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AI-BCC End of Project Report OCTOBER 2005 - DECEMBER 2009

AI-BCC

Prepared by AED


ta b l e of c on t e n ts

INTRODUCTION 1

VIETNAM 4

LAO PDR 16

CAMBODIA 32

INDONESIA 42

KEY INSIGHTS 46

Case studies (titles in italics) mentioned throughout the report can be found at www.avianflu.aed.org. org/whitepapers.htm


INTRODUCTION

It was 2005 and outbreaks of avian influenza (AI) were regular occurrences in Southeast Asia, leading to the deaths of nearly 140 million domestic poultry and 57 people — and fueling daily headlines in the region and worldwide. International health authorities worried about whether the culprit, the H5N1 virus, would evolve into a global influenza pandemic – a scenario that set many donors to action.


In Vietnam, Lao PDR and Cambodia, KAP surveys were undertaken to gather insights about farmers’ knowledge, beliefs and practices relevant to preventing and controlling avian and human influenza.

As part of a series of emergency measures to stave off the spread of AI and avert a pandemic, the United States Agency for International Development (USAID) awarded a Task Order to AED to collaborate with the governments of Vietnam, Lao PDR, and Cambodia in planning and implementing behavior change and communication (BCC) activities to prevent and control the virus transmission in poultry. Called the Avian Influenza Behavior Change and Communication project, or AI-BCC, the project started quickly in Vietnam and Cambodia in October 2005, and in early 2006 in Lao PDR. Because support came from emergency funds, the project operated on a yearly funding and work-planning cycle in each country. In most of the countries, there was not much known about avian influenza, and the capacity of animal health workers and other first responders was inadequate to respond to outbreaks of that magnitude. Due to the inexperience of many of these players, emergency response and capacity building occurred handin-hand, and approaches were regularly revised due to evolving discoveries about the virus and how to prevent and control it. This created an interesting learning laboratory on how to respond to outbreaks in a rapid manner, while also adhering to an evidence-based, BCC approach.

This report is not intended to summarize all of the activities undertaken in each of the countries, but rather provide highlights and reflect on challenges encountered and how they were addressed.

Taking a Baseline Temperature Because epidemiologic information about the H5N1 virus was still evolving at the time – debates swirled over whether wild birds were the main vectors of the virus’s spread, or whether domestic poultry were the culprits – and because there was relatively little known about the target audience of small, backyard poultry (Sector 4) farmers, AED began its process with a baseline Knowledge, Attitudes and Practices (KAP) survey in late 2005. In Vietnam, Lao PDR and Cambodia, KAP surveys were undertaken to gather insights about farmers’ knowledge, beliefs and practices relevant to preventing and controlling avian and human influenza (API). The findings helped to narrow down communication approaches that should be used. In Vietnam, for example, 90 percent of the farmers were aware of AI and understood that it is spread through contact with sick or infected poultry. This was mostly due to wideAI-BCC END OF PROJECT REPORT

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spread news coverage of the outbreaks, as well as government attention to the issue. Despite these high awareness levels, however, farmers did not perceive the virus as a risk to their own poultry, mostly because they knew that their flocks were vaccinated against AI. They also were relatively unaware of biosecurity practices that would protect poultry from getting AI (e.g., keeping new poultry separate from existing poultry). As a result, AED quickly launched mass media and interpersonal communication (IPC) activities to provide information to poultry farmers on AI prevention and control measures in as many provinces as possible. A similar mass media and IPC approach was taken in Cambodia –where there were varying levels of awareness and knowledge – and was supplemented by capacitybuilding activities with the Ministries of Agriculture and Animal Health. In Lao PDR, awareness levels were lower – the baseline survey showed that farmers lacked elementary knowledge of AI prevention, such as knowing the signs of avian influenza in poultry and the main causes of AI transmission to humans. This knowledge gap signalled a need for

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basic public awareness-raising through community-based communication via partners such as the Lao Women’s Union and the Lao Journalists Association. Having gathered this initial data, AED embarked on targeted programs in each country – and in most cases, in each province and district. These details are provided in the following sections on Vietnam, Lao PDR, Cambodia, and Indonesia. Many of the initial communication materials developed in Lao PDR and Cambodia starred a new type of superhero: “SuperChicken”. SuperChicken was developed by AED along with government officials in Cambodia, and later adapted by officials in Lao PDR. SuperChicken was intended to serve as a credible source of good behaviors and best practices to stop the spread of the AI virus. Somewhat bossy in temperament, he has traveled by motorcycle and boat to help farmers and communities prevent avian flu outbreaks. See Super Chicken®: Using an Icon in the Fight against AvianInfluenza for additional details.


