baseline kap study

CARE INTERNATIONAL IN VIETNAM

Disclaimer: The views expressed herein are those of CARE Viet Nam and do not necessarily reflect the official position of the Australian Government, the Australian Agency for International Development (AusAID) or any other Party.

AVIAN INFLUENZA LOCAL RISK REDUCTION PROJECT

BASELINE KAP STUDY

August 2006

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Table of Contents CARE INTERNATIONAL IN vIETNAM.................................................................0

Disclaimer: The views expressed herein are those of CARE Viet Nam and do not necessarily reflect the official position of the Australian Government, the Australian Agency for International Development (AusAID) or any other Party.Table of Contents....................................................................................0 Table of Contents .............................................................................................1 Introduction.......................................................................................................2

Avian influenza in Vietnam.............................................................................2 CARE’s STOP AI program .............................................................................2 Aim..................................................................................................................3

Methods............................................................................................................3 1. Study population.........................................................................................3 2. Data collection ............................................................................................4 3. Statistical analysis ......................................................................................4

Results..............................................................................................................4 1. Part 1: General information ........................................................................4

Attitudes towards AI.........................................................................................5 2.1. Part 2A: Knowledge of AI transmission and symptoms in poultry ..........6

21.1.1 Question 10: Transmission routes among poultry..........................6 2.1.2 Question 11: Symptoms of AI in chickens .........................................7 2.1.3 Question 12: Symptoms of AI in ducks...............................................7

2.2 Part 2B: Knowledge of AI transmission and symptoms in humans .........7 2.2.1 Question 13: Transmission of AI in humans ......................................7 2.2.2 Question 14: Symptoms of AI in humans...........................................8

3. Part 3: Knowledge of AI practices ..............................................................8 3. Part 3: Knowledge of AI practices ..............................................................9

3.1 Question 14: Prevention methods against AI for family ......................9 3.2 Question 15: Protection methods for AI when slaughtering poultry ..9 3.3 Question 16: Protection methods for AI when cooking poultry ........10 3.4 Question 17: Prevention methods against AI for poultry ..................11 3.5 Question 18: What do you do when you suspect AI in your poultry?..........................................................................................................................11 3.6 Question 19 and 20: Reporting suspect AI .........................................12 3.7 Question 21: Vaccination of poultry......................................................13

4. Part 4: Direct Observation ........................................................................13 Conclusion......................................................................................................14 Annexes..........................................................................................................16

Annex1. Study Protocol for KAP ..................................................................17 Methods ...............................................................................................................17 Study population.................................................................................................17 Data collection ....................................................................................................17 Statistical analysis..............................................................................................18 Timeline ...............................................................................................................18

Annex 2. KAP Tools .....................................................................................20

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Introduction Avian influenza in Vietnam The H5N1 avian influenza virus (AI) is a particularly virulent poultry disease that has caused billions of dollars of livestock losses in Asia and is now considered endemic in Vietnam. It is a zoonotic disease that has already caused deaths in humans, and threatens to mutate into a human infection with potential consequences larger than the scale of the 1918 influenza pandemic. Direct losses from the 2003-2004 outbreaks in Vietnam resulted in 44 million birds either dying or being destroyed. Vietnam has been “ground zero” for human cases of avian influenza, reporting the highest number of human AI infections in any country by a substantial margin until just recently. Vietnam has experienced 93 cases resulting in 42 deaths as of 11 August 2006. Almost all the human cases to date have had presumed contact with infected birds. The most important exposures have been from handling sick or dead birds, although limited human-to-human transmission through close contact with infected relatives has recently been confirmed in Indonesia. The nature of the threat to humans persists so long as birds and other animals continue to be infected with highly pathogenic AI. The effective management and control of AI is critical not only for the livelihoods and food security of the rural poor in Vietnam, but because of the potential of the virus to mutate and become capable of human-to-human transmission.

CARE’s STOP AI program CARE in Vietnam has been working with communities since 2004 to address the major gap in AI awareness, prevention, and outreach support and, based on considerable experience, has developed a successful AI model to be replicated and expanded to the most vulnerable communities. CARE couples Behaviour Change Communication (BCC) with creative new approaches to develop the IEC messaging through both formal and informal community structures. CARE’s model encourages partnership and a multi-sectoral approach to community mobilization for understanding of and response to AI. CARE initially conducted a Knowledge, Attitude and Practice survey in December 2004- January 2005 in Long An, An Giang, Binh Dinh and Son La provinces to obtain an in-depth understanding of mainly small-scale rural farmers’ knowledge, attitude and practices (KAP) on poultry rearing in order to inform health education in regards to AI. Using the results from this report, CARE developed the STOP-AI program (Strengthening Training, Outreach and Prevention services for the ongoing Avian Influenza response), which was funded by NZAID and implemented in four districts in Binh Dinh and Long An Provinces, between May 2005 and February 2006. An independent evaluation of the STOP-AI project was favourable, and concluded that the project effectively contributed to raising the awareness of Avian Influenza for small-scale poultry producers in Binh Dinh and Long An provinces. Further funding from McDonalds in early 2006 allowed CARE to expand the program to four districts in Hai Phong, Bac Ninh, Dong Thap and An Giang provinces (STOP-AI2). This project has been conducted in 64 communes and is

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due for completion in September 2006. In June 2006 AusAID also provided funding to expand STOP-AI2 in four different districts in these same four provinces (referred to as Local Risk Reduction project (LRR) from now on). This phase will reach an additional 32 communes. One of the additional components of the STOP-AI2 program is to conduct a knowledge, attitude and practices (KAP) survey of households in all four provinces at the beginning and towards the end of the project cycle in order to evaluate the effectiveness of the program.

