This workshop highlights the interventions and implied priorities for enhanced awareness of rabies and FRD among schoolchildren in India, irrespective of the respective school’s socioeconomic standing. The listed interventions (Table 2) can be a game-changer in improving awareness of rabies and FRD among students and reducing mortality in children less than 15 years of age due to the disease. Unlike traditional Delphi, where the anonymity of the experts is paramount (39), a modified method that traded unanimity for anonymity was used that facilitated discussion among experts and encouraged them to express their opinions freely in an open forum as the Indian social fabric promotes free argumentation (40). The strategy ensured that the final rankings of the interventions were based on consensus and incidentally required minimal input for their implementation, contrary to existing ones(23).
The initial sessions of the workshop comprised talks, presentations, group discussions, and experience-sharing on rabies and FRD to help overcome mutual inhibitions and allow open conversation among experts (41,42). It ensured all experts reached a levelled understanding of dog-mediated rabies and the importance of disease awareness among schoolchildren. Such a participatory approach involving experts as stakeholders helps to identify interventions that can have long-term impacts on students (31).
Interestingly, consensus-driven priorities and corresponding interventions turned out to be low or no-cost activities that prevail upon the resource constraints and infrastructure deficiencies of schools. For example, incorporating talks and discussions on the topic of rabies, citing dog-related quotes in morning assemblies, promoting paintings or story-telling during co-curricular activities, and introducing interdisciplinary projects can be ensured within the realms of existing resources (43,44). These interventions ensure the dissemination of information about the risks of rabies exposure with the active participation of students and teachers (33). Establishing dedicated rabies information stalls during school functions and distributing information, education, and communication (IEC) materials periodically is evidenced to improve understanding of the disease as demonstrated by educational interventions for HIV and filariasis in Egypt and India, respectively resulting in long-term compliance (45,46). In Sikkim, India, IEC materials played an important role in schools to effectively increase knowledge and awareness of rabies(27). Further, school-based educational programs on rabies proved to be effective in Sri Lanka and the Philippines to improve the knowledge of school children(23,47). Leveraging existing school resources and encouraging students to create IEC materials during painting competitions, or digital media projects is a viable option to mitigate the concerns over the lack of availability of the former as shown during the focused suicide prevention initiative for young adults that was developed based on input from college students in India (48). To involve students in creating informative and educational material through a wall magazine that focuses on the broader concept of 'One Health’ augurs well for dog-mediated rabies which warrants a comprehensive collaborative approach for its prevention, control, and elimination (49,50). Interestingly, although ‘One Health’ was introduced by moderators as a priority, the experts were unanimous on the interventions suggested to accomplish the One Health approach (initiate interdisciplinary projects). In fact, the sentiment of integrating One Health principles into education aligns with local religious and cultural beliefs, as one of the participants mentioned parallels with the symbolic representations of the bull, snake, and tiger belonging to the same family of a deity in India. The presence of such cultural acceptance makes it easy for the at-risk population to understand the framework of One Health to address zoonoses in general, including dog-mediated rabies (51).
The intervention, 'discussing rabies and FRD in the parent-teacher meetings' underscores social involvement and sharing of responsibility to improve behaviour and attitude in children towards FRD thereby accelerating schoolchildren's learning by promoting discussion on health-related topics at home and fostering community involvement in health education initiatives (52). The proposed intervention of erecting stalls or booths during exhibitions and school functions to advocate positive attitudes towards FRD and spread awareness is novel, and despite initial scepticism among experts about its practicality, it found a place in the list of top eight interventions. The outcome of the workshop in the form of consensus-driven interventions reflects a pragmatic and contextually relevant approach to advancing knowledge about rabies and FRD as part of health education within school settings and requiring minimal external aid. Increased awareness can bring behavioural change in children resulting in a significant decrease in animal bite incidences as evidenced in the Philippines (24).
Some seemingly important interventions failed to make it to the top eight after the consensus-building process lacked unanimity. Those worth the mention here included, ‘following a structured educational approach by incorporating the topic in the academic curriculum’, ‘involvement with animal welfare organisations’, ‘forming animal-friendly student communes or clubs’, and ‘promoting e-learning modules’. A structured educational intervention is effective in promoting sustained awareness by including the topic in the academic curriculum (32), the process involves long winding decision-making involving bureaucratic rigmaroles that delay implementation. On the contrary, a semi-structured approach can be implemented immediately using the existing school infrastructure and requires minimal approvals to ensure continuity in awareness efforts. Moreover, mere inclusion in the curricula may not be effective in the face of a shortage of resources and skills (24,53). Surprisingly, in this digital age, 'access to online information' as an intervention did not rank high. The non-availability of television screens in schools was the prime reason that renders activities requiring visual aids inefficient (54,55). The online e-learning modules were not ranked high as experts felt that creating them requires substantial investment, and require computer-literate teachers (56,57). The reluctance to prioritise e-learning highlights the computer literacy equity challenges in Indian schools, especially among economically disadvantaged ones. Despite its effectiveness (55,58), e-learning's feasibility is also hampered by insufficient technology infrastructure, including limited internet access and smartphone usage (59). These challenges are accentuated by lack of the pedagogues' computer or digital skills. There is a need for a context-specific and resource-appropriate approach to rabies awareness among children, as mentioned by Allensworth et al. regarding health education initiatives in the United States (60). The introduction of e-learning modules could be effective in schools of higher socio-economic status, and the reluctance of experts to rank it high could be because their respective schools were rated low or medium on infrastructure. The remote location of the schools presumably poses a challenge in identifying and inviting subject experts, particularly in specialised areas such as rabies (6,61). Further, activities mandated by the state education department take precedence over additional activities such as disease awareness to be taken up (62). Moreover, potential funding difficulties (29,63) in organising hands-on activities and logistical constraints of student visitations to animal welfare centres may limit the applicability of suggested interventions. Some approaches that appear theoretically logical, and their feasible implementation weigh heavily on existing resources, infrastructure, and logistical realities within school environments (64). The interventions must be evidence-based and contextually sensitive for students (65). As Murray et.al (34), emphasised, active engagement in learning is more important than limitations of socio-economic settings to derive maximum impact.
The workshop successfully listed contextually relevant interventions for immediate implementation in schools, and it is only imperative that the gains of employing the interventions are assessed in future KAP studies. A limitation of the workshop is that despite a diverse panel of pedagogues, the involvement of critical stakeholders like the health and veterinary departments, policymakers, and politicians, who play vital roles in resource allocation and leading change in the education sector were not involved. Moreover, the outcomes represent observations from a single state in India, and their applicability to the rest of India needs further research. Finally, recruitment and response biases may have influenced the findings, highlighting the need for broader participation in future consensus-building exercises. Future studies should strive for greater engagement and geographic representation across diverse stakeholder groups to enhance the validity and applicability of the outcomes.