# Do awareness campaigns improve communities' knowledge, attitudes and practices on rabies? A two-stage studies in Menabe region, Madagascar

Daouda Kassie, Volatiana Randriafaraniaina, Arlette Florine Ravolatsara, Vincent Michel Rakotoharinome, Eric Cardinale

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## ► To cite this version:

Daouda Kassie, Volatiana Randriafaraniaina, Arlette Florine Ravolatsara, Vincent Michel Rakotoharinome, Eric Cardinale. Do awareness campaigns improve communities' knowledge, attitudes and practices on rabies? A two-stage studies in Menabe region, Madagascar. International journal of advanced research, 2023, 11 (11), pp.639-650. [hal-05181414](https://hal.science/hal-05181414v1)

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Submitted on 23 Jul 2025

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ISSN NO. 2320-5407

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RESEARCH ARTICLE

DO AWARENESS CAMPAIGNS IMPROVE COMMUNITIES' KNOWLEDGE, ATTITUDES, AND PRACTICES ON RABIES? A TWO-STAGE STUDIES IN MENABE REGION, MADAGASCAR

Kassié Daouda¹,², Randriafaraniaina Volatiana¹,³, Ravolatsara Arlette Florine⁴, Rakotoharinome Vincent Michel⁵ and Cardinale Eric¹

1. CIRAD Bios, UMR ASTRE, Univ Montpellier, INRAE, Montpellier, France.

2. Institut Pasteur de Madagascar (IPM), Antananarivo, Madagascar.

3. Université d'Antananarivo, Faculté de médecine vétérinaire, Antananarivo, Madagascar.

4. Centre National de la Recherche en Environnement (CNRE), Madagascar.

5. Direction des Services Vétérinaires (DSV), Madagascar.

Manuscript Info

Manuscript History

Received: 15 September 2023

Final Accepted: 17 October 2023

Published: November 2023

Key words:-

Rabies, Awareness, Knowledge-Attitudes-Practices, Menabe, Madagascar

Abstract

In November 2020, a Baseline study was conducted among 342 participants, followed by an awareness campaign. Then an Endline study was carried out with 337 other participants in January 2021, to assess communities' knowledge, attitudes, and practices (KAP) related to rabies in the same study areas. The same questionnaires were used to assess communities KAP. A significant improvement in participants' KAP related to rabies was observed. The good knowledge average score increased from 36% to 61%, positive attitudes improved from 39% to 55%, and good practices increased from 7% to 81%. The participants mean KAP score increases from 27% at Baseline to 66% at Endline. Multivariable logistic regressions performed after both phases revealed that participants who heard or saw information about rabies during an awareness campaign had higher KAP levels compared to others. This study demonstrated the awareness campaign importance, and the need to continue and intensify efforts to raise rural communities' awareness, by using mass communication methods such as radio broadcasts, video spots and flyers in local language to reach more people.

Copy Right, IJAR, 2023. All rights reserved.

Introduction:-

Rabies, a zoonotic disease caused by Lyssavirus, is a significant public health concern, leading annually to 50,000 to 100,000 deaths annually (Singh et al., 2017). The disease is transmitted through the bite of rabid animals and 95% of human deaths occur in Africa and Asia, particularly in rural communities of developing countries (Hampson et al., 2021; Okonko, 2010; Schnell McGettigan et al., 2010; WHO, 2012). Rabies is a fatal disease, but it can be prevented through vaccination in both animals and humans (Chernet, 2016; Fooks et al., 2014), and in the event of a bite, particularly in the case of a deep bleeding bite wound, post-exposure prophylaxis (PEP) is required, even if the biting animal is vaccinated (Dumas et al., 2016). Awareness campaigns are also important in rabies prevention because they may significantly improve knowledge of rabies symptoms and vaccination schedules, leading to increased pet vaccination rates (Hasanov et al., 2017).
Rabies prevention requires appropriate knowledge of all its reservoirs, vectors, and contamination modes, as well as positive attitudes and recommended practices following an animal bite incident. However, most health care management is heavily concentrated in urban areas, leaving rural communities at a disadvantage. This is further exacerbated by the unavailability and access to appropriate health care services in rural areas. The geographical inaccessibility of health facilities including PEP, and low awareness about rabies are significant factors contributing to this disparity. In this context, the rural communities Knowledge-Attitudes-Practices (KAP) assessment is an important aspect of rabies control. In fact, the wildlife role in rabies transmission is often overlooked, particularly in developing countries (Aiyedun et al., 2017).

