PONE-D-24-09033Knowledge and Attitude towards Monkeypox: Systematic review and meta-analysisPLOS ONE

Dear Dr. Valladares-Garrido,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Summary

In this paper, the authors conducted a systematic review and meta-analysis to determine knowledge and attitudes towards Monkey pox and pose a good argument for justifying the study. The methods used in conducting the review are clearly described and are robust as they conform to the PRISMA checklist and the use of three independent reviewers. The authors report suboptimal prevalence of good knowledge and positive attitude toward Mpox and advocate for an increase in education and communication to improve them.

I recommend that this paper be accepted after the following revisions:

Major Issues

Discussion

1) The discussion section needs some revision. Most comparisons made with the pooled estimates of the review were from the individual studies that were included in the systematic review. I suggest that the authors focus on the overall implications of the results and discuss aspects of validity or quality of the evidence, biases and strengths and limitations of the paper.

2) Discuss the implications of the possible presence of publication bias as mentioned under section 3.3 Quality of included studies and publication bias.

Minor Issue

3) Exclusion criteria: “Lastly, attempts were made to establish contact with the corresponding author via e-mail, but unfortunately, it was impossible”. Please revise the statement as it is unclear. Is reference being made to articles lacking full text?

Reviewer #2: The meta-analysis presents significant heterogeneity (I² > 90%) between the included studies, persisting even after performing subgroup analyses. This high level of heterogeneity raises concerns about the reliability and validity of pooled prevalence estimates. The manuscript does not adequately address the underlying causes of this heterogeneity nor does it discuss its implications for the generalization of results. The discussion section inadequately addresses the issue of persistent heterogeneity, leading to a superficial interpretation of the results and an unclear understanding of how this variability affects the overall conclusions. An in-depth discussion of heterogeneity is essential, including possible reasons for it and how it affects the interpretation of results. The discussion should encompass considerations of methodological differences, cultural contexts, and the temporality of included studies to ensure better interpretation of results.

Reviewer #3: Dear authors: The manuscript is written well and the subject is very important in the present scenario. Increased ecological and temporal gap and decreased small pox vaccine protected population, the number of outbreak of monkey pox have increased. The specific knowledge of certain transmission factor are very important for prevention and control of the monkey pox and inclusion of specific knowledge parameter in the manuscript would increase the impact of the study.

1. In subheading of Knowledge about monkeypox and Attitude towards monkey pox which are main parameter of the study, more detail should be included as it is not clearly mentioned. The criteria on which you have determined the pooled prevalence of knowledge (knowledge about modes of transmission, clinical symptoms, treatment and prevention etc) and attitude should have been mentioned in the manuscript.

2. To perform this evaluation, a checklist composed of eight critical parameters was used to assess the responses as "yes," "no," "unclear," or "not applicable.": give the detail of these eight parameters and one parameter is “Dealing with confounding factors”, and in the selected studies there was no consideration of confounding variables so why it was included in scoring.

3. A forest plot format was used to present the pooled prevalence of monkeypox and attitudes towards it, including 95% confidence intervals: in this sentence are you saying the pooled prevalence of monkey pox or pooled prevalence of knowledge of monkey pox, please check it and correct it

4. Of the included studies, 27 addressed the prevalence of knowledge, six addressed the prevalence of attitude, and six managed both knowledge and attitude towards monkeypox: in this sentence

27 addressed the prevalence of knowledge

Six addressed the prevalence of attitude

Six managed both knowledge and attitude towards monkeypox

Total no of article taken is not clear ?

5. As you included Limitations of the study is the absence of a standardized measurement of "good knowledge" and "positive attitude" among different population groups in the published research, but some common parameter used to determine the knowledge and attitude in these studies can be discussed and /or could have been analyzed, so the impact of this research would be increased substantially.

a. Please explain what positive attitude is and how it may affect the control of monkey pox in discussion.

b. The inclusion of parameters used to assess the knowledge of monkey pox in the studied articles would be more helpful in the process of making strategies, as the knowledge and awareness certainly play major role in prevention and control of the diseases.

Reviewer #4: The authors' efforts on a meticulously executed systematic review are commendable. The comprehensive analysis and clear presentation greatly enhance understanding of the topic.

1. Short explaination about Inverse variance weighted random effects model and Egger's regression test's applications and interpretation can be added.

2. Couldnt find results from funnel plot in article.

3. In the supplementary material, subgroup analysis was provided according to study year, whereas in the article, it is mentioned as subgroup analysis based on the year of publication. Does this imply that the study year and publication year are the same for all the studies?

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Reviewer #1: No

Reviewer #2: Yes: Andressa Souza Cardoso

Reviewer #3: Yes: Baleshwari Dixit

Reviewer #4: No

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Knowledge and Attitude towards Monkeypox: Systematic review and meta-analysis

PONE-D-24-09033R1

Dear Dr. Valladares-Garrido,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Sirwan Khalid Ahmed

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #3: Dear Authors: Yours efforts in compilation and presentation of the study are great and all the suggested point have been addressed.

Reviewer #4: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: Yes: Baleshwari Dixit

Reviewer #4: No

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