Resident Physicians’ Knowledge and Preparedness Regarding Human Monkeypox: A Cross-Sectional Study from Saudi Arabia

This study aimed to evaluate knowledge about monkeypox and confidence in dealing with monkeypox diagnosis and management among resident physicians in the Asir region of Saudi Arabia. The data of this cross-sectional study were collected online through a structured questionnaire (N = 315). Knowledge about monkeypox was assessed by 24 questions and a three-item scale assessed confidence in managing monkeypox cases. Multiple logistic regression analysis was performed to assess the associations. Overall, two-thirds of the respondents (67.3%) showed good knowledge about monkeypox and the rest of them (32.7%) had poor knowledge. Respondents who received a copy of the Saudi MOH protocol for monkeypox and attended any conference or lecture about monkeypox were more likely to have good knowledge about monkeypox. Moreover, almost two-thirds of the participants were not confident that they could diagnose or manage the monkeypox. Respondents who received information about monkeypox during residency or medical school had higher confidence in managing monkeypox cases. It can be concluded that the Saudi healthcare system has scope to take necessary steps to contain the monkeypox endemic. The Saudi MOH should arrange conferences and educational programs on monkeypox so that healthcare professionals can improve their knowledge and be confident in the management and diagnosis of monkeypox cases.


Introduction
Monkeypox (Mpox) virus, a Poxviridae family virus, is now regarded as an international concern. Though it primarily causes small outbreaks or endemics, there are concerns that it might cause the next epidemic if people and the medical world remain ill prepared. Mpox is a zoonotic infection, and various rodents and primates in Africa serve as its reservoirs. It is transmitted in two ways: (i) humans to animals or (ii) humans to humans [1,2]. Its human-to-human transmission occurs through close contacts like skin-to-skin, respiratory droplets, and sexual contact. In the current 2022 outbreak, it has particularly affected the condition. Thus, a cross-sectional study carried out from May to July 2022 assessing the knowledge of the general population in Saudi found that only about half of the participants had some understanding of the condition [22].
Although Saudi Arabia has not experienced a major outbreak like many other nations, and only a few cases (less than 10) have been reported, this does not mean that Mpox does not threaten the nation [23]. There are many reasons why the Saudi healthcare system must be concerned about Mpox. First, numerous large-scale outbreaks have occurred outside Africa for the first time, affecting many people. Second, it has started spreading from human to human. Thirdly, its virulence has changed due to mutations. Fourth, it poses a greater risk to specific population groups. Fifth, it highlights major gaps in understanding viral transmission dynamics [24]. All this means that Saudi Arabia must prepare to counter the Mpox outbreak. Since healthcare workers play a vital role in countering any epidemic, understanding their preparedness for emerging diseases or conditions is crucial. Thus, it is important to explore how prepared Saudi healthcare workers are in preventing and managing the condition. To address the knowledge gap and provide evidence in this regard, the current study, therefore, aimed to evaluate knowledge about human Mpox and confidence in dealing with Mpox diagnosis and management among resident physicians in the Asir region of Saudi Arabia.

Study Design, Settings, and Subjects
This was an analytical cross-sectional study with the primary objective to determining the preparedness for managing human Mpox infection of resident physicians under the Saudi Commission for Health Specialties (SCFHS) in the Asir region of Saudi Arabia during the academic year of 2023. In this study, "preparedness" was defined as the comprehensive knowledge, skills, and abilities required to provide care and prevent disease.
This study was conducted in various governmental healthcare facilities in the Asir multi-center regions of Saudi Arabia, including Khamis Mushait General Hospital, Khamis Mushait Maternity and Children Hospital, Armed Forces Hospitals in the Southern Region, Asir Central Hospital (ACH), Abha Maternity and Children Hospital, and King Khalid University Medical City.

