Rabies is a viral zoonosis caused by lyssaviruses and is almost invariably fatal once clinical symptoms appear.[1] Human rabies is nevertheless preventable through timely post-exposure prophylaxis (PEP), including immediate wound washing, anti-rabies vaccination (ARV), and rabies immunoglobulin (RIG) when indicated.[2] The global “Zero by 30” strategy aims to eliminate human deaths from dog-mediated rabies by 2030 through a One Health approach that combines mass dog vaccination, access to PEP, surveillance, and sustained community awareness.[3] India remains rabies-endemic. A nationwide community-based survey conducted during 2022–2023 estimated 5,726 human rabies deaths annually and documented a substantial burden of animal bites.[4, 5] India’s National Rabies Control Programme emphasizes prompt management of animal bites, training of health-care personnel, surveillance, and public awareness.[6] However, inappropriate wound care, delayed reporting, traditional remedies, incomplete vaccination, and limited understanding of RIG continue to undermine prevention.[6-17] Knowledge, attitude, and practice (KAP) studies are useful for identifying educational needs, but knowledge alone may not ensure safe behavior after an exposure. This distinction is particularly relevant among people who have already experienced an animal bite, because their reported actions provide an opportunity to examine whether awareness is translated into practice. Previous Indian community-based research has demonstrated gaps in first aid and vaccination knowledge and has used KAP score correlations to assess this relationship.[7] The present study therefore assessed knowledge, attitudes, practices, and health-seeking behavior related to animal bites and rabies among animal-bite cases attending a government referral hospital in Punjab, North India. It also examined associations with selected demographic characteristics and the relationships among knowledge, attitude, and practice scores.

Study design and setting A hospital-based cross-sectional study was conducted at the anti-rabies clinic and emergency department of a government hospital in Punjab, North India, which functions as a referral center for animal-bite cases. The study population comprised patients presenting for management of animal bites. Study Timeline Ethical approval was obtained in February 2025. Data collection was conducted during March and April 2025, followed by data analysis and preparation of the study report. The final report was submitted in December 2025. Sample size and sampling The sample size was calculated using an estimated prevalence of 50.4% for receipt of PEP from government hospitals in Punjab,[8] a 95% confidence level, and a 7% absolute margin of error. The calculated sample size was 197. Eligible new and follow-up animal-bite cases attending the study sites were recruited using a consecutive convenience approach. Study tool and data collection Data were collected using a predesigned, pretested, semi-structured interview schedule translated into the local language. The questionnaire was adapted from the KAP instrument reported by Sivagurunathan et al.[7] and modified for the study objectives and local setting. It included sociodemographic characteristics, socioeconomic status using the updated B.G. Prasad classification,[18] bite characteristics, knowledge of rabies and PEP, attitudes toward prevention and treatment, previous post-bite practices, and health-seeking behavior. Interviews were conducted in person after written informed consent by the principal investigator, trained staff nurses, and medical interns. KAP scoring Nine determinants (awareness of rabies, fatality, causative organism, animals responsible for transmission, mode of transmission, correct first aid, ARV, tetanus vaccination, and action regarding the biting animal) were used for the knowledge score. Four attitude determinants and five practice determinants (first aid, doctor visit, ARV, tetanus vaccination, and action regarding the biting animal) were used for the attitude and practice scores, respectively, following the scoring framework adapted from the source KAP study.[7] Statistical analysis Data were entered in Microsoft Excel and analyzed using IBM SPSS Statistics version 30.0. Continuous variables were summarized using mean and standard deviation, and categorical variables using frequencies and percentages. Pearson’s Chi-square test was used for categorical comparisons. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported where applicable. Spearman’s rank correlation was used to examine relationships between knowledge, attitude, and practice scores. A P value <0.05 was considered statistically significant. Ethical considerations The study was conducted after approval by the Institutional Ethics Committee. Written informed consent was obtained from adults. For participants younger than 18 years, consent was obtained from a parent/guardian and assent from the participant, as applicable. Confidentiality was maintained throughout the study.

