Willingness to pay for rabies vaccination services and associated factors among communities in Geita District, Tanzania

doi:10.21203/rs.3.rs-4926351/v1

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Willingness to pay for rabies vaccination services and associated factors among communities in Geita District, Tanzania

https://doi.org/10.21203/rs.3.rs-4926351/v1

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Background: Rabies remains a significant public health and economic problem in Tanzania, causing a high economic burden due to medical costs and productive lives lost due to premature deaths. Despite all the effort put into rabies vaccination campaigns, there are still new cases all the time, and vaccination coverage is still low. Therefore, this study aimed to explore the willingness to pay for rabies vaccination services and associated factors among communities in Geita district, Tanzania.

Methods: A cross-sectional study was conducted among 312 respondents in Geita district from August to September 2023. The study deployed a willingness-to-pay (WTP) technique using a bidding game to elicit the maximum values respondents were willing to pay for rabies dog vaccination and human post-exposure prophylaxis. An interviewer-administered questionnaire was used to collect all the necessary data. Linear regression models were used to evaluate the WTP and associated factors.

Results: The results suggest that people are willing to pay slightly more for dog vaccination services ($0.3 above the prevailing price) compared to human post-exposure prophylaxis (PEP), in which the average WTP is the same as the prevailing price. 62% of the respondents were willing to pay above the prevailing price ($1.2) for dog vaccines compared to 32% for PEP ($20). In dog vaccination and human PEP services, men are more willing to pay than women.

Conclusion: This study highlights the significance of economic consideration in rabies vaccination decisions. In addition to awareness, availability, and access to vaccines, it is crucial to consider socioeconomic factors and financial values individuals place on the welfare of animals.

Trial registration: Not Applicable

Rabies

Willingness-to-pay

dog vaccination

human post-exposure prophylaxis

Tanzania

Rabies is a viral disease that affects the central nervous system of mammals, ultimately affecting the brain cells and causing death [1]. The virus is commonly transmitted to humans through bites by rabid animals, especially dogs [2]. Rabies is a significant public health threat and the most underreported neglected tropical disease in low-income countries [3, 4]. Rabies is estimated to cause 59,000 human deaths annually in over 150 countries, with 95% of cases occurring in Africa and Asia [5].

Rabies has a significant impact on communities. The disease is associated with an increased economic burden, with control and management costs estimated to reach up to $20 million in Africa [4]. In Tanzania, where rabies is endemic, it is estimated to cause over 1,400 annual deaths [6]. The direct medical cost associated with a complete regime of post-exposure prophylaxis (PEP) is estimated at an average of $100 per person in the country [4]. These expenses impose a substantial burden, particularly on impoverished and rural communities where access to preventive measures such as vaccination may be limited. Geita is among the districts in Tanzania that experience a notable burden of rabies cases among human and animal populations, where in 2023, there were about 11 rabies cases in the region.

Dog vaccination is considered one of the most cost-effective methods for preventing and controlling dog-mediated human rabies and associated deaths [7]. Evidence shows that an increase in domestic dog vaccination coverage is strongly associated with a decrease in the incidences of rabies [8, 9]. This is because 99% of human exposures occur through rabid dogs [10, 11]. Also, prompt administration of PEP prevents human rabies in victims of dog bites [12]. Unfortunately, the cost of PEP can be a significant barrier for bite victims and governments in LMICs [13, 12]. Although dog vaccination against rabies is mandatory for every owner in Tanzania, the vaccine is considered a private good. Therefore, owners are usually charged a fee to vaccinate each dog. However, the higher the cost, the lower the compliance is likely to be [14]. Therefore, before setting the prices, it is essential to understand whether communities see the value of rabies vaccination and are willing to pay for the associated benefits. The willingness to pay enables involved parties to determine the price that will promote the uptake of rabies vaccination services among vulnerable communities.

