Knowledge, attitudes, and practices (KAP) of rabies prevention among communities living in proximity to game reserves in the Eastern Cape of South Africa.

Knowledge, attitudes, and practices (KAP) of rabies prevention among communities living in proximity to game reserves in the Eastern Cape of South Africa. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 7 February 2025 V1 Latest version Share on Knowledge, attitudes, and practices (KAP) of rabies prevention among communities living in proximity to game reserves in the Eastern Cape of South Africa. Authors : Jillian Pape F 0000-0001-8299-7382 , Calvin Price W [email protected] , Woutrina Smith 0000-0001-8976-8347 , Brian Bird , William Fowlds , Claude T. Sabeta , and Jay Graham P Authors Info & Affiliations https://doi.org/10.22541/au.173891356.69004698/v1 427 views 202 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Rabies is a fatal viral zoonotic disease that is maintained in certain wildlife populations in South Africa, and is associated with spillover events between wildlife, domestic animals, and humans. Control efforts consist primarily of mass vaccination drives targeting domestic dogs, which stem from the One Health intersectoral collaboration including humans, animals, and the environment in mitigation approaches. The risk of human rabies infection is an important public health concern, given that the human encroachment on previously unused, privately owned land is increasing. With the rewilding of the Addo-to-Fish Biodiversity Corridor between Addo Elephant National Park and the Great Fish River Nature Reserve, previously isolated wildlife populations are now interacting with each other and the communities that line these borders. We conducted a survey (n = 56) in areas around the Addo to Fish Biodiversity Corridor focused on townships that are within or share a border with game reserves, or those that are further away from game reserve borders. The survey was designed for households with pets and/or livestock. Survey results identified a need for education on rabies and access to the rabies vaccine for their pets, with an overall 67% vaccination rate reported among households sampled. Although slightly below the World Health Organization recommendation of a minimum 70% coverage, the overall vaccination rate demonstrates great coverage from private veterinary clinics in the region. In rural areas within and nearer to private reserves, dogs were under vaccinated and included households not highly educated, thus representing increased risk for contracting rabies. More resources are necessary to reach the 70% vaccination rate per township, and dog owners should be given more support and educational awareness in understanding the clinical signs associated with rabies virus infection in animals and humans. Knowledge, attitudes, and practices (KAP) of rabies prevention among communities living in proximity to game reserves in the Eastern Cape of South Africa. Jillian F Pape, MPH [email protected] UC Berkeley School of Public Health University of California, Berkeley 2121 Berkeley Way, Berkeley, CA 94704 Calvin W Price, MPVM (Corresponding author) [email protected] UC Davis School of Veterinary Medicine University of California, Davis 944 Garrod Dr, Davis, CA 95616 Woutrina Smith, DVM, MPVM, PhD [email protected] UC Davis School of Veterinary Medicine 944 Garrod Dr, Davis, CA 95616 Brian Bird, DVM, MSPH, PhD [email protected] UC Davis School of Veterinary Medicine 944 Garrod Dr, Davis, CA 95616 William Fowlds, DVM [email protected] Ikhala Veterinary Clinic 3 Strowan Rd, Makhanda, 6139, South Africa Claude Sabeta, PhD, M. Phil [email protected] University of Pretoria Lynnwood Rd, Hatfield, Pretoria, 0002, South Africa Jay P Graham, PhD, MPH, MBA [email protected] UC Berkeley School of Public Health University of California, Berkeley 2121 Berkeley Way, Berkeley, CA 94704 Knowledge, attitudes, and practices (KAP) of rabies prevention among communities living in proximity to game reserves in the Eastern Cape of South Africa. Jillian F Pape 1 , Calvin W Price 2* , Woutrina Smith 2 , Brian Bird 2 , William Fowlds 3 , Claude Sabeta 4 , Jay P Graham 1 1 School of Public Health, University of California, Berkeley, Berkeley, CA 94720, USA 2 School of Veterinary Medicine, University of California, Davis, Davis, CA 95616, USA 3 Ikhala Veterinary Clinic, 3 Strowan Rd, Makhanda, 6139, South Africa 4 University of Pretoria, Lynnwood Rd, Hatfield, Pretoria, 0002, South Africa * Correspondence: School of Veterinary Medicine, University of California, Davis, 1089 Veterinary Medicine Dr, Davis, CA 95616; [email protected] Abstract: Rabies is a fatal viral zoonotic disease that is maintained in certain wildlife populations in South Africa, and is associated with spillover events between wildlife, domestic animals, and humans. Control efforts consist primarily of mass vaccination drives targeting domestic dogs, which stem from the One Health intersectoral collaboration including humans, animals, and the environment in mitigation approaches. The risk of human rabies infection is an important public