Participant characteristics Among 197 participants, 127 (64.5%) were male. The mean age was 28 ± 15.5 years (range: 10 months–67 years), and 90 (45.7%) were aged 21–40 years. Category II exposures accounted for 53.8% and Category III exposures for 45.7%. Socioeconomic Class I and II comprised 29.9% and 29.4% of participants, respectively. Characteristic n (%) Age <20 years 68 (34.5) Age 21–40 years 90 (45.7) Age 41–60 years 28 (14.2) Age >60 years 11 (5.6) Male sex 127 (64.5) Socioeconomic Class I 59 (29.9) Class II 58 (29.4) Class III 46 (23.4) Class IV 26 (13.2) Class V 8 (4.1) Family size >5 75 (38.1) Knowledge and attitudes regarding rabies prevention Overall, 81.2% knew that animal bites can cause disease and 66.5% had heard of rabies. Among those who had heard of rabies, 90.8% knew it was fatal and 71.8% knew that animals other than dogs can transmit rabies. Only 42.6% identified washing with soap and running water as appropriate first aid. ARV was recognized as preventive by 68.5%, whereas only 6.6% knew that ARV is safe during pregnancy. Most participants (96.4%) agreed that completion of the ARV course is necessary, but only 43.1% disagreed that indigenous materials can prevent rabies. Indicator n/N (%) Had heard of rabies 131/197 (66.5) Knew rabies is fatal 119/131 (90.8) Knew animals other than dogs can transmit rabies 94/131 (71.8) Identified microorganism/germs as cause 72/131 (54.9) Knew soap and running water as first aid 84/197 (42.6) Knew ARV can prevent rabies 135/197 (68.5) Knew ARV is safe during pregnancy 13/197 (6.6) Knew tetanus vaccination should be given 182/197 (92.4) Knew RIG is given after animal bite 119/197 (60.4) Agreed ARV course should be completed 190/197 (96.4) Reported practices after previous animal bite Forty-seven participants (23.9%) reported a previous history of animal bite in their family. Of these, 68.1% involved stray animals and 93.6% involved dogs. Only 29.8% reported washing the wound with soap and running water, while 46.8% reported no first aid. Most (93.6%) visited a doctor and received ARV. Tetanus immunization was reported by 81.8%. None reported observing the biting dog for the recommended period in the practice history. Practice among those with previous family animal bite n/N (%) Stray animal 32/47 (68.1) Dog bite 44/47 (93.6) Washed with soap and running water 14/47 (29.8) No first aid 22/47 (46.8) Visited a doctor 44/47 (93.6) Received ARV 44/47 (93.6) Received tetanus immunization 36/44 (81.8) Reported four ARV doses 25/44 (56.8) Did not know number of ARV doses 15/44 (34.1) Associations and relationship among KAP scores Females had significantly higher odds of believing that ARV is unsafe during pregnancy than males (OR=2.17; 95% CI: 1.25–3.81; P=0.029). Other examined gender associations were not statistically significant. Participants aged <40 years had higher odds of correct first-aid knowledge and of believing ARV unsafe during pregnancy than those aged ≥40 years, but neither association reached statistical significance. Comparison OR (95% CI) P value Female vs male: not heard of rabies 1.56 (0.85–2.88) 0.151 Female vs male: correct first-aid knowledge 1.11 (0.62–2.00) 0.899 Female vs male: believes ARV unsafe in pregnancy 2.17 (1.25–3.81) 0.029 <40 vs ≥40 years: correct first-aid knowledge 1.36 (0.69–2.68) 0.373 <40 vs ≥40 years: believes ARV unsafe in pregnancy 1.77 (0.86–3.63) 0.118 The mean knowledge, attitude, and practice scores were 4.4, 3.0, and 2.9, respectively. A moderate positive correlation was observed between knowledge and attitude (rₛ=0.571, P<0.001; Figure 1). In contrast, knowledge was not significantly correlated with practice (rₛ=−0.055, P=0.715; Figure 2), and attitude was not significantly correlated with practice (rₛ=−0.184, P=0.216; Figure 3).