Sample Size, Sampling, and Data Collection Techniques
The target population consisted of 1200 physicians undergoing postgraduate training in the Asir region under the SCFHS. The minimum sample size required for this study was calculated by the single-sample proportion test. The following assumptions were considered: (i) 55% of physicians had good knowledge about Mpox based on a previous study in Saudi Arabia [20], (ii) a confidence level of 95%, and (ii) a margin of error of 5%. Thus, a sample size of 289 resident physicians was estimated.
A simple random sampling procedure was applied to enroll the participants. We collected a list of 1200 trainees from the SCFHS, which contained contact details such as email addresses. All individuals' information was inserted into an Excel spreadsheet (i.e., 1200 individuals comprised the sampling frame) and a random sample was generated from the sampling frame using Excel. Thus, 500 resident physicians were randomly selected for sending invitations to participate in the study. Finally, 315 resident physicians consented to participate in this study (i.e., sample size of this study was 315).
An online technique was used to gather the survey data. Three research staff distributed invitation links to the randomly selected resident physicians (n = 500) to complete the survey via social media platforms (such as Telegram, WhatsApp, etc.) and email. The questionnaire was attached to the invitation link in the form of a Google survey file. The survey questionnaire was disseminated between 1 March and 1 May 2023. The questionnaire was designed in English and all survey items were required to be answered to minimize non-response bias. Approximately, 8-12 min was required to complete each response. Data were stored in Excel for subsequent statistical analysis.

Survey Contents
A structured questionnaire was used in this study, which was based on the previous literature [18,[20][21][22]. Some parts of the questionnaire were previously used in Saudi Arabia (e.g., knowledge about Mpox) [18,20]. The survey questionnaire consisted of three subsections: (i) sociodemographic and profession-related information, (ii) knowledge about human Mpox, and (iii) confidence in dealing with monkeypox diagnosis and management (see Supplementary File S1). Sociodemographic and profession-related information, such as age, gender, marital status, level of work, work center, nature of work, etc., were included. Moreover, knowledge about human Mpox was assessed by 24 questions which included knowledge about the epidemiology, clinical aspects, transmission, and treatment of the disease [18,[20][21][22]. Knowledge score was computed by summing up the 24 knowledge items with correct responses assigned as "one" point and incorrect responses assigned as "zero". The mean knowledge score was set as a cutoff value for categorizing the overall knowledge. An individual who scored above the mean knowledge score was categorized as having "good knowledge". Finally, confidence in human monkeypox diagnosis and management was assessed by three items, retrieved from Harapan et al. [25]. The two available answers were "yes" or "no," with "yes" receiving a score of one and "no" receiving a score of zero. A total score is a range of 0 to 3, with higher scores signifying greater confidence.

Pilot Study and Reliability of the Questionnaire
Before administrating the final version of the questionnaire, a pilot study was conducted among fifteen residents undergoing training in different specialties, and necessary modifications were made to the questionnaire based on feedback from a committee of twelve medical consultants/specialists. Hence, the questionnaire was easily understandable and clear for the population group. Moreover, reliability analysis was performed using Cronbach's alpha to assess the internal consistency of the study variables. The Cronbach's alpha for the knowledge section was 0.929 and for the confidence was 0.834. A good level of internal consistency was found for both sections, indicating that the questions within each section are highly related and measure the same construct.

Data Analysis
Data were analyzed by statistical package for the social sciences (SPSS) version 28. Descriptive statistics (such as frequency, percentage, mean, etc.) were calculated to summarize the data. The chi-square/Fisher's exact test was used to examine associations between dependent variables. Finally, logistic regression analysis was performed to determine predictors of good knowledge and high confidence. p values of <0.05 were considered statistically significant.

Ethics
Ethical approval was obtained from the Abha Health Ethics Committee and the Saudi Commission for Health Specialties, Asir Region (IRB Log No: REC-4-2-2023). Informed consent was taken from all participants before their study enrollment. Participation was self-nominated and did not offer any incentives. Participants were assured that participation was anonymous. Any identifying information, such as participants' names, contact numbers, etc., was not asked for or not disclosed publicly. The confidentiality of their personal information was strictly maintained, and it was ensured that the data were used only for research purposes.

