One Health policy communities’ perspectives on zoonoses risk factors and management: A multiple qualitative methods approach

Abstract

Zoonoses emergence and endemicity are serious global public health problems that disproportionately affect low-resource settings. One Health (OH) serves as a framework to understand the interconnection of zoonoses risk factors and incentivizes collaboration, coordination, and communication among sectors. However, OH encounters barriers related to power imbalances, gaps in coordination, and conflicts of interest among diverse communities of practice, which are groups that share a problem and domain of interest and engage in collective learning. This research aims to elucidate the mental models of policy communities, which are representations of the environment, and how humans explain and predict their surroundings to describe their perspectives on zoonoses’ risk factors and management. We used a multiple methods approach, including qualitative system dynamics and rapid qualitative methods (RQM), to describe the perspectives of policy communities regarding the drivers of zoonoses emergence and endemicity and the complexity of zoonoses management. Participants included national and sub-national policy makers and key informants integral to zoonoses programs in Peru, including representatives of human, animal, and environmental systems. We completed 77 semi-structured interviews from June 2023 to November 2023, and the final analytical sample included 75 interviews, excluding 2 incomplete interviews. Participants’ mental models were represented with synthesized systems dynamics diagrams. Main themes and quotes from the RQM added context to the diagrams and described participants’ perspectives regarding zoonoses management complexity. Representatives from animal, human, and environmental public organizations described a similar structural conceptualization of the risk factors related to pets, humans, wildlife, and livestock, identifying economic, social, and environmental risk factors linked to zoonoses emergence and endemicity. Central themes include: global structural economic and social forces; factors affecting biodiversity and natural reservoirs; environmental changes; medical and public health services; country economic factors; rural reliance on farming and limited funding; agricultural factors; and water, hygiene, and sanitation-responsive governance. The system dynamics diagrams illustrated interrelationships between pet, human, wildlife, and livestock populations. However, risk factors related to zoonoses affecting livestock were more prominently represented. Participants recognized the need to apply OH to address zoonoses; however, contextual factors, such as regional adaptation, were necessary in poor rural areas. The study’s results inform about value systems that guide political action and decision making among the diverse OH communities of practice. A similar application in high-income settings could identify differences in zoonoses’ risk factors that may not be related to rural vulnerability or poverty. Further research is needed to describe the interconnection of organizational factors associated with OH collaborations.

Introduction

The emergence and re-emergence of zoonotic diseases are serious global public health problems. It is estimated that three out of four emerging infectious diseases are zoonotic (CDC, 2023), with the majority (71.8%) originating in wildlife (Chomel, 2009). The burden of endemic or emergent zoonotic disorders is more significant in low-resource settings (LRS), affecting human health, reducing livestock, and imposing a cost on local farmers and domestic and international trade (Grace and Cook, 2022). Under-resourced communities in LRS are usually inhabited by farmers and pastoralists who live near animals in areas with poor water and sanitation systems, increasing humans’ risk of infection (Grace et al., 2017). Emergent or endemic zoonoses are underreported, underdiagnosed, and undertreated, causing high mortality and morbidity due to overloaded and deprived public health systems (Schelling et al., 2007; Tan, 2021).

One Health (OH) serves as a framework to understand the interconnection of zoonoses risk factors in LRS and to propose comprehensive and sustainable solutions (Karesh et al., 2012; Zinsstag et al., 2020). OH proposes integrated solutions to sustainably balance and optimize the health of people, animals, and ecosystems, considering their interdependence with the ecosystems in which they live (One Health High-Level Expert Panel-OHHLEP et al., 2022). OH incorporates systems thinking, which recognizes the complex interrelations among factors within an ecosystem and leverages transdisciplinary methods to foster collaboration, coordination, and communication. These efforts involve different levels of government (e.g., global, multinational, national, regional, and local), disciplines (e.g., veterinary, public health, and environment), and policy communities (e.g., researchers, government workers, community leaders, and health systems managers) (Hitziger et al., 2018; Mettenleiter et al., 2023).

While the OH approach is promising, it has been translated into policy in only a few countries, and concerns remain over the concept’s practicality owing to its complex nature and the need for joint work among diverse communities of practice (Bardosh et al., 2017). Communities of practice are groups that share a problem and a domain of interest, and engage in collective learning and joint activities that result in outputs (Lave, 1991; Wenger et al., 2002). However, they experience barriers related to power imbalances, gaps in coordination, and conflicts of interest (Wenger et al., 2002; Eckert, 2006; Binot et al., 2015). In the context of OH, qualitative and mixed methods studies that analyzed semi-structured interviews with key informants found similar barriers to OH implementation, such as conflict of priorities, tasks, and budget assignments among ministries and the high costs of establishing and maintaining collaborations (Okello, 2012; Nyariki et al., 2017; Dos S Ribeiro et al., 2019). In addition, the variability of disciplines and organizational sub-cultures is reported to hinder communication (Husein, 2020). The complexity of the social dynamics among OH communities of practices requires methodologies that facilitate a shared understanding of value systems and norms that mediate political action and social change (Bardosh et al., 2017; Waltner-Toews, 2017).

