Service-learning and community engagement yields benefits in zoonotic disease control: the case of rabies control in Mbuya II Zone in Kampala, Uganda

Service-learning and community engagement yields benefits in zoonotic disease control: the case of rabies control in Mbuya II Zone in Kampala, Uganda

Joshua Isiko¹, Samuel George Okech^1,&, Berna Nakanwagi², Samuel Majalija¹, David Okello Owiny¹, Margaret Khaitsa³, John Baligwamunsi Kaneene⁴, Florence Wakoko⁵

¹College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, PO Box 7062, Kampala, Uganda, ²Kampala Veterinary Surgery, Plot 1249 / PO Box 37111, Kampala, Uganda, ³Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, PO Box 6100, Mississippi, 39762, USA, ⁴Center for Comparative Epidemiology, College of Veterinary Medicine, Michigan State University, 736 Wilson Road, Room A-109, East Lansing, Michigan, 48824, USA, ⁵Columbus State University, 4225 University Ave, Columbus, Georgia, USA

^&Corresponding author
Samuel George Okech, College of Veterinary Medicine, Animal Resources and Biosecurity Makerere University, PO Box 7062, Kampala, Uganda

Introduction    

Rabies, a zoonotic disease commonly called “mad dog” disease is caused by the rabies virus that belongs to Rhabdoviridae family. Rabies is estimated to kill, on average, one person every ten minutes worldwide thereby killing between 24,000 and 70,000 people in Africa and Asia every year [1]. The incidence of human rabies in Uganda was estimated to be 42.4 - 56.73 per 100,000 people/persons in the period 2001 to 2009 [2] showing a general increase in number of rabies cases in Uganda. Rabies is transmitted to humans through bites or contact with saliva from rabid animals. The other susceptible animals such as livestock get clinical rabies from dogs and cats and any wild canines through bites. Dogs and cats get the disease mainly from the wild canines and cats that act as reservoirs [3]. Domestic dogs and cats have been highly associated with the introduction of the disease to livestock and humans leading to higher number of cases in Africa [4, 5]. The classic strategies of rabies control worldwide include dog and cat population management, mass vaccinations, concerted surveillance, community education, mass awareness and a mobilization program [6].

Human rabies has several factors contributing to its existence including free movement of domestic dogs and cats leading to contact with potentially infected stray animals including wild carnivores, the main reservoirs of the disease. Preventing dogs and cats from interacting with wild reservoirs of rabies may be achieved through community sensitization on dog and cat management, pet population control and the transmission pathway of the disease [6] which should be a multi-stakeholder concern. It needs integration of animal and public health experts, community, social scientists, government and non-governmental institutions, among others, in the concerted efforts for the control of rabies. Just as reported, [7, 8] communities must be involved in the fight against rabies in a holistic (One Health) manner through collaborative community engagement.

Collaborative community engagement is an important factor in the transfer of scientific expertise and statistical data for practicability in the complex community problem solving interventions. Expertise and statistical data become more efficient when community problems are viewed beyond professional boundaries. This involves harnessing community knowledge, skills of people, resources and unique contributions from various professions and organizations. Community involvement in problem solving achieves sustainability of the project in the community after the end of external funding support [9]. Furthermore, involving communities in problem solving leads to more effective, feasible, and responsive solutions, prevents repetition of ill-advised decisions, and enhances the acceptance and legitimacy of decisions [9]. In addition, integrating many experts in the intervention is reported to achieve better results in diseases management [3].

In 1994, Uganda adopted the multi-sectoral approach to disease control involving communities in problem and solution identification [10]. Additionally, in 2010 and 2011, the One Health approach involving veterinary, nursing and public health students and professionals was initiated and implemented in various parts of the country as part of the students´ professional training [11]. Such activities that provide students opportunity to offer service, reflect on the experience from which the onset is designed with a goal to cause students to attain learning outcomes as the community gains a service that can be characterized as service-learning fitting with the National Society for Experiential Education´s broad [12]. There are demonstrable achievements of service-learning implemented in different ways for science disciplines at higher education levels [13, 14].

