Ethics statement

This study adhered to the principles of the Declaration of Helsinki and received ethical approval from the Fujian Medical University Research Ethics Committee, China (Approval: FJMU 2024 NO.300). Participants were informed about the voluntary nature of their involvement, and they could withdraw from the survey at any time without providing justification. Written consent to participate was obtained through a consent statement displayed on the first page of the online survey, where participants were required to click an agreement button to proceed. The ethics committee approved the online consent process, and no identifying information was collected from participants during the survey. Consent for publication was also obtained, ensuring participants were aware that their data would be used for research and publication purposes. All data were handled confidentially and stored securely in compliance with data protection regulations. Participants did not receive any financial incentives for their participation in the study. There were no anticipated risks or potential harms associated with taking part in the research.

Study participants and survey design

A nationwide cross-sectional survey using an online questionnaire was conducted from 25^th August to 26^th September 2024. The inclusion criteria were Chinese citizens above the age of 18 years and able to comprehend and read Chinese. A convenience sampling method was employed, with a survey company distributing the survey link through its existing database. Participants received the survey link via their mobile WeChat accounts. Participants were collected nationwide across six regions in China. The sample size was calculated using the formula: n = Z² P(1-P)/d². Using a margin of error of 0.05 (5%), with a 95% CI and 50% response distribution, the calculated sample size was 384 for each region. The sample size was multiplied by the predicted design effect of two to account for the use of convenience sampling and an online survey [16]. Hence, the optimal sample size was set to 768 (384 x 2).

Instruments

The questionnaire (S1 Appendix) consisted of eight sections: 1) demographic information, 2) knowledge of mpox symptoms, 3) risk perception regarding mpox, 4) preventive practices, 5) attitudes towards vaccines authorized under EUA, 6) trust in future EUA vaccines influenced by the COVID-19 vaccination, and 7) willingness to receive an EUA-authorized mpox vaccine and willingness to pay for it.

Statistical analysis

The sample characteristics were summarized using means ± standard deviations (SD) or frequencies, depending on the variable types. The internal consistency of the items was assessed using Cronbach’s alpha coefficient for the relevant domains. The Cronbach’s α values were 0.849 for the knowledge score, 0.811 for preventive practices, and 0.886 for attitudes towards the EUA vaccine, indicating good reliability; an alpha coefficient between 0.6 and 0.7 suggests an acceptable level of reliability, while a coefficient of 0.8 or higher indicates very good reliability [17]. Partial least squares structural equation modeling (PLS-SEM) was employed to identify factors influencing vaccination willingness. This analytic method effectively evaluates the reliability of the dataset, the statistical significance of coefficients, and the errors in the estimated path coefficients. Bootstrapping was conducted using Smart PLS software version 3.2.8 (SmartPLS GmbH). All statistical analyses were performed using the IBM SPSS Version 20.0 (IBM Corp, Armonk, NY, USA) [18].

Knowledge about mpox symptoms and risk perception

The study on mpox symptom knowledge, based on the weighted proportions of correct responses, indicates that participants had a moderate understanding overall. Fever and rashes were the most recognized symptoms, while awareness of less common symptoms like swollen lymph nodes and chills was notably lower. Since no item on symptom was correctly identified by more than half of the participants, it suggests that the general knowledge of mpox symptoms is moderate. This points to a clear need for increased public education and awareness campaigns to cover the full range of mpox symptoms. The lack of knowledge may be due to the absence of reported mpox cases in China and the limited media coverage of the disease. It is recommended that public health authorities launch comprehensive educational campaigns to raise awareness of mpox, even though it is not currently a pandemic in China, to ensure public preparedness. The findings suggest that participants had a moderate perception of their susceptibility to mpox, likely due to the absence of reported mpox cases during the study period, which resulted in a lower sense of urgency and perceived risk. The absence of mpox cases and limited media coverage likely contributed to gaps in knowledge, emphasizing the need for targeted public health interventions to boost awareness and preparedness.

Prevention practices

Findings on preventive measures, such as avoiding close contact, frequent handwashing, mask-wearing in crowded places, and staying updated with public health guidelines, showed that these practices were widely adopted, with the majority of participants often or always adhering to them. However, the total preventive practices score suggests that further efforts are needed to encourage consistent and widespread compliance with health recommendations. Similarly, the absence of reported mpox cases in China during the study period likely reduces the perceived urgency of maintaining strict preventive behaviors among the population. Strengthening public health messaging, even in the absence of a local outbreak, could help sustain a higher level of precautionary measures and ensure preparedness should the situation change [22].

