Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
DOI 10.1186/s40249-015-0061-1
RESEARCH ARTICLE
Open Access
On dogs, people, and a rabies epidemic:
results from a sociocultural study in
Bali, Indonesia
Maria Digna Winda Widyastuti1*, Kevin Louis Bardosh2*, Sunandar1, C. Basri3, E. Basuno4, A. Jatikusumah1,
R. A. Arief1, A. A. G. Putra5, A. Rukmantara6, A. T. S. Estoepangestie7, I. Willyanto8, I. K. G. Natakesuma9,
I. P. Sumantra9, D. Grace10, F. Unger10 and J. Gilbert10
Abstract
Background: Previously free of rabies, Bali experienced an outbreak in 2008, which has since caused a large
number of human fatalities. In response, both mass dog culling and vaccination have been implemented. In
order to assess potential community-driven interventions for optimizing rabies control, we conducted a study
exploring the relationship between dogs, rabies, and the Balinese community. The objectives of this study were to:
i) understand the human-dog relationship in Bali; ii) explore local knowledge, attitudes, and practices (KAPs) relating
to rabies; and iii) assess potential community-driven activities to optimize rabies control and surveillance.
Methods: Conducted between February and June 2011, the study combined a questionnaire (n = 300; CI = 95 %;
error margin = 5 %) and focus group discussions (FGDs) in 10 villages in the Denpasar, Gianyar, and Karangasem
regencies. The questionnaire included a Likert scale to assess community knowledge and attitudes. For the
knowledge assessment, three points were given for a correct answer, while wrong answers and uncertain answers
were given zero points. For the attitudes assessment, three points were given for a positive answer, two points
for a neutral answer, and one point for a negative answer. Respondent knowledge was categorized as good
(score >40), fair (score 20–40), or poor (score <20), based on a maximum total score 60. Respondent attitudes were
categorized as positive (score >26), neutral (score 13–26), or negative (score <13), based on a maximum total score
of 39. Mixed-gender FGDs in each sub-village (banjar) were conducted, each involving 7–15 participants to
complement the questionnaire results. On a follow-up research trip in mid-2013, the data analysis was triangulated
and validated using semi-structured interviews. Questionnaire data were analyzed descriptively using SPSS 17.0, while
qualitative data from interviews and FGDs were analyzed manually according to accepted methods of coding and
memo writing. The chi-square test was then used to analyze the statistical relationships between knowledge
and attitudes of the respondents.
(Continued on next page)
* Correspondence: diawindadigna@gmail.com; bardosh_kevin@hotmail.com
1
Center for Indonesian Veterinary Analytical Studies, Bogor, Indonesia
2
School of Social and Political Science, The University of Edinburgh,
Edinburgh, UK
Full list of author information is available at the end of the article
© 2015 Widyastuti et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
Page 2 of 18
(Continued from previous page)
Results: Out of the total 300 respondents, most were predominantly male (82 %), Hindu (99 %), married (96 %),
older than 30 years of age (92 %), and owned dogs (72 %). Dog ownership was motivated by culture, personal taste,
and function, with dogs was being used as guards (85 %) and companion animals (27 %), and was sometimes related
to religious or traditional obligations (2 %). Relating to their culture and local beliefs, and eventually becoming their
way of life, 79 % of respondents kept free-roaming dogs. With the rabies outbreak in Bali and Western breeds
becoming more popular, more responsible dog ownership (leashing, confining, regular feeding) became more
acceptable and changed community perceptions on keeping dogs, even though the sustainability of this practice
cannot be gauged. In addition, the economic situation posed major problems in rural areas. The level of community
knowledge about rabies and its associated control programs were generally fair and community attitudes were
positive. However, community KAPs still need to be improved. A total of 74 % respondents reported to have vaccinated
their dogs in 2011, but only few were found to report rabid animals to livestock officers (12 %) and a significant number
believed that washing a bite wound was not important (62 %). Moreover, free-roaming dog practices and discarding
of unwanted female puppies still continue and possibly create difficulties for rabies elimination as these practices
potentially increase the stray dog population. We identified three major sociocultural aspects with potential for
community-driven interventions to optimize current rabies elimination efforts: integrating local notions of ahimsa
(non-violence) into education campaigns, engaging communities through the local banjar sociopolitical system, and
working with traditional legal structures to increase local compliance with rabies control.
Conclusion: The human-dog relationship in Bali is multifaceted. Due to the uniqueness of the culture and the local
beliefs, and encouraged by a socioeconomic aspect, a number of local practices were found to be constituting risk
factors for continued rabies spread. Community knowledge and attitudes, which can consequently result in behavioral
changes, needs to be improved across different genders, ages, educational backgrounds, and roles in the community,
regardless of the individual village’s experiences with rabies. Furthermore, community-driven activities based on
sociocultural conditioning and community capacity at the banjar and village levels, such as public awareness
activities, vaccination, dog registration, dog population management, and rapid response to dog bites, were
identified as being able to complement the rabies control program in Bali. The program also needs recognition or
acknowledgement from governments, especially local government as well as regular mentoring to improve and
sustain community participation.
Keywords: Bali, Rabies, Sociocultural, KAPs, Community-driven activities
Multilingual abstracts
Please see Additional file 1 for translations of the abstract into the six official working languages of the
United Nations.
Background
Rabies is a significant but neglected disease predominantly
transmitted through dog bites and responsible for an estimated 55,000 to more than 70,000 human deaths annually
worldwide, but occurring mostly in Asia and Africa [1–4].
The rabies virus is endemic in 24 of the 33 Indonesian
provinces where there have been numerous outbreaks in
the last few decades [5–7]. A popular tourist destination,
the island of Bali, remained free from rabies until 2008, but
in November of that year, fishermen travelling with an infected dog from a neighboring island introduced the virus.
The initial emergency response attempted to contain the
disease to the southern peninsula by vaccinating dogs (the
most accepted public health strategy for rabies control)
and eliminating unconfined or free-roaming dogs, but the
disease nevertheless quickly spread throughout the island.
A much larger campaign then followed which, apart from
canine vaccination, also included the mass culling of
100,000 dogs. This provoked opposition from international
rabies experts and animal welfare groups who argued that
culling is not only inhumane but also ineffective for controlling the rabies virus [3, 8]. Additionally, the lengthy
campaign time lowered population immunity through high
population turnover and the short life of the vaccine that
was used [9, 10]. In late 2010, a local non-governmental
organization (NGO), the Bali Animal Welfare Association
(BAWA), together with the Balinese government, initiated
an island-wide canine vaccination campaign, vaccinating
250,000 dogs over six months by using an innovative technique to deal with the massive free-roaming dog population: dog-catcher teams. This achieved an estimated
coverage of more than 70 %, which is the accepted coverage target to sustainably reduce virus circulation. Two additional mass vaccination rounds were then conducted by
the Balinese government and the Food and Agriculture
Organization of the United Nations (FAO) in 2011 and
2013, with a corresponding reduction in human rabies
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
fatalities and reported rabid dogs [5]. This encouraged
the Balinese local government to set 2015 as the official
target year for rabies elimination.
Since 2008, rabies has cost the Balinese government
more than US $13 million, led to the death of more than
150 people, and has been responsible for tens of thousands of expensive human post-exposure prophylactic
(PEP) treatments that are given after suspected rabid
dog bites [5]. Bali is a densely populated island inhabited
by some four million people and before the introduction
of rabies had one of the highest dog densities in the world;
the estimated dog population was between 400,000 and
800,000 before the rabies outbreak [9–12].