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VIETNAM

Vietnam, with a total human population of 86 million and poultry population of 226 million1, was one of the first countries to report AI in poultry. In the first wave of the AI epidemic (December 2003-April 2004), 57 of the country’s 64 provinces were affected, and nearly 45 million poultry died or were culled. The economic loss was estimated at US$630 million2 in the first two years of the epidemic. During this same period, Vietnam reported a large number of human H5N1 infections. By March 2004, 23 persons were infected with H5N1, and 16 of them died. Since then, Vietnam has succeeded in significantly reducing the number of AI outbreaks and human H5N1 infections. The government established the National Steering Committee for Avian Influenza Disease Control and Prevention (NSCAI), which approved a five-year plan called the “Integrated National Operational Programme for Avian and Human Influenza 2006 to 2010,” or the “Green Book.” Vietnam instituted efforts to improve surveillance and early reporting. In 2005, it launched a mass poultry vaccination campaign on a twice yearly basis. Since this first wave, subsequent AI outbreaks occurred in fewer provinces, with a drastic reduction in the number of dead or culled poultry reports. Although no AI outbreaks were reported from mid-December 2005 to November 2006, outbreaks resurfaced, albeit in greatly reduced numbers, in December 2006 and continue to occur sporadically to the present. Human H5N1 infections are still reported. As of December 31, 2009, Vietnam recorded the second-largest number of human infections in the world (112) and the second-highest number of deaths (57).

1Data 2Data

4

source: Vietnam Department of Animal Health (DAH) source: www.avianinfluenza.org.vn

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In 2005, Vietnam launched a mass poultry vaccination campaign on a twice yearly basis. Since this first wave, subsequent AI outbreaks occurred in fewer provinces with a drastic reduction in number of dead or culled poultry reports.

The AI-BCC Project in Vietnam ran from October 2005 to December 2009. For the first two work plan years (October 2005 to September 2007), AED aimed to deliver correct information on AI prevention and control to a wide net of poultry farmers in as many provinces as possible. With Indochina Research Ltd (IRL), a Knowledge, Attitudes and Practices (KAP) survey of backyard poultry farmers was conducted in 2005.

Through partnerships with the Department of Animal Health, Ministry of Health, and nongovernmental organizations (NGOs) with extensive networks in the provinces, such as Agronomes et Veterinaires sans Frontieres, AED trained 8,488 animal health workers, 3,850 volunteer health workers, 3,783 women leaders and 2,125 small commercial (sector 3) farmers in 35 provinces in the high-risk Red

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River and Mekong River deltas on AI communication. The project produced 3.2 million AI prevention leaflets, 150,000 AI outbreak leaflets and 38,000 AI prevention booklets. This trained cadre of AI communicators, armed with these AI print materials, organized farm visits, club meetings, group discussions, AI competitions and skit showings, which reached more than 400,000 people in the rural areas. A survey conducted the following year (2008) among a representative sample of animal and human health workers, women leaders and small commercial farmers trained by AI-BCC in 2007 revealed that a large majority still continued to hold AI communication activities in their communities one year after training. One of the more notable collaborations was with the Vietnam Women’s Union (VWU). For a glimpse at some of the work with VWU, see Mobilizing Local Women Leaders to Spread the

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Word on Avian Influenza Prevention. AED, through Ogilvy Vietnam, implemented a nationwide radio and TV campaign in early 2006 and 2007, which promoted two prevention practices – fencing poultry and separating poultry for two weeks – as agreed to by the U.N. Food and Agriculture Organization (FAO) and government partners. The project produced and distributed 38,000 fencing posters and 38,000 separation posters to complement these mass media messages. In the third year of the program, late 2007 to late 2008, AED moved from an emergency mode to a more integrated, “consolidation” phase. AED focused training and communication interventions on seven high-risk provinces selected by the Vietnam Department of Animal Health (DAH): Hai Duong, Nam Dinh and Thai Binh in the north; Nghe An in the center; and Bac Lieu, Tra Vinh and Hau Giang in the south.


