Assessment of Public Knowledge, Attitude and Practices (KAP) and its Predictors towards Rabies Disease among Rural Households in North Wollo Zone, Ethiopia

Addisalem Seyoum Tegegne^*
*Correspondence: Addisalem Seyoum Tegegne, Department of Veterinary Science, North Wollo Zone Livestock Development Promotion Office, Woldia, Ethiopia, Email:

Keywords

Knowledge • Practices • Rabies • North Wollo • Attitude • Prevention

Abbreviations

PEP: Post-Exposure Prophylaxis; KAP: Knowledge, Attitudes and Practices; CSA: Central Statistics Agency; SPSS: Statistical Packages for Social Science

Introduction

Rabies is a viral disease and human infection usually occurs following a transdermal bite or scratch by an infected animal [1]. The causative agent for this viral disease belongs to the genus Lyssavirus of the family Rhabdoviridae [2]. Rabies is the most widely salivary transmitted viruses. Injection of infected saliva through the bite of a rabid animal appears to be the predominant mode of rabies transmission from contaminated to normal animal. Hence, broken skin and mucous membrane such as mouth, nasal cavity or eyes by fresh saliva or neurological tissues are used for entry of the virus may result for infection [3].

Quarantine measures such as elimination of homeless dogs, extension programs for control of rabies in the wild life, registration of dogs and prophylactic vaccination help to prevent and control rabies [4,5]. Human rabies is almost entirely preventable through prompt delivery of Post-Exposure Prophylaxis (PEP) to victim bitten by rabid animals [6,7].

After its development with in any animals including human being, the disease is 100% fatal [8,9]. Next to Asia, Africa is the continent mostly affected by rabies with an estimated proportion of 44% of annual rabies deaths in the world [9]. About 90% of the main source of human rabies in Africa is domestic dogs [10].

Ethiopia, one of the eastern and horn of Africa, is highly affected by rabies and more than 88% of the source of the disease is due to dog bites [11]. In the country, about 2771 human deaths per year are caused by the endemic named Canine rabies [12,13].

Amhara region, one of the eleven regions in the country is highly affected by rabies. Hence, a countrywide surveillance conducted in the country from 2007 to 2012 indicates that about 15,178 exposure cases and 272 fatal cases with 1.5 incidence rates in every 100,000 people are living in the Amhara region [14]. North-Wollo, one of the eleven regions in the Amhara region, is the area where the disease is pandemic and many people, especially, rural community are infected and died because of rabies and related diseases [15]. Rural people exposed for rabies disease in the zone, seek PEP treatment after exhausting the traditional medicinal intervention and usually after loss of a family member [16,17]. The different prevention mechanisms like nervous tissue vaccine, cell culture vaccine and rabies immunoglobulin, only few of them are accessed in the study area [17,18]. Poor public awareness towards rabies is considered as one of the bottlenecks for the prevention and control of the disease in North Wollo rural areas [19].

Most of the studies regarding to rabies conducted previously are concentrated in the capital city of the country, Addis Ababa and there is scarcity of studies conducted previously towards KAP of rural community [20]. Hence, as far as the authors’ knowledge is concerned, there is a limited research conducted recently in the study area. Some of the previous researches focused on unban people and excluded rural community. Therefore, objective of this study was to assess the level of Knowledge, Attitudes and Practices (KAP) and associated factors regarding to the rabies disease among the rural community in North Wollo zone, Ethiopia. The result obtained in the current study helps to identify the intervention areas in reducing mortality of people by rabies disease and its fatality.