Sociodemographic and Profession-Related Information
This study comprised 315 samples, of which two-thirds (66%) were male. The majority of the respondents (80%) were between 25 and 34 years of age. Approximately a quarter of the respondents (27.9%) had more than five years of medical practice experience. Only 36.2% of respondents received an Mpox infection management protocol copy from the Saudi MOH. Respondents' sociodemographic and profession-related information is depicted in Table 1.

Knowledge about Mpox and Its Associated Factors
The assessment of knowledge regarding human Mpox is summarized in Table 2. Approximately half of the respondents knew about the high prevalence of Mpox in Western and Central Africa, and more than half did not have much knowledge about its transmissibility. Similarly, half of the participants had some understanding of its symptoms and disease presentation. The study also found significant gaps in the knowledge regarding disease prevention and management (Table 2). Overall, two-thirds of the respondents (67.3%) showed a good level of knowledge about monkeypox and the rest of them (32.7%) had poor knowledge. The mean knowledge score was 14.0 (SD: 6.4). Table 3 shows the association between demographic variables and knowledge about Mpox. Bivariate analysis found that participants' age (p = 0.01) and level of work (p < 0.01), and identifying as dentists were indicative of significantly poorer knowledge compared to those who identified as preventive medicine specialists (p = 0.001), who engaged in routine work (p = 0.01), had medical practice experience (p = 0.01), received information about Mpox during residency or medical school education (p = 0.02), had a copy of the Saudi MOH Protocol (p < 0.01), had received information earlier (p < 0.01), and attended a conference (p = 0.01) were significantly associated with having a good knowledge score for Mpox.
The multiple logistic regression model revealed that respondents who received a copy of the Saudi MOH protocol for patients suspected/confirmed with monkeypox had a good level of knowledge about monkeypox compared to their counterparts (Adjusted Odds Ratio (AOR) = 4.25, 95% Confidence Interval (C.I.) = 2.49 to 5.64). Moreover, respondents who attended any conference or lecture about Mpox were more likely to have good knowledge about Mpox compared to their counterparts (AOR = 3.34, 95% C.I. = 2.12, 6.96) ( Table 3).

Confidence in the Management and Diagnosis of Monkeypox
Regarding the confidence in diagnosing and managing the condition based on present knowledge, almost two-thirds (61.6% to 72.4%) were not confident that they could diagnose or manage the Mpox (Table 4). Specifically, for the first question, only 27.6% of respondents said they were confident about managing Mpox cases based on their current knowledge and skills, while the majority (72.4%) said they were not confident. This suggests a lack of preparedness among respondents when it comes to managing Mpox cases. For the second question, 38.4% of respondents said they were confident about diagnosing Mpox cases based on their current knowledge and skills, while 61.6% said they were not confident. This indicates that a significant number of respondents may not have the necessary knowledge and skills to diagnose Mpox cases accurately. Finally, for the third question, only 35.6% of respondents said they were confident about diagnosing Mpox cases based on the ability of their current facility to perform diagnostic tests, while 64.4% said they were not confident. This suggests there may be issues with the availability or reliability of diagnostic tests for Mpox in the respondents' facilities.   Multiple logistic regression analysis found a significant association between the level of work and confidence with dealing with Mpox patients, as those in senior levels, i.e., R4, had the highest confidence compared to all other junior levels of work, i.e., R1 and R2 (AOR = 5.15, 95% CI = 1.19 to 13.68), with (p = 0.001). Regarding medical specialty, dermatology residents had a higher confidence in dealing with Mpox compared to their counterparts (AOR = 1.70, 95% CI = 1.06 to 2.73). Moreover, respondents who received information about Mpox during residency or medical school (AOR = 2.26, 95% CI = 1.18 to 3.89) and working in administrative roles (such as General Directorate, Weqaa, Gulf CDC, etc.) (AOR = 2.27, 95% CI = 1.16 to 4.45) had a higher confidence compared to their counterparts (Table 5).