Attitudes towards EUA vaccine

The results on attitudes toward EUA vaccines among participants revealed that many expressed concerns about various aspects of these vaccines, particularly regarding the rapid approval process and quality control. Doubts about their effectiveness compared to fully approved vaccines were also prevalent. The belief that EUA vaccines are less effective than fully approved vaccines may arise from several factors. Firstly, EUA vaccines receive authorization based on interim clinical trial data rather than extensive long-term studies, raising concerns about their reliability [23,24]. Additionally, the EUA designation is often associated with an experimental or incomplete approval process. Past instances of expedited vaccine rollouts with unexpected side effects may further deepen skepticism [24,25]. Addressing these concerns through clear communication and transparency in vaccine development and authorization processes is crucial for maintaining public trust. Additionally, worries about potential unknown long-term side effects reflected broader societal skepticism toward rapidly developed vaccines during health emergencies, consistent with findings in other studies, which have highlighted similar hesitations among populations regarding new COVID-19 vaccines [26,27]. Despite these concerns, many participants acknowledged the necessity of EUA vaccines during pandemics and indicated a willingness to receive one if it were the only option available. This willingness aligns with previous research showing that, while apprehensions about safety exist, individuals often recognize the critical role of vaccines in controlling infectious diseases. On a positive note, a considerable portion of respondents believed that the benefits of EUA vaccines outweighed potential risks, illustrating a pragmatic perspective. However, a considerable number also feared that the use of EUA vaccines could undermine public trust in vaccines overall, echoing concerns raised in many reports that emphasize the importance of maintaining confidence in vaccine development, especially in the context of emergency use approvals with accelerated development timelines [28]. Therefore, public health strategies in China should inform and reassure the public about the rigorous standards that underpin vaccine development.

Lessons learned from COVID-19 vaccination on trust in future EUA vaccines

Overall, the responses suggest that the success of EUA vaccines during the COVID-19 pandemic has positively impacted public trust in future EUA vaccines for infectious diseases. The positive shift in trust observed in this study may be linked to China’s unique vaccination approach during the COVID-19 pandemic. Unlike many countries that used mRNA vaccines, China primarily relied on inactivated virus vaccines like Sinovac and Sinopharm. These vaccines, based on traditional technology, may have fostered higher public confidence due to their established safety record. During the COVID-19 pandemic, China’s decision to primarily use inactivated virus vaccines, instead of mRNA vaccines was influenced by a combination of scientific, logistical, and strategic factors. One key reason was the familiarity and established track record of inactivated vaccine technology, which had been used for decades in China and globally for diseases such as polio and Hepatitis A [29]. This established track record likely bolstered confidence in the safety and effectiveness of inactivated vaccines among regulators, manufacturers, and the general public Additionally, China prioritized domestic production capacity to ensure supply security and reduce dependence on foreign pharmaceutical companies [30]. Another factor was the challenges China faced in mRNA vaccine development during the early phase of the pandemic, including limited expertise and restricted access to specialized technologies.

This familiarity likely contributed to the increased trust in future EUA vaccines, including for mpox. Research shows that trust in vaccines is often influenced by the perceived safety and consistent public health messaging [31,32]. China’s success with its COVID-19 vaccination campaign and the population’s greater confidence in familiar vaccine platforms may explain the higher trust levels compared to countries that used newer vaccine technologies, where skepticism was more prevalent [33]. In China, the National Medical Products Administration (NMPA) has established clear guidelines for EUA vaccines to ensure that safety and efficacy. The guidelines for vaccines development in China require comprehensive preclinical studies, including laboratory and animal testing, to evaluate the vaccine’s safety and immunogenicity. While clinical trials typically progress through Phases I, II, and III to evaluate a vaccine’s safety and effectiveness, EUA allows for expedited approval based on interim data from early-phase trials, requiring at least Phase II data, if not Phase III. Even under accelerated timelines, these trials must meet stringent scientific and ethical standards. Vaccine manufacturers must adhere to good manufacturing practices to ensure the consistency and quality of vaccine production. Additionally, post-authorization monitoring is also a critical component, with robust pharmacovigilance systems in place to track adverse events and long-term effects after the vaccine is deployed [34].

Nevertheless, the country has since emphasized the importance of learning from the West’s advancements in mRNA vaccine technology and has called for global collaboration with an open-minded approach [35]. Therefore, there is a need to enhance public trust in mRNA vaccine technology for future pandemics as well as in the development of vaccines for NTDs such as mpox, as the future of vaccine development is increasingly shifting toward mRNA due to its superiority over traditional vaccines.

