ArticleBMJ public health2026
Rabies risk and response in tea-estate health systems in Assam, India: a constructivist grounded theory analysis.
Article in BMJ public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Introduction: Dog-mediated rabies disproportionately affects marginalised and geographically isolated communities, including tea-estate (TE) populations in Assam, India. Although epidemiological patterns of rabies transmission are well documented, the structural, behavioural and governance mechanisms shaping prevention and response within estate-based health systems remain poorly understood. This study used a constructivist grounded theory approach to examine how TE health systems perceive and respond to rabies risk. Methods: We conducted 26 interview events comprising 25 in-depth individual interviews and one group interview, involving 28 participants from estate healthcare, welfare, management and labour representative roles across 10 TE in Udalguri district, Assam. Purposive maximum-variation sampling ensured representation across roles, responsibilities and decision-making influence. Initial line-by-line coding, constant comparison, focused category development and memo writing informed the development of an emergent explanatory model, which subsequently informed an applied theory of change. Rigour was ensured through reflexive team discussions, consensus-based resolution of coding discrepancies and adherence to Consolidated Criteria for Reporting Qualitative Research (COREQ) criteria. Results: Responses to rabies risk were shaped by five interacting mechanisms: structural inequities in access to postexposure prophylaxis; incident-driven vigilance; fragmented governance and the absence of institutionalised dog-population management; limited health literacy resulting from ineffective communication approaches and weak surveillance systems. Collectively, these processes produced a system that remains predominantly reactive rather than preventive, perpetuating cycles of delayed care, incomplete prophylaxis and unmanaged dog-human interfaces. The emergent theory of change highlights feasible opportunities for shifting estate-based systems towards proactive rabies prevention. Conclusion: This study offers an analytically transferable health-systems model that may inform structurally peripheral or semi-autonomous labour communities across comparable plantation, industrial and labour settlements in South and Southeast Asia, identifying implementation pathways aligned with India's National Action Plan for Rabies Elimination 2030 and the global 'Zero by 30' agenda.
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