Mass dog vaccination is the most effective approach for interrupting canine rabies transmission. However, current vaccination strategies are typically centralized and conducted annually, leaving some communities excluded and with few opportunities to vaccinate their dogs. A community-based continuous mass dog vaccination strategy was piloted in the Mara region of Tanzania. We investigate factors that influenced the delivery of this approach and how the processes were sustained over two years.
Methods
We employed mixed methods to explore what influenced vaccination delivery. We conducted in-depth interviews (n = 24) and focus group discussions (n = 12) with implementers and community members, and non-participant observation of vaccinations (n = 172 h). We documented time spent by dog owners attending campaigns (n = 610) and how dogs were handled (n = 696), and audited how components of the community-based continuous approach were delivered (n= 47). Qualitative data was analyzed thematically, and regression and descriptive statistics used to assess factors affecting delivery.
Main findings
Factors that facilitated participation in the campaigns included delivering vaccination free of charge, more frequent availability of vaccinations, and co-implementation with communities. Limiting factors were distance to vaccination points, difficulties in handling dogs and vaccination schedules conflicting with local socioeconomic activities. Sub-village level campaigns were more accessible and required less time from dog owners.
Interpretation
Involving community-based persons facilitated planning and advertising of campaigns. Mass dog vaccination campaigns can achieve and maintain herd immunity if organized at least twice a year and at subvillage levels. Educating vaccinators and communities on dog behavior and handling could improve participation in campaigns.
community-basedmass dogprocess evaluationrabiesvaccinationLyssavirusThe author(s) declared that financial support was received for this work and/or its publication. Funding for the postgraduate study of (CTD) and supervision by (EM & KK) was received from the DELTAS Africa Initiative [Afrique One-ASPIRE/DEL-15-008]. Afrique One-ASPIRE is funded by a consortium of donors, including the African Academy of Sciences (AAS), Alliance for Accelerating Excellence in Science in Africa (AESA), the New Partnership for Africa’s Development Planning and Coordinating (NEPAD) Agency, the Wellcome Trust [107753/A/15/Z] and the UK government. The mass dog vaccination and research activities were funded by the Department of Health and Human Services of the National Institutes of Health [R01AI141712]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dog vaccines were donated by MSD Animal Health. Funding for researchers was from the Wellcome Trust [207569/Z/17/Z and 224520/Z/21/Z]. None of the funders had a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.section-at-acceptanceNeglected Tropical DiseasesIntroduction
Rabies is a viral zoonosis of mammals, mainly transmitted to humans through the bites of infected domestic dogs (1, 2). Once rabies infection progresses to clinical disease, death is inevitable (3). Each year, approximately 59,000 human rabies deaths occur globally and about 550 in Tanzania (4). Yet, rabies is 100% vaccine-preventable in both humans and dogs. The most cost-effective approach for rabies prevention is mass dog vaccination (3). Different modes of delivering dog vaccination campaigns have been deployed in different settings including temporary static points, house-to-house, capture-neuter-vaccinate-release, and use of oral vaccine baits, as well as coupling vaccination with dog population control measures (5).
Modeling of the impact of mass dog vaccination on rabies transmission showed that consistently sustaining vaccination coverage above 25-40% of the domestic dog population for several years interrupts transmission among domestic dogs and therefore prevents transmission to humans, livestock and wildlife (6–8). Dog vaccination has eliminated rabies from high-income countries, but examples of elimination from low- and middle-income countries (LMICs) remain limited, with Mexico the only country validated as free from human rabies since the global strategy to end human rabies deaths, ‘zero by 30’, was launched (9). When implemented, the degree of success in controlling rabies can be attributed to how dog vaccination campaigns have been i) designed, planned and delivered, ii) affected by complex socio-economic activitiesof targeted communities, and iii) how the intended beneficiary communities received and or participated in the processes (10, 11).
Like in most rabies-endemic countries, the organization of dog vaccination in Tanzania has been top-down, centralized, and annually conducted (hereafter referred to as the pulse approach). This approach provides limited agency for the targeted communities to manage and tailor the delivery processes to their local circumstances (10–13). Consequently, even when campaigns have been offered free of charge, dog owner participation has not always been adequate (12–14). Additionally, it has been amply documented in the Americas (5, 15, 16), Africa (17–20) and Asia (21) that, in addition to how campaigns are planned, factors such as owner knowledge of dog behavior, handling techniques and ownership practices, impact participation.
Decentralized community-based vaccination approaches have recently been developed in Tanzania. These approaches resulted from two discoveries: First, following storage at ambient temperatures (< 25 °C), the potency of the Nobivac® Canine Rabies vaccine was maintained for up to six months (22); and second, the potency was also maintained following storage within a locally engineered passive cooling device, which, despite ambient temperatures reaching 40 °C, kept storage temperatures under 25 °C (23). These findings allowed novel decentralized community-based approaches to be designed so that rabies vaccines could be stored for several months within communities without cold chain facilities. Hence, the approach could be managed by community members and allow vaccination to be provided year-round, i.e., as a community-based continuous mass dog vaccination (CBC-MDV) strategy.