Systems dynamics approaches propose studying problems among complex organizations that are unpredictable and ambiguous (De Savigny and Adam, 2009; Carey et al., 2015). They depict individuals’ behavior patterns in response to systems and facilitate the understanding of communities of practice’s mental models, which are representations of the environment and how humans explain and predict their surroundings (Rouse and Morris, 1986; Evans and Baker, 2012). Systems dynamics models use a systems thinking approach to identify the changing relationships among variables at different analysis levels, considering the notion of the whole entity to inform policy problems and alternatives (Sterman, 2000; Luna-Reyes and Andersen, 2003). Systems dynamics approaches are also used in the problem articulation phase of the policy process to understand mental models that may lead to erroneous inferences and behaviors that undermine policy implementation effectiveness (Sterman, 2006). Studying the mental models of people within OH communities of practice, including zoonoses policy makers and experts, could provide essential information about their perspectives on the complexity of zoonoses management and their relation to group dynamics and decision making (Hitziger et al., 2018). Previous management of zoonotic outbreaks has demonstrated how political responses shaped by values (communitarian vs. individualistic) considered morally acceptable by the community can be harmful in the absence of adequate scientific evidence (Degeling et al., 2015).

Transdisciplinary research proposes democratizing policy research, closing the gap between researchers, policy makers, and the public from the initial phases of the policy process by engaging with policy communities to understand their perspectives on the problem and solutions (Walt et al., 2008; Bardosh, 2016; Bardosh et al., 2017). This article applies systems thinking methods, such as systems dynamics and transdisciplinarity concepts, to elucidate the mental models of OH policy communities among national and sub-national systems involved in preventing and controlling zoonoses in Peru.

PERUVIAN ZOONOSES PREVENTION AND CONTROL LANDSCAPE

Peru has a decentralized government that endowed the sub-national level, regions, provinces, and districts with political, economic, and administrative autonomy (Fuentes, 2023). The regional governments oversee the local public institutions and have administrative, economic, and political power and autonomy. The regional government develops and approves regional norms and policies and designs, manages, and implements projects (Digital Platform of the Peruvian State, 2023). The Peruvian government unit coordinating strategic public health interventions to address zoonoses is the Department of Prevention and Control of Vector-Borne Diseases and Zoonoses, part of the Peruvian Ministry of Health. This unit follows the directives of the Vice-Ministerial Office of Public Health. The unit in charge of managing animal health, mainly livestock, is the Agricultural Health Services and the unit managing forest and wildlife is the National Forestry and Wildlife Service, both within the Ministry of Agriculture.

In 2019, a national policy was passed to create a multisectoral commission for the prevention and control of zoonotic diseases to propose policies and guidelines to manage zoonoses and establish guidelines to promote multisectoral collaboration among various ministries (MINAGRI, 2019). Another multisectoral initiative is the temporary multisectoral working group for surveillance, prevention, and control of Avian Influenza against the risk of transmission from animals to humans, comprised of multisectoral national and sub-national organizations (Wildlife Conservation Society, 2023).

THEORETICAL FRAMEWORK

This research organizes relevant factors on a hierarchical, macro-to-micro scale by applying the Social-Ecological Systems (SES) framework (Ross, 2013; Wilcox et al., 2019). The SES framework recognizes the interconnections among organisms, the environment, and social systems (Wilcox and Gubler, 2005). The primary factors are human- and technology-related, such as population growth and resource consumption. Human behavior, institutional dynamics, and social dimensions of SES influence changes in urbanization, agricultural intensification, forest alteration, and public health policies. At the natural level, changes in hosts, pathogens, and biodiversity alter ecosystems, thereby affecting host-pathogen dynamics and shaping the transmission or persistence of zoonoses (Wilcox and Steele, 2020).

The Institutional Analysis and Development (IAD) framework for policy analysis designed by Polski and Ostrom (1999) provides guidelines for policy research. The IAD encourages input from multiple disciplines and sectors in policy design, understanding the use of information and incentives for policy adoption, and assessing how policies fit in a particular context. Figure 1 illustrates the key components of the IAD framework, with the action situation – the social space where policy actions occur – serving as the main component. This study is part of a policy analysis series that examines community attributes, conditions, rules-in-use, and interactions, with the primary goal of informing new policy initiatives and future multisectoral policies to address zoonoses in LRS. This study focuses on understanding the attributes of the community that influence policy actions. Supplementary Material: Additional document A1 includes a table outlining the theories used in this study and their role in informing our research design.

Fig. 1.

Institutional Analysis and Development framework (Polski and Ostrom, 1999).

This study aims to describe policy communities’ mental models regarding the drivers and consequences of zoonoses’ emergence and endemicity among policy makers and experts from Peruvian organizations involved in preventing and controlling zoonoses. We have two objectives: (1) to graphically depict participants’ perspectives on the underlying factors that cause zoonoses and describe patterns of behavior and interconnections related to health, and (2) to elucidate policy actors’ views of system interconnections, the complexity of preventing and controlling zoonoses, and the need for multisectoral approaches.

Methods

We employed a multiple qualitative method approach that included the rapid qualitative method (RQM) and system dynamics, utilizing semi-structured interview data from zoonoses policy makers and experts across national and sub-national human, animal, and environmental systems in Peru. Ethical approval was obtained from Oregon Health and Science University (IRB ID: STUDY00024870) and Cayetano Heredia University (IRB ID: 209853).

SETTING

This research occurred within the socio-political system of organizations responsible for zoonoses management and policy in Peru. At the national level, we included organizations such as the Ministries of Health, Agriculture, and Environment as well as educational and academic institutions, all located in Lima, Peru. At the sub-national level, we focused on organizations responsible for zoonoses management in the regions of Tumbes and Piura, where our local research team, the cysticercosis working group, was based. Long-term research partnerships were developed in those regions to control and prevent cysticercosis, a zoonotic disease transmitted between pigs and humans, and one of the leading causes of acquired epilepsy in low-resource settings (Bruno et al., 2013).

