Infectious Disease · Medical Literature
Implementing mass dog rabies vaccination through a community-based continuous approach: A socio-anthropological process evaluation.
Abstract
Mass dog vaccination to control rabies usually involves centralized planning and team-led annual campaigns. We evaluated the implementation processes of a decentralized, community-based continuous approach to mass dog vaccination (CBC-MDV), delivered as an arm of a randomized controlled trial (RCT) across the Mara region, Tanzania. We employed the socio-anthropological framework to assess the implementation process of the CBC-MDV approach. We embedded a mixed method process evaluation into the RCT and conducted in-depth interviews with district and village-level implementers, focus group discussions with ward-level implementers and community leaders and members, non-participant observation of the campaigns, and an audit of the vaccination campaign activities. We analyzed the resulting data following the five domains of the socio-anthropological framework. Refining the five domains, we report that 1) Environmental context affected CBC-MDV campaigns, which were interrupted by rainy and farming seasons, school schedules, market days and funerals, whilst village size and routes of access reduced their reach. 2) Social difference and pressures, and community involvement influenced delivery; cultural celebrations and social statuses of implementors hindered delivery, while by-laws and perceived rabies risk improved delivery. Community involvement facilitated implementation, but there was a need to strategically select who did what and how. 3) Strategies and incentives affected implementers, who were motivated by training and resources provided, and delivered 88% of components as planned. 4) Socio-materiality and resilience of intervention strategies and tools made it feasible to deploy the required equipment across a wide geographic scale, with adequate vaccination opportunities, but implementers found house-to-house and on-demand strategies demanding and less effective than central point delivery. 5) Governance also affected delivery with closer supervision by veterinary officials and community leaders, and co-reflexive appraisal of implementation with communities constrained by resource limitations. CBC-MDV with local storage of dog vaccine can be deployed across the rural landscape of Tanzania. Deeper involvement of communities in planning when and how campaigns are conducted, and in the appraisal of outcomes can significantly address barriers to dog-owner participation. The socio-anthropological framework provides a useful framing for understanding intervention delivery but not refinement for use cases.
Clinical relevance
How do environmental, sociocultural, organizational, and implementer-level factors affect the delivery of a decentralized, community-based continuous mass dog vaccination (CBC-MDV) approach to rabies control, as evaluated within a randomized controlled trial in the Mara region of Tanzania? __SNAPSHOT__ {"studyDesign":"Mixed-methods process evaluation (socio-anthropological framework) embedded within a stratified parallel cluster randomized controlled trial (RCT); data collected via in-depth interviews, focus group discussions, non-participant observation, and implementation audit","setting":"Mara region, northern Tanzania; six districts encompassing 112 administrative wards (90 rural [80%], 22 urban [20%]); district and village veterinary and community implementers","sampleSize":"not reported for the process evaluation specifically; the parent RCT covered 112 wards across 6 districts with an estimated dog population of 183,000 and a human population of approximately 1,096,136 at trial start (2020)","population":"Village- and district-level implementers (including ward-based animal health officers and community leaders), community members, and ward-level rabies coordinators and One Health Champions engaged in CBC-MDV delivery in the Mara region, Tanzania","intervention":"Decentralized community-based continuous mass dog vaccination (CBC-MDV): multiple rounds of vaccination campaigns per year, locally stored vaccines, managed by ward-based animal health officers and village community leaders","comparator":"Standard centralized, team-led annual (pulse) mass dog vaccination strategy (the other RCT arm); however, the process evaluation itself focused on the CBC-MDV arm","primaryOutcome":"Implementation process of CBC-MDV as assessed across five domains of the socio-anthropological framework: environmental context, social difference and pressures, community involvement, implementer motivation and capacity, and strategic/organizational factors","followUp":"Three years (November 2020 to October 2023), corresponding to the duration of the parent RCT","fundingSource":"Mixed: Deltas Africa (Afrique One-ASPIRE), National Institutes of Health (NIH), and Wellcome Trust; government and non-profit"}
Key findings