Rabies has been circulating in Madagascar since at least the 19th century with a high prevalence in domestic animals, particularly dogs (Morvan et al., 1993; Reynes et al., 2011), and it remains an ongoing issue, with a high incidence of human deaths and a widespread presence of the virus in domestic animals. The provision of post-exposure prophylaxis (PEP) has been effective in reducing the burden of rabies, but access to PEP is limited to only a few health care facilities in the country (Rajeev, 2018). In order to develop diagnostic and surveillance methodologies across Madagascar 31 Antirabies Treatment Center (ATC), the Pasteur Institute of Madagascar and the Malagasy Ministry of Public Health have collaborated for years.

However, due to many rabies cases being under-reported, a lack of awareness and knowledge about PEP, the available data underestimate its importance, and these are significant issues in many countries, where the disease is prevalent (Meng et al., 2011; Rajeev et al., 2018). Nevertheless, since the 1990s, the number of suspected cases of human rabies reported by health care facilities has been increasing. More than 80% of animals' rabies cases involve dogs, the primary vector (Nobel et al., 2005). Eliminating rabies in dogs is hindered by factors such as the increasing number of stray dogs, insufficient awareness, strong control policies, and low dog vaccination rates. So, reducing the burden of rabies in both animals and humans requires controlling the disease at its source. That requires many actions like mass vaccination campaigns for dogs, effective management and control strategies, veterinary education, interdisciplinary collaboration, etc. (Cripps et al. 2000; Kassié et al., 2023).

According to the consultation forms from the Antirabies Treatment Center (ATC) at the Pasteur Institute of Madagascar, the Menabe region, which hosts natural reserves and an ACT, a total of 528 consultations (268 in 2017 and 260 in 2018) were recorded for rabies exposure. Among these, 82.4% (435 consultations) were due to dogs, 4.9% (26 consultations) to cats, and 2% (11 consultations) to lemurs, bushbabies and others (unspecified). Children under 15 years old were the most exposed (28.6% or 151/528 of consultations). Few data are available on the Knowledge-Attitudes-Practices of communities in this region (Randriafaraniaina, 2022).

This study's main objective was to evaluate the awareness campaign importance about rabies control and prevention, including knowledge, attitudes, and practices, using tools designed for a local context. The specific objectives were: i) to assess the knowledge, attitudes, and practices (KAP) of communities living in the neighboring Fokontany of the Menabeproected area regarding rabies, ii) to lead raising awareness about rabies by using the potential most suitable tools, iii) to evaluate the knowledge, attitudes, and practices (KAP) in the same studied areas.

## Materials and Methods:-

### Study area

In Madagascar, administrative divisions include Districts, which cover a larger geographical area compared to Communes and Fokontany. This study focused on participants from ten Fokontany located within natural reserves (protected areas) in the Menabe region of western Madagascar. These natural areas are tourist sites that are regularly visited by many tourists. This choice is important because rabies virus the circulation has been confirmed in both animals (domestics and wilds) and humans' interface across the island (Reynes et al., 2011). These Fokontany are located at approximately 650 km from the capital Antananarivo, and are between 6 km (Bemanonga) and 95 km (Tsimafana) from Morondava (Figure 1).
<figure><img src="image_5.png" /><figcaption>**Figure 1:-** Maps of Morondava District in Madagascar and study areas (A). Red: Communes limits; Black studied fokontany limits (B).</figcaption></figure>

**Study Methodology:-**

A descriptive cross-sectional community study was conducted in ten Fokontany, carried out in two phases (Baseline and Endline). For both phases, questionnaires were administered to random selected heads of households or their representatives. The same number of participants was expected in each Fokontany for both phases. Data were collected on sociodemographic characteristics, dog ownership, and information on the communities' knowledge, attitudes, and practices regarding rabies, using questionnaires surveys. The questionnaires were available in both French and Malagasy language, through KoboCollect on smartphones, and the data were collected face-to-face.

The Baseline took place from November 5 to 29, 2020. Following this phase, awareness messages on rabies were broadcast through two local radio stations, a video spot designed for this study, and described elsewhere by Kassié et al. (2023) was displayed in each Fokontany, then distributed via Bluetooth, USB keys, and compact discs and to people who wanted to keep it. Flyers were distributed to people, including the non-surveyed. Posters were dispatched in each Fokontany in attractive places like markets and Fokontany's main office. The Endline study took place from January 5 to 22, 2021. The same baseline questionnaire was used and administered to a randomly selected heads of households or their representatives.
For each participant, Knowledge, Attitude, and Practices (KAP) score was calculated from 25 questions. This score was calculated by attributing one point to each correct answer, and zero point for incorrect or unknown answers. These points were summed to determine Knowledge score, Attitude score, and Practice score. An individual KAP score, then a proportion of correct answers were calculated for each participant.

