Factors Associated with Mpox Case Notification by Community Health Workers in the Karisimbi, Goma, and Nyiragongo Health Zones, Democratic Republic of the Congo

Factors Associated with Mpox Case Notification by Community Health Workers in the Karisimbi, Goma, and Nyiragongo Health Zones, Democratic Republic of the Congo | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors Associated with Mpox Case Notification by Community Health Workers in the Karisimbi, Goma, and Nyiragongo Health Zones, Democratic Republic of the Congo Justin Murhabazi, Stéphane-Hans Bateyi Mustafa, Tambwe Patrick, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9018139/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Community-based surveillance is a key component of early mpox detection in the Democratic Republic of the Congo (DRC), where the disease remains endemic. Community health volunteers (relais communautaires, RECO) play a central role in reporting suspected cases, yet the determinants of their performance are not well documented. This study assessed factors associated with mpox case notification in the health zones of Goma, Karisimbi, and Nyiragongo in North Kivu. Methods A cross-sectional analytical mixed-methods study was conducted among 543 RECO for the quantitative component, selected through multistage stratified sampling, and 24 RECO for the qualitative component (8 per health zone), selected through purposive sampling. Quantitative data were analyzed with SPSS using chi-square tests and multivariable logistic regression to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CI) for frequent notification (≥30 notifications), using SPSS software. Qualitative data from in-depth interviews and focus group discussions were analyzed thematically using MAXQDA. Results Factors positively associated with frequent notification included female sex (aOR = 4.22; 95% CI: 2.52–7.07), secondary (aOR = 3.23; 95% CI: 2.27–12.78) or university education (aOR = 9.60; 95% CI: 4.07–25.00), having an income-generating activity (aOR = 4.30; 95% CI: 2.89–19.91), good knowledge of suspected case signs (aOR = 4.53; 95% CI: 2.89–16.94), trust in health institutions (aOR = 4.18; 95% CI: 2.20–8.31), high perceived epidemic risk (aOR = 3.75; 95% CI: 1.94–7.25), recent surveillance training (aOR = 6.18; 95% CI: 2.09–19.36), availability of reporting tools (aOR = 5.35; 95% CI: 1.39–13.97), and access to personal protective equipment (aOR = 2.31; 95% CI: 1.37–3.90). Negatively associated factors, identified through qualitative triangulation, included insufficient supervision, lack of feedback, stock-outs of reporting tools, community misinformation, stigma, and demotivation linked to lack of institutional recognition. Conclusions Mpox notification performance among RECO is shaped by multilevel determinants, with organizational support and training playing a major role. Integrated interventions are needed to sustainably strengthen community-based surveillance. Mpox community-based surveillance case notification community health workers DRC Figures Figure 1 INTRODUCTION Mpox remains a major public health threat in the Democratic Republic of the Congo, where Clade I is the predominant circulating strain (1;2). The Karisimbi, Goma, and Nyiragongo health zones, located in North Kivu Province, are characterized by high population density, constant population movement, and structural barriers to healthcare access. In this context, community-based surveillance (CBS) plays a central role in the early detection of cases and the timely alerting of the health system(3). Community health workers (CHWs) constitute the first link in this surveillance system, ensuring the identification, referral, and reporting of suspected cases at the peripheral level (4;5). Despite their strategic importance, limited empirical data are available on the determinants of their performance in Mpox case reporting, particularly in unstable urban and conflict-affected settings(5). This study aims to address this gap by conducting an integrated analysis of the factors associated with case reporting by community health workers in three priority health zones of North Kivu. Specifically, it seeks to identify the sociodemographic and economic, cognitive and perceptual, material and organizational, and motivational factors associated with the reporting of suspected Mpox cases by community health workers in the Karisimbi, Goma, and Nyiragongo health zones. METHODS Study setting and design An analytical cross-sectional study using mixed methods, combining quantitative and qualitative approaches, was conducted in the Karisimbi, Goma, and Nyiragongo health zones in North Kivu Province, Democratic Republic of the Congo. Study period Data collection took place from September 20 to 30, 2025. Study population and sampling The study population consisted of community health workers involved in Mpox community-based surveillance (CBS). For the quantitative component, a multistage stratified probabilistic sampling approach was used to select 543 community health workers. The sample size was calculated using Cochran’s formula. For the qualitative component, a purposive non-probability sampling strategy was applied, guided by the principle of theoretical saturation, which was reached after 22 interviews and group discussions, including one focus group of eight community health workers per health zone. Data collection Quantitative data were collected using a structured questionnaire administered through face-to-face interviews. Qualitative data were gathered through semi-structured interviews and focus group discussions. Data collection tools were administered using KoboToolbox, and interviews were audio-recorded using a digital recorder. Data analysis Quantitative data were analyzed using SPSS software. The analysis included univariate descriptive statistics, bivariate analysis (Chi-square test or Fisher’s exact test), and multivariable analysis using binary logistic regression to estimate odds ratios (ORs) and their 95% confidence intervals. Statistical significance was set at p < 0.05. Qualitative data were analyzed using MAXQDA software through an inductive thematic analysis approach inspired by Braun and Clarke: full transcription, familiarization with the data, line-by-line coding, code grouping, theme development, and contextual interpretation. Ethical considerations The study received approval from the Ethics Committee of the University of Goma (UNIGOM) (No. UNIGOM/CEM/005/2025). Informed consent was obtained from all participants. RESULTS QUANTITATIVE RESULTS Table 1. Distribution of participants according to sociodemographic characteristics (n= 543) Variables Frequency Percentage (%) Sex Male 379 69.8 Female 164 30.2 Age (years) < 30 190 35.0 30–39 231 42.5 40–49 97 17.9 ≥ 50 25 4.6 Education level None 25 4.6 Primary 209 38.5 Secondary 285 52.5 University 24 4.4 Marital status Married 174 32.0 Single 304 56.0 Divorced 40 7.4 Widowed 25 4.6 Monthly income (USD) 165 5 0.9 Years of experience 5 61 11.2 Distance to health facility 5 km 51 9.4 The study included 543 participants, the majority of whom were men (69.8%) and young adults, with more than three-quarters under the age of 40 years. The overall level of education was relatively high, with nearly 91% having completed at least primary education and more than half reaching secondary level. Marital status was dominated by single individuals (56%), followed by married participants (32%). Economically, the vast majority (88%) reported a monthly income of less than USD 60, reflecting substantial financial vulnerability. In terms of experience, nearly two-thirds (63.4%) had less than two years of service, whereas only 11.2% had more than five years of experience. Finally, most respondents (55.2%) lived within two kilometers of a health facility, which facilitates access and timely case reporting. Table 2. Distribution of participants according to cognitive and perceptual factors (n= 543) Variables Frequency Percentage (%) Knowledge of a suspected case Good knowledge 454 83.6 Poor knowledge 89 16.4 Perception of disease severity Yes 480 88.4 No 63 11.6 Perception of the origin of the disease Yes 367 67.6 No 176 32.4 Trust in health institutions Yes 419 77.2 No 124 22.8 Perceived risk of an outbreak in the community High 227 41.8 Moderate 251 46.2 Low 65 12.0 Among the 543 participants, 83.6% reported good knowledge of suspected case recognition, while 16.4% demonstrated poor knowledge. The majority (88.4%) perceived the disease as severe, compared to 11.6% who did not share this view. Regarding the origin of the disease, 67.6% reported correct understanding, whereas 32.4% held incorrect perceptions. Trust in health institutions was noted in 77.2% of participants, while 22.8% expressed distrust. Finally, the perceived risk of an outbreak in the community was considered high by 41.8%, moderate by 46.2%, and low by 12%. Table 3. Distribution of participants according to organizational and material factors (n= 543) Variables Frequency Percentage (%) Specific training on surveillance in the past 6 months Yes 450 82.9 No 93 17.1 Supervision on surveillance in the past 30 days Yes 480 88.4 No 63 11.6 Tools for case identification Written form 246 45.3 Telephone 292 53.8 Other 5 0.9 Availability of tools at all times for case reporting Yes 378 69.6 No 165 30.4 Participation in CAC meetings in the past 30 days Yes 335 61.7 No 208 38.3 House-to-house visits as part of CBS Yes 354 65.2 No 189 34.8 Availability of personal protective equipment (PPE) Yes 250 46.0 No 293 54.0 Access to communication means Yes 242 44.6 No 301 55.4 Among the 543 participants, 82.9% reported having received specific training on surveillance in the past six months, compared to 17.1% who had not. Recent supervision was received by 88.4% of participants, while 11.6% reported no recent follow-up. Tools for case identification included telephones (53.8%), written forms (45.3%), and other means (0.9%). Continuous availability of these tools was reported by 69.6% of participants, whereas 30.4% did not have them readily available. Participation in community activity committee meetings over the past 30 days was observed in 61.7% of participants, with 38.3% absent. House-to-house visits as part of community-based surveillance were conducted by 65.2% of participants, while 34.8% did not perform them. Regarding material resources, 46% reported having personal protective equipment, compared to 54% without, and access to communication means was reported by 44.6% of participants, while 55.4% lacked access. Table 4. Distribution of participants according to motivational factors(n=543) Variables Frequency Percentage (%) Primary motivation Financial incentives / bonuses 44 8.1 Professional development opportunities 177 32.6 Team belonging and cohesion 69 12.7 Willingness to contribute to community health 233 42.9 None 20 3.7 Existence of an income-generating activity (IGA) Yes 340 62.6 No 203 37.4 Among the 543 participants, 42.9% were motivated by the desire to contribute to community health, 32.6% by professional development opportunities, 12.7% by team belonging and cohesion, 8.1% by financial incentives, and 3.7% reported no motivation. Regarding the existence of an income-generating activity, 62.6% had one, while 37.4% did not. Table 5. Multivariate logistic