Willingness to pay (WTP) is one of the important economic values. It is a fundamental economic concept that provides insights into consumers’ preferences, elasticity of demand, and perceived benefits of the good or service [15]. The WTP analysis has been used in a different field for economic valuation to estimate the economic value of non-market goods and services such as environmental services [16], forest management [17], and health interventions [18–20]. Willingness to pay for healthcare services has been reported to correlate with age, education, income, household size, perception/perceived risk, healthcare quality, locality, and ability to pay [21–23]. WTP has been used in Rabies studies to estimate the monetary value individuals place on services such as dog vaccine costs and vaccination cards [14, 24, 25]. However, no studies have been conducted individually on WTP for human rabies vaccine. Understanding WTP for rabies interventions is key to improving policies and programmatic strategies to enhance access to rabies vaccination services and reduce the burden of rabies, particularly in resource-limited settings. Therefore, his paper aims to provide insights into the economic preferences and priorities of residents regarding rabies prevention and control strategies by evaluating community willingness to pay for rabies vaccination services (Dog vaccines and human vaccines) in Geita District, Tanzania. The conceptual framework guiding this study is rooted in health economics and behavioural economics theories, which recognise the interplay between individual perceptions, socio-economic factors, and healthcare decision-making processes.

Description of the study area

Geita district is among the districts located in the Geita region in northwestern Tanzania. The district is made up of 35 wards and 145 villages. According to the 2022 National Population and Housing Census, the district had a total population of 1,035,214 people, of which 507,788 (49%) were male and 527,426 (51%) were female [26]. Geita district was selected for this study because of the following reasons: (i) Between 2018 and 2021, eleven (11) cases of Rabies in dogs were reported in the animal health surveillance system, putting 3085 dogs at risk (Ministry of Livestock and Fisheries, personal communication). (ii) The presence of Burigi-Chato National Park in the region is also considered a risk factor for fueling rabies transmission via wildlife-human interaction. Two sites (rural village and urban sites) were selected to get diverse contexts on the systems-level factors attributed to rabies prevention and control in the district.

Figure 1. Map of Tanzania showing study site

Study design

This analytical cross-sectional study was conducted among community members in the Geita district from August to September 2023.

Study population

The study population comprised all households in the selected areas in Geita district council. The study targeted dog owners and non-owners in Geita because we hypothesised that individuals have diverse understandings and willingness to pay for vaccination-related services for rabies. Dog owners and non-owners over 18 years old residing in the selected areas were eligible to gather diverse perspectives regarding the subject.

Sample size estimation

The researchers did not have enough information on the population size (total number of households) for each village. Therefore, the sample size estimation formula for unknown populations was used as described by Charan and Biswas (2013) [27]. It is used for calculating the sample size of a qualitative variable in prevalence or cross-sectional studies:

Sample size (n) =(Z _1−∝/2)² *p (1-p)/d²

Where:

n = Sample size

Z _1−∝/2= Standard normal variate at p < 0.05 is 1.96

p = estimated proportion of the study variable, at 50% (for maximum variability)

d = Margin of error, 5%

The margin of error accommodated non-responses and refusals; hence, the sample is sufficient for estimating the parameters. As a result, a sample of 384 respondents was obtained

Sampling procedures

Household was the sampling unit, and multi-stage sampling procedures were followed as indicated in Fig. 2:

Figure 2. Multistage Sampling procedure

A total of six villages were selected depending on the following strata: location (rural or urban category), dog population (high and low population) and recent incidents of bites and rabies in the area (high and low prevalence) to compare multiple variables across them. A proportional technique was used to determine the number of respondents, where 5% of the total households in the village were recruited for the study. During the selection, gender split was considered, and it was ensured that at least 30% of the selected households were female-headed. A random number generator (https://www.randomizer.org/) randomly selected eligible households.

Data collection

Data were collected using an interviewer-administered electronic questionnaire built on the Open Data Kit (ODK) mobile application [28]. The instrument covered the socio-demographic characteristics of the respondents, such sex, education, age, occupation, as dog ownership, risk perception, awareness about rabies, rabies vaccination services, and willingness to pay for rabies vaccination services. The questionnaire was administered to a household head except in a few cases where the potential respondent chose an adult representative within the household who is more informed.