A collaboration among US- and Peru-based scientists, supported by the U.S. National Institute of Neurological Disorders and Stroke, is underway for the implementation of the Ring Treatment (RT), a government-run community-engaged program aimed at controlling cysticercosis (2R01NS080645). RT is a targeted approach in which an antiparasitic drug for taeniasis is delivered to clusters of households around the home where an infected pig or meat is identified (O’Neal et al., 2014). RT has been found to reduce the prevalence of taeniasis in humans and cysticercosis in pigs and is an efficient solution as it requires fewer drugs to achieve the control gains (O’Neal et al., 2021). Oregon Health and Science University Institutional Review Board approved the RT implementation study. Results from the formative evaluation of the implementation of the RT informed about the need to study the country’s zoonoses policy context, as well as the application of comprehensive approaches such as One Health, which incentivizes the integration of various sectors and levels of government to study zoonoses management in Peru.

PARTICIPANTS

Participants were national and sub-national policy makers and key informants integral to zoonoses programs in Peru, including representatives of human health, veterinary, agriculture, research, and international organizations, such as the Peruvian Ministry of Health, Agriculture, and Environment at the national level and Regional Health and Agriculture Directorates at the sub-national level in Tumbes and Piura. Experts in zoonoses prevention and control from educational centers and research institutes, as well as national and international organizations nominated by others, were also included. The sampling strategy was purposive, using snowball sampling (Etikan et al., 2015). The base sampling frame was obtained from the directory of the Department of Vector-Borne and Zoonotic Diseases of the Ministry of Health and the Directorate General of Animal Health of the National Agrarian Health Service. Informants recommended by interviewees and experts in zoonoses management identified during previous research work in the region were included in the base sampling. We prioritized those with more nominations and those considered leaders in policy making and multisectoral collaborations for zoonoses prevention and control by their peers. The research team had biweekly meetings to review the recruitment report to obtain a sample representative of the relevant organizations at sub-national and national levels. We conducted 77 interviews and excluded two that were incomplete. The final analytical sample was 75.

DATA COLLECTION

The participant interviews had two sections: a semi-structured interview and a network survey (a copy of the interview guide and survey questions are in Supplementary Material: Additional document A.2). To address the aims of this article, we used a sub-section of the semi-structured interviews that elicited information related to complexity, problem definition, and zoonoses management. Some of the questions included were: “Do you believe that the prevention and control of zoonotic diseases are a complex problem to address?” Which are the leading causes of their appearance and endemicity?”; “How would you describe the negative effects that cause zoonoses?” Semi-structured interview questions were identified from interview guides used in policy process research studies, as well as questionnaires used in a formative evaluation with district-level healthcare leaders in Tumbes (Ministry of Agriculture and Natural Resources and Federal Democratic Republic of Ethiopia, 2005; Pastrana et al., 2020). The research team conducted five in-person interviews to validate the questionnaire in the Lambayeque region, located in northern Peru. The interviewees were representatives of the Ministries of Health and Agriculture. The research team listened to the interview recordings and, after discussion, improved the language and order of the questions.

The interviews were conducted in Spanish as this is the primary language at the study site. The research team consisted of two interviewers and an operations manager. Data were collected from June 2023 to November 2023. Potential participants were invited to participate in the study through email, phone, and official letters when interviewees requested it. Subsequently, individuals were contacted by phone to schedule the interviews. In line with the local research practices, no compensation or incentives were provided for participation.

All research participants signed a consent form. We completed most of the interviews in person, with four conducted via video conference calls at the participants’ request. Interviews were conducted by a single research assistant and lasted an average of 1 h. The sessions were recorded using a digital audio recorder or a video recorder for video conference calls. A native Spanish speaker transcribed the semi-structured interviews. Identifiers were assigned to guarantee anonymity during the data analysis.

DATA ANALYSIS

To address the aims of this study, we used RQM and qualitative system dynamics. RQM is a theory-informed deductive process that can be applied in qualitative research design, data collection, and analysis by applying various rapid techniques such as scribing and theory-informed data collection tools (Watkins, 2017; Nevedal et al., 2021; Brown et al., 2025). RQM has been applied in health services and implementation research to comply with constricted timeframes without missing scientific rigor (Keniston et al., 2023; Brown et al., 2025). For instance, during the COVID-19 pandemic, researchers used RQM to study operational issues in hospitals across 60 institutions in the United States (Keniston et al., 2023).

We utilized RQM in our study to synthesize and analyze the semi-structured interview transcripts by developing summaries and matrices rather than in-depth manual coding (Nevedal et al., 2021; VA QUERI Rapid Qualitative Learning Hub et al., 2023). In the initial phase, a team consisting of two coders (LD and VCH) read all transcripts, documented the initial impressions, and selected the final analytic sample. We conducted three rounds of initial coding and discussion until both coders agreed on the level of detail to include and were comfortable with splitting the data and coding independently. The resulting summaries from this initial phase were condensed into merged summaries. In the next phase, each coder worked independently on the remaining transcripts that were split equally. Coders met frequently to discuss questions.

The final RQM phase consisted of creating a data matrix to categorize synthesized data to find patterns and identify similarities, differences, and trends among groups of participants (Averill, 2002). The leading coder (LD) developed the matrix with columns representing the main domains (e.g., complexity of zoonoses emergence, complexity of zoonoses management) and each row representing each participant. The data were organized at the ministry and government levels. The summarized transcripts were divided among coders, and each analyst reviewed the transcription summaries of the other coders. Each coder performed the remaining analysis independently.

