Assessment of the effect of animal bite management training, among frontline healthcare workers in a rural field practice area of Bangalore Medical College and Research Institute.
Rabies is the viral communicable disease caused by the Lyssavirus type I. It is primarily a zoonotic disease affecting the warm-blooded animals, which get transmitted to man through the bite of the infected rabid animals.  Domestic dogs are responsible for transmission of the virus in 99% of the cases. 
Rabies is present on all continents except Antarctica, with over 95% of the deaths occurring in Asia and African regions.  In India, around 18000-20000 deaths from rabies occur every year, contributing around 36% of the world's death from disease, around three-quarters of them occurring in rural areas.  Rabies most commonly occurs in the people of lower socioeconomic status (SES) and among the vulnerable population who live in the remote areas. 
Although rabies is a highly fatal disease, it is 100% preventable through prompt appropriate medical care  such as immediate washing of the wound with soap and water, which can reduce the chances of developing rabies by 80%, but unfortunately, very few patients get it in right time.  Through adequate animal vaccination, educating those at risk and enhancing access of those bitten to appropriate medical care such as wound wash, antivirus vaccination, and immunoglobulin can help to eliminate rabies among humans. 
According to the World Health organization, there is a lack of knowledge among the doctors and other health professionals about the appropriate management of the animal bite victims. 
One of the important aspects of the human component of the National Rabies Control Programme in India is to train the health professionals regarding the prevention of rabies. 
In rural areas, accredited social health activist (ASHA), Anganwadi workers (AWW), and auxiliary nurse midwife (ANM) are the first to come in contact with a victim of an animal bite, and first aid is usually sought from them.  They also act as the important sources to create and spread awareness among the population and for early referral to the health facilities for vaccination. Therefore, their knowledge, attitude, and practices (KAP) is crucial in reducing the incidence of this disease as they form an important link in the treatment of animal bite cases.
In India, most of the studies about KAP of rabies are done among the general populations or the clinicians. Studies done among the healthcare workers are rare. The studies done in Uttarakhand  among the health workers showed moderate knowledge, positive attitudes but less satisfactory practices regarding animal bite management. The study done in West Bengal  showed that there was a gap in the knowledge of the health workers which were filled up by giving the training to them. Hence, this study was conducted with similar objectives to assess the KAP gap among the frontline health workers and to train them, so that they can effectively manage animal bites among the people under their care and to assess the effect of training on KAP among them.
The objectives of the study were to assess the effect of animal bite management training, on KAP among frontline healthcare workers in a rural field practice area of Bangalore Medical College and Research Institute (BMCRI).
MATERIALS AND METHODS
Study Area and Study Population
An interventional study was done using health education by Information, Education, and Communication method as the intervention tool, during April-June 2017 among the frontline healthcare workers in Nelamangala, a rural field practice area of BMCRI. The frontline healthcare workers who did not give consent for the study were excluded from the study.
By taking 75.3% as the knowledge about the wound wash with soap and water following animal bites for 15 min from Kishore et al. study  with 5% allowable errors and 95% confidence interval, using the formula 4pq/[d.sup.2], the required sample size was calculated to be 131.
In Nelamangala rural field practice area, there were 127 ASHA workers, 42 ANM workers, and 287 AWW were present. By multistage random sampling and using population probability proportionate sampling method, a sample size of 131 was attained.
Method of Data Collection
After the Institutional Ethical Clearance, consent was taken from each individual and self-administered pre-tested and semi-structured questionnaire was used and data was collected on the knowledge, attitude and the practices regarding the animal bite management.
Following, health education was given, and post-training questionnaire was given after 1 month.
Data were entered into MS Excel sheet and analyzed in SPSS version 16 statistical software. Descriptive statistics were presented in tables and figures. Chi-square test was used.
All the 131 participants were females. Among them, 37 were ASHA workers, 82 were AWW, and 12 were ANMs. Around 14 were lost to follow-up in the post-interventional period. The 117 participants were considered in the final evaluation.
Among 117 participants, 53 (45.3%) had received some form of training regarding rabies previously, and 105 (89.7%) had heard about the disease.
About 95 (81.2%) of the study participants knew the wound should be washed immediately with soap and water as compared with 110 (94.0%) knew following the health education. About 45 (38.5%) had heard and knew the importance of rabies immunoglobulin whereas 117 (100%) knew about it following health education. About 103 (88.0%) knew the anti-rabies vaccination was available in Nelamangala PHC as compared to 117 (100%) following training.
