Knowledge, Attitudes and Practices (KAP) Model of Rabies

Prevention Efforts Among Households in Low and Middle-Income

Countries: A Systematic Review

Made Karma Maha Wirajaya

, Putu Ika Farmani

and Putu Ayu Laksmini

Faculty of Health Sciences, Health Information Management, Universitas Bali Internasional, Denpasar, Bali, Indonesia

Keywords: KAP, Rabies, Household.

Abstract: Rabies is considered one of the infectious diseases caused by rhabdovirus. It is the deadliest disease in the

world which contributes to more than 59,000 deaths every year globally. About 95% of human cases originate

from Asia and Africa, and 99% of all human rabies is transmitted through dog bites. Poor public awareness

of rabies hampers preventive and control measures against the disease. This current study aimed to determine

whether knowledge, attitudes, and practice (KAP) are related to rabies experienced by households in low and

middle-income countries. This study used a literature review approach by collecting 10 articles on Pubmed.

The data were analyzed descriptively and presented in tabular form. This study found that most of the

households had good knowledge, attitude, and practice related to rabies prevention efforts. However,

differences were found between households from lower economic group and the upper middle economic

group. Lower economic groups had less knowledge, attitudes, and behavior towards rabies prevention efforts

than those from the upper middle groups. Factors that affect KAP related to rabies prevention were education,

occupation, age, family size, and also dog ownership. This study shows that households in several countries

already had a good KAP.

1 INTRODUCTION

Rabies is a zoonotic disease caused by the

neurotrophic virus of the genus Lyssavirus and the

family Rhabdoviridae. Humans can be infected with

rabies through direct contact with animals suffering

from rabies. Rabies can be transmitted either through

biting, scratching, or licking injured skin. After the

bite, the virus replicates in the muscles and then

enters the central nervous system, causing an

infection in the brain known as encephalitis. Rabies is

mostly spread through infected dog bites (Murray P,

Rosenthal K, 2013). Globally, rabies causes more

than 61,000 human deaths (World Health

Organization, 2013), and approximately 15 million

dog-bite victims received post-exposure prophylaxis

each year (World Health Organization, 2019). Asia

and Africa were reported to have more than 95% of

mortalities because of rabies, and about 43% of

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deaths occurred in Africa (Jibat T, Hogeveen H,

2015). Dog-bite rabies cases in Asia and Africa

annually exceeded 31,000 and 24,000, respectively

(Alie A, Assefa A, Derso S, 2015). According to the

World Health Organization, rabies resulted in more

than 60,000 human deaths every year. Children (aged

5-14 years) are the most vulnerable group to rabies

infection (WHO, 2020) (Sessou P, et al., 2019).

Rabies diseases mostly occur more in lower-

middle countries. In Ethiopia, rabies is highly

endemic and causes approximately 10,000 deaths

annually ( Guadu T, Shite A, Chanie M, Bogale B, F.

T. 2014). More than 50,000 dog-bite rabies cases and

approximately 6,000 deaths were found in Pakistan,

leading to huge economic losses(Coleman PG, Fèvre

EM, 2004) (Ahmed T, Asghar MW, 2019). Rabies is

a fairly big problem in other countries such as and

Indonesia. Almost all areas of India except Andaman

and Nicobar and Lakshadweep islands face the risk of

Wirajaya, M., Farmani, P. and Laksmini, P.

Knowledge, Attitudes and Practices (KAP) Model of Rabies Prevention Efforts Among Households in Low and Middle-Income Countries: A Systematic Review.

DOI: 10.5220/0011938900003576

In Proceedings of the 2nd Bali Biennial International Conference on Health Sciences (Bali BICHS 2022), pages 49-53

ISBN: 978-989-758-625-5

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

rabies infection. India has the highest stray dog

population in the world. With unvaccinated dogs, the

risk of transmitting rabies is even greater. West

Bengal in India is known to have the highest number

of rabies cases every year (Health Status Indicators:

Cbhidghs, 2019). Meanwhile, only nine out of 34

provinces in Indonesia are rabies-free provinces

(Kementerian Kesehatan Republik Indonesia, 2016).

According to the Indonesian Ministry of Health, the

number of rabies cases was 78,413 cases, of which

65,534 cases received the anti-rabies vaccine from

2011 to 2015. For example, Bali Province was ranked

first for having a huge number of rabies cases

amounting to 38,187 cases, followed by East Nusa

Tenggara Province with 13,599 cases (Kementerian

Kesehatan Republik Indonesia, 2020). Bangli, one of

the districts in Bali province, was reported to have a

high number of rabies cases (Nugroho DK, Diarmitha

IK, Tum S, 2013). This trend may suggest that rabies

prevention and control programs have not optimally

run.