There is need to evaluate and document contributions of interventions that involve many disciplines, different sectors, students and the communities in rabies control so as to establish their impact. This study focuses on assessing the effectiveness of an integrated approach, involving a suburban community in Uganda, to control rabies. The intervention also involved service-learning pedagogy in its design. The findings of this study contribute to practical approaches to the rabies control strategies in Uganda.

Methods     

Overview of the study

In July 2012, a collaborative community engagement to control rabies in Kampala, Uganda was jointly organized by the College of Veterinary Medicine, Animal Resources and Biosecurity (COVAB) at Makerere University, Kampala Veterinary Surgery (KVS), the Ministry of Agriculture, Animal Industry and Fisheries (MAAIF) and Ministry of Health (MoH) in Uganda. The other institutions that participated included “Akutwala Ekilo” Women´s group in Mbuya II Zone (community association), Capacity Building in Integrated Management of Transboundary Animal Diseases and Zoonoses project (CIMTRADZ), Tree Shade Primary and Nursery School in Mbuya and Mbuya Local Council leaders. The intervention, a service-learning activity for students from the disciplines of human and animal health, biotechnology, and animal production, was suburban-based and built on previous experiences in rural communities.

Study area

The study took place in Uganda, 241,550.7 square kilometers in surface area [15] located in East Africa at coordinates 1.0667° N, 31.8833° E. It is bordered by Kenya in the east, Southern Sudan in the north, Democratic Republic of Congo in the west, Rwanda in the south-west and Tanzania in the south. Uganda has a population of 35.4 million people with an urban population of 6.4 million [15]. While Uganda is estimated to have a total of 1,580,930 dogs and 640,690 cats, its central region has about 370,830 dogs and 141,310 cats [16]. Kampala, the Capital of Uganda, is located in central Uganda on the shores of Lake Victoria. It is divided into five divisions: Central, Kawempe, Lubaga, Makindye and Nakawa. Nakawa Division where Mbuya II Zone is located is East of Kampala city, and has a population of 5,795 people per square kilometer. This division is listed as one of the areas of Kampala with high population density, extreme poverty, hunger and violation of human rights [17]. Of the 41.2% of Kampala land under agriculture, Nakawa Division contributes the largest portion (35.1%) among other divisions [18]. The study population comprised residents of Mbuya II Zone located in Mbuya parish, Nakawa Division at coordinates 0° 20' 0" N, 32° 38' 0" E.

Overview of data collection approaches

Data collection tools and materials included: in-depth interview question guide, consent form and copy of intervention records. Data on the assessment of the effectiveness of the intervention was collected using methods including documentation, observation and in-depth interviews as described by Canadian Volunteerism Initiative project guide-evaluation tools matrix [19]. Participatory observation data was collected throughout the course of the intervention. Pictures were taken and field notebooks were used to record data on the activities of the intervention. Eighteen (18) days after mass vaccination of dogs and cats, in-depth interviews were conducted with twenty (20) interviewees selected by purposive and snowballing sampling methods as described previously. The in-depth interviews were stopped at the 20th interviewee when there was no more new information obtained. The information provided by the interviewees was recorded on individual semi-structured questionnaires.

Design and implementation of the community intervention

A technical team of thirty three (33) people from various disciplines (veterinary surgeons, veterinary students, biotechnology students, public health students, animal production students, sociologists) participated in the rabies control intervention. They performed two major categories of activities, 1) community sensitization and 2) animal health-related activities. The community sensitization was done through talks with school children of Tree Shade Primary and Nursery School, during a meeting with the women´s group, and also at the venue of the mass vaccination of animals (to members of the community who brought dogs and cats for vaccination). The message covered servant leadership; animal welfare; rabies - its dangers, transmission cycle, control measures and community´s role in its control. This intervention was also publicized by use of a horn loud speaker (“Ekizindaalo” in the local dialect). The animal health-related activities included mass vaccination and deworming of dogs and cats; demonstration of dog grooming and provision of advice on animal welfare and care. At the vaccination point, dogs, cats and their respective owners´ identities were registered. People who brought animals to the vaccination point were briefed about the public health and economic significance of animal welfare and rabies vaccination before any treatment was provided. Physical clinical examination of all animals was completed to ensure that only healthy animals were vaccinated to protect the desirable outcome of the vaccination. All animals were dewormed and groomed before discharge, both as a service but also as a demonstration to the owners of good companion animal management practices. The discharge message emphasized the value of vaccination of companion animals, the regimen of rabies vaccination and companion animal management tips including appropriate confinement procedures, feeding and general healthcare. Vaccination certificates indicating the type of vaccine used, the date of vaccination, date for the next vaccination and contact of the local veterinarian were issued to owners of every animal vaccinated.