For the entire study population, the overall KAP score was determined in each phase by summing these three KAP scores. The overall KAP score was split into two levels based on its mean: Participants whose individual KAP score was at least equal to the overall KAP mean were characterized as having "Good KAP", and the others as having "Poor KAP".

## Study population

The questionnaires were administered to household heads or their representatives over 18 years old, who consented to participate. The sample size was determined using Cochran's sample size formula (Giezendanner, 2012).

$$n = \frac{t^2p(1-p)}{e^2}$$

n: Expected sample size;

t: Z-score corresponding to the desired confidence level (e.g., for a 95% confidence level, Z might be approximately 1.96);

p: Estimated proportion of the population with the characteristic being studied in the survey. We considered p to be 32.3%, which is the estimated proportion of rural populations in the Moramanga District (Madagascar) with a goodq level of knowledge on rabies control and prevention practices (Leblanc, 2019).

e: Desired margin of error has been set at 5%;

$$\text{By applying the formula: } n = \frac{(1.96)^2 \times 0.32(1-0.32)}{(0.05)^2}$$

The calculated sample size is 335 adults (household heads or respondents).

## Sampling Method:-

Stratified random sampling technique was chosen in this survey. The sampling frame was based on the number of people given by the Fokontany offices. For each Fokontany, the number of households to be surveyed was estimated by using the total population and the average number of individuals per household (4.3 individuals per household). The number of households to survey by Fokontany was proportional to the size of the Fokontany (Table 1). The households to survey were randomly selected, based on an adult willingness to participate in the study. In each household, only one adult (the household head or his/her respondent) was surveyed. If there was no adult at home or he refused, another household was randomly selected.

<table><caption>**Table 1:-** Number of households to survey by Fokontany.</caption><thead><tr><th>Fokontany</th><th>Total population<br>N=8 289</th><th>Estimated number<br>of households<br>(N=1 928)</th><th>Proportion<br>households<br>survey (%)<br>(N=100)</th><th>of<br>to<br>survey<br>(n=335)</th></tr></thead><tbody><tr><td>Ampataka</td><td>1089</td><td>253</td><td>13</td><td>44</td></tr><tr><td>Andranomena</td><td>767</td><td>178</td><td>9</td><td>31</td></tr><tr><td>Ankoraobato</td><td>1006</td><td>234</td><td>12</td><td>41</td></tr><tr><td>Bevolonga</td><td>547</td><td>127</td><td>7</td><td>22</td></tr><tr><td>Marofandiliha</td><td>858</td><td>200</td><td>10</td><td>35</td></tr><tr><td>Lambokely</td><td>675</td><td>157</td><td>8</td><td>27</td></tr><tr><td>Mandroatsy</td><td>334</td><td>78</td><td>4</td><td>13</td></tr><tr><td>Anketrevo</td><td>187</td><td>43</td><td>2</td><td>8</td></tr><tr><td>Tsimafana</td><td>1877</td><td>437</td><td>23</td><td>76</td></tr><tr><td>Kiboy</td><td>949</td><td>221</td><td>11</td><td>38</td></tr></tbody></table>

## Tools for communities' awareness campaign

There are several tools for mass communication activities. However, for this study, the tools used were printed media (posters and flyers), radio, and a short video spot, all in Malagasy language. The posters were placed in attractive areas including markets and the Fokontany offices. The flyers were distributed to people in the same attractive places, including non-participants in the study. Awareness campaigns by a video spot on rabies were
scheduled, and people were invited to attend it. The same content was broadcast on local radio stations covering the studied Fokontany.

## Data management and analysis

The data collected through questionnaires were centralized on the Kobo Toolbox platform. R software was used for data management and analysis. Descriptive statistics, then Chi-square tests were performed to seek the association between the dependent variable (KAP levels on rabies) and explanatory variables (dog ownership, sociodemographic characteristics, etc.). Multivariable logistic regression models were performed to determine the factors influencing the KAP levels on rabies. The non-parametric Wilcoxon test was used to compare the means of each Fokontany at Baseline and Endline.

## Results:-

### Participants sociodemographic characteristics during both phases

At least 335 households were estimated to be surveyed for each phase. Finally, 342 households were selected during the Baseline and 337 households during the Endline. During the Baseline, 145/342 (42.3%) respondents (participants) were women, whereas, during the Endline, 207/337 (61.42%) respondents were women. The mean age of the respondents was 42 years. In the Baseline, 157/342 (45.9%) respondents were aged 41 to 60, while during the Endline, the mean age was 41 years and 176/337 (52.2%) respondents were aged 18 to 40.