This is a qualitative and mixed-methods process evaluation; no randomized efficacy data, p-values, confidence intervals, or NNT/NNH are derived from this study itself. Key implementation findings across the five socio-anthropological domains were as follows: (1) Environmental context: CBC-MDV campaigns were disrupted by rainy and farming seasons, school schedules, market days, and funerals, while village size and terrain limited geographic reach. (2) Social difference and pressures: social factors including community involvement, local leadership, and social hierarchies meaningfully influenced campaign delivery and uptake. (3) Community involvement: implementers and community members positively evaluated the CBC-MDV approach and recommended expansion nationally; free-of-charge vaccination was reported to facilitate community mobilization. However, routine feedback-sharing between the research team, implementers, and communities was found to be lacking. (4) Implementer-level factors: implementers generally delivered CBC-MDV components satisfactorily and infrastructure existed to support logistics, but implementers did not feel empowered to adapt the protocol in response to field experience. Attrition of implementers over the two-year period was tracked but specific rates are not reported in the abstract. (5) Strategic and organizational factors: local by-laws and village governance structures were identified as potential policy levers to sustain the approach. The parent RCT demonstrated that CBC-MDV achieved vaccination coverage of 49–62% versus 22–46% with team-based delivery, with an odds ratio of 1.48–3.49 (from the separate RCT effectiveness paper, not this process evaluation). The critical herd immunity threshold (~40% coverage) was consistently exceeded by CBC-MDV but frequently was not by the pulse strategy. The process evaluation concluded that careful local tailoring of CBC-MDV delivery, co-reflexive appraisal, and support for field implementers through training, resourcing, supervision, and community involvement would be necessary to sustain implementation.
Practice implications
This study established that the CBC-MDV approach is feasible and acceptable to community implementers and members in rural Tanzania, and that a range of modifiable and non-modifiable contextual factors (seasonal, cultural, geographic, social) affect its delivery fidelity and reach. It did not establish efficacy in reducing rabies incidence or mortality—those outcomes are the subject of the parent RCT. Findings from this process evaluation apply primarily to rural, low-resource, rabies-endemic settings in sub-Saharan Africa with similar community structures and veterinary systems; generalizability to other geographic contexts (e.g., urban sub-Saharan Africa, Asia) is uncertain. The study was not designed to compare implementer performance between CBC-MDV and the pulse strategy, and the process evaluation findings cannot independently confirm the RCT's quantitative coverage results. The abstract provided was truncated, meaning several domains of the socio-anthropological analysis may be incompletely captured in this summary. Only the abstract was available for review, which is a notable limitation for this synthesis. __LIMITATIONS__ Only the abstract was available; full qualitative data, thematic analysis, and complete socio-anthropological domain findings were not accessible for this review.,Process evaluations embedded in RCTs are inherently subject to reactivity bias (Hawthorne effect); observation of campaigns and interviews with implementers may not fully reflect routine unobserved practice.,Study conducted exclusively in the Mara region of Tanzania; geographic, cultural, and veterinary system differences limit direct applicability to other rabies-endemic regions or countries.,Purposive sampling of implementers and community members for qualitative data collection may not capture the full spectrum of implementer and community experience, particularly those with more negative perceptions.,Attrition of implementers was documented but quantitative rates are not reported in the abstract, limiting assessment of implementation sustainability.,The process evaluation cannot determine whether identified barriers (e.g., seasonal disruptions, terrain) were adequately mitigated in practice, or their relative contribution to coverage gaps.,Social desirability bias is a recognized risk in qualitative interviews with implementers embedded within a research trial context.,The process evaluation does not provide inferential statistics; all findings are descriptive and interpretive.,The parent RCT coverage outcomes (49–62% vs. 22–46%) are from a separate effectiveness paper and should not be conflated with the qualitative process findings reported here. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ This mixed-methods process evaluation demonstrates that community-based continuous mass dog vaccination (CBC-MDV) is feasible and well-received in rural Tanzania, but that seasonal, cultural, geographic, and organizational barriers require proactive mitigation through local tailoring, implementer support, and genuine community co-involvement. The findings do not independently establish rabies control efficacy—that evidence resides in the parent RCT—but they provide actionable implementation science insights for programs considering decentralized, community-led dog vaccination strategies in similar low-resource, rabies-endemic settings. Practice adoption should be considered in conjunction with the parent RCT's quantitative coverage and effectiveness data.