Ubiquitous around markets, temples, beaches, garbage
dumps, and rice paddies, the majority of Bali’s dogs are
owned, free-roaming, indigenous street dogs. Known to
be independent, aggressive, and territorial, the Balinese
street dog remains one of the most genetically diverse
canine populations, related to the Australian Dingo and
Chow Chow [13, 14]. A small proportion of the overall
dog population, the Kintamani dog of Bali (an emerging
breed unique to the Kintamani region), contrasts significantly with the wider canine population, in that these
dogs show physical affection to people, and climb roofs,
garden walls, and trees [14]. With the increase in tourism in the mid-1990s [15], Western dog breeds have also
become increasingly popular but are largely confined to
urban areas. For many of Bali’s free-roaming dogs, these
socioeconomic changes together with a high birth rate
have led to many dogs being neglected, malnourished,
and suffering from skin diseases [12, 16].
Aside from a unique dog population, Bali has also long
been known for its unique culture, arts, and religion, and a
diverse amount of anthropological research has been conducted on the island since the early Dutch colonial era.
Much of this work has shown the interrelatedness between
Balinese religion, society, and the natural world; for instance, the importance of water temples in regulating irrigation networks used in rice cultivation as well as the central
role of the Balinese cockfight to notions of identity and
socialization [17, 18]. A mixture of traditional Hinduism
and Buddhist and animist elements, Balinese Hinduism is
both deeply communal and ritually prescriptive, orientated
around the need to maintain harmony between humans,
nature, and the spiritual realm through daily sacrifices to
both gods and demons, some of which involve animals
[19]. Religious cosmology and iconography make significant
use of animal motifs in depicting the world of spirits, including the abundant use of teeth and fangs [20].
Due to the island’s dense dog population, current efforts to eliminate rabies from Bali have received much
international attention. If successful, the Balinese elimination campaign could help set a precedent for the feasibility of rabies elimination through mass dog vaccination
Page 3 of 18
in Asia [10]. While a number of studies have examined
sociocultural aspects to dog ownership and rabies control
in the region (including in Bhutan, Cambodia, India, Sri
Lanka, and Vietnam) [21–25], there is a dearth of such information available from the unique Balinese context.
There have also been surprisingly few knowledge, attitudes, and practices (KAPs) studies that have used qualitative methods or explored potential community-driven
strategies in relation to rabies more generally [26]. The
aims of this study, therefore, were to: i) understand the
human-dog relationship in Bali; ii) explore local KAPs relating to rabies; and iii) assess potential community-driven
activities to optimize rabies control and surveillance.
Methods
This cross-sectional study was conducted from February
to June 2011 in 10 banjars (sub-villages) selected purposively from 10 villages in Denpasar city, and the Gianyar
and Karangasem districts. These areas were chosen due to
their demographic and economic differences, representing
an urban, suburban, and rural district, respectively (see
Fig. 1 and Table 1). Based on government records, half of
the selected banjars had experienced both human and
canine rabies, while half remained free from rabies. A
questionnaire exploring knowledge, attitudes, and practices (KAPs) towards dogs, rabies, and canine vaccination was first administered, which used both open and
closed-ended questions. A total of 30 participants per
banjar (n = 300; CI = 95 %; error margin = 5 %) participated in the questionnaire, with a proportional number
of government officers, religious leaders, and members
of the general population being selected in each village.
The questionnaire included a Likert scale to assess
knowledge and attitudes using a scoring system. For the
knowledge assessment, three points were given for a correct answer, while wrong answers and uncertain answers
were given zero points. Respondent knowledge was categorized as good (score >40), fair (score 20–40), or poor
(score <20), based on a maximum total score of 60. For
the attitude assessment, three points were given for a
positive answer, two points for a neutral answer, and one
point for a negative answer. Respondent attitudes were
categorized as positive (score >26), neutral (score 13–26),
or negative (score <13), based on a maximum total score
of 39. In order to triangulate and further explore, we subsequently conducted interviews as well as one mixedgender focus group discussion (FGD) in each banjar,
which lasted between one to two hours and involved 7–15
participants. The participants were often the same people
who had answered our previous questionnaires, but the
FDGs also included other key persons, such as traditional
leaders and village leaders. The FGDs revisited the same
questions as our questionnaires but allowed for much
more nuanced explorations of emerging themes and sub-
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
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Fig. 1 Study location, Bali, Indonesia
themes. During a follow-up research trip in mid-2013,
semi-structured interviews were used to triangulate and
validate the data analysis.
Questionnaire data were analyzed descriptively using
SPSS 17.0, while qualitative data from interviews and
FGDs were analyzed manually according to accepted
methods of coding and memo writing. The chi-square
test was then used to analyze the statistical relationships
between knowledge and attitudes of the respondents.
According to our system, approval for this study was obtained from the Political Unity and Nation Agency at
Bali Province and Livestock Services Office of Bali
Province, and acknowledged by the Directorate of Animal
Health, Directorate General of Livestock and Animal
Health, Ministry of Agriculture, Republic of Indonesia.
Results
Table 1 Study location in the Bali province, by villages with and
without rabies experience
Villages status
No.
Villages
District/city
With rabies experience
1
Renon
Denpasar
2
Blahbatuh
Gianyar
3
Kenderan
Gianyar
4
Bungaya Kauh
Karangasem
Without rabies experience
5
Padang Kerta
Karangasem
1
Dangin Puri
Denpasar
2
Abianbase
Gianyar
3
Kelusa
Gianyar
4
Menanga
Karangasem
5
Sindhuwati
Karangasem
Dog ownership and management practices
Slightly less than three-quarters of the questionnaire respondents (72 %) reported to own a dog. Out of the total
number of respondents, most were predominantly male
(82 %), Hindu (99 %), married (96 %), and older than
30 years of age (92 %). The respondents’ demographic
profiles are presented in Table 2. It was not intentional
to choose a larger number of male respondents, but this
is what happened when convenience sampling was done
for the household level. More than 50 % of the respondents
(59 %) either graduated from high school or attended university, and 65 % had an important role in the community,
such as being in government or in a traditional leader role.
Roughly half of the respondents considered dog ownership
integral to both Balinese and Hindu traditions, though not
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
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Table 2 Respondents’ demographic profiles
No.
1
Variables
Villages with rabies experience (n = 150)
n
%
n
▪ Male
118
79
129
86
247
82
▪ Female
32
21
21
14
53
18
150
100
150
100
300
100
▪ <30 years old
18
12
7
5
25
8
▪ 30–50 years old
83
55
97
64
180
60
Age
Total
▪ Moslem
Total
▪ Single
Total
31
95
32
100
300
100
148
99
149
99
297
99
2
1
1
1
3
1
150
100
150
100
300
100
140
93
147
98
287
96
10
7
3
2
13
4
150
100
150
100
300
100
9
6
5
3
14
4
▪ Elementary school (graduated)
40
27
34
23
74
25
▪ Junior high school (graduated)
20
13
15
10
35
12
▪ High school (graduated)
44
30
64
43
108
36
▪ University
37
24
32
21
69
23
150
100
150
100
300
100
▪ Farmer (agricultural)
27
18
32
22
59
19
▪ Housewife
12
8
21
14
33
11
▪ Government officer
89
60
78
52
167
56
▪ Works at a private company
2
1
2
1
4
1
▪ Entrepreneur
5
3
6
4
11
4
▪ Unemployed
15
10
11
7
26
9
150
100
150
100
300
100
Total
Occupation
Total
7
46
150
Educational background
▪ No formal education
6
33
100
Marital status
▪ Married
5
49
150
Religion
▪ Hindu
4
%
Sex
▪ >50 years old
3
Total (n = 300)
%
Total
2
Villages without rabies experience (n = 150)
n
Role in local community
▪ Local government
46
31
50
33
96
32
▪ Traditional leader
49
32
50
33
99
33
▪ Part of general community
Total
55
37
50
33
105
35
150
100
150
100
300
100
necessarily part of religious obligation. Table 3 shows dog
ownership patterns in villages with and without rabies
cases, revealing no clear distinctions between these groups.