Most of the participants during the Baseline, 214 (62.6%) had received formal schooling, while during the Endline, 207 (61.4%) respondents were non-schooled. The main ethnic group from the study area was the Sakalava. They were 132 respondents (38.6%) during the Baseline and 132 respondents (39.2%) during the Endline. Dogs were owned by 16.7% of the respondents (342) during the Baseline, and by 8.3% of the respondents (337) during the Endline.

### Knowledge, attitudes, and practices description during both phases

Most of the participants had already heard about rabies, 269 respondents (78.7%) at Baseline and 325 (96.4%) at Endline. Regarding the knowledge, the means for all participants at Baseline were 0.36 (36% of good knowledge) and at Endline 0.61 (61% of good knowledge). The means of attitudes towards rabies were 0.39 (39% positive attitudes) at Baseline and 0.55 (55% positive attitudes) at Endline. For practices related to rabies, the means were 0.07 (7% of good practices) at Baseline and 0.81 (81% of good practices) at Endline. When taking into account together knowledge, attitudes and practices (KAP), the overall KAP means scores for participants were 0.27 (27% correct responses) at Baseline and 0.66 (66% correct responses) at Endline. The difference between the two means was statistically significant (p<0.001).

### Bivariate analysis between KAP level and participants' characteristics at Baseline

At Baseline, some sociodemographic characteristics of the participants were closely associated with their KAP level about rabies, at a chi-square test p-value less than 0.20, in bivariate analysis. These variables were ethnicity, religion, literacy level, having heard of rabies (Table 2).

<table><caption>**Table 2:-** Bivariate analysis between KAP level and participants' characteristics at Baseline.</caption><thead><tr><th rowspan="2">Variables/modalities</th><th colspan="2">Number of participants at Baseline</th><th rowspan="2">p-value</th></tr><tr><th>Poor KAP n(%)</th><th>Good KAP n(%)</th></tr></thead><tbody><tr><td>Age</td><td></td><td></td><td>0.257</td></tr><tr><td>[18-40]</td><td>78(22.8)</td><td>65(19)</td><td></td></tr><tr><td>[41-60]</td><td>71(20.8)</td><td>86(25.1)</td><td></td></tr><tr><td>[61-78]</td><td>22(6.4)</td><td>20(5.8)</td><td></td></tr><tr><td>Gender</td><td></td><td></td><td>1</td></tr><tr><td>Male</td><td>98(28.7)</td><td>99(28.9)</td><td></td></tr><tr><td>Female</td><td>73(21.3)</td><td>72(21.1)</td><td></td></tr><tr><td>Ethnicity</td><td></td><td></td><td>&lt; 0.001</td></tr><tr><td>Sakalava</td><td>54(15.8)</td><td>78(22.8)</td><td></td></tr><tr><td>Antandroy</td><td>62(18.1)</td><td>60(17.5)</td><td></td></tr><tr><td>Antesaka</td><td>39(11.4)</td><td>17(5)</td><td></td></tr><tr><td>Betsileo</td><td>3(0.9)</td><td>10(2.9)</td><td></td></tr></tbody></table>
<table><tr><td>Others</td><td>13(3.8)</td><td>6(1.8)</td><td></td></tr><tr><td>Activities carried out</td><td></td><td></td><td>0.319</td></tr><tr><td>Several activities</td><td>137(40.1)</td><td>145(42.4)</td><td></td></tr><tr><td>One activity</td><td>34(9.9)</td><td>26(7.6)</td><td></td></tr><tr><td>Religion</td><td></td><td></td><td><strong>&lt; 0.001</strong></td></tr><tr><td>Engaged in religious practice</td><td>94(27.5)</td><td>127(37.1)</td><td></td></tr><tr><td>Non-practicing religion</td><td>77(22.5)</td><td>44(12.9)</td><td></td></tr><tr><td>Literacy level</td><td></td><td></td><td><strong>&lt; 0.001</strong></td></tr><tr><td>Non-schooled</td><td>84(24.6)</td><td>44(12.9)</td><td></td></tr><tr><td>Schooled</td><td>87(25.4)</td><td>127(37.1)</td><td></td></tr><tr><td>Having heard of rabies</td><td></td><td></td><td><strong>&lt; 0.001</strong></td></tr><tr><td>Yes</td><td>102(29.8)</td><td>167(48.8)</td><td></td></tr><tr><td>No</td><td>69(20.2)</td><td>4(1.2)</td><td></td></tr><tr><td>Ownership of a dog</td><td></td><td></td><td>0.384</td></tr><tr><td>Yes</td><td>32(9.4)</td><td>25(7.3)</td><td></td></tr><tr><td>No</td><td>139(40.6)</td><td>146(42.7)</td><td></td></tr><tr><td>Experiencing a dog bite in the family</td><td></td><td></td><td>0.665</td></tr><tr><td>Yes</td><td>13(3.8)</td><td>10(2.9)</td><td></td></tr><tr><td>No</td><td>158(46.2)</td><td>161(47.1)</td><td></td></tr><tr><td>Having received recent information about rabies</td><td></td><td></td><td>0.246</td></tr><tr><td>Yes</td><td>0(0)</td><td>3(0.9)</td><td></td></tr><tr><td>No</td><td>171(50)</td><td>168(49.1)</td><td></td></tr><tr><td>Awareness of animal health care professional existence</td><td></td><td></td><td>1</td></tr><tr><td>Yes</td><td>104(30.4)</td><td>105(30.7)</td><td></td></tr><tr><td>No</td><td>67(19.6)</td><td>66(19.3)</td><td></td></tr></table>