The willingness to Pay (WTP) method was presented as a bidding game to assess the respondent’s perceived costs and benefits of vaccinating their dogs and post-exposure prophylaxis (human vaccine) as reported in [24]. To assess WTP for dog vaccination fee, the respondent was first offered an initial price for a dog rabies vaccine of 3,000 TZS (approximately $1.20). This is the standard price that the district veterinary officials have set to charge for vaccination services. If the respondent accepted or answered “Yes” to this initial price, he/she was directed to the next question. He/she was continuously offered higher and higher prices step by step until the s/he rejected or said No. Alternatively, if the respondent rejects (“No”) the initial price (first question), then the respondent was directed to a lower price option, and the prices repeatedly decreased step by step until the respondent accepted a given price or reached zero. The same methodology was used to assess Willingness to Pay for Post-exposure prophylaxis.

Data processing and analysis

Data from the questionnaire was downloaded from the ODK server, cleaned using Microsoft™ Excel and converted into a CSV (Comma-Separated Values) file for easy transfer and analysis in other software. The analysis was done using Microsoft™ Excel statistical analysis package and Python programming language (version 3.9). Descriptive statistics summarised participants’ demographics and responses to the selected variables, including mean, median, mode, range, and variance. Multinomial logistic regression analysis was used to assess the influence of independent variables on the categorical outcome variables. Multiple linear regression analysis predicted the values between independent and continuous outcome variables. The chi-square test was used to evaluate whether there is a significant association between two categorical variables. A P value of less than 0.05 was considered statistically significant.

Summary statistics

In this study, a total of 384 households were selected. However, only 312 (81%) participated in the study (Table 1). There were no non-responses, rather, some (72) selected participants were not available for interviews on the allocated dates.

Table 1

Villages selected for the study in Geita District
Village	Location	Dog population*	Incidences of dog bite/rabies*	Sample
Bugogo	Urban	High	High	53
Nyakagomba	Rural	High	Low	40
Nyamigota	Urban	Low	Low	51
Lwamgasa	Urban	Low	Low	45
Bukondo	Rural	High	High	73
Butundwe	Rural	High	High	49
TOTAL				312
*This was unpublished report of the dog population reported by the district veterinarian

Socioeconomic Demographic characteristics of the respondents

Table 2 details the socio-economic-demographic characteristics of 312 respondents who participated in the survey. Of these, 92 (29.5%) were female. The median age of the respondents was 47 years old, ranging from 18 to 83 years old. More than half (52.3%) had completed primary education, and 18.6% had no formal education. The primary income source for most households (91%) was selling/trading agricultural produce and products, and 53.5% reported an annual income of less than 500,000TZS ($200). Fifty-two percent of the respondents lived in rural areas.

Table 2

Socio-Economic Demographic information of participants
Variable	Frequency	Percentage
Gender
Male	220	70.5
Female	92	29.5
Household headship
Male-headed	255	81.7
Female-headed	57	18.3
Rural/Urban
Rural	163	52.2
Urban	149	47.8
Marita status
Married/living together	247	79.2
Divorced/separated	15	4.8
Widowed	40	12.8
Single/never married	10	3.2
Respondent’s education
No formal education	58	18.6
Primary education	209	67.0
Secondary education	41	13.1
Tertiary education	4	1.3
Annual household income (TZS)
< 500,000	167	53.5
500,000–1,000,000	67	21.5
1,000,000–5,000,000	70	22.4
> 5,000,000	8	2.5

Dog Ownership

A third (34%) of the households owned dogs. Only 23.4% of female-headed households owned dogs. On average, each household kept two dogs (range: 1–12). Over half of the owners (53.4%) were from rural localities, and more than 80% claimed that they keep dogs as security animals to protect against thieves and wild animals. This was particularly important for those involved in livestock keeping and agricultural activities. However, more than 65% of the respondents were not keeping dogs in their households. Reasons for not owning dogs included: cost incurred when it bites someone, not seeing the need since they did not keep livestock, not seeing the value of keeping dogs.

Incidence and distribution of animal bites and rabies cases

The survey also revealed that there has been a surge of rabies cases among dogs in Geita, as approximately 42% recalled seeing a suspected rabid dog between 2020 and 2023 (Fig. 3). Among 312 respondents, 45 (14.4%) had ever been bitten by a dog, while 32 (10.3%) reported their dogs being bitten by other animals. When asked about their response to a suspected rabid animal, 52% of the respondents said they would kill the animal, while 19% said they would not act.

