THE KNOWLEDGE AND ATTITUDES OF THE COMMUNITY IN SIBANGKAJA VILLAGE, BADUNG, REGARDING THE RABIES INCIDENT

Background: The challenges in overcoming the rabies epidemic include the public's lack of knowledge and attitudes regarding the control and first aid in dog bites. Sibangkaja is one of the villages in Badung Regency, which is an endemic area for rabies. Purpose: This study aimed to describe the knowledge, attitudes, and factors influencing the behavior of the residents of Sibangkaja Village, Badung, regarding rabies. Methods: This descriptive observational study was carried out using a cross-sectional design. The samples were 250 residents of Sibangkaja Village, taken by convenience sampling. Data were collected from February to March 2020 through interviews using the digital questionnaire. The variables were knowledge and community attitudes toward rabies vaccination in the village. Results: The results showed that the respondents' knowledge was good, but 34% did not know the symptoms of rabies. It was discovered that attitudes toward rabies prevention and management are significantly more in favor of vaccination than eliminating dogs . Furthermore, there is an association between knowledge and dog ownership on people's attitudes (p-value=0.01). Conclusion: Information and education about the symptoms of rabies is needed for residents to exercise caution and pay more attention to themselves and the surrounding dogs.


INTRODUCTION
Rabies is a global health problem and an endemic in almost all continents except Antarctica. The prevalence is severe in Asia because it can significantly impact animal welfare, the economy, and human health. It was also reported that there are approximately 39,000 human deaths annually. Domesticated dogs are the main reservoir and source of rabies (1). Generally, rabies is a disease caused by warm-blooded carnivores such as dogs, cats, wolves, monkeys, and bats transmitted to humans through bite or lick (2). Based on a retrospective study, Indonesia experienced the first disease outbreak in 1884 in West Java. The next occurrence was reported in 1953 in Central Java, East Java, and West Sumatra, followed by North Sumatra in 1956. Meanwhile, in early 2019, it spread to 26 provinces, which include Nanggroe Aceh Darussalam, North Sumatra, West Sumatra, Riau, Riau Islands, Jambi, South Sumatra, Bengkulu, Lampung, Banten, West Java, Bali, East Nusa Tenggara, North Sulawesi, Gorontalo (4). The dog population in the province is relatively high because it relates to cultural aspects as guardians of houses/agricultural land/plantations, and ceremonial facilities (5).
Zahrotunnisa et al (6) stated that Sibangkaja Village in Badung Regency is one of the endemic areas for rabies. This disease mainly occurs in 80% of poor rural communities, with minimal awareness and access to treatment facilities (7). Although mass vaccination can prevent the disease, it is a public health burden in developing countries without the technical and financial resources to control rabies in the animal population (8).
Some challenges faced in overcoming the rabies epidemic in Bali include the lack of knowledge and public attitudes regarding the control and first aid in cases of dog bites (9). Knowledge, attitudes, and behavior are theories widely used globally for various applications in public health. This was based on the principle that increased knowledge will change attitudes and behavior to minimize disease burden (10). Therefore, this study aims to identify the knowledge and attitudes of the Sibangkaja village community regarding the incidence of rabies.

METHODS
This descriptive observational study was carried out using a cross-sectional design. The population included 250 residents in Sibangkaja Village, selected using convenience sampling. Data were collected from February to March 2020 using a digital questionnaire. The independent variables used were socio-demographic characteristics consisting of age, sex, education level, monthly income, and dog ownership. Meanwhile, the knowledge variable consisted of three questions answered correctly and incorrectly. The questions included when the rabies vaccine was given, symptoms, and steps to take when bitten by a dog, as well as attitudes towards vaccination and elimination. A score of 1 is given to the correct answer, while the incorrect is 0, and the total score of the three knowledge indicators is 3. Knowledge is categorized based on the median value into good and poor, with a score range of 2-3 and 0-1, respectively.
The dependent variable is attitudes, measured by four statements, including people's attitudes about dog elimination and vaccination. Each statement is measured by a Likert scale of 1-5, indicating Strongly Disagree-Strongly Agree. The maximum total score of the four indicators is 20.
In this study, the data collected were analyzed using univariate and bivariate. Univariate analysis was conducted to obtain the distribution of the results of the variables in the form of descriptive statistics, namely frequency, percentage, mean, and standard deviation. Meanwhile, bivariate analysis was carried out with linear regression analysis to determine the association between knowledge and socio-demographic characteristics with the dependent variable, namely attitudes about rabies. The bivariate analysis showed a significant relationship when the p-value was <0.05. Furthermore, this study has received ethical approval No. 759/UN 14.2.2.VII.14/LT/2021 from the Research Ethics Commission of the Faculty of Medicine, Udayana University/ Sanglah Hospital, Denpasar.