We used a deductive and inductive analytical approach. Deductive qualitative analysis was done to obtain the overall themes informed by the IAD framework. We also used inductively generated themes in the last stage of analysis. The two coders independently produced a list of themes for each domain in the matrix at the ministry and government levels. Afterward, the team discussed and condensed the list into the final list of themes. Most of the RQM data analysis was conducted in Spanish, and only the main resulting themes identified from the resulting matrix were written in English in the last phase, including the translation of the main quotes included in this paper by LD.

Systems dynamics diagrams represent complex problems by identifying relationships between items and feedback loops in a graphical output, a first step in informing systems conceptualization and model formulation (Coyle, 2000). Previous research in public health has applied system dynamics to inform decision making among public health policy makers and help evaluate mitigation strategies (Araz, 2013; Freebairn et al., 2019). System dynamics diagrams have also been used to synthesize findings from qualitative data (Kenzie et al., 2025). In our study, qualitative systems dynamics were used to capture participants’ perceptions and mental models regarding zoonoses prevention and control in a graphic format. Qualitative system dynamics is used in the first phases of problem definition or articulation using tools such as causal loops and stock and flow diagrams (Luna-Reyes and Andersen, 2003). Systems dynamics diagrams represent hypothesized causal relationships between factors, as seen in individuals’ mental models. Two analysts (LD & EK) reviewed the transcripts and the data matrix, an output from the RQM, to identify relationships and causal structures to include in the diagram, which was rendered using the software Kumu to convey key feedback dynamics found in the data (Kumu, 2024). The resulting diagrams were developed iteratively with both analysts providing continuous feedback during each iteration. Approximately nine drafts of the diagrams have been reviewed and improved.

Results

Table 1 presents descriptive information on the participants’ organizations and government levels. At the national level, 35 participants reported working at the Ministry of Health, affiliated with various national institutes, such as the Peruvian Center for Disease Control and Prevention, the National Institute of Health, and the Directorate of Medicine and Supplies. Eight people reported affiliation with the Ministry of Agriculture, four worked at the Agriculture Health Service Unit, and four worked at the Forest and Wildlife Management Unit. Two participants represented the Ministry of the Environment. At the sub-national level, interviews took place in two regions, Piura and Tumbes, with 19 participants affiliated with the Regional Directorate of Health, five affiliated with the Regional Directorate of Agriculture, and six regional or municipal administrators. Finally, we interviewed external actors, who were considered vital players in zoonoses’ policy development by interviewees. Two individuals represented an international health organization, while eight were from academic or educational institutions.

Table 1.

Description of organization and government affiliation of participants.

	N
National level	35
Ministry of Health	25
Ministry of Agriculture	8
Ministry of Environment	2
Sub-national level	30
Regional Directorate of Health	19
Regional Directorate of Agriculture	5
Regional authority/municipal administrator	6
External organizations	10
Academia & Education	8
International organizations	2
Total	75

PERSPECTIVES ON THE COMPLEXITY OF ZOONOSIS EMERGENCE AND ENDEMICITY

The perspective regarding the complexity of zoonotic disease emergence and endemicity dynamics and the interplay with social and environmental factors are depicted with systems dynamic diagrams comprised of stock-and-flow and causal loop-diagrams. We used the Susceptibility, Exposed, Infected, and Recovered (SEIR) model as the central structure to capture the factors related to zoonoses’ progression. The SEIR model is a common structure for modeling infectious diseases among humans and livestock, and simulating interventions in hypothetical scenarios (Biswas et al., 2014; Mat et al., 2021). We focus on conveying systems interrelation related to the SEIR, so the model is not focused on a particular zoonosis. As participants identified factors related to zoonoses among pets, livestock, and wildlife, we proposed four SEIR models for these groups and assumed a similar disease progression among them. The diagram does not reflect other paths in the model such as natural death after exposure or recovery.

Figure 2 shows the four SEIRs in a stock-and-flow diagram. The stocks represent the quantities of a specific factor in the boxes, such as the number of people or animals in each SEIR phase. The flows are changes in stock quantities over time, indicating the mechanism that moves people or animals from one stage to another. The clouds represent the flow sources outside the boundaries of this study. For instance, the SEIR for humans starts with the flow of humans becoming susceptible, thereby increasing the stock of susceptible humans. The flow of exposure involves various mechanisms that increase the number of exposed humans. Becoming infected increases the number of infected individuals. The following are two paths: disease progression, which increases the number of deaths among humans, and recovery, which increases the number of recovered humans.

Fig. 2.

Susceptibility, Exposed, Infected, and Recovered (SEIR) model for zoonotic diseases among pets, livestock, wildlife, and humans. The stocks represent the quantities of a specific factor in boxes; the flows are the changes in stock quantities over time, and the clouds represent the flow source.

The synthesized system dynamics diagram in Fig. 3 depicts all participants’ mental models with the risk factors related to zoonosis emergence and endemicity, which includes participants from the human systems – Ministry of Health at the national level and the Regional Directorate of Health at the sub-national level; animal systems – the Ministry of Agriculture at the national level and the Regional Directorate of Agriculture at the sub-national level; environmental systems – the Ministry of Environment at the national level; and external organizations. The synthesized systems dynamics diagram includes a combination of stocks-and-flows and causal loop-diagrams with variables, connections, and feedback loops. The stock and flows are the main structure that organizes the risk factors around the SEIR models. The variables represent the risk factors, and the connections represent causal influence from one variable to the other, either positive (i.e., they increase or decrease together) or negative. The reinforcing or balancing loops indicate where solutions are needed (Barbrook-Johnson and Penn, 2022). Balancing feedback loops, indicated by an odd number of negative signs, represent resistance to change with stabilization or goal-seeking behavior. Reinforcing feedback loops, indicated by an even number of negative signs, show the amplification of forces and exponential growth or wanes (Swierad et al., 2020).

