Abstract
Background and objectives
Rabies is a fatal zoonotic viral disease preventable by prophylactic vaccination. About 60% of dog bite cases in India haven’t completed vaccination schedules, and the reason among half of the defaulters was forgetfulness. This study was conducted to assess the effectiveness of telephonic reminders in vaccination completion status and explore the determinants of the intervention.
Methods
This is a quasi-experimental study conducted at a rural primary health centre, Puducherry, between June 2022 and November 2024. The intervention consisted of structured telephonic reminders delivered prior to scheduled anti-rabies vaccine (ARV) doses. Intervention effects were assessed using interrupted time series analysis with segmented regression, following formal assessment of autocorrelation. In addition, individual-level multivariable logistic regression with cluster-robust standard errors was used to estimate adjusted associations with ARV completion. Exploratory subgroup analyses were conducted using interaction terms and adjusted marginal effects.
Results
Among 695 animal bite victims, ARV completion increased from 60.2% in the pre-intervention period to 70.4% post-intervention. Interrupted time series analysis showed a statistically significant increase in post-intervention level and slope, indicating the effectiveness of the intervention. In adjusted individual-level analyses accounting for clustering by month, the post-intervention period was independently associated with higher odds of ARV completion [adjusted odds ratio 1.60, 95% Confidence interval (CI) 1.2 to 2.1]. Subgroup analyses demonstrated a significantly greater intervention effect among males, with an adjusted absolute increase in completion of 17.3% points and a significant interaction between intervention and sex of victims.
Interpretation and conclusions
Telephonic reminders integrated into routine primary care were associated with improved completion of the anti-rabies vaccination schedule among animal bite victims. The effect was consistent across most subgroups, with greater benefit among males. Reminder-based strategies can strengthen rabies post-exposure prophylaxis delivery in primary care.
Keywords: Determinants, Epidemiologic, India, Interrupted time series, Rabies, Telephone, Vaccination
Rabies is a zoonotic viral neglected tropical disease that is fatal in 100% of cases, but the mortality can be prevented by appropriate vaccination.1 The disease is estimated to cause 59,000 human deaths annually in over 150 countries, of which 40% are children <15 years of age, with 95% total cases occurring in Africa and Asia, with dogs being responsible for virus transmission in 99% of human rabies cases based on a WHO report.2 As per the National Centre for Disease Control statistics, there were 3.7 million dog bite cases and 54 suspected human rabies deaths reported in 2024 under the National Rabies Control Programme (NRCP), which portrays the national burden of the disease requiring an integrated one health approach for control.3,4 Among the multiple strategies, pre-exposure and post-exposure prophylaxis of rabies are the short-term, feasible, and effective recommendations to prevent fatality in humans. Modified Thai Red Cross regime is recommended under the NRCP, which includes four doses of intradermal vaccination on days 0,3,7, and 28 post-animal bite.5 It was estimated, from a nationwide multicentric cross-sectional survey, that about 60% of the dog bite cases in India did not complete the vaccination schedule.6 Similarly, studies conducted in Puducherry and Tamil Nadu, India, found that about 42% and 51% of dog bite cases have not completed the vaccination course, respectively.7,8 The primary reason for non-compliance among 52% defaulters, as assessed by a qualitative study, was failure to remember the vaccination schedule.7 Studies conducted in Kenya have proven that text message reminders were helpful in ARV completion.9 But the effectiveness of the intervention may vary based on context, as studies have shown that the success of any telehealth intervention depends on various determinants specific to the local context. Identifying such determinants will help policymakers tailor interventions based on study settings.10
This study addresses the gap in ARV completion by implementing a combination of the proposed global strategies of improving vaccination status, through technology interventions, utilising the existing resources efficiently, and measuring impact objectively.11 This study was conducted to assess the effectiveness and determinants of telephonic reminders, administered by healthcare providers a day before their vaccination due date, in achieving ARV completion among animal bite victims registered during June 2022 - November 2024 at a rural primary health centre (PHC), Puducherry. The telephonic reminder intervention alongside the existing standard of care is a quality improvement initiative in a PHC, embedding evidence-based strategies into real-world settings to improve population health outcomes.
