Co-creating Community Engagement Strategies to Increase Rabies Post-Exposure Prophylaxis Uptake: A Multicountry Study in Tanzania, Côte d'Ivoire and Chad

Background: Rabies deaths prevail in many low-resource settings due to limited access to post-exposure prophylaxis (PEP). In preparation for the potential roll-out of PEP integration into the Expanded Program for Immunization (EPI), Gavi commissioned a study with the objective to evaluate how co-created community engagement strategies (CES) may increase demand for PEP after a bite. Methods: We conducted a qualitative study in Tanzania, Côte d’Ivoire, and Chad using participatory approaches to co-design CES for PEP uptake. Using a Human-Centered Design approach we conducted interviews and FGDs with stakeholders on community and provider level during the inspiration phase, including children, women and nomadic populations. Results were analyzed following the WHO framework on behavioral and social drivers of vaccination. In the ideation phase, co-design workshops were conducted to refine and validate a draft CES. The implementation phase piloted and evaluated the CES through follow-up interviews and discussions, complemented by indicators on bite reporting and PEP uptake. Results: High costs, long travel distances, and limited awareness of services are consistent barriers to PEP. Inconsistent availability of PEP leads to reduced trust in health services and reliance on traditional healers. Knowledge of rabies and its fatal outcome is high, but importance of wound washing and timely PEP is less known. Children were identified as the most vulnerable group due to close contact with dogs and unreported dog bites linked to fear of punishment. Participants emphasized the need for child- and mother-focused awareness strategies through school-based education and women’s associations to improve exposure detection. Co-creation workshops produced context-adapted sensitization materials and engaging communication formats, such as theatrical performances and audio sketches. Trusted community actors and community health workers were identified as preferred vehicles for message dissemination. The co-creation process was a valuable learning opportunity, bringing together community members with representatives from the human and animal health sectors. Conclusion: Co-creation approaches that engage trusted community actors and develop context-adapted communication tools strengthen awareness efforts and foster shared ownership. Strengthening PEP supply systems alongside community demand generation will also be essential during Gavi’s rollout of PEP to build trust in health services.