We hypothesized that the CBC-MDV approach could overcome participation problems associated with centralized delivery and thus result in coverage being sustained above the 40% needed to attain herd immunity and interrupt transmission. To investigate this, CBC-MDV was piloted in the Mara region of Tanzania and demonstrated coverage remained above 60% thoughtout the year (24). An evaluation of the implementation processes also demonstrated that it was feasible to deliver the components of CBC-MDV with high fidelity to the protocol (25) Additionally, normalization process theory was employed to investigate the feasibility of integrating CBC-MDV into the context of communities and the veterinary system of Tanzania as a standard approach for delivering dog vaccination (26).
Following on from this, the objective of this paper is to explore how design-, context- and implementer-related factors influenced the delivery of CBC-MDV over a two-year period and to provide formative insights into how CBC-MDV can be optimized and contextualized when replicated in other settings. Additionally, the paper explores how community engagement, coordination and delivery of the mass dog vaccination activities, and outputs were sustained over two years.
MethodsStudy setting
The study was implemented in three rural districts (Butiama, Rorya and Tarime) of the Mara region, bordering on the south with Serengeti and Bunda Districts, on the west with Lake Victoria, on the east with the Serengeti National Park and with Kenya to the north. These districts are home to four major ethnic groups who are primarily engaged in pastoral and agro-pastoral activities, such as fishing, livestock keeping and trading.
The pilot vaccination was delivered at the ward level of these districts from July 2019 to August 2021. In Tanzania, administrative wards are clusters of three to four villages (streets in urban districts), each divided into sub-villages (ranging from 2–13 per village in the 35 study villages where CBC-MDV was delivered). Sub-villages comprise approximately 50–150 households, which are grouped into units of ten, headed by leaders called “mabalozi”. The wards targeted were purposively selected to include a range of geographies, cultures, levels of urbanization, microclimates, agricultural activities, and dog ownership practices, all of which could influence participation in dog vaccinations (25) (Figure 1).
Mara region showing pilot districts and wards where CBC-MDV was delivered. The administrative shapefiles were downloaded from the Tanzania Bureau of Statistics website in January 2022.
Map of the Mara Region in Tanzania highlighting selected wards by intervention strategies: red for Strategy 1, green for Strategy 2, blue for Strategy 3, and navy for Pulse Wards. Key geographic features include Serengeti National Park, Lake Victoria, and district boundaries. An inset map shows the region's location within Tanzania.
The vaccination activities took place in four wards in each district: three wards from each district were randomly assigned to receive dog vaccination through one of the three novel CBC-MDV strategies, and the delivery and outcomes were compared to that of a fourth ward that received vaccination by the standard pulse approach.
Description of the intervention
In contrast to the pulse approach [described in Lugelo et al. (24)], where mass dog vaccination (MDV) campaigns are conducted once annually, the CBC-MDV was designed to provide continuous access to dog vaccination. The CBC-MDV approach was developed during five iterative workshops held between May 2018 and May 2019 by the research team in association with district, regional and national veterinary and health officers, the local government and One Health officials from the prime minister’s office and the WHO’s coordinator for Neglected Tropical Diseases in Tanzania (25). Following this development process, the 45 components of CBC-MDV were detailed in a Manual to guide implementation (Supplementary File 1).
Three different strategies were piloted to investigate ways CBC-MDV could be delivered: 1) Strategy One - central point campaigns delivered quarterly at village levels; 2) Strategy Two - central point campaigns delivered quarterly at sub-village levels, and 3) Strategy Three - delivery approaches chosen at the discretion of implementers and communities. In all strategies, dog owners were allowed to request that their dogs be vaccinated ad hoc at any point during the year (on demand).
CBC-MDV was delivered by district livestock field officers (DLFOs) (who managed vaccination logistics and supervised the campaigns, n = 3), ward livestock field officers, designated as Rabies Coordinators (RCs) (who organized the vaccination campaigns, n = 9), and village-based One Health champions (OHCs), (who mobilized communities and advertised the campaigns, n = 35). These implementers were trained in a three-day workshop focused on CBC-MDV and skills for its delivery, that included practical sessions in a selected village. Full description of CBC-MDV following the Template for Intervention Description and Replication (TIDieR) Checklist was made (Supplementary File 2).
Study design
We employed mixed methods to explore the two-year pilot delivery of CBC-MDV at the district, ward, and village levels. This involved interviewing implementers and community members, observing vaccination campaigns and quantifying delivery activities through auditing the implementation process.