In focus groups and interviews, dog ownership was discussed in more detail, and was linked to culture, personal
taste, and local livelihoods.
According to focus group participants, dogs were a
ubiquitous part of the Balinese landscape and people
were accustomed to having many free-roaming dogs
around their fields, streets, homes, and markets since
childhood. Representative of the influence of Hinduism,
the popular story of King Yudhistira in the Hindu epic
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
Page 6 of 18
Table 3 Dog ownership patterns, by villages with and without rabies experience
Characteristic
Have a dog as it’s part of the Balinese tradition
Villages with rabies experience (n = 150)
Villages without rabies experience (n = 150)
n
%
n
%
84
56
89
59
Have a dog as it’s part of the Hindu tradition
75
50
77
51
Keep free-roaming dog(s)
122
81
116
77
Keep a dog to guard the house
122
81
132
88
Dogs sleep around your property
150
100
149
99
You provide food for your dog
147
98
147
98
Type of food provided:
▪ Commercial food
5
3
9
6
▪ Leftover food
26
17
33
22
▪ A mixture
You can handle your dog
120
80
107
71
144
96
146
97
116
77
113
75
Preference for dog gender
▪ Male
▪ Female
5
3
12
8
▪ Either
32
21
26
17
134
89
134
89
Feeling discomfort/fear of stray dogs
The Mahabharata was continuously invoked to explain
why the Balinese respected and tolerated so many freeroaming dogs. The story goes that after enduring the death
of his family on a perilous journey to the Gates of Heaven,
an ill-kept dog faithfully accompanies King Yudhistira and
when the dog (considered spiritually unclean) is refused
entry into the celestial city by the God Indra, Yudhistira refuses to enter without the dog. At this point, the dog transformed into the God Dharma (representing righteousness
and justice) and Yudhistira is commended for his loyalty.
In the words of one male focus group participant:
“Keeping dogs for the Balinese is just part of the way
we are…we respect dogs due to the story of
Yudhistira…they have a number of functions but
many times people just want dogs around and they
feel that life is quiet, or something is missing or not
complete if a dog is not there. We are used to having
so many dogs around since we were young”.
Considered “owned but free-roaming”, the Balinese dog
was described as “semi-wild”, “fiercely independent”, “untamable”, and “very territorial”, spending most of the
day roaming within one to four kilometers, and some only
returning to their owner compound at night. While dogs
were fed a mixture of leftover and commercial dog food,
they also ate from local hotels, restaurants, religious offerings, and garbage dumps. Due to recent health messaging
campaigns, the majority of the respondents (84 %) felt that
dogs should be caged and put on leashes, although these
recommendations have not been widely put into practice.
The study showed that 79 % of respondents kept their dogs
roaming free. Leashed dogs were perceived to be too aggressive and confining dogs was, in the words of one interviewee, “against the spirit of the Balinese dog”. Although
most owners reported that they could handle their dogs
within the family compound (97 %), focus group participants emphasized that this only lasted a few seconds before
the dog resisted. Those who fed the dog were usually the
same ones that could touch it—and most physical contact
was confined to the time when the dog was a puppy.
Not all owned dogs were indigenous Balinese street
dogs. Although mostly found in the southern tourist region (including Denpasar and Gianyar), Western breeds
were considered to be confined on leashes and kept
within the home as companion animals. The population
of these companion dogs has increased since the 1990s
in parallel to private veterinary practices in Bali and the
growth of the expat community. A second significant
characteristic of the dog population is the presence of
stray dogs, thought to range from 2 to 10 % in the study
villages. Considered more aggressive and prone to physically harming people, stray dogs caused discomfort and
fear among community members and were widely believed to be responsible for the spread of rabies in Bali.
People emphasized that the stray population was maintained by the growth of open garbage dumps (having
grown in parallel with the tourism industry), as well as
the local practice of discarding unwanted female puppies. In total, 76 % of the questionnaire respondents who
had dogs preferred male dogs due to their perceived superior guard dog abilities and the fact that in mating
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
season, packs of unruly males gather at the homes of female dogs, causing a great nuisance to their owners. While
male dogs could be given to friends as gifts, female puppies
were generally not appreciated. However, unwanted females were not killed outright but often discarded in garbage areas, near restaurants and waterways. This practice
was considered widespread throughout the island and motivated by the Hindu principle of ahimsa (non-violence)
towards the unwanted puppies. However, this local practice
was also thought to maintain the stray dog population.
The role of dogs in Balinese society
Questionnaire respondents reported to use dogs as guards
(85 %) and some as companion animals (27 %), while only
2 % related dog ownership to religious or traditional obligations. The idea of dogs being used for recreational purposes was seen as a recent phenomenon. As foreign
breeds have been increasingly imported, it is not uncommon to see both expats and the Balinese with small nonindigenous breeds on their scooters in urban areas; what
one interviewee called “the Paris Hilton poodle”, alluding
to a popular Western celebrity. Western breeds were
linked to symbols of affluence and modernity while they
were also generally considered much better companion
animals. Despite this, the Balinese dog was believed to be
superior in a number of areas. The most widely cited was
that they barked louder and more often at strangers,
making them better guard dogs. During focus groups, it
became clear that dogs function more as an “alarm bell”
alerting family members to strangers than as attack
dogs, as crime was believed to be low and the dogs were
absent (roaming) for most of the day. Farmers living
near mountainous areas also reported the use dogs for
hunting small animals and for protecting agricultural
land from monkeys.
There was also a second, more nuanced way that dogs
played the role of an alarm bell. Dogs were considered
to be able to “see”, “sense”, and “know” when evil spirits
were around the home and acted as de facto “evil spirit
alarms”. Alerted by unusual howling, people would reportedly pray for protection, stay indoors, or avoid some
future activity to evade calamity. These types of events
were believed to coincide with specific times in the Balinese calendar when the movement of spirits was believed to be more prevalent. As one interviewee, a male
village leader, noted:
“A dog is a type of alarm bell for spirits because it is
more sensitive than people to the negative powers and
can see sorcerers approaching you. Some people
believe it is because dogs have evil spirits inside of
them, but I disagree. Dogs are loyal creatures and
want to warn their owners of the dangers…you find
that on certain times of the month, on sacred days
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such as Kajeng Kliwon when spirits roam, you find
the dogs are howling like mad”.
