Introduction
Rabies is a neglected zoonotic tropical disease that usually affects the poorest communities. It is the world’s deadliest disease which has 100% fatality and at the same time 100% preventable globally. It is estimated that rabies accounts for more than 59,000 deaths every year and the majority of human rabies deaths occur due to biting of the rabid dogs. About 96% of the mortality and morbidity is associated with dog bites. Cats, wolf, jackal, mongoose and monkeys are other important reservoirs of rabies in India. Bat rabies has not been conclusively reported from the country. In India, rabies is a problem of considerable magnitude. India is endemic for rabies and except for the islands of Andaman and Nicobar and Lakshadweep, which are historically rabies‑free. India is one of the countries that have the highest population of stray dogs in the world.1
The global conference of rabies constructed a framework for the elimination of human death from dog‑mediated rabies by 2030. To achieve this target, the most important strategy should be focusing on continuous and consistent mass awareness campaigns on health‑seeking behaviour during the animal bites, proper animal bite wound management, and vaccination strategies among the general public.
Materials and Methods
A cross-sectional study was conducted on 135 eligible participants in rabies vaccination clinics (ARV). We performed a face-to-face interview to investigate the rabies KAP of these participants using a self-designed questionnaire consulted with experts was done. Study was conducted from January to March 2022 by using consecutive sampling till the sample size was achieved.
Ethical consideration
The study was approved by Institutional Ethics committee (IEC) of Indira Gandhi Government Medical College, Nagpur, and Maharashtra, India. Written informed consent will be taken from participant before enrolling them in study; Confidentiality of the participant was assured and maintained throughout the study.
Study area
Anti-rabies vaccination out-patient department (ARV OPD) in tertiary health care center in central India.
Sample size estimation
Where, n = sample size,
p = expected prevalence in proportion of one
d = precision in proportion of one.
For the level of confidence of 95%, this is conventional.
Z Value is 1. 96 p=74% d = 10% relative error
To calculate values for “p” studies done by Herbert M, and et al (2012 Dec) in Bangalore, Karnataka was used as reference for expected prevalence [74%] of awareness of rabies among adults. Sample size came to be 135
Questionnaire and construction of KAP scores
The questionnaire was designed by reviewing similar literature2 and consulting with experts. A preliminary test was conducted to ensure that the questions were clear and understandable. All the data were collected from the study participants by interview method and universal sampling method was adopted for selection of study participants till the sample size is achieved.
The questionnaire consisted of four parts the first part was designed to obtain Socio-demographic characteristics, the first part was designed to obtain demographic characteristics including name, age, gender, educational level, place of resident ,Socio-economic status, name of animal bites, circumstance of bite, site of exposure, and time spent to the rabies prevention clinics (ARV OPD), WHO category and reason for delay for vaccination,the second part investigated the knowledge of rabies which included nine questions: 1Have you Ever Heard of Rabies, 2) Which Organism Causes Rabies, 3) Which Animal Harbours Rabies organism, 4)How does Rabies Spread, 5)Is the Disease Fatal, 6) Can Rabies be prevented by Vaccination?
7) whom will you Consult After Dog/Cat/other Suspected Animal Bite? 8) How to Avoid Rabies Infection and 9). Do you think rabies can be spread through contaminated food or water, except question number 8, all had a single correct answer, and respondents received one point for each correct answer and the question no.8 had three correct answers, and the respondent received one point for each correct choice and zero for an incorrect choice. The total correct responses were calculated to show the scores of overall knowledge, ranging from 0 to 11.
The third part, attitudes assessment towards rabies and its prevention and control involved nine questions: 1) Rabies is a risk to human health, 2) Elimination of dog-mediated and cat-mediated rabies is vital, 3) Vaccinating susceptible dogs and cats can prevent the transmission of rabies, 4) It is not necessary to vaccinate dogs and cats against rabies usually, 5) Injecting rabies vaccine as soon as possible after being bitten by suspected rabid animals, 6) Completing the full courses of vaccination after being bitten by suspected rabid animals, 7) Willing to learn the knowledge of rabies, 8) it is necessary to promote rabies knowledge in the community and 9) Is washing of dog bite wound with soap and water useful.