Data collectionIn-depth interviews and focus group discussions
To explore the experiences of implementers and communities with the delivery of CBC-MDV, we conducted in-depth interviews (IDIs; n = 24) with the DLFOs (n = 3), RCs (n = 7), OHCs (n = 8) and community leaders (n = 6). Whilst every DLFO and RC was interviewed, OHCs and community leaders were purposively selected to ensure district representation. We conducted focus group discussions (FGDs) with the RCs and OHCs (n = 3, involving 9 RCs and 35 OHCs), community leaders (n = 3, involving 35 leaders), and community members (n = 6, involving 24 men and 29 women aged 15–71 years). Participants in the community members’ FGDs were purposively selected for representation of leadership, age groups and genders across the 35 villages.
The interviews and FGDs were conducted between December 2019 and July 2020: both used topic guides (translated into Swahili) and were conducted in Swahili by an experienced interviewer, in person and following participants’ consent to be interviewed. The IDIs and FGDs lasted 18–65 minutes and were recorded with an Olympus VN-541PC voice recorder.
Non-participant observations
To document factors that acted as facilitators, barriers, or drivers of variation during advertising and delivery of vaccination campaigns, we conducted non-participant observations (NPO; n = 172 hours) using a structured proforma guide. The proforma guide queried: i) advertising methods/activities; ii) advertising timing and message content; iii) reactions of villagers to advertising; iv) what influenced the timing of, and turn out at vaccination campaigns; vi) fidelity to protocol; (vii) if implementers were able to deliver the CBC-MDV components and vii) the enhancers and barriers that they faced.
The topic guides and proforma guide were revised after the first three interviews and observations, respectively, to ensure validity and effective administration.
Documenting intervention delivery
Semi-structured questionnaires were administered to implementers at month 0, 6 and 12 (n=47) to document how CBC-MDV was delivered, and to document observed variations to the implementation manual and reasons for variations.
Dog owner participation and dog handling
We documented the time spent by dog owners attending vaccination, the number of animals brought by dog owners, and vaccinated according to strategy used. The documentation occurred during nine vaccination events that took place in month three of Year Two. These campaigns were purposively selected to ensure equal representation across the districts. Numbered cards were given to dog owners when they arrived at the center, and the time and the number of dogs they brought were recorded on the cards. The cards were collected once they completed the vaccination process and the time was recorded allowing time spent to be calculated.
We documented whether a dog struggled during inoculation, and collected relevant data such as the age of the persons who brought the dog and how each dog was restrained (‘owner-held only’ or ‘owners assisted’).
How the delivery of key CBC-MDV activities and outputs were sustained
We explored whether the momentum of campaign activities and numbers of animals vaccinated were sustained over the two years. To do this we documented a) how frequently the implementers delivered components of CBC-MDV that were aimed at engaging communities during delivery rounds timed at months 0, 6 and 12, b) comparing the number of days the implementers spent conducting vaccinations in Year One and Two, and c) the total number of animals vaccinated in Year One and Two. Attrition (the rate at which implementers left the project) over the two years was recorded and the status of CBC-MDV equipment and challenges associated with supply and management of logistics were audited. All the data collecton tools are compiled in Supplementary File 3.
Data analysisFactors that influenced the delivery of CBC-MDV
Data from IDIs and FGDs were transcribed verbatim and translated into English. The transcripts, together with field notes from NPOs were assigned unique identifiers and imported into NVivo 12 Plus version 20.7.1.1534.
Data were coded by the first author (CTD), guided by a coding manual developed by CTD and the second author (SW), following the 7-stage framework method (27). CTD and SW independently applied the coding manual to five transcripts. They then met repeatedly to clarify coding differences until a consensus was reached and the coding frame finalized. All transcripts were then read and coded. The coded extracts were studied to explore the experiences of implementers and communities concerning the delivery of CBC-MDV.
Factors that influenced (facilitated or hindered) the delivery of CBC-MDV were identified and classified as relating to i) the design of CBC-MDV, ii) the delivery of CBC-MDV and iii) contextual elements.
We employed a linear model (with Poisson error structure) to explore how factors, such as the vaccination strategy, the number of animals brought by a dog owner and the number of dogs vaccinated on the day, influenced the time dog owner’s spent attending a vaccination campaign. We used descriptive statistics to explore how dogs were handled during inoculation.
How the delivery of CBC-MDV was sustained
The number of times the teams delivering CBC-MDV implemented activities aimed at bringing communities on board (sensitization, engagement, discussing schedules with community leaders and providing feedback to communities), were compared during implementation at months 0, 6 and 12. The days spent by each strategy team on vaccination campaigns and the number of animals vaccinated were compared between Years One and Two. The attrition rate among the implementers and the experiences of vaccinators with the supply of vaccination materials over the period were reported.