In developing countries, some deprived

communities may not receive life-saving treatment

such as Post-Exposure Prophylaxis (PEP) treatment

because it is too expensive. Other than that, the reason

is that individuals cannot visit clinics for treatment

due to a lack of awareness about rabies (Buchy P, et

al., 2017). This shows that the community has

inadequate understandings of the dangers of rabies.

Knowledge, attitudes, and practice (KAP) are

possible factors that influence one’s understanding.

KAP surveys have widely been used throughout the

world for studies related to public health such as

health-seeking behavior and preventive practices

against diseases (Sambo M, Lembo T, Cleaveland S,

2014). Results from the survey may provide basic

data for planning, implementing, and evaluating

national control programs (Espinoza-Gómez F,

Hernández-Suárez CM, 2002). Therefore, this study

focuses on reviewing the AKP against rabies in low-

and middle-income countries.

2 MATERIALS AND METHOD

2.1 Literature Search Strategy

This study used a systematic review approach to

examine KAP-related research for rabies prevention.

Literature was searched on Pubmed using some

keywords such as "Knowledge, Perception, Practice

of Rabies Prevention". Research in the articles was

conducted in various countries.

2.2 Article Inclusion and Exclusion

Criteria

Selected articles were full articles that were published

in the last three years, had titles with KAP topics, used

a cross-sectional design, focused on households or the

community amounting to a minimum of 100 sampled

respondents. Meanwhile, articles which only consist

of letters or abstracts were excluded from the

selection.

2.3 Article Selection

In the selection procedure, keywords i.e.,

"Knowledge, Perception, Practice of Rabies

Prevention" were entered in Pubmed. The first search

obtained 162 articles. Then, the number of articles

was limited by publication year and full-text

categories. The articles were published in the last

three years and available in full texts. From the

second selection, 43 articles were gathered. Then, the

articles were selected based on the inclusion and

exclusion criteria. This process resulted in 16 articles.

In the last stage, 10 articles were eventually selected

as they sufficed the predetermined inclusion criteria.

Figure 1: Selection process for knowledge, attitudes, and

practices (KAP) of rabies prevention among households in

low- and middle-income countries using the PRISMA

method.

Bali BICHS 2022 - The Bali Biennial International Conference on Health Sciences

2.4 Data Extraction and Analysis

Data were analyzed descriptively and presented in a

tabular form. Tables present KAP related to rabies

prevention in middle and lower countries. Data

extraction was provided in tables to give information

about the research titles, method, design, sampling,

data collection, and key information/results.

3 RESULT

Nine selected articles show KAP of rabies prevention

in middle and lower middle countries as presented in

Table 1.

Table 1: Knowledge, attitude, and practice (KAP) of rabies

prevention in low- and middle-income countries.

Authors Results

(Hagos,

Weldegerima

Gebremedhin,

Kindie Fentahun

Muchie, 2020

)

Overall, people in Mekelle city,

Ethiopia had good knowledge

(56.1%), positive attitude (56.2%),

and good practice (61.3%) of rabies

revention.

(Ahmed,

Touseef, Sabir

Hussain, 2020)

People who had pets at home were

not vaccinated against rabies due to a

lack of knowledge and awareness of

rabies pre-exposure prophylaxis

preventive efforts. They also less

likely visited health services after

having dog

ites.

(Christopher,

Paulus Mario,

Cucunawangsih

Cucunawangsih,

2021)

In general, most of the respondents in

this study had good knowledge,

positive attitudes and good practices

of rabies prevention.

(Rahaman, M.

Mujibur, Umme

Ruman Siddiqi,

2020)

Most respondents had adequate KAP

levels and positive thoughts of rabies

prevention.

(Sivagurunathan,

Chinnaian,

Ramachandran

Umadevi, 2021)

About 27.7% of the research

participants had good knowledge of

animal bites and rabies; 34.6% of the

participants had good attitudes

towards animal bites and rabies, and

18.1% of the participants had good

ractice after having animal

ites.

(Glasgow,

Lindonne, Andre

Worme,

Emmanuel Keku,

2019)

About 40% of the respondents were

informed about the protective level

of rabies vaccination. Respondents

did not show a very high level of

knowledge about animals that might

e infected with rabies.

(Tiwari, Harish

Kumar, Mark

O’Dea, Ian

Duncan

Overall, the community had good

knowledge of rabies. Most people

had good attitudes and practices of

rabies

revention.

Robertson,

2019a

)

(Tiwari, Harish

Kumar, Mark

O’Dea, Ian

Duncan

Robertson,

2019b)

Respondents did not understand the

disease, especially its transmission

that dogs and other animals such as

rabid animals carry through licking

and scratching and its preventive

measures. Respondents' attitudes and

practices of rabies prevention in

households were not goo

(Pal P, Yawongsa

A, Bhusal TN,

Bashyal R, 2021)

Male respondents who had higher

education and better socioeconomic

status were likely to have good KAP

of rabies prevention. On the other

hand, female respondents who had

less education and less

socioeconomic status were likely to

have poor KAP. In general, the

respondents had low knowledge of

rabies, posing bad attitudes and

ractices of rabies

revention.