Aim To conduct a baseline knowledge, attitude and practices (KAP) survey of households in Hai Phong, Dong Thap, Bac Ninh and An Giang before conducting CARE’s Local Risk Reduction project in these provinces.

Methods The study design is a cross-sectional survey, administered at the beginning of the project cycle. The same survey will be administered towards the end of the project cycle and compared to the results of this baseline. This report includes the baseline survey results only.

1. Study population The baseline study was conducted in one commune in each of the four provinces of the LRR project – Hai Phong, Bac Ninh, An Giang and Dong Thap. The participating communes were randomly selected from the eight communes in each province that will be involved in the LRR project. The total number of households to be interviewed in each commune was 100. For each of the selected communes, information was gathered about the structure of the commune and this was used to determine the selection method of households for that commune. In Bach Ninh, the selected commune was Tam Giang, which consists of five villages. Each of these villages had a different number of hamlets (streets), and these were divided to allow for twenty interviews from each village as follows:

1. Hamlet 1 – 5 interviews in all 4 sub villages 2. Hamlet 2 – 4 interviews in all 5 sub villages 3. Hamlet 3 – 10 interviews in all 2 sub villages 4. Hamlet 4 – 4 interviews in all 5 sub villages 5. Hamlet 5 – 5 interviews in all 4 sub villages

In Hai Phong, the selected commune was Lai Xuan, which consists of four villages. Each of these villages has twelve hamlets and five of these were randomly selected. Five interviews were conducted in each hamlet to give the total of 100 interviews (5×5×4). For these two provinces, the first house in each hamlet was selected, followed by every fifth house until all interviews were completed. In Dong Thap, the selected commune was My Ngai, which consists of three villages. As there were five interviewers to conduct twenty interviews each, forty interviews were conducted in the two large villages and twenty in the smaller village. As there are 740 households in the village, every seventh house was

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selected for interview. In An Giang, the selected commune was My Hoa Hung, which consists of 106 groups of houses. One house per group was interviewed.

2. Data collection Data was collected through a knowledge, attitude and practice (KAP) questionnaire. The questionnaire was developed during a CARE AI team meeting whereby the team brainstormed all the AI prevention messages that form the basis of the LRR project, under the three headings of knowledge, attitude and practice. From these the most important twelve were chosen for inclusion in the questionnaire. The questions were then based on previous KAP studies conducted in Vietnam by CARE and the Academy of Educational Development (AED), with new questions developed where necessary. The questions were either of yes/no format or open, with the interviewers selecting responses from a list provided in the questionnaire and recording those not on the list as “other”. These “other” responses were then recoded. The questionnaire is attached in Appendix 1. Five interviewers were recruited in each province from the Provincial Women’s Union (PWU) and the District Women’s Union (DWU). A CARE staff member conducted training in each province which included working through each question and receiving feedback from the interviewers. The interviewers then took turns interviewing each other for practice. Each interviewer was responsible for conducting 20 interviews. The head of the household or an adult member was interviewed. The interviewer also made some direct observations as indicated in the questionnaire. Once all interviews were completed they were sent to the team leader in each province for checking and any missing data was re-collected. The forms were then sent to CARE.

3. Statistical analysis All data was entered into an Access database designed for this survey. The data was then exported and analysed in Stata where basic frequencies were calculated. Tables and graphs were then developed in Excel.

Results 1. Part 1: General information

• 67.2% (n=267) of respondents were female and most were aged between 30 and 59 (Figure 1). Male respondents were mostly aged over 40.

• Most respondents (74.3%) were of middle income, this proportion ranged from 57% in Bac Ninh to 88% in Hai Phong. Bac Ninh had the highest proportion of rich respondents, at 38% and Dong Thap had the highest proportion of poor and very poor respondents, at 12% (Figure 2).

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• 71.5% (n=276) of participants reported raising poultry at their home. This ranged from 37.6% in An Giang to 92.9% in Bac Ninh.

• For those respondents that reported raising poultry, the numbers that they raise are shown in Table 1. The most common size of poultry farm was 10-99.

Table 1: Number of poultry raised by participants

No. of poultry Frequency Percent Less than 10 62 22.5 10-99 166 60.1 100-999 42 15.2 More than 1,000 6 2.2 Total 276 100.0

• One respondent (0.3%) reported having a previous human case of AI in

their household; 7.1% (n=27) reported having a previous case of AI in their poultry. 24 of these 27 reported still raising poultry at their home.

• 96.5% of participants (n=386) had heard of AI. The 14 people that hadn’t were all from Hai Phong province. These 14 were excluded from the analysis making total sample size 386.

Attitudes towards AI • 59.6% (n=229) of participants reported that they thought AI would occur

again in Vietnam, 22.7% (n=87) reported they didn’t think AI would occur again and 17.7% (n=68) answered “Don’t know”.

• 77.1% (n=296) reported that they thought it was possible to prevent AI from spreading; 7.0% (n=27) thought it was not possible and 15.9% (n=61) answered “Don’t know”.

• Seven participants (1.8%) reported having attended an AI community event sponsored by CARE, 81.5% reported they hadn’t and 16.7% (n=64) answered “Don’t know”.

• Of those that reported raising poultry (n=276), half (48.2%) believed that it is very unlikely that their poultry will be infected with AI (Figure 3). A tenth (9.8%) reported thinking it is very likely that their poultry will be infected with AI.