Fig. 3.

Synthesized system dynamics diagram of zoonoses emergence and endemicity risk factors. Systems dynamics diagram combining stocks and flows, and causal loop diagrams. The stocks represent the quantities of a specific factor in boxes, the flows are the changes in stock quantities over time, and the clouds represent the flow source. The variables represent risk factors, and the connections represent causal influence of one variable on the other. Positive (i.e., they increase or decrease together) or negative. Balancing feedback loops, indicated by R and an odd number of negative signs, represent resistance to change. In contrast, reinforcing feedback loops (R), indicated by an even number of negative signs, show amplification of forces and exponential growth or wane. The burgundy color represents structural economic and social forces, such as the influence of capitalist economic systems, human population, overcrowding, and the rise in migration of people, which leads to closer human-animal proximity. The blue font represents environmental changes, such as climate change and El Niño Southern Oscillation, increasing harmful ecological changes affecting animal habitats. Green represents the factors that impact biodiversity, such as wildlife trafficking. Purple is related to medical and public health services, and the mechanisms that advance human disease prevention and recovery. Red includes factors related to the economic impact of infectious diseases on individuals and nations. Brown shows rural communities’ vulnerability factors related to zoonoses, reliance on farming, and limited funding. Black shows agriculture-related factors that influence livestock exposure to infectious diseases. The gray font represents the impact of WASH-responsive governance on sanitary behavior and exposed water and food sources.

The main themes identified by analyzing the systems dynamics diagrams and semi-structured interviews are further developed below.

Economic, social, and environmental factors related to zoonosis emergence and endemicity

Participants from the Ministries of Health, Agriculture, and Environment and representatives from regional health and agriculture institutions indicated that the complexity of zoonoses is related to multiple economic, social, and environmental risk factors, which are captured and grouped by themes and colors in Fig. 3. The main themes are: Global structural economic and social forces; factors affecting biodiversity and natural reservoirs; ecological changes; medical and public health services; country economic factors; rural limited public funding and reliance on farming; agricultural infrastructure and technology; and water, hygiene, and sanitation responsive governance. An interviewee from the Ministry of Environment described it as follows: “The causes of zoonotic outbreaks are multifactorial, including factors that affect biodiversity, such as deforestation, illegal wildlife trafficking, high interaction between by-products of wild areas, and concentrations of people, such as markets.” Participants from all ministries and government levels thought that various factors made zoonoses management complex, as interventions needed collaboration and communication among sectors, disciplines, and government levels.

Figure 3 shows a higher representation of the risk factors pertaining to zoonotic infections among livestock, with the region on the top right showing a higher density and connections. We developed diagrams of the risk factors and relationships at the ministry level to contrast perspectives among organizations and assess whether participants identified factors outside their organization functions or responsibilities (e.g., Ministry of Health identifying environmental risk factors). Diagrams by organization can be found in the Supplementary Material: Additional document A.3. We found a similar representation of risk factors linked to zoonoses in pets, livestock, wildlife, and humans, as well as themes across human, animal, and environmental systems. Although the Ministry of Agriculture representatives identified more risk factors linked to SEIR of livestock. We also developed separate diagrams for participants identified as regional authorities or municipal administrators, those affiliated with an academic or educational organization, as well as international organizations. All these groups identified risk factors linked to zoonoses in pets, livestock, wildlife, and humans. However, participants affiliated with an international organization focused on structural risk factors such as climate change or ecological changes affecting animal habitats.

Zoonotic diseases are underdiagnosed and therefore deprioritized, underfunded, and neglected

Participants from the Ministry of Health reported that zoonotic diseases were not prioritized because they affect low-income populations with limited access to public health services and adequate surveillance systems. Some zoonotic diseases, such as parasitic diseases, have delayed symptoms, causing the affected population to seek medical evaluation only when the disease has progressed significantly. Low-income rural population’s access to health services is also limited, and diagnostic tests are often prohibitively expensive. One participant described the issue: “Zoonotic diseases are not perceived as dangerous by the population, or they learn to live with the problem, and it seems normal to them.” Participants emphasized that zoonotic diseases could cause severe damage, including disability and mortality, and have a significant negative impact on family economic well-being. Table 2 highlights the feedback loops that capture how inadequate surveillance systems contribute to the vulnerability of rural low-income populations to zoonoses.

Table 2.

Vulnerability to zoonoses due to limited adequate surveillance systems

Similarly, participants from the Ministry of Agriculture and Environment reported under-diagnosis of zoonotic diseases in livestock and wildlife as a concern for increasing the spread of infections among animals and becoming a health and social problem, especially among farmers. Existing surveillance systems are predominantly passive and rely heavily on reports from farmers and producers. Additionally, regional health and agriculture directorates have reported that underdiagnosis affects funding allocation for zoonoses. Without accurate data, prevention plans remain underdeveloped and the issue is inadequately addressed. They stated: “More than complex, I would say, it is tedious with limiting factors… such as the economic one. All programming needs funding, and it is often insufficient. We cannot guarantee the prevention of zoonoses [without] epidemiological surveillance.”