Methods
Study setting
The study was conducted at a selected rural PHC of Puducherry in South India, a union territory which has 32 PHCs and two community health centres, spanning 294 square kilometres serving a population of approximately 1.2 million. About 86% and 91% of individuals aged 15 years and above use mobile phones in India and Puducherry, respectively, as per the National Sample Survey report 2025. The study site is a round-the-clock operating PHC catering to a population of about 10,500 people divided into four service areas. On average, about 30 animal bite cases were reported to the PHC every month, and no mortality due to animal bites had been reported in the past five years. Victims of animal bites reporting to the PHC were assessed by the duty medical officers and managed based on the bite category. Intradermal ARV was administered based on the Modified Thai Red Cross regime after routine wound care as per the NRCP guidelines for all category two animal bite victims (nibbling of uncovered skin, minor scratches or abrasions without bleeding). Category three victims (transdermal bites or scratches, contamination of mucous membrane with saliva from licks, licks on broken skin) were referred to a higher centre for immunoglobulin and wound care and first dose of ARV. Later, they were followed up by a phone call to ensure they received the prescribed dose of immunoglobin. While administering the first dose of ARV, the healthcare workers counselled the individuals on the importance of completing ARV vaccination by educating them on the nature of the disease and the role of ARV in mortality prevention. Details of the victims, like name, age, gender, address, and phone number, and details related to the animal bite, like type and category of animal bite, were collected by the nursing officer and recorded in the ARV register maintained at the PHC. The due dates of ARV doses were calculated by the nursing officer and mentioned in the case sheet of the victims for further follow-up. All details documented in the ARV register were reviewed in the weekly meetings, monthly meetings, and routine case audits conducted at the PHC as a part of quality monitoring. All the animal bite cases reported at the PHC were entered into the Integrated Health Information Platform (IHIP) under IDSP on a daily basis. There was no stock-out of vaccines, change of administrative policies, and staffing pattern in the PHC, ensuring uniformity in the service delivery, throughout the study period. This study was conducted in a single PHC to ensure uniformity in service delivery, staff practices, vaccine availability, and record-keeping systems. While this approach limits generalisability, it allowed focused evaluation of the intervention under real-world primary care conditions.
Study design and participants
This study was conducted as a quasi-experimental study, using interrupted time series analysis, where the study period after the implementation of telephonic reminders acted as the intervention period. Randomised allocation was not feasible in this programmatic setting, as the intervention was implemented at the facility level as a service delivery improvement, and ethical concerns would arise if the provision of services were limited to a group of eligible individuals. Hence all the first-time animal bite victims, from the service areas of the selected PHC, reaching the PHC for day zero dose of ARV were recruited as participants of the study. As the victims with re-exposure (contributing 4% of the total bite cases) required only two doses of ARV and the schedule completion rate among them is higher than that of the first-time bite victims throughout the study period, they were excluded from the analysis to avoid bias in effect estimation.
Intervention and study period
In order to improve the ARV completion rates, telephonic reminders were made to the eligible victims by the healthcare providers of the PHC, a day prior to the scheduled due date of ARV vaccination. The telephonic reminder mechanism was explained to the participants by the nursing officer during ARV day 0 dose administration. Phone numbers of the caretakers, relatives, or neighbours were obtained for those victims without a mobile phone. Verifying the phone numbers, by making a call during the initial visit, was done to reduce the problem of incorrect contact details being provided, thus improving the implementation of the intervention. The pre-existing phone number of the PHC, from which the call would be administered, was provided to the individuals to reduce the frequency of unanswered calls. If phone calls were not picked up, repeat calls were made on the same day and the subsequent two days before being declared unanswered, and these details were documented in the register. If the due vaccine was taken from another health facility, the same was verified by the field staff from the case sheet of the victims, before recording the dose taken. Healthcare workers were provided with refresher training on the programme guidelines, counselling strategies, and appropriate documentation in the register. This was implemented as a part of routine health services through the existing health system. Hence, no additional cost was incurred for this intervention as five phone calls were made on an average day during the regular working hrs of the health personnel from the prepaid PHC phone. It was ensured that the routine health services were not affected by these telephonic reminders. The process of documentation in the registers and programmatic management of the cases remaining same throughout the study period, making the comparison of completion status across the intervention periods authentic. As the telephonic reminders intervention was initiated in October 2023, the period June 2022 – September 2023 was taken as the pre-intervention period, and October 2023 – November 2024 was taken as the post-intervention period. Intervention effectiveness was assessed by ARV completion as per schedule (day 28 dose).