Materials and Methods

Study area

The study was conducted at North Wollo zone, located under Amhara regional state, Ethiopia. Geographically, it is located on elevation of 1500-2500 m with latitude and longitude of 11.91290 N and 39.15440 E respectively, and it is 503 km far from the capital city, Addis Ababa to the North East direction. The annual average rainfall in the zone is about 531 mm (from mid Feb up to mid-May) and 1005 mm (from June up to September) and the average annual temperature is 11.4-27.7°C. The area is bordered on the South by South Wollo, on the West by South Gondar, on the North by Wag Himira, on the Northeast by Tigray region and on the east by Afar region. The capital of the zone, Woldia, has a total land area of 12,172.50 km2 with total population of 1,500,303. According to the information obtained from the 2019 CSA data, the livestock population of the zone consists of 818,816 cattle, 248,755 equines, 173,408 sheep, 643,615 goats, 37,464 dogs and 41,171 cats. The zone is also divided into 9 woredas. The zonal map is indicated in Figure 1.

Figure 1. Location of the study area of North Wollo zone.

Study design and study period

A cross-sectional study design was employed to assess the Knowledge, Attitudes, and Practices (KAP) towards rabies and associated risk factors among the community of North Wollo zone from June 2022 to September 2022.

Study population

The study population was dog owners who had lived in randomly selected North Wollo zone districts (Gubalafto, Woldia, Habru, Raya kobo and Kobo town) as permanent residents for more than six months. Both male and females with the age group above 18 years of age was included in this study. Head of households were selected to answer the structured questionnaires developed by the investigators.

Sample size determination and sampling techniques

Sample size was determined using Cochran’s sample size formula for categorical data. Where it is the value for selected alpha level of 0.025 in each tail=1.96. (p), (q) is the estimate of variance=0.25, d is the acceptable margin of error=0.05. However due to north Ethiopia conflict only 206 samples were collected. Out of 14 districts in the north Wollo zone, 5 of them were included in this study. The questionnaire, originally prepared in English, was translated to the local language, Amharic. This questionnaire was administered to randomly selected households in the study area to check the understandability as pretest of the questions, and simultaneously it was used as part of the data collection training for data collectors. Ambiguous words were edited carefully based on the feedback. The veterinary professionals were participated for data collection to get quality data efficiently with less cost. The professionals participated in the current study gave awareness about variables under study for data collectors so that they were ready to clarify any ambiguities in the questionnaire and answer other rabies related questions that may be raised during the interviews. Proportional numbers of randomly selected samples from each district were collected. Hence, about 57 (27.7%) in Raya, 49 (23.8%) in Kobo Gubalafto, 37 (18%) in Habru, 33 (16%) in Woldia and about 30 (14.6%) in Kobo town were collected. Systematic random sampling was used in selecting the households by choosing a person who economically supports or manages the household (heads of the family) was interviewed.

Inclusion and exclusion criteria

A head of households who lived for more than 6 months as permanent residents in the study area were included in this study and the rest of the residents were excluded in the current study.

Data management and analysis

After collecting, the data were cleaned and checked for its completeness. Those incomplete and inconsistent were corrected when possible and removed otherwise. After a complete check-up, the data were coded and entered into a Microsoft Excel sheet and then transmitted to SPSS software to investigate predictors of KAP of rural residents about the prevention of rabies disease. The frequency distribution of both dependent and independent variables was worked out by using descriptive statics techniques.

Results

Socio-demographic characteristics

A randomly selected 206 heads of households were selected for managing and answering the structured questionnaire during the study period. The majorities of the respondents were male 162 (78.6%) and were above 18 years of age (Figure 2). The majority of the respondents 164 (79.6%) were Orthodox religion followers followed by Muslim 38 (18.4%). Concerning educational status, 68 (33%) of the participants were non-educated (can’t read and write) followed by read and write 52 (25.2%). Of the participants, 40 (19.4%) and 46 (22.3%) were in primary school and secondary school and above, respectively. The majority of the respondents were farmers 115 (55.8%) followed by government employees 43 (20.9%) (Table 1).

Figure 2. Percentage of samples taken from each district, North Wollo zone, 2022.

Table 1. Socio-demographic characteristics of the study participants, North Wollo zone, 2022.