Figure 1: Age and sex distribution of participants

0

10

20

30

40

50

10-19 20-29 30-39 40-49 50-59 60+

Age group

Perc

ent

Male Female

Figure 2: Economic status of participants by province

020406080

100

An Giang Bac Ninh DonThap

HaiPhong

Perc

ent

Poor Middle income Rich Unspecif ied

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2.1. Part 2A: Knowledge of AI transmission and symptoms in poultry

21.1.1 Question 10: Transmission routes among poultry • 18.3% (n=73) participants did not know how AI was spread amongst

poultry. Figure 4 shows the responses for 313 participants that did respond to this question. Respondents could provide more than one transmission route.

• “Other” responses included: airborne transmission (n=11), from the H5N1 virus (n=9), weather or environment (n=6), wild birds (n=8), transport (n=3), large scale farms (n=1), small scale farms (n=1) and storing chickens and geese together (n=1).

• Half (49.2%) of respondents reported one transmission route, 28.4% reported two, 15.7% reported three and 6.7% reported more than three transmission routes.

Figure 4: Transmission routes of AI in poultry (n=313)

51.8

34.5

27.5

25.9

18.5

12.8

9.3

2.9

0 10 20 30 40 50 60

Contact with infected/sick birds

Contact with contaminated environment/feed

Purchase of unidentified poultry

Contact with infected manure

Free-ranging chickens or ducks

Other

Contact with contaminated farming equipment

Contact with contamination clothing or footware

Percent

Figure 3: How likely do you think it is that your poultry will be infected with AI?

48.2

10.9 10.513.8

3.6 1.8

9.8

0

10

20

30

40

50

1 2 3 4 5 6 7

Ranking

Perc

ent

(1=Very unlikely to 7=Very likely)

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2.1.2 Question 11: Symptoms of AI in chickens • 67.9% (n=262) reported that you can always see when chickens are

infected with AI. This proportion was higher in those reported raising poultry compared with those that did not report raising poultry (74.2% compared with 53.2% respectively).

• Figure 5 shows the most commonly reported symptoms of AI from the 262 participants that reported that you can always see when chickens are infected with AI.

• Less commonly reported symptoms (not on Figure 5) included fast breathing (n=15), excessive thirst (n=13), fever (n=12), stop laying eggs (n=11) and bleeding (n=10).

• “Other” responses were varied and have been grouped into the following categories: symptoms in the leg (n=15), symptoms in the neck/head (n=12), drooping wings (n=5), cough (n=4).

• 21.3% of participants reported one symptom, 34.1% report two, 24.3% reported three and 20.3% reported more than three symptoms. Two people reported nine different symptoms.

Figure 5: Reported symptoms of AI in chickens (n=262)

47.7

32.1

31.7

31.3

21.0

17.9

15.6

11.1

10.3

9.9

7.6

0 10 20 30 40 50 60

Sleepiness

Ruffled feathers

Discharge from eyes and nose

Loss of appetite

Dark/red/blue combs and wattles

Sudden onset of illness or death

Other

Sudden death in large number

Swollen and puffy looking eyes

Diarrhoea

Discoloured manure

Percent

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2.1.3 Question 12: Symptoms of AI in ducks • 44.5% (n=172) reported correctly that you cannot always see when ducks

are infected with AI. This proportion was higher in those reporting not raising poultry at home compared with those that did report raising poultry (54.1% compared with 41.5% respectively).

• Due to a sequencing error in the questionnaire, only those participants that answered “yes” to Question 12a (Can you always see the symptoms of AI in ducks?) were then asked to list the symptoms of AI in ducks (n=109). Figure 6 shows the most common responses.

• Less commonly reported symptoms (not on Figure 5) included diarrhoea (n=9), bleeding (n=9), fever (n=7), excessive thirst (n=6) and fast breathing (n=4).

• “Other” responses included drooping wings (n=4), discoloured manure

(n=3), symptoms in the leg (n=3), symptoms in the neck/head (n=3) and cough (n=2).

• 15.7% of participants reported one symptom, 35.2% report two, 31.5% reported three and 17.6% reported more than three symptoms.

2.2 Part 2B: Knowledge of AI transmission and symptoms in humans

2.2.1 Question 13: Transmission of AI in humans • 87.0% (n=334) of participants correctly responded that humans can be

infected with AI; 6.0% (n=23) reported they could not be infected and 7.0% (n=27) reported “Don’t know”.

• Of the 334 participants, 16 (4.8%) responded “Don’t know” to the question about transmission routes of AI in humans. The responses from the remaining 318 participants are shown in Figure 7.

• “Other” responses included no personal protection (n=5), killing poultry (n=4), lack of hygiene (n=2), pollution (n=2) and airborne route (n=2).

Figure 6: Reported symptoms of AI in ducks (n=109)

38.5

33.9

25.7

24.8

22.0

21.1

17.4

13.8

12.8

11.9

0 10 20 30 40 50 60

Sleepiness

Loss of appetite

Ruffled feathers

Sudden onset of illness or death

Other

Discharge from eyes and nose

Stop laying eggs

Sudden death in large number

Dark/red/blue combs and wattles

Swollen and puffy looking eyes

Percent

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• 44.2% of participants reported one transmission route, 33.4% reported two, 14.8% reported three and 7.6% reported more than three transmission routes.

2.2.2 Question 14: Symptoms of AI in humans • Of the 334 participants that responded that humans could be infected with

AI, 61 (18.3%) responded “Don’t know” to the question about symptoms of AI in humans. Responses from the remaining participants (n=273) are shown in Figure 8.

• “Other” responses included headache (n=6), runny nose (n=5), loss of appetite (n=3) and vomiting (n=3).

• 38.6% of participants reported one symptom, 35.7% reported two, 15.1% reported three and 8.4% reported more than three symptoms.