Figure 3: The last time the respondent saw a rabid dog

Awareness about rabies

Most of the respondents (96%, n = 312) had heard of rabies, and they highly associated the risks with dogs compared to other animal species, as 78% of them have ever seen a rabid dog. They were also aware that rabies can be transmitted between animals and humans and can be transmitted through dog bites (98%, n = 301) or when scratched by a rabid dog (57.8%). The level of awareness was normally distributed across the respondents. The median awareness level was 60% (range: 18%-91%, Fig. 4). Respondents were more aware of risks associated with dog bites regardless of who the owner is (51%, n = 312), hence they were ready to take the anti-rabies vaccine. They were also more aware of symptoms of rabid dogs (24%) than humans (8%). Generally, there was very little knowledge of the source of the rabies virus, as only 17% of the respondents got it right.

Figure 4: Awareness of rabies among respondents

Vaccination against Rabies

Ninety-five per cent of respondents (n = 107) who own dogs have ever vaccinated their dogs (females = 24/25, males = 78/82). Most respondents (70%) vaccinated their dogs between 2021 and 2023 (Fig. 5). However, respondents reported that most of the time, vaccination is sporadic as there is no clear schedule, and they cannot vaccinate on their own because vaccines are not readily available in the area. In 2023, many respondents vaccinated their dogs, but there had been no vaccination for the past three years. The district veterinary officer also confirmed that resentment that mass vaccination was budgeted for the first time in three years in 2023, where community members were to contribute a maximum of 3000 TZS ($1.2).

Figure 5: Dog vaccination against Rabies in years

Willingness to pay for dog vaccination services

Respondents were asked how much they would pay for dog vaccination services. The median maximum WTP for individuals was $1.5 (3,750 TZS), with bids ranging from $0–12. Four percent of the respondents were unwilling to pay anything for the dog vaccination, claiming it should be free because rabies is a public health issue. Twenty-six percent (26%) were willing to pay less, while 62% were willing to pay more than the prevailing price for one dose ($1.2). Some felt that the cost of dog vaccines should not be higher than the price of food animals like cattle as dogs are not used for food as one of them resented, “Why should the cost of vaccinating a dog be raised when you can’t eat it?”

Factors associated with willingness to pay for dog vaccination services.

There were slight differences in willingness to pay for dog vaccination services depending on demographic characteristics, dog ownership, and risk perception towards rabies. Men were willing to pay more ($1.9) than women ($1.65). Respondents who were single or never married were ready to pay $1.6 more than the indicative price, while widowed or separated respondents were willing to pay an additional $0.3. On the other hand, there was little difference in WTP between dog owners and non-owners, as their bids were $1.81 and $1.84, respectively. Higher education levels were associated with a greater willingness to pay for dog vaccines (Fig. 6). Respondents with Tertiary education were willing to pay more ($2.76) than respondents with primary and secondary education ($1.86) and respondents with no formal education ($1.6). Linear regression analysis indicates that age and level of perceived risk are significantly associated with willingness to pay (p = 0.024 and p = 0.025, respectively). Younger age groups show a greater willingness to pay compared to older groups.

Figure 6: Association of Respondents’ level of education and Willingness to pay for dog vaccine

There was an association between individual risk perception towards rabies and the willingness to pay for dog vaccination services (Table 3). A person who a dog has never bitten is willing to pay $1.86 ($0.66 above the prevailing price), while the one who was bitten was willing to pay $1.6. On the other hand, a person who has ever seen a rabid dog is willing to pay $1.9 ($0.7 above the prevailing price), while someone who has never seen a rabid dog is willing to pay $1.56 ($0.36 above the prevailing price). A person who has ever seen a person with rabies was willing to pay the highest for rabies vaccination services compared to others.