Vaccination willingness and WTP

The disparities in willingness to receive the mpox vaccine across different regions in China may be influenced by the varying economic profiles of these regions. Northeastern and Northwestern regions, which showed the highest willingness rates of 84.9% and 81.8%, are less economically developed compared to the more affluent Eastern region, which reported a willingness rate of 71.2%. In contrast, the economically developed Northern region exhibited a moderate willingness of 63.6%, suggesting that higher economic development does not necessarily translate to higher vaccine acceptance. The lower willingness rates in the Southern (59.2%) and Southwestern (57.9%) regions, which are known for significant economic disparity, further highlight the complex relationship between regional economic conditions and vaccine confidence. Further research is needed to understand the underlying reasons for these disparities. Regional disparities in vaccine acceptance in China remain uncertain in the literature. In the context of COVID-19 vaccine, some studies have reported higher COVID-19 vaccine acceptance in the more developed eastern region [36,37], while others have found lower acceptance in the same region [38,39]. Nonetheless, tailored communication strategies and outreach efforts could be vital in boosting vaccine confidence, particularly in regions where acceptance remains low. The overall willingness across all regions is approximately 67.9%, which, while moderately high, underscores a need for targeted public health interventions in regions with lower acceptance. Similar strategies have been successfully employed during the COVID-19 vaccination campaign, where digital platforms, community and healthcare workers engagement, and transparent communication were used to address hesitancy and improve coverage [40]. Additionally, while vaccination rates in Chinese cities remain relatively high due to smooth mobilization and strong health risk awareness, rural areas have faced challenges in uptake. To address this, targeted efforts such as free shuttle services, extended vaccination hours, mobile healthcare teams, and door-to-door education campaigns have been implemented to improve coverage [41].

The PLS-SEM analysis highlights several factors associated with the willingness to an EUA-authorized mpox vaccine, with trust in EUA vaccines emerging as the strongest positive predictor. This is consistent with findings from previous studies in a systematic review, which highlighted the crucial role of trust in government-endorsed vaccines in shaping public acceptance, particularly during emergencies [42]. The significant influence of fear of the disease and perceived susceptibility is consistent with studies on COVID-19 vaccine acceptance, where risk perception drives vaccine uptake [43,44]. However perceived severity is not significant, this could be due to during the study period there are no mpox cases yet in China.

The finding that prevention practices about mpox have also been identified as important in shaping health behaviors, echoing earlier research emphasizing the role of awareness and proactive measures in COVID-19 vaccine acceptance [44–46]. People with high preventive practices related to mpox also demonstrate significantly higher vaccination willingness implies that individuals who are more engaged in health-protective behaviors are more likely to trust and accept vaccines, reinforcing the link between preventive actions and vaccine confidence [47].

Interestingly, the study finds a small but positive impact of education, reinforcing the notion that higher education often correlates with greater health literacy and vaccine acceptance, which has been observed during COVID-19 pandemics [48]. Regarding urban-rural disparities in vaccine acceptance in China, a large-scale national study on COVID-19 vaccine acceptance found that urban participants were more hesitant to receive the vaccine compared to their rural counterparts [49]. In contrast, this study shows that urban residents exhibited a higher willingness to vaccinate against mpox, emphasizing the potential role of health literacy [50]. Concerning income disparities in vaccine acceptance, several studies in China have found that higher income levels were linked to COVID-19 vaccine hesitancy [51]. This was rationalized by the fact that individuals with higher incomes have greater access to vaccine information through social media, including misinformation, which can heighten concerns about vaccine safety and efficacy [52]. Similarly, an inverse relationship between income and mpox vaccine acceptance was observed in this study, although the association was not statistically significant. This may reflect the more complex socio-economic dynamics surrounding mpox, where fear may outweigh financial considerations. Further study is needed to confirm this finding. Lastly, the lack of impact of gender, age, and attitude towards EUA vaccines suggests that these factors may play a lesser role in the context of mpox.

