A web-based cross-sectional survey was conducted among residents of Palestine from March 2025 to August 2025 to assess rabies awareness, knowledge, and related practices. The study setting is characterized by a heterogeneous landscape comprising urban cities, rural villages, and refugee camps, each with varying levels of infrastructure and municipal capacity, particularly regarding veterinary services. Due to logistical constraints and the geographically fragmented nature of Palestine, a non-probability snowball sampling strategy was employed. This approach was used for feasibility rather than representativeness and relied entirely on online dissemination. A structured, pre-validated questionnaire was adapted from Al-Mustapha et al. (12).

The survey link was disseminated using digital snowball sampling through university networks, community organizations, local social media groups, health-awareness forums, and municipality pages. Participants were encouraged to share the survey within their personal and community networks. While this approach enabled the survey to circulate across different governorates, it reached only individuals with stable internet access and active online engagement, and therefore should be understood as a convenience sample of digitally connected respondents, rather than coverage of the broader population. Because household visits and offline recruitment methods were not feasible, the online method did not ensure inclusion of individuals without internet access particularly older adults, residents of remote rural areas, and lower-income groups. Self-reported residence categories (urban, rural, and camp) were collected for descriptive purposes only and should not be interpreted as evidence of population-level representation.

The questionnaire was reviewed for content and face validity by multiple experts to ensure clarity and functionality. It was self-administered in Arabic and hosted online via Google Forms, distributed exclusively through social media platforms (e.g., Facebook, WhatsApp). The survey link was initially distributed by the research team to “seed” participants across different governorates, who then shared it within their networks. Because this non-probability digital sampling design inherently excludes individuals without adequate internet access, the sample reflects only those reachable through online referral chains. Participation was voluntary and anonymous, with no incentives offered, and the study does not claim representativeness of the general Palestinian population.

A total of 417 respondents participated in the study. The target population comprised adult Palestinian residents (≥18 years). Eligibility was determined based on self-reported demographic data provided in the initial screening section of the questionnaire. Inclusion criteria required participants to be residents of Palestine, aged 18 years or older, and capable of reading Arabic. To minimize bias arising from specialized professional knowledge, we explicitly excluded healthcare professionals (human and veterinary) and students in these fields. While the study aimed to recruit from diverse localities, we acknowledge that the reliance on online sampling creates a “digital divide” bias. Consequently, even among respondents from rural areas, the sample likely over-represents those with higher literacy and socioeconomic status, while individuals without internet access who may be at varying risks for rabies exposure are effectively excluded. As this was an anonymous web-based survey, independent verification of age, residency, and professional status was not feasible; thus, eligibility relied entirely on the honesty of respondents’ self-declarations.

Prior to data collection, we estimated a baseline sample size using standard formulas (Raosoft® sample size calculator) with a 95% confidence level and a 5% margin of error. Since this is the first study to assess rabies knowledge in Palestine, no prior prevalence data were available; therefore, we used a conservative response distribution of 50% to maximize variance and yield the largest required sample size. This calculation resulted in a minimum target of 377 respondents. However, we acknowledge that this formula assumes probability-based simple random sampling, whereas this study employed a non-probability snowball recruitment strategy. Consequently, the calculated sample size served as an approximate operational target to ensure sufficient data volume for analysis, rather than a definitive threshold for statistical power or generalizability. We further recognize that while obtaining a sample size (n = 417) larger than the calculated target improves the precision of estimates within the sampled group, it does not correct the systematic selection bias inherent to the non-random sampling design.