It was found that some groups of people also eat dogs,
a practice that is widespread in other areas of Indonesia
including North Sumatra, North Sulawesi, and East Nusa
Tenggara. During the initial rabies outbreak, there were
reports that dogs were being stolen and moved to northern Bali to be served in restaurants, which may have facilitated the spread of the virus. While it was difficult to
confirm this, focus groups and interviews gave varying
reports about the popularity of dog meat. Some people
commented that it was widely consumed until the rabies
epidemic created a fear of transmission, while others reported that it was only practiced in areas with migrant
non-Balinese populations. There were few reasons given
for the consumption of dog meat. The most accepted was
that certain parts of a dog were eaten under the supervision of a traditional doctor for medical conditions, including a dog’s heart for the treatment of asthma. The second,
albeit a less discussed idea, related to the consumption of
dog for the increase of the male libido, linked to the belief
that dog meat could confer magical powers and increase
sexual dexterity. To some, however, dogs were synonymous with evil spirits and these respondents were opposed
to eating dogs on religious grounds, arguing that this practice should be avoided because, in the words of one focus
group participant,“…it would make you dirty and destroy
your aura since evil spirits can be inside dogs and this
should be avoided”.
Dogs also played a very specific role in religious ceremonies. Contrary to Indian Hinduism, the Balinese use
animals in their religious sacrifices, including dogs. The
Bhuta Yadnya is the practice of providing specific types
of ritual sacrifices of flowers and food to feed and show
respect to evil spirits that are believed to hide in natural
objects and places. Such sacrifices appease these demons, at which point they turn into guards that defend
the household from other spirits. The sacrifice that involves dogs is believed to target evil spirits residing
throughout the banjar area and is done when advised
under the direction of a priest. This was reported to
occur numerous times every year in each of the study
villages by different households. The type of dog needed
was the blang bungkem, a dog with reddish brown fur
and a black snout, chosen because its red color corresponds to the symbolic color of the evil spirit targeted
for such sacrifices. There was no reported breeding of
the blang bungkem; this breed was considered relatively
rare to find but could be bought at certain markets if
not found within the community. An elaborate ceremony, which can cost many hundreds of dollars to conduct, is involved in the sacrifice where the body parts of
the dog are offered up to the evil spirit(s). Interviewed
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
Page 8 of 18
priests explained that the dog then attains a higher state
of re-incarnation as spiritual balance is returned to the
community.
Community knowledge and attitudes towards rabies
Considered a dangerous and fatal disease, 97 % of the
questionnaire respondents had heard of rabies (see
Table 4). Respondents knew that rabies could be transmitted by dogs (95 %), cats (61 %), monkeys (44 %), and
bats (6 %), but a few wrongly believed that rabies can be
transmitted by chickens (0.6 %), mosquitoes (1 %), and
flies (0.6 %). Transmission was thought to be largely
through bites (96 %), which was believed to be the common way of disease transmission. Only a few respondents understood that licks (18 %) and scratches (15 %)
also had the potential to transmit the disease. Focus
groups revealed that people had varying degrees of familiarity with canine rabies. The most commonly described symptoms included: aggression, hyperactivity,
salivation, and fear of water and light. Major sources of
Table 4 Knowledge and experience of rabies, by villages with and without rabies experience
Characteristic
Villages with rabies experience (n = 150) Villages without rabies experience (n = 150)
n
%
n
%
Had heard of rabies
146
97
146
97
▪ Dogs
143
95
143
95
▪ Cats
83
55
101
67
▪ Monkeys
54
36
77
51
▪ Bats
5
3
14
9
▪ Bite
141
94
146
97
▪ Lick
29
19
26
17
▪ Scratch
26
17
20
13
Which animals can transmit rabies:
How rabies can be transmitted:
Source of information to learn about rabies:
▪ Broadcast media (TV & radio)
98
65
105
70
▪ Neighbors
48
32
33
22
▪ Print media
29
19
42
28
▪ Banjar meetings
24
16
26
17
▪ Livestock officers
24
16
36
24
▪ NGOs
5
3
12
8
▪ Internet
0
0
2
1
Seeking medication if bitten by suspected dogs
131
87
128
85
Washing the wound if bitten by suspected rabid dog
53
35
62
41
Reporting to livestock services if bitten by suspected rabid dog 21
14
14
9
Action if suspected rabid dog is identified:
▪ Catch it
21
14
17
11
▪ Kill it
113
75
116
77
▪ Let it go
17
11
18
12
Believe that canine vaccination can eliminate rabies from Bali
147
98
137
91
Believe that culling stray dogs can eliminate rabies from Bali
128
85
120
80
Had their dogs vaccinated for rabies
110
73
111
74
If PEP is provided in your community:
▪ It’s free
71
47
63
42
▪ There is a cost
30
20
36
24
▪ Don’t know
50
33
51
34
122
81
99
66
Dog culling had taken place in your village
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
Page 9 of 18
understood that they should visit a hospital or get treatment, but didn’t really consider this to be a matter that
required urgent treatment. Moreover, a widespread local
belief (held prior to the rabies outbreak) was that dog
licks could heal wounds and this led to the practice of
not washing wounds, including bite wounds. Only 12 %
of the respondents reported that it was important to
consult with local livestock officers in case of dog bites.
This small number could be attributed to the fact, at
least partially, that most people (76 %) reported that killing a suspected rabid dog was the immediate community
response, with only a small number believing that rabid
dogs should be caught (13 %) or let go (12 %). A total of
17 % reported that they had previously been bitten by a
dog.
Based on the scoring system, more than a half of the
total respondents (n = 300, 62 %) had a fair knowledge
about rabies (see Table 5). Similar results were found
information on rabies included television and radio
(68 %), neighbors (27 %), print media (24 %), and livestock officers (20 %).
Most respondents (86 %) believed that visiting a local
hospital or clinic was necessary after a suspected rabid
dog bite and that injection and/or vaccinations (post-exposure prophylactic [PEP]) should be sought. More than
half of the respondents (61 %) wrongly believed there
was a medicine to treat rabies. Only 39 % understood
that injections and/or vaccinations can only block the
virus transmission, and was not the same as medicine.
While PEP treatment was freely available in the outbreak
situation, 22 % of the questionnaire respondents believed
there was a fee involved, while 34 % did not know
whether there was a fee or not.
A significant number of respondents (62 %) did not
think that washing a wound from a suspected rabid dog
bite was important. Our results show that respondents
Table 5 Level of community knowledge about rabies and the rabies control program (n = 300)
No.
Variables
Level of knowledge
Good
n
1
%
n
%
92
37
151
61
4
2
247
100
16
30
34
64
3
6
53
100
108
36
185
62
7
2
300
100
Age
0.187
▪ <30 years old
10
40
14
56
1
4
25
100
▪ 30–50 years old
73
41
103
57
2
2
180
100
▪ >50 years old
25
26
68
72
4
2
95
100
108
36
185
62
7
2
300
100
108
36
182
61
7
3
297
100
0
0
3
100
0
0
3
100
108
36
185
62
7
2
300
100
Religion
0.390
Total
0.0021
Educational background
▪ No formal education
3
21
10
72
1
7
14
100
▪ Elementary school (graduated)
15
20
54
73
5
7
74
100
▪ Junior High school (graduated)
12
34
23
66
0
0
35
100
▪ High school (graduated)
45
42
63
58
0
0
108
100
▪ University
33
48
35
51
1
1
69
100
108
36
185
62
7
2
300
100
Total
0.0341
Role in local community
▪ Local government
46
48
49
51
1
1
96
100
▪ Traditional leader
28
28
69
70
2
2
99
100
▪ Part of general community
Total
1
n
▪ Female
▪ Moslem
5
%
▪ Male
▪ Hindu
4
n
Total (n = 300)
0.156
Total
3
%
Poor
Sex
Total
2
p-value
Fair
: statistically significant at 95 % confidence level
34
32
67
64
4
4
105
100
108
36
185
62
7
2
300
100
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
both in the villages with (66 %) and without (57 %) rabies experience (see Table 6). From the total number of
respondents, 36 % had a good knowledge, while only
2 % had a poor knowledge about rabies. Based on the
village status, less than 5 % of the respondents had a poor
knowledge about rabies (3 % in the villages with rabies
experience; 2 % in the villages without rabies experience),
and more than a quarter of respondents had a good knowledge about rabies (31 % in the villages with rabies experience; 41 % in the villages without rabies experience).