Isolated, rural, and multicultural communities are the most affected by zoonoses

Participants from the Ministry of Health believe that the variety of the country’s cultures, customs, and idiosyncrasies are substantial challenges to the prevention and control of zoonoses. Beliefs regarding raising animals and farming practices vary by region; one participant expanded on this idea by describing the geographical farming risk factors linked to fasciola, a zoonosis that affects mammalian livers and is transmitted by sheep and cattle to humans: “Fasciola in Puno is caused by eating a sweet plant in the irrigation canals; in Cajamarca, it is caused by eating another type of plant called “chocho” which is grown differently.” Ministry of Agriculture’s interviewees described a similar idea captured in the loops in Table 3 (R3), explaining that cultural beliefs among rural communities and producers can lead to unsafe human health and farming practices that could increase zoonosis outbreaks. Regional-level participants described it: “Some populations have deeply rooted beliefs such as ‘quackery,’ witchcraft and traditional medicine, which leads to some resistance to issues of zoonotic disease prevention.” Community stigma from owning infected animals prevents safe behavior, such as reporting infected cases among livestock and farmers experiencing mental health issues related to losing their animals.

Table 3.

Rural vulnerability to zoonoses by harmful cultural norms and reliance on farming.

Representatives from universities and research have also indicated that zoonoses are related to social dynamics, living conditions, and economic activities in regions that depend on agriculture and livestock. This pattern is identified in Table 3 (R7): Regional health and agriculture experts described that activities in rural, isolated regions require more resources and logistical planning with specific and adapted materials. Local governments have skipped public health activities in these areas. In addition, these communities are multicultural and require inclusive and adaptable strategies for behavior change. One participant explains: “Farmers are often barefoot, [in] puddles of contaminated water by infected animals. It is challenging to change a culture, [to be] careful with the issue of water storage”. They reported that these communities were the most affected because they had limited public funding to improve water and sanitation infrastructure and healthcare services. Health workers need training to report emergent zoonoses and farmers often need financial assistance to participate in zoonotic prevention and control programs.

Structural economic forces and environmental changes are linked to zoonosis emergence

Zoonoses experts from international organizations reported that structural economic forces and environmental changes are increasing the emergence of zoonosis, as shown in Table 4 (R8). Population growth and the demand for mass food processing cause an imbalance in the ecosystem. The expansion of agricultural frontiers and invasion of animal habitats affect the environment, and low-income countries lack regulations to protect the environment. Researchers reported that only zoonoses that affect intensive animal production are prioritized, as captured in Table 4 (R9). Participants reported that national emergency funding was among the few financing tools to conduct active surveillance and provide informed responses. One participant described how this short-term prioritization process affects neglected and local zoonotic diseases: “We are convinced that the state will not create programs for some diseases such as cysticercosis because it mainly affects local economies and small-scale farmers.”

Table 4.

Economic and environmental factors linked to zoonoses emergence and endemicity.

Representatives from the Ministry of Health believe that health governance has a biomedical bias. They reported that programs to address zoonotic diseases focused on therapeutics instead of prevention. Regional experts agreed with this assertion and believed that there was limited information about zoonoses and risk factors among the affected population and local governments. They also thought it was a structural issue that needed a social determinant of health approach; therefore, the lack of adequate water and sanitation infrastructure must be prioritized. Figure 4 shows a subsection of the synthesized systems dynamics diagram and captures the described economic forces and the impact of responsive and accessible public health, veterinary, water and sanitation, and environmental programs on zoonotic infections among humans, pets, livestock, and wildlife, particularly in low-resource settings with vulnerable poor rural communities. The diagram highlights the need for a coordinated response and a comprehensive evaluation of the impact of multisectoral programs.

Fig. 4.

Economic and environmental factors related to zoonosis emergence in wildlife, pets, livestock, and humans.

PERSPECTIVE ON THE COMPLEXITY OF ZOONOSES MANAGEMENT

Most participants from the Ministry of Health (88%), regional health and agriculture zoonoses experts (88%), and all representatives from the Ministries of Agriculture (100%) and Environment (100%) thought that zoonotic disease prevention and control is a complex problem. Approximately half of the local authorities (two out of five) thought otherwise. Below, we describe the main themes.

Zoonotic disease control and prevention requires comprehensive solutions and collaboration among sectors and government levels

Participants from the Ministry of Health described the complexity of preventing and controlling zoonoses, emphasizing their multifactorial nature, which requires interventions targeting both animal and human populations. One interviewee elaborated: “It is a super complex issue, and as such, we must address it from comprehensive and dynamic responses, and collaboration among sectors is needed.”

Participants provided examples of potential strategies, such as integrating efforts to deliver vaccines to humans and animals and partnering with law enforcement and public health organizations to reduce informal slaughterhouses. Researchers have highlighted the importance of involving various disciplines such as anthropologists, entomologists, and communicators in this initiative. They added that an anthropological approach, for instance, could facilitate cultural adaptations for the dissemination of preventive measures for managing infected livestock. Additionally, participants emphasized the value of collaborating with international partners, such as the Pan American Health Organization, to promote policies and prioritize certain diseases. Representatives from the Ministry of Agriculture added that it is essential to engage the private sector and academia in enacting policies with adequate funding for sustainability.