Figure 7: Transmission routes of AI in humans (n=318)

75.5

36.2

28.9

16.0

11.9

7.9

6.9

0 10 20 30 40 50 60 70 80 90 100

Contact with infected poultry

Eating undercooked infected poultry/eggs

Eating raw poultry product

Contact with infected poultry feces

Contact with humans infected with AI

Contact with contaminated farm equipment

Other

Percent

Figure 8: Symptoms of AI in humans (n=273)

85.7

49.8

49.1

18.3

14.7

11.7

5.1

4.8

4.0

0 10 20 30 40 50 60 70 80 90 100

Fever

Cough

Difficult/fast breathing

Muscle Ache

Other

Diarrhoea

Sore throat

Tiredness

Eye infection

Percent

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3. Part 3: Knowledge of AI practices

3.1 Question 14: Prevention methods against AI for family • The purpose of this question was to determine what participants are

currently doing to prevent AI in humans. However, a lot of responses were focused on poultry prevention methods. These have been included in the “other” section, as they did not correspond to the prepared list of responses.

• 8.0% of participants (n=31) responded “Don’t know” to the question about prevention methods currently being conducted by the family. Figure 8 shows the responses from the remaining 355 participants.

• “Other” responses included cleaning the farm/equipment (n=51), using PPE (n=30), spraying chemicals (n=23), not eating sick or dead poultry (n=16), isolating poultry rearing from the home (n=11), using lime (n=5), vaccination (n=7) and medicine (n=5).

• 54.3% of participants reported one prevention method only, 24.7% reported two, 9.7% reported three and 10.9% reported more than three prevention methods.

• An additional question asked if there were any other prevention methods that the family was planning to adopt to prevent AI. This question was not well understood as many participants repeated those methods they are currently doing (eg repeating answers from Question 14a). Only a small proportion mentioned different prevention methods, therefore this question was not included in this report.

3.2 Question 15: Protection methods for AI when slaughtering poultry • 9.8% of participants (n=38) responded “Don’t know” to the question on

protection methods against AI when slaughtering poultry. The responses from the remaining 348 participants are shown in Figure 10.

• “Other” responses included using boiling water (n=5), slaughtering poultry from known sources (n=5), using other PPE (n=5) and using salt (n=3).

Figure 9: Prevention methods currently being conducting by the family (n=355)

37.7

36.3

29.3

20.8

18.3

14.6

10.1

9.3

5.4

0 5 10 15 20 25 30 35 40 45 50

Do not eat under cooked poultry and egg

Other

Do not eat duck or geese blood pudding

Don't eat birds that fall dead; bury or burn them instead

Wash hand with soap before/after contact with poultry

Wash hand with soap before handling/ preparing food

Do not let children handle poultry eggs

Change and wash clothes after taking care of poultry

Do / Done Nothing

Percent

10

• 29.2% of participants reported one protection method for AI when slaughtering poultry, 44.8% reported two, 19.1% reported three and 6.7% reported more than three protection methods.

3.3 Question 16: Protection methods for AI when cooking poultry • 8.5% of participants (n=33) responded “Don’t know” to questions about

protection methods against AI when cooking poultry. The responses from the remaining 353 participants are shown in Figure 10.

• “Other” responses included wearing a face mask (n=14), not eating poultry (n=5), embalming poultry with ginger or other spices (n=6), keeping the pot covered while cooking (n=2), not eating the viscera (n=2) and not eating the water the poultry is cooked in (n=2).

• 48.4% of participants reported one protection method for AI when cooking poultry, 29.5% reported two, 13.9% reported three and 7.7% reported more than three protection methods.

Figure 10: Protection methods against AI when slaughtering poultry (n=348)

76.4

60.1

26.1

21.6

9.5

8.9

0 10 20 30 40 50 60 70 80 90 100

Wear a mask

Wear gloves

Clean area afterwards

Wash hands afterwards

Do it away from thehouse

Other

Percent

Figure 11: Protection methods against AI when cooking poultry (n=353)

86.7

34.3

22.7

12.7

10.8

8.5

5.7

0 10 20 30 40 50 60 70 80 90 100

Cook the poultry completely

Do not drink ducks blood

Do not eat poultry with suspected AI

Use a separate chopping board

Wash hands before/after preparing food

Other

Keep kitchen clean

Percent

11

3.4 Question 17: Prevention methods against AI for poultry • The remainder of the questions were asked to those households that

reported raising poultry in their home (n=276). • When asking about prevention methods against AI in poultry, five (1.8%)

responded “Don’t know”. The responses from the remaining 271 participants is shown in Figure 11.

• There were 120 “Other” responses to this question, and when analysed some of these were more commonly reported that those in the set list. These were added to Figure 11. Less common responses to this question included controlling entries to the farm (n=8), feeding garlic to poultry (n=8), keeping all new poultry separate (n=5) and changing clothes after being at another farm (n=4).

• 53.0% of participants reported one prevention method, 23.7% reported two, 16.2% reported three and 5.3% reported more than three prevention methods.

• Similar to question 14, we also asked if there were any other prevention methods the family was planning to adopt for prevention of AI in poultry. Again this question was not well understood as many participants repeated those methods they were currently doing (eg repeating answers from Question 17a). Only a small proportion mentioned different prevention methods and so these results have not been presented.

3.5 Question 18: What do you do when you suspect AI in your poultry? • 2.9% of participants (n=8) responded “Don’t know” in regards to what to

do when suspecting AI in poultry. The remaining 268 responses are shown in Figure 13.

• “Other” responses included kill them and throw them into the river (n=5), vaccinate them (n=3), eat them (n=2), monitor them (n=2) and do nothing (n=1).