A range of educational statuses were represented
among the respondents: 4 % never attended school,
25 % completed elementary school, 12 % completed junior high school, 36 % completed senior high school, and
23 % completed university (see Table 2). It was observed
that there was a significant relationship between knowledge and educational background (p-value = 0.002) (see
Table 5). Table 5 also shows the significant relationship
that was observed between knowledge and the role of
respondents in the community (p-value = 0.034), even
though there was no significant variation in the range of
the respondents’ roles: 32 % worked for the local government, 33 % were traditional leaders, and 35 % were
just part of the general community (see Table 2). Moreover, based on village status, there was no significant relationship observed between knowledge and both of
these variables (see Table 6).
Based on the village status, there was a significant relationship observed between knowledge and the variables
of sex and age (sex, p-value = 0.029 and age, p-value =
0.045) in villages without rabies experience, while no significant relationship was found between knowledge and
these variables in villages with rabies experience.
The majority of the respondents had positive attitudes
towards the rabies control program (96 %), while 4 %
had neutral feelings towards it, and no one showed a
negative attitude (see Table 7). Similar results were
found in the different villages, but the majority of respondents had positive attitudes (96 % in villages with
rabies experience, 95 % in villages without rabies experience), and only a small proportion was neutral (4 %
in villages with rabies experience, 5 % in villages without
rabies experience) (see Table 8). No significant relationship was observed (p-value > 0.05) between respondents’
attitudes and the examined variables (sex, age, religion,
educational background, role in local community), both
based on the total number of respondents and the
village status.
We also found no significant relationship between respondents’ knowledge and attitude towards rabies and
the rabies control program (n = 300) in villages without
rabies experience. However, a significant relationship between these variables was found in villages with rabies
experience (p-value = 0.009) (see Table 9).
Page 10 of 18
Attitudes towards vaccination
Most of the respondents (91 %) reported that there was
a free vaccination program in their area, and that it had
been conducted by the government (66 %) or an NGO
(34 %). A high percentage (94 %) agreed that annual vaccination was necessary for rabies control. A total of 74 %
claimed to have had their dog(s) vaccinated during the
first island-wide vaccination campaign in 2011. Focus
group participants were unanimous that the majority of
dogs were not vaccinated at central points but rather by
dog-catching teams moving around the banjar. This was
considered a necessary strategy in Bali due to the particular character of the Balinese dog. In the words of one female interviewee:
“You cannot bring these roaming dogs to get
vaccinated as they will fight you, and once a dog sees
or hears another dog being vaccinated, it will run
away because it wants to be free and howl about the
pain involved and it will hide…you cannot bring these
dogs so dog-catchers must come”.
Similar to a recent study done in Tanzania [26], other
reasons stated for the lack of compliance with a central
vaccination point involved: people being too busy, owners
being unable to handle their dogs, most dogs remaining
outside their homes for most of the day, and information
about vaccination being disseminated only the night before the campaign. While vaccination coverage was felt to
be very high (over 70 %), doubts about the coverage in
puppies and stray dogs were widespread.
Community members referred to two main challenges
related to dog-catchers. A general perception was that it
was becoming exceedingly more difficult to catch dogs
during the second (in late 2011) and third (in 2013)
vaccination rounds since the dogs were believed to have
become “resistant” to the catching system, which was ascribed to their traumatic experience of being caught and
vaccinated, as well as their “intelligence” and “memory”
of the event. Second, specific ecological areas such as
garbage dumps and large forest or agricultural areas
were thought to be difficult for dog-catchers, especially
when targeting stray dogs. In one of the study villages
which had experienced two rabies deaths and many more
suspected rabid dogs, over 60 % of the area was covered
with snakeskin fruit trees. Snakeskin fruit trees are short,
dense, thorny trees obstructing visibility and mobility. Besides guarding houses, dogs are also used to guard these
plantations and it was believed that these trees allowed
dogs to “hide” during the vaccination campaigns due to
the remoteness of and inaccessibility to the area.
Interestingly, slightly more than half of the questionnaire respondents (57 %) agreed that rabies vaccination
was not too expensive for the community and focus
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
Page 11 of 18
Table 6 Level of community knowledge towards rabies and the rabies control program, based on village status (n = 150)
No.
Variables based on village status
Level of knowledge
Good
1
Sex
Religion
%
n
%
76
64
3
3
118
100
23
72
1
3
32
100
Village without rabies
experience
▪ Men
▪ Women
Village with rabies
experience
47
31
99
66
4
3
150
100
53
41
75
58
1
1
129
100
8
38
11
52
2
10
21
100
61
41
86
57
3
2
150
100
▪ <30 years old
7
39
11
61
0
0
18
100
▪ 30–50 years old
29
35
52
63
2
2
83
100
▪ >50 years old
11
22
36
74
2
4
49
100
Total
47
31
99
66
4
3
150
100
▪ <30 years old
3
43
3
43
1
14
7
100
▪ 30–50 years old
44
45
51
53
2
2
97
100
▪ >50 years old
14
30
32
70
0
0
46
100
Total
61
41
86
57
3
2
150
100
Village with rabies
experience
▪ Hindu
47
32
97
65
4
3
148
100
▪ Moslem
0
0
2
100
0
0
2
100
Village without rabies
experience
▪ Hindu
▪ Moslem
Village with rabies
experience
Village with rabies
experience
99
66
4
3
150
100
85
57
3
2
149
100
0
0
1
100
0
0
1
100
61
41
86
57
3
2
150
100
2
22
6
67
1
11
9
100
6
15
31
77
3
8
40
100
▪ Junior high school (graduated)
7
35
13
65
0
0
20
100
▪ High school (graduated)
18
41
26
59
0
0
44
100
▪ University
14
38
23
62
0
0
37
100
47
31
99
66
4
3
150
100
▪ No formal education
1
20
4
80
0
0
5
100
▪ Elementary school (graduated)
9
26
23
68
2
6
34
100
▪ Junior high school (graduated)
5
33
10
67
0
0
15
100
▪ High school (graduated)
27
42
37
58
0
0
64
100
▪ University
19
59
12
38
1
3
32
100
61
41
86
57
3
2
150
100
▪ Local government
20
43
26
57
0
0
46
100
▪ Traditional leader
11
22
36
74
2
4
49
100
Total
16
29
37
67
2
4
55
100
47
31
99
66
4
3
150
100
▪ Local government
26
52
23
46
1
2
50
100
▪ Traditional leader
17
34
33
66
0
0
50
100
▪ Part of genera; community
Total
: statistically significant at 95 % confidence level
31
41
▪ Elementary school (graduated)
▪ Part of general community
Village without rabies
experience
47
61
▪ No formal education
Total
1
n
25
Village without rabies
experience
Role in local community
%
33
Total
5
n
8
Total
Educational background
%
39
Total
4
n
▪ Women
Village without rabies
experience
3
Total (n=150)
▪ Men
Total
Age
p-value
Poor
Village with rabies
experience
Total
2
Fair
18
36
30
60
2
4
50
100
61
41
86
57
3
2
150
100
0.682
0.0291
0.494
0.0451
0.593
0.688
0.053
0.107
0.176
0.183
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
Page 12 of 18
Table 7 Level of community attitudes towards rabies and the rabies control program (n = 300)
No.