Each appropriate attitude item was scored on a five-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’ coded with values from 5 to 1. Conversely, scores of 1 to 5 were assigned for each inappropriate attitude item, with the same response options. The maximum score of attitudes is 45 points, and a minimum score is 9 points.
The fourth part assessed the practices related to rabies prevention and control by six questions: 1) Taking the rabies vaccine on schedule, 2) Needing someone to remind you to get vaccinated when you were bitten, 3) Discontinuing the rabies regimen if the wound is not serious, 4) Advising bite victims to be vaccinated after a suspected rabid bite and 5) Keeping away from aggressive animals. Response options included ‘always,’ ‘often,’ ‘sometimes,’ and ‘never’, and scores of 4, 3, 2, and 1 were assigned for each proper practices item. Conversely, scores of 1, 2, 3, and 4 were assigned for each improper practices item. The maximum score of practices is 20 points, and a minimum score is 5 points.
Table 1
Distribution of study participants according to socio-demographic characteristics.(n=135)
Table 2
Knowledge parameter of rabies among study participant.(n=135)
Table 3
Attitude parameter of rabies among study participant.(n=135)
Table 4
Practice parameter of rabies among study participant.(n=135)
Table 5
Univariate analysis showing association of socio-demographic characteristics with mean KAP scores of study participants.
Table 6
Multivariate logistic regression analysis of factor associated with KAP scores towards rabies.
Data analysis
Data analysis was done by using statistical software Microsoft office excel 2013 and SPSS Version 20(licenced).Continuous variables were described by mean and standard deviation (SD), and categorical data were described using frequency and percentage.
Analyses of variance (ANOVA) and independent student t-test were conducted to compare different groups' scores on knowledge, attitudes, and practices of rabies. Three separate multivariable logistic regression models were performed to explore the association of outcome variables with the socio-demographic characteristics of the victims. The cumulative score obtained for questions based on the three response criteria (knowledge, attitudes, and practices towards rabies, respectively) was converted into binomial outcomes by categorizing the respondents as having scored ≤ or > the average score of each response criteria and then association was found by applying regression.
Result
Distribution of study participants according to socio-demographic characteristics
Table 1. Presents distribution of study participants according to socio-demographic characteristics. Out of 135 participants majority are male (81.5%)with mean age of 37.26 ± 14.70 years and with range of : 18-79 years.18.5% were female participants with mean age of 34.36± 14.69years and range of 18-62years.maximum number of participants are high school and intermediate school certificate holder 72(53%) and residing in urban area 120 (88.88%). Majority of participants belongs to upper socioeconomic class 88 (65%) Majority of participant having Dog bite 115(85%) and 85 (63%) participant having lower extremity site of exposure, maximum number of participant time to spend in ARV OPD are 67 % while 79% participant have less than or equal to 10 km distance from hospital.
Knowledge
Table 2 Shows the knowledge of participant. Only 48.18 % participant aware about rabies disease.18.51 % participant not able gave correct responds regarding causative agent of rabies however majority of respondents knew which animal harbor rabies.71 % participant was aware about fatality of rabies at the same time 64 % respondent aware about rabies can be prevented byvaccination. Although participant had less knowledge regarding rabies but 90 % participant had consulted doctor/hospital after animal bite. 16% participant had not idea regarding how to avoid rabies infection.19 % participant had given correct response that rabies is not spread through food and water.
Attitude
Table 3 Shows attitude of respondent towards rabies prevention and control. 50% participant believes that rabies is risk to human while 49% participants believe that elimination of dog-mediated and cat-mediated rabies is vital. Only 43% respondents were aware regarding vaccination susceptible dogs and cats can prevent the transmission of rabies however majority of participant were aware Injecting rabies vaccine as soon as possible after being bitten by suspected rabid animals. Majority of participants believes that it is necessary to completing the full courses of vaccination after being bitten by suspected rabid animals however majority of participant not willing to learns knowledge of rabies.39% participant believes to promote rabies knowledge in the community while 38% were aware regarding washing dog bite wound with soap and water useful.