Post-intervention in-depth interview

In-depth interviews were conducted 18 days post-intervention. The study population included all adult males and females who lived and/or worked within Mbuya Zone II, a suburb of Kampala city that was mostly residential. The residents were medium and low income earners with a few rich families - based on the nature of housing (slum-like areas to permanent multi-storeyed residential buildings) which was suggestive of the income levels. Twenty (20) community members purposively sampled using the snowballing sampling technique were selected (based on work and social life) for in-depth interviews. Every adult member of the community qualified to participate in the study irrespective of whether they owned companion animals (dogs and cats) or not. Verbal consent was obtained from all respondents and confirmed by signing consent forms. Translation and interpretation was done for respondents who could not read English before they made the decision whether or not to sign and participate in the study. Only those who accepted and signed consent forms were interviewed. Interviewees were requested to recommend the next respondent living within the community who they knew/believed kept at least one companion animal, and were asked about: their knowledge on rabies and its control and preventive measures, how they heard about the mass vaccination activity, their perception about the intervention exercise, their ownership of dogs or cats, and whether these animals were vaccinated or not. Through the interviews, vaccination coverage (percentage) was computed from the number of interviewees who took their dogs or cats for vaccination as the numerator and the total number of interviewees who had dogs or cats as the denominator.

Data analysis

Responses (from all the respondents) were analyzed by inductive content analysis method. Data were categorized into emerging themes for presentation. The categories included pet management, dog and cat ownership, knowledge about rabies, mobilization, mass vaccination and servant leadership meetings.

Results     

Results for the qualitative analysis are presented in five sub-sections: 1) ownership of dog and cat, 2) knowledge about rabies, 3) mass vaccination exercise, 4) mobilization, and 5) servant leadership meetings.

Ownership and welfare of dog and/or cat

Seventy percent (70%) of the respondents had at least a dog or a cat while some had both. Although the owners of the dogs and cats were always the family heads, it was mainly children who brought more dogs and cats for vaccination. Respondents who did not own any cat or dog confessed being close to and getting into contact with either domesticated dogs and/or cats from their neighbours or stray dogs and cats roaming freely in the community. While all the others owned and were content with mongrels, and only one respondent had a plan to own a purebred dog. All respondents reported that they provided food for their dogs and cats. However, in some instances the animals were partly fed from home and partly left free to scavenge as they were not confined within the premises of their owners. They observed that as a result, such animals would be at a higher risk of interacting with infected animals be they feral or stray. Some respondents were aware that dogs and cats needed confinement and vaccination and some reportedly confined their dogs during the day and freed them in the night to perform security functions.

Knowledge about rabies

Respondents reportedly acquired new knowledge about rabies from the sensitization done during the intervention. They reported that hitherto, they did not know that cats and other animals (different from dogs) were involved in the transmission of rabies, and further that even domestic animals are important players in the transmission of rabies. They earlier associated rabies with only stray dogs.

Mass vaccination exercise

Most of the respondents heard about the mass vaccination of dogs and cats against rabies at Tree Shade Nursery and Primary School, Mbuya. Eighty percent (80%) of the respondents who had either a dog or cat took their animals for rabies vaccination. Those who did not take their animals for vaccination reported to have not heard about the mass vaccination while others had new pets. One of the responses was “I enjoyed that day and it was a unique way of vaccinating dogs and cats”. Respondents reported learning about categories of animals that can be affected by rabies, ways of preventing rabies, and communities´ responsibility in controlling rabies. A total of 96 dogs and 23 cats were vaccinated on July 21, 2012 most of which were brought by children. Most people had their dogs and cats vaccinated, dewormed and groomed for the first time.