regression analysis of sociodemographic factors and notification frequency Notifications frequency [95% Conf. Interval] Odds Ratio P value Sexe Male 1.0 Female 2.520355 7.073404 4.222261 0.000 Age (Year) ˂ 30 1.0 30-39 2.1869664 16.5085471 4.3083525 0.000 40-49 1.9838135 11.7778317 3.3781216 0.008 ≥ 50 0.076388 1.061112 0.2847037 0.061 Marital status Married 1.0 Single 0.4871147 1.240547 0.77736 0.291 Divorced 5.0528272 29.3484137 6.1356677 0.000 Widowed 2.0228361 11.4449813 3.100805 0.002 Niveau d’éducation None Primary 0.0354824 5.413221 0.121087 0.061 Secondary 2.2680104 12.7750257 3.2295861 0.018 University 4.0724849 25.00264 9.6021758 0.001 Distance >5 km 1.0 2- 5 km 0.4904924 1.374272 0.8210177 0.453 >2 km 1.8058488 7.5863124 2.2243529 0.002 Year of experience ˂ 2 1.0 2-5 2.535183 14.823914 3.721321 0.001 > 5 2.306878 10.50796 4.923471 0.000 The multivariate analysis shows that women are 4.2 times more likely to report frequently than men (OR = 4.22; p < 0.001). Participants aged 30–39 years (OR = 4.31; p < 0.001) and 40–49 years (OR = 3.38; p = 0.008) also had higher odds of reporting compared to those under 30 years. Divorced (OR = 6.14; p < 0.001) and widowed participants (OR = 2.10; p = 0.002) were significantly more likely to report than married individuals. Higher education levels—university (OR = 9.12; p = 0.001) and secondary (OR = 3.23; p = 0.018)—substantially increased the likelihood of reporting. Additionally, proximity to a health facility (<2 km; OR = 2.22; p = 0.002) and professional experience of 2–5 years (OR = 3.72; p = 0.001) or more than 5 years (OR = 4.92; p < 0.001) were also positively associated with higher notification frequency. Table 6. Multivariate logistic regression analysis of cognitive and perceptual factors associated with notification frequency Notifications frequency [95% Conf. Interval] Odds Ratio P value Knowledge of a suspected case Good knowledge 1.0 Poor knowledge 2.8931823 16.9425421 4.5256773 0.031 Trust in health institutions Yes 1.0 No 2.1980376 8.3124382 4.1750163 0.000 Perceived risk of an outbreak in the community Low 1.0 Moderate 0.5407986 1.21523 0.8106755 0.310 High 1.943089 7.254552 3.754496 0.000 Perception of the origin of the disease Yes 1.0 No 2.049922 9.760196 3.123785 0.000 Participants with good knowledge of suspected case recognition were significantly more likely to report frequently than those with poor knowledge (OR = 2.53 ; p = 0.031). Trust in health institutions was also significantly associated with more frequent reporting (OR = 4.18; p < 0.001). Regarding perceived epidemic risk, those who perceived a high risk were 3.75 times more likely to report frequently than those who perceived a low risk (OR = 3.75; p < 0.001), while a moderate risk perception was not statistically significant (OR = 0.81; p = 0.31). Participants who did not know the origin of the disease were 3.12 times more likely to report frequently (OR = 3.12; p < 0.001). Table 7. Multivariate logistic regression analysis of organizational and material factors associated with notification frequency Notifications frequency [95% Conf. Interval] Odds Ratio P value Tools for case identification Other 1.0 Written form 2.4257424 11.9559918 3.6379704 0.029 Telephone 0.1021444 4.92965326 2.147890 0.046 Availability of tools at all times for case reporting No 1.0 Yes 1.391822 13.965276 5.349246 0.001 Availability of personal protective equipment (PPE) No 1.0 Yes 2.370969 5.898625 2.311903 0.002 Access to communication means Yes 1.0 No 0.4205918 1.240789 0.7224028 0.239 Supervision on surveillance in the past 30 days No 1.0 Yes 0.8745832 2.552546 1.494126 0.052 Specific training on surveillance in the past 6 months No 1.0 Yes 2.0919069 19.3621796 6.1824467 0.000 Participants who used written forms for case identification were 3.64 times more likely to report frequently than those using other tools (OR = 3.64; p = 0.029), whereas telephone use was not statistically significant (p = 0.056). Continuous availability of reporting tools increased the likelihood of frequent notifications by more than fivefold (OR = 5.35; p = 0.001). The availability of personal protective equipment was also associated with a higher probability of frequent reporting (OR = 2.31; p = 0.002). Receiving specific surveillance training within the past six months increased the likelihood of frequent notifications more than sixfold (OR = 6.18; p < 0.001), while recent supervision was associated with a modest but significant increase (OR = 1.49; p = 0.042). Table 8. Multivariate logistic regression analysis of motivational factors associated with notification frequency (n = 543) Notifications frequency [95% Conf. Interval] Odds Ratio P value Primary motivation Financial incentives / bonuses 1.0 Professional development opportunities 2.798278 20.6705 7.605381 0.000 Team belonging and cohesion 2.029731 11.1083 3.843313 0.013 Willingness to contribute to community health 2.4358 10.14124 4.915861 0.007 None 0.0037906 9.110055 0.466311 0.249 Existence of an income-generating activity (IGA) No 1.0 Yes 2.8926508 19.906584 4.304574 0.017 Participants motivated by professional development opportunities were 7.61 times more likely to report frequently than those motivated by financial incentives (OR = 7.61; p < 0.001). Team belonging and cohesion were also significantly associated with higher reporting frequency (OR = 3.84; p = 0.013). The willingness to contribute to community health was linked to a markedly higher likelihood of frequent reporting (OR = 3.82; p = 0.007). Finally, having an income-generating activity was associated with a modest increase in the likelihood of frequent reporting (OR = 4.30; p = 0.017), suggesting that economic support may enhance engagement in community-based surveillance. QUALITATIVE RESULTS Qualitative interviews with community health workers identified multiple interrelated factors influencing Mpox surveillance, reporting, and community engagement across the three health zones. Theme 1 : Perception of the Epidemiological Situation Participants reported that Mpox remains present in all three health zones. However, they emphasized that community awareness about the disease is still limited, particularly regarding its clinical signs and modes of transmission. Inadequate risk communication and the persistence of rumors were described as major barriers to prevention and early detection. One participant noted: “People still do not clearly understand how Mpox is transmitted.” Misinformation was perceived to contribute to fear, stigma, and delayed care-seeking behaviors. Theme 2 : Capacity of Community Health Workers Although some community health workers had received training on Mpox, participants reported that training coverage was limited and incomplete, with only about ten CHWs trained per health zone. While basic knowledge was present, many respondents felt they lacked mastery of key health messages needed for effective sensitization. Several participants expressed feelings of insufficiency in their role: “I am limited when it comes to educating the community.” This perceived gap in competence was reported to reduce confidence and effectiveness in community-level communication. Theme 3 : Detection and Notification Process Participants indicated that the standard surveillance procedure detection, referral, notification, and follow-up was generally understood and applied. However, several operational challenges were reported to hinder timely notification. These included refusal of suspected cases to seek care, delays in receiving laboratory results, and the absence of official documentation for suspected cases. These barriers were perceived to compromise the completeness and timeliness of surveillance data. Theme 4 : Reporting Tools and Documentation A critical gap identified was the lack of standardized reporting tools. Many RCs reported not having access to notification forms, registers, or mobile phones for communication. As a result, case information was often recorded informally. One participant explained: “We write the information on any paper we find.” There was strong interest in adopting digital tools, such as mobile data collection platforms (e.g., KoboCollect) and photo-based reporting, to improve documentation and reporting efficiency. Theme 5 : Motivation of Community Health Workers Community health workers described their primary motivation as a commitment to protecting their communities from disease. Despite this intrinsic motivation, several factors contributed to demotivation, including lack of financial incentives, unfulfilled promises of support, increased workload, and insufficient logistical resources. These challenges were perceived to reduce engagement and sustainability of surveillance activities at the community level. Theme 6 : Coordination and Supervision Participants described communication between community actors and higher levels of the health system as irregular. Supervision was reported to be inconsistent, and coordination between health zones, the Provincial Health Division, and partners (including WHO) was perceived as weak. Respondents suggested that improved coordination and more regular supervision would strengthen surveillance performance and data flow. Theme 7 : Community-Level Barriers Several socio-cultural factors were identified as barriers to case detection and reporting. These included rumors, refusal of household visits, misconceptions about Mpox, and reluctance to seek care at health facilities. Such community resistance was perceived to delay detection and reduce notification rates. Theme 8 : Synthesis of Factors Contributing to Under-Notification Across interviews, participants highlighted multiple interconnected drivers of Mpox under-notification. These included insufficient training of community health workers, lack of formal reporting tools, weak coordination and supervision, low motivation due to absence of incentives, and persistent community rumors and resistance. Together, these systemic, operational, and socio-cultural challenges were perceived to significantly undermine effective Mpox surveillance at the community level. DISCUSSION 1. Sociodemographic and economic factors associated with notification The analysis shows that female sex, secondary or university education, and having an income-generating activity (IGA) are associated with a higher frequency of suspected Mpox case reporting. These variables can be interpreted as structural determinants of performance, influencing clinical recognition capacity, community communication, and the stability of community health worker engagement(6;7). The observed association with female sex takes on particular epidemiological significance in the current context. The emergence of Clade Ib, characterized by APOBEC3-type mutational signatures suggesting increased adaptation to the human host, has been accompanied by sustained human-to-human transmission within households and heterosexual networks, significantly affecting women and children(8;9). In this context, female community health workers may have a social and domestic access advantage, facilitating the early identification of cases within these groups, which are now more exposed (10). This profile contrasts with Clade II–dominated outbreaks, notably in Nigeria in 2017 and during the global 2022 outbreak (Clade IIb), where the majority of cases occurred among adult men. (11). In contrast, recent data from a Clade Ib circulation context in Kinshasa show a high proportion of female cases, consistent with the dynamics observed in our study(4). This convergence suggests that the increased effectiveness of female community health workers may be contextually dependent on the circulating viral transmission profile. (12; 13) . The association between education level and reporting aligns with a cognitive gradient, whereby higher educational attainment enhances the understanding of case definitions, recognition of atypical signs, and the quality of health communication(1). Similarly, having an income-generating activity may serve as a factor of economic stability, reducing reliance on external incentives and promoting sustained engagement in surveillance activities. (11). However, qualitative triangulation (Theme 5) introduces an important nuance. Community health workers with this favorable profile reported gradual demotivation related to the lack of incentives, unfulfilled promises, and increasing workload. This results in a gap between individual capacity and systemic constraints, suggesting that the effects observed in statistical models could be attenuated in the medium term by unmeasured organizational factors. Finally, the statistical association does not imply direct causality. Uncontrolled intermediate variables, such as the gendered distribution of caregiving roles or community tenure, may contribute to the observed effect. 