All quantitative analyses were performed in R version 4.2.1 (28).
ResultsDesign-related factors that influenced CBC-MDV deliveryCost
Implementers and community members held the view that the main encouragement to their participation in the campaigns was the vaccination of dogs for free:
“Frankly, the major policy which caused the community members to bring their dogs is that the vaccination is free of charge” [OHC-31, Implementation Audit, District 3].
“So, the good thing is they have brought this service near to us and no one pays even a hundred shillings” [P10, Adult Female FGD, District 2].
They asserted that charging fees will prevent people from bringing dogs for vaccination:
“People like free services, if you say they have to contribute they will not come, the government should vaccinate our dogs for free” [Community Leader, IDI, District 2].
“If only it doesn’t involve costs because many citizens fear cost. Cost is the biggest barrier but if there is no cost then I think there is no problem” [DLFO, IDI, District 2].
During the non-participant observations on advertising alone, eight people asked if there was rather a vaccination for chicken and cattle.
Accessibility
The additional opportunities for dog vaccination provided by the CBC-MDV approach were appreciated by community members and implementers:
“[ … ] the dog vaccination service is more available now and more dogs are vaccinated” [P9, Adult Male FGD, District 3].
“The community-based strategy is good because we also had time to educate people about rabies” [RC-5, Implementation Audit, District 2].
CBC-MDV provided dog owners with continuous access to vaccination as intended. However, this created some challenges for implementers as owners appeared less committed to vaccinating their dogs at a specified time:
“You will find out that you had assured a person you would visit his household the next day to vaccinate the dogs for free but you will arrive there only to find out he is not around. So, the difficulty which we have seen is that the community doesn’t consider this as a serious case” [RC-5, IDI, District 2].
Community involvement
The use of village-based OHCs to lead the organization of campaigns at village levels was noted to have facilitated mobilization of dog owners and navigation of sociocultural and physical terrains. This was important from the point of view of a community leader:
“The use of people selected at the village level; those who came from the community, it was easy for them to reach everyone and explain the bad effects of rabies” [P9, Community Leaders FGD, District 3].
Community entry and engagement processes were not carried out as planned: none of the nine vaccination teams reported conducting community engagement, only two of 35 OHCs were introduced at village meetings and only four of the nine teams discussed campaign timetables with a village leader in the first year of implementation.
Some community members expressed the view that engaging the community more could facilitate the process:
“This problem (rabies) can be eliminated if implementers will cooperate with the community [ … ]. When implementers engage the village leaders, then the leaders will involve the whole community” [P1, Adult Females FGD, District 2].
Implementers reported that involving village leaders in the process was helpful:
“Also, by working with the village government (leadership), together with the RC we got a good timetable; on a day that was easy for the community members to bring their dogs” [OHC-34, RCs & OHCs FGD, District 3].
Advertising
In CBC-MDV delivery, advertising of campaigns was by village-based OHCs who had more time to advertise (1–3 days before campaigns) and used different media, including school sessions, social gatherings (religious, funerals and village meetings) and pasting posters at vantage points in the villages. Using megaphones either on foot or bicycles, the OHCs could reach houses on the village periphery. From the views of implementers and community members, the CBC-MDV advertising methods were more effective than the pulsed approach at spreading information.
“Formerly people only got information after the vaccination team had left. But now with this new strategy, we go hamlet by hamlet to give information about the campaigns so many people become aware and we have seen the response” [OHC-6, OHC IDI, District 1].
“This strategy has benefits to society in terms of dog vaccination because it creates more awareness among the people” [P6, Adult Male FGD, District 3].
Implementation design
The CBC-MDV strategies determined the number of days the various teams spent conducting vaccination; the distances dog owners had to cover to reach vaccination points and the time they spent attending the vaccinations.
Campaign days
Over the two years, the mean days to complete the vaccination activities per village was 6.9 for Strategy One (main campaigns at village-level), 15.8 for Strategy Two (main campaigns at sub-village-level) and 6.9 for Strategy Three (discretionary strategy). The strategy designs that focused on more localized vaccination generally required more days, e.g., the Strategy Three team of District 2 conducted sub-village level campaigns during month 1 of Year One and took 35 days to reach all sub-villages of the ward. The vaccinators observed this impacted their other responsibilities:
“The strategy had challenges because of the number of days it took but the researchers wanted to know which strategy was the best so we had to follow although it interfered with other activities” [RC-6, Implementation Audit, District 2].
Travel distance
Hosting the vaccination at the village center (Strategy One) meant that people on the outskirts of the village had to travel several kilometers with their dogs to reach the vaccination point. This was a widely shared concern among community members who considered walking their dogs for a long distance as unsafe (as they may encounter aggression from other dogs) or tedious:
“It is the long distance from my home to the vaccination center, I can’t bring a dog from that far because it can cause any danger along the way” [P1, Young Mixed FGD, District 1].