Medical Specialties
The relationship between study participants' medical specialties and their level of knowledge about Mpox is shown in Figure 2a. The figure shows that participants with medical specialties in preventive medicine (91.9%), dermatology (87.5%), emergency medicine (81.8%), internal medicine (79%), and family medicine (74.3%) were more likely to report having a good understanding of monkeypox. Participants with medical specialties in other areas, such as general practice (22.2%) and surgery (30.6%), were less likely to report having a good knowledge about Mpox. Received information about Mpox during residency or medical school education

Medical Specialties
The relationship between study participants' medical specialties and their level of knowledge about Mpox is shown in Figure 2a. The figure shows that participants with medical specialties in preventive medicine (91.9%), dermatology (87.5%), emergency medicine (81.8%), internal medicine (79%), and family medicine (74.3%) were more likely to report having a good understanding of monkeypox. Participants with medical specialties in other areas, such as general practice (22.2%) and surgery (30.6%), were less likely to report having a good knowledge about Mpox. Figure 2b shows the confidence in dealing with Mpox according to medical specialties; it shows that medical specialties may play a role in the level of confidence that healthcare providers have in their ability to diagnose and manage Mpox cases. Healthcare providers with medical specialties in dermatology (87.5%), preventive medicine (62.2%), emergency medicine (54.6%), and family medicine (40%) may be more likely to have received training and experience in the diagnosis and management of Mpox cases. As a result, they may be more confident in their ability to provide care for patients with Mpox.   Figure 2b shows the confidence in dealing with Mpox according to medical specialties; it shows that medical specialties may play a role in the level of confidence that healthcare providers have in their ability to diagnose and manage Mpox cases. Healthcare providers with medical specialties in dermatology (87.5%), preventive medicine (62.2%), emergency medicine (54.6%), and family medicine (40%) may be more likely to have received training and experience in the diagnosis and management of Mpox cases. As a result, they may be more confident in their ability to provide care for patients with Mpox.