Description of knowledge of participants in the cause and mode of transmission of rabies disease

From the total of respondents, about 62.2% of them heard about the name of the disease, rabies, only 43.7% of respondents knew that the cause for rabies is the virus. The majority of the participants (53.9%) were found to have a misperception about a causative agent are shortage of food and water. The majority of the respondents, 118 (57.3%) didn’t know that all warm blooded animals can be affected by the disease. Out of 206 respondents, only 87 (42.2%) had the knowledge about rabies through informal way of communication (such as traditional healer’s neighbors, friends and relatives) followed by formal way of communication (Such as radio and television) (37.4%) and half of the respondents (50%) did not know the fatality nature of the disease.

The majority of the respondents, 147 (71.4%), didn’t know how the disease is transmitted form infected domestic animals to human beings and only few of them knew that bite is one means of transmission of the disease (Figures 3 and 4). Few of the participants, 24.8% knew that stop eating and drinking was described as a major clinical sign of infected animals by the disease. Among the participants, about half of them (50.5%) were aware of the post exposure prophylaxis for rabies while only 29.1% of the respondents were aware of dog vaccination as a means of rabies prevention (Table 2).

Figure 3. Percentages of rabies outbreak in different season, North Wollo zone, 2022.

Figure 4. Percentage of reservoir of animals for rabies, North Wollo zone, 2022.

Table 2. Knowledge of participants related to cause, host range, clinical signs mode of transmission and treatment, prevention and control of Rabies, North Wollo zone, 2022.

Attitudes of the study participants towards rabies

Majority of the respondents (55.8%) were believed stray dogs are dangers and almost half of (48.5) participants agreed rabies can be prevented by killing stray dogs. Concerning to attitude about cured by holly water was not agreed by most respondents instead of that educating peoples about rabies was better prevention (43.2%) for the disease. Seventy percent of the respondents believed that all government, NGO and community were responsible to control rabies in stray dogs. Majority of participants taken Measurements after bite was washing of wounds with water and soap. Most of the participants were contacted with dog and cat (55.8%) however had a habit of washing after contact (56.8%) the first choice by 130 (63.1%) of the participants after bitten by the dog was go to traditional healer even though some respondents 62 (30.1%) prefer health center (Figure 5). However most of the respondents (89.3%) didn’t know about traditional drugs most frequently used were Mehanendod 14 (6.8%), holy water 5 (2.4%) steam by hot water 3 (1.5%). Majority of the respondent’s preferred to care their dogs housed in cages 63 (30.6%). Majority of the respondents practiced dog-mediated rabies can be controlled in humans by regular vaccination of dog 86 (41.7%) (Table 3).

Figure 5. Percentages of measures taken after bitten by rabid dog, North Wollo zone, 2022.

Table 3. Attitudes of participants towards rabies in North Wollo Zone, 2022.

Practices of the study participants towards rabies

Majority of the respondents 130 (63.1%) used traditional healers rather than the animal science expertise and some of them use Mehan endod 14 (6.8) as traditional drug. Majority of participants 86 (41.7%) were applied regular vaccination for the control of dog mediated rabies as shown as in Table 4.

Table 4. Practice of participants towards rabies after suspected animal/dog bite in North Wollo zone, 2022.

Predictors for the level of KAP of rural population in the study area

Factors associated with knowledge Variables including sex, occupation, dog ownership, training, monthly income, educational status and exposed family to dog bite with p-value less than 0.2 in bivariate analysis were entered in to multivariable binary logistic regression analysis model. The multivariable analysis result of this study declared that sex, occupation, dog ownership, training and monthly income had statistically significant association with knowledge about rabies at 5% level of significance. Factors associated with attitude Variables including marital status, educational status, household size, dog ownership, exposure of family to dog bite, monthly income and knowledge with p-value less than 0.2 in bivariate analysis were entered in to multivariable binary logistic regression analysis model. The multivariable analysis result of this study revealed that marital status, educational status, household size, dog ownership and family exposure to dog bite had statistically significant association with attitude about rabies at 5% level of significance.

