Rabies is an acute viral zoonotic disease that causes progressive encephalitis and is almost invariably fatal once clinical manifestations appear. Nevertheless, human rabies is almost entirely preventable through timely and appropriate PEP. Globally, rabies continues to cause approximately 59,000 human deaths annually, with more than 95% of deaths occurring in Africa and Asia, and dog-mediated transmission remains the predominant route of human infection.1,2 PEP consists of immediate and thorough wound cleansing, rabies vaccination and, for severe exposures, administration of RIG. WHO Category III exposure includes single or multiple transdermal bites or scratches, licks on broken skin, contamination of mucous membranes with saliva and certain bat exposures. Such exposures require appropriate wound management, vaccination and RIG when indicated.3,4 Although RIG is a critical component of PEP for severe exposures, its timely administration remains challenging in endemic settings. The WHO has highlighted the need for prudent RIG use because of its cost, limited availability in some settings and the requirement for correct infiltration into and around the wound.3,4 In India, delays may be compounded by inadequate awareness, misconceptions regarding the severity of the exposure, financial constraints, difficulties in accessing health facilities, referral between facilities and interruptions in RIG availability. The National Rabies Control Programme emphasises prompt initiation of appropriate PEP and access to rabies prophylaxis services.5 Previous Indian studies have identified lack of money, perception of a minor injury, non-availability of vaccine or immunoglobulin, referral between facilities, lack of an accompanying person, alternative treatment preferences and delays as important barriers to PEP and RIG utilization.6-11 However, numerical frequencies alone cannot explain why patients interpret a wound as minor, how they distinguish vaccine from RIG, how fear of injection affects decision-making, or how experiences with healthcare workers and health facilities influence trust and acceptance. Qualitative inquiry is therefore useful for understanding the meanings and experiences underlying RIG-related decisions. The present study was designed to explore these experiences in depth among Category III animal-bite victims attending an ARC. The qualitative approach focused on participants' own accounts of the bite episode, healthcare-seeking process, communication with healthcare providers, understanding of RIG, decision-making, experiences of administration and barriers to timely treatment. The objectives of the research are as below 1. To explore the experiences of Category III animal-bite victims during the process of seeking and receiving rabies immunoglobulin. 2. To understand participants' perceptions regarding the severity of rabies, the need for RIG, its effectiveness and safety, and its relationship to rabies vaccine.

A qualitative study was undertaken using a grounded-theory-informed approach, with purposive sampling, semi-structured individual interviews, iterative coding and constant comparison during 24th December to 31st March. The approach was selected because the study sought to understand participants' perspectives and to develop an explanatory account of how perceptions, experiences and contextual barriers interact in decisions concerning RIG. The structure follows the qualitative example provided, in which sampling, data collection and analysis were conducted iteratively until saturation. Study setting: The study was conducted at the Anti-Rabies Clinic, Department of Community Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India. The clinic provides evaluation and PEP services to individuals presenting after animal exposure, including assessment of exposure category and provision or facilitation of recommended rabies prophylaxis. Study population: The study population comprised individuals with documented WHO Category III animal exposure who attended the ARC during the study period and were eligible for RIG as part of PEP. Participants were selected to capture variation in treatment experience, including those who received RIG promptly, those who experienced delays, and those who did not receive RIG despite an indication. Sampling and sample size: Purposive sampling was used rather than probability sampling. Maximum variation was sought with respect to age, sex, rural/urban residence, educational and socioeconomic background, time to first healthcare contact, distance from the ARC, RIG availability at the first facility and whether RIG was ultimately administered. Recruitment was undertaken concurrently with data analysis so that emerging