Variables
Level of attitude
Positive
1
Total
n
%
n
%
238
96
9
4
247
100
49
92
4
8
53
100
287
96
13
4
300
100
25
100
0
0
25
100
0.513
▪ 30–50 years old
172
96
8
4
180
100
▪ >50 years old
90
95
5
5
95
100
287
96
13
4
300
100
Total
Religion
1.00
▪ Hindu
284
96
13
4
297
100
▪ Moslem
3
100
0
0
3
100
287
96
13
4
300
100
Total
Educational background
0.343
▪ No formal education
14
100
0
0
14
100
▪ Elementary school (graduated)
72
97
2
3
74
100
▪ Junior high school (graduated)
35
100
0
0
35
100
▪ High school (graduated)
102
94
6
6
108
100
▪ University
64
93
5
7
69
100
287
96
13
4
300
100
▪ Local government
89
93
7
7
96
100
▪ Traditional leader
95
96
4
4
99
100
▪ Part of general community
103
98
2
2
105
100
287
96
13
4
300
100
Total
5
%
Age
▪ <30 years old
4
n
0.371
▪ Female
3
Total (n = 300)
Sex
▪ Male
2
p-value
Neutral
Role in local community
Total
0.170
groups consistently highlighted that a significant number
of people would be willing to pay for the vaccination of
puppies, if this service was not widely available (which it
was not).
Attitudes towards dog culling and sterilization
Most respondents reported that dog culling had taken
place in their village (74 %) and that it had been carried
out by the government; only 2 % claimed that culling
had been done by the community itself. This aversion to
culling was explained in reference to the Hindu principle
of ahimsa (or non-violence) towards all sentient beings.
At the first outbreak, government culling targeted any
dog that was not tied or left indoors. Many expressed
anger at having their animals killed (some of which had
been vaccinated) and complained about the large number of corpses left by the culling teams. The culling had
generated some reluctance during the first round of
vaccinations as people hid their dogs in fear that the
vaccination teams would kill them. However, most had
accepted and even welcomed the culling, regardless of
their religious beliefs, due to the widespread fear of
rabies. A total of 83 % of the questionnaire respondents
reported that the elimination of stray dogs was necessary
to eliminate rabies, despite the acknowledgement that it
was difficult to differentiate between an owned and a
stray dog, as well as that the stray dog population had
not been dramatically affected by the culling. Although
culling initially reduced the dog population (which was
also perceived to have reduced the number of motorcycle accidents caused by high dog numbers), it was perceived that the stray dog population was again quickly
growing. It was found that the traditional methods of
canine sterilization were practiced only in isolation (adding bread yeast to dog food, for example). While some
expressed reluctance to having their dogs sterilized (due
to a perception that it made them less aggressive), there
was an expectation that the government should conduct
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
Page 13 of 18
Table 8 Level of community attitude towards rabies and the rabies control program based on village status (n = 150)
No. Variables based on village status
Level of attitude
Positive
n
1
Sex
Village with rabies experience
Village with rabies experience
4
3
118
100
94
2
6
32
100
144 96
6
4
150
100
124 96
5
4
129
100
19
90
2
10
21
100
143 95
7
5
150
100
▪ Men
▪ <30 years old
18
100 0
0
18
100
▪ 30–50 years old
79
95
4
5
83
100
▪ >50 years old
47
96
2
4
49
100
144 96
6
4
150
100
▪ <30 years old
7
100 0
0
7
100
▪ 30–50 years old
93
96
4
4
97
100
▪ >50 years old
43
93
3
7
46
100
143 95
7
5
150
100
▪ Hindu
142 96
6
4
148
100
▪ Moslem
2
100 0
0
2
100
Total
3
Religion
Village with rabies experience
Total
Village without rabies experience
▪ Hindu
▪ Moslem
Educational background Village with rabies experience
Role in local community Village with rabies experience
150
100
5
149
100
100 0
143 95
0
1
100
7
5
150
100
9
100 0
0
9
100
38
95
5
40
100
2
▪ Junior high school (graduated) 20
100 0
0
20
100
▪ High school (graduated)
42
96
2
4
44
100
▪ University
35
95
2
5
37
100
144 96
6
4
150
100
▪ No formal education
5
100 0
0
5
100
▪ Elementary school (graduated)
34
100 0
0
34
100
▪ Junior high school (graduated) 15
100 0
0
15
100
▪ High school (graduated)
60
94
4
6
64
100
▪ University
29
91
3
9
32
100
143 95
7
5
150
100
▪ Local government
43
93
3
7
46
100
▪ Traditional leader
47
96
2
4
49
100
54
98
1
2
55
100
144 96
6
4
150
100
▪ Part of general community
Total
Village without rabies experience
4
7
▪ Elementary school (graduated)
Total
5
6
142 95
▪ No formal education
Total
Village without rabies experience
144 96
1
Total
4
%
30
Total
Village without rabies experience
n
114 97
Total
Age
%
▪ Women
▪ Women
2
n
p-value
Total (n=150)
▪ Men
Total
Village without rabies experience
%
Neutral
▪ Local government
46
92
4
8
50
100
▪ Traditional leader
48
96
2
4
50
100
49
98
1
2
50
100
143 95
7
5
150
100
▪ Part of general community
Total
0.823
0.562
0.639
0.683
1.00
1.00
0.820
0.331
0.486
0.350
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
Page 14 of 18
Table 9 Level of community knowledge and attitudes towards rabies and the rabies control program, based on the respondent
group
No.
Respondent/Village group (number
of respondents)
Level of
knowledge
Level of attitude
Positive
n
1
All respondents (n = 300)
n
%
102
94
6
6
108
100
97
6
3
185
100
6
86
1
14
7
100
287
96
13
4
300
100
▪ Good
43
91
4
9
47
100
▪ Fair
98
99
1
1
99
100
3
75
1
25
4
100
144
96
6
4
150
100
Total
Village without rabies experience (n = 150)
%
179
▪ Poor
3
n
▪ Fair
Total
Village with rabies experience (n = 150)
%
Total
▪ Good
▪ Poor
2
p-value
Neutral
▪ Good
59
97
2
3
61
100
▪ Fair
81
94
5
6
86
100
3
100
0
0
3
100
143
95
7
5
150
100
▪ Poor
Total
0.274
0.0091
0.717
1
: statistically significant at 95 % confidence level
more sensitization for the benefit of population control,
provide free sterilization services, and address the problem of stray dogs.
The impact of rabies on dog ownership
The introduction of rabies in Bali was perceived to have
impacted Balinese attitudes towards dogs. Most of the
questionnaire respondents (83 %) reported that the outbreak changed the way they kept dogs, motivating them
to keep less dogs and, for some, to confine and leash
them. Whilst adoption of leashing was limited to urban
areas, even in rural sub-village settings, it was no longer
considered socially acceptable to own more than one or
two dogs; prior to rabies many dog owners had two to
five dogs. Hence, through both education and fear of rabies, the outbreak was believed to have altered, to varying degrees, dog management practices with long-term
implications. As one male village leader noted in a FGD:
“The fear of rabies has really changed the way we are
keeping dogs [in Bali]. We now vaccinate dogs and
feed them well, not like before!…Some people do not
want to keep dogs anymore saying that they prefer
their own safety to having a dog…and more people
are starting to leash or even cage their dogs in town
areas…even when Bali becomes rabies-free, people
will still keep these better habits”.