### Multivariable analysis between KAP level and participants' characteristics at Baseline

Multivariable logistic regression model was performed by integrating variables with a chi-square test p-value less than 0.20 in previous bivariate analysis at Baseline. After this logistic regression analysis, a significant association was found between having already heard of rabies and a good KAP level (OR = 23.5, 95% CI: 9.25-79.69, p<0.001). Participants who had already heard of rabies before our survey were 23.5 times more likely to have a good KAP level than those who had never heard of this disease (Table 3).

<table><caption>Table 3:- Multivariable analysis between KAP level and participants' characteristics at Baseline</caption><thead><tr><td>Variables/modalities</td><td>p-value</td><td>OR [IC95%]</td></tr></thead><tbody><tr><td>Ethnicity</td><td>0,146</td><td></td></tr><tr><td>Sakalava</td><td></td><td>2,29[0,72-7,62]</td></tr><tr><td>Antandroy</td><td></td><td>2,07[0,65-6,90]</td></tr><tr><td>Antesaka</td><td></td><td>1,06[0,31-3,92]</td></tr><tr><td>Betsileo</td><td></td><td>4,31[0,72-7,62]</td></tr><tr><td>Others</td><td></td><td></td></tr><tr><td>Religion</td><td>0,119</td><td></td></tr><tr><td>Engaged in religious practice</td><td></td><td></td></tr><tr><td>Non-practicing religion</td><td></td><td>0,63[0,35-1,12]</td></tr><tr><td>Literacy level</td><td>0,105</td><td></td></tr><tr><td>Schooled</td><td></td><td>0,90[0,8-2,90]</td></tr><tr><td>Non-schooled</td><td></td><td></td></tr><tr><td>Having heard of rabies</td><td>&lt;0,001</td><td></td></tr><tr><td>Yes</td><td></td><td>23,5[9,25-79,69]</td></tr><tr><td>No</td><td></td><td></td></tr></tbody></table>

Examining this variable closely in our study, the proportion of participants who had previously heard of rabies was 78.7% (269/342). For the very first time, their relatives were the main information source (89.2% or 240/269), while
the school represented 3.7% (10/269), and other sources, such as a doctor, a veterinarian or other people were 7.1% (9/269) of respondents.

### Bivariate analysis results between KAP levels and participants' characteristics at Endline

At Endline some sociodemographic characteristics of the participants were closely associated with their KAP level about rabies, at a chi-square test p-value less than 0.20, in bivariate analysis. These variables were ethnicity, religion, literacy level, having heard of rabies, awareness of animal health care professionals' existence, having seen rabies awareness tools during the last three months (Table 4).