“It is the distance from my home; by the time I reached the vaccination center I was very tired from handling the dog” [P4, Young Mixed FGD, District 1].
The implementers also faced a similar challenge:
“The other challenge is the distance between hamlets, it is difficult to find a central location in some villages” [RC-1, Implementation Audit, District 1].
Some implementers switched from Strategy One to Two by resorting to organizing campaigns at the sub-village levels to surmount these challenges:
“Many dogs remained after the first village-level campaign, we then vaccinated at the sub-village level; the sub-village level is very good for reaching more dogs” [RC-1, Implementation Audit, District 1].
Time required
One key contribution dog owners make in taking their dogs for vaccination is their time. During the first round of campaigns, we observed that people attending village-level central points had to wait for up to six hours to have their dogs vaccinated and were heard complaining.
“[ … ] and sometimes you find the vaccination center had a very large number of people and your dog could miss vaccine and it can suffer from rabies” [P7, Young Mixed FGD, District 1].
Dog owners had to spend more time at campaigns held at village levels rather than sub-village levels and at campaigns that vaccinated more dogs on the day (Table 1).
Determinants of owner-time-spent during vaccination campaigns.
Variable
Coefficient
CI 2.5-97.5%
P-value
Intercept
1.76
1.71 – 1.81
0.0001
Level of campaign (village)*
0.26
0.23 – 0.30
0.0001
Number of dogs the owner brought
0.00
-0.02 – 0.02
0.9810
Number of dogs vaccinated
0.01
0.01 – 0.02
0.0001
*Levels of campaign – sub-village (baseline) and village.
Context-related factors that influenced vaccination deliverySocial and environmental factors
non-participant observations and implementation audits showed the campaign schedules and durations were affected by rainfall and farming activities, sociocultural events like month-long puberty rites celebrations, funerals and school sessions, nationwide activities like livestock vaccinations, elections and censuses, and local livestock auctions, that also deployed RCs. Implementers considered these when scheduling vaccinations:
“The main thing we considered is days that do not interfere with social activities, for example, there are some days on which there are markets so if you plan to conduct the vaccination exercise on that day people won’t come” [P6, RCs & OHCs FGD, District 3].
“For us here during the farming season, is either you will be on the farm or your dog will be there to protect the crops from those monkeys” [OHC-35, Implementation Audit, District 3].
The scattered nature of most houses also impacted transport needs during advertising, house-to-house or on-demand vaccination and OHCs household visits after each round to document pregnant dogs or dogs needing vaccination:
“The first challenge is transport, there are some remote areas of the village that are difficult to reach by foot, you need to hire a motorcycle” [P3, OHC, RCs & OHCs FGD, District 1].
Financing
All 35 OHCs thought they should be given allowances of 10,000 shillings per campaign day. The majority (40%; 14) of OHCs reported that the sub-village chairpersons or ‘mabalozi’ they contacted to work with requested payment. All district-, ward- and village-level implementers thought they were not adequately financed to deliver certain activities (such as supervision and advertising) on CBC-MDV:
“We also faced a challenge when advertising because the OHCs were not adequately financed to recharge the megaphones and to move around, some villages are big so you have to use a motorcycle to move around. (…) So, we are requesting that when doing such kind of work adequate funds should be allocated to enable the champion to move easily” [P4, RCs & OHCs FGD, District 3].
Perceived impact
There was a strong belief that the vaccine prevented dogs from getting rabies and reduced economic losses:
“We had the problem of dog bites for a long time and when we go to hospitals there were no post-exposure vaccines, and when you find it, it was costly. But now it is easy, you ask if the dog was vaccinated, and if the answer is yes, then only normal injury treatments will be given to the person” [Community Leader, IDI, District 2].
However, some community members expressed concerns that following vaccination dogs might die (16 times), become infertile (2 times), lose the ability to bark (2 times), stop hunting (1 time), or develop rashes (1 time). One OHC reported that:
“There is someone spreading information in one sub-village that dogs will die when vaccinated” [OHC-24, Implementation Audit, District 3].
Dog handling
during observations of campaign advertising, one of the commonly heard responses from community members was complaints about their dogs being fierce and their inability to bring them to vaccination points:
“When you advertise, people will respond my dog is fierce, I cannot bring it” [OHC-20, Implementation Audit, District 3].
From group discussions with dog owners, they pointed out that their ability to restrain and bring their dogs to vaccination points also influenced their decision to participate:
“Sometimes you will find the dog is fierce and refuse to walk so you have to postpone taking it to the vaccination” [P5, Young Mixed FGD, District 1].