• 59.8% of participants reported one action, 28.4% reported two, 9.2% reported three and 1.5% reported more than three actions.

Figure 12: Prevention methods currently being conducting for poultry (n=271)

76.4

19.2

17.0

16.6

14.4

6.6

6.3

5.2

4.4

4.4

0 10 20 30 40 50 60 70 80 90 100

Vaccinate poultry

Clean cages/farm

Use medicine

Keep poultry in good condition

Keep poultry in a protected environment

Spray disinfectant

Use lime

Separate the chickens from the ducks

Washs hands before/after contact with poultry

Do / Done Nothing

Percent

12

3.6 Question 19 and 20: Reporting suspect AI • 78.0% of participants (n=215) responded that they would report

suspected cases of AI in their poultry. The remaining 58 (22.0%) responded that they would not report it.

• Of those that would report suspect cases, the person they would report to is shown in Figure 14.The two “other” are to a “neighbour”, and “not sure who to report to”. Local authorities included village/hamlet leaders (n=64), commune leaders (n=7), village officers (n=4), commune committee (n=1), head of police (n=1) and farmer association member (n=1).

• Reasons for not reporting include: have small number of poultry (n=39), would burn/bury instead (n=8), do not know who to inform (n=3), no vets in village (n=2) and will lose money (n=1).

Figure 13: What to do when you suspect AI in your poultry (n=268)

41.4

38.8

26.1

15.7

11.6

9.7

0 10 20 30 40 50 60

Kill them and/or burythem

Report to an authority

Follow instructions fromOfficial

Kill them and burn them

Keep them separate

Give them medicine

Percent

Figure 14: Who to report suspect cases of AI in poultry to (n=215)

69.8

48.4

4.7

2.8

0.9

0 20 40 60 80 100

Animal Health Worker

Local Authority

Commune/village healthworker

Mass organisation

Others

Percent

13

3.7 Question 21: Vaccination of poultry • 67.7% of participants (n=187) reported that they had had their poultry

vaccinated. • Of the 28.2% of participants (n=78) that reported that their poultry had not

been vaccination, reasons this included: - Poultry too young for vaccination (n=15) - Only have a small number of poultry (n=11) - Vaccinator did not come (n=7) - Not home when vaccinators came (n=5) - Did not know when vaccinators were coming (n=5) - Poultry are healthy (n=5) - Could not catch them (n=4) - Gave medicine instead (n=4) - Can not eat poultry for a long time after vaccination (n=4) - Don’t know (n=2).

4. Part 4: Direct Observation • Table 2 shows the results for the direct observations. Most participants

(78.6%) had soap for hand washing and nearly two-thirds (60.3%) of those with chickens kept them in a closed-off area. This proportion was less for those with ducks, at 34.6%.

• Interestingly in 78.3% of those households with poultry, the poultry were let free in the backyard and were able to go outside. This contradicts the result referring to poultry being kept in closed-off areas and reasons for this are unclear.

• A large proportion of households with poultry (77.0%) allowed their poultry to have contact with other animals. This again contradicts the result referring to poultry being kept in closed-off areas and again, reasons for this are unclear.

• Two-thirds of households with poultry (62.4%) had feces lying on the ground outside the area where the poultry were kept, which again suggests poultry were not being kept in closed-off areas.

• Not many households (12.1%) with poultry kept a manure composting pit. Table 2: Results for Direct Observations

Direct observation Yes No Total Percent

yes Can you show me if you have soap for hand washing? 291 79 370 78.6Are all chickens kept in a closed building or fenced-in area? 158 104 262 60.3Are all ducks kept in a closed building or fence-in area? 18 34 52 34.6If poultry are let free in the backyard, can they go outside? 188 52 240 78.3Are there other animals which can come in contact with the poultry? 187 56 243 77.0Is there poultry faeces lying on the ground outside the area where the poultry is kept? 156 94 250 62.4 Is there a poultry manure composting pit? 29 210 239 12.1

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Conclusion Most of the households involved in the study reported raising poultry and most of the participants had heard of AI. However, the fourteen respondents in Hai Phong province that had not heard of AI is worrying. Two thirds of participants think that AI will occur again in Vietnam, but reassuringly most (77%) believe that it is possible to prevent AI from spreading. Half of the respondents that raise poultry believe that their poultry is unlikely to be infected with AI. With regards to knowledge about AI, most participants were able to report at least one transmission route and symptom of AI in poultry and one transmission route and symptom of AI in humans. The most commonly reported transmission route in poultry was contact with infected birds, and the most commonly report symptoms were sleepiness, ruffled feathers and discharge from eyes and nose. In humans, the most common transmission route reported was contact with infected poultry and eating undercooked infected poultry/eggs and the most common symptoms reported were fever, cough and difficulty/fast breathing. Nearly all participants reported one prevention method that their family is currently conducting to prevent AI. The most common were not eating undercooked poultry/eggs and not eating blood puddings. Washing hands was not commonly reported. The most common protection methods reported when slaughtering chickens was wearing a mask and gloves and the most common prevention method when cooking was to cook poultry completely. All but five participants that raised poultry reported at least one prevention method they are currently doing to protect their poultry from AI. Vaccination was by far the most commonly reported prevention method, all other prevention methods were reported by less that a fifth of participants. Most participants were also able to report what they would do if they suspected their poultry had AI. Killing and/or burying them was the most common response, followed by reporting to an authority. Two-thirds of participants that raise poultry reported having their poultry vaccinated. There was a variety of reasons given for not having poultry vaccinated. One fifth of participants that raise poultry reported they would not report suspected cases of AI in their poultry. Reasons for this included only having a small number of poultry, burning or burying instead and not knowing who to inform or not having a vet in their village to inform. Only one participant reported compensation as a reason for not reporting. For the remainder that said they would report, animal health workers and local authorities were the person to report to. Most households were able to show the interviewer that they had soap for hand washing. The results from the remainder of the direct observations were somewhat contradictory. Although two-thirds of poultry rearing households were observed as keeping their chickens in a closed-off area, higher proportions were observed having poultry let free in the backyard that were able to go outside, poultry having contact with other animals and having feces lying on the ground outside the area where the poultry were kept. Reasons for this are unclear. Few households were observed having manure composting pits.