The questionnaire was adapted from a previously published survey on rabies in Nigeria (12). It was translated into Arabic by bilingual experts and back-translated to ensure linguistic validity. The survey instrument was focused exclusively on assessing awareness, knowledge, and practices. Attitudes were not measured in this study. To ensure the instrument’s suitability for the Palestinian context, the Arabic version was pilot-tested among 15 adults from the target population to assess clarity, flow, and comprehensibility. Feedback from this pilot led to minor refinements in wording, and the final version was approved by an expert panel prior to data collection. The questionnaire’s awareness section asked respondents if they had ever heard of rabies. Those answering “yes” moved on to the knowledge section, which included items on the cause of rabies, its symptoms, modes of transmission, and prevention measures. Each knowledge item was multiple-choice or multiple-response with correct answers predetermined based on scientific fact. The practices section covered topics such as intended actions after a dog bite (e.g., washing wound, seeking medical care), dog confinement habits (e.g., tethering indoors), willingness to have a veterinarian vaccinate one’s dog, typical dog feeding and care practices, sources of dogs (e.g., buying, adoption), and how dogs are managed when they can no longer be kept. Given the low prevalence of dog ownership in the study population (4.8%), restricting practice questions to current owners would have yielded an insufficient sample size for analysis. Therefore, hypothetical scenarios (e.g., “if you owned a dog…”) were utilized to assess the latent preparedness of the broader community. We acknowledge that these hypothetical responses reflect intended behaviors rather than actual observed practices and may be subject to social desirability bias. Demographic items used standard categorical formats (e.g., age in ranges, education level). The questionnaire structure and content closely followed the original Nigerian study, with any necessary cultural adaptations. The internal consistency of the knowledge items was assessed using Cronbach’s alpha coefficient, which was calculated at 0.728, indicating satisfactory reliability for the study population. Unlike the knowledge scale, practice items were analyzed individually using frequencies and percentages rather than as a composite scale score. This analytical approach was chosen because the items represent conceptually distinct and independent behaviors that do not measure a single underlying construct. Calculating internal consistency reliability coefficients like Cronbach’s alpham would be inappropriate for such heterogeneous behavioral items, as low inter-item correlations reflect the multidimensional nature of the practices rather than poor measurement quality.

Completed survey data were downloaded from Google Forms and exported into SPSS (version 26) for analysis. Completed questionnaires were coded and entered into a database for analysis. Descriptive statistics summarized the sample: frequencies and percentages for categorical variables (e.g., gender, education, residence) and means (±SD) for continuous measures. Knowledge responses were scored by assigning one point for each correct answer and only those who had heard of rabies contributed to the knowledge score calculation. A composite knowledge score was computed by summing all correct responses (across cause, symptoms, transmission, prevention, and control questions) for each respondent. Scores were converted to a percentage of the maximum possible; consistent with prior studies, we classified scores ≥50% as “satisfactory” knowledge. This threshold was chosen to establish a baseline of fundamental awareness necessary for rabies prevention, this threshold represents a minimum competency level, indicating that respondents correctly answered at least half of the knowledge items, and has been validated in similar survey-based assessments of rabies knowledge in endemic settings (11, 12). We report the mean knowledge score (and SD) and the proportion of respondents with satisfactory knowledge. Practices items were analyzed via frequencies (e.g., percentage who own dogs, who would take a bite victim to the hospital, etc.).

To identify factors associated with satisfactory rabies knowledge, multivariable logistic regression analysis was performed among the 371 respondents who had heard of rabies. Socio-demographic variables were recoded for analysis: age was grouped into four categories (18–25, 26–35, 36–45, ≥46 years), education into low, medium, and high, employment into employed, student, and not working, locality into city versus village/camp, and household economic status into low, average, and high. Knowledge scores were dichotomized at 50% (≥7.5 out of 15) to classify knowledge as satisfactory versus unsatisfactory, consistent with established conventions in health knowledge assessment research. Prior to analysis, logistic regression assumptions were systematically assessed. Variance Inflation Factors (VIF) for all predictors ranged from 1.10 to 2.35, all well below the acceptable threshold of 10, indicating minimal multicollinearity. Model fit was evaluated using the Hosmer-Lemeshow goodness-of-fit test, which yielded χ² = 8.06 (df = 8, p = 0.427), indicating adequate calibration, with an area under the ROC curve (AUC) of 0.649 reflecting modest but acceptable discrimination. Sample size sufficiency was verified with at least 10 outcome events per predictor variable. Univariate logistic regression was performed for each predictor, and variables were then entered simultaneously into a multivariate model to estimate adjusted odds ratios with 95% confidence intervals. Statistical significance was set at α = 0.05 using two-sided tests. However, given the non-probability snowball sampling design, we explicitly acknowledge that these inferential statistics (p-values and confidence intervals) cannot be generalized to the wider Palestinian population. Instead, they should be interpreted descriptively as exploratory associations within this specific convenience sample.

Handling of Missing Data: Prior to analysis, data were screened for missing values. Given the online nature of the survey, responses were mandatory for all Rabies-related items, minimizing missing data. However, for demographic variables, any cases with >10% missing responses were excluded from the final analysis. For cases with ≤10% missing values, mean imputation was applied to maintain statistical power.

The study protocol was reviewed and approved by the Institutional Review Board of Al-Quds University. All procedures conformed to the ethical standards of the Declaration of Helsinki. Before beginning the survey, participants were presented with an online informed-consent statement explaining the objectives, procedures, voluntary nature of participation, and confidentiality measures. Only those who consented were allowed to proceed. Data were collected anonymously; no personally identifying information was obtained. Participants were informed that they could withdraw at any time without penalty. Survey data were stored securely and accessed only by the research team.

