Association between Ebola prevention training and prevention-related cognitive and behavioral factors among Chinese expatriates in the Democratic Republic of the Congo: a cross-sectional study informed by the RANAS framework

Objective This study aimed to explore the associations between Ebola prevention training experience and multiple prevention-related outcomes (infectious disease knowledge, risk perception, protective attitudes, and psychological self-regulation) among Chinese expatriate workers in the Democratic Republic of the Congo (DRC), and to further assess potential ceiling effects and whether educational attainment modified these associations. Methods Based on the Risk-Attitude-Norms-Ability-Self-regulation (RANAS) framework, a cross-sectional questionnaire survey was conducted among 951 Chinese expatriates in the DRC. Mann–Whitney U test and χ 2 test were applied for univariate comparisons. General linear models (GLMs) adjusted for age, educational attainment, and residence duration in the DRC were constructed to evaluate independent associations between training experience and each outcome. Ceiling effects were quantitatively described, and sensitivity analyses excluding maximum-score participants were performed to assess potential analytical bias. Two-way interaction terms were further incorporated to test the effect modification of educational attainment. Results Adjusted GLM results showed that participants with training experience exhibited significantly higher adjusted marginal means in basic knowledge, prevention-and-response knowledge, and psychological self-regulation ( p < 0.05). No significant between-group differences were observed in risk perception and protective attitudes. Obvious ceiling effects existed in perceptual and attitudinal indicators, with 66.67% of participants achieving full scores in risk perception and 62.99% in protective attitudes. Sensitivity analyses indicated that ceiling effects might mask potential associations for psychological and behavioral outcomes and cause instability in the association of prevention-and-response knowledge. Significant educational modification effects were detected for the associations of training with basic knowledge and psychological self-regulation ( p < 0.05). Stratified analyses further showed that positive associations were observed among participants with high-school education or below and those with junior-college/bachelor-level education, but not among those with postgraduate education or above. Conclusion Ebola prevention training experience was independently associated with higher epidemic-prevention knowledge scores and better psychological self-regulation, while associations with risk perception and protective attitudes were substantially constrained by ceiling effects. The associations between training and health outcomes are heterogeneous across educational strata. Targeted and stratified health education strategies, rather than uniform training schemes, should be adopted for overseas populations to better tailor infectious-disease prevention training programs to heterogeneous overseas populations.