concepts could inform subsequent participant selection. Interviews were continued until thematic saturation, defined as the point at which successive interviews yielded no substantially new concepts relevant to the research questions. Inclusion criteria were: documented Category III animal exposure; attendance at the ARC during the study period; eligibility for RIG according to prevailing PEP guidance; ability to communicate sufficiently for an interview; and willingness to participate. For participants below 18 years, parental or guardian consent and participant assent were obtained where appropriate. Participants were excluded if they had completed PEP for the same exposure, were presenting for a re-exposure for which RIG was not indicated, were unable to provide a reliable account of the exposure or treatment process, declined participation, or had circumstances that prevented a meaningful interview. Data collection: Data were collected through individual semi-structured, in-depth interviews conducted in a private setting at the ARC. An interview guide was developed from the original questionnaire domains and the published literature on RIG compliance, PEP delays, perceptions and barriers. The guide contained open-ended prompts rather than fixed-response items, allowing participants to describe events in their own words and permitting the interviewer to probe unexpected issues. Core interview domains 1. Understanding of rabies and perceived seriousness of the animal bite. 2. Knowledge and understanding of the difference between rabies vaccine and RIG. 3. Thoughts and emotions immediately after the bite. 4. First actions taken and reasons for choosing the first healthcare facility. 5. Communication and counselling received from healthcare workers. 6. Decision-making regarding acceptance, delay or refusal of RIG. 7. Experiences of pain, fear, adverse effects and satisfaction after RIG administration. 8. Financial, transport, distance and family-related difficulties. 9. Referral experiences and RIG availability at the first facility. 10. Suggestions for improving counselling and RIG services. Interviews were audio-recorded with permission and supplemented by field notes documenting the context of the interview, notable non-verbal responses and reflections of the interviewer. Treatment details such as RIG administration and timing were cross-checked against ARC records where available, while the qualitative analysis remained focused on participants' experiences and meanings. Data analysis: Audio-recorded interviews were transcribed verbatim. Transcripts were read repeatedly to achieve familiarity with the data. Initial codes were generated line-by-line and were kept close to participants' words. Similar codes were compared and grouped into focused categories. Constant comparison was used across participants and across cases with different RIG experiences. Categories were then examined for relationships and organised into broader themes that explained the pathways from exposure and interpretation of risk to healthcare-seeking, acceptance or non-utilization of RIG. Coding was iterative: the interview guide and subsequent interviews were refined in response to emerging concepts. A qualitative data management programme such as NVivo may be used for organisation and retrieval of coded material. Two researchers should independently review a subset of transcripts, discuss discrepancies and agree on the final coding framework. Reflexive notes should be maintained throughout analysis to identify the influence of researcher assumptions on interpretation. Trustworthiness: Credibility was strengthened through prolonged engagement with the study question, purposive maximum-variation sampling, probing during interviews, iterative analysis and member clarification of key interpretations where feasible. Dependability was supported by maintaining an audit trail of interview-guide changes, coding decisions and theme development. Confirmability was enhanced through reflexive documentation and independent review of a subset of transcripts. Transferability was addressed through detailed description of the study setting and participant characteristics. Ethical considerations: Ethical approval was obtained from the Institutional Ethics Committee of Government Medical College, Srinagar, before commencement of the study. Written informed consent was obtained from adult participants. For participants below 18 years, consent was obtained from a parent or legally authorised guardian and assent was obtained where appropriate. Participation was voluntary and refusal did not affect clinical care. Interviews were conducted privately and identifying information was removed from transcripts.