The descriptive findings of vaccine preferences in this study reveal important insights into public sentiment towards different vaccine types in the context of China. The findings show that a larger segment of the population favors traditional vaccines for mpox. This trend aligns with the broader context of China’s vaccination landscape, where traditional vaccines, particularly inactivated virus vaccines like Sinovac and Sinopharm, were extensively used during the COVID-19 pandemic. A multi-country study that includes China found that the novelty of the mRNA vaccine for COVID-19 increases hesitancy, with the single-country study in China revealing a preference of 53.2% for conventional vaccines compared to 50.9% for mRNA vaccines among participants [52]. The established safety record and familiarity of these conventional vaccines, widely used during the COVID-19 pandemic in China, likely contribute to the higher public confidence and acceptance of traditional vaccines. Notably, the first Chinese mpox vaccine was approved for clinical trials on September 9, 2024. Developed independently by the Shanghai Institute of Biological Products, a subsidiary of China National Pharmaceutical Group (Sinopharm), this vaccine is based on a live, attenuated orthopoxvirus [53]. Our findings, showing a preference for conventional vaccines, are timely and offer valuable insights into the potential acceptance of this vaccine once it becomes available.

Lastly, the results of the WTP for a potential mpox vaccine revealed a relatively lower amount that participants were willing to pay, highlighting potential barriers to accessing the mpox vaccine should it become available at a cost. Given China’s diverse socio-economic landscape, where disparities in income levels exist, pricing strategies for future vaccines must be carefully considered to ensure equitable access across different demographic groups. However, it is important to note that the demographic characteristics of the study participants reflect a predominantly young, educated, and urban population with relatively high-income levels, which may limit the generalizability of the findings to broader populations. In summary, the findings emphasize the need for public health initiatives in China to focus not only on promoting the safety and efficacy of vaccines but also on addressing affordability concerns to enhance vaccine acceptance and uptake in the context of emerging infectious diseases like mpox.

Limitations

While this study has several strengths, such as its large sample size, rigorous data collection methods, and broad representation across major provinces in China, it also has some limitations. One notable limitation is the potential bias stemming from the non-random selection of participants in the online survey, which may not fully capture the diversity of the entire population. These biases could limit the generalizability of the findings to the broader population of China. Additionally, the reliance on self-reported data introduces the possibility of recall bias and social desirability bias. Furthermore, as a cross-sectional study, it is unable to establish causal relationships between variables.

Of note, despite the intended target of 768 participants per region, actual sample sizes varied, with the Northwestern and Southwestern regions notably underrepresented (77 and 126 respondents, respectively). The imbalance in participation may be influenced by regional socioeconomic disparities in China. The Eastern and Southern Central regions, which have relatively large sample sizes, are more economically developed, urbanized, and have higher levels of education and digital engagement. These factors likely contribute to greater awareness of health-related issues and a higher willingness to participate in online surveys. This uneven distribution may limit the generalizability of the findings, as smaller sample sizes reduce statistical power and increase the risk of bias in regional comparisons. Underrepresentation of certain areas may also skew results, as perspectives from these regions may not be fully captured, potentially affecting conclusions on vaccination willingness. Moreover, the imbalance in sample distribution may lead to a demographic profile that is disproportionately young, educated, urban, and higher-income. To improve representativeness and reliability, future studies should adopt targeted recruitment strategies and ensure a more balanced sample across all regions.

Furthermore, it is also important to note that the decision to categorize responses by region rather than by province limits the ability to analyze provincial-level variations, which may have important consequences. Given the diverse socio-economic, cultural, and healthcare landscapes across China’s provinces, aggregating data at the regional level may conceal significant differences in vaccine confidence. This limitation affects the applicability of findings for policymakers, as province-specific insights are crucial for tailoring interventions.

Based on the findings of this study, specific recommendations to enhance vaccine confidence and acceptance include implementing comprehensive educational campaigns to increase awareness of mpox symptoms and risks, particularly in regions with lower knowledge levels. Strengthening public health messaging, even in the absence of reported cases, can help sustain preventive practices and preparedness. Efforts should also focus on addressing concerns regarding EUA vaccines by transparently communicating their rigorous approval processes and safety measures. Tailored outreach strategies should be developed to address regional disparities in vaccine acceptance, particularly in economically developed areas where hesitancy may be higher. Additionally, affordability concerns must be considered to ensure equitable access to vaccines across diverse socio-economic groups. Given the strong preference for traditional vaccines, building confidence in mRNA and other new vaccine technologies requires emphasizing their rigorous safety evaluations, highlighting successful real-world applications, and ensuring clear, transparent communication about their benefits and potential risks. Lastly, we acknowledge that this study was conducted during a period without reported mpox cases and with limited media coverage in China, which may have influenced public awareness, perceptions, and willingness to receive the mpox vaccine.