Some owners then invited the vaccinators to vaccinate their dogs at home:
“The few challenges which we had were there were some dogs which are very aggressive, [ … ] the owner will come and say my dog cannot come here” [P1, RCs & OHCs FGD, District 3].
Not everyone who brought a dog was able to restrain it. Vaccinators perceived this as a limitation:
“… also, some people bring their dogs but they are afraid of them hence OHC or RC was supposed to help them in handling the dog” [P2, RCs & OHCs FGD, District 2].
In total, 696 inoculations were observed across nine vaccination campaigns. Of these, 122 (18%) dogs struggled. As observed, irrespective of age, owners who showed stronger bonding with their dogs and those who applied appropriate dog-handling techniques mostly had their dogs vaccinated without struggle. Dog aggression and struggling during inoculation tended to be frequent with more dogs at the center.
We observed that when a dog struggled during the inoculation and microchipping processes, it took longer to finish, and sometimes vaccinators refrained from vaccinating dogs that were struggling.
Implementer-related factors that influenced vaccination delivery
Non-participant observations and implementation audits revealed that how implementers understood certain CBC-MDV components and had skills to deliver them influenced their delivery decisions. For example, some OHCs (6 of 35) thought they were to work with sub-village chairs instead of ‘mabalozi’ (10-house unit leaders) to estimate dog populations and monitor vaccinations in those units.
To minimize dog aggression at vaccination points, vaccinators were taught to separate the registration and inoculation desks by at least 20 meters, identify potentially aggressive dogs and muzzle them beforehand. But, none (of 9) of the vaccination teams were observed to implement these measures; registration and inoculation points were at the same spots; none were seen applying knowledge of dog behavior to calm dogs so they could muzzle or inoculate them; and some vaccinators thought muzzles provided were not always useful or strong enough:
“I have one piece of advice on the dog muzzles, they should be strong and have big holes so we can use them for dogs of different sizes” [P8, OHC, RCs & OHCs FGD, District 3].
Availability of RCs
Comments from OHCs suggested that official and personal businesses of RCs influenced their availability for vaccination campaigns, which impacted vaccination schedules. RCs, who were all government officers, had to deliver services including livestock dipping and treatment, meat inspection, and collection of levies at livestock markets. In addition, RCs also had their personal business activities to attend. This was a source of frustration for some OHCs:
“I had difficulty, we will prepare the community for vaccination campaigns then later I may find that my RC has other commitments” [OHC-15, IDI, District 3].
Sustaining implementation
Out of five CBC-MDV components (community engagement, scheduling campaigns with community leadership, advertising before the start of campaigns, community self-monitoring of campaigns and providing feedback to communities) aimed at bringing communities on board the implementation process, only two (scheduling campaigns with community leadership and advertising campaigns) were implemented. None of these five components were done from months 6 – 12.
Overall, vaccination teams spent the same number of days (237) conducting campaigns in Year Two as in Year One. The days spent decreased sharply after the first round of vaccinations; 80% and 78% were spent on the first and second rounds of Year One and Year Two respectively. Despite spending the same number of days in Year One and Year Two, fewer dogs were vaccinated per village across all the strategies in Year Two. The percentage reduction differed across strategies (Figure 2): Strategy One - main campaigns at village levels (44%), Strategy Two - main campaigns at sub-village levels (26%) and Strategy Three – discretionary campaign strategies (15%).
Number of animals vaccinated and days spent per village on the campaign in each of the three campaign strategies.
Bubble plot with three panels comparing strategies for vaccination outcomes per village versus campaign days per village. Panel one shows higher vaccinations in the first year with fewer days. Panel two shows moderate outcomes with larger bubbles for the second year. Panel three shows highest vaccinations in the first year and more campaign days in the second year. Bubbles represent campaign days; pink for the first year, blue for the second year.
Our observations of advertising and central point campaigns in Year Two showed many dog owners were not accustomed to the campaign design to vaccinate their dogs yearly. Upon hearing the announcement, they mostly responded, “What if my dog was vaccinated last year”?
At a central point campaign, a young adult insisted:
“I have vaccinated my dog recently, there is no need for me to bring it again” [Young Male, NPO, Central Point Campaign, District 3].
Attrition of implementers
One of the 47 OHC implementers (2%) left their position in the two years of the study. The district- and ward-level implementers saw dog vaccination as a part of their responsibilities. In response to ease of completion, their experiences are summed up as follows:
“It was easy (to make time) because it is among my responsibilities” [RC-4, IDI, District 2].
And 34 out of the 35 village-based OHCs described their roles as service to their communities and said that they wished to continue.