Through enhanced collaboration with existing partners, AED trained 506 animal health workers and 909 women leaders. New partners like the Vietnam Poultry Association (VIPA), Vietnam Farmers Association (VFA), Vietnam Farmers Union (VNFU) and Center of Agricultural Extension Volunteers (CAEV) trained 1,500 sector 3 farmers, 554 feed sales agents who are in regular direct contact with farmers, 320 farmer leaders or local influentials and 756 agricultural extension workers who will be able to promote AI prevention and control in their communities. AED provided technical support to strengthen participatory methods, improve visual aids and assess learning gains. With minimal AED support, VIPA piloted 40 poultry clubs in Thai Binh and Nghe An as venues to improve farm biosecurity and disease prevention practices. For a snapshot on the experience with poultry clubs, see Building the Capacity of Local Farmers: Vietnam Poultry Clubs Offer Camaraderie, Discounts, Leadership Skills, and Help in Preventing Disease Outbreaks. AED also conducted a qualitative study of duck farmers that provided insights for messaging, and led to the production of three posters for

supply chain actors – one each for poultry transporters, slaughterers and market vendors – who were channels for poultry infections and were themselves at high risk for human AI infections. A total of 50,000 copies of each poster and 100,000 AI leaflets were produced. DAH, using their government funds, printed an additional 540,000 copies of the materials which they currently use for their training activities. Coordination with the DAH and provincial Sub-Department of Animal Health (SDAH) resulted in enhanced involvement from local government counterparts. In May 2008, the DAH organized a Strategic Country AI Review of USAID-funded projects. As a result, USAID decided to support five provinces – Ha Nam, Hung Yen, Quang Tri, Can Tho and Kien Giang – where all USAID funding would converge during the next implementation cycle. AED had to shift its focus from the previous year’s seven provinces to these five provinces from October 2008 onwards. Because Abt Associates, another USAID partner, had been working in Hung Yen and Can Tho since 2006, AED activities targeted Ha Nam, Quang Tri and Kien Giang, except for supply chain trainings which were done in all five provinces.

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In the third year of the project, from late 2008 to late 2009, activities converged in 160 communes of Ha Nam, Quang Tri and Kien Giang, which were selected by the SDAH offices as high-risk. Collaboration with VIPA, VFA, VWU, VNFU and a new partner, the Vietnam Veterinary Association (VVA), trained as “avian and human influenza (AHI) communicators” 800 animal health workers, 320 agricultural extension workers, 2,600 commune officials and 3,200 sector 3 farmers in these 160 communes. In the five provinces, VVA held sessions to improve the knowledge of 800 supply chain actors on prevention of animal and human H5N1 infections. AED technical support further strengthened trainers’ participatory skills, revised training modules for better comprehension, improved visual aids, and added sessions to make the learning experience more memorable and enjoyable. Certificates, caps, bags and aprons with AI messages were given to all the trainees to recognize their participation and to enhance their image as “AHI communicators.” For a more in-depth look at awareness activities along the poultry supply chain, see Awareness of How to Prevent Avian Influenza Outbreaks Travels through the Poultry Supply Chain. For an illustration of the participatory methods used to train animal health workers and others, see Using Participatory Methods to Prevent the Flu: Animal Health Workers in Vietnam Become Hands-on Participants in Preventing Avian Influenza.