4 DISCUSSION

Rabies remains an important global public health

problem, especially in low and middle-income

countries. It is considered a neglected tropical

disease; however, the public's knowledge and

awareness of the disease are still lacking and limited.

Recent work by the World Health Organization under

the umbrella of “Zero Rabies by 2030” is aimed to

minimize the risk of rabies transmitted through dog

bites in many countries (Yurachai O, Hinjoy S, 2020).

Most respondents from low-middle-income

countries had good knowledge of rabies. In Ethiopia,

88.2% of all respondents had heard of rabies. They

mostly had their dogs vaccinated. This indicates that

their knowledge is quite good about rabies

management. In India, especially in rural areas,

people have good knowledge of rabies including

transmission and dangers of rabies, animals that

transmit rabies, and management of rabid animal

bites. This current study also found that smaller

households (<6 members) were more aware of rabies

vaccination compared to larger households. In

addition, smaller family sizes (<6 members) and

animal ownership affected public knowledge about

rabies besides socioeconomic status. Higher

socioeconomic status tends to contribute to better

possession of knowledge about rabies than lower

socioeconomic status. Overall, Bali had performed

good rabies management, given that most of the

people had a good education and knowledge of rabies.

Although several countries showed good knowledge

of rabies, some countries such as Pakistan lack

Knowledge, Attitudes and Practices (KAP) Model of Rabies Prevention Efforts Among Households in Low and Middle-Income Countries:

A Systematic Review

information about rabies. The community in

Gaibandha area, Bangladesh, showed good

knowledge of rabies. Most respondents identified

rabies as the deadliest disease, which can be

transmitted through dog bites and manifested in forms

of sudden behavior changes. A similar finding was

also found in Nepal. In conclusion, factors that

influence knowledge of rabies are education and

social status.

Geographic area i.e., rural areas was a place where

people mostly had no vaccinations or awareness.

Dogs are often found roaming freely on the streets of

rural areas (Tiwari, Harish Kumar, Mark O’Dea, Ian

Duncan Robertson, 2019b). This current study shows

that the respondents did not vaccinate their pets

against rabies. They mostly did not seek medical

attention when bitten by a dog. Poor knowledge of

rabies contributes to the risk of developing rabies

cases. Besides in India, people in urban Pakistan

posed very low knowledge of rabies. Only 27.7% of

participants had adequate knowledge of animal bites

and rabies. A similar situation was found in Grenada.

It means that only a few people understand the

transmission of rabies and how to prevent and treat

rabies. In general, animals that are susceptible to

rabies are commonly identified by people. Most

people are only aware of dogs as rabies-transmitting

animals but not other animals. As a result, limited

knowledge about rabies also prevents people from

detecting signs of rabies in animals.

Most households from low-middle-income

countries performed good attitudes and practices of

rabies prevention. In Ethiopia, 56.25% respondents

showed good attitudes and preventive practices as

well. This shows that the community has a good

awareness of rabies. Shirsuphal village in Western

India was dominated by people who had good

attitudes and practices of rabies prevention. They

mostly understood how to handle and seek health

services. People bitten by dogs treated their wounds

using soap and water or come to health services. Most

people from Bali province and Gaibandha had good

attitudes and practices of rabies prevention. Most of

them understood about rabies treatment and the

importance of leashing and vaccinating dogs. Any

dogs suspected of having signs such as rabies were

reported by the community to the authorities.

Lack of reporting rabies cases and infrequent visit

to health services because of rabid animal-suspected

bites were found among people from India and

Panchkula. The same treatment practiced by people

in Bali and Gaibandha was also done by people in

India. A low number of vaccinated animals were

often found. Rabies surveillance was still not optimal.

Some health workers did not understand how to

handle rabies. The government, therefore, needs to

launch programs that can control stray dogs, provide

civet traps and public education, report people bitten

by animals. Moreover, people from Nepal generally

used more traditional medicine to treat wounds as a

result of dog bites rather than health services.

5 CONCLUSION

Overall, people in low and middle-income countries

had good knowledge, attitudes, and practices of rabies

prevention. However, some did not have good enough

knowledge, attitudes, and practices of rabies

prevention. Factors influencing these three aspects

are family size, animal ownership, socioeconomic

status, and age. Developing knowledge, attitudes and

practices of rabies prevention may reduce rabies

cases.

ACKNOWLEDGEMENTS

The authors would like to thank lecturers in the

Health Information Management Study Program of

the International Bali University for supporting this

study.

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Knowledge, Attitudes and Practices (KAP) Model of Rabies Prevention Efforts Among Households in Low and Middle-Income Countries:

A Systematic Review