Data analysis
Data were entered using MS Excel, and statistical analysis was conducted using STATA software v14 (StataCorp LLC, College Station, TX, USA). Categorical variables like age category, gender, type, and category of animal bite were expressed as frequencies with proportions. As this study was an interrupted time-series evaluation using routinely collected programmatic data, a conventional a priori sample size calculation was not applicable. Adequacy was instead ensured through inclusion of sufficient pre- and post-intervention time points to assess changes in level and trend, consistent with established interrupted time-series methodology, mentioning 3-12 time points before and after intervention as adequate.
An interrupted time-series (ITS) analysis was performed using monthly proportions of completion of the ARV schedule. Segmented regression models were fitted with terms for baseline trend, level change at intervention, and change in post-intervention trend to evaluate the impact of the telephonic reminders intervention on ARV schedule completion rates. The time series data consisted of 30 monthly time points (June 2022 – November 2024), with the intervention introduced at time point 17 (October 2023), dividing the series into two distinct segments: pre-intervention (16 months) and post-intervention (14 months). As the outcomes were categorical, a binomial generalised linear model (GLM) with logit link was used, with the number of eligible individuals per month as the denominator. Autocorrelation was assessed using residual diagnostics, including autocorrelation and partial autocorrelation plots and portmanteau tests for white noise before GLM analysis.
Individual-level exploratory subgroup analyses were conducted to identify factors associated with completion of the vaccination schedule alongside the intervention. Logistic regression models were fitted with robust standard errors clustered by month of registration. Interaction terms between the intervention and selected variables (sex, age group, bite category, and animal type) were examined to assess potential effect modification.
The findings of the study are reported in accordance with the SQUIRE 2.0 guidelines for quality improvement research.12
Results
A total of 695 animal bite victims were included in the study; among them, 377 individuals were in the pre-intervention period and 318 in the intervention period, with none of them having missing data. The socio-demographic variables and the nature of animal bites among the individuals in the pre-intervention and post-intervention periods are described in Table I. The two groups, though non-randomised, were comparable in age, gender, type, and category of animal bite distribution. The weekly moving average of animal bite cases reported during the study period is depicted in Figure 1. Seasonal variation in the cases was similar across the pre- and post-intervention periods.
Table I.
Socio-demographic details of animal bite victims from service area of Rural Health Centre recorded before and after intervention during June 2022 – November 2024 (N=695)
| Variable | Pre-intervention (N1=377); n (%) | Post-intervention (N2=318); n (%) | P value* |
|---|---|---|---|
| Age group (yr) | |||
| <18 | 118 (31.3) | 89 (28) | 0.47 |
| 18-59 | 214 (56.8) | 183 (57.5) | |
| ≥60 | 45 (11.9) | 46 (14.5) | |
| Sex | |||
| Male | 221 (58.6) | 174 (54.7) | 0.30 |
| Female | 156 (41.4) | 144 (45.3) | |
| Type of animal bite | |||
| Dog | 336 (89.1) | 271 (85.2) | 0.12 |
| Others (cat, rat, monkey) | 41 (10.9) | 47 (14.8) | |
| Category of animal bite | |||
| Two | 255 (67.6) | 229 (72) | 0.21 |
| Three | 122 (32.4) | 89 (28) | |
Chi-Square test
Fig. 1.
Four weekly moving averages of animal bite victims from service area of the Rural Health Centre recorded before and after intervention during June 2022 – November 2024 (N=695).