Factors associated with practice: Variables including marital status, educational status, age, household size, knowledge, attitude, dog ownership and family exposure to dog bite with p-value less than 0.2 in bivariate analysis were entered in to multivariable binary logistic regression analysis model. The multivariable analysis result of this study revealed that dog ownership and exposure family to dog bite had statistically significant association with practice about rabies at 5% level of significance. According to this study, educational status, age, household size, knowledge and attitude were not significantly associated with practice about rabies in the multivariable analysis.

Discussion

The findings of this study indicated that, majority of the respondents in the current study are not aware of rabies. This finding is lower than the findings of different studies done by Nanjundeswaraswamy T, et al. in Debark, and in Debre Tabor. Amare, et al. in south Gondar and Weldegerima, et al. in Mekelle reported that the rate of knowledge was 77.9% and 32.9% respectively. The reason could be due to real difference in incidence of rabies in the areas of study and living status of the community, communication and information sharing about what is happening in their residential area. The sources of information for the majority of the participants are informal. This may be due to the presence of community based radio station in the study area and radio is the major source of information in the rural area of Ethiopia. Out of those respondents, majority of them had misunderstanding on the cause of rabies; they believed that the disease in dog is caused by starvation and thirst. It was lower when compared with the result obtained from study conducted in the catchment area of Dessie town, Ethiopia which was 86%, from Gondar and Dabat, Ethiopia.

In addition, the current study was better than the findings in Bahir Dar town, 39.9%. This could be due to sample size difference, study area and community awareness difference. In this study, bite and saliva contact with open wound was mentioned as a mode of transmission for rabies to humans by the majority of the respondents which is higher (65.5%) with the findings (59.4%) and a considerable percent of participants mentioned that bite by rabid dog is the only source of mode of transmission. In this finding, few of the respondents knew that the disease could affect all warm blooded animals which is contradicted with another previous study conducted in Bahir Dar. This difference may be due to the availability of different host range in the rural district of my study site and could be due to the educational status and/or awareness of the community. Few of the respondents are aware of common clinical signs of rabies in animals which is salvation and madness. This finding is aligned with another study named Tadesse, et al. reported from Bahir Dar, Ethiopia. Madness was mentioned as a second major clinical sign in this study next to salivation by the majority of the respondents. This form of rabies is more easily identifiable clinical form by most people. In this study 41.7% of the respondents indicated regular vaccination of dogs and depopulation (59.2%) of stray dogs as an effective measure for the control of rabies in animals and humans. Similar reports were by Bülow P, et al. from Bahir Dar, Ethiopia. Both vaccination and depopulation will play a vital role in prevention and control programs, while in this community, vaccination might be preferable. More than 61% of respondents are aware of post-exposure prophylaxis. A similar study around South Gondar zone in Ethiopia reported 39.6% awareness level of the community about post-exposure prophylaxis.

Low level (30.1%) of participant’s preference for health center (for PEP) was observed in this study. Most respondents choose other options like traditional healer (63.1%). Similarly, studies conducted in Gondar Zuria district, Ethiopia, reported about 62.2% of the study participants had strong beliefs in traditional medicine. In Satkhira, Bangladesh, 59% of the dog bite victims first seek treatment from traditional healers instead of visiting the hospitals. A higher (84%) reliance of respondents on traditional treatment was reported from Dabat and Gondar. In contrast to these report, almost all respondents agreed to consult health professional in case of animal bite was reported in Addis Ababa. The preference for traditional practices might be arise from many factors including easy access to traditional medicine, lack of awareness, long duration of treatment. Reliance on traditional medicines with unproven efficacy is very risky and nothing can be done to save one’s life after the first symptoms of the disease occur. Even though the extent of transmission varies, all possible modes of transmission including bite, contact with saliva, and consumption of animal products from infected animal should be avoided.