Research and university representatives have also reported that comprehensive solutions that apply social determinants of health are needed to manage zoonoses. They think that there is a biomedical bias, and unfortunately, most of the responsibility is attributed to the health sector. They added: “Most authorities assume that the problem is improved by treating the patient rather than enhancing social determinants.” Similarly, regional human and agriculture zoonoses experts thought hygiene education programs were insufficient to help communities adopt safety behaviors, despite inadequate sanitation infrastructure. They stated: “As part of prevention, it is important to have policies that focus on education, such as teaching young people good habits such as handwashing. However, this policy should also consider implementing the resources or conditions necessary to comply with it since we often teach and require handwashing to families that do not have essential services such as water.”

Zoonotic disease control and prevention requires regional cultural adaptations and participation from the community and farmers

The Ministries of Health and Agriculture participants reported that the country has a highly diverse geography, with many cultures and languages, which requires regional program adaptations to address zoonoses. Moreover, implementation barriers include working under the same policy and system structure, without considering the anthropological context. One participant explained this point for implementing community-engaged interventions: “Community dynamics and activities in rural areas are different from that of Tumbes [urban area] because the population is generally found in the fields, harvesting […]. So, if you want to find them, you either go early or after 5 or 6 in the afternoon.”

Similarly, experts from the Ministry of Agriculture and regional zoonoses indicated that it is necessary to understand the culture and customs of local producers and that the level of complexity is linked to the social aspect of agriculture. Therefore, farmers must be closely involved in public health projects from the start to achieve sustainable solutions. They reported that producers helped fund treatments and motivated others to vaccinate their animals. Specific research on local diseases in livestock is also needed. Researchers have added that it requires community education, dissemination of information about disease risks and preventive measures to impacted communities, and empowerment of communities, including them in the development of strategies for controlling zoonotic diseases.

Zoonotic disease control and prevention needs structural change from a human focus to ecosystems with leadership of other sectors

The Ministry of Environment representatives thought that a structural change that shifts the focus from humans to animals and expands the assessment of the disease burden from humans to other species is needed. They recommended comprehensive procedures for zoonoses control considering the impact on vulnerable wildlife. They added: “It requires multidisciplinary work with leadership from sectors other than human health.” The Ministry of Health and Agriculture regional experts believe that there is political apathy in endemic regions that struggle with limited funding and local expertise to address zoonoses. Local authorities have limited information on the burden of zoonoses and delegate responsibilities to the health sector. Participants also reported that technical and management capacity building and political skills should be strengthened to prioritize zoonoses and ensure financing.

Lastly, representatives from academia and education thought that there should be more communication among researchers and technical experts in public health agencies to translate evidence-based interventions into policies. They expand on this idea: “The [research] work carried out for twelve years for the control of Taeniasis/cysticercosis was transferred to DIRESA [Regional Health Directorate], and it is an implementation of a surveillance system that works because there is external funding, but to date, it has not been adopted as a regional policy yet.”

Discussion

This study employs the OH approach and multiple qualitative methods to describe mental models regarding the systems and interconnections that contribute to the emergence and endemicity of zoonoses, as well as the complexity of their management among decision makers and experts from various animal, human, and environmental systems in an LRS. Guided by the OH principles of systems thinking and transdisciplinarity, this study captures the perspectives of representatives from different sectors (animal, human, environment, education, and research) and levels of government (international, national, and sub-national). Using systems dynamics diagrams, we depicted the interrelation between systems and risk factors contributing to zoonotic infections in humans, livestock, wildlife, and pets.

Synthesized systems dynamics diagrams identified predominantly reinforcing loops or problematic system behaviors that describe rural communities’ vulnerability to zoonoses. Moreover, qualitative findings highlight the complexities of managing zoonoses in LRS, including the challenges of implementing control and prevention programs in communities with diverse farming cultural norms and languages. In these hard-to-reach areas, addressing risk factors linked to regional farming practices and evaluating the burden of diseases with an ecosystem approach is essential for informing adaptations of regional zoonoses programs and improving sustainability (Merino et al., 2017).

Synthesized diagrams also showed how representatives from different sectors and government levels identified systems-level risk factors or underlying causes of zoonoses, such as climate change, the influence of capitalism, low public funding in rural communities, and community norms. Instead of conflating proximal risk factors, this structural conceptualization of disease risk emergence can influence policy responses and program models and incentivize collaboration among disciplines and sectors (Wallace et al., 2015). In our study, participants identified risk factors for zoonoses outside their field, such as the Ministry of Health representatives reporting inadequate water and sanitation infrastructure as a risk factor for the emergence of zoonoses, enhancing the need to apply a comprehensive approach that incentivizes collaborative work. Similar results were found in other studies that applied systems dynamic methods to conceptualize a model for managing Brucellosis in Jordan and rabies control in Burkina Faso (Savadogo et al., 2022; Taha et al., 2023). Both studies found delayed responses from other sectors and limited communication with the Ministry of Health, leading to a response gap and disorganized management of zoonoses.

Our study also developed systems dynamics diagrams of risk factors linked to zoonoses emergence and endemicity by animal, human, and environmental systems (stratified diagrams are found in Supplementary Material: Additional document A3). Comparing the diagrams by systems, we found that across the animal, human, and environmental systems, participants captured most of the themes represented in the synthesized systems dynamics diagram. However, representatives of the environmental systems did not report as many risk factors linked to livestock zoonoses as participants from human and agricultural systems. This finding validated the results from the RQM that found a need to expand the focus of zoonoses management toward an ecosystem approach.