Completion of the anti-rabies vaccination (ARV) schedule increased from 60.2% in the pre-intervention period to 70.4% in the post-intervention period, corresponding to an absolute increase of 10.2 percentage points. Individuals in the post-intervention period had a statistically significantly higher odds of completing the ARV schedule compared to those in the pre-intervention period [adj odds ratio (OR) - 1.6, 95% confidence interval (CI): 1.2–2.1] as represented in Table II. The intervention was implemented with fidelity throughout the study period, and no modifications were made to the content or delivery of telephonic reminders.
Table II.
ARV completion status of animal bite victims from service area of the Rural Health Centre recorded before and after intervention during June 2022 – November 2024 (N=695)
| ARV status | Pre-intervention (N1=377); n (%) | Post-intervention (N2=318); n (%) | Adjusted OR (95%CI)* | P value |
|---|---|---|---|---|
| Completed | 227 (60.2) | 224 (70.4) | 1.6 (1.2-2.1) | 0.001 |
| Not completed | 150 (39.8) | 94 (29.6) |
Adjusted for age group, sex of victim, bite category and type of animal bite along with clustering of victims by month of bite using multivariable logistic regression with cluster-robust standard error
The interrupted time-series analysis of the monthly completion of the ARV schedule is presented in Figure 2. Formal assessment of residual autocorrelation using autocorrelation and partial autocorrelation plots, along with portmanteau tests for white noise, demonstrated no evidence of residual autocorrelation (P >0.05 across tested lags). On this basis, the binomial GLM without autoregressive terms was considered appropriate for inference. In the binomial GLM, the baseline monthly trend showed a statistically significant decrease in completion with a log-odds coefficient of −0.023 (95% CI: −0.032 to −0.015; P<0.001), indicating a relative reduction of 2.3% per month in the odds of completing the vaccination schedule during the pre-intervention period. The introduction of telephonic reminders was associated with a statistically significant immediate increase in ARV completion with an estimated level change at the point of intervention corresponding to a log-odds coefficient of 0.55 (95% CI: 0.46 to 0.64; P<0.001), translating to a 73% increase in the odds of completing the vaccination schedule immediately following implementation. In addition to the immediate effect, the post-intervention period demonstrated a statistically significant improvement in the underlying trend. The change in slope after the intervention was positive, with a log-odds coefficient of 0.033 per month (95% CI: 0.021 to 0.045; P<0.001), indicating a sustained monthly increase in the odds of ARV completion following implementation of the intervention. When combined with the pre-intervention trend, this resulted in a reversal of the declining pattern observed prior to the intervention, yielding a net positive post-intervention trend. Model-based marginal predictions showed that the estimated probability of ARV completion increased from 58.5% (95% CI: 52.4%–64.6%) immediately before the intervention to 71.1% (95% CI: 61.2%–81.0%) immediately after implementation, corresponding to an absolute increase of 12.6 percentage points. This improvement was maintained and further increased over subsequent months in the post-intervention period.
Fig. 2.
Interrupted time series analysis of ARV completion among animal bite victims from service area of the Rural Health Centre recorded before and after intervention during June 2022 – November 2024 (N= 695).
Sensitivity analyses demonstrated that the interrupted time-series findings were robust to alternative modelling assumptions. After accounting for a potential implementation transition period by including a transition indicator, the magnitude and statistical significance of both the level change and slope change remained largely unchanged, and similar estimates were observed when the transition period was excluded, indicating that the observed effect was not driven by short-term implementation artefacts. Also, adjustment for seasonality using month-of-year and quarter-yearly indicators did not alter the intervention effect estimates, with both level and slope changes remaining positive and statistically significant.
Exploratory subgroup analyses conducted to assess heterogeneity of the intervention effect using adjusted marginal effects and formal interaction testing are presented in Table III. The intervention was associated with a significantly higher probability of ARV schedule completion among males, with an adjusted absolute increase of 17.3% points (95% CI 9.2 to 25.5). A statistically significant interaction between intervention and sex of the victim was observed, with an interaction odds ratio of 2.03 (95% CI: 1.11 to 3.70; P for interaction=0.022), indicating a stronger intervention effect among males compared with females. Smaller but statistically significant improvements were also observed among non-elderly participants, those with category two bites, and individuals bitten by dogs or cats; however, no evidence of effect modification was observed by elderly status, bite category, or animal type (all P for interaction > 0.05).