Traditional law and rabies control
Although controlling rabies is believed to be the government’s responsibility, 67 % agreed that rabies control
could be optimized by instituting dog ownership regulations based on traditional law at the banjar level, which
had already been put in place in late 2010 in some villages (according to 20 % of the questionnaire respondents). There are two types of traditional Balinese laws:
perarem is considered to be a trial law that has an informal amount of enforcement, while awig-awig is a law
that has been sacredly encoded through religious rituals
and must be followed. The awig-awig laws are considered too difficult to institute for rabies control and rather the perarem was widely discussed and implemented
in some areas. These laws included: i) accepting that
your dog has to be culled if it was roaming outside the
household; ii) having to pay all medical costs if someone
was bitten by your dog; iii) incurring a fine if you were
caught discarding unwanted puppies; and iv) paying all
human funeral costs (including cremation) if your dog
caused a human death. Such laws, although informal,
were believed to act as “drivers of responsibility” in the
community, motivating people to leash their dogs and
vaccinate them, although the exact impact was difficult
to measure in this study. In practice, dogs are free roaming and people usually recognize their dogs. The first
point of the laws described above was mainly implemented in first outbreak. In later outbreaks, this point
was mainly implemented when dog bite cases caused
human death, in which the owners were made responsible for both human medication and traditional ceremonies (include cremation).
Socially, Bali has a unique traditional structure and social meeting groups, with traditional laws playing an important role in daily community activities. Banjar men,
women, and youth groups meet on a regular basis, i.e.
monthly or by need. These social group meetings become
a space in which the community can share information on
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
new traditional laws and their implementation. In this type
of community structure, traditional leaders have the responsibility to determine whether important issues should
be regulated with traditional laws to ensure community
awareness and responsibility, including issues on rabies
and its control.
Discussion
The human-dog relationship in Bali is very unique and
closely related with: (1) religion (Hindu), (2) culture, and
(3) socioeconomic contexts. These aspects contribute to
how intensive the human-dog relationship is and how
important of a role dogs play in the daily lives of Balinese
communities, i.e. to guard houses, be companions for
people working in fields or plantations, as well their roles
in religion or traditional ceremonies. These aspects also
drive the practice of free-roaming dogs, which in the context of rabies can pose a high risk for spreading the disease.
Many respondents (79 %) allow their dogs to free roam
and only few could handle their dogs during mass vaccination. These dog management practices need to be improved because dog vaccination can only protect the
population from rabies if an adequate level of herd immunity is achieved (>70 % coverage). Moreover, the practice of discarding unwanted (and unvaccinated) female
puppies will increase the number of uncontrolled freeroaming dogs (or even lead to a higher presence of stray
dogs) and decrease vaccination coverage, despite vaccination campaigns reporting 70–74 % coverage [10]. Many
respondents reported that their communities were keeping fewer dogs since the introduction of rabies, but such
trends might change as the turnover in the dog population is believed to be really high [10]. During the FDGs,
community members expressed concerns regarding the
large number of puppies born every year. In the long
term, these practices increase the burden of rabies
control programs.
Improving dog management practices without stigmatizing community beliefs on the importance of dogs requires a better understanding of community knowledge
and attitudes towards rabies and relevant control programs. Community knowledge related to rabies and the
rabies control program was generally fair, but FGDs revealed that incorrect information was also circulating in
the communities, i.e. rabies is curable, culling is an effective control measure for rabies, and that a fee is charged
for PEP provided by the government. Hence, there is a
need for more community outreach to address these information gaps and improve community knowledge.
Despite the strong influence of Hindu principles in
Bali (which likely contributes to the lack of community
involvement in dog culling), it appears that many people
passively accepted the mass culling of dogs due to a combination of fear generated by the outbreak and wanting to
Page 15 of 18
abide by the government. Culling, however, was not effective in reducing the number of rabies cases [27, 28], and
some vaccinated dogs were also likely culled as a result.
This practice still continues at community levels in several
areas because of fear and a perception generated by a previous government program. Therefore, public awareness
campaigns for rabies should discourage culling.
While most questionnaire respondents understood the
basics of rabies transmission, the study revealed a number of important gaps. This included: i) a lack of awareness about washing suspected rabid dog bite wounds; ii)
a lack of knowledge concerning that PEP must be given
prior to the development of symptoms in humans; iii) a
limited knowledge that scratches could transmit rabies;
and iv) a lack of emphasis on reporting rabid animals to
the local livestock office to facilitate diagnostic testing
and outbreak surveillance. These knowledge gaps at the
local level have important public health consequences
and should be included in the key messages of future
campaigns. Community awareness on PEP must also be
evaluated because people will want to get PEP, however,
some don’t understand that the injection must be sought
as soon as they are bitten (prior to symptoms) and that
late treatment would be ineffective. Lack of awareness
on washing dog bite wounds might be encouraged by
widespread local beliefs (that existed prior to the rabies
outbreak) that dog licks could heal human wounds. It
might also be the reason why only 18 % of respondents
answered that licks are also potential rabies transmitters.
Moreover, there should be a rapid community response to
dog bite cases, and this should be improved overall, not
only in terms of first-aid actions and seeking medical
treatment, but also ensuring reporting to the livestock office in order to prevent suspected rabid dogs from spreading the disease further. More rabies centers (reference
hospitals or village/sub-district health centers) should also
provide free services for PEP, as some people are still not
aware that free PEP services are provided for rabies outbreak areas, such as Bali.
To improve community knowledge, better dog ownership should be encouraged, which involves educating
people about leashing their dogs and regular feeding. If
owners and communities can become closer with their
dogs, then dogs can be handled more effectively during
vaccination campaigns. In addition, it would also greatly
improve the efficiency of mass vaccination programs.
Since the economy poses a major challenge to the implementation of leashing and regular feeding in some rural
areas, more effective strategies need to be explored.
Public awareness programs on rabies prevention and
control and responsible dog ownership must be delivered
regularly to ensure community knowledge improvement
and to encourage behavioral changes. We found no significant relationship between gender and knowledge level
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
or community attitudes towards rabies and its control.
Based on the FGDs, men and women share equal roles
and responsibilities in managing dogs. Youth and children
have daily contact with dogs, for play and companionship,
while adults also have contact in houses or at their workplaces. Therefore, different genders and ages have similar
potential risks to contribute to the rabies spread, but could
also provide valuable assistance to rabies control programs
if their knowledge and attitudes are improved.
While community knowledge was generally fair and
attitudes were mostly positive, the community in general
still maintains free-roaming dogs. While there was a significant relationship observed between knowledge and
educational level, and also between knowledge and the role
in the community, there was no significant relationship observed between community knowledge, attitudes, and dog
keeping practices. Dogs were generally free roaming, regardless of these variables. Therefore, campaigns should
target people of all genders, ages, religions, educational
backgrounds, occupations, and roles in the community, regardless of their rabies experience, to ensure appropriate
information dissemination.
Once active rabies cases have been significantly reduced
(as they have in Bali), elimination efforts must focus heavily on strengthening surveillance capacity and rapid response, as well as maintaining vaccination coverage [29].