Table 3

Association between risk perception and WTP (numbers in brackets are the additional amount from prevailing price, $1.2)
Risk perception		Respondents WTP (In US Dollars)
Ever Bitten by a dog	Yes	1.6 (+ 0.4$)
Ever Bitten by a dog	No	1.86 (+ 0.66$)
Heard about rabies	Yes	1.84 (+ 0.64$)
Heard about rabies	No	1.25 (+ 0.05$)
Ever seen a rabid dog	Yes	1.9 (+ 0.7$)
Ever seen a rabid dog	No	1.56 (+ 0.36$)
Ever seen a person with rabies	Yes	2.1 (+ 0.9$)
Ever seen a person with rabies	No	1.75 (+ 0.55$)

Willingness to pay for anti-rabies vaccine (Human PEP)

The range for the WTP for anti-rabies was estimated to be between 0–80 USD, respectively, while the median WTP was $20. Respondents expressed willingness to pay the stated amount and added that human life is priceless. The willingness to pay differed across genders, with the average amount for men being $19.2 while for women being $14. The willingness to pay was associated with the respondent’s level of risk perception based on their experience. Respondents who had heard about rabies were willing to pay more ($18.1) than those who hadn’t ($4.9). Similarly, respondents who had ever seen a rabid dog were willing to pay 32% more ($18.9) than those who hadn’t seen one ($12.8). Moreover, those who had seen a rabies victim were willing to pay the highest amount of $21. One of the respondents even mentioned, “Human life cannot be traded for any other thing, so I will pay whatever amount just to stay alive ”.

Rabies remains a significant public health and economic problem in Tanzania, where canine rabies is endemic. Our study explored community willingness to pay for dog vaccines and human anti-rabies in Geita district, Tanzania, and the associated determinants. The results suggest that people are willing to pay slightly more for dog vaccination services ($0.3 above the prevailing price) compared to human post-exposure prophylaxis (PEP), in which the average WTP is the same as the prevailing price. Furthermore, the study revealed that 62% of the respondents were willing to pay above the prevailing price ($1.2) compared to 32% for PEP ($20). In dog vaccination and human PEP services, men are more willing to pay than women. The results also showed a strong association between age and WTP where young groups were willing to pay more than older groups.

The study indicated that risk perception and experience with rabies-related incidents play a role in individual WTP. Particularly, a person who has ever seen a rabid dog or rabies victim was willing to pay the highest for dog vaccination ($0.9 above the prevailing price) and human PEP ($1 more) compared to others. This can partly be attributed to high awareness of rabies, including its transmission and symptoms in the dog. This suggests that individual experience and perception are critical factors when advocating for collective actions towards rabies control. Previous studies also support this, which shows that people are willing to pay for vaccines only when the perceived risk is high [29]. Respondents generally share that they attach the highest value to human life; therefore, they would do whatever it takes to protect it through PEP in case a stray dog bites someone. This sentiment also reflects a sentiment shared by many individuals when faced with the threat of a deadly disease like rabies.

Compared to specific rabies-endemic countries, the WTP value exceeded the estimated per-dog vaccination cost in Thailand (0.52 USD) while being lower than in the Philippines (1.67 USD) for dog vaccination [24]. Several factors are associated with WTP for vaccination services. This study explored the association between dog ownership, number of dogs, age, income, gender, education, and risk perception with WTP to vaccination services for dogs and human PEP. However, it was found that only age and perceived risk were strongly associated with WTP. This contradicts previous studies on WTP for vaccines that explored the same factors [30, 31]. This may be explained by the homogenous nature of the visited villages in terms of economic activities, education level, and the number of dogs they keep.

Gender differences were observed in WTP, with men expressing a higher average amount than women in dog vaccination and human PEP. This difference could be influenced by various socio-cultural factors and men's economic power in the household. The previous studies [32, 33] also show that men are more willing to vaccinate than women, contrary to the common narrative that women are risk averse than men. One potential explanation could be that willingness to pay involves financial decisions, which men often make.

One noteworthy aspect is the comparison made by some participants between the cost of dog vaccines and that of vaccines for food animals like cattle. There is a sentiment that the price of dog vaccines should not exceed that of vaccines for animals raised for food production. This perspective reflects a utilitarian view of animals, whose value is primarily assessed based on their utility to humans, such as providing food. This sentiment is captured in the participant's statement, questioning why the cost of vaccinating a dog should be raised when it is not consumed as food.

