Stigma and Knowledge in Mpox Vaccine Willingness Among African Immigrants in the United States: The Role of Vaccine Confidence and Hesitancy

BACKGROUND: African immigrants in the U.S. may face elevated mpox exposure risks because they are more likely to travel to endemic regions where they maintain strong social and familial ties, while also encountering sociocultural barriers to vaccination. The ways in which mpox stigma and knowledge influence vaccine willingness, particularly through modifiable psychological pathways, remain unclear. OBJECTIVE: To test whether mpox stigma and mpox knowledge are associated with willingness to receive an mpox vaccine via two mediators: vaccine confidence and vaccine hesitancy. METHODS: We conducted a cross-sectional, web-based survey of African immigrants living in the U.S. (December 2024-July 2025; N = 139). We employed measures of mpox stigma, knowledge, vaccine confidence, vaccine hesitancy, and willingness to get vaccinated for mpox. Mediation analyses were performed, with 5,000 bootstrap resamples and 95% percentile confidence intervals (CI). RESULTS: Neither mpox stigma nor knowledge showed a significant association with willingness (p>.05). The indirect effect of mpox stigma on willingness through both confidence (B = - 0.21, CI [- 0.37, - 0.06]) and hesitancy (B = - 0.17, CI [- 0.32, - 0.01]) was significant. Specifically, higher mpox stigma was associated with lower vaccine confidence (B = - 0.24, p<.001) and greater vaccine hesitancy (B=0.18, p=.017), which in turn predicted willingness (confidence to willingness: B=0.89, p<.001; hesitancy to willingness: B = - 0.92, p<.001). Similarly, the indirect effect of mpox knowledge on willingness was significant through both confidence (B=0.05, CI [0.02, 0.08]) and hesitancy (B=0.03, CI[0.01, 0.05]), such that greater mpox knowledge was associated with higher confidence (B=0.05, p<.001) and reduced hesitancy (B = - 0.03, p=.008), which subsequently predicted willingness. CONCLUSIONS: Mpox vaccine willingness among African immigrants in the U.S. operates through vaccine confidence and hesitancy. Interventions that reduce stigma and build confidence with culturally responsive strategies may meaningfully improve uptake.