A purposively selected group of Category III animal-bite victims with diverse demographic and treatment experiences was interviewed. The final qualitative sample should be reported as the number recruited and interviewed until saturation. Participant characteristics should be presented descriptively to demonstrate variation relevant to the research question, rather than to perform statistical association testing. Emergent themes Theme 1: RIG was poorly understood and was often perceived as optional Participants commonly described uncertainty about what RIG was, why it was needed and how it differed from rabies vaccine. Some recalled hearing the term for the first time only after reaching a healthcare facility. RIG was sometimes viewed as an additional treatment rather than an essential component of PEP for severe exposure. This uncertainty was particularly apparent when information provided at the first facility was brief or when participants were referred elsewhere. "I knew about the rabies injection, but I did not know there was another injection that had to be given in the wound." (illustrative hypothetical quotation) Participants who received a clear explanation tended to describe RIG as necessary and expressed greater confidence in accepting it. Conversely, incomplete explanations left participants dependent on family members, neighbours or previous experiences to interpret the need for treatment. Theme 2: The apparent severity of the wound shaped perceptions of risk A recurring narrative was that the visible size of the wound influenced participants' assessment of whether RIG was necessary. Small punctures, superficial-looking scratches or wounds that had stopped bleeding were sometimes interpreted as low-risk. The appearance or behaviour of the biting animal also influenced perceived danger; a healthy-looking dog was sometimes considered reassuring. "The wound was very small and there was not much bleeding, so initially I thought the vaccine would be enough." (illustrative hypothetical quotation)These accounts illustrate a gap between clinical categorization of exposure and patients' everyday understanding of severity. Participants often judged risk through what they could see rather than through the exposure category. Theme 3: Fear of pain and adverse effects competed with the perceived benefit of RIG Fear of injection, anticipated pain during wound infiltration and concern about adverse effects were prominent emotional barriers. Some participants described anxiety before the procedure, particularly after hearing that RIG was infiltrated around the wound. However, among participants who underwent the procedure, the experience of pain did not necessarily translate into regret or refusal. Reassurance and explanation before administration appeared to reduce uncertainty. "I was afraid because they told me it would be injected around the wound. After they explained why it was necessary, I agreed." (illustrative hypothetical quotation) Participants frequently considered the procedure acceptable when they trusted the healthcare worker and understood its purpose. This suggests that fear may be modifiable through anticipatory counselling rather than being treated as an unavoidable reason for refusal. Theme 4: Household resources determined how easily participants could reach and obtain treatment Participants described financial and logistical barriers that extended beyond the direct cost of RIG. Transportation expenses, distance from the ARC, loss of daily wages and the need for an accompanying family member influenced the ability to seek care promptly. Rural participants and those living farther from the ARC described greater dependence on peripheral health facilities and family arrangements. "We had to arrange money and someone to come with me. By the time everything was arranged, the treatment had already been delayed." (illustrative hypothetical quotation)These accounts indicate that treatment decisions were embedded in household circumstances. Even when participants understood that RIG was important, practical constraints could make immediate access difficult. Theme 5: Referral pathways and RIG availability created missed opportunities Health-system barriers were described as particularly consequential. Participants reported being sent from one facility to another, being told that RIG was unavailable, or receiving inconsistent advice. Referral created uncertainty about where treatment could actually be obtained and sometimes increased delay. When RIG was available and healthcare workers gave a clear recommendation, the pathway was perceived as straightforward. "They told us to go to another hospital because the immunoglobulin was not available there. We did not knowwhere to go or whether it would be available at the next place." (illustrative hypothetical quotation)Participants therefore viewed RIG access as dependent not only on personal willingness but also on whether the health system could provide the treatment at the point of need. Theme 6: Trusting and non-judgmental communication facilitated acceptance The quality of interaction with healthcare providers emerged as a cross-cutting facilitator. Participants valued explanations that were simple, direct and respectful. They wanted to understand why both vaccine and RIG were needed, why RIG had to be infiltrated into the wound and what discomfort they could expect. Positive communication increased confidence, whereas rushed or unclear interactions contributed to hesitation. "When the doctor explained that the vaccine and immunoglobulin do different things, I understood why both were needed." (illustrative hypothetical quotation) This theme linked the other barriers: awareness, fear, perceived severity and trust were not independent experiences but were influenced by the way information was communicated. Integrative interpretation The themes suggested an interconnected pathway rather than isolated barriers. Participants first interpreted the bite according to visible wound severity and perceived characteristics of the animal. This interpretation shaped the urgency with which care was sought. At the healthcare facility, the clarity of counselling and availability of RIG either strengthened or weakened the perceived need for treatment. Fear and cost influenced the feasibility of acceptance, while referral and stock availability could override willingness even when participants understood the need for RIG. The central process emerging from the data can therefore be conceptualised as 'making sense of risk while navigating access to a time-sensitive treatment'.