2. Cognitive and perceptual factors associated with notification The results indicate that good knowledge of suspected signs, increased trust in health institutions, and a high perceived risk are associated with more frequent reporting. These factors fall within the cognitive–perceptual model of health behavior, influencing the likelihood that a clinical suspicion is translated into a formal reporting action(14;6). However, triangulation with the qualitative data (Themes 1 and 2) highlights a significant methodological discordance (15; 16) . While the quantitative indicators suggest an adequate level of knowledge, the interviews reveal fragmented understanding, difficulty in explaining the disease to the community, and a high prevalence of circulating rumors(17)This divergence suggests a measurement bias related to self-reporting, where the “good knowledge” variable likely reflects recognition of key symptoms rather than comprehensive operational mastery, including differential diagnosis, atypical presentations, and risk communication(18 ;19). Risk perception emerges as a significant determinant; however, qualitatively, it appears to be strongly influenced by the local visibility of the outbreak and community narratives, suggesting that it may function more as a proxy for contextual vigilance than as an objective assessment of infection probability(16). These findings are consistent with recent African syntheses, which identify lack of awareness and stigma as major barriers to Mpox reporting. The same studies also highlight systemic shortcomings, notably in diagnostic capacity and specimen transport, echoing the community health workers’ observations regarding delays in feedback(13). An important limitation lies in the self-reported nature of the cognitive variables. The use of standardized tools, such as clinical vignettes or diagnostic concordance tests, would allow for a more accurate estimation of the true predictive validity of participants’ knowledge. 3. Material and organizational factors associated with notification La disponibilité d’outils permanents (fiches de notification, supports standardisés, EPI), une formation récente et une supervision régulière sont fortement associées à une notification accrue. Ces variables représentent des facteurs structurels de capacité opérationnelle , influençant directement la faisabilité technique de la notification(18;20). Qualitative triangulation (Themes 3, 4, and 6) reveals marked concordance : absence of standardized forms, reliance on improvised documentation, irregular supervision, and weak coordination. (21;22). This convergence confirms that the observed statistical associations reflect tangible systemic deficits. (22) . These results illustrate the limitations of a predominantly passive surveillance system, where case detection relies on individual initiative without adequate logistical support. Passive systems are known for low sensitivity, underreporting, and vulnerability to demotivation among community actors(23). The absence of standardized tools increases the risk of data loss, misclassification, and transmission delays, compromising the overall quality of surveillance(14). A limitation of the study lies in the lack of precise quantification of the logistical deficit (e.g., the proportion of community health workers without standardized forms over a given period), which restricts the ability to estimate the full extent of the problem(24;8). In the short term, the results support strengthening the passive system through a standardized minimal package of tools and regular supervision. In the longer term, the introduction of targeted active surveillance components in high-risk households could improve system sensitivity. 4.Facteurs motivationnels associés à la notification The analyses show that intrinsic motivation such as a sense of social utility, community contribution, and personal fulfillment is more strongly associated with reporting than financial incentives alone(25). This suggests that community health worker engagement is based on a vocational model, in which social identity and symbolic recognition play a central role. However, qualitative data (Theme 5) describe a gradual erosion of this motivation, linked to a lack of institutional recognition, insufficient logistical support, and work overload(5). Thus, intrinsic motivation functions as an unstable protective factor, which may decline in the absence of minimal extrinsic reinforcement. The clinical context of Clade Ib exacerbates this vulnerability(26). The observed forms include a high number of skin lesions and a significant frequency of bacterial superinfections, exposing community health workers to repeated severe cases, an elevated perceived risk of infection, and increased emotional burden(16;22). The lack of adequate personal protective equipment (PPE) and training in safe triage exacerbates these constraints and may indirectly contribute to reduced reporting. Team cohesion, identified quantitatively as a positive factor, appears qualitatively as a buffering mechanism, helping to sustain engagement in an adverse environment. However, this social capital remains fragile and dependent on institutional support(16). Motivational variables are subject to social desirability bias, and the lack of direct observation of practices limits the assessment of actual behavior. Nevertheless, the convergence of the data suggests that a sustainable model must combine formal recognition, reduction of operational risk, and guaranteed minimal material support. CONCLUSION The findings show that women, individuals aged 30–49 years, divorced and widowed participants, and those with secondary or university education report more frequently than their counterparts. Geographic proximity to a health facility and greater professional experience also enhance performance. From a cognitive perspective, good knowledge of suspected cases, a high perceived epidemic risk, and trust in health institutions emerge as key facilitators. Organizational factors—including the availability of written tools, continuous access to reporting materials, provision of personal protective equipment, and recent training and supervision—play a decisive role. Mpox continues to circulate in the three health zones studied. Several factors contribute to underreporting: limited training, lack of formal tools, weak coordination, insufficient motivation, rumors and community resistance. Despite these challenges, community health workers remain motivated and committed to “protecting the community.” The system can be strengthened through realistic and targeted interventions. RECOMMENDATIONS For Health Zones Train all community health workers Implement standardized tools (forms, registers, tokens) Strengthen supervision and feedback mechanisms Provide mobile phones and airtime for rapid reporting For Partners (WHO, Provincial Health Division, NGOs) Ensure regular minimal financial incentives Provide logistical support (transport, vests, boots, badges) Harmonize interventions to prevent inter-partner disparities Promote the use of digital tools (e.g., Kobo Collect) For the Community Intensify awareness campaigns on Mpox signs and symptoms Address rumors and misconceptions Strengthen collaboration with community health workers Declarations Ethics Approval and Consent to Participate Ethical approval for this study was obtained from the Ethics Committee of the University of Goma (UNIGOM) under approval number UNIGOM/CEM/005/2024 . All participants were fully informed about the study objectives, procedures, potential risks, and benefits. Verbal informed consent was obtained from all participants following ethics committee authorization. The research was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (2013 revision) . Participation was voluntary, anonymous, and confidential, and participants were free to withdraw at any time without consequence. Consent for Publication Not applicable. Availability of Data and Materials The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request. To protect participant confidentiality, only de-identified data will be shared. Competing Interests The authors declare that they have no competing interests. Funding This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The research was conducted as part of the ongoing Mpox surveillance and response activities coordinated by the Mpox Incident Management System, North Kivu, Democratic Republic of Congo. Authors’ Contributions S.H.B.M. and R.B. conceived and designed the study. J.M. and T.P. coordinated data collection and analysis. T.P. performed the statistical analyses and wrote the first draft of the manuscript. M.N. provided methodological supervision and critical revisions. All authors contributed to data interpretation, reviewed the manuscript, and approved the final version for submission. Acknowledgements The authors extend sincere appreciation to all participants who supported the study. The team also acknowledges the Mpox Incident Management System, North Kivu, for technical guidance and logistical support. References Mukadi-Bamuleka D, Kinganda-Lusamaki E, Mulopo-Mukanya N, Amuri-Aziza A, O’Toole Á, Merritt S, et al. 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Fu Y, Chen W, Yuan R, Wang X, Yang Z. Factors associated with mpox awareness among men who have sex with men recruited through the internet: a cross-sectional survey in China. Front Public Heal. 2025; Ogoina D, Izibewule JH, Ogunleye A, Ederiane E, Anebonam U, Neni A, et al. The 2017 human monkeypox outbreak in Nigeria—Report of outbreak experience and response in the Niger Delta University Teaching Hospital, Bayelsa State, Nigeria. PLoS One. 2019; Jiang L, Xu A, Guan L, Tang Y, Chai G, Feng J, et al. A review of Mpox: Biological characteristics, epidemiology, clinical features, diagnosis, treatment, and prevention strategies. Exploration. 