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In conclusion, this study shows that most households in these communes have some knowledge about avian influenza and are conducting some prevention methods. However, there are gaps in knowledge and prevention methods and these should be addressed by the LRR project.

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Annexes

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Annex1. Study Protocol for KAP

Methods The study design is a cross-sectional survey, administered at the beginning of the project cycle (pre-test), and then repeated at the end of the project cycle (post-test). Comparisons between the two studies will provide evidence for increase awareness, knowledge and improved practices in relation to avian influenza as a result of the STOP-AI (AusAID) project.

Study population The baseline study will be conducted in each of the four provinces the AusAID project will be conducted – Hai Phong, Bac Ninh, An Giang and Dong Thap.

The study will be conducted in one commune in each of the four provinces. The study selection process is shown in Figure 1. One district per province and one commune per district will be randomly selected (RS). In each commune, five villages will be randomly selected and in each village, five hamlets/sub villages will be randomly selected. Four households will be interviewed in each and these households will be selected using systematic sampling (SS), whereby the first house in each hamlets/sub village will be interviewed, followed by every fifth house until four interviews are completed. Information on the lay out of each village will be provided by the commune women’s district, and CARE staff will undertake the random selection at each level. Therefore, there will be four interviews per hamlets/sub villages, giving twenty interviews per village, 100 interviews per commune, with a total sample size of 400 over the four provinces.

Data collection Data will be collected through a knowledge, attitude and practice (KAP) study. The questionnaire will be developed based on previous KAP studies conducted in Vietnam by CARE and AED, in consultation with CARE Vietnam staff. The

All Provinces

1 of 4 districts (RS)

5 Villages (RS)

1 of 4 communes (RS)

5 Hamlets / sub-villages (RS)

4 households (SS)

Figure 1: Study selection process

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questionnaire will consist of twelve key questions and four behavioural observations. There are two options for administering the questionnaire at the commune level:

1. Women’s Union only CARE will train three WU members per commune to conduct the interviews. Training will take approximately two hours. After this the interviewers will be given four days to conduct their interviews (33 each). These will be handed in to the District Women’s union at the end of each day, who will check that each interview form has been filled in correctly. Any that are not, will be followed up. Forms will then be sent to CARE.

2. University students As it is university holidays, we could use Public Health students as our interview trainers and quality control officers. CARE would train these students in the methodology of the study, and then they would train three WU members per commune. The students will remain in the commune for the interview period, to observe the interviewers for consistency, and to conduct the checking of forms before they are submitted to CARE.

The head of the household or an adult member will be interviewed. The interviewer will also ask to observe the behaviours as indicated in the questionnaire. Once the interviews have been completed, the interviewer will give their forms to the District Women’s Union/University student for checking, and once these are all completed, they will be returned to CARE office for data entry and analysis. The study will be repeated at the end of the project cycle. The same hamlet/sub villages will be interviewed, although different households will be selected.

Statistical analysis A database will be designed by CARE staff to facilitate data entry and analysis. This will be compiled in Excel. Basic frequencies will be reported from the pre-test, and upon completion of the post-test comparisons between the two studies will conducted. Reports for each commune and a comparison across all communes will be produced and disseminated to the communes. These results can then be used to assist in the planning of community events.

Timeline Activity July August October 10-14 17-21 24-28 01-04 07-11 14-18 21-25 Develop methodology and questionnaire X

Liaise / organise with Women’s Union X X

Conduct KAP in Cao Lanh (Don Thap) X

Conduct KAP in An Giang province (TBA)

Conduct KAP in Yen Phong (Bac Ninh) X

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Conduct KAP in Thuy Nguyen (Hai Phong) X

Surveys returned to CARE, follow up X

Analysis undertaken X X X

Repeat KAP XXX

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Annex 2. KAP Tools

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AVIAN INFLUENZA KAP SURVEY

Interviewer Name:

Date of Interview

Region: Province District Commune Village

Respondent's Name:

Address:

Gender: Male: 1 Female: 2

Economic indicator:Please circle the level of household economic status based on the following criteria:

Very poor No electricity

Poor Has electricity, no TV, no bicycle

Middle Has electricity, has TV, has motorbike/bicycle

Rich Has electricity, has TV, has motorbike, has refridgerator - at lower standard

Very rich Has electricity, has TV, has motorbike, has refridgerator - at higher standard

Good morning/ afternoon, my name is ............................I am an interviewer for CARE Vietnam.We are conducting a study on Avian Influenza in Vietnam and would like to interview for our study.The interview will take approximately 30 minutes. You do not have to participate in the Interview if it is inconvenient for you. May we talk with you now?Please be assured that any information you provide will be anonymous and no personal informationcollected will appear in any documents or reports based on this survey.

1 How old are you?

2 Have you heard of Avian Influenza?

PART 1: GENERAL INFORMATION

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2 Have you heard of Avian Influenza?