Table III.
Completion status of ARV schedule among animal bite victims from the service area of Rural Health Centre recorded before and after intervention during June 2022 – November 2024 across subgroups, with interaction analysis (N=695)
| Sub-group | Category | Pre-intervention n/N (%) |
Post-intervention n/N (%) |
Adjusted marginal effect of intervention* (95% CI) | P value | P value for interaction# |
|---|---|---|---|---|---|---|
| Sex | Female | 106/156 (67.9) | 99/144 (68.8) | 0.013 (−0.090 to 0.115) | 0.811 | |
| Male | 121/221 (54.8) | 125/174 (71.8) | 0.173 (0.092 to 0.255) | <0.001 | 0.022 | |
| Elderly status (≥60 yr) | No | 197/332 (59.3) | 188/272 (69.1) | 0.105 (0.037 to 0.173) | 0.003 | |
| Yes | 30/45 (66.7) | 36/46 (78.3) | 0.099 (−0.032 to 0.230) | 0.137 | 0.891 | |
| Bite category | Two | 153/255 (60.0) | 165/229 (72.1) | 0.127 (0.050 to 0.203) | 0.001 | |
| Three | 74/122 (60.7) | 59/89 (66.3) | 0.050 (−0.090 to 0.190) | 0.482 | 0.338 | |
| Animal type | Cat | 12/29 (41.4) | 26/41 (63.4) | 0.215 (0.026 to 0.405) | 0.026 | |
| Dog | 206/336 (61.3) | 196/271 (72.3) | 0.106 (0.029 to 0.182) | 0.007 | ||
| Other | 9/12 (75.0) | 2/6 (33.3) | −0.439 (−1.039 to 0.162) | 0.152 | 0.189$ |
Adjusted marginal effects represent absolute risk differences (change in predicted probability of completion) associated with the intervention, estimated using post-estimation margins after multivariable logistic regression.
#P value for interaction obtained from Wald tests of the intervention × subgroup interaction term in models including the corresponding interaction.
For animal type (three levels), the P value represents a joint Wald test of the intervention × animal type interaction.
All models adjusted for sex, elderly status, bite category, and animal type as appropriate, with cluster-robust standard errors at the month level.
Discussion
In this quasi-experimental evaluation, the telephonic reminder intervention was associated with a sustained improvement in completion of the post-exposure prophylaxis of ARV schedule with an adjusted odds ratio of 1.6, consistent with findings from a study conducted at a tertiary care centre in Punjab, India, reporting a higher odds ratio of 2.3.13 The difference in effect size may be attributed to the distinct study setting of being conducted in a well-equipped and adequately staffed tertiary care facility. Similarly, a study from a referral hospital in Kenya that implemented SMS reminders observed a threefold increase in ARV completion odds post-intervention.9 The effectiveness of telephonic reminders for various other conditions, like treatment initiation in tuberculosis patients and hypertension control monitoring have shown significant improvements, verifying the efficacy of the intervention mode.14,15 Similarly, SMS and WhatsApp reminders have been successfully used for follow up in hypertension and mental health conditions.16,17 These approaches could be explored in future studies within our context.