2025. Ugwu CLJ, Bragazzi NL, Wu J, Kong JD, Asgary A, Orbinski J, et al. Risk factors associated with human Mpox infection: A systematic review and meta-Analysis. BMJ Glob Heal. 2025; Effiong FB, Elebesunu EE, Ogunniyi TJ, Olawuyi DA, Ekpor E, Ahiadorme M, et al. Mpox surveillance in endemic regions: a scoping review of trends, challenges, and recommendations. BMC Infect Dis. 2025;25(1). Hantz S, Mafi S, Pinet P, Deback C. De la variole du singe à la Mpox ou la réémergence d’une ancienne zoonose. Rev Francoph des Lab. 2023; Jadhav V, Paul A, Trivedi V, Bhatnagar R, Bhalsinge R, Jadhav S V. Global epidemiology, viral evolution, and public health responses: a systematic review on Mpox (1958–2024). J Glob Health. 2025; Panag DS, Jain N, Katagi D, De Jesus Cipriano Flores G, Silva Dutra Macedo GD, Rodrigo Díaz Villa G, et al. Variations in national surveillance reporting for Mpox virus: A comparative analysis in 32 countries. Front Public Heal. 2023; Panag DS, Jain N, Katagi D, De Jesus Cipriano Flores G, Silva Dutra Macedo GD, Rodrigo Díaz Villa G, et al. Variations in national surveillance reporting for Mpox virus: A comparative analysis in 32 countries. Front Public Heal. 2023;11(April). WHO. Who. 2024 [cited 1BC Jul 24]. Community experiences of the 2022–2023 mpox outbreak in Europe and the Americas. Available from: https://www.who.int/publications/i/item/9789240077287 WHO. WHO. 2024 [cited 2024 Mar 20]. Surveillance, case investigation and contact tracing for mpox ‎‎(monkeypox)‎: Interim guidance, ‎20 March 2024. Available from: https://www.who.int/publications/i/item/WHO-MPX-Surveillance-2024.1 Yadav R, Chaudhary AA, Srivastava U, Gupta S, Rustagi S, Rudayni HA, et al. Mpox 2022 to 2025 Update: A Comprehensive Review on Its Complications, Transmission, Diagnosis, and Treatment. Viruses. 2025;17(6):753. European Centre for Disease Prevention and Control. European Centre for Disease Prevention and Control. 2025 [cited 2025 Dec 16]. Mpox worldwide overview. Available from: https://www.ecdc.europa.eu/en/mpox-worldwide-overview Xie L, Zhou Y, Zhang X, Lan T, Sun W. Global Trends in MPOX Research (2014–2025): A Bibliometric Analysis and Overview. Vet Med Res Reports. 2025;Volume 16(December):99–112. Selekon B, Malaka C, Mounchili JL. Strengthening Africa ’ s resilience to Mpox : Preparedness and response initiatives of the Pasteur network. :1–5. Hrynick T, Muzalia G, James M. clés: Communication des risques et engagement communautaire pour la vaccination contre la mpox dans l’est de la République démocratique du Congo. 2024;1–17. Available from: https://opendocs.ids.ac.uk/articles/report/Consid_rations_cl_s_Communication_des_risques_et_engagement_communautaire_pour_la_ vaccination_contre_la_mpox_dans_l_est_de_la_R_publique_d_mocratique_du_Congo/26363647 Hantz S, Mafi S, Pinet P, Deback C. [Monkeypox to Mpox or the re-emergence of an old zoonosis]. Rev Francoph des Lab RFL. 2023; Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9018139","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":599841511,"identity":"6cbc81ef-96a1-42c1-814f-e65395357d77","order_by":0,"name":"Justin Murhabazi","email":"","orcid":"","institution":"Goma university","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"","lastName":"Murhabazi","suffix":""},{"id":599841512,"identity":"2b611cb5-5c36-4a60-b396-f6a54f3f5620","order_by":1,"name":"Stéphane-Hans Bateyi Mustafa","email":"","orcid":"","institution":"Free University of the Great Lakes Countries (ULPGL), Democratic Republic of Congo","correspondingAuthor":false,"prefix":"","firstName":"Stéphane-Hans","middleName":"Bateyi","lastName":"Mustafa","suffix":""},{"id":599841513,"identity":"c7e594a3-6d73-45c8-81aa-b038ee5431fd","order_by":2,"name":"Tambwe Patrick","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYHACNijJxvgASPPwEVLPA9FiANLCbAASYCNaC5Bmk0BYigfYs59Oe1xQ8yefj/1YWuXXHDsZNgbmh49u4LOFJ3e78YxjBpZtPGnHbstuSwY6jM3YOAevw3K3SfOwGRiwSbC33ZbcxgzUwsMmjVcL/1ugln8QLcWS2+qJ0CIBtIW3DaSF7Rjjx22HidBy4+1245l9xgZsPGnJ0ozbjvOwMRPwC3t/7rbHBd/kDOTbjxl+/Lmt2p6fvfnhY3xaQIAZzuBB4RKjhfEHEapHwSgYBaNg5AEAh+46+yDw1OoAAAAASUVORK5CYII=","orcid":"","institution":"Mpox Incident Management System, Democratic Republic of Congo","correspondingAuthor":true,"prefix":"","firstName":"Tambwe","middleName":"","lastName":"Patrick","suffix":""},{"id":599841514,"identity":"1ddd5c43-711b-4658-905e-b6450829d602","order_by":3,"name":"Robert Biya","email":"","orcid":"","institution":"Mpox Incident Management System, Democratic Republic of Congo","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Biya","suffix":""},{"id":599841515,"identity":"09ca7a2c-09fe-4ab4-ab84-b055066ee13f","order_by":4,"name":"Jean Bindu Balume","email":"","orcid":"","institution":"Goma university","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"Bindu","lastName":"Balume","suffix":""},{"id":599841516,"identity":"9420cb87-0dfb-442a-9eb3-3c8898f34b91","order_by":5,"name":"Ruvamwabo hagumagatsi amos","email":"","orcid":"","institution":"Provincial Health Division of North Kivu (DPS), Democratic Republic of Congo","correspondingAuthor":false,"prefix":"","firstName":"Ruvamwabo","middleName":"hagumagatsi","lastName":"amos","suffix":""}],"badges":[],"createdAt":"2026-03-03 08:53:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9018139/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9018139/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104179863,"identity":"a8a0b854-4ff8-41d9-ad5e-585682b73a89","added_by":"auto","created_at":"2026-03-08 17:09:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":28490,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9018139/v1/3a57fdec7f5826586891e8f4.png"},{"id":105734872,"identity":"1a0c0936-189d-4949-bce4-f55c3366373a","added_by":"auto","created_at":"2026-03-30 11:47:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2239295,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9018139/v1/47997fe3-b0e8-4f98-9998-21cd2c07aa3a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Associated with Mpox Case Notification by Community Health Workers in the Karisimbi, Goma, and Nyiragongo Health Zones, Democratic Republic of the Congo","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMpox remains a major public health threat in the Democratic Republic of the Congo, where Clade I is the predominant circulating strain (1;2). The Karisimbi, Goma, and Nyiragongo health zones, located in North Kivu Province, are characterized by high population density, constant population movement, and structural barriers to healthcare access. In this context, community-based surveillance (CBS) plays a central role in the early detection of cases and the timely alerting of the health system(3).\u003c/p\u003e\n\u003cp\u003eCommunity health workers (CHWs) constitute the first link in this surveillance system, ensuring the identification, referral, and reporting of suspected cases at the peripheral level (4;5). Despite their strategic importance, limited empirical data are available on the determinants of their performance in Mpox case reporting, particularly in unstable urban and conflict-affected settings(5). This study aims to address this gap by conducting an integrated analysis of the factors associated with case reporting by community health workers in three priority health zones of North Kivu. Specifically, it seeks to identify the sociodemographic and economic, cognitive and perceptual, material and organizational, and motivational factors associated with the reporting of suspected Mpox cases by community health workers in the Karisimbi, Goma, and Nyiragongo health zones.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy setting and design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn analytical cross-sectional study using mixed methods, combining quantitative and qualitative approaches, was conducted in the Karisimbi, Goma, and Nyiragongo health zones in North Kivu Province, Democratic Republic of the Congo.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy period\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection took place from September 20 to 30, 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population and sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population consisted of community health workers involved in Mpox community-based surveillance (CBS).\u003c/p\u003e\n\u003cp\u003eFor the quantitative component, a multistage stratified probabilistic sampling approach was used to select 543 community health workers. The sample size was calculated using Cochran’s formula.\u003c/p\u003e\n\u003cp\u003eFor the qualitative component, a purposive non-probability sampling strategy was applied, guided by the principle of theoretical saturation, which was reached after 22 interviews and group discussions, including one focus group of eight community health workers per health zone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were collected using a structured questionnaire administered through face-to-face interviews. Qualitative data were gathered through semi-structured interviews and focus group discussions. Data collection tools were administered using KoboToolbox, and interviews were audio-recorded using a digital recorder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were analyzed using SPSS software. The analysis included univariate descriptive statistics, bivariate analysis (Chi-square test or Fisher’s exact test), and multivariable analysis using binary logistic regression to estimate odds ratios (ORs) and their 95% confidence intervals. Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eQualitative data were analyzed using MAXQDA software through an inductive thematic analysis approach inspired by Braun and Clarke: full transcription, familiarization with the data, line-by-line coding, code grouping, theme development, and contextual interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received approval from the Ethics Committee of the University of Goma (UNIGOM) (No. UNIGOM/CEM/005/2025). Informed consent was obtained from all participants.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eQUANTITATIVE RESULTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Distribution of participants according to sociodemographic characteristics\u003c/strong\u003e\u003cstrong\u003e(n= 543)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e304\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonthly income (USD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e478\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u0026ndash;165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e339\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026ndash;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistance to health facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 2 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026ndash;5 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 5 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe study included 543 participants, the majority of whom were men (69.8%) and young adults, with more than three-quarters under the age of 40 years. The overall level of education was relatively high, with nearly 91% having completed at least primary education and more than half reaching secondary level. Marital status was dominated by single individuals (56%), followed by married participants (32%).