The study findings indicate that participants recognized the need to apply comprehensive solutions and establish multisectoral collaboration to address zoonoses. However, representatives from the environment and agriculture sectors, particularly those working in wildlife zoonoses, emphasized that shifting the focus from a human-centered approach to considering the impact on animals or the environment should be a critical first step. Reinforcing loops within the study highlighted that zoonoses affecting commercial livestock are often prioritized, underscoring the influence of global socio-economic forces on policy makers’ priorities and decision making. These findings reflect the ethical and monetary value assigned to different species and the environment, which shapes the focus and allocation of resources for zoonoses management (Zinsstag, 2012; Wallace et al., 2015; Wallace and Ràfols, 2018).

OH evaluation could provide a more comprehensive assessment of joint control and detection programs and how they could increase public health efficiencies and cost-effectiveness compared to current isolated systems when the emphasis is extended to other species, which may result in a shift in perspectives (World Bank, 2012; Zinsstag et al., 2015). However, OH concepts and principles must be applied correctly and rigorously during their implementation and policy development. A comprehensive analysis of narratives used in policy documents of OH antimicrobial resistance programs revealed that activities were primarily focused on improving human health, without mentioning animal health or its environmental impact (Kamenshchikova et al., 2021). The authors concluded that narrow and damaging human bias and hierarchical systems hinder multisectoral collaboration.

This study is among the first to examine the complexity of zoonoses prevention and control, including the perspectives of various sectors and levels of government in Peru. Study recommendations for the management of zoonoses in the country include empowering local technicians and experts to provide recommendations and adapt policies, considering the diversity of cultural beliefs, customs, habits, agricultural and livestock practices, and sociodemographic factors. Additionally, there is a need to enhance capacity building among local experts to develop or propose local policies and formalize the roles of external policy communities, such as those in education, in multisectoral activities.

This study has some limitations. The snowballing and purposive sampling strategy influenced the representation and sample sizes across systems. The objective was to capture zoonoses networks comprised of zoonoses experts and policy makers collaborating in zoonoses management in Peru at that time. The resulting sample had more participants affiliated with human health systems and fewer with animal and environmental systems. We adjusted the recruitment strategy to capture perspectives from all systems and governmental levels by including participants from environmental systems and the sub-national level, even though they may not have been the most nominated.

The findings are not necessarily generalizable to other contexts, and snowball sampling could have missed isolated experts with perspectives not captured in this study. We did not have feedback from the participants when analyzing the semi-structured interviews or developing the systems dynamics diagrams. However, we collaborated with a local analyst who assisted in verifying and validating the coding and diagrams, and enhanced the interpretation of the results. We also applied a cyclical feedback method among analysts to strengthen the study’s methodological rigor.

Our study provides essential information about zoonoses policy makers’ and experts’ perceptions of the problem, which is a vital step in the policy process to understand stakeholders’ mental models that shape decision-making and narratives (Araz, 2013; Freebairn et al., 2019). Applying a similar research approach to a high-resource setting could help identify risk factors associated with zoonosis emergence and endemicity that are not influenced by limited funding and rural vulnerability. Study findings could be strengthened with a comprehensive evaluation of the mental models that influence integration tasks (targeted services, organizational goals, vision) and organizational performance (role clarity, information patterns), which could inform strategies to improve cooperation, coordination, and engagement of multisectoral collaborations (Evans and Baker, 2012).

Conclusion

Zoonoses prevention and control OH programs require collaboration among various policy communities, comprised of representatives from animal, human, and environmental sectors and different government levels. However, there are barriers to its implementation related to power imbalances, conflicts of interest, and communication issues among the various disciplines and subcultures of organizations. A study of the mental models that conceptualize the world of policy communities is needed to inform about the value systems that inform political action and decision making. We applied a multiple qualitative method approach to describe policy community attributes regarding the factors that drive zoonosis emergence and the complexity of their management among policymakers and experts in Peruvian organizations involved in preventing and controlling zoonoses. Representatives from animal, human, and environmental public organizations described a structural conceptualization of the risk factors related to pets, humans, wildlife, and livestock, identifying the economic and environmental risk factors linked to zoonosis emergence and endemicity. However, more risk factors were represented around zoonoses that affected livestock. Participants recognized the need to apply comprehensive solutions and establish multisectoral collaboration to address zoonoses; however, they indicated that contextual factors, such as regional adaptation, are needed in poor rural areas most affected by zoonoses. Study recommendations include a similar application of systems dynamics in high-income settings to identify risk factors not attributed to limited funding, a more comprehensive analysis of mental models, and how they inform organizational structure and performance for multisectoral collaborations.

Supplementary Material

The supplementary material is available in the online version of this article.

One Health impact statement.

Zoonoses control and prevention require collaboration, communication, and coordination among disciplines, organizations, communities, and regions. In this context, policy communities with different perspectives and agendas require a shared understanding of the problem to align their interests for collaboration. One Health provides an adequate framework for context-specific analysis of the policy process, incentivizing the inclusion of various levels of government and sectors. Our study investigated policy communities’ perspectives on the drivers and consequences of zoonoses’ emergence and endemicity in a low-resource setting. We included policy makers and experts from national and sub-national Peruvian organizations in animal, environmental, and human systems.

This study examines the existing policy process and narratives surrounding the prevention and control of zoonoses in Peru. It is the first step to understanding how systems could be efficient and effective in facilitating multisectoral collaboration and coordination while informing efforts to scale up One Health programs in low-resource settings.

DATA AVAILABILITY

Supplementary Material: Additional document A3 provides a more detailed description of the results by organization and government level. The datasets generated and/or analyzed during the current study are not publicly available because they can include identifiers.