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AI-BCC provided communication support to the government’s mass poultry vaccination program, as a large number of AI outbreaks after 2007 occurred among unvaccinated ducks. The qualitative research on duck farmers conducted by AED in 2008 revealed that duck farmers were not aware that ducks required two vaccinations 28 days apart. Farmers also thought that vaccination was harmful to young ducks. In consultation with the DAH and FAO, the project produced 100,000 copies of a leaflet and 220,000 copies of a duck vaccination flyer and poster version to correct these misconceptions. These materials were distributed to duck farmers in high-risk provinces in time for the launch of DAH’s twice yearly vaccination campaign in 2009. In June 2009, AED guided the development of AHI provincial communication plans in Ha Nam, Quang Tri and Kien Giang through a hands-on workshop in each province attended by provincial and district DAH and Department of Health (DOH) officials. The cornerstone of these plans was a multi-media communication campaign called “3 Good Things.” The campaign promoted three key practices: Buy and sell only healthy poultry; Wash hands with soap and water before and after handling poultry; and Immediately report sick or dead poultry to the veterianarian or village head as recommended by the government’s National Strategic Framework for Avian and Human Influenza Communications, 2008-2010.


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AED produced 60-second entertaining audio spots for each “good” practice that aired on loudspeakers in the 160 target communes and provincial radio stations of the three provinces five days per week for six weeks from October to November 2009. A total of 400,000 comic flyers and 126 billboards using the storyline and characters from the audio spots was distributed and installed. The billboards will continue to be installed until the end of 2010. Thirty market events and one road show in major markets of the three provinces were organized. These events used interactive games, quizzes, skits, and songs to educate supply chain actors and farmers on the “3 Good Things,” reaching over 1,700 participants. The “3 Good Things” campaign was continued by Abt associates as its pre-Tet campaign for 2009-2010. AED also supported FAO’s Getting Evidence for a Transition Strategy (GETS) for a Mass Poultry Vaccination pilot program in the five provinces of Nam Dinh, Ninh Binh, Quang Binh, Hau Giang and Soc Trang. AED launched a provincial mass media campaign called “A New Stage” using two 30-second TV spots aired five days a week for six weeks from October to November 2009. AED produced four 30-second audio spots for airing by FAO on provincial radio stations and commune loudspeakers. AED printed 500,000 flyers echoing the storyline and messages of the two TV spots, which FAO distributed through the provincial DAH offices. Around the same time, three KAP surveys were undertaken among animal health workers,

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sector 3 poultry farmers and supply chain actors, marking the first time research of this type was done among these three target groups. The survey results were presented to government and other animal and human influenzas (AHI) partners during dissemination seminars, where implications for communication and other actions were discussed. The poultry supply chain survey was conducted in the five USAID priority provinces. This study aimed to gain information among breeders, transporters, slaughterers, market vendors and cooked food sellers on their practices, knowledge, attitudes and beliefs. There were 1,752 randomly selected respondents: 242 hatchery owners or workers, 298 transporters, 265 slaughterers, 309 live market vendors, 333 plucked meat vendors and 305 cooked food sellers from the five provinces who were questioned individually by trained interviewers. The data collected in the supply chain research, combined with the other KAP research, led to several insights that had implications for communication activities: •

Although poultry farmers, supply chain actors and animal health workers think that AI or human H5N1 infection are serious diseases, they believe that the infection will not affect their poultry or themselves. For the past four years, communication has focused on increasing personal risk perception – which is very difficult to achieve. Effective communication programs on AHI thus need to create other meaningful and


perceived “entry points” for poultry farmers and supply chain actors. •

Although the government’s vaccination program has been effective in helping reduce AI outbreaks significantly, it has created a false sense of security among poultry farmers who believe that vaccination immunizes their poultry from the virus. This may account for prevailing poor biosecurity practices.

The government has been actively promoting farm cleaning and disinfection. This campaign has been successful as demonstrated by an increase in both practices. However, this may be a reason why other biosecurity practices promoted by FAO (e.g., segregation and isolation of poultry) lag behind.

Poultry farmers do not normally consult their local veterinary or animal health worker for poultry diseases. They feel that they “know their poultry best” and use their past experience in treating sick poultry. Moreover, farmers may feel that it is not necessary to consult a veterinarian since a few dead birds do not involve the same financial loss as a dead pig or cow.