Logistical issues
The state of the equipment used in CBC-MDV was audited. Four of the nine locally made passive cooling devices cracked within the first year. Two of the nine temperature loggers mounted on the cooling devices to monitor internal temperatures stopped functioning within the first year. All nine teams reported a delay in delivery of requested vaccine and vaccination materials in the second year and shortages of at least one item. This highlights some issues that need to be dealt with to ensure the momentum of campaign activities is sustained.
Discussion
Following on from the process evaluations of the pilot trial (25), this study has explored how design-, context- and implementer-related factors influenced the delivery of CBC-MDV and has provided insights into how CBC-MDV can be optimized when replicated in other settings. To this end, the study demonstrated the following key findings: i) that providing vaccination for free promoted participation in the campaigns in both CBC-MDV and the pulse approach; ii) the continuous (quarterly campaigns and vaccination on-demand) strategies provided more vaccination opportunities to dog owners; iii) participation was improved by the more extended and community involvement in advertising and the more accessible sub-village level central points; iv) however, delivery of CBC-MDV was challenged by weak community engagement, difficulty in restraining dogs and sociocultural factors.
Both implementers and community members believed that high dog owner participation was because dogs were vaccinated free of charge. This has generally been the case for MDV where fee charging has been cited as a barrier to participation (13, 29, 30). A key part of Mexico’s strategy for eliminating human rabies was the designation of dog vaccination as a public good (9). Other studies have shown that investing in free dog vaccination is needed to achieve herd immunity, with healthcare savings at the system and individual levels (31–34), and higher cost-effectiveness compared to owner-charged campaigns (29, 35).
We repeatedly found that an important contributory factor to why dogs may not be vaccinated was the inability to restrain them both at home and at vaccination points. Handling challenges has been widely reported as a reason why people do not take their dogs for vaccination in countries in the Caribbean (36), South America (15), Asia (21), and Africa (37) including Tanzania (17). Inability to restrain dogs can result from fear and anxiety of dogs at the vaccination station, mishandling, lack of adequate knowledge of dog behavior, and dog territoriality or aggression; issues that can potentially be overcome through education (38).
Achieving adequate dog-owner participation hinges to a large extent on effective rabies education and community buy-in. The Global Alliance for Rabies Control asserts that the benefits of rabies education include improved human-dog relationships, increased participation in dog vaccination, decreased dog bites and increased adherence to PEP (39). Regarding rabies education, one uncertainty in planning and implementation of annual campaigns is the need for booster vaccinations and how messages are communicated to dog owners. For the vaccine used in this study, a single dose protects for three years, so annual booster vaccinations should not technically be required. However, advocacy, communication and implementation are simplified if owners are advised to bring every dog for vaccination every year. This would also provide greater assurance of protection if some dogs were not adequately immunized in any one campaign. We, therefore, suggest owners be advised of the benefits of booster vaccination even if they have previously vaccinated their dogs.
The experiences with CBC-MDV showed that advertising a few days before the vaccination day may have ensured dog owners had ample time to prepare. The reach of the campaign advertisers in CBC-MDV, going off the main community roads to reach households on the outskirts, as also reported by other studies, enabled greater reach (37, 40). Strategies to ensure campaigns are sufficiently close to the majority of dog owners, such as holding campaigns in sub-villages, also make it easier to participate (36, 41–43) and reduces the time that owners must wait for their dogs to be vaccinated. As might be expected, people were discouraged from participating when having to travel over long distances and endure long waiting times.
The type of strategy implemented and the number of rounds of vaccination conducted each year had implications for both access of dog owners to vaccination and workload for vaccinators. Given the veterinary resource constraints in many rabies-endemic countries (44), careful consideration is needed as to how to balance the time of animal health workers in delivering essential services. Findings from other process evaluations in the public health sector show that when faced with time constraints, implementers reduce the frequency of delivery or omit intervention components (45). Furthermore, as pointed out by the implementers of CBC-MDV, providing too many vaccination time points and house-to-house visits may even be counterproductive, creating a sense of complacency among owners. A balance needs striking between providing vaccination annually, as in the pulsed approach, which leads to coverage troughs between campaigns, and providing vaccination more regularly which can overburden implementers and induce dog owner complacency. Essentially, the strategy choices including the number of campaign rounds per year need to be contextualized to the local population, and what fits the schedules of both implementers and communities. This highlights the need to involve local actors at the conception stage of campaign strategies.
In this regard, both implementers and community members pointed out that the use of community-based implementers (OHCs) facilitated the delivery of CBC-MDV components and mobilization of owners. Similar effects were observed for community-based mass drug administration campaigns against onchocerciasis and trachoma in Cameroon (46) and Tanzania (11), respectively. Community-based personnel can enhance the ability of the implementation team to carry out their duties due to their knowledge of, and ability to better maneuver local terrains. The experiences of implementers in CBC-MDV and the views of community members reveal that community-based personnel are also more likely to foster trust and increased acceptance of the intervention by the local population. This was also observed in the delivery of interventions against Neglected Tropical Diseases in Uganda, Tanzania and Zambia (10, 11), in which the advantages of local implementers were accentuated when dealing with culturally homogenous communities (11). Further, and in a broader sense of intervention delivery, local implementers usually come with reduced operational costs and superior contextual knowledge which helps to tailor delivery to local circumstances (44). However, ample time should be given to training local implementers to assimilate the intervention strategies and ensure implementation is undertaken as intended or reconfigured intentionally.
