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Abstract
Background
In Laos, small backyard poultry systems predominate (90%). The first lethal human
cases of highly pathogenic avian influenza (HPAI) occurred in 2007. Few studies have
addressed the impact of outbreaks and education campaigns on a smallholder producer
system. We evaluated awareness and behaviours related to educational campaigns and
the 2007 HPAI outbreaks.
Methods
During a national 2-stage cross-sectional randomised survey we interviewed 1098 households
using a pre-tested questionnaire in five provinces representative of the Southern
to Northern strata of Laos. We used multivariate analysis (Stata, version 8; Stata
Corporation, College Station, TX, USA) to analyse factors affecting recollection of
HPAI educational messages, awareness of HPAI, and behaviour change.
Results
Of the 1098 participants, 303 (27.6%) received training on HPAI. The level of awareness
was similar to that in 2006. The urban population considered risk to be decreased,
yet unsafe behaviours persisted or increased. This contrasted with an increase in
awareness and safe behaviour practices in rural areas.
Reported behaviour changes in rural areas included higher rates of cessation of poultry
consumption and dead poultry burial when compared to 2006. No participants reported
poultry deaths to the authorities. Overall, 70% could recall an educational message
but the content and accuracy differed widely depending on training exposure. Washing
hands and other hygiene advice, messages given during the HPAI educational campaign,
were not recalled. Trained persons were able to recall only one message while untrained
participants recalled a broader range of messages. Factors associated with an awareness
of a threat of AI in Laos were: having received HPAI training, literacy level, access
to TV, recent information, living in rural areas.
Conclusion
We report a paradoxical relationship between unsafe behaviours and risk perception
in urban areas, as well as exposure to HPAI training and message misinterpretation.
Future educational campaigns need to be tailored to specific target populations and
farming styles, for example, small holder farms as compared to commercial farms. Special
attention must be given to varying risk perceptions and the risk of misinterpretation
of key messages, economic hardship, and real life consequences of reporting.
Because avian influenza H5N1 infection risks are associated with exposure to infected poultry, we conducted a knowledge, attitudes, and practices survey of poultry-handling behavior among villagers in rural Cambodia. Despite widespread knowledge of avian influenza and personal protection measures, most rural Cambodians still have a high level of at-risk poultry handling.
To the Editor: After the 2004 outbreak of highly pathogenic avian influenza (HPAI) in poultry in Lao People’s Democratic Republic (PDR), the Ministry of Health implemented extensive virologic surveillance ( 1 , 2 ). Surveillance began in July 2005, and by early 2006, only sporadic cases were found. In July 2006, an outbreak of HPAI was confirmed on 2 chicken farms in Vientiane, the capital city of Lao PDR ( 1 , 3 ). Most of Laos’ ≈20 million chickens are kept on family-owned backyard farms; 3.2 million are on commercial farms ( 4 ). This production meets 80% of Lao poultry (chicken, duck, goose, quail) needs; imports from neighboring countries, either through legal trade or cross-border smuggling, account for the rest ( 3 ). Common poultry diseases occur frequently during the cold season, and lack of reporting of poultry deaths is of concern ( 4 ). Until February 2007, no human cases of influenza A (H5N1) had been reported in Lao PDR. To learn more about Laotians’ knowledge of HPAI and perceptions of their risk, we conducted a cross-sectional survey. In March–April 2006, participants in 3 settings (Vientiane, urban; Oudomxay, semiurban; Attapeu Province and Hinheub District, both rural) were interviewed in the Lao language by means of a standardized 33-question survey. We recorded information about behavior, poultry handling and keeping practices, and poultry deaths. We used multivariate analysis (Stata, version 8; Stata Corporation, College Station, TX, USA) to analyze the factors associated with behavior changes. Using a random sampling list of visitors and vendors, we interviewed 461 respondents in 4 Vientiane city markets (Vientiane has 114,793 households and 3,700 registered poultry farms) ( 5 ). Semiurban respondents were recruited in Oudomxay (40,987 households, 715 poultry farms), an active trading zone near the Chinese border. Rural respondents were recruited from Hinheup District and in Attapeu (19,050 households, 360 poultry farms), near the Vietnam border. Twenty villages were randomly selected, and 10 participants per village were randomly selected for interview. Approval for the investigation was obtained from the health and market authorities. Oral consent for interview was obtained from participants. A