The Context of Rabies in Bombali District, Sierra Leone: Final Program Outcomes Monitoring Assessment

"Program achievements at endline showed that use of mass media and community engagement can increase awareness, knowledge, and behavior change for rabies prevention among communities."



The emergence of zoonotic diseases, such as the 2014 Ebola Virus Disease (EVD) outbreak, has demonstrated the need for a coordinated, harmonised, targeted, and effective global health response to public health emergencies. A priority focus of the government of Sierra Leone is to reduce the prevalence of rabies, a zoonotic disease, in animals and humans and to increase awareness and knowledge of rabies risk and prevention among the general population. The Johns Hopkins Center for Communication Programs, through the United States Agency for International Development (USAID)-funded Breakthrough ACTION programme, worked with the Sierra Leone One Health sectors to develop and implement a communication campaign for dog bites and rabies prevention under the broader concept of Healthy Animals, Healthy People. This report summarises results of outcomes monitoring at baseline and endline, and in relation to exposure to the campaign.



To create the campaign, Breakthrough ACTION carried out formative research to understand community members' knowledge, attitudes, and perceptions related to zoonosis and rabies, as well as the factors influencing risk of illness, prevention behaviours, reporting, and uptake of treatment and support services. Implemented in Bombali district, the campaign's initial focus was on behaviour change and prevention of dog bites; this focus on prevention was influenced in part by the chronic limited availability of vaccines (both canine and human) in the country. The campaign also focused on strengthening reporting channels within and between sectors for improved surveillance and response to dog bites.



The campaign included radio, print, WhatsApp, and community engagement activities. Radio materials included a campaign song, three 3-minute spots covering the key campaign messages, and two 5-minute spots featuring Q&A. Print materials included a poster for the general public with the key campaign messages, a reminder card for community leaders that covered the key campaign messages as well as steps to report dog bites, and a job aid poster for health workers. A WhatsApp number for the campaign was shared through radio and community engagement activities. Individuals could send a hello message to the number and receive all the campaign materials through their WhatsApp. Community engagement activities included one-off community outreach on ferry boats and through road shows; community-based engagement through Red Cross volunteers over a period of six months; and monthly constituency-level meetings with Paramount Chiefs, section chiefs, and community leaders across 16 communities.



Two waves of data collection were conducted, each of which included 1,312 adult participants, over the course of programme implementation: at baseline in June 2018 and at endline in July 2021. The endline followed about six months of implementation of the campaign.



Key results:

• Although baseline estimates were very high, at the endline, the proportion of participants with high knowledge of rabies further increased, reaching levels close to 100% for all constituencies. In addition, general awareness of rabies increased from 38% at baseline to 77% at endline.
• The baseline estimates for knowledge of risk associated with rabies varied widely across participating constituencies, with a high of 98% and a low of 69%. By endline, at least 90% or more of participants from all participating constituencies had high knowledge of risk associated with rabies.
• Baseline estimates were moderate for knowledge of how to prevent rabies, with 69% of all participants demonstrating high knowledge. At endline, the proportion with high knowledge of prevention of rabies increased to 84% overall.
• Baseline estimates were moderate (67%) regarding participants' knowledge of when to report suspected rabies. At endline, the proportion of participants with correct knowledge of when to report suspected rabies increased to 88%.
• Baseline and endline results were very high for correct knowledge of reporting channels for suspected rabies, at 97% and 98% respectively. However, for reporting channels for sick animals, only 13% of participants identified the community animal health officer (AHO), veterinarian, or livestock officer (LO) as correct individuals to report to; this figure rose to 55% of participants at endline.
• The proportion reporting high-risk incidents in the past 12 months remained unchanged between baseline and endline. Overall, 26% at baseline and 28% at endline reported being aware of someone in their community who had been scratched or bitten by a dog or had signs of sickness from an animal. Among participants who were aware of such incidents, 75% at baseline and 74% at endline reported the incident to a health worker, AHO/LO, or the 117 toll-free hotline.
• There was a decrease in the proportion of individuals who reported high-risk interactions with animals linked to rabies in the past 12 months at endline compared to baseline. At baseline, 77% of all participants reported having a high-risk interaction; however, the range was wide, from a low of 43% to a high of 94%. At endline, there was a decrease in the proportion of participants who reported having high-risk interactions (69%). Nonetheless, the proportion of individuals who reported having high-risk interactions with animals that are linked to rabies remains high; eating (65%) and preparing (46%) bush meat accounted for the persistent high proportions.
• In terms of the change in the proportion of individuals who sought care after high-risk interactions with animals, the percent change was highest for one constituency that had a 10% increase.
• At endline, 90% of participants reported they were aware of the Healthy Animals, Healthy People campaign tagline, or radio jingle, or song.
• Programme recall was very high and closely mirrored participant awareness of the Healthy Animals, Healthy People campaign. At the endline, 89% of participants correctly, and unaided, recalled a specific rabies-related message broadcast or shared by the campaign.

The results support the following recommendations (see the report for more) through a socio-behavioural lens:



Implementing strategies for sustaining high levels of awareness, knowledge, and behaviour change among community members:

• Carry out interventions to sustain awareness, risk reduction and prevention behaviours, and appropriate reporting of dog bites and suspected rabies cases in animals and humans to secure the long-term health of community members and extend the achievements of the programme.
• Use informative and easy-to-interpret videos and case stories to supplement written information and discussions, which may help convince individuals that rabies is real and has consequences.
• Continue supporting interventions that shift ownership and management of rabies prevention activities to community members, which may help to increase community accountability for health promotion.
• As vaccines become available, consider expanding the campaign's focus to areas of prevention such as responsible animal ownership (getting your dog registered/licensed and vaccinated) and receipt of the post-exposure vaccine.
• Use community radio, town criers, and community social structures (churches, women and youth groups, local clubs, counselors, and associations) as channels for sustaining messages.

Continuing and strengthening focus and activities on risk-reduction behaviours in communities:

• Consider interventions that distinguish risk-enhancing behaviours and that support risk reduction behaviours, with a focus on developing rabies prevention strategies and risk reduction messages specifically for young children and school-age populations. (Rabies prevention information may be integrated through the academic curriculum or school clubs and activities, and schools may be engaged during canine vaccination drives, as children are often the ones who provide care for animals in their home.)
• Tailor rabies prevention activities to reach older individuals, as the results showed decreased odds of responding appropriately among older individuals and a lack of correlation between knowledge of prevention and expected behaviours in this group. (There may be a level of complacency among older individuals who may be used to seeing stray dogs in their communities and/or living with animals.)
• Foster community dialogue and specific messages that focus on safe preparation and consumption of dog and bush meat (and avoidance of dead animals), and integrate farming and animal husbandry campaigns that focus on improving diets in these areas. (Additional information about risk and appropriate steps to take to protect self when handling, preparing, and eating dog and bush meat also may be warranted.)

Reaching groups with high-risk behaviours: Sustain impact by identifying and providing information to high-risk, perhaps hard-to-reach groups within the larger community that have close and frequent contact with dogs or dog meat, such as hunters (especially younger males), butchers, and meat vendors.

Reinforcing reporting and surveillance mechanisms:

• Increase focus on timely data capture, sustained reporting, and data use to proactively identify areas that exhibit changes in risk profiles.
• Develop supporting roles for individuals with direct responsibility for coordinating One Health activities in each district (at chiefdom, constituency, and community levels), and include surveillance and data management in role responsibilities.
• Explore opportunities to engage other community influencers in community-based strategies for reinforcing appropriate reporting and healthcare seeking for dog bites, such as traditional healers, medicine and herbal vendors, pharmacists, and chemical sellers, and others. This engagement may require additional training.
• Critically review, in collaboration with local authorities, existing guidance for the dog bites and canine rabies reporting pathway, and ensure that it provides clearly defined structure for communication (who, when, how, etc.) between community, health workers, and AHOs.
• Strengthen communication mechanisms, and especially feedback loops, for rabies surveillance, reporting, and communication, and share guidance documents widely with community leaders and human and animal health workers.

Exploring opportunities to scale-up the rabies campaign to other districts:

• In light of the fact that density maps showed a relationship between radio broadcasts listenership and higher knowledge scores, expand the programme to other districts and partners to complement other ongoing rabies prevention activities. (This involves sharing rabies-related information resources and campaign materials to support scale-up beyond Bombali.)
• Consider focusing awareness and prevention information near national borders and entry points where there is reportedly a high occurrence of dogs crossing borders, and in southern areas of the country where prevalence of dog bites is higher.
• Distil lessons learned from programme experiences to improve design and delivery of the programme prior to scale-up. (In addition, while not included in the original rabies campaign, pharmacists were identified as a common point of care for dog bites and represent an opportunity for engaging other influential individuals within the community, in rabies prevention.)

Adapting the approach to prevention of other zoonoses: Adapting the programme strategy and interventions for application to prevention of other priority zoonotic diseases (PZD) in Sierra Leone such as Lassa fever may help facilitate reaching of Sierra Leone's joint risk assessment goals for PZD.



Updating national guidance documents:

• Support the process of completing the establishment of the National Public Health Agency with a mandate that includes the topic of animal health and zoonosis.
• Incorporate new evidence, lessons learned, and related recommendations into policy, regulatory and guidance documents for rabies, laying out priorities for health promotion and behaviour change for each component.