It follows that the delivery of CBC-MDV could have been less impacted seasonally (by farming, markets, and cultural celebrations) if communities had been involved in planning. To maximize reach, the delivery of CBC-MDV should be strategically planned around the socio-economic activities of targeted communities. This requires participation of local actors at all stages of the process to facilitate the identification of the most suitable windows for dog vaccination (10, 11). For many rural Tanzanian communities, the most appropriate periods would likely be just at the ends of farming seasons (e.g., when people are less busy), outside of rainy seasons, local sociocultural events, other nationwide animal/human vaccination programs and national election and census periods, but during school vacations when children can bring dogs (10, 11, 25). Planning to account for these periods would likely improve delivery.
Involving communities could have other positive influences on vaccination delivery. In Tanzania, community leadership has significant agency, such that engaging them in CBC-MDV could result in communities taking leading roles in planning, implementing and enforcement of dog vaccination, incorporating dog vaccination into annual itineraries, allocating financial and material resources to vaccination delivery, and assigning village members to deliver certain components of CBC-MDV with appropriate remuneration (11). The responsibilities of such members may include rabies education, building a village dog registry, advertising, assisting during campaigns (to restrain dogs, issue certificates and mark vaccinated dogs), conducting post-vaccination transects for coverage assessment, and identifying households with dogs yet to be vaccinated. This community buy-in, as cited in the delivery of other community-based interventions, can increase community support for and participation in dog vaccination (47–49).
It is worth noting, therefore, that with time, communities were less involved, for example in scheduling campaigns. Sustaining vaccinations over successive years requires a clear understanding from the community that these are long-term programs and that control of rabies can only be achieved if enough dogs are vaccinated year after year. Community involvement at the planning stages of CBC-MDV could, for example, have afforded the ‘mabolozi’ the opportunity to openly discuss their roles and financial benefits ahead of the start of campaigns, and this could have fostered ownership and support among the ‘mabolozi’. On the other hand, the district and ward-level implementers saw CBC-MDV as part of their routine work, and the village-based OHCs also viewed their participation as a service to their communities, likely explaining the low attrition among implementers. However, close monitoring of the logistics supply and maintenance of equipment is needed to ensure challenges are promptly resolved to sustain delivery.
Conclusions
Key factors influenced dog owner participation and vaccination coverage that can be achieved through CBC-MDV strategies and need to be appropriately addressed for optimal outcomes. Owners were encouraged to participate through the provision of vaccines free of charge, and by the proximity and accessibility of vaccination centers to the majority of households and higher frequency of campaigns. However, caution needs to be taken regarding the workload for implementers and the potential for dog owners to become complacent due to the increased number of campaigns. Campaign schedules should be planned to avoid clashes with local socioeconomic activities and stronger community engagement is needed to sustain buy-in and participation. While the involvement of community-based implementers encourages owner participation, sufficient training, time, and resources are also needed to ensure compliance with implementation guidelines and to build confidence in safe handling of dogs.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
The studies involving humans were approved by Institutional Animal Care and Use Committee, Washington State University [Approval No. 04577 – 001], The Tanzania National Medical Research Institute [NIMR/HQ/R.8a/Vol.IX/2788], The Tanzania Regional Administration and Local Government [AH.213/420/01] and the Ifakara Health Institute [IHI/IRB/No:024-2018]. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
The authors would like to acknowledge the Government of the United Republic of Tanzania for providing a conducive environment to implement this research. In particular, the authors are grateful to the veterinary authorities of Rorya District Council, Butiama District Council and Tarime Town Council for granting administrative permission for the research activities. The authors wish to extend their gratitude to Ifakara Health Institute, Nelson Mandela African Institution of Science and Technology, the National Institute for Medical Research and the Tanzania Commission for Science and Technology for permission to undertake this research. The authors wish to acknowledge the contributions of the following persons: Machunde Bigambo for his supporting role to the vaccination campaigns; Thekla Mushi and Elizabeth January for conduction the interviews; Bertha Lwakatare and Fadhila Kihwele for translating and transcribing the interviews; and Elaine Ferguson for assisting with making of the map study site.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that generative AI was not used in the creation of this manuscript.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fitd.2026.1746125/full#supplementary-material
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Edited by: Walter Muleya, University of Zambia, Zambia