Majority (53.4%) of the study population were in the age group of 31-40 years [Table 1]. Majority (34.35%) of the study population were belonging to the Class III of Modified B G Prasad (2016) classification of SES [Table 2]. Before intervention majority of the health workers (106) knew only dog as the animal transmitting rabies to humans, whereas in post-intervention period majority (87) knew that all warmblooded animal bites can potentially transmit rabies [Figure 1]. About the sites of bites which are dangerous, the knowledge increased in the post-intervention period. Following the intervention, many (113) had known that bites anywhere in the body can be dangerous and should not be neglected [Figure 2]. Regarding the knowledge of first aid measures to be taken following animal bites, the misconceptions such as applying tight bandages and application of herbal medicines were clarified. Knowledge regarding the correct methods of first aids was improved in the post-interventional periods [Figure 3]. Only 28 (24%) knew the correct technique of washing the wound for 10-15 min under running tap water with soap and water before the intervention and 102 (87.2%) knew it following the intervention [Figure 4]. Only 9.4% of the study participants knew about both four and five doses schedules of anti-rabies vaccination which improved to 52.1% in the post-interventional period [Table 3]. Only 4.3% of the study participants knew about both intradermal and intramuscular routes of vaccination, which improved to 35.04% in the post-interventional period [Table 4].
Around 91 (77.8%) agreed that following the animal bites, tetanus toxoid injection is needed and 114 (97.4%) agreed following health education.
Among the participants, 60 (51.3%) told there is no need for anti-rabies vaccination if the vaccinated animals bite. 47 (40.2%) told it is required and 10 (8.5%) told they do not know about it. Post-training, 98 (83.8%) agreed that it is needed. Among the participants, 96 (82.1%) agreed that rabies is the preventable disease which was increased to 113 (96.58%). Majority, 99 (84.6%) had the misconception that rabies can be cured completely once symptoms appear, which was reduced to 36 (30.76%).
The attitude was changed significantly (P < 0.05) among the participants with respect to the indication of anti-rabies vaccination among pregnant and lactating mothers, following the bite by the younger animals, in cases of repeated bites and about diet restrictions in animal bite victims [Table 5].
Before the intervention around 88 participants had seen animal bite victims, for whom majority 52.3% had not given any treatment. Following the educational intervention, in 1 month, around 46 participants had seen the animal bite victims, and majority had given wound wash (91.3%) and referred to the hospitals for immunization. [Figure 5]
In our study, it was found that there were knowledge lacunae with respect to the sources of infection; only 4.27% participants knew that all warm-blooded animals are the potential sources of infection. Majority knew only dog (90.5%) as the source of infection. These knowledge lacunae can cause negligence of bites by the other warm-blooded animals. This was improved with the health education to 74.35% of the participants knowing all the potential sources of infection. Knowledge about the need of wound washing was improved from 81.2% to 94% following the intervention. The false conceptions regarding the first aid measures such as application of irritants, herbal medicines, and tight bandages were solved following the intervention to the minimum to zero levels. Wound washing technique was not properly known by majority before the intervention, which was improved from 24% to 87.2%. Even though wound washing can help to reduce the chances of developing the disease and kills the virus, insufficient and improper technique will serve no much help. Knowledge regarding the routes and dosages of the ant rabies vaccination is crucial as they can advise the victims to adhere to the Regimen. In our study, the knowledge was found to be poor 4.3% and 9.4% which increased to 35.04 % and 52.1%, respectively. The attitude was changed positively toward the need of anti-rabies vaccinationamong pregnant women, repeated exposures and following bites from the immunized animals. The practices were also changed significantly among the participants following the health education; wound wash was given by majority (91.3%) of the participants to the animal bite victims, following the intervention. Hence, the intervention was found to be useful in filling up the gap in knowledge, changing the attitudes and the practices of the participants.
Similar findings were found in a study by Dasgupta et al.  on the effectiveness of health education on knowledge regarding rabies among health workers of West Bengal: The number of respondents giving correct responses to the knowledge questions regarding the rabies agent, the transmission, category of bites, management, dose, schedule, route, etc., was significantly improved following the health education. In a study by Kishore et al.  on the KAP assessment in health workers regarding rabies disease and its prevention in district Dehradun of Uttarakhand found that all the 162 health workers had heard about the disease and all knew about the major mode of spread. The knowledge regarding the first aid; 75.3% knew need and correct method of wound washing, 22% knew about need for antiseptics, which was much higher than the knowledge among our study participants as in our study, ASHA and AWW are also included along with ANMs. In a study by Tschopp et al.  on dog demography, animal bites management and rabies KAP in Eastern Ethiopia, showed that the source of infection was unknown by 25% of the respondents. Transmission route from animals to humans was thought to be through bites, saliva, milk, and/or meat consumption, while 37.5% did not know the route. Cure for rabies was said to be good disinfection of the bite wound, injection, and post-exposure prophylaxis (PEP). Knowledge about the number of PEP injections needed by a patient, 2 medical staff did not know, 2 said 2 injections, 2 said 14 injections, 4 said 17 injections, and 1 said 18 injections. Study by Nguyen et al.  on awareness of rabies prevention and control measures among public health workers in Northern Vietnam showed that overall knowledge was patchy. Important gaps in knowledge were identified particularly in relation to indications for rabies vaccine and rabies immunoglobulin and routes of exposure to rabies virus. One in 10 respondents did not know that rabies virus could be transmitted by the bite of an infected animal.