This qualitative study highlights that RIG non-utilization is not simply a matter of refusal or lack of knowledge. Participants' accounts suggest a dynamic interaction between perceived risk, emotional responses, household resources, communication and the organization of healthcare services. This interpretation is consistent with previous Indian and international evidence showing that behavioural and structural barriers influence PEP-seeking and completion.6,8-11. A major theme was the tendency to judge the seriousness of exposure from the appearance of the wound. This barrier represents a mismatch between biomedical classification and lay interpretation of risk. Participants may use bleeding, wound size, healing and the apparent health of the animal as cues for safety, whereas Category III classification is based on the nature of exposure.3,4 The distinction between vaccine and RIG also emerged as an important explanatory gap. Patients may not regard PEP as a set of distinct interventions with different purposes. Counselling should therefore explain not only that RIG is recommended, but why it complements rather than duplicates vaccine. Fear of pain was another important theme. Anticipation of pain may be more important than the eventual experience itself. Participants who received an explanation and reassurance were able to reconcile discomfort with the perceived benefit of treatment. This supports a patient-centred counselling approach before wound infiltration. Economic and accessibility barriers extended beyond the price of RIG. Transportation, distance, loss of wages and dependence on another person to accompany the patient can collectively delay care. Health-system barriers were particularly important because they could prevent treatment even when patients were willing. Non-availability at the first facility was the strongest predictor of non-utilization in the original analysis, and referral difficulties were also frequently reported. The qualitative themes suggest that patients experience such barriers as uncertainty and fragmentation: they may not know which facility has RIG, whether they will be accepted there, or how quickly treatment must be obtained. Strengthening referral protocols and ensuring reliable availability may therefore have a greater immediate effect than awareness campaigns alone. Communication emerged as a cross-cutting facilitator. Participants valued providers who were confident, respectful and willing to explain the rationale for RIG. This is compatible with previous qualitative work showing that patient perceptions of healthcare interactions can influence health-seeking behaviour.6 The implication is that counselling should be standardized but delivered conversationally, allowing patients to express concerns and correct misconceptions. Implications for practice a) Provide a brief standardized explanation of Category III exposure, vaccine and RIG at the first point of care. b) Explicitly address the misconception that a small, healed or minimally bleeding wound is necessarily low risk. c) Explain expected pain and local discomfort before wound infiltration and provide reassurance. d) Use clear referral pathways when RIG is unavailable at the first facility. e) Maintain uninterrupted RIG availability at designated facilities and communicate availability to peripheral centres. f) Consider the transport, wage-loss and accompanying-person needs of rural and economically vulnerable patients. Strengths: The qualitative design allows the study to move beyond frequencies and explore how participants make sense of RIG, how treatment decisions are negotiated and how patient-level and health-system barriers interact. Purposive maximum-variation sampling and iterative analysis can provide perspectives from participants with different RIG experiences. Verification of treatment information through clinic records can also complement the participant narratives. Limitations: Qualitative findings are context-specific and are not intended to estimate the prevalence of barriers in the wider population. Participants may under-report refusal or alternative treatment use because of social desirability. Recall may influence accounts of events preceding ARC attendance. Interviewer characteristics and prior assumptions may also influence the data and interpretation; reflexivity is therefore important. The qualitative findings presented in this converted manuscript are hypothetical and must not be reported as actual empirical results until supported by real interview transcripts.

The qualitative perspective suggests that experiences surrounding RIG administration are shaped by an interaction of risk perception, knowledge, fear, household resources, healthcare communication and system-level access. Patients may perceive a small wound or healthy-looking animal as evidence of low risk, may not clearly understand the distinct role of RIG, or may hesitate because of anticipated pain. At the same time, financial constraints, distance, referral and non-availability can delay or prevent treatment even among willing patients. Improving RIG utilization therefore requires more than increasing awareness. Patient-centred counselling, clear explanation of vaccine and RIG, rapid recognition of Category III exposure, reliable referral mechanisms and uninterrupted RIG availability should be integrated into rabies PEP services

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