health concern, given that the human encroachment on previously unused, privately owned land is increasing. With the rewilding of the Addo-to-Fish Biodiversity Corridor between Addo Elephant National Park and the Great Fish River Nature Reserve, previously isolated wildlife populations are now interacting with each other and the communities that line these borders. We conducted a survey (n = 56) in areas around the Addo to Fish Biodiversity Corridor focused on townships that are within or share a border with game reserves, or those that are further away from game reserve borders. The survey was designed for households with pets and/or livestock. Survey results identified a need for education on rabies and access to the rabies vaccine for their pets, with an overall 67% vaccination rate reported among households sampled. Although slightly below the World Health Organization recommendation of a minimum 70% coverage, the overall vaccination rate demonstrates great coverage from private veterinary clinics in the region. In rural areas within and nearer to private reserves, dogs were under vaccinated and included households not highly educated, thus representing increased risk for contracting rabies. More resources are necessary to reach the 70% vaccination rate per township, and dog owners should be given more support and educational awareness in understanding the clinical signs associated with rabies virus infection in animals and humans. Key words: Canine rabies, rabies vaccination, Eastern Cape, South Africa, dog owners, game reserves, spillover, One Health Introduction Rabies is a zoonotic infectious disease that is endemic to certain wildlife populations in South Africa (Thys et al., 2021). In most human infections, particularly if clinical symptoms have developed, rabies has close to a 100% fatality rate (Digafe et al., 2015). In rural South African communities, domestic canine populations have a low vaccination rate (Nadal, Beeching, et al., 2022). The causative agent of rabies is the genus Lyssavirus of the family Rhabdoviridae , and the predominant source of exposure is inoculation through the bite of an infected animal. Lyssavirus rabies is the most ubiquitous of all lyssaviruses globally, and still causes major public and veterinary health impacts in South Africa. It is one of the greatest zoonotic threats in the region. After Asia, the African continent comes in as the most impacted by rabies, with 21,000-25,000 human deaths annually, about 42% of the 59,000 deaths globally (Nyasulu, et al. 2021). A low vaccination rate exposes livestock, other companion animals, endangered wildlife species, and humans to rabies, as the interaction between rabies-infected companion animals and unvaccinated populations increases. Due to the 2021 outbreak of rabies in the Eastern Cape, officials in the provincial healthcare system have made rabies a “core vaccination” for owned animals and compulsory vaccination as required by law (Hayes et al., 2022). However, this has done little to assist more rural populations, as the outbreak of COVID-19 led to national lockdown throughout 2020, drastically decreasing rabies vaccine turnout (Nadal, Beeching, et al., 2022). The COVID-19 pandemic also led to decreased rabies vaccination rates in urban areas, as it lowered the Eastern Cape’s financial allocation to non-COVID-19 public health efforts (Nadal, et al., 2022). Moreover, areas surrounding the Eastern Cape have vast numbers of free-roaming domestic dog populations, which frequently interact with varying animal populations in and around wildlife reserves. These wildlife-domestic animal interactions occur in the wild spaces that surround these communities, leading to a higher susceptibility to the transmission of rabies. To our knowledge this is the first study to investigate the relationship between game reserves and knowledge on rabies virus infection in the Eastern Cape. Furthermore, it is one of the few studies that has evaluated the relationship between game reserves and the communities that live alongside or within their borders. The Eastern Cape of South Africa is an amalgamation of different cultures and practices, a geographical area that includes sprawling public and private game reserves, a handful of cities ranging from 5,000 residents to 140,000 residents, and many townships, which range anywhere from 32 residents to more than 10,000 residents. It is important to consider the relationship between private game reserve owners (typically high socioeconomic status) and the associated adjacent communities, or townships in the Eastern Cape (typically low socioeconomic status), and recognize the complicated relationship between different identities, access, conservation, and land use in the region (Spierenburg & Brooks, 2014). The mean years of schooling is 6.65, significantly lower in the Eastern Cape than the South African average for children, which is just below 8 years, demonstrating high inequality in the province. Around 60% of the population in the Eastern Cape earn an income below the lower-bound poverty line of $62 USD monthly (Moyo, et al., 