This study was carried out in a rural field practice area, as the need and role of the grass root workers are more in rural areas where majority of rabies deaths occur in India. This study mainly focuses on improving the knowledge, changing the attitude and practices among all the grass root workers such as ASHA, AWW, and ANMs who act as the first point of contact and play an important role in management cycle. Since the majority of the studies were done among the medical students, nursing staffs, and general practitioners, the results cannot be compared to their qualifications and role in management cycle is different.
The knowledge lacunae were found and were improved with training. The misconceptions regarding animal bite management were also improved with the health education. Practices were changed in terms of providing the wound wash before referring to the hospitals. Thus, the health education was found to act as an effective intervention in reducing the misconceptions, improving the knowledge and practices regarding the management of animal bite victims.
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Sofiya Crastha, Selvi Thangaraj
Department of Community Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
Correspondence to: Sofiya Crastha, E-mail: firstname.lastname@example.org
Received: March 19, 2018; Accepted: April 26, 2018
Table 1: Age distribution of population (n=131) Age group (year) Number (%) 20-30 24 (18.3) 31-40 70 (53.4) 41-50 26 (19.8) 51-60 11 (8.4) Table 2: Modified B G Prasad (2016) classification of SES (n=131) Class n (%) I 7 (5.34) II 19 (14.50) III 45 (34.35) IV 40 (30.53) V 20 (15.26) SES: Socioeconomic status Table 3: Knowledge about doses of anti-rabies vaccine (n=117) Number Pre-intervention (%) Post-intervention (%) of vaccines required One 2(1.7) 0 Two 5 (4.3) 2 (1.7) Four 27 (23.0) 34 (29.1) Five 32 (27.4) 20 (17.1) Four or Five 11 (9.4) 61 (52.1) Fourteen 23 (19.7) 0 Do not know 17 (14.5) 0 Table 4: Knowledge about route of anti-rabies vaccination (n=117) Site of Pre-intervention (%) Post-intervention (%) vaccination Intradermal 36 (30.8) 42 (35.8) Intramuscular 16 (13.7) 34 (29.05) Both IM and 5 (4.3) 41 (35.04) ID Abdomen 29 (24.8) 0 Do not know 31 (26.5) 0 Table 5: Attitude regarding the animal bites management amongst the health workers Attitudes Number (%) Pre-intervention Post-intervention Anti-rabies vaccine can be given to pregnant and lactating mothers Agree 71 (60.7) 107 (91.4) Disagree 17 (14.5) 10 (8.5) Do not Know 29 (24.8) 0 (0) Anti-rabies vaccination needed following the bites of the younger animal Agree 83(71) 109 (93.2) Disagree 21 (18) 8 (7) Do not Know 13 (11.2) 0 (0) Anti-rabies vaccine needed in case of repeated bites Agree 82 (70.08) 96 (82.05) Disagree 22 (18.80) 21 (18) Do not Know 13 (11.2) 0 (0) Diet restrictions should be done to the animal bite victim Agree 21 (18) 10 (8.6) Disagree 81 (69.2) 107 (91.4) Do not Know 15 (12.8) 0 (0) Attitudes P* Anti-rabies vaccine can be given to pregnant and lactating mothers Agree <0.001 Disagree Do not Know Anti-rabies vaccination needed following the bites of the younger animal Agree 0.031 Disagree Do not Know Anti-rabies vaccine needed in case of repeated bites Agree 0.008 Disagree Do not Know Diet restrictions should be done to the animal bite victim Agree <0.001 Disagree Do not Know * Chi-square test was used Figure 1: Knowledge about the animals transmitting rabies (*multiple responses considered) Pre-Intervention Post intervention Rat 7 2 Snake 4 0 Only Dogs 106 30 Wild 1 0 animals Warm blooded 5 87 animals Figure 2: Knowledge about the at-risk sites of an animal bite (n=117) Pre- intervention Post-intervention All bites 99 113 Face and head 2 Genital bites 2 Hands and legs 14 4 Figure 3: Knowledge about the first aid treatment following animal bite (*multiple responses considered) Pre intervention Post intervention Irritants at home 5 2 Tight bandage 6 5 Washing with soap and 104 115 water Herbal medicine 3 0 Antiseptics 12 26 Note: Table made from bar graph. Figure 4: Knowledge about the wound cleaning duration following an animal bite Pre- intervention Post-intervention 10-15 mins 28 102 15-10 minutes 55 9 11-5 minutes 21 4 Do not know 13 2 Note: Table made from bar graph. Figure 5: Practices about the treatment of rabies Pre-intervantion (N=88) Post-intervantion (N=46) No treatment 19 6 Wound wash 23 42 Directly sent 46 11 to hospital Note: Table made from bar graph.
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|Title Annotation:||Research Article|
|Author:||Crastha, Sofiya; Thangaraj, Selvi|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Aug 1, 2018|
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