This study among animal-bite victims identified a clinically important gap between general awareness and actionable preventive behavior. Although two-thirds had heard of rabies and most of those recognized its fatal nature, fewer than half knew that immediate washing with soap and running water is appropriate first aid. Awareness of ARV safety during pregnancy was particularly poor. These findings identify specific messages that should be prioritized during health education at anti-rabies clinics and in community communication. The level of rabies awareness was broadly comparable with previous Indian studies, although the pattern of specific knowledge varied. Sivagurunathan et al. reported that 76% of an urban community had heard of rabies, but only about one-third knew appropriate wound washing.[7] Studies from Haryana and rural Punjab have similarly documented deficiencies in first aid and post-exposure actions.[8,9] Evidence from Nepal, Bhutan, Bangladesh, Ethiopia, and Sri Lanka also demonstrates persistent misconceptions about wound washing, transmission, vaccination, and traditional remedies.[12,13,17,19,20] The most striking finding was the disconnect between knowledge or favorable attitude and actual practice. Knowledge correlated with attitude, but neither knowledge nor attitude showed a significant positive relationship with practice. In contrast, Sivagurunathan et al. reported positive correlations among all three KAP domains.[7] The present finding is important for health promotion because it suggests that information provision alone may be insufficient to produce correct post-bite behavior. Educational strategies should therefore emphasize skills and immediate actions, use repeated counseling, address practical barriers, and verify understanding rather than relying only on awareness messages. The discrepancy between knowledge and behavior is also consistent with broader evidence on rabies education. Educational interventions can improve rabies knowledge and perceived vulnerability, but improvement in preventive behavior is not always proportional.[21] This supports a shift from awareness-only communication toward behavior-focused education: demonstration of wound washing, clear explanation of PEP schedules, reassurance regarding vaccination in pregnancy, and explicit instructions about the biting animal. Only 6.6% of participants knew that ARV is safe during pregnancy, and women had significantly higher odds of believing it to be unsafe. This misconception is potentially consequential because pregnancy is not a contraindication to indicated rabies PEP. Targeted counseling for women of reproductive age and consistent messaging by health-care workers should therefore form part of routine bite management. Most participants with a previous bite history reported visiting a doctor and receiving ARV, which is encouraging. However, correct first aid was substantially less common, and many participants did not know the number of vaccine doses received. These findings indicate that contact with health services does not automatically ensure complete understanding of PEP. Anti-rabies clinics provide a teachable moment in which brief standardized counseling can reinforce wound care, vaccine adherence, RIG indications, and follow-up actions. Limitations The study was conducted at a single referral hospital and used a consecutive convenience approach; therefore, the findings may not represent people with animal bites who do not seek formal care. For minors, KAP information was obtained from the accompanying parent or older family member rather than directly from the child. Practice questions were based on previous animal-bite experience in the family and were therefore subject to recall and social-desirability bias. The cross-sectional design also precludes causal inference regarding the relationship between knowledge, attitude, and practice. Implications for health education Counseling at the point of care should move beyond general rabies awareness and focus on observable behaviors: immediate washing with soap and running water, avoidance of harmful indigenous applications, timely PEP, completion of the prescribed vaccination schedule, RIG when indicated, and correct advice regarding the biting animal. Simple demonstration-based messages and a brief take-home instruction sheet may help bridge the knowledge–practice gap identified in this study.

Animal-bite victims attending a government referral hospital had reasonable awareness of rabies fatality and vaccination, but substantial gaps persisted in correct first aid, vaccine safety during pregnancy, and post-bite practices. Knowledge was associated with more favorable attitudes but did not translate into better reported practice. Rabies prevention education should therefore prioritize behavior-focused, repeated, and practical counseling at anti-rabies clinics and in community health-promotion activities.

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