This study highlights the significance of economic consideration in rabies vaccination decisions. In addition to awareness, availability, and access to vaccines, it is crucial to consider socioeconomic factors and financial values individuals place on the welfare of animals. Greater awareness of the risks associated with the disease is necessary to persuade more people to pursue vaccination services. When developing vaccination programs to promote collective actions towards rabies elimination, it is also important to consider intersectional factors such as age and gender.

Ethics approval and consent to participate

The ethical clearance for this study was sought from the Research Ethics Committee of the Sokoine University of Agriculture (SUA). Research clearance was granted with reference number SUA/DPRTC/R/186/65. Permission to conduct the study at study sites was obtained from the President’s Office- Regional Administration and Local Government Authorities (PO-RALG). Before the interviews and questionnaire administration, participants signed a consent form after the consent declaration as per the Declaration of Helsinki (2013).

Consent for publication

The authors have no conflict of interest to declare.

Competing interests

The authors have no conflict of interest to declare

Funding

The study was part of the TAPROD Research Small Grants Award (Ref #: TA/Tanzania/002) funded by the US Agency for International Development (USAID) through Transition Award 7200AA22CA00014 to Africa One Health University Network (AFROHUN). The funder had no role in the design of the study, data collection, analysis, interpretation, or preparation of this manuscript.

Author Contribution

JG, MM, LK and GS: Conceptualize the study with critical input from JK, HM, DK and MC. JG, MM, LK and GS: Data collection. JG and MM: Data analysis, interpretation and preparation of the first draft of the manuscript. JG, MM, GS, LK, JK, HM, DK and MC: Substantively revised the first draft and subsequent modifications. All authors contributed to the article and approved the submitted version.

Acknowledgement

This study was made possible by the generous support of the American people through the US Agency for International Development (USAID) Transition Award 7200AA22CA00014 to AFROHUN. The contents and associated materials are the responsibility of the authors and do not necessarily reflect the views of USAID or the US Government. We would also like to thank the Geita Regional secretariat, specifically Mr Shani Gervas (Regional Livestock Field Officer) and Dr. Israel Tarimo, district veterinarian from the Geita district council, for their immense support during the fieldwork.

Availability of data and materials

The datasets used in this study are available from the corresponding author on request

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No competing interests reported.

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21 Aug, 2024
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21 Aug, 2024
First submitted to journal
16 Aug, 2024

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Willingness to pay for rabies vaccination services and associated factors among communities in Geita District, Tanzania

Status:

Version 1

Abstract

Figures

Background

Methods

Description of the study area

Study design

Study population

Sample size estimation

Sample size (n) =(Z _1−∝/2)² *p (1-p)/d²

Sampling procedures

Data collection

Data processing and analysis

Results

Summary statistics

Socioeconomic Demographic characteristics of the respondents

Dog Ownership

Incidence and distribution of animal bites and rabies cases

Awareness about rabies

Vaccination against Rabies

Willingness to pay for dog vaccination services

Willingness to pay for anti-rabies vaccine (Human PEP)

Discussion

Conclusion

Declarations

Competing interests

Funding

Author Contribution

Acknowledgement

Availability of data and materials

References

Additional Declarations

Status:

Version 1

Willingness to pay for rabies vaccination services and associated factors among communities in Geita District, Tanzania

Status:

Version 1

Abstract

Figures

Background

Methods

Description of the study area

Study design

Study population

Sample size estimation

Sample size (n) =(Z 1−∝/2)2 *p (1-p)/d2

Sampling procedures

Data collection

Data processing and analysis

Results

Summary statistics

Socioeconomic Demographic characteristics of the respondents

Dog Ownership

Incidence and distribution of animal bites and rabies cases

Awareness about rabies

Vaccination against Rabies

Willingness to pay for dog vaccination services

Willingness to pay for anti-rabies vaccine (Human PEP)

Discussion

Conclusion

Declarations

Competing interests

Funding

Author Contribution

Acknowledgement

Availability of data and materials

References

Additional Declarations

Status:

Version 1

Sample size (n) =(Z _1−∝/2)² *p (1-p)/d²