Conclusion

As a conclusion, this study showed that rabies was a fatal and series disease in the study area and it is considered to be a disease of significant public health importance. There are some gaps in the community concerning with cause and mode of transmission, host range of the disease, clinical signs of rabies, prevention. On the other hand, there is a lack of knowledge about what to do after exposure, like immediate visits to health facilities, and use of anti-rabies post exposure prophylaxis, which might be due to lack of awareness creation. In the present study, the existence of high risk of the disease, low level of awareness, the presence of low vaccination coverage, low accessibility and affordability of the vaccine and high dependency on traditional medicine especially in the study area of the community, were also well indicated. Low level of knowledge and traditional practice would cover community participation in rabies control.

Recommendation

As a recommendation, the zonal and woreda veterinarians and health professionals should prepare and deliver continuous and strategic community awareness programs on prevention and control of rabies. All governmental and non-governmental organizations like Federal Ministry of Health, Federal Ministry of Livestock and fishery resource and University of Woldiya should work in cooperation with information sources like radio and television programs to give information which will enhance the awareness level of the community. The regional laboratories and Amhara regional health bureau should also design training for veterinarians accurate and urgent. Community based rabies education program with emphasis on mode of transmission, clinical signs and immediate benefits of wound management and need for anti-rabies vaccine following dog bite. The Amhara livestock and fishery resource bureau should register the dog population of the region and prepare a legislation that will enforce the owners to vaccinate their animals.

Ethical Consideration and Consent to Participation

Ethical approval was obtained from North Wollo Agricultural department research committee. In this study, Informed consent was obtained from all subjects and/or their legal guardian during data collection.

Availability of Data and Materials

The data used in this study is available within the hand of corresponding author and can be submitted to the journal upon request.

Competing Interests

As no individual or institution funded this research, there was no conflict of financial and non-financial interest between authors or between authors and institutions.

Funding

There is no any agent funded this project.

References

1. Oyda, Semayat, and Bekele Megersa. "A review of rabies in livestock and humans in Ethiopia." Int J Res Granthaalayah 5 (2017): 561-577.
2. Liang, Hong-Ru, Quan Liu, Xue-Xing Zheng, and Wei-Wei Gai, et al. "Aptamers targeting rabies virus-infected cells inhibit viral replication both in vitro and in vivo." Virus Res 173 (2013): 398-403.

   [Crossref] [Google Scholar] [PubMed]

3. Slathia, Pallvi, Riya Abrol, Satuti Sharma, and Sakshi Sharma. "Rabies: A review on clinical signs, prevention and control." J Pharm Innov 12 (2023): 1675-1680.
4. Zavoshti, Fereydon Rezazadeh, Amir Babak Sioofy Khoojine, Javad Ashrafi Helan, and Belal Hassanzadeh, et al. "Frequency of caseous lymphadenitis (CLA) in sheep slaughtered in an abattoir in Tabriz: comparison of bacterial culture and pathological study." Comp Clin Path 21 (2012): 667-671.

   [Crossref] [Google Scholar] [PubMed]

5. Webber, Ann L, and Joanne Wood. "Amblyopia: prevalence, natural history, functional effects and treatment." Clin Exp Optom 88 (2005): 365-375.

   [Crossref] [Google Scholar] [PubMed]

6. Rupprecht, Charles E, Reeta S. Mani, Philip P Mshelbwala, and Sergio E. Recuenco, et al. "Rabies in the Tropics." Curr Trop Med Rep 9 (2022): 28-39.

   [Crossref] [Google Scholar] [PubMed]

7. Hergert, Melinda, Kevin Le Roux, and Louis H. Nel. "Risk factors associated with nonvaccination rabies status of dogs in KwaZulu-Natal, South Africa." Vet Med (Auckl) 7 (2016): 75-83.

   [Crossref] [Google Scholar] [PubMed]

8. Beyene, Tariku Jibat, Monique CM Mourits, Abraham Haile Kidane, and Henk Hogeveen. "Estimating the burden of rabies in Ethiopia by tracing dog bite victims." PLoS One 13 (2018): e0192313.