A total of 417 respondents completed the survey. Reflecting the nature of the online recruitment strategy, the sample exhibited a substantial demographic skew toward younger and more educated individuals. 36.7% were aged 18–25 years and 22.5% were 26–35 years. The sample was 55.4% female. Participants resided mainly in Hebron (32.9%), Salfit (19.7%), and Ramallah/Al-Bireh (17.3%), with smaller proportions from other areas; Over half of the respondents lived in urban areas (52.3%), 44.8% in rural communities, and 2.9% in refugee camps. Educational attainment was high: 62.1% held a university bachelor’s degree and 10.8% had postgraduate education, whereas only 1.0% had no formal education. Over half were employed (56.6%), with students and housewives comprising 19.2 and 10.8%, respectively. Most reported an average household income (68.8%), with 19.7% low income and 11.5% high income. We acknowledge that this overrepresentation of digitally connected respondents likely inflates the reported awareness and knowledge scores compared to the general population and may influence the strength of the observed regression associations. (Table 1).

Most respondents (89.0%) reported having heard of rabies. These 371 respondents completed the knowledge assessment. The knowledge scale consisted of 15 items covering causes, symptoms, transmission, and prevention, with a possible score range of 0 to 15. The overall mean knowledge score was 6.71 (SD 3.54), corresponding to a mean knowledge percentage of 44.7%. Using the pre-defined cut-off of ≥50% to indicate a minimum competency level, fewer than half (42.3%) achieved a “satisfactory” knowledge level (≥50% correct). Only 56.9% correctly identified a virus as the cause of rabies, but 20.8% admitted they did not know the cause. Other misconceptions persisted: 17.0% thought it was caused by bacteria, 3.0% by protozoa, and 2.4% by fungi. Respondents were asked about rabies symptoms (multiple responses allowed) and the most commonly recognized symptoms were behavioral changes (46.6%) and seizures (45.3%). Other symptoms cited included fever (46.1%), hydrophobia (36.7%), inability to swallow (31.8%), paralysis (19.4%), dropped jaw (7.5%) and pica (11.9%); 21.6% responded “I do not know” to the symptom question. Most respondents understood that dog bites can transmit rabies – 81.4% identified dog bites as a mode of transmission. A majority (59.3%) also recognized that the virus can penetrate open wounds via dog saliva. All other listed transmission routes had lower recognition, and 9.2% reported “I do not know” for transmission routes. Regarding prevention of human infection from dogs, 58.8% of aware respondents identified human vaccination as a preventive measure, and 65.0% identified mass vaccination of dogs. A smaller proportion mentioned other measures, for example 35.6% suggested killing stray dogs and 32.6% incorrectly suggested antibiotics. Only 9.7% answered “do not know.” For control of rabies in the dog population, 65.0% recommended mass dog vaccination and 54.2% recommended public awareness campaigns. Other options – killing stray dogs (40.4%) and spaying (41.5%) – were cited less frequently, and 9.7% said “do not know” (Table 2). This indicates that although basic awareness of rabies was high, detailed knowledge of symptoms and control measures was limited in most participants. (Table 2).

All 417 respondents answered the practice questions. However, only 20 respondents (4.8%) reported current dog ownership, while 397 (95.2%) did not own dogs. It is important to note that the practice results below represent a mix of actual behaviors (among the 20 dog owners) and hypothetical or intended responses (among the 397 non-owners) (Table 3). For example, non-owners were asked how they would respond if they owned a dog or experienced a dog bite, whereas dog owners reported their actual practices. This distinction should be considered when interpreting the findings, as hypothetical intentions may not fully align with actual behaviors. In the event of a dog-bite, 83.2% of respondents indicated they would take the victim to a hospital or health facility, and 11.8% said they would immediately wash the wound with soap and water. A small proportion reported other actions: 1.0% self-treat, 1.0% use traditional medicine, 0.5% take the victim to a spiritual healer, and 2.6% said they would do nothing.

Almost all respondents (95.9%) stated they would allow a certified veterinarian or trained veterinary technician to vaccinate their dog, whereas 4.1% would not. Regarding dog confinement, 38.8% said they would always confine their dog, 37.4% sometimes confine it, 7.2% would never confine it, and 16.5% were unsure. If they owned a dog, 57.1% indicated “everybody” would primarily care for it, 39.1% said the father, and small minorities said the mother 2.4% or children 1.4% In terms of feeding, 64.3% reported they would feed commercial dog food, 54.2% family leftovers, and 14.6% would cook a special pot for the dog.