Our interrupted time series analysis revealed a significant sustained increase of 12.4% in ARV completion immediately following the introduction of telephonic reminders, and this finding aligns with previous research conducted in a tertiary hospital in North-India, thereby confirming the reliability of the intervention.13 The sustained improvement with the intervention is consistent with findings from studies on childhood immunisation, where reminder interventions showed a significant improvement in the uptake of immunisation.18
Subgroup analysis revealed that the intervention has limited effectiveness among elderly individuals and females in ARV completion, showing that age and gender can act as potential social determinants of the intervention uptake. This finding may stem from their reliance on family members for transportation to the PHC on scheduled vaccination dates, which aligns with previous research indicating that transportation difficulties and limited access to healthcare services contribute to vaccine default.19 We noted higher ARV completion among victims of dog and cat bites than those bitten by other animals like rats, monkeys, and cattle, which may be due to a lack of awareness about the severity of bites by other animals in rabies transmission, underscoring the importance of targeted counselling for those bitten by other animals. Our findings also showed greater ARV completion among category two bite victims than category three. This may be explained by the referral of category three bite cases to higher-level centres for immunoglobulin and vaccine administration, which could reduce trust in the PHC during emergencies, and also depends on the adequacy of counselling provided at referral centres.20,21
One of the major strengths of this study is adopting an interrupted time series analysis to check for level and slope changes before and after intervention, using GLM with robust standard error regression after formal testing of autocorrelation. This study not only involves analysis of the effectiveness of the intervention but also helps in understanding the factors playing a vital role in the success of the intervention, thereby helping policymakers formulate strategies to supplement this intervention for those groups with limited effectiveness. The quality and validity of the data maintained in records were ensured by constant monitoring in weekly review meetings.
As this study was done as part of a quality improvement initiative in a PHC, only the variables maintained in the ARV register were included, missing out some confounding variables, like the victim’s education, occupation, and socio-economic status. As a single-centre quasi-experimental study without a concurrent control group, the findings may be influenced by unmeasured time-varying factors. Being a telephonic reminder intervention, some people who didn’t have or were unaware of their telephone numbers were prone to being excluded from the intervention, but this issue was addressed by collecting the phone numbers of relatives or neighbours and reminding them to convey the message to the individuals. Also, the study did not include a qualitative assessment of beneficiaries’ experiences or reasons for non-completion, which could have provided additional insights into behavioural and contextual barriers that need to be explored further.
Thus, a telephonic reminder is an effective and scalable strategy that can be integrated into the existing health system to improve completion of ARV schedules, providing a meaningful public health gain for a disease as fatal as rabies. Supplementary targeted interventions, including community-based approaches like engagement of elderly and female volunteers is required to improve completion in groups with lower adherence. Further exploration of the use of automated digital reminder systems and qualitative research on barriers to intervention uptake among specific groups are required to achieve universal ARV completion and achieve a global goal of zero dog-mediated human rabies deaths by 2030.
शोध-संदेश
भारत में 60% लोग कुत्ते के काटने के बाद रेबीज टीकाकरण के कोर्स को पूरा नहीं कर पाते। इसका मुख्य कारण टीके की तारीख याद न रहना है। इस अध्ययन में पाया गया कि टेलीफ़ोन द्वारा याद दिलाना ग्रामीण प्राथमिक स्वास्थ्य केंद्रों में एंटी-रेबीज टीकाकरण को पूरा कराने में प्रभावी साबित हो सकते हैं। फोन कॉल के माध्यम से याद दिलाने पर टीकाकरण पूरा करने की दर में सुधार हुआ। शोधकर्ताओं के अनुसार, इस प्रकार की रणनीतियाँ प्राथमिक स्वास्थ्य सेवाओं में रेबीज रोकथाम कार्यक्रम को अधिक प्रभावी बना सकती हैं।
Acknowledgment
Medical officer and Nursing officers of the primary health centre, for assistance in the smooth conduct of the study.
Footnotes
How to cite this article: Rajan SV, Parasuraman Udayakumar KR, B Gumataj A, Raj R, Gola A, Sarkar S, et al. Telephonic reminders for improving anti-rabies vaccination completion at a rural primary health centre – A quality improvement initiative. Indian J Med Res. 2026;164:29-36. doi: 10.25259/IJMR_3376_2025
Author contributions
VRS: Conceptualisation, methodology, data collection, data analysis, interpretation of findings, drafting of manuscript; KRPU: Conceptualisation, methodology, drafting of manuscript; ABG: methodology, data collection, interpretation of findings; RR: Methodology, data analysis, interpretation of findings, manuscript review, AG: Methodology, data collection, interpretation of findings, manuscript review; SS: Project guidance, supervision, interpretation of findings, manuscript review; SL: Project guidance, supervision, interpretation of findings, manuscript review.
Financial support and sponsorship
None.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
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