2022). The area has struggled to evolve post-apartheid, with poverty, and economic instability exemplified through poor road conditions, a lack of transportation, and inconsistent veterinary and public health care for the population at hand. Among these conditions, many private landowners have made the move from an agrarian business model to the wildlife business, a venture that includes game ranches, nature reserves, and protected conservation areas. This land-use change is significant, accelerated by the overuse of farmland in the area and the lack of soil productivity in the wake of more recent climate change events. Previous farm residents and workers are now finding employment on the game reserves and conservation areas, their labor utilized for the geographical closeness of their family homes and knowledge of the area (Spierenburg & Brooks, 2014). The Addo to Fish Biodiversity Corridor (ABC) Project is a conservation area located in the Eastern Cape, South Africa, encompassing 2 million acres and including national, provincial, and private game reserves as well as land that was previously used for agricultural purposes. Beyond the need for species conservation is the need for disease surveillance, especially related to zoonotic diseases. There is an increased concern for disease outbreaks from previously isolated animal groups, following new human use of previously unused lands. This demonstrates a need for more research on potential disease transmission throughout the biodiversity corridor, as well as the impact these diseases can have on local rural communities that surround these parks. Given the lack of research in this region, a questionnaire was administered to households in townships surrounding the Addo to Fish Biodiversity Corridor to evaluate their knowledge, attitudes, and practices regarding rabies in this part of the Eastern Cape. This research is important for enhancing our understanding and augmenting rabies prevention and control efforts. Figure 1: Townships sampled in the Eastern Cape of South Africa: Location and distribution in relation to game reserves in the area. Methods 2.1 Study Site We evaluated areas around the Addo to Fish Biodiversity Corridor, specifically focusing on townships that are within or share a border (0-5 km) with game reserves, or those that are further (5-15 km) away from game reserve borders. Many of the community members in these townships have lived and worked in the area for many years: the majority of them having worked the land since it was established for agricultural productivity centuries ago and converted to wildlife land use in the past 2-3 decades. In this study, 56 households were surveyed within the communities of Buffalo Kloof, Kraaibos, Seven Fountains, Paterson, Leeuwenbosch, Kariega, and Kenton-on-Sea (Figure 1). 2.2 Study design and analysis A cross-sectional study design using a qualitative survey was utilized across eight communities during a two-month period. Between June 1 and August 1, 2023, structured face to face interviews were conducted using a door-to-door survey method, involving participants that gave consent to participate and were at home during the time of the survey. The survey was aimed at households with pets and/or livestock. The survey consisted of sixteen questions asked verbally in Xhosa by a two-person team, consisting of a trained interpreter and the lead field investigator. Participants were asked about access to veterinary care, understanding of rabies virus, vaccination coverage, and wildlife interaction. We also assessed access to healthcare to understand how communities would receive care in the case of rabies. After data collection was completed, responses were compiled and analyzed using RStudio. Chi-Squared tests with a P-value significance of 0.05 were applied to assess the relationship between community proximity to game reserves and key attitudes or behaviors related to rabies awareness and vaccination. 2.3 Ethics This study protocol was approved under the Institutional Review Board (IRB) of the University of California, Berkeley and under the Chief State Veterinarian under the Department of Rural Development and Agrarian Reform in the Province of the Eastern Cape, South Africa. Oral informed consent was obtained from all study participants before the administration of the survey. Only those who consented to participate were interviewed in the study, and all information obtained was kept confidential. No personally identifiable information was obtained from the study participants. Results: Out of the survey responses from 56 individuals that were analyzed, more than half of the respondents (56%, n = 32) were not aware of what the disease rabies was and did not understand the context of the issue. We found that 21 respondents had household pets only, 7 had livestock, 23 had both household pets and livestock, and 5 had neither. Out of the respondents that had household pets, 84% (n = 37) reported that their dogs lived inside the house with them. Out of the 30 respondents that had livestock, 20 had chickens, 9 had pigs, 15 had cows, and 5 had