Cognizant that there are both strengths and challenges involved in instituting community participation in disease
control programs [30–32], it is important to consider how
the Balinese community could be more actively involved
in optimizing these efforts. Our study has identified a
number of sociocultural aspects that can be driven to a
potential community-based rabies control program,
which can also go in line with a community knowledge
improvement program.
First, the Balinese have a local belief that has a strong
emphasis on ahimsa (non-violence). Such culturally embedded logics could be used to frame education efforts
targeting compliance to vaccination as well as more responsible dog ownership practices. This could include
more physical contact with dogs from a young age, leashing, regular feeding, and animal healthcare. Additionally, a
major emphasis on education should address the practice
of discarding unwanted female puppies (due to their
maintenance of the stray dog population) and the reporting of rabies cases in dogs. The principle of ahimsa could
also be used to promote a sterilization program, to explore
animal welfare issues, to stop culling, to promote regular
vaccination of puppies, as well as to emphasize the importance of reporting dog rabies cases to livestock officers
in order to curtail further spread to dogs and humans.
Second, our research has shown unique community
structures and regular social meetings (men, women, and
youth) that could be engaged to facilitate increased public
Page 16 of 18
awareness of rabies elimination and a community’s capacity for supporting rabies control programs. Training for
banjar or village-based volunteers (locally called kader),
and working with banjar leaders through, for example, a
“trainer-of-trainee” model would offer a useful pathway in
raising local awareness and engaging communities in rabies control and animal health more generally. Moreover,
the head of banjar is usually also on the board of directors
for schools in the area and this means that schools can
also help disseminate knowledge about rabies.
Lessons can be learnt from other similar campaigns,
such as the Bohol Rabies Prevention and Elimination
Project in the Philippines, which generated considerable
village level involvement through thousands of volunteers, dog registration efforts, school-based education
modules, and engaging legislative enforcement [33]. Bali
cannot fully adopt this volunteer system because mass
vaccinations in Bali have to be done by veterinarians
appointed by the government. However, communities can
be encouraged to participate in other ways, such as assisting vaccination programs, conducting public awareness
programs, registering their dogs at the banjar level, and
responding to any rabies outbreaks quickly. With the employment of dog-catchers, dogs were believed to have
shown more “resistance” (i.e. aggressive and harder to
catch) with each passing campaign and some reported to
“hide” and avoid the teams as well as villagers in general.
However, dog-catchers were useful for vaccinating dogs
that were not owned dogs (stray dogs) or free-roaming
dogs that could not be handled by their owners. Door-todoor vaccination is still relevant since not all owners can
handle their dogs or bring them to vaccination points in
banjars due to owning a large number of dogs. At this
point, volunteers can assist vaccination teams in handling
the dogs or by providing baseline data of dogs registered
at the banjar level. Formal acknowledgement and institution of community volunteers in rabies control programs needs to be considered. Volunteers may feel
more appreciated and be encouraged to work harder.
Moreover, volunteers will need technical assistance from
the government to improve their capacity in supporting
the programs to combat rabies.
Lastly, our study reveals people’s endogenous attempts
to use traditional legal structures in order to increase
local compliance with rabies control, which has also
been reported in Tanzania [26]. With the “spirit of togetherness” (locally called tanggung renteng), legal codes
have important social punishment dimensions and are
used for a range of daily activities in Bali. Although there
are certainly problems with coercive public health measures, some of which arise from community inequities
[34], these are unlikely to emerge with a free state-led
vaccination campaign. Such community-driven activities
could be used to build support for a greater involvement,
Widyastuti et al. Infectious Diseases of Poverty (2015) 4:30
information, and guidelines for supporting elimination of
rabies. Over time, it may also be useful to try and encode
additional rabies-related norms into village legal structures, such as forbidding people to discard unwanted
puppies, placing restrictions on the number of dogs a
household can own, and making it obligatory to vaccinate
dogs as many respondents stated they are willing to pay
for the vaccination of puppies and accept free sterilization
services, if offered by the government. However, these
need to be carefully developed in collaboration with the
government, NGOs, and the public to avoid misunderstandings and distortions.
As a sociocultural study that also included an analysis
of risk factors of a disease, this research had number of
limitations that need to be acknowledged. There was a
high proportion of male respondents, determined by
the convenience sampling and analysis based on village
groups, and this could have biased our results, even
though the study tried to complement the questionnaire data by the findings elucidated by the FGDs.
Moreover, the research involved a small number of selected villages in regencies and therefore extrapolation
to other areas should be made with caution. Despite
the weaknesses of this research, study results and recommendations should be considered and implemented
as potential pathways to optimize the rabies control
program in Bali.
Conclusion
The human-dog relationship in Bali is multifaceted.
With the uniqueness of culture and local beliefs and encouraged by a socioeconomic aspect, a number of local
practices were found to constitute risk factors for continued rabies spread. Community knowledge and attitudes to encourage gradual behavior changes need to be
improved across different genders, age groups, educational backgrounds, religions, and roles in the community, regardless of the villages’ experiences with rabies.
Community-driven activities based on sociocultural conditions and community capacity at the banjar and village
levels were identified as potential ways for supporting
the ongoing rabies control program in Bali. These include public awareness activities, vaccination, dog registration, dog population management, and rapid response
to dog bites. The program also needs some recognition
or acknowledgement from the governments, especially
from local government as well as regular mentoring to
improve and sustain community participation.
Additional file
Additional file 1: Multilingual abstracts in the six official working
languages of the United Nations.
Page 17 of 18
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
MDWW and KLB prepared and finalized the paper. S, CB, EB, AJ, RAA, AAGP,
IW, AR, and ATSE contributed in the study conception, design, acquisition of
data, data analysis and interpretation, and critically revised the paper. IKGN
and IPS contributed in acquiring the data and made technical inputs. FU,
DG, and JG provided technical input to the design and implementation of
the study and critically revised the paper. All authors read and approved the
final manuscript.
Acknowledgements
We would like to thank the International Livestock Research Institute (ILRI)
that led this project and the International Development Research Center
(IDRC) for their financial support. Our gratitude also extends to the Livestock
and Animal Health Services Office of the Bali province, the Livestock Services
Office of Denpasar city, the Livestock, Fisheries and Marine Services Offices
of the Gianyar District, the Livestock, Marine and Fisheries Services Offices
of the Karangasem district, local governments, traditional leaders, and
community members in villages who supported our activities in the field.
We also thank the research and field teams involved in this study.
Author details
1
Center for Indonesian Veterinary Analytical Studies, Bogor, Indonesia.
2
School of Social and Political Science, The University of Edinburgh,
Edinburgh, UK. 3Faculty of Veterinary Medicine, Bogor Agricultural University,
Bogor, Indonesia. 4Center for Socio Economic and Agricultural Policy Studies,
Ministry of Agriculture, Bogor, Indonesia. 5Disease Investigation Centre
Denpasar, Ministry of Agriculture, Denpasar, Indonesia. 6Edelman Indonesia,
Jakarta, Indonesia. 7Faculty of Veterinary Medicine, Airlangga University,
Surabaya, Indonesia. 8InI Veterinary Service, Surabaya, Indonesia. 9Bali
Provincial Livestock and Animal Health Services Office, Denpasar, Indonesia.
10
International Livestock Research Institute, Nairobi, Kenya.
Received: 31 October 2014 Accepted: 28 May 2015
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