\u003c/p\u003e\n\u003cp\u003eEconomically, the vast majority (88%) reported a monthly income of less than USD 60, reflecting substantial financial vulnerability. In terms of experience, nearly two-thirds (63.4%) had less than two years of service, whereas only 11.2% had more than five years of experience. Finally, most respondents (55.2%) lived within two kilometers of a health facility, which facilitates access and timely case reporting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Distribution of participants according to cognitive and perceptual factors\u003c/strong\u003e\u003cstrong\u003e(n= 543)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of a suspected case\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e454\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerception of disease severity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerception of the origin of the disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e367\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrust in health institutions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e419\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived risk of an outbreak in the community\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAmong the 543 participants, 83.6% reported good knowledge of suspected case recognition, while 16.4% demonstrated poor knowledge. The majority (88.4%) perceived the disease as severe, compared to 11.6% who did not share this view. Regarding the origin of the disease, 67.6% reported correct understanding, whereas 32.4% held incorrect perceptions. Trust in health institutions was noted in 77.2% of participants, while 22.8% expressed distrust. Finally, the perceived risk of an outbreak in the community was considered high by 41.8%, moderate by 46.2%, and low by 12%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Distribution of participants according to organizational and material factors\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(n= 543)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific training on surveillance in the past 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e450\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupervision on surveillance in the past 30 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTools for case identification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWritten form\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTelephone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailability of tools at all times for case reporting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e378\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipation in CAC meetings in the past 30 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e335\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHouse-to-house visits as part of CBS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailability of personal protective equipment (PPE)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to communication means\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e242\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e301\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAmong the 543 participants, 82.9% reported having received specific training on surveillance in the past six months, compared to 17.1% who had not. Recent supervision was received by 88.4% of participants, while 11.6% reported no recent follow-up. Tools for case identification included telephones (53.8%), written forms (45.3%), and other means (0.9%). Continuous availability of these tools was reported by 69.6% of participants, whereas 30.4% did not have them readily available. Participation in community activity committee meetings over the past 30 days was observed in 61.7% of participants, with 38.3% absent. House-to-house visits as part of community-based surveillance were conducted by 65.2% of participants, while 34.8% did not perform them. Regarding material resources, 46% reported having personal protective equipment, compared to 54% without, and access to communication means was reported by 44.6% of participants, while 55.4% lacked access.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Distribution of participants according to motivational factors(n=543)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary motivation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFinancial incentives / bonuses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProfessional development opportunities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTeam belonging and cohesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWillingness to contribute to community health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExistence of an income-generating activity (IGA)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e340\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAmong the 543 participants, 42.9% were motivated by the desire to contribute to community health, 32.6% by professional development opportunities, 12.7% by team belonging and cohesion, 8.1% by financial incentives, and 3.7% reported no motivation. Regarding the existence of an income-generating activity, 62.6% had one, while 37.4% did not.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Multivariate logistic regression analysis of sociodemographic factors and notification frequency\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNotifications frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e[95% Conf.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterval]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexe\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2.520355\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e7.073404\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.222261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (Year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e˂ 30\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2.1869664\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e16.5085471\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.3083525\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e40-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e1.9838135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11.7778317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.3781216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u0026ge; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.076388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.061112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.2847037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.4871147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.240547\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.77736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.291\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e5.0528272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e29.3484137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6.1356677\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2.0228361\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11.4449813\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.100805\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNiveau d\u0026rsquo;\u0026eacute;ducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.0354824\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5.413221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.121087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2.2680104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e12.7750257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.2295861\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e4.0724849\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e25.00264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e9.6021758\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u0026gt;5 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e2- 5 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.4904924\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.374272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.8210177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u0026gt;2 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e1.8058488\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e7.5863124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2.2243529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear of experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e˂ 2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e2-5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2.535183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e14.823914\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.721321\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u0026gt; 5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2.306878\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e10.50796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.923471\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe multivariate analysis shows that women are 4.2 times more likely to report frequently than men (OR = 4.22; p \u0026lt; 0.001). Participants aged 30\u0026ndash;39 years (OR = 4.31; p \u0026lt; 0.001) and 40\u0026ndash;49 years (OR = 3.38; p = 0.008) also had higher odds of reporting compared to those under 30 years. Divorced (OR = 6.14; p \u0026lt; 0.001) and widowed participants (OR = 2.10; p = 0.002) were significantly more likely to report than married individuals. Higher education levels\u0026mdash;university (OR = 9.12; p = 0.001) and secondary (OR = 3.23; p = 0.018)\u0026mdash;substantially increased the likelihood of reporting. Additionally, proximity to a health facility (\u0026lt;2 km; OR = 2.22; p = 0.002) and professional experience of 2\u0026ndash;5 years (OR = 3.72; p = 0.001) or more than 5 years (OR = 4.92; p \u0026lt; 0.001) were also positively associated with higher notification frequency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Multivariate logistic regression analysis of cognitive and perceptual factors associated with notification frequency\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNotifications frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e[95% Conf.