goats. Forty one percent of respondents (n = 23) have at some point noticed wild animals on their property, interacting with their animals. The relationship between knowledge of rabies and distance to game reserve demonstrated no statistical significance after analysis, with a Chi-Squared statistic of 1.697 and a p-value of 0.4281 (Figure 3c). When differentiated by distance to game reserve, 58% (n = 14) of individuals that live within or alongside the borders of a game reserve noticed wild animals on their property, 43% (n = 12) of individuals that live closer than 10 km noticed wild animals on their property, and 0% of 11 individuals sampled 15 km from a game reserve noticed wild animals on their property (Figure 3, Panel D). Statistical analysis indicated a highly significant relationship between the presence of wild animals reported on one’s property and distance to game reserve, with a Chi-Squared statistic of 10.649 and a p-value of 0.004871, indicating a strong deviation from the expected frequencies under the null hypothesis (Figure 3d). Ninety six percent (n = 54) of respondents had not received a rabies vaccine, and 67% (n = 37) had pets that had previously been vaccinated (Figure 3, Panel A), with a variation in vaccine rate by township. The disparity between the vaccination of pets and knowledge of rabies is due to the lack of awareness for the disease. Oftentimes vaccination may occur without full communication of why and how, due to the lack of resources available to encourage that communication. Figure 2 shows two townships reporting less than 50% vaccination rate in domestic dogs, as compared to the six townships that reported vaccination rates over 50% for their dogs. The average vaccination rate of 67% across all eight townships is just below the WHO recommendation rate of 70%. Out of the respondents that had their pets vaccinated, 86% (n = 32) had been vaccinated by a private veterinary clinic, during a rabies vaccination drive administered by the clinic volunteers and veterinary staff. These private veterinary clinics include Ikhala Veterinary Clinic (84%, n = 27) and Kariega Veterinary Clinic (16%, n = 5). Figure 2: Percent of rabies vaccinated canine population as sampled by township in 2023. The distribution of vaccines is dependent on location, with Ikhala Veterinary Clinic vaccinating most townships in the area, and Kariega Veterinary Clinic vaccinating the townships closest to Kariega Game Reserve (Kenton-On-Sea and Kariega). Figure 3a indicated an association between the rabies vaccination and distance to game reserve, with a Chi-Squared statistic of 6.0613 and a p-value of 0.04828. This finding suggests that there is a significant association at the conventional threshold of 0.05. Among the wild animals reported on or around their property, the most common included warthogs, nyala, wild cats, and stray domestic dogs. Sixteen percent (n = 8) of the respondents possessing pets reported that their animal had been attacked or bitten by a wild animal adjacent to their property. When asked on the perspective of how rabies has impacted their community, 40% (n = 22) of people were not worried at all about rabies, 25% (n = 14) had only heard about it, and 35% (n = 20) stated that they were worried about it. When differentiated by distance to game reserve, 37% (n = 9) of respondents living within or along the borders of a game reserve were equally worried about the rabies and had only heard of rabies, while 25% (n = 6) of respondents were not worried about rabies. For the individuals that lived 10 km from a game reserve, 42% of individuals (n = 9) were worried about rabies, while 29% (n = 6) of individuals equally were not concerned and had only heard about rabies. In the townships furthest from a game reserve, 9% (n = 1) of respondents were worried about rabies, and 91% (n = 10) respondents were not worried about rabies. Statistical analysis demonstrated a Chi-Squared statistic of 15.906 and a p-value of 0.003148, showing a highly significant association between perception of rabies and distance from game reserve. (Figure 3b). When asked about access to healthcare, 50% (n = 28) of respondents had access to a healthcare facility that was within their community or next door, 12% (n = 7) had a healthcare facility that was “close” or within 30 km, 30% (n = 17) of respondents were “far”, or more than 30 km away from a healthcare facility. Very few respondents, (n = 2, 4%) of respondents reported having access to a mobile clinic due to the distance away from the nearest healthcare facility, and two respondents noted that they had private healthcare through the game reserve in which they work. Eighty-six percent (n = 48) of respondents reported that they only seek out care from the facility closest to them in an emergency, 13% (n = 7) sought care from their closest healthcare facility for regular treatment, and one respondent reported that they never sought care from their nearest healthcare facility. When asked what the respondents’ feelings were regarding access to healthcare in and around their community, 44% (n = 19) of respondents