandemics.⁴³ The role of social media in raising knowledge of Mpox among students should be further reinforced. In addition, one study suggested that lectures, seminars, and the use of electronic and print media were also some important ways to improve the knowledge of Mpox.⁴⁴ An intervention study of 960 medical students used a range of teaching and learning techniques, including interactive lectures, group discussions, demonstrations and re-demonstrations, instructional materials, such as data shows and lab models, and printed handouts.⁴⁵ The intervention study revealed that total knowledge scores of students increased 20 points approximately after the intervention.⁴⁵ These findings offered practical approaches for schools to promote students’ awareness and knowledge of Mpox. This study also found that university students had different degrees of mastery of different types of knowledge about Mpox. This study found that university students lacked knowledge regarding vaccination, treatment methods, and susceptible populations for Mpox, which was the direction that schools should strive to promote Mpox knowledge. This study found that 39.57% students were concerned about the Mpox outbreak, similar to two studies in China.^27,30 However, the result was lower than medical workers (56.7%)²⁴ and the public (62.7%)²⁶ in China. The possible reasons for this difference may be explained by having to do with both the increased understanding of Mpox over time and differences in identity itself. This study reported that the percentage of university students in China willing to receive the Mpox vaccine was 76.30%, which was higher than that of university students in Pakistan (67.7%).³⁷ Previous studies showed that rates of vaccine acceptance varied from 68.8%²⁶ to 76.4%²⁸ in the public in China, which were similar to the willingness rate of university students in this study. On the contrary, a review reported that vaccine hesitancy was common in the general population from other countries, with acceptance/willingness rates ranging from 29% to 50.6%.⁴⁶ The WHO ranked vaccine hesitancy as one of the top ten global health threats.⁴⁷ A review expressed that vaccination would be an important strategy for prevention toward Mpox because of the global rapid transmission, the existence of effective vaccines, and risk-benefit uncertainty of antivirals.⁴⁸ And the application of smallpox vaccines and antiviral drugs could also inhibit the spread of local viruses and reduce lesion pain after exposure.⁴⁹ However, China stopped vaccinating against it after 1982 since the WHO declared smallpox virus extinct worldwide in 1980.⁵⁰ In addition, there currently exists no Mpox vaccine in China. Therefore, the government should speed up the introduction of foreign vaccines and accelerate the development of domestic vaccines. Meanwhile, it is essential that schools should strengthen publicity effort, which aims to increase students’ willingness to vaccinate. This study found that some major aspects that were not in favor of vaccination, which contained concerns about adverse or protective effects, which contributed to the development of targeted vaccine publicity strategies in schools.

The study found that a good knowledge level was associated with age, study discipline, education level, and a high level of concern about Mpox. Other studies also reported that medical students could have a better knowledge level than non-medical students.^37,40 Younger students had a higher level of knowledge than older students, contrary to other studies.^38,40,51 The possible reason was that young students were more familiar with the internet and thus better access to information on Mpox from the internet.⁴⁰ The association between a high level of knowledge about Mpox and increased worries about Mpox was also found in another study on the Mpox perception among medical workers in China.²⁴ The possible speculation that high levels of Mpox knowledge were more aware of the severity of the global Mpox outbreak.²⁴

The study revealed that male, elderly, or highly educated participants had a low level of concern about Mpox, which was similar to previous research.^27,52 The gender and age differences in Mpox concerns might be attributed to themselves in coping with stress.²⁷ Previous studies have also reported a higher level of concern and fear of coronavirus disease 19 among female compared to male.^53,54 This gender difference is evident not only in the context of infectious diseases but also extends to other socio-natural hazards,⁵⁵ potentially attributed to heightened ability to perceive warning signs as credible in females and exhibiting a high inclination toward risk perception.⁵⁶ Older people are better able to adapt to stressors than younger people,⁵² which may potentially alleviate older people’s concerns regarding the Mpox epidemic. Additionally, people with higher education have better access to reliable psychosocial resources for coping with anxiety about Mpox.⁵²

The study has demonstrated that sociodemographic factors, including age and gender, exhibit a significant correlation with the acceptance of vaccination. A previous study also found that younger participants were more receptive to vaccines than older participants²⁶ because they could be more trusting of modern medical technology.⁵⁷ A possible explanation for the greater vaccination acceptance in females is that females have a higher level of concern about Mpox than males, which motivates them to seek vaccination for disease prevention. Similar to previous research,^24,26,28 participants with a high level of knowledge toward Mpox were more likely to have vaccination willingness. The finding highlights the importance of enhancing students’ knowledge of Mpox to improve students’ willingness to vaccinate.