Yes ……………. 1No ……………. 2

3 Do you raise poultry at your home?

Yes ……………. 1No ……………. 2

4 How many of the following poultry do you have?

Chicken ……………

Duck ……………

Other poultry such as geese, turkeys, quails etc. ……………

Total

5 How likely do you think it is that poultry on your farm will be infected with AI?

(rate from 1-7. 1 means very unlikely and 7 means very likely of catching AI)SHOW SCALE CARD

Very Unlikely>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>Very likely

Your poultry risk 1 ………. 2 ………. 3 ………. 4 ………. 5 ………. 6 ………. 7

6 Have any humans or poultry in your household previously been infected with AI?

Humans PoultryYes …………… 1 ……………. 1No …………… 2 ……………. 2

Don't know …………… 98 ……………. 98

If no, prompt with "I'm talking about the poultry disease that caused many

outbreaks in 2004 and 2005", If still say no then thank them and terminate the

interview

If yes implement interview with all available questions.

PART 1: GENERAL INFORMATION

If no skip Questions 4 and 5, then continue the interview from

Question 6, terminate the interview at Question 16

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7 Do you think that AI will occur again in Viet Nam?Yes ……………. 1No ……………. 2

Don't know ……………. 98

8 Do you think that it is possible to prevent AI from spreading?Yes ……………. 1No ……………. 2


9 Have you attended any events about Avian Influenza that have been sponsored by CARE?Yes ……………. 1No ……………. 2


10 In your opinion, how is AI spread among poultry/birds? DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below.

If the response is not in the list, please write in Other section

Contact with another infected/sick birds .……… 1Contact with infected manure .……… 2

Contact with other contaminated environment, feed .……… 3Contact with infected farming equipment .……… 4

Purchase of unidentified poultry .……… 5Free-ranging chickens or free-ranging ducks .……… 6

ntact with virius brought in by people, their clothing or footware .……… 7Other Specify:_____________________________ .……… 8

Don't know .……… 98

11a Can you always see the symptoms of illness in chickens when your chickens are infected with AI ?ASK EVEN IF THEY HAVE NO CHICKENS

Yes ……………. 1 Go to 11bNo ……………. 2 Go to Q12

Don't know ……………. 98 Go to Q12

PART 2A: KNOWLEDGE - AI TRANSMISSION AND SYMPTOMS OF POULTRY

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11b How can you tell? DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below.


Sudden onset of illness or death .………….... 1Sudden death in large number .………….... 2

Sleepiness .………….... 3Stop laying eggs .………….... 4

Dark/red/blue combs and wattles .………….... 5Excessive thirst .………….... 6

Swollen and puffy looking eyes .………….... 7Discharge from eyes and nose .………….... 8

Diarrhea .………….... 9Fast Breathing .………….... 10

Fever .………….... 11Loss of appetite .………….... 12Reffled feathers .………….... 13

Bleeding .………….... 14Other Specify:_____________________________ ……………. 15

12a Can you always see the symptoms of illness in ducks when they are infected with AI ?ASK EVEN IF THEY HAVE NO DUCKS

Yes ……………. 1 Go to 12bNo ……………. 2 Go to Q13


12b How can you tell? DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below.


Sudden onset of illness or death .…………... 1Sudden death in large number .…………... 2

Sleepiness .…………... 3Stop laying eggs .…………... 4

Dark/red/blue combs and wattles .…………... 5Excessive thirst .…………... 6

Swollen and puffy looking eyes .…………... 7Discharge from eyes and nose .…………... 8

Diarrhea .…………... 9

PART 2A: KNOWLEDGE - AI TRANSMISSION AND SYMPTOMS OF POULTRY (Cont'd)

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Swollen and puffy looking eyes .…………... 7Discharge from eyes and nose .…………... 8

Diarrhea .…………... 9Fast Breathing .…………... 10

Fever .…………... 11Loss of appetite .…………... 12Reffled feathers .…………... 13

Bleeding .…………... 14Other Specify:_____________________________ ……………. 15

13a Can humans get AI?Yes ……………. 1 Go to 13b,cNo ……………. 2 Go to Q14


13b How can humans catch AI?DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below.


Contact with infected poultry .…………... 1Contact with infected poultry feces .…………... 2

Eating undercooked infected poultry/eggs .…………... 3Eating raw poultry product (ie. Blood Pudding) .…………... 4

Contact with humans infected with AI .…………... 5Contact with contaminated farm equipment .…………... 6

Other Specify:_____________________________ .…………... 7Don't know .…………... 98

13c What are the signs and symptoms of AI among humans?DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below.


Difficult/fast breathing .…………... 1Fever .…………... 2

Cough .…………... 3Muscle Ache .…………... 4

Sore throat .…………... 5Eye infection .…………... 6

Diarrhoea .…………... 7Other Specify:_____________________________ .…………... 8

Don't know .…………... 98

PART 2B: KNOWLEDGE - AI TRANSMISSION AND SYMPTOMS OF HUMANs

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PART 3: KNOWLEDGE OF PRACTICES

14a What are you/your family currently doing to protect you and your family from getting AI?DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below. If the response is not in the list, please write in Other section

Wash hand with soap before and after taking care taking care of poultry …………1Wash hand with soap before handling/ preparing food …………2Change and wash clothes after taking care of poultry …………3

Do not let children handle poultry eggs …………4Do not eat duck or geese blood pudding …………5

Do not ean under cooked poultry and egg …………6Don't eat birds that fall dead; bury or burn them instead …………7

Do / Done Nothing …………8Other Specify:___________________________________________ …………9

Don't know …………10

14b Are there any other things you can do to protect you and your family from getting AI?DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below. If the response is not in the list, please write in Other section