noted that they did not know how to access healthcare. When asked how difficult it is to access healthcare where they live, 50% (n = 28) of respondents noted that it was “very difficult” to access healthcare, 38% (n = 21) of respondents noted that it was “moderately difficult” to access healthcare where they live, and the remaining 13% of respondents (n = 7) reported that it was easy to access healthcare where they live. When differentiated by distance to game reserve, 65% (n = 15) of respondents inside or alongside the borders to a game reserve said it was very difficult to access healthcare from where they live, 30% (n = 7) of respondents said it was moderately difficult, and 5% (n = 1) of respondents said healthcare was easily accessible. For individuals living 10 km from a game reserve, 48% (n = 10) respondents said it was very difficult to access healthcare where they live, 38% (n = 8) of respondents said it was moderately difficult, and 14% (n = 3) said healthcare was easily accessible. In the group of people living the furthest distance from a game reserve, 25% (n = 3) of respondents said it was very difficult to access healthcare where they live, 50% (n = 6) of respondents said it was moderately difficult to access healthcare where they live, and 25% (n = 3) of respondents said it was easy to access healthcare where they live (Figure 3, Panel C). When completing statistical analyses of this relationship, we saw no significance between accessibility to healthcare services and distance to game reserve (Figure 3c) with a demonstrated Chi-Squared statistic of 6.173 and a p-value of 0.1866. Figure 3 Panel A - Distribution of vaccinated pets by distance to game reserve (GR); Panel B - Perceptions of rabies virus in communities by distance to game reserve (GR); Panel C - Perceptions in difficulties in accessing healthcare by distance to game reserve (GR); Panel D - Observations of wild animals on property by distance to game reserve (GR); Panel E - Understanding of what rabies virus is by distance to game reserve (GR). Discussion: Knowledge of Rabies Evaluating community perspectives on rabies is crucial to the health and well-being of the communities in most rural areas including the Eastern Cape, especially as human-animal interactions are common. Community education and awareness is one of the most important factors that contributes to rabies prevention and control (Digafe, et al., 2015). The World Health Organization (WHO) recommends that at least 70% of a dog population should be vaccinated against rabies to prevent a rabies outbreak (Acharya et al., 2020). Additionally, the vaccination of dogs is one of the most important factors in rabies control; at least a 70% vaccination coverage may prevent over 90% of human rabies cases (Hergert & Nel, 2013). Our study revealed that in the eight townships sampled, 67% (n = 37) of respondents reported that their pets were vaccinated against rabies, vaccine rate by township ranging from 20% coverage to 100% coverage. Recollection of when and how often a pet was vaccinated seemed variable across survey respondents. A lack of education and awareness, transportation limitations, and inaccessibility were all reasons that may contribute to a vaccination rate below the WHO recommendation of 70% (Willie & Maqbool, 2023). We found it interesting that vaccination rates differed so significantly between geographically close townships, especially between Brentwood (20% vaccination rate, n = 5), Leeuwenbosch (56% vaccination rate, n = 9), and Kraaibosch (100% vaccination rate, n = 2), all of which are within bounds of the same game reserve. This demonstrates that the resources may be inadequate to match the needs even in a relatively small area. Although the overall vaccination rate is seemingly close to the WHO recommendation, this average is not entirely representative as each township has its own unique circumstances. The current study revealed that 43% of respondents did not know what the rabies virus was, while 57% respondents reported that they knew what rabies was. When stratified by distance to game reserve, only 33% of respondents that lived close to or on the border of a game reserve (inside or 0 km) knew what rabies was, while 52% and 45% of respondents living <10 km and <15 km respectively away from the borders of game reserves knew what rabies was (Figure 3, Panel E). While not statistically significant, this relationship between location and knowledge level seems important to explore further given the possible interventions that could relate to educational access and socioeconomic status. This demonstrates a gap in knowledge about infectious disease between the communities that live in or on the border of game reserves and the communities that live further away and closer to a town or city center. Interestingly, similar studies evaluating awareness of rabies in the KwaZulu-Natal (KZN) Province of South Africa have demonstrated a higher level of awareness of rabies in the region (Hergert & Nel, 2013; LeRoux et al., 2018). This could be due to differences in education, reporting, and access to