Mobilization

Eighty percent (80%) of the respondents heard about the event mainly through a door to door public announcement “Ekizindaalo” by the local council leaders of Mbuya II Zone. Some people learnt about the event through neighbors, friends, school announcements and posters. Some respondents learnt of the intervention on the very day of the event when they saw other people taking their companion animals for vaccination. Motorcycle taxi riders, locally known as “Boda-boda” or simply as “Boda”, widely distributed in the community, also played an unsolicited role of spreading the message as reported by some respondents.

Servant leadership meeting

Meetings held with the women´s association members and local leaders and school pupils were used for sharing information on servant leadership, animal welfare, and rabies control and also for sensitization about the subsequent activities of the intervention. All the respondents were willing to participate next time if such an event were organised. They promised to bring their animals, and even offered to bring their neighbors´ animals as well as mobilizing the rest of the community for the event. One of the respondents said, “I can even give them my car to bring the community´s dogs for vaccination against rabies.”

Discussion     

This community intervention was an integration of different principles including: community servant leadership training; interdisciplinary and intersectoral engagement; community engagement and service-learning. The team of service providers comprised of members from various disciplines including veterinary medicine, public health, biomedical laboratory technology, wildlife biology and social sciences. They worked together collaboratively with specific and shared roles to achieve a common goal which qualifies the intervention as an interdisciplinary approach [20]. This approach is similar to one encouraged for control and prevention of the neglected zoonotic diseases including rabies in Africa [21]. Integration of various approaches may have contributed to effectiveness of this intervention which included two of the three crucial activities in the control of canine rabies highlighted by “Canine Rabies Blueprint” [22]. Although three crucial activities are identified, the intervention in this study implemented only two of them (dog vaccination and rabies awareness/communication) as they are the first steps in the process, and also because the implementation of the third one (making post exposure prophylaxis (PEP) available and accessible) is largely a Ministry of Health activity that could not be implemented within this intervention. Although it is currently relevant to Uganda due to the endemicity of rabies (hence the probability of human infection and need for PEP), it is sound to argue, at least theoretically, that in situations where the first two activities are implemented well to reach the recommended 70% vaccination coverage [23] the need for the third activity would be greatly diminished. It has also been reported that the cost of rabies control in animals (through vaccination) is outweighed by the cost of PEP treatment of humans by far [24].

Professionals from human and animal health sectors with various skills worked as a team to plan, mobilize, sensitize the community and vaccinate dogs and cats against rabies,. This intervention applied inter-sectoral and interdisciplinary approaches typical of One Health focusing on integrating different disciplines to manage diseases [25]. This is required for successful community engagement and sustainability [26]. This approach was earlier reported as a strategy for achieving more success in controlling rabies [27, 28].

The success of this intervention was partly attributed to the involvement of the community which participated in mobilizing for the mass rabies vaccination. Related observations have been made elsewhere [26, 29]. The Local Council leaders (LCs) and group members used a simple public address system, the horn loudspeaker (locally known as “Ekizindaalo”), to inform the community to bring their dogs and cats for rabies vaccination. This is probably one of the factors that contributed to the high response and successful vaccination of 96 dogs and 23 cats. Most of the interviewees confessed that they heard about the vaccination exercise through this door-to-door announcement.

Most of the people who brought their dogs and cats confessed that their animals were vaccinated for the first time against rabies. Similar studies that involved communities reported that community engagement in disease control yields better results [7-9, 30]. For successful community engagement, the intervention has to take a longer time building relationships between the health organizations and the community [26]. However, this intervention took a shorter time compared to other interventions implemented and yet attained good response and results. It is possible that varied methods of mobilization and the involvement of local councils, and particularly the participation of children, could have contributed to this achievement.

Community engagement empowers the community to design and implement sustainable strategies and measures [9]. The intervention in this study aimed at imparting servant leadership and improving on the community knowledge regarding the transmission, impact, control and prevention of rabies. Qualitative analysis revealed the community´s willingness to participate in the next mobilization for vaccinations against rabies and also pay for the booster vaccinations, which demonstrates the spirit of servant leadership, and in turn focuses on the growth and well-being of people and the building of communities. The community was aware of their role in preventing and controlling rabies, a finding different from what is reported in India [31]. This signifies that the community´s ability to solve the problem of rabies improved, hence the empowerment.