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterval]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of a suspected case\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.8931823\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.9425421\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.5256773\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrust in health institutions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.1980376\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.3124382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.1750163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived risk of an outbreak in the community\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5407986\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.21523\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8106755\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.310\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.943089\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.254552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.754496\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerception of the origin of the disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.049922\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.760196\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.123785\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants with good knowledge of suspected case recognition were significantly more likely to report frequently than those with poor knowledge (OR = 2.53 ; p = 0.031). Trust in health institutions was also significantly associated with more frequent reporting (OR = 4.18; p \u0026lt; 0.001). Regarding perceived epidemic risk, those who perceived a high risk were 3.75 times more likely to report frequently than those who perceived a low risk (OR = 3.75; p \u0026lt; 0.001), while a moderate risk perception was not statistically significant (OR = 0.81; p = 0.31). Participants who did not know the origin of the disease were 3.12 times more likely to report frequently (OR = 3.12; p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7. Multivariate logistic regression analysis of organizational and material factors associated with notification frequency\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNotifications frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e[95% Conf.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterval]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTools for case identification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWritten form\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.4257424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.9559918\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.6379704\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTelephone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.1021444\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.92965326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.147890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailability of tools at all times for case reporting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.391822\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.965276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.349246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailability of personal protective equipment (PPE)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.370969\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.898625\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.311903\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess to communication means\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4205918\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.240789\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7224028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.239\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupervision on surveillance in the past 30 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8745832\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.552546\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.494126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific training on surveillance in the past 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.0919069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.3621796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.1824467\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants who used written forms for case identification were 3.64 times more likely to report frequently than those using other tools (OR = 3.64; p = 0.029), whereas telephone use was not statistically significant (p = 0.056). Continuous availability of reporting tools increased the likelihood of frequent notifications by more than fivefold (OR = 5.35; p = 0.001). The availability of personal protective equipment was also associated with a higher probability of frequent reporting (OR = 2.31; p = 0.002).\u003c/p\u003e\n\u003cp\u003eReceiving specific surveillance training within the past six months increased the likelihood of frequent notifications more than sixfold (OR = 6.18; p \u0026lt; 0.001), while recent supervision was associated with a modest but significant increase (OR = 1.49; p = 0.042).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8. Multivariate logistic regression analysis of motivational factors associated with notification frequency (n = 543)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNotifications frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e[95% Conf.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterval]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;P value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary motivation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eFinancial incentives / bonuses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eProfessional development opportunities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e2.798278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e20.6705\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e7.605381\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eTeam belonging and cohesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e2.029731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e11.1083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.843313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eWillingness to contribute to community health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e2.4358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e10.14124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.915861\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.0037906\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e9.110055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.466311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExistence of an income-generating activity (IGA)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e2.8926508\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e19.906584\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.304574\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants motivated by professional development opportunities were 7.61 times more likely to report frequently than those motivated by financial incentives (OR = 7.61; p \u0026lt; 0.001). Team belonging and cohesion were also significantly associated with higher reporting frequency (OR = 3.84; p = 0.013). The willingness to contribute to community health was linked to a markedly higher likelihood of frequent reporting (OR = 3.82; p = 0.007). Finally, having an income-generating activity was associated with a modest increase in the likelihood of frequent reporting (OR = 4.30; p = 0.017), suggesting that economic support may enhance engagement in community-based surveillance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQUALITATIVE RESULTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative interviews with community health workers identified multiple interrelated factors influencing Mpox surveillance, reporting, and community engagement across the three health zones.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1 : Perception of the Epidemiological Situation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported that Mpox remains present in all three health zones. However, they emphasized that community awareness about the disease is still limited, particularly regarding its clinical signs and modes of transmission. Inadequate risk communication and the persistence of rumors were described as major barriers to prevention and early detection.\u003c/p\u003e\n\u003cp\u003eOne participant noted:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;People still do not clearly understand how Mpox is transmitted.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eMisinformation was perceived to contribute to fear, stigma, and delayed care-seeking behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2 : Capacity of Community Health Workers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough some community health workers had received training on Mpox, participants reported that training coverage was limited and incomplete, with only about ten CHWs trained per health zone. While basic knowledge was present, many respondents felt they lacked mastery of key health messages needed for effective sensitization.\u003c/p\u003e\n\u003cp\u003eSeveral participants expressed feelings of insufficiency in their role:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I am limited when it comes to educating the community.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThis perceived gap in competence was reported to reduce confidence and effectiveness in community-level communication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3 : Detection and Notification Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants indicated that the standard surveillance procedure detection, referral, notification, and follow-up was generally understood and applied. However, several operational challenges were reported to hinder timely notification. These included refusal of suspected cases to seek care, delays in receiving laboratory results, and the absence of official documentation for suspected cases.\u003c/p\u003e\n\u003cp\u003eThese barriers were perceived to compromise the completeness and timeliness of surveillance data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4 : Reporting Tools and Documentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA critical gap identified was the lack of standardized reporting tools. Many RCs reported not having access to notification forms, registers, or mobile phones for communication. As a result, case information was often recorded informally.\u003c/p\u003e\n\u003cp\u003eOne participant explained:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We write the information on any paper we find.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThere was strong interest in adopting digital tools, such as mobile data collection platforms (e.g., KoboCollect) and photo-based reporting, to improve documentation and reporting efficiency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 5 : Motivation of Community Health Workers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunity health workers described their primary motivation as a commitment to protecting their communities from disease. Despite this intrinsic motivation, several factors contributed to demotivation, including lack of financial incentives, unfulfilled promises of support, increased workload, and insufficient logistical resources.\u003c/p\u003e\n\u003cp\u003eThese challenges were perceived to reduce engagement and sustainability of surveillance activities at the community level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 6 : Coordination and Supervision\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described communication between community actors and higher levels of the health system as irregular. Supervision was reported to be inconsistent, and coordination between health zones, the Provincial Health Division, and partners (including WHO) was perceived as weak.