There is a need to provide more specifics on the ideal biosecurity practices that are promoted. Grouping some practices together may not be realistic. For example, it is important to distinguish between actions for sick birds versus actions for dead birds.

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In this final year, AED was able to achieve, and even exceed, its targets for the indicators established by RDMA for AI-BCC Vietnam, as shown by the following table.

Indicators for AI-BCC VIETNAM

Target FY 2008

Actual FY 2008

Target FY 2009

Actual FY 2009

Percent of people in target areas with regular exposure to poultry who report practicing at least 3 “key behaviors” to decrease the risk of AI infection to their flocks

n/a

19.2% (N=603)

30%

70.0%

Percent of people in target, high risk areas with regular exposure to birds who report practicing at least 3 “key behaviors” to decrease the risk of human H5N1 infection

n/a

Number of people trained in animal health, human health and/or behavior change communication related to AI supported by USAID

4609

Source: KAP Survey of small commercial poultry farmers 2009

29.0% (N=602)

30%

43.0% Source: KAP Survey of small commercial poultry farmers 2009

4609

6670

7763 (animal health workers, agricultural extension workers, small scale farmers, farmer and women leaders, supply chain actors) Source: AED partner reports and trainee sign-in sheets

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The table below summarizes AI-BCC’s training results in Vietnam through the four project years.

Summary of People Trained 2005 – 2009, AI-BCC vietnam

Trainee Category

20052006

20062007

Agricultural Extension Workers Animal Health Workers

6,089

2,399

20072008

20082009

Total

756

320

1,076

506

800

9,794

2,600

2,600

Commune Officials Farmer Leaders

320

320

Feed Sale Agents

554

554

Poultry Clubs

40

43

83

1,500

3,200

6,825

800

800

Sector 3 Farmers

2,125

Supply Chain Actors Village Health Motivators

3,850

Women Leaders Total

9,939

3,850 3,783

909

8,307

4,585

4,692 7,763

30,594

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Looking Forward Over the life of the project, Vietnam made remarkable progress in its effort to contain avian flu, and has succeeded in significantly reducing the number of AI outbreaks. From mid-December 2005 to November 2006, no AI outbreaks were reported. AI outbreaks resurfaced, starting in December 2006, but in greatly reduced numbers, and mainly in small commercial (sector 3) farms and duck farms. Human H5N1 infections are still reported, but cases have declined considerably. Despite this success, however, AI remains a major concern in Vietnam. The HPAI virus is still widely circulating among birds in the country. Illegal movement of potentially infected chickens, ducks and eggs across country borders is a big problem.

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Poor farm biosecurity practices predominate among backyard and small commercial poultry operations. As of December 2009, Vietnam still had the second-largest number of human infections in the world (112) and the secondhighest number of deaths (57). Considering this situation, efforts to promote practices which will prevent transmission of AI in poultry and in humans continue to be essential. Indeed, the capacity building invested in local organizations by the AI-BCC project paid off in sustained AI activities. Even after the AI-BCC project ended, several activities are ongoing, including continued training of animal health workers, supply chain actors, and animal and human health workers. There is also potential for the poultry clubs to continue if they are properly nurtured and linked with commercial poultry companies, and can be venues for sustained biosecurity practices.


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Lao PDR

Lao PDR first reported incidents of H5N1 virus in the winter of 2004, when 46 poultry farms experienced massive poultry deaths in three villages. The virus would not be officially detected again until July 2006, when an outbreak at a state-owned farm, near the capital of Vientiane, led to the culling of over 30,000 birds within a 1 kilometer radius of the farm, encompassing poultry across three villages. This culling led to consternation not only among the farmers who had lost seemingly healthy poultry, but also among the Lao PDR government, which had only recently formed a National Avian Influenza Coordination Office (NAHICO) to plan for and respond to virus outbreaks. In early 2007, a third occurrence of AI hit five of Lao PDR’s 17 provinces, leading to 345,632 birds being culled. The 2007 outbreak also marked the first human cases and deaths of avian influenza in Lao PDR. The following year, Lao PDR experienced its usual winter-season outbreak in four districts, but this experience, however, was markedly different from the previous outbreaks, and indicated some progress in the control of AI in Lao PDR. Prompt reporting by village veterinary workers (VVWs) led to early detection and response, and was complemented by adequate disease investigation by district livestock staff.

