Knowledge, Attitudes, and Practices regarding Avian Influenza (H5N1), Afghanistan

From February through April 2007, avian influenza (H5N1) was confirmed in poultry in 4 of 34 Afghan provinces. A survey conducted in 2 affected and 3 unaffected provinces found that greater knowledge about reducing exposure was associated with higher socioeconomic status, residence in affected provinces, and not owning backyard poultry.

From February through April 2007, avian infl uenza (H5N1) was confi rmed in poultry in 4 of 34 Afghan provinces. A survey conducted in 2 affected and 3 unaffected provinces found that greater knowledge about reducing exposure was associated with higher socioeconomic status, residence in affected provinces, and not owning backyard poultry.

A vian infl uenza (H5N1) has been reported in southern
Asia (1). In Afghanistan, avian cases were confi rmed from February through April 2007 in 4 of 34 provinces (1). No human cases have been detected, although limited human-to-human transmission has been reported from Pakistan (2). Backyard poultry (chickens) were affected in 20 of 22 outbreak sites in 4 eastern provinces. No outbreaks have been reported from commercial facilities. The response in Afghanistan was to cull all poultry within a 3-km radius, restrict poultry movement and importation, and conduct intensive infl uenza-like illness surveillance and information, education, and communication (IEC) campaigns within affected provinces. IEC campaigns included leafl ets distributed in affected areas and broadcast media coverage on local television and radio. The campaign was designed to inform the public through messages aimed at reducing exposure to disease, preventing spread in poultry, and encouraging reporting. Additional IEC messages were aired nationally and outbreaks were widely reported by local news media. We conducted a survey of knowledge, attitudes, and practices (KAPs) regarding avian infl uenza in Afghanistan. The aim was to assess factors associated with KAPs.

The Study
Five provinces in Afghanistan were selected as a convenience sample (accessibility) that included both affected and unaffected areas. Two accessible districts in each province were randomly selected by using a random number generator. Random transects were used to select 10 households per village. To give an approximately equal male:female ratio, either the head of household, spouse (woman), or the oldest person available at the time was selected. Participants provided informed consent. Ethical approval was provided by the Institutional Review Board, Ministry of Public Health, Afghanistan.
A standardized, structured questionnaire collected information on demographic and socioeconomic measures, avian infl uenza information sources and knowledge of appropriate preventive measures, poultry and animal handling, food and generic hygiene, and human infl uenza knowledge and treatment seeking. Questions related to KAPs were scored by a panel of experts in related disciplines. The questions were ranked for importance in preventing avian infl uenza transmission in poultry or reducing human exposure and awarded 5 points, 3 points, or 1 point for correct answers. For each respondent, the sum of scores for correct answers divided by the sum of available points generated a percentage score. Blank responses to questions were counted as such and not included in individual denominators. The questionnaire was back-translated and pilot-tested. The survey was conducted in May 2007, by trained Afghan surveyors. Data were double-entered by using Microsoft Access (Microsoft, Redmond, WA, USA) and analyzed by using Stata 8 software (Stata Corporation, College Station, TX, USA).
KAP scores provided a weighted measure of KAPs related to prevention of avian infl uenza. Percentage scores for each respondent were ranked and classifi ed as above or below the median. The primary analysis was conducted to compare factors (age, sex, socioeconomic status, provincial exposure to avian infl uenza IEC campaigns, and poultry ownership) associated with knowledge above the median. Socioeconomic quintiles (SEQs) were defi ned by principle components analysis using employment, education, and household assets as indicators (3). Factors independently associated by univariate regression at the 95% confi dence level were included in a stepwise multivariate logistic regression model. To numerically evaluate KAP levels, a secondary analysis assessed differences between mean percentage scores, stratifi ed by factors identifi ed by logistic regression analysis.
Data for 304 respondents were included in the analysis. Of the 5 provinces, Kabul and Nangahar had had infl uenza outbreaks in poultry in 2007. Enrollment characteristics are shown in the For secondary analysis, overall mean KAP score was 44.4%. Mean KAP score differed between SEQ (p<0.001, by analysis of variance) and was higher in provinces previously exposed to IEC campaigns (50.2% vs. 40.1%; p<0.001, by t test).
Specifi c, self-reported practices also differed by SEQ. Reporting of sick or dead poultry to authorities was less frequent among lowest SEQ (

Conclusions
Human cases of avian infl uenza (H5N1) have resulted from contact between humans and infected backyard poultry (4). Risk to humans is also related to frequency of disease occurrence in the avian population (5). Recently, human-to-human transmission has been reported in the neighboring Northwest Frontier Province of Pakistan (2). Knowledge of disease is therefore a key factor in reducing exposure and enhancing reporting.
Overall knowledge was low, although in provinces exposed to intensive IEC campaigns, KAP scores of the population were higher. This fi nding indicated that campaigns had some success in increasing awareness. The level of concern generated by the campaign, government response, media reports, and proximity to the outbreak are all likely to contribute to this association. Despite this encouraging evidence, level of knowledge was far higher among persons with higher socioeconomic status. This fi nding contrasts with frequency of poultry ownership. Exposure risk is therefore likely to be considerably higher among lower socioeconomic groups.
Our results can be broadly generalized to the population, although we did not have access to unsafe districts (most of the districts in southern and eastern Afghanistan). This limitation may introduce selection bias, which would underestimate the effect of socioeconomic status because those living in inaccessible areas likely have a lower status than persons in accessible areas. Preintervention and postintervention surveys would provide a more robust measure of effectiveness. In the immediacy of an outbreak, this was unfeasible and would have been unethical. Although there are limitations to the study design in concluding intervention effectiveness, the results provide evidence to support further intensive campaigns as a response to infl uenza outbreaks in poultry.
Several reports have examined KAPs and behavior related to avian infl uenza (H5N1) (6)(7)(8)(9). Similar to the fi nding in the Lao People's Democratic Republic (6), our study suggests that conventional education and behavior change messages have a limited effect in populations with highest exposure. Efforts to ensure that IEC messages are suitable for lower socioeconomic groups should be adopted, specifically by improving the knowledge of community leaders, designing messages in a suitable format for the poor and illiterate, and ensuring that the most accessible channels are used. Messages should carefully balance the risk for human disease against potential nutritional and economic consequences of high population concern (e.g., food scares).
Successfully promoting behavior change is a lengthy process and requires frequent reinforcement. The acuteness of avian infl uenza (H5N1) outbreaks requires a concerted effort to enhance knowledge and change behavior among those most at risk in low-income countries. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 9, September 2008 This study was supported by the Afghan Public Health Institute and the US Naval Medical Research Unit 3, Cairo, Egypt, with funding from the Centers for Disease Control and Prevention, Atlanta, Georgia, USA, and the United Nations Children's Fund, Kabul, Afghanistan.
Mr Leslie is an infectious disease epidemiologist, working as a technical advisor to the Afghan Public Health Institute in Kabul, and a doctoral student at the London School of Hygiene and Tropical Medicine, conducting research on malaria in Afghanistan and Pakistan. His research interests include infectious disease epidemiology (primarily vector-borne and zoonotic disease), outbreak investigation, and socioeconomic factors related to disease.