Practices
Represents practice parameter of rabies among study participant. Most of the participant was taking rabies vaccine on schedule however majority of participant needs to remind someone for rabies vaccination. Majority of participant not discontinuing rabies vaccination if wound is not serious. 52% participant advising bite victims to be vaccinated after a suspected rabid bite while 49% particpant keeps away from aggressive animal.
Univariate analysis
Table 5 Shows KAP score based on participant characteristics and result of univariate analysis. The mean score of rabies knowledge was 6.16 ± SD=2.22 from maximum of 11 points. Younger age group and graduate & above had higher score compared to older and less educated are statically significant. Participant belongs to lower socioeconomic class (p=0.01) and distance from hospital more than or equal to 10 km (0.01) had lower score.
The mean score of rabies attitude was 36.46 ± 6.1SD from maximum of 45 points. Younger age group and graduate & above had higher score compared to older and less educated are statically significant. Participant belongs to lower socioeconomic class (p=0.05) and distance from hospital more than or equal to 10 km (0.00) had lower score. The mean score of rabies practices was 16.79 ± 2.61SD from maximum of 20 points. Younger age group and graduate & above had higher score compared to older and less educated are statically significant. Participant distance from hospital more than or equal to 10 km (0.01) had lower score.
Table 6. represents Multivariate logistic regression analysis of factor associated with KAP toward rabies where the dependent variable was level of knowledge, attitude and practices. Middle age (AOR=5.31, 95%CI: 1.232-22.09) and high school and intermediate (AOR=12.56, 95%CI: 4.055-38.93) similarly less than high school (AOR=30.40, 95%CI: 7.21-128.14) were associated with poor knowledge.
High school and intermediate (AOR=7.93, 95%CI: 2.97-21.18) and less than high school (AOR=36, 95%CI: 8.05-160) while middle class (AOR=3.36, 95%CI: 1.11-10.13) and distance more than 10 km (AOR=2.48, 95%CI: 1.03-5.96) were associated with inappropriate attitude.High school and intermediate (AOR=3.28, 95%CI: 1.37-7.83) and less than high school (AOR=15.58, 95%CI: 4.18-58.05) were associated with inappropriate practices.
Discussion
The present study showed that the 48.14% of respondents were aware that dogs and cats can spread rabies and that the disease can be transmitted via bites or licks from rabid animals. This is consistent with previous reports from Ethiopia,3, 4 Sri Lanka5 and Indian.6
Similarly to other studies conducted in the china2 and New Mexico,7 more than 29% of respondents did not know that rabies is invariably fatal once the clinical signs are manifested in the present study. Given that insufficient knowledge of rabies might be a main reason for improper PEP7 educational programs should be conducted to help the public have a comprehensive understanding of rabies.
More than 90% of the respondents believed that the rabies vaccine should be injected as soon as possible after a suspected rabid bite. This favourable attitude is in line with the World Health Organization guidelines on rabies that people should seek medical attention immediately when they are bitten by a suspected rabid animal,8 Most respondents believed that vaccinating susceptible dogs and cats can prevent the transmission of rabies. Similar results were reported in Haiti9 Poor family income or the high cost of vaccines may hinder individuals from vaccinating their pets or themselves despite awareness of the benefits of rabies vaccination.2
Previous studies showed that educational level was a major determinant of the level of rabies knowledge.10, 3, 11, 12 A similar result was found in our study that the knowledge score increased with the educational level. This may be because people with a better education had more learning opportunities and a better ability to acquire rabies knowledge.
Conclusion and Recommendation
This study was done at tertiary health care center; lack of knowledge and attitude is suboptimal however practice regarding rabies vaccination is good in male and younger population, this study concludes that knowledge and attitude regarding rabies should be highlighted in national rabies control programme of India to acknowledge Indian population regarding fatal rabies.
Public education campaigns need to be conducted to make people aware of rabies, especially in remote area and of the vital importance of seeking medical care immediately after an animal bite. Good knowledge and attitude regarding rabies will be definitely helpful in rabies prevention and effective efforts to eliminate this fatal disease.
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