Discussion
To control any epidemic in the early stages, the knowledge and preparedness of healthcare organizations play a crucial role. Healthcare workers must be prepared to identify any outbreak in its early stages, initiate preventive measures, and isolate and manage those affected by the infection. However, lapses in this early control mechanism may result in the spread of infection and thus result in an epidemic. Identifying the gaps in the knowledge and preparedness of healthcare workers regarding Mpox infection is the first step in preventing this endemic disease from becoming a pandemic. Therefore, our study evaluated knowledge about human Mpox and confidence in managing Mpox cases among resident physicians in the Asir region of Saudi Arabia.
In our sample, two-thirds of the resident physicians (67.3%) had a good level of knowledge about human Mpox. The overall prevalence of good knowledge is higher than that of reported in a previous study conducted among general practitioners in Indonesia [21]. They reported that around one-third (36.5%) of the study participants had good knowledge about Mpox (based on a 70% cutoff point for the knowledge domain) [21]. Another study reported that clinicians in Ohio have poor levels of knowledge about Mpox [26]. A recent study by Alshahrani and colleagues, carried out among physicians in Saudi Arabia, revealed that more than half (55%) of the study subjects had a good level of knowledge about human Mpox [20]. However, our study found a significant number (32.7%) of resident physicians had poor knowledge about Mpox, which represents a matter of concern for the country's healthcare systems. For instance, our study found more than half of the participants had less knowledge about monkeypox's transmissibility. It is imperative that physicians have better knowledge of Mpox so that they can develop the capacity to treat human Mpox cases.
Based on the findings from the regression model, resident physicians receiving a copy of the Saudi MOH protocol for patients suspected/confirmed with Mpox and attending any conference or lecture about Mpox were predictors of good knowledge about Mpox. These findings suggest that arranging conferences and lecture programs on the preparedness for human Mpox would be effective in improving knowledge about Mpox.
Another key finding of this study is that almost two-thirds of the study physicians were not confident that they could diagnose or manage Mpox. Evidence shows that Saudi physicians had poor attitudes towards Mpox [20]. A recent study from Indonesia reported that general practitioners had a low level of confidence to diagnose and manage Mpox cases based on their current knowledge, skills, and facilities [25]. The previous literature reported that knowledge and attitudes regarding Mpox are positively correlated, indicating that good knowledge showed a significant association with positive attitude [15]. Future explanatory studies are recommended to observe whether there is a relationship between knowledge, attitudes, and confidence levels.
Our study also found that respondents who received information about Mpox during residency or medical school and worked in administrative roles (such as General Directorate, Weqaa, Gulf CDC, etc.) had a higher confidence in managing Mpox cases. Another study also found that general practitioners are likely to be more confident if they received education about Mpox during their education in medical school [16,25]. Since informal information may produce uneven results, learning from a formal curriculum during medical education would offer a better learning experience [27,28].
An important finding is that dermatology residents have a higher confidence in dealing with Mpox. Because of the predominant skin symptoms of Mpox (including anogenital skin lesions), dermatologists can play vital role in identifying new Mpox cases, assisting in the diagnosis and prevention of disease spread through identification and isolation, contact tracing, and education [29,30]. In the case of knowledge about Mpox, participants with medical specialisms in preventive medicine and dermatology have also showed a higher prevalence of good knowledge about Mpox. However, in the regression model, there was no significant association between knowledge about Mpox and dermatology residents. A small sample size of dermatology respondents may have influenced the results, leading to a higher risk of skewing. Further studies, which may include a representative sample of all medical specialists, are recommended to better understand the knowledge gap regarding human Mpox among medical specialists. Moreover, the adjusted regression model showed that respondents who worked at a senior level (R4) had higher confidence compared to those who worked at the R1 level (junior level). These findings imply that experienced health professionals may have greater knowledge and confidence about a certain disease. A previous Turkish study reported that older physicians had greater knowledge about Mpox [31]. However, in our study, age was not statistically significant in terms of knowledge and confidence about Mpox.
Further, the study regarding the preparedness of the Saudi Healthcare sector for countering Mpox is justified based on the reports from other regions and also early studies covering Saudi healthcare. For example, reports show that one of the reasons for the significant spread of the infection in Latin America has been an insufficient response to infection. Despite the availability of some experimental drugs like cidofovir and the known effectiveness of the classical smallpox vaccine in countering the spread, none have been available in the region and the medical fraternity has mainly been unprepared [24]. Similar causes of outbreaks in Portugal, the UK, and Nigeria have been identified, that is, ill preparedness and the poor knowledge of medical staff in the nations resulting in poor and delayed responses to the outbreak [32,33]. Similarly, findings from a cross-sectional study of general practitioners in Indonesia are also discouraging. In the study, 88.8% of physicians agreed that there is a need to understand the condition better, as most physicians lack confidence in diagnosing and treating the condition based on their current skills [21].

Implications of the Findings
Since this study was one of the first studies on the topic in Saudi Arabia, the findings provide baseline evidence and contribute to the literature. Policymakers can use the findings to develop potential steps for improving the preparedness against Mpox as an initial preventive measure. An effective way to prepare for an Mpox outbreak in Saudi Arabia is to develop and implement practical workshops and hands-on courses about emerging Mpox to improve the knowledge and skills of medical professionals. In addition, the Saudi MOH should disseminate updated information regarding Mpox among health professionals as well as the general public through newspapers, websites, and social media platforms.

Limitations of This Study
The use of a cross-sectional design limits the ability to infer causality from the results. The reliance on self-reported data may introduce bias, as participants may overestimate or underestimate their knowledge and preparedness. Future studies could consider using objective measures, such as knowledge tests or assessments of actual performance in simulated scenarios. The sample may not be representative of all resident physicians in Saudi Arabia, limiting the generalizability of the findings.

Conclusions
Our findings conclude that the Saudi healthcare system has scope to take necessary steps to contain the Mpox endemic. Approximately one-third of the resident physicians had poor knowledge about monkeypox, and two-thirds of them had a lack of confidence and skills to diagnose and manage the condition on time, which is critical in preventing the spread of infection. These findings highlighted that the Saudi MOH should arrange conferences or lecture programs, educational programs, and information dissemination on monkeypox so that healthcare professionals can improve their knowledge and be confident in the management and diagnosis of Mpox cases.