RESULTS
The results showed that out of the 250 respondents, 94% were male, and the average age was 47, whereas the youngest and oldest were 20 and 80, respectively. Based on the highest level of education completed, most respondents were senior high school students, and the income level was in the range of 1,500,001-2,500,000, as shown in Table 1. Furthermore, almost 55% of residents have a dog, while 45% do not. Table 2 shows respondents' knowledge about the period of rabies vaccination, the symptoms, and the steps to take when bitten by a dog. It was discovered that 61.6% know that the rabies vaccine should be given to dogs annually, while 38.2% do not know. Furthermore, 34.4% admitted that they did not know the symptoms of rabies, and some knew that the first step was to wash the wound with soap and water after being bitten by a dog. The level of knowledge of Sibangkaja village, according to the median score, which was 54.00%, indicated that most respondents have good knowledge about rabies. Table 3 shows respondents' attitudes regarding vaccination and eliminating rabies. Approximately 40.8% agreed that mass elimination should be carried out even though only one dog in the banjar/area showed symptoms of rabies, and 29.2% did not agree. Furthermore, 64.40% agreed with eliminating dogs with symptoms, while nearby dogs only needed vaccination. Most 69.60% of respondents also preferred vaccination over elimination and agreed that vaccinated dogs protect the surrounding community.    Table 4 shows the association between knowledge and socio-demographic characteristics with attitudes about rabies. Knowledge and ownership of dogs statistically affect attitudes toward rabies prevention related to vaccines and dog elimination (p<0.05). The coefficient B in the linear regression analysis stated that as knowledge improves, the predictive model will increase public attitudes towards rabies prevention by 0.8 times.

DISCUSSION
Rabies is a disease caused by animals such as dogs and is transmitted to humans through the bite or lick of a rabid animal (11). This study showed that the people's knowledge in Sibangkaja Village, Badung, is quite good. The results indicated that 61.60% are aware of vaccination to prevent rabies. The types of vaccines commonly used are Rabivax, Rabipur and Rabivet, and Nabivac (12). This is in line with Kristina (13), which stated that rabies prevention can be carried out by giving rabies vaccine to pets once a year. This is because administering the anti-rabies vaccine provides immunity for the animal to become resistant to infection.
A total of 34.40% did not know the symptoms of rabies. Moreover, the symptoms can be divided into three stages: the prodromal, which usually lasts 2-3 days; excitation; and paralysis. In the prodromal stage, the animal usually does not know its master, often avoids, ignores orders, is easily surprised, and quickly rebels when provoked. There is also an increase in body temperature, pupillary dilation, and decreased corneal reflexes to stimuli (14).
The excitation stage is characterized by the animal hiding under the bed, a table, or a chair. Furthermore, the dog looks restless, and there are hallucinatory movements and acts like eating insects that fly in the air. When a dog is in the cage, it will walk back and forth while growling. The behavior develops more sensitive and violent and will attack all moving objects. The mouth often bleeds from missing teeth or chewing hard, sharp objects, and a change in the voice. Stiffness of the swallowing muscles can occur to allow hypersalivation, the frequency of breathing changes rapidly, and the saliva is foamy, sometimes accompanied by blood from wounds in the gums or mouth. The paralysis stage is characterized by paralysis of the masticatory muscles, making the jaw appear to hang. The dog's voice is often like choking due to paralysis of the throat muscles. There is paralysis of the hind legs, which are dragged when walking (8).
The first treatment when a person is bitten by an animal that causes rabies is to immediately wash the bite wound with clean water and soap or detergent for 5-10 minutes. Subsequently, rinse the wound with running water and dry it with a clean cloth or tissue paper. Red medicine can be given to the wound, covered with a clean bandage, and the patient is immediately taken to the nearest hospital for further treatment (15). An anti-rabies substance, Human Rabies Immunoglobulin = HRIg, is administered to the bite wound, followed by a rabies vaccine on the other side to stimulate the body's active anti-rabies formation.
Bite wounds are not allowed to be sutured except for situational sutures. When stitches are necessary, Anti-Rabies Serum (SAR) is given according to the dose, infiltrating around the wound, and the rest is injected intra-muscularly (16). Furthermore, administering anti-tetanus serum/vaccine, antibiotics to prevent infection, and analgesics should also be considered.
Attitudes of Sibangkaja residents prefer vaccination as a form of rabies prevention. It was discovered that mass vaccination of dogs is needed to stop the cycle of transmission of rabies from animals to humans. According to WHO, vaccination coverage must reach at least 70% of the dog population to break this cycle (17). Vaccination also has a chance of failing to prevent rabies due to several factors, namely the quality of the vaccine, poor handling (wrong cold chain), expiration of immune period based on the type of vaccine used, the incubation period of dogs, and individual response (18). However, the transmission of the disease can stop when dog owners realize the importance of vaccinating their pets, specifically dogs (19).
Prevention of rabies by vaccination can save treatment costs due to bites and reduce the incidence of bites among the human population (20). The One Health Concept approach is based on the idea that closer cooperation between veterinary and human health services can create added value for both sectors. Rabies is one of the best examples to illustrate the positive effects of this collaboration to control disease (21). Alam et al. (22) also stated that a form of this concept is dog mapping because reducing stray dogs and strengthening vaccinations will minimize rabies transmission and protect humans.

Research Limitations
This study is limited to several aspects of community knowledge and attitudes toward the incidence of rabies. In the future, further investigation is recommended on the factors that influence the knowledge and attitudes, as well as the community's behavior in preventing and controlling rabies in their area to minimize the burden of the disease.

CONCLUSION
Knowledge and ownership of dogs affect people's attitudes toward rabies prevention related to vaccines and dog elimination. The results indicated that most respondents' knowledge about rabies is good. However, there is still a need for detailed information and education about the symptoms. This aims to make residents careful and pay more attention to themselves and the surrounding dog. Attitudes towards the prevention and management of rabies are good due to more support for vaccination than elimination. Meanwhile, it is necessary to increase knowledge about the prevention and management of the disease, which will affect the changing of attitudes and behavior to minimize the rabies problem in Sibangkaja Village.

CONFLICT OF INTEREST
There were no conflicts of interest during this study, from finance, licensing, and data collection to preparing reports.