healthcare and veterinary facilities. Due to the proximity of our study area to game reserves, we focused on community members’ knowledge of wild animals that live within the parks and risks associated with zoonotic infectious disease. Oftentimes, poor infrastructure surrounding the communities that live close to, or within game reserves, lead to increased interaction between their pets and the wild animals that live on the reserve. There remains the question of whose responsibility it is to maintain key infrastructure for reducing animal-animal interactions such as electric fences and other safety measures around communities. This is crucial so that domestic canines are unable to interact with game reserve animals and other wild animals that may be infected with rabies. Vaccination rate The primary method for curbing rabies infection among dogs is mass dog vaccination drives. When asked who vaccinated pets in their communities, out of the 36 respondents (64%) who reported that their pets were vaccinated, 32 (89%) acknowledged that their pets were vaccinated by a private veterinarian that led vaccine drives out of their own volition. The state veterinary clinicians covered only 11% of the households in the eight communities that were sampled, demonstrating the importance of the private veterinary clinics and their relationship with the communities. These vaccinations are often not sought after, but are administered voluntarily by the clinic during times of availability. In speaking to members of the communities, many mentioned difficulties in communication between the pet owners and the veterinary clinics, leading to a gap in understanding between what rabies is and why their pets should be vaccinated. This lack of knowledge was hypothesized to result in many of the community members not having their pets vaccinated if it were not for the vaccine drives. However, it was clear among respondents that many households understood that vaccinations of any kind were necessary for the health and safety of their animals and their family. In speaking to heads of households, those townships with a community delegate aimed at achieving vaccine coverage for the community were the most organized when it came down to the success of the vaccine drive. Community involvement is crucial in the success of the vaccine drives and the coverage that is achievable through one private veterinary clinic. Due to the COVID pandemic, most pets had not been vaccinated over a two-year period, while legally vaccination should be undertaken annually. During the pandemic, not only did attention shift to COVID vaccination and restrictions, the additional movement restrictions, and fear of COVID shifted attention away from rabies and exacerbated the inability to import and distribute rabies vaccines (Nadal, Abela-Ridder, et al., 2022). During this post-Covid outbreak, a rabid domestic dog of unknown origin found its way into Amakhala game reserve and was seen attacking a warthog. Shortly after, the dog was eaten by a pride of lions. The brain of the dog confirmed a positive case of rabies, and the entire lion pride of 3-4 adults had to be euthanized. The impact of the pandemic and the global shift in health priorities sidelined animal health and the implementation of One Health initiatives, leading to a decrease in rabies vaccination coverage and education (Nadal, Beeching, et al., 2022). Access A large percentage of respondents reported that it was “very difficult” or “moderately difficult” to access healthcare where they live (Figure 3, Panel C). Respondents noted anecdotally that due to poor road conditions and lack of transportation, emergency services were oftentimes unreliable and may not come until the next day. Reliance on a community member with a vehicle was commonplace, and for the most part respondents relied on walking or hitchhiking to get to the nearest town. In the event of a medical emergency, such as the need for post-exposure prophylaxis (PEP), it would be difficult for an individual to receive the life-saving treatment. PEP is highly effective in preventing the onset of rabies, but only if administered promptly after infection (Purwo Suseno et al., 2019). As consistent with other studies done on canine-mediated rabies in South Africa, equatorial Africa, South Asia, and Indonesia, (Acharya et al., 2020; Häsler et al., 2014; Lechenne et al., 2017; LeRoux et al., 2018; Purwo Suseno et al., 2019), a One Health approach involving the intersectionality of humans, animals, and the environment is crucial. To manage large populations of free roaming domestic dogs, effective communication strategies are needed to maintain community interests and understanding of the risks of rabies for their animals and families. In rural areas such as the Eastern Cape Province of South Africa, the social-ecological regime shift to game farming has led to changes in community and family dynamics. A regime shift, defined as a large, persistent change in the structure and function of the intertwined social and ecological components of a landscape, (Achieng et al., 2020; Shackleton & Luckert, 