total of 842 participants were interviewed (Table). Differences in occupation and literacy were associated with different study areas. Differences in participant sex and age were also noted because, in the rural areas, interviews took place in the home. A total of 583 (69.3%) participants were female: 302 (65.5%), 139 (68.2%), and 150 (79.3%), in urban, semiurban, and rural areas, respectively; p = 0.002, 95% confidence interval 66–72. Mean ages for participants in these areas were 41 (range 40–43), 34 (range 32–36), and 38 (range 37–41) years, respectively; p 1 poultry death, past 2 mo† 58 (31.3) 84 (86.5) 95 (59.7) 239 (54.1) 5 m) 58 (31.3) 30 (31) 114 (71.7) 202 (45.8) <0.001 41.2–50.5 Regular poultry vaccination 81 (43.7) 54 (55.6) 19 (11.9) 154 (34.2) <0.001 30.5–39.4 Information source Never heard 8 (1.7) 11 (5.1) 7 (3.7) 26/837 (3.1) 0.02 1.9–4.3 Heard from television 388 (86.4) 158 (87.8) 178 (97.8) 724 (89.2) <0.001 (86.4–90.8) Heard from radio 19 (4.2) 12 (6.6) 4 (2.2) 35 (4.3) 0.1 (3.02–5.9) Read in paper 6 (1.3) 1 (0.5) 0 7 (0.8) 0.003 (0.34–1.8) Perceive risk for avian influenza In Laos 369 (81.6) 110 (60.7) 8 (4.3) 487 (59.6) <0.001 56.3–63 At home 293 (64.8) 72 (40.0) 5 (2.6) 370 (45.7) <0.001 41.9–48.8 Unable to describe human disease 116 (25.6) 116 (63.7) 182 (97.5) 414 (50.7) <0.001 47.3–54.2 Able to describe as lethal for poultry 306 (67.5) 90 (49.7) 2(1.0) 398 (48.7) <0.0001 45.3–52.2 Behavior change‡ 416 (91.8) 125 (69.0) 7 (3.8) 548 (67.1) <0.0001 63.9–70.4 Stopped eating chicken 328 (72.4) 120 (66.2) 0 448 (54.9) <0.000 51.5–58.3 Avoided contact 348 (76.8) 60 (33.1) 3 (1.6) 411 (50.3) <0.000 46.9–53.8 Stopped keeping poultry 335 (73.9) 13 (7.1) 1 (0.5) 349 (42.7) <0.000 39.4–46.2 Wore mask 338 (74.6) 10 (5.5) 1 (0.5) 349 (42.7) <0.000 39.4–46.2 Washed hands after contact 100 (22.0) 3 (1.6) 1 (0.5) 104 (12.7) <0.002 10.5–15 Ate well-cooked chicken 155 (34.2) 3 (1.6) 1 (0.5) 159 (19.4) <0.000 16.8–22.2 *CI, confidence interval; NA, not applicable. †Mean nos. of poultry deaths were 15 (range 10–19), 27 (range 22–32), and 15 (range 13–18) for urban, semiurban, and rural areas, respectively. Total mean = 19.3; p<0.0001; 95% CI, 17.0–18.4. ‡95% CIs were 89–94, 62–76, and 1–7 for urban, semiurban, and rural areas, respectively. Overall, 96.9% of respondents had already heard of HPAI, mainly through television. Urban residents ranked it as the most well-known poultry disease, but rural residents ranked it fifth. Less than half of the respondents had some knowledge of the disease signs and symptoms for humans and poultry; 28.4% could describe 1 symptom. Half of the respondents believed that they were not at risk for human avian influenza or that their poultry were not at risk for it. Respondents in urban and semiurban areas knew more about avian influenza than those in rural areas. During the cold season, poultry deaths were higher in the north (colder) and south than in Vientiane. The poultry mortality rate during the cold season was similar to that of Cambodia ( 6 ). Behavior regarding poultry deaths differed between areas. Despite a high rate of poultry deaths, none of the interviewees had notified authorities. Since hearing about HPAI, 67.1% respondents, mainly in Vientiane, claimed that they had changed behavior regarding poultry. Multivariate analysis showed the following factors to be associated with behavior change: level of education (p = 0.002), urban living (p<0.001), knowledge of avian influenza risk (p<0.001) and disease (p<0.001), owning poultry (p<0.001), and being a government worker (p<0.001). This study had limitations but provides new insights on Laotians’ knowledge and poultry practices with regard to HPAI. Despite a high level of awareness, populations underestimated the risk, particularly those in rural areas. Most respondents were unaware of appropriate poultry-handling measures to reduce risk ( 6 ). The claimed changes were higher (more frequent and more substantial) in urban (91.8%) than in rural sites (3.8%, p<0.001), higher than changes made by their counterparts in Thailand ( 7 ), and confirmed by reports after the 2004 outbreaks ( 8 , 9 ). These differences between urban and rural areas might be explained not only by participant characteristics but also by a lower extent of the awareness campaign in rural areas. Failure to report poultry deaths should be addressed and has several possible explanations. Farmers are accustomed to common yearly poultry deaths, which are not reported. In the absence of an official compensation statement, farmers may fear income loss from massive poultry culling. Our results emphasize the need for more accurate information about transmission risks, notification requirements, safer behavior and practices, and compensation for losses. Focus also needs to be placed on building capacity in the veterinary system ( 10 ). These issues should be integrated in the Laos National Avian Influenza Control and Pandemic Preparedness Plan (2006–2010).
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