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Prompt reporting by village veterinary workers (VVWs) led to early detection and response, and was complemented by adequate disease investigation by district livestock staff.

In the fledgling months of the AI-BCC project’s work in Lao PDR, it was decided the government and other stakeholders that the project would focus on four priority provinces for activities, primarily because these provinces comprised 45 percent of the population, housed a highdensity of poultry, and contained many trade routes and economic centers: Vientiane, Savannakhet, Champassack, and Luang Prabang. The project’s activities spanned four main areas: research, media, training and capacity-building, and materials development.

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Before work could begin in earnest, however, AED brokered and facilitated the signing of a Memorandum of Understanding with the Government in June 2006, officially enabling the project to provide technical assistance in preventing and controlling AI outbreaks. In the following month, July 2006, the Lao PDR Government formed the National Avian Influenza Coordination Office (NAHICO), housing all avian and pandemic influenza-related activities under one roof in the Office of the Prime Minister. This action enabled the project to have a single but multi-sectoral hub of contact for all of its activities. From the start, the trademark of the AI-BCC project in Lao PDR was to work collaboratively with a wide spectrum of partners. Predominantly through active participation on the National Avian Influenza Information, Education and Communication (IEC) Working Group, comprised of both national government and international partners, AED’s professional experts in Lao PDR worked with partner organizations including the U.N. Food and Agriculture Organization (FAO), UNICEF, World Health Organization (WHO), the Lao Journalists Association, the Lao Women’s Union, various media channels, as well as relevant ministries and departments within the Lao PDR Government. As with many behavior change and communication programs, one of the first tasks in Lao PDR involved collecting baseline information through a KAP study. AED conducted the baseline KAP in 2006 and a follow-up KAP in 2007. Baseline interviews of approximately 1,000 rural backyard poultry farmers showed that they lacked elementary knowledge of AI prevention, such as

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the signs of avian influenza in poultry and the main causes of AI transmission to humans. This knowledge gap signalled a need for basic public awareness-raising through channels with broad nationwide reach, such as targeted media.

Working with Media As a result, AED initiated a partnership with the Lao Journalists Association (LJA) to educate target populations, particularly due to the reliance on government-run radio and television for information. The project mobilized the LJA/ Lao News Agency network of print, radio and television workers to deliver public awareness and education. This activity transcended mere AI education and addressed skills training (particularly for radio and television journalists) that included computer animation, timing a story, and putting together a storyboard. In February 2006, 93 reporters and editors from local and national print and electronic media were trained in workshops. A more focused, smaller workshop was held later that year to develop media production plans, coverage, and outputs on AI by 13 journalists and editors, thereby facilitating more skill building and in-depth news development. The more tangible results of the workshop included at least six news articles on AI appearing in print media, the production of the firstever animated television spot aired in Lao PDR, and the first documentary fully produced in the country. A shorter TV spot, featuring SuperKai (SuperChicken), was also created, as were two magazine format 30-minute radio programs. For the radio waves, two 30-minute radio programs, and five 60-second radio PSAs were produced and aired on Lao Radio AM and FM.


Almost 1,000 music CDs and video CDs containing the five radio spots, the television spot, and the TV and radio documentaries were distributed to approximately 200 villages to expand the reach of these media tools. In addition to the 60-second spots, radio was also used to deliver live-read scripts during outbreaks. Speaking to the importance of community connections – and because KAP results indicated that villagers tend to trust and rely on information conveyed by neighbors, family and peers – the project focused on capacity building and education activities, particularly cascade training of trainers workshops, mostly through the established channels of the Lao Women’s Union and its provincial and village-level offshoots. Other community activities included outreach through factories, hospitals and schools, and taking advantage of special events where large numbers of people gathered, such as annual festivals. Among the community partnerships, one of the most notable was with the Lao Women’s Union. For a more detailed synopsis of collaborations with the LWU, see The Power of Women Unites Communities to Prevent Avian Influenza, and Nurturing a Social Network to Respond to Avian Influenza Outbreaks: AI-BCC and the Lao Women’s Union.