<table><caption>**Table 4:- Bivariate analysis results between KAP levels and participants' characteristics at Endline**</caption><thead><tr><th rowspan="2">Variables/modalities</th><th colspan="3">Number of participants at Endline</th><th rowspan="2">p-value</th></tr><tr><th>Poor KAP n(%)</th><th>Good n(%)</th><th>KAP</th></tr></thead><tbody><tr><td>Age</td><td></td><td></td><td></td><td>0.674</td></tr><tr><td>[18-40]</td><td>50(14.8)</td><td>126(37.4)</td><td></td><td></td></tr><tr><td>[41-60]</td><td>38(11.3)</td><td>83(24.6)</td><td></td><td></td></tr><tr><td>[61-78]</td><td>14(4.2)</td><td>26(7.7)</td><td></td><td></td></tr><tr><td>Gender</td><td></td><td></td><td></td><td>0.488</td></tr><tr><td>Male</td><td>36(10.7)</td><td>94(27.9)</td><td></td><td></td></tr><tr><td>Female</td><td>66(19.6)</td><td>141(41.8)</td><td></td><td></td></tr><tr><td>Ethnicity</td><td></td><td></td><td></td><td>0.12</td></tr><tr><td>Sakalava</td><td>31(9.2)</td><td>101(30)</td><td></td><td></td></tr><tr><td>Antandroy</td><td>39(11.6)</td><td>71(21.1)</td><td></td><td></td></tr><tr><td>Antesaka</td><td>28(8.3)</td><td>50(14.8)</td><td></td><td></td></tr><tr><td>Others</td><td>4(1.2)</td><td>13(3.9)</td><td></td><td></td></tr><tr><td>Activities carried out</td><td></td><td></td><td></td><td>0.842</td></tr><tr><td>Several activities</td><td>48(14.2)</td><td>115(34.1)</td><td></td><td></td></tr><tr><td>One activity</td><td>54(16)</td><td>120(35.6)</td><td></td><td></td></tr><tr><td>Religion</td><td></td><td></td><td></td><td>0.001</td></tr><tr><td>Engaged in religious practice</td><td>37(11)</td><td>132(39.2)</td><td></td><td></td></tr><tr><td>Non-practicing a religion</td><td>65(19.3)</td><td>103(30.6)</td><td></td><td></td></tr><tr><td>Literacy level</td><td></td><td></td><td></td><td>0.003</td></tr><tr><td>Non-schooled</td><td>75(22.3)</td><td>132(39.2)</td><td></td><td></td></tr><tr><td>Schooled</td><td>27(8)</td><td>103(30.6)</td><td></td><td></td></tr><tr><td>Having heard of rabies</td><td></td><td></td><td></td><td>&lt; 0.001</td></tr><tr><td>Yes</td><td>90(26.7)</td><td>235(69.7)</td><td></td><td></td></tr><tr><td>No</td><td>12(3.6)</td><td>0(0)</td><td></td><td></td></tr><tr><td>Ownership of a dog</td><td></td><td></td><td></td><td>0.396</td></tr><tr><td>Yes</td><td>6(1.8)</td><td>22(6.5)</td><td></td><td></td></tr><tr><td>No</td><td>96(28.5)</td><td>213(63.2)</td><td></td><td></td></tr><tr><td>Experiencing a dog bite in the family</td><td></td><td></td><td></td><td>0.568</td></tr><tr><td>Yes</td><td>4(1.2)</td><td>5(1.5)</td><td></td><td></td></tr><tr><td>No</td><td>98(29.1)</td><td>230(68.2)</td><td></td><td></td></tr><tr><td>Having seen rabies awareness tools during the last three months</td><td></td><td></td><td></td><td>&lt; 0.001</td></tr><tr><td>Yes</td><td>57(16.9)</td><td>234(69.4)</td><td></td><td></td></tr><tr><td>No</td><td>45(13.4)</td><td>1(0.3)</td><td></td><td></td></tr><tr><td>Awareness of an animal health care professional existence</td><td></td><td></td><td></td><td>0.159</td></tr><tr><td>Yes</td><td>57(16.9)</td><td>152(45.1)</td><td></td><td></td></tr><tr><td>No</td><td>45(13.4)</td><td>83(24.6)</td><td></td><td></td></tr></tbody></table>
## Multivariable analysis between KAP level and participants' characteristics at Endline

A multivariable logistic regression model was also performed by integrating variables with a chi-square test p-value less than 0.20 in previous bivariate analysis at Endline. After this logistic regression analysis, having already heard of rabies before our Endline survey and having seen rabies awareness campaign tools during the last three months before our Endline survey were statistically associated with the good KAP level of participants (p<0.05). In comparison to participants who have never heard of rabies, those who have heard of rabies were 6.7 times more likely to have a good KAP level (OR=6.7; 95% CI=6.3-14, p<0.001). Compared to respondents who have not seen any rabies awareness tools, those who have seen the tools are 21 times more likely to have a good KAP level on rabies (OR=21; 95% CI=4.3-38, p<0.001) (Table 5).

Examining this variable closely in our study, the proportion of participants who had previously heard of rabies was 96.4% (325/337). For the very first time, their relatives were the main information source (95.4% or 310/325), while the school represented 2.5% (8/325), and other sources, such as the veterinarian or other people were 3.4% (11/325) of participants.

Participants who saw rabies awareness campaign tools during the last three months before our Endline survey were 291 (86.3% of the 337) of respondents.