2015), has led to a relative reliance on game reserve owners for infrastructure improvement and access to healthcare. Low education levels, unemployment, and poverty are stressors that have impacted respondents’ ability to have agency in accessing veterinary and health services, as well as the instability and polarization of the country (Shackleton & Luckert, 2015). Our statistical comparison of access to healthcare and distance to game reserve demonstrated insignificance, with a p-value of 0.1866. We postulate that this is due to small sample size across strata and the differing management of health services to different game reserve employees. Because different communities may have different health care support given to them by employers, there may be differing support in who receives health services. For example, the community of Brentwood had access to a biweekly mobile clinic, but the community of Kraaibosch did not have access to that same clinic, despite their geographical proximity to both each other and the same game reserve. The private veterinary sector in the Eastern Cape has demonstrated capabilities for improving vaccine coverage for the canine populations at hand, but preventing rabies spillover will require close communication of key information between the state and the local communities for rabies awareness and vaccine access. Private veterinary clinics may not have the resources or capacity to manage this level of communication, and so more support from the state is likely needed. The high level of dissatisfaction with healthcare services is consistent with other studies done in the Eastern Cape, in which an imbalance in access between rural and urban healthcare services are prevalent (Ewing et al., 2020). Conclusion: Rabies is an infectious disease of concern in the study area but is not considered to be of significant importance according to our survey results, likely due to a lack of awareness. Transportation limitations, inadequate access to education, and the disproportionate healthcare services in the region may have led to a lower awareness of rabies, and the vaccination of the canine population is almost fully dependent on private veterinary clinics. Although private veterinary clinics have achieved a reasonable vaccine coverage of 67% across all townships, there were disparities between townships that were dependent on the relationship with game reserves and the relative nearness to urban areas. Underserved, more rural areas within and nearer to private reserves seemed to be under vaccinated, undereducated, and at increased risk for contracting rabies. Dog owners should be given more support and education regarding the signs of rabies in animals and humans, as community awareness programs are crucial to prevent human cases in the sampled area. Future research should consider potential mistrust of government or health authorities, and how community engagement can be better consolidated into health policy and vaccination efforts. Additionally, the capacity for a larger sample size would allow for more inclusive data that integrates diverse perspectives of vaccination methods and coverage. Funding This research was funded by the UC Berkeley Center for Global Public Health (CGPH) and the UC Berkeley Center for Emerging and Neglected Diseases (CEND). Acknowledgements Data acquired for this study would not have been possible without the assistance of Melumzi Matiwane and the time he dedicated to engaging in meaningful conversation with the community members we were introduced to. I am grateful for the enlightening conversations we were able to have with the many folks we spoke to, and it was a privilege to be welcomed into their homes. Additionally, I greatly appreciate the consent and assistance of the game reserve managers and landowners in the Eastern Cape at Amakhala Game Reserve and Buffalo Kloof Game Reserve, as well as the Ikhala Veterinary Clinic and the Conservation Landscapes Institute, without whom we could not have completed this questionnaire. Conflicts of interest The authors declare no conflicts of interest for this study. References Acharya, K. 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Access to Public Health Services in South Africa’s Rural Eastern Cape Province (SSRN Scholarly Paper 4405870). https://doi.org/10.2139/ssrn.4405870 Information & Authors Information Version history V1 Version 1 07 February 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords one health rabies zoonoses Authors Affiliations Jillian Pape F 0000-0001-8299-7382 University of California Berkeley School of Public Health View all articles by this author Calvin Price W [email protected] University of California Davis One Health Institute View all articles by this author Woutrina Smith 0000-0001-8976-8347 University of California Davis One Health Institute View all articles by this author Brian Bird University of California Davis One Health Institute View all articles by this author William Fowlds Ikhala Veterinary Clinic View all articles by this author Claude T. 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