Among all respondents, 8.4% said they would obtain a dog by buying one, 3.8% by finding or rescuing one, 3.1% by gift, and 1.4% from offspring of an owned dog. The majority 78.7% stated they do not plan to own a dog. If a dog could no longer be kept, 70.0% of respondents said they would give it away to someone else, 20.6% said they would sell it, and 9.4% said they would not give it away. Finally, when asked about veterinary services in their community, only 7.4% felt services were adequate, whereas 67.9% felt they were inadequate and 24.7% were unsure.

Among the 371 respondents who had heard of rabies, multivariable logistic regression identified several demographic factors significantly associated with satisfactory knowledge. Age was inversely associated with knowledge: in multivariate analysis, those 36–45 years old had OR = 0.49 (95% CI: 0.24–0.99; p = 0.048) and those ≥46 years had OR = 0.35 (95% CI: 0.17–0.73; p = 0.005), each relative to 18–25-year-olds. Education again showed strong associations: medium education was associated with higher knowledge (OR = 2.86, 95% CI: 1.02–8.03; p = 0.046) and high education with even higher knowledge (OR = 4.66, 95% CI: 2.23–9.72; p < 0.001) versus low education. On univariate analysis, students had greater odds of satisfactory knowledge (OR = 1.75; p = 0.043) but this was not significant after adjustment. No significant associations were observed for gender, locality, or household economic status in the multivariate model. These results are detailed in Table 4.

The findings of this study carry several important policy implications for public health authorities in Palestine. Strengthening national mass dog vaccination programs is essential, given the central role of dog-mediated transmission and the widespread public perception of inadequate veterinary services. Expanding dog vaccination coverage particularly in rural areas requires improved veterinary workforce capacity, mobile vaccination campaigns, and coordinated partnerships with municipalities and local NGOs. Likewise, access to timely post-exposure prophylaxis (PEP) must be improved through decentralizing availability to primary healthcare centers, ensuring continuous vaccine supply chains, and training frontline health workers in standardized rabies management protocols. Enhancing rabies surveillance systems, integrating human and animal health reporting, and promoting public awareness of PEP availability are also critical steps. Taken together, these policy actions would substantially strengthen Palestine’s capacity to prevent rabies and reduce reliance on personal knowledge or informal practices after animal bites.

This study has several notable strengths. It represents the first large web-based survey on rabies awareness, knowledge, and practices in Palestine, providing important preliminary insights to guide future public health initiatives. The use of a validated, pre-tested questionnaire adapted from previous studies enhances the reliability of the findings and facilitates meaningful comparison with research conducted in other rabies-endemic regions. Although derived from a non-probability, web-based convenience sample, the large number of respondents improves the precision of estimates within this digitally connected population. The inclusion of diverse sociodemographic variables such as age, education, and geographic location allows for a nuanced description of factors associated with rabies-related knowledge and practices. Finally, ethical rigor was maintained throughout the study, with informed consent obtained from all participants and ethical approval provided by Al-Quds University.

Despite its strengths, this study has several limitations. First, the cross-sectional design limits our ability to draw causal inferences, as it only captures a snapshot of rabies knowledge and practices at one point in time. Second, the online snowball sampling method may have introduced selection bias, as it likely overrepresented younger, more educated, and digitally connected individuals while underrepresenting older or rural populations who may have limited internet access. This limits the generalizability of the findings to the broader Palestinian population. Third, self-reported data is prone to social desirability bias, particularly regarding health-related behaviors, as participants may have overstated their intentions to seek medical care or vaccinate their dogs. Finally, the lack of direct observation of actual behavior (such as seeking care post-bite) limits the ability to confirm whether respondents’ reported practices align with their real-world actions.

To build upon the findings of this study, longitudinal research should be conducted to track changes in rabies knowledge and practices over time, particularly after the implementation of targeted educational interventions. Randomized controlled trials or intervention studies could be used to evaluate the effectiveness of different educational campaigns aimed at improving knowledge of rabies transmission, prevention, and first-aid practices. Additionally, future studies should consider using more representative sampling methods, such as random household surveys, to ensure that all demographic groups, especially those without access to the internet, are adequately represented. Further research into the barriers to seeking veterinary care, including both logistical and attitudinal factors, would help to better understand how to improve access to rabies prevention services. Geographically expanded studies across rural and underserved areas of Palestine would provide a more comprehensive picture of regional differences in rabies knowledge and prevention efforts. Lastly, canine morbidity and rabies surveillance are critical to better understanding the actual burden of rabies risk in Palestine, and studies that track dog bite incidents and veterinary reports of rabies will help to refine control strategies.