Certainly, schools should also be prepared when Mpox strikes in addition to enhancing students’ perceptions of Mpox. The High Council for Public Health in French recommended specific guidelines in case of occurrence of an Mpox infection in schools, including coordinating management by the medical and social workers in schools, identifying high-risk contacts, self-surveillance, adjusting infection control measures according to the occurrence of clustered cases, enhancing cleaning and ventilation of the building, and more.⁵⁸ A model-based analysis has shown that control with timely detection and isolation of symptomatic cases are important ways to future outbreaks of Mpox on college campuses.²² Understanding students’ knowledge of Mpox, concerns, and willingness to vaccinate will help the government and schools to develop effective coping strategies. The findings of this study are valuable for the schools in identifying students’ insufficient knowledge of Mpox and implementing targeted publicity strategies. Simultaneously, understanding students’ willingness to vaccinate will also lay the groundwork for future promotion of the Mpox vaccine within schools. Furthermore, these results can serve as fundamental data for future extensive cross-sectional studies and intervention programs aimed at enhancing students’ understanding of Mpox in China.

This study showed several limitations. First, although this study included many participants from seven schools, it could not provide a comprehensive representation of all students in North and Northeast China. Additionally, this study employed convenience sampling and predominantly recruited participants from schools in Beijing, leading to potential selection bias. The generalizability of the results in this study to all Chinese students was limited, thus further research should consider expanding the sample sizes to enhance the representativeness. Second, this was a cross-sectional survey, where causality cannot be determined. Cohort studies could be needed to observe this dynamic change of students’ Mpox knowledge in the future. Third, due to the voluntary nature of participant selection, the study lacked information regarding the knowledge level of Mpox and vaccination intentions among non-responding participants, which might potentially lead to an overestimation or underestimation of the findings, resulting in non-response bias. In addition, the simplicity of statistical methods was insufficient for comprehensively discussing the factors influencing Mpox perceptions and vaccination intention. Furthermore, preliminary findings can be gained by employing the logistic regression method, but future research necessitates the utilization of more advanced statistical techniques to explore novel discoveries.

Conclusion

This study found a relative insufficiency in Mpox knowledge among university students, with less than half expressing concern about Mpox outbreak, and the majority exhibiting a positive attitude to vaccination. Meanwhile, the findings of this study stress that a high level of Mpox knowledge tends to be easier to improve students’ willingness to vaccinate against Mpox. Utilizing social media, publicity campaigns, lectures, and teaching techniques could effectively enhance students’ knowledge of Mpox. In addition, the introduction of foreign vaccines and the development of domestic vaccines should be included in the agenda by our country. What’s more, controlling with timely detection and isolation of symptomatic cases were also important ways to future outbreak of Mpox on college campuses. In conclusion, this study might help governments and schools to understand students’ Mpox perceptions and vaccination intentions. In the future, further research is warranted to comprehend the knowledge of Mpox and vaccination acceptance among university students nationwide. And there exists a necessity and urgency for governments and schools to effectively intervene to improve Mpox knowledge and vaccination acceptance among university students.

Author contributions

XQ and HZ conceived the study and designed the protocol. KW, BH, YL, WW, XZ, MZ conducted this study. JW drafted the manuscript. LF and HM performed processing and analyzes of the data. XQ, HZ, KW, BH, YL, YZ, BW, and WZ revised the manuscript. All authors have read and approved the final manuscript.

Ethics approval and informed consent statement

All procedures contributing to this work comply with the ethical standards of relevant national and institutional committees on human experimentation and with the Helsinki Declaration. Online informed consent will be obtained from all participants before any procedure of this study. The study (including online informed consent) was approved by the Human Research Ethics Committee of the School of Public Health (Shenzhen), Sun Yat-sen University (approval number SYSU-PHS[2022]051).

Acknowledgments

We appreciate all the students that participated in this study. We thank all the schools that participated in this study, including Beijing University of Technology, the Capital University of Economics and Business, Capital Medical University, Jilin University, Harbin Medical University, Hebei Medical University, and Baotou Medical College. We thank the individuals who helped us recruit participants.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data collected in this study will not be publicly available. However, the corresponding author can be contacted for de-identified data and questionnaire upon reasonable request.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2339922.

Additional information

Funding

The article was funded by the 2021 Beijing Key Specialty Program for Major Epidemic Prevention and Control.