Going to Where the People Are: Factories, Bus Stations, Hospitals, and Universities Looking for places where large audiences could be found led the project to factories, bus stations, hospitals, and universities. The university activi-

ties were particularly encouraging, as the students expressed strong interest and were the types of individuals who could be harnessed to help in the event of a widespread outbreak. Outreach activities were conducted at a medical school, police school, political school and technical school, with over 1,000 students attending the events that included interactive discussions on AI prevention, control and response; material distribution; presentations; and quizzes with prizes. At the student orientation on AI at the Medical College, students were given the opportunity to sign up as volunteers for the Ministry of Health to assist in conducting community awareness-raising activities. The bus station orientation sessions were also effective because they honed in on a key audience – people who transport chickens and poultry products. Working with the Center for Information and Education in Health (CIEH) and the Department of Livestock and Fisheries (DLF), the project educated people using public and private transport in how to minimize the risk of AI transmission. Trainings took place in three bus stations in Vientiane, reaching roughly 300 bus operators, transport workers and longdistance travelers with AI information. To reach factory workers, AED partnered with CIEH to conduct a factory education drive in 2007, and then another series of workshops in 2008. Initially working together with the National and Vientiane Capital chapters of the Lao Front for National Reconstruction, the health education team provided important AI information to over 3,000 workers in five factories in and around Vientiane Capital. The orientations provided the workers – the majority of whom live on backyard

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poultry farms – with important information about AI. Through the orientation, the workers learned how to recognize the clinical signs of AI and how to prevent the spread of AI. Overall, the project reached a total of 20 public and privatesector factories, reaching over 10,000 people.

Using Festivals and Other Special Events to Engage the General Population Every year, October through December marks the Lao PDR festival season, occasions that were deemed effective vehicles of information dissemination because they allow for entertainment and information sharing, and because of the large volume of people that participate from both urban and rural areas. For example, the project linked with the annual Boat Racing Festival to sponsor a boat and distributed materials with the help of SuperKai. Participation in the Boat Racing Festival in subsequent years featured two days of activities in Vientiane capital and Champassack province that brought over 50,000 backyard farmers to an avian influenza booth. Other festival events included drama performances with AI prevention messages by a drama troupe, SuperKai appearances on the AI boat, AI videos on stage, and live demonstrations of key behaviors, including hand washing with soap and biosecurity for poultry raising. The That Luang Festival, which brings over 100,000 visitors to the That Luang temple grounds in Vientiane, also became an annual activity for the project. AED again, under the sponsorship of NAHICO, collaborated with CARE, FAO, UNICEF and WHO, as well as

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Lao PDR Government counterparts, to sponsor a booth and host three days of activities including demonstrations on hand washing, how to keep farming equipment clean, cooking, and food preparation. Other partners, such as the International Organization of Migration (IOM) were added over the years. To engage ever-elusive minority populations, the project conducted outreach activities surrounding Hmong New Year. Other special events where outreach was held included the Chinese and Vietnamese New Year period, which provided an opportunity to conduct orientation sessions on AI at live bird markets during the holidays, as many families slaughter or purchase birds for their celebrations. AI messages and products were also disseminated at events marking International Children’s Day and International Women’s Day, where over 3,000 people participated in 2007. AI-BCC and other partners helped to support the Lao Women’s Union in celebrating International Women’s Day every year.