Wash hand with soap before and after taking care taking care of poultry …………1Wash hand with soap before handling/ preparing food …………2Change and wash clothes after taking care of poultry …………3

Do not let children handle poultry eggs …………4Do not eat duck or geese blood pudding …………5

Do not ean under cooked poultry and egg …………6Don't eat birds that fall dead; bury or burn them instead …………7

Do / Done Nothing …………8Other Specify:___________________________________________ …………9

Don't know …………10

15 When killing poultry, how can you protect yourself from AIDON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below. If the response is not in the list, please write in Other section

Wear gloves …………… 1Wear a mask …………… 2

Do it away from the house …………… 3Wash hands afterwards …………… 4

Clean area afterwards …………… 5Other Specify:___________________________ …………… 6

Don't know …………… 7

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PART 3: KNOWLEDGE OF PRACTICES CONT'D16 When cooking poultry how can you protect yourself and your family from AI?

DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below. If the response is not in the list, please write in Other section

Use a separate chopping board …………… 1Cook the poultry completely …………… 2

Do not drink ducks blood …………… 3Wash hands before and after preparing food …………… 4

Do not eat sick or dead poultry with suspected AI …………… 5Keep kitchen clean …………… 6

Other Specify:___________________________ …………… 7Don't know …………… 8

FOR NON-POULTRY FARMING HOUSEHOLDS TERMINATE QUESTIONNAIRE AND CONDUCT THE FOLLOWING DIRECT OBSERVATION QUESTION

Can you show me if you have soap for handwashing? Yes No….. 1 ….. 2

17a What are you/your family currently doing to protect your poultry from getting AI?DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below. If the response is not in the list, please write in Other section

Vaccinate poultry against AI …… 1Keep poultry in good condition (access to clean water, and adequate food/housing) …… 2

Keep poultry in a protected environment (enclosed building/ fenced area) …… 3Separate the chickens from the ducks …… 4

Keep all poultry brought to the farm separate from other poultry for at least 2 weeks …… 5Was hand with soap before and after taking care of poultry and other animals …… 6

Change clothes/shoes/sandals when coming from another farm or market …… 7Control entries into the farm (do not let middleman/visitors enter the farmyard etc.) …… 8

Store manure from another farm for at least 3 weeks …… 9Do / Done Nothing …… 10

Other Specify:___________________________________________ ………… 11Don't know …… 12

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17b Are there any other things you think you could do to protect your poultry from getting AI?DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below.


Vaccinate poultry against AI …… 1Keep poultry in good condition (access to clean water, and adequate food/housing) …… 2

Keep poultry in a protected environment (enclosed building/ fenced area) …… 3Separate the chickens from the ducks …… 4

Keep all poultry brought to the farm separate from other poultry for at least 2 weeks …… 5Was hand with soap before and after taking care of poultry and other animals …… 6

Change clothes/shoes/sandals when coming from another farm or market …… 7Control entries into the farm (do not let middleman/visitors enter the farmyard etc.) …… 8

Store manure from another farm for at least 3 weeks …… 9Do / Done Nothing …… 10

Other Specify:___________________________________________ ………… 11Don't know …… 12

PART 3: KNOWLEDGE OF PRACTICES CONT'D18 What do you do with poultry that you suspect of having AI?

DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below. If the response is not in the list, please write in Other section

Keep them in a closed building/separate from other poultry & animals …………… 1Sell them …………… 2Eat them …………… 3

Kill them and throw them away in the river/pond …………… 4Kill them and throw them outside/ garbage …………… 5

Kill them and bury them …………… 6Kill them and burn them …………… 7

Report to an authority …………… 8Follow Animal Health Dept (or other official) instructions …………… 9

Do nothing …………… 10Other Specify:___________________________________ …………… 11

Don’t know …………… 12

19a If you thought you had an outbreak of AI in your poultry, would you report it?

Yes …………1 Go to Q19bNo …………2 Go to Q20

Refuse …………3 Go to Q20

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19b To who would you be most likley to report an outbreak of AI in your poultry to?DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below. If the response is not in the list, please write in Other section

Animal Health Worker ………. 1Commune/village health worker ………. 2

Local Authority (Village Chief, Police etc.) ………. 3 >> specify:__________________________Mass organisation (womens/farmers union) ………. 4

Others ………. 5 >> specify:__________________________

20 Why would you choose not to report the case?

21a Have your poultry been vaccinated against AI

Yes …………… 1 Go to 21bNo …………… 2

21b Why not?DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below. If the response is not in the list, please write in Other section

Vaccinator did not come …………… 1Note home when vaccinators came …………… 2

Did not know vaccinators were coming …………… 3Not enough vaccines …………… 4

Vaccination make poultry sick / died / not lay egg …………… 5Can not eat poultry for long time after vaccination …………… 6

Can not sell poultry for long time after shot …………… 7Other …………… 8

Don't know …………… 98PART 4: DIRECT OBSERVATION22 Can you show me if you have soap for handwashing Yes No

….. 1 ….. 2

23 Can I see where you keep your chicken, duck and other animals to check some details Do not ask the questions. Observe and check off the answer after having observed the situation

Yes Noa Are all chickens kept in a closed building or fence-in area? ….. 1 ….. 2b Are all ducks kept in a closed building or fence-in area? ….. 1 ….. 2c If poultry are let free in the backyard, can they go outside? ….. 1 ….. 2d Are there other animals (such as pig) which can come in contact with the po….. 1 ….. 2e Is there poultry feces lying on the ground outside the area where the poultry….. 1 ….. 2f Is there a poultry manure composting pit? ….. 1 ….. 2

baseline kap study

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