Beyond Knowledge and Attitude: Structural Drivers Dominate Canine Rabies Vaccination Decisions in Rural China: A Multilevel Modeling Study.

The knowledge-attitude-practice (KAP) model guides rabies health promotion but insufficiently explains the knowledge-practice gap. Existing research largely focuses on individual cognitive factors, lacking integration of multilevel and structural determinants. This study is based on multistage sampling and conducts a cross-sectional survey of rural populations. The multilevel mixed effects model and structural equation model were used to analyze the KAP path of the general population, and a binomial mixed effects model was used to analyze the factors affecting dog vaccination in dog-owning households. A total of 2148 rural residents were included in the study. The KAP analysis revealed a moderate mean knowledge score (68.04 ± 22.24) and a high proportion of positive attitudes (88.13%), the active practice rate was low (26.53%). Attitude emerged as a significant mediator, through which knowledge positively influenced (β = 0.12, p < 0.001). The indirect effect accounts for 91.04% of the overall. An analysis of 282 dog-owning households found that the vaccination rate for dogs was 36.17%. The mixed effects model showed that the vaccination rate of purchased dogs was 3.38 times higher than that of home-bred dogs (OR = 3.38, 95% CI: 1.53-7.45), and the vaccination rate of leash-restrained dogs was 3.77 times higher than that of free-ranging dogs (OR = 3.77, 95% CI: 1.84-7.72). In addition to knowledge and attitude, structural factors such as dog sources and dog management methods significantly affect dog vaccination. Rabies prevention should evolve from education toward comprehensive interventions that include dog management reforms, and the creation of supportive policy and environments that reduce structural barriers.