Generally, African communities and authorities in several countries are not aware of rabies [32], and Uganda is no exception. Therefore, it was not surprising that the community of Mbuya Zone II had little knowledge on the involvement of cats and livestock in the rabies cycle. However, the post intervention interview conducted in this study revealed that most people were aware of rabies in dogs and humans, which is an achievement attributed to this intervention in Mbuya Zone II community. Most interviewees reported that it was during the intervention that they got to know that cats are involved in the rabies cycle. The low number (23) of cats vaccinated may be attributed to the lack of knowledge on the involvement of cats in the rabies transmission cycle. It is also possible that fewer cats are kept in homes in this community due to cultural influences, a factor earlier reported in another community [33]. Also, it is reported that communities in Uganda keep cats for controlling mice, rats and snakes in houses and less care is taken to look after them including not vaccinating [34]. Therefore, most cats are partly domestic and partly wild thus difficult to restrain for vaccination against rabies.

Most of the people who brought animals for vaccination were children. This justifies the need to involve children (5 = years) in the control and prevention of rabies. In this study, sensitization was conducted in one of the Nursery and Primary schools in Mbuya II Zone community which probably contributed to this and in turn contributed to the large number of animals vaccinated in the small area.

The high vaccination coverage achieved (80%) of the cats and dogs during this intervention was above the recommended highest coverage (75%) by the World Health Organization (WHO) [35]. This may be attributed to involvement of the community in mobilization, servant leadership meetings, and the interdisciplinary and inter-sectoral approach employed. Multidisciplinary and multi-sectoral approaches are recommended for effective rabies control [36]. Furthermore, such approaches have been reported to lead to development of trust in the interventions by communities [26]. The vaccination coverage (80%) achieved was comparable to that reported for the Agro-pastoralists community in Tanzania [37] and higher than 64.5 to 73.7% reported for a similar intervention in another community [36]. The Tanzania intervention used veterinarians only, while we involved local leaders in mobilization and meeting community groups and schools. This mobilization approach may have contributed to the high turn up for the rabies vaccination exercise. Additionally, Mbuya II Zone higher vaccination coverage was comparable to that reported for other peri-urban communities [38] compared to rural areas [36, 37].

The community education and vaccination of dogs and cats done in this intervention is one approach to rabies control. The design of this intervention did not include vaccination of stray dogs and cats, which are reported by respondents to be many in the area. Furthermore, it did not include spay and neuter clinics as population control measures for both stray and domestic dogs and cats, an indirect method for the control of rabies [39]. One of the challenges we experienced as reported earlier [40, 41] was inability to vaccinate all stray dogs due to lack of access (requires a lot of time and resources for capture and restraint that were not available to the team at the time). Although we do not believe that conducting pre-intervention interviews would have changed any observations made and findings reported in this case study, we recommend that interventions that will adopt this approach and are interested in quantifying changes should consider it. It might also be good to conduct exit interviews/surveys either to capture further information about the intervention or for related investigations as part of leveraging resources.

Conclusion     

Overall, the community engagement intervention for rabies control through service-learning was successful particularly in increasing vaccination coverage and should be incorporated into strategies for control of rabies and other infectious zoonotic diseases in Uganda and other communities.

Competing interests     

The authors declare no competing interest.

Authors´ contributions     

The primary author (Joshua Isiko) participated in the service learning activity to control rabies in Kampala city, Uganda; Dr. Khaitsa (CIMTRADZ Partnership Director & co-instructor), Dr. Kaneene (CIMTRADZ partner), Dr. Okech (lead instructor and coordinator of service learning activity), Dr. Nakanwagi (the local private partner clinic that provided human capital and material), Dr. Majalija (technical field instructor on public health issues), Dr. Owiny (College Dean and field activity manager) and Dr. Wakoko (promoter and researcher of the service learning education pedagogy) and the College of Veterinary Medicine, Animal resources and Biosecurity (COVAB) for planning and implementing the service learning activity. All authors contributed to writing the article, reviewed several drafts, and approved the version to be published.

Acknowledgments     

The authors wish to acknowledge all collaborators that participated in the project. Funding for the training of students from Makerere University was provided by US Agency for International Development (USAID) through Higher Education for Development (HED).

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