Using Materials as Tools, Not as an End Product Throughout the project, a wide variety of products were developed – ranging from booklets, brochures and posters, to calendars and job aids – not only for the sake of developing IEC materials, but rather as tools to carry out other activities. Project staff and partners learned this from the July 2006 outbreak, when the project was in its early stages and there were not many materials already in existence that could help in getting information out to concerned parties. The need to have a collection of products ready


for an outbreak, and a strategy for disseminating them, became a priority. Soon thereafter, a packet of outbreak-ready materials was printed and disseminated along established channels (e.g., LWU members). A compilation of products can be found on the web at www.avianflu.aed.org. One notable product was an emergency flyer created by AED, UNICEF and FAO to be distributed in outbreak areas. The flyer includes key messages relevant to the outbreak and surrounding areas, including reporting of dead birds, how to handle sick and dead birds, and basic hygiene. AED also developed a series of five color-coded posters for prevention, alert or outbreak: blue indicated prevention, yellow indicated alert, and red indicated outbreak. Creating a brochure intended mostly for backyard poultry farmers also turned out to be a significant exercise because it reflected the evolu-

tion of messages and a shift from text-heavy materials to more pictorial, low-literate materials. This evolution of materials began with an initial brochure for the Lao Women’s Union that provided “everything you ever wanted to know about avian flu” in a three-paneled brochure. A subsequent brochure intended for farmers incorporated more illustrations to accompany the text, but was still too wordy for the target audience of backyard poultry farmers. The most recent version of the brochure for farmers features the most simplified messages, emphasizing their visual representation rather than the words themselves.

Reflection and Fine-Tuning via Research These messages and activities were refined based on continual feedback, reflection on experiences,

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and on analyzing follow-up KAP data. Based on the follow-up KAP findings, the project refined strategies on mass media, community outreach and interpersonal communication, and revised communication materials, with a strong emphasis on low-literacy and the use of existing community networks. Follow-up KAP data confirmed some hypotheses and parts of initial strategy, including that the media is of vital importance in conveying information, often serving as the first source of information, but interpersonal and community networks and meetings are also key in delivering information, and may be more effective in delivering a greater depth of information. The KAP also found that the BCC activities were successful in creating ‘top-of-mind’ awareness quickly. A few behaviors were found to be relatively easy to change, such as hand washing, while others – especially those related to animal raising and poultry-to-poultry transmission – were more difficult and have changed more slowly. These behaviors include separating poultry from ducks and other animals, quarantining new poultry before allowing them to mingle with existing flocks, cleaning away feces regularly, and reporting suspected cases of AI. The potential and thusfar untapped importance of the village veterinary workers was also highlighted, as was the importance of the village chief as a conduit of information and action. Key findings of the quantitative portion of the survey included: • Awareness of AI and AI initiatives in Lao PDR is high: 95% of respondents were aware of AI, and 87% have seen an AI initiative.

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• • •

Knowledge about AI control is generally low, with the exception of knowing whom to notify during an AI outbreak, and the need to take a potential victim to a health facility. Knowledge is alarmingly low regarding AI symptoms in humans and preventive actions. TV and radio are the main media used, and TV watching is highly concentrated during the evening hours.

Barriers to taking action to prevent AI included that: • • • •

Money is perceived to be a significant barrier to building a pen or enclosure to separate poultry from humans. Farmers are not aware that “keeping visitors away from poultry” is a preventive action. Farmers are not aware that “not letting children handle poultry” is a preventive action. Eating sick or dead poultry, blood pudding, and undercooked poultry are all potential dangers. Around 70 percent of respondents do not believe it is an important preventive action to refrain from eating sick or dead poultry, blood pudding, and undercooked poultry.

The qualitative portion of the research revealed even more about motivations and potential stumbling blocks. For example, despite direct experience with AI in two out of the three provinces researched, respondents demonstrated a fundamental lack of concern and disbelief regarding its relevance to humans. AI in Lao PDR also faces “disease competition” from other serious diseases affecting the population (malaria, liver disease, HIV/AIDS). Along with AI, these specific diseases dominate people’s health concerns.


In fact, while AI was noted by farmers at the top of their health concerns, it was not necessarily ranked at the top by all stakeholders until prompted. When prompted, both farmers and stakeholders keenly felt the danger of AI, demonstrating that communication and awareness drives concern. Farmers can clearly articulate that AI is a dangerous poultry disease that