   [Crossref] [Google Scholar] [PubMed]

9. Yoak, Andrew J, Abraham Haile, Jeanette O’Quin, and Maria Belu, et al. "Barriers and opportunities for canine rabies vaccination campaigns in Addis Ababa, Ethiopia." Prev Vet Med 187 (2021): 105256.

   [Crossref] [Google Scholar] [PubMed]

10. Jemberu, Wudu Temesgen, Wassie Molla, Gizat Almaw, and Sefinew Alemu. "Incidence of rabies in humans and domestic animals and people's awareness in North Gondar Zone, Ethiopia." PLoS Negl Trop Dis 7 (2013): e2216.

    [Crossref] [Google Scholar] [PubMed]

11. Ali, Abraham, Eshetu Yimer Ahmed, and Desalegn Sifer. "A study on knowledge, attitude and practice of rabies among residents in Addis Ababa, Ethiopia." Ethiop Vet J 17 (2013): 19-35.

    [Google Scholar]

12. Yizengaw, Endalew, Tamyalew Getahun, Wondemagegn Mulu, and Mulat Ashagrie, et al. "Incidence of human rabies virus exposure in northwestern Amhara, Ethiopia." BMC Infect Dis 18 (2018): 1-7.

    [Crossref] [Google Scholar] [PubMed]

13. Yamada, Akio, Kohei Makita, Hazumu Kadowaki, and Naoto Ito, et al. "A comparative review of prevention of rabies incursion between Japan and other rabies-free countries or regions." Jpn J Infect Dis 72 (2019): 203-210.

    [Crossref] [Google Scholar] [PubMed]

14. Hampson, Katie, Francesco Ventura, Rachel Steenson, and Rebecca Mancy, et al. "The potential effect of improved provision of rabies post-exposure prophylaxis in Gavi-eligible countries: a modelling study." Lancet Infect Dis 19 (2019): 102-111.

    [Crossref] [Google Scholar] [PubMed]

15. Rajeev, Malavika, Glenn Edosoa, Chantal Hanitriniaina, and Soa Fy Andriamandimby, et al. "Healthcare utilization, provisioning of post-exposure prophylaxis, and estimation of human rabies burden in Madagascar." Vaccine 37 (2019): A35-A44.

    [Crossref] [Google Scholar] [PubMed]

16. N'Guessan, Rose Delima, Kathrin Heitz-Tokpa, Djedou Martin Amalaman, and Sopi Mathilde Tetchi, et al. "Determinants of rabies post-exposure prophylaxis drop-out in the region of San-Pedro, Côte d'Ivoire." Front Vet Sci 9 (2022): 878886.

    [Crossref] [Google Scholar] [PubMed]

17. Beyene K, A Derese, G Teshome, and D Teshome. "Review on rabies vaccine: as prevention and control option of rabies." Austin J Vet Sci Anim Husb 5 (2018): 1049.
18. Ertl, Hildegund CJ. "Historical Progression from Nerve Tissue-Based Rabies Vaccines to Recombinant Biologics for Humans and Companion Animals." In History of Rabies in the Americas: From the Pre-Columbian to the Present, Volume I: Insights to Specific Cross-Cutting Aspects of the Disease in the Americas, pp. 121-142. Cham: Springer International Publishing, (2023).
19. Bihon, Amare, Desalegn Meresa, and Abraham Tesfaw. "Rabies: knowledge, attitude and practices in and around South Gondar, North West Ethiopia." Diseases 8 (2020): 5.

    [Crossref] [Google Scholar] [PubMed]

20. Abdela, Nejash, Boru Midekso, Jemal Jabir, and Wezir Abdela. "Knowledge, attitudes and practices towards rabies in Dedo district of Jimma zone, southwestern Ethiopia: A community based cross-sectional study." Int J Med Med Sci 9 (2017): 61-71.