Understanding Multi-Level Factors that Influence Risk of Rabies in Ghana

"It is essential to strengthen and maintain the capacity of Ghana to prepare and respond to health events through improved risk communication."



Rabies is a preventable disease; however, there is little information about community-level perceptions and behaviours that influence transmission of rabies in Ghana. The Ghana Health Service (GHS) cites risk communication and community engagement (RCCE) as key for rabies prevention. In response, Breakthrough ACTION, in collaboration with the GHS Health Promotion Division, Directorate of Veterinary Services, Ministry of Agriculture and Health, the United States Agency for International Development (USAID), and other in-country stakeholders, is working to design communication strategies and salient public health messages to promote rabies prevention behaviours and safe shared living environments with animals among the general population. As part of this effort, the programme conducted formative research to inform ongoing national health priorities designed to decrease the prevalence of rabies and dog bites in Ghana. This report provides data to inform evidence-based RCCE programming for rabies in Ghana.



Qualitative methods were used to collect information on rabies-related knowledge, perceptions, and behaviours. Focus group discussions (FGDs) were conducted with adult men and women 18 years and older, and with children between the ages 10-17 years. Children were included to provide a richer understanding of the perceptions and cultural practices that put community members at risk of rabies (in Ghana, young children sometimes hunt bats and bushmeat found in small spaces inaccessible to larger adults). In all, 48 FGDs among 480 individuals were conducted in 2 regions over a period of 3 weeks in February and March 2023.



Key findings:

1. Awareness and knowledge: Awareness of rabies was high, but there were substantial knowledge gaps in cause and transmission of the disease. There also was limited knowledge about how to live safely with animals in the home and community. Recommendations:
   • Community members may benefit from strategic rabies social and behaviour change (SBC) campaigns with targeted health messaging that addresses causes and transmission pathways, appropriate first aid responses, and the need for prompt treatment from health workers and facilities. Such campaigns may help facilitate a shift from awareness to knowledge building, and should also aim to influence other behavioural determinants and ideational factors underlying dog bites and rabies risk.
   • Interpersonal and community dialogue approaches may provide an opportunity to understand deep- seated cultural norms and prevailing myths and misconceptions about rabies, as well as the conflict between risk perceptions and engagement in risk behaviours. These approaches afford individuals the opportunity to share experiences and discuss the issues that influence their current beliefs, perceptions, and behaviours.
   • Community and healthcare educators may benefit from continued education and resources for rabies education. Training and development of information resources for community champions and groups (social groups, youth groups, leadership councils, teachers, etc.) for standardising the education and information provided to community members about rabies and living safely with animals may be useful. These interventions may be more effective when they are integrated into regional and district rabies prevention strategies, are harmonised among different community programmes, mobilize community members to action, and are monitored for effectiveness.
   • Raising the level of awareness about rabies and dog bite prevention among school-age children (which includes child hunters) is a vital part of building the foundation to encourage responsible pet ownership among community members. The curriculum may include fundamentals of responsible pet ownership and how to live with and handle animals in a safe and respectful manner. School-based interventions provide an opportunity to engage with the public on the importance of animals to the larger ecosystem. Through interpersonal and community-level communication, a generation of young people with the knowledge and skills to care for animals responsibly and safely may be created.
2. Risk perception and behaviours: There was much concern among community members about the risk of getting rabies. Poor understanding of transmission pathways for rabies may be associated with failure to recognise ways one can contract the illness. While there was general agreement that the free roaming of animals in the community amplifies risk of dog bites and rabies, the practice of not confining animals continues to be an issue. While some participants considered eating the meat of animals sick from, or that died from, rabies to be a health hazard, others believed that cooking meat of an infected animal eliminated the risk of contracting rabies. Recommendations:
   • Community-level engagement about transmission pathways for rabies and insights about behavioural risk identified through the daily activities and needs of community practices may be helpful for defining the context of risk for community members. Community-based interventions that directly engage community members in dialogue and SBC activities that support the realities of community life may support the acceptance and adoption of new behaviours.
   • Animal health clubs could facilitate the interpersonal approach to engaging communities in rabies prevention programmes. These clubs also could be a way to support and reinforce other large-scale communication approaches that provide education and information to the general public.
   • Rabies-related communication and resource materials used in rural areas require careful adaptation to ensure they are low literacy, highly visual, and user-friendly and that they are tested among the population. Materials should include links to a free information hotline where correct answers to questions about rabies, responding to a dog bite, and reporting dog bites are provided.
   • Community leaders, such as chiefs, opinion leaders, traditional healers, influential community members, youth leaders, and teachers, should be encouraged to work with animal health authorities to prioritise and engage in activities that encourage a participatory approach and harmonise the separate rabies prevention efforts of different activities and groups within communities.
3. Reporting: There was low reporting of pets or stray animals that were sick or involved in bite incidents in the study area. Some informants were unaware of how to make a report and to whom. Limited access to veterinarians may have contributed to poor reporting and not wanting to cause tensions with neighbours who own dogs. Recommendations:
   • A centralised mechanism of reporting may foster coordinated inter-sectoral collaboration and communication between human and animal health professionals. Furthermore, all participating stakeholders and community members should receive clear and accessible communication that explains the reporting structure. Strengthening surveillance mechanisms with the inclusion of district codes for dog bites that can be easily reported via texting channels should be considered. In addition, framing reporting of sick animals and dogs that bite around the need to track cases rather than on punitive responses may motivate community members to report incidents.
   • Developing the capacity for reporting diseases by leveraging community leaders, community-based animal health workers, or respected members of the community as focal points may improve reporting at the community level. Community members should be encouraged to participate more actively in epidemic control and surveillance by reporting suspected cases early and to the correct channels. A focus on conveying the importance of accurate and prompt reporting so that treatment can start early may motivate individuals to adopt this behaviour.
   • Community members could benefit from information about when to report sick or suspected rabid animals and to whom. Health messages should contain explicit information about the purpose and effect of reporting, as well as about what to expect after reporting, so community members can see the value and be motivated to continue reporting incidents appropriately. Campaigns that incorporate the benefits of reporting into messages to encourage community members to participate in reporting guidelines may be useful.
4. Community needs: Community needs included access to affordable medicines and vaccines for rabies, trained and accessible animal health personnel, education (about rabies, risk factors, symptoms, and reporting), management of the stray dog population, and enforced regulations for animal ownership. Recommendations:
   • Interventions that include a focus on methods to manage dog populations humanely could be beneficial in the study area. Collaboration between authorities and local experts who understand the local dog population, the dynamics around animal ownership, local demographics, and attitudes of community members towards dogs may provide contextual information as a basis for a tailored package of interventions.
   • Increasing visibility of and access to animal health workers may facilitate reporting of sick animals and animal bites. Training a new cadre of locally resident, community-based assisting animal health workers may improve access to animal health services and provide continuity in delivery of routine SBC activities regarding animal care. Involving veterinarians and medical personnel in the delivery of SBC interventions may help increase credibility and acceptance of these workers within the community.
   • Rabies prevention and treatment messages that are rooted in history and experiences, rather than solely based on knowledge and scientific content, may be more appealing to informants. The use of storytelling to share experiences and pass on codes of behaviour is an integral part of traditional African culture and may be well received as an SBC tool. For example, animal health clubs use storytelling and dramas to convey rabies-related information and facilitate dialogue in communities.
   • Stakeholders such as government agencies, veterinarians, public health professionals, and local community organisations and members should prioritise strategies that increase access (supply and reduced cost) to rabies vaccine so that it is affordable to community members. SBC campaigns to emphasise the importance of vaccinating animals are also needed.
   • Development of community-focused information and expectations for responsible dog ownership, including rabies vaccinations, should include regulatory mechanisms and consequences for non- compliance. Success of these interventions may be influenced by an improved supply chain for rabies vaccines.

The results of the research may be used by GHS, in collaboration with Breakthrough ACTION and other local stakeholders, to develop national SBC interventions and resources that provide accurate information, address risk behaviours, and create demand for rabies prevention information and interventions among the general population.