\u003c/p\u003e\n\u003cp\u003eRespondents suggested that improved coordination and more regular supervision would strengthen surveillance performance and data flow.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 7 : Community-Level Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral socio-cultural factors were identified as barriers to case detection and reporting. These included rumors, refusal of household visits, misconceptions about Mpox, and reluctance to seek care at health facilities. Such community resistance was perceived to delay detection and reduce notification rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 8 : Synthesis of Factors Contributing to Under-Notification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross interviews, participants highlighted multiple interconnected drivers of Mpox under-notification. These included insufficient training of community health workers, lack of formal reporting tools, weak coordination and supervision, low motivation due to absence of incentives, and persistent community rumors and resistance.\u003c/p\u003e\n\u003cp\u003eTogether, these systemic, operational, and socio-cultural challenges were perceived to significantly undermine effective Mpox surveillance at the community level.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cstrong\u003e1. Sociodemographic and economic factors associated with notification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe analysis shows that female sex, secondary or university education, and having an income-generating activity (IGA) are associated with a higher frequency of suspected Mpox case reporting. These variables can be interpreted as structural determinants of performance, influencing clinical recognition capacity, community communication, and the stability of community health worker engagement(6;7). The observed association with female sex takes on particular epidemiological significance in the current context. The emergence of Clade Ib, characterized by APOBEC3-type mutational signatures suggesting increased adaptation to the human host, has been accompanied by sustained human-to-human transmission within households and heterosexual networks, significantly affecting women and children(8;9). In this context, female community health workers may have a social and domestic access advantage, facilitating the early identification of cases within these groups, which are now more exposed (10). This profile contrasts with Clade II–dominated outbreaks, notably in Nigeria in 2017 and during the global 2022 outbreak (Clade IIb), where the majority of cases occurred among adult men.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;(11). In contrast, recent data from a Clade Ib circulation context in Kinshasa show a high proportion of female cases, consistent with the dynamics observed in our study(4). This convergence suggests that the increased effectiveness of female community health workers may be contextually dependent on the circulating viral transmission profile.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(12;\u003c/strong\u003e\u003cstrong\u003e13)\u003c/strong\u003e. The association between education level and reporting aligns with a cognitive gradient, whereby higher educational attainment enhances the understanding of case definitions, recognition of atypical signs, and the quality of health communication(1).\u0026nbsp;Similarly, having an income-generating activity may serve as a factor of economic stability, reducing reliance on external incentives and promoting sustained engagement in surveillance activities.\u0026nbsp;(11). However, qualitative triangulation (Theme 5) introduces an important nuance. Community health workers with this favorable profile reported gradual demotivation related to the lack of incentives, unfulfilled promises, and increasing workload. This results in a gap between individual capacity and systemic constraints, suggesting that the effects observed in statistical models could be attenuated in the medium term by unmeasured organizational factors. Finally, the statistical association does not imply direct causality. Uncontrolled intermediate variables, such as the gendered distribution of caregiving roles or community tenure, may contribute to the observed effect.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Cognitive and perceptual factors associated with notification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results indicate that good knowledge of suspected signs, increased trust in health institutions, and a high perceived risk are associated with more frequent reporting. These factors fall within the cognitive–perceptual model of health behavior, influencing the likelihood that a clinical suspicion is translated into a formal reporting action(14;6). However, triangulation with the qualitative data (Themes 1 and 2) highlights a significant methodological discordance\u003cstrong\u003e(15;\u003c/strong\u003e\u003cstrong\u003e16)\u003c/strong\u003e. While the quantitative indicators suggest an adequate level of knowledge, the interviews reveal fragmented understanding, difficulty in explaining the disease to the community, and a high prevalence of circulating rumors(17)This divergence suggests a measurement bias related to self-reporting, where the “good knowledge” variable likely reflects recognition of key symptoms rather than comprehensive operational mastery, including differential diagnosis, atypical presentations, and risk communication(18\u0026nbsp;;19). Risk perception emerges as a significant determinant; however, qualitatively, it appears to be strongly influenced by the local visibility of the outbreak and community narratives, suggesting that it may function more as a proxy for contextual vigilance than as an objective assessment of infection probability(16).\u003c/p\u003e\n\u003cp\u003eThese findings are consistent with recent African syntheses, which identify lack of awareness and stigma as major barriers to Mpox reporting. The same studies also highlight systemic shortcomings, notably in diagnostic capacity and specimen transport, echoing the community health workers’ observations regarding delays in feedback(13). An important limitation lies in the self-reported nature of the cognitive variables. The use of standardized tools, such as clinical vignettes or diagnostic concordance tests, would allow for a more accurate estimation of the true predictive validity of participants’ knowledge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Material and organizational factors associated with notification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLa disponibilité d’outils permanents (fiches de notification, supports standardisés, EPI), une formation récente et une supervision régulière sont fortement associées à une notification accrue. Ces variables représentent des\u0026nbsp;\u003cstrong\u003efacteurs structurels de capacité opérationnelle\u003c/strong\u003e, influençant directement la faisabilité technique de la notification(18;20). Qualitative triangulation (Themes 3, 4, and 6) reveals marked concordance : absence of standardized forms, reliance on improvised documentation, irregular supervision, and weak coordination.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;(21;22). This convergence confirms that the observed statistical associations reflect tangible systemic deficits.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(22)\u003c/strong\u003e. These results illustrate the limitations of a predominantly passive surveillance system, where case detection relies on individual initiative without adequate logistical support. Passive systems are known for low sensitivity, underreporting, and vulnerability to demotivation among community actors(23). The absence of standardized tools increases the risk of data loss, misclassification, and transmission delays, compromising the overall quality of surveillance(14).\u003c/p\u003e\n\u003cp\u003eA limitation of the study lies in the lack of precise quantification of the logistical deficit (e.g., the proportion of community health workers without standardized forms over a given period), which restricts the ability to estimate the full extent of the problem(24;8). In the short term, the results support strengthening the passive system through a standardized minimal package of tools and regular supervision. In the longer term, the introduction of targeted active surveillance components in high-risk households could improve system sensitivity.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e4.Facteurs motivationnels associés à la notification\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe analyses show that intrinsic motivation such as a sense of social utility, community contribution, and personal fulfillment is more strongly associated with reporting than financial incentives alone(25). This suggests that community health worker engagement is based on a vocational model, in which social identity and symbolic recognition play a central role. However, qualitative data (Theme 5) describe a gradual erosion of this motivation, linked to a lack of institutional recognition, insufficient logistical support, and work overload(5). Thus, intrinsic motivation functions as an unstable protective factor, which may decline in the absence of minimal extrinsic reinforcement. The clinical context of Clade Ib exacerbates this vulnerability(26). The observed forms include a high number of skin lesions and a significant frequency of bacterial superinfections, exposing community health workers to repeated severe cases, an elevated perceived risk of infection, and increased emotional burden(16;22). The lack of adequate personal protective equipment (PPE) and training in safe triage exacerbates these constraints and may indirectly contribute to reduced reporting. Team cohesion, identified quantitatively as a positive factor, appears qualitatively as a buffering mechanism, helping to sustain engagement in an adverse environment. However, this social capital remains fragile and dependent on institutional support(16).\u003c/p\u003e\n\u003cp\u003eMotivational variables are subject to social desirability bias, and the lack of direct observation of practices limits the assessment of actual behavior. Nevertheless, the convergence of the data suggests that a sustainable model must combine formal recognition, reduction of operational risk, and guaranteed minimal material support.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe findings show that women, individuals aged 30\u0026ndash;49 years, divorced and widowed participants, and those with secondary or university education report more frequently than their counterparts. Geographic proximity to a health facility and greater professional experience also enhance performance. From a cognitive perspective, good knowledge of suspected cases, a high perceived epidemic risk, and trust in health institutions emerge as key facilitators. Organizational factors\u0026mdash;including the availability of written tools, continuous access to reporting materials, provision of personal protective equipment, and recent training and supervision\u0026mdash;play a decisive role.\u003c/p\u003e\n\u003cp\u003eMpox continues to circulate in the three health zones studied.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSeveral factors contribute to underreporting:\u003cbr\u003e\u0026nbsp; limited training,\u003c/li\u003e\n \u003cli\u003elack of formal tools,\u003c/li\u003e\n \u003cli\u003eweak coordination,\u003c/li\u003e\n \u003cli\u003einsufficient motivation,\u003c/li\u003e\n \u003cli\u003erumors and community resistance.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDespite these challenges, community health workers remain motivated and committed to \u0026ldquo;protecting the community.\u0026rdquo; The system can be strengthened through realistic and targeted interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRECOMMENDATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFor Health Zones\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eTrain all community health workers\u003c/li\u003e\n \u003cli\u003eImplement standardized tools (forms, registers, tokens)\u003c/li\u003e\n \u003cli\u003eStrengthen supervision and feedback mechanisms\u003c/li\u003e\n \u003cli\u003eProvide mobile phones and airtime for rapid reporting\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFor Partners (WHO, Provincial Health Division, NGOs)\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eEnsure regular minimal financial incentives\u003c/li\u003e\n \u003cli\u003eProvide logistical support (transport, vests, boots, badges)\u003c/li\u003e\n \u003cli\u003eHarmonize interventions to prevent inter-partner disparities\u003c/li\u003e\n \u003cli\u003ePromote the use of digital tools (e.g., Kobo Collect)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFor the Community\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eIntensify awareness campaigns on Mpox signs and symptoms\u003c/li\u003e\n \u003cli\u003eAddress rumors and misconceptions\u003c/li\u003e\n \u003cli\u003eStrengthen collaboration with community health workers\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the \u003cstrong\u003eEthics Committee of the University of Goma (UNIGOM)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eunder approval number \u003cstrong\u003eUNIGOM/CEM/005/2024\u003c/strong\u003e. All participants were fully informed about the study objectives, procedures, potential risks, and benefits. \u003cstrong\u003eVerbal informed consent\u003c/strong\u003e was obtained from all participants following ethics committee authorization. The research was conducted \u003cstrong\u003ein accordance with the ethical principles outlined in the Declaration of Helsinki (2013 revision)\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e Participation was voluntary, anonymous, and confidential, and participants were free to withdraw at any time without consequence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during this study are available from the corresponding author upon reasonable request. To protect participant confidentiality, only de-identified data will be shared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The research was conducted as part of the ongoing Mpox surveillance and response activities coordinated by the Mpox Incident Management System, North Kivu, Democratic Republic of Congo.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.H.B.M. and R.B. conceived and designed the study.\u003cbr\u003e\u0026nbsp;J.M. and T.P. coordinated data collection and analysis.\u003cbr\u003e\u0026nbsp;T.P. performed the statistical analyses and wrote the first draft of the manuscript.\u003cbr\u003e\u0026nbsp;M.N. provided methodological supervision and critical revisions.\u003cbr\u003e\u0026nbsp;All authors contributed to data interpretation, reviewed the manuscript, and approved the final version for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend sincere appreciation to all participants who supported the study. The team also acknowledges the Mpox Incident Management System, North Kivu, for technical guidance and logistical support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMukadi-Bamuleka D, Kinganda-Lusamaki E, Mulopo-Mukanya N, Amuri-Aziza A, O\u0026rsquo;Toole \u0026Aacute;, Merritt S, et al. First imported cases of MPXV Clade Ib from Goma, Democratic Republic of the Congo. Commun Med. 2025; \u003c/li\u003e\n\u003cli\u003eWHO. Who. 2023 [cited 2023 Nov 23]. Mpox (monkeypox) - Democratic Republic of the Congo. Available from: https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON493\u003c/li\u003e\n\u003cli\u003eWHO. Who. 2024 [cited 2024 Jun 14]. Mpox - Democratic Republic of the Congo. Available from: https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON522\u003c/li\u003e\n\u003cli\u003eAmisi Kengea L, Ihekambangu Ngwakaha B, Masamba Bikoki W, Ndumbi Temuangudi V, Nsinga Bungiena JC, Kape Kalume JJ, et al. 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BMC Infect Dis. 2025;25(1). \u003c/li\u003e\n\u003cli\u003eHantz S, Mafi S, Pinet P, Deback C. De la variole du singe \u0026agrave; la Mpox ou la r\u0026eacute;\u0026eacute;mergence d\u0026rsquo;une ancienne zoonose. Rev Francoph des Lab. 2023; \u003c/li\u003e\n\u003cli\u003eJadhav V, Paul A, Trivedi V, Bhatnagar R, Bhalsinge R, Jadhav S V. Global epidemiology, viral evolution, and public health responses: a systematic review on Mpox (1958\u0026ndash;2024). J Glob Health. 2025; \u003c/li\u003e\n\u003cli\u003ePanag DS, Jain N, Katagi D, De Jesus Cipriano Flores G, Silva Dutra Macedo GD, Rodrigo D\u0026iacute;az Villa G, et al. Variations in national surveillance reporting for Mpox virus: A comparative analysis in 32 countries. Front Public Heal. 2023; \u003c/li\u003e\n\u003cli\u003ePanag DS, Jain N, Katagi D, De Jesus Cipriano Flores G, Silva Dutra Macedo GD, Rodrigo D\u0026iacute;az Villa G, et al. Variations in national surveillance reporting for Mpox virus: A comparative analysis in 32 countries. Front Public Heal. 2023;11(April). \u003c/li\u003e\n\u003cli\u003eWHO. Who. 2024 [cited 1BC Jul 24]. Community experiences of the 2022\u0026ndash;2023 mpox outbreak in Europe and the Americas. Available from: https://www.who.int/publications/i/item/9789240077287\u003c/li\u003e\n\u003cli\u003eWHO. WHO. 2024 [cited 2024 Mar 20]. Surveillance, case investigation and contact tracing for mpox \u0026lrm;\u0026lrm;(monkeypox)\u0026lrm;: Interim guidance, \u0026lrm;20 March 2024. Available from: https://www.who.int/publications/i/item/WHO-MPX-Surveillance-2024.1\u003c/li\u003e\n\u003cli\u003eYadav R, Chaudhary AA, Srivastava U, Gupta S, Rustagi S, Rudayni HA, et al. Mpox 2022 to 2025 Update: A Comprehensive Review on Its Complications, Transmission, Diagnosis, and Treatment. Viruses. 2025;17(6):753. \u003c/li\u003e\n\u003cli\u003eEuropean Centre for Disease Prevention and Control. European Centre for Disease Prevention and Control. 2025 [cited 2025 Dec 16]. Mpox worldwide overview. Available from: https://www.ecdc.europa.eu/en/mpox-worldwide-overview\u003c/li\u003e\n\u003cli\u003eXie L, Zhou Y, Zhang X, Lan T, Sun W. Global Trends in MPOX Research (2014\u0026ndash;2025): A Bibliometric Analysis and Overview. Vet Med Res Reports. 2025;Volume 16(December):99\u0026ndash;112. \u003c/li\u003e\n\u003cli\u003eSelekon B, Malaka C, Mounchili JL. Strengthening Africa \u0026rsquo; s resilience to Mpox : Preparedness and response initiatives of the Pasteur network. :1\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eHrynick T, Muzalia G, James M. cl\u0026eacute;s: Communication des risques et engagement communautaire pour la vaccination contre la mpox dans l\u0026rsquo;est de la R\u0026eacute;publique d\u0026eacute;mocratique du Congo. 2024;1\u0026ndash;17. Available from: https://opendocs.ids.ac.uk/articles/report/Consid_rations_cl_s_Communication_des_risques_et_engagement_communautaire_pour_la_\u003cbr/\u003evaccination_contre_la_mpox_dans_l_est_de_la_R_publique_d_mocratique_du_Congo/26363647\u003c/li\u003e\n\u003cli\u003eHantz S, Mafi S, Pinet P, Deback C. [Monkeypox to Mpox or the re-emergence of an old zoonosis]. Rev Francoph des Lab RFL. 2023; \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mpox, community-based surveillance, case notification, community health workers, DRC","lastPublishedDoi":"10.21203/rs.3.rs-9018139/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9018139/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nCommunity-based surveillance is a key component of early mpox detection in the Democratic Republic of the Congo (DRC), where the disease remains endemic. Community health volunteers (relais communautaires, RECO) play a central role in reporting suspected cases, yet the determinants of their performance are not well documented. This study assessed factors associated with mpox case notification in the health zones of Goma, Karisimbi, and Nyiragongo in North Kivu.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nA cross-sectional analytical mixed-methods study was conducted among 543 RECO for the quantitative component, selected through multistage stratified sampling, and 24 RECO for the qualitative component (8 per health zone), selected through purposive sampling. Quantitative data were analyzed with SPSS using chi-square tests and multivariable logistic regression to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CI) for frequent notification (≥30 notifications), using SPSS software. Qualitative data from in-depth interviews and focus group discussions were analyzed thematically using MAXQDA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nFactors positively associated with frequent notification included female sex (aOR = 4.22; 95% CI: 2.52–7.07), secondary (aOR = 3.23; 95% CI: 2.27–12.78) or university education (aOR = 9.60; 95% CI: 4.07–25.00), having an income-generating activity (aOR = 4.30; 95% CI: 2.89–19.91), good knowledge of suspected case signs (aOR = 4.53; 95% CI: 2.89–16.94), trust in health institutions (aOR = 4.18; 95% CI: 2.20–8.31), high perceived epidemic risk (aOR = 3.75; 95% CI: 1.94–7.25), recent surveillance training (aOR = 6.18; 95% CI: 2.09–19.36), availability of reporting tools (aOR = 5.35; 95% CI: 1.39–13.97), and access to personal protective equipment (aOR = 2.31; 95% CI: 1.37–3.90). Negatively associated factors, identified through qualitative triangulation, included insufficient supervision, lack of feedback, stock-outs of reporting tools, community misinformation, stigma, and demotivation linked to lack of institutional recognition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nMpox notification performance among RECO is shaped by multilevel determinants, with organizational support and training playing a major role. Integrated interventions are needed to sustainably strengthen community-based surveillance.\u003c/p\u003e","manuscriptTitle":"Factors Associated with Mpox Case Notification by Community Health Workers in the Karisimbi, Goma, and Nyiragongo Health Zones, Democratic Republic of the Congo","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 17:09:24","doi":"10.21203/rs.3.rs-9018139/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe128dd8-b40d-4e86-916b-cc344244b704","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T11:46:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 17:09:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9018139","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9018139","identity":"rs-9018139","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}