<table><caption>Table 5:- Multivariable analysis between KAP level and participants' characteristics at Endline.</caption><thead><tr><th>Variables/modalities</th><th>p-value</th><th>OR [IC 95%]</th></tr></thead><tbody><tr><td>Ethnicity</td><td>0,82</td><td></td></tr><tr><td>Sakalava</td><td></td><td>1,0[0,6-4,4]</td></tr><tr><td>Antandroy</td><td></td><td>7,1[1,1-29,4]</td></tr><tr><td>Antesaka</td><td></td><td>1,04[0,1-4,8]</td></tr><tr><td>Others</td><td></td><td>1</td></tr><tr><td>Religion</td><td>0,55</td><td></td></tr><tr><td>Engaged in religious practices</td><td></td><td>1</td></tr><tr><td>Non-practicing a religion</td><td></td><td>5,65[2,7-11,4]</td></tr><tr><td>Literacy level</td><td>0,26</td><td></td></tr><tr><td>Non-schooled</td><td></td><td>1</td></tr><tr><td>Schooled</td><td></td><td>2,3[0,01-4,6]</td></tr><tr><td>Awareness of an animal health care professional existence</td><td>0,21</td><td></td></tr><tr><td>Yes</td><td></td><td>1,9[0,1-3,4]</td></tr><tr><td>No</td><td></td><td>1</td></tr><tr><td>Having heard of rabies</td><td>&lt; 0,001</td><td></td></tr><tr><td>Yes</td><td></td><td>6,7[6,3-14]</td></tr><tr><td>No</td><td></td><td>1</td></tr><tr><td>Having seen rabies awareness tools during the last three months</td><td>&lt; 0,001</td><td></td></tr><tr><td>Yes</td><td></td><td>21[4,3-38]</td></tr><tr><td>No</td><td></td><td>1</td></tr></tbody></table>

## Fokontany's average KAP scores evolution between Baseline and Endline

At the Fokontany scale, a means KAP means scores were calculated before (Baseline) and after the awareness-raising campaign (Endline). These scores were calculated from all participants living in each Fokontany. The overall KAP means scores for all ten Fokontany were found improved between the two phases, with correct responses increasing from 27.9% at Baseline to 66.1% at Endline. The difference between the means was statistically significant (p<0.001). The mean scores by Fokontany also increased after the awareness campaign (Table 6).

<table><caption>Table 6:- Knowledge-Attitudes-Practices average scores average at Baseline and Endline per Fokontany.</caption><thead><tr><th rowspan="2">Fokontany</th><th colspan="2">KAP scores average</th><th rowspan="2">p-value</th></tr><tr><th>Baseline</th><th>Endline</th></tr></thead><tbody><tr><td>Ampataka</td><td>0,29</td><td>0,6</td><td rowspan="3">&lt; 0,001</td></tr><tr><td>Andranomena Sud</td><td>0,29</td><td>0,68</td></tr><tr><td>Ankaraobato</td><td>0,21</td><td>0,65</td></tr></tbody></table>
<table><tr><td>Anketrevo</td><td>0,12</td><td>0,59</td></tr><tr><td>Bevolonga</td><td>0,25</td><td>0,74</td></tr><tr><td>Kiboy</td><td>0,27</td><td>0,67</td></tr><tr><td>Lambokely</td><td>0,25</td><td>0,68</td></tr><tr><td>Mandroatsy</td><td>0,24</td><td>0,59</td></tr><tr><td>Marofandiliha</td><td>0,18</td><td>0,67</td></tr><tr><td>Tsimafana</td><td>0,41</td><td>0,67</td></tr></table>

## Awareness tools scope within community

For this study, the awareness tools used were posters, flyers, a radio spot, and a short video spot. All these materials contained identical information about the measures to be taken in the event of a dog bite and the rabies epidemiological surveillance. The broadcast messages are divided into two parts.

The first part was about rabies transmission mode to humans, the animals willing to contract rabies, and the recommended actions following a dog bite, such as:

- Washing the wound with water and soap for at least 15 minutes and thoroughly rinsing it;

- Seeking immediate treatment at the nearest health care facility and adhering to the medical staff's instructions.

The second part addressed rabies epidemiological surveillance:

- Recommended actions and prohibitions when encountering a biting dog (prohibitions against killing, isolating, or tethering this biting dog);

- People to inform in the event of a dog bite (Fokontany chiefs, law enforcement, medical staff, veterinarians, or livestock technicians);

- People authorized to isolate the biting dog (the owner if known, or the Fokontany chief if the owner is unidentified);

- Responsibilities of the veterinarian about a biting dog (observing the dog for fifteen days, sampling its tissues in case of death, and sending the samples to the Pasteur Institute of Madagascar).

During the Endline survey, as respondents were asked if they saw rabies awareness tools during the last three months, we were able to ask more about these tools. The awareness tools used in this study were seen by 291 (86.3% of the 337) of respondents. Among them, 85.9% (250/291) watched the video spot. For printed media, 63.2% (184/291) saw the posters, and 47.7% (139/291) received our flyers about rabies. Only 13.4% (39/291) of the participants were reached by the local radio messages on rabies we broadcast over the study area.

## Discussion:-

This study aimed to understand if awareness campaigns can improve communities' knowledge, attitudes, and practices on rabies through operational research activities in Menabe region of Madagascar.

Most study participants are literate and Sakalava, the main ethnic group of the region (Alain, 2015). Dog ownership rate was lower than in other studies, such as in the Philippines (76%) (Dalvin et al., 2014), Grenada (52.3%) (Glasgow et al., 2019), Ethiopia (48.4%) (Kabeta et al., 2015), and Zimbabwe (49%) (Spargo et al., 2021). One reason for this difference is that dogs are not particularly liked by some participants in our study (182) and they are also sometimes taboo by some of them. This is in contradiction with the Kuujjuaq community, who considers dogs part of their identity and family tradition (Brunet et al., 2017).

Our study results indicated that the participants KAP level was lower at Baseline compared to what was found in the literature. This could be attributed to many reasons such as the absence of a community-based health education project, the dog management ignorance due to taboos, and trust in traditional healers' practices. The presence of traditional treatments is sometimes a reason for not seeking medical care, similar to the case in Asia (Awuni et al., 2019; Ntampaka et al., 2019). The KAP level increases like in our study with the presence of rabies health programs (Matibag et al., 2009).

During the Endline, rabies was already known by most (96.4%) of the participants. The first sources of information were neighbors. This may be attributed to social relationship and sharing information between people in their communities, after being aware of rabies. A study conducted in Sri Lanka had similar results, where 94.5% of participants had already heard of the disease after an awareness campaign (Matibag et al., 2009). Whether in the
Baseline or the Endline, most of the participants first time heard about rabies from their relatives. This situation underscores the importance of exposing communities to awareness campaigns, enabling them to educate others.

Interestingly, the participants' KAP average score during the second phase is twice more important than their KAP average before the awareness campaign, demonstrating that awareness campaign can significantly increase participants' KAP level. Other studies conducted in Sri Lanka and Azerbaijan showed a similar increase in the KAP level regarding rabies after an awareness campaign (Matibag et al., 2009; Hasanov et al., 2017).

As a limitation, this study could have been designed as a case-control study if the study area were larger and participants were farther apart to better capture the scope of the tools. Moreover, a multilevel logistic regression would have allowed for a direct examination of the random effect of Fokontany.

**Conclusion:-**

This study assessed the knowledge, attitudes, and practices of the population, implemented many communication tools, identified the tools that most reached people, and evaluated its own results. While some tools have a broader reach, the complementarity of these tools remains a better approach to reach many people to raise their awareness about rabies. However, future studies are needed at the territorial scale to generalize our findings.

**Conflict of interest**

All authors hereby declare no conflict of interest. The authors declare that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

**Ethics issues**

No ethical issues. This study received approval from the local administrative and health authorities. There was no risk for study participants during the application of the research. Oral and written consent were obtained from all participants involved in the study. Confidentiality and anonymity were assured. Participants had the right to refuse to participate or withdraw from the study without any rationale at any time. The questionnaires were administered to households, and each participant was informed of the study objectives, their voluntary participation, and their right to withdraw from the study if desired.

**Author contributions**

Daouda Kassié (DK) and Volatiana Randriafaraniaina (VR) contributed to the conception, design, the study implementation and data analysis; DK, VR, Arlette Florine Ravolatsara (AFR), Vincent Michel Rakotoharinome (VMR) performed the data collection; DK, VR, Arlette Florine Ravolatsara (AFR), Vincent Michel Rakotoharinome (VMR) and Eric Cardinale reviewed the results; DK wrote the first draft of the manuscript; All authors contributed to review the draft of the manuscript and wrote sections of it. All authors contributed to the manuscript revision, read and approved the submitted version.

**Funding**

This work was funded in part by the OneHealth-Indian Ocean platform (https://www.onehealth-oi.org/), Centre de Coopération International en Recherche Agronomique pour le Développement (CIRAD).

**Acknowledgments:-**

We are grateful to all participants in the study, the veterinarian of Menabe region, the Veterinary Services of Madagascar and all people who contributed to the progress of this project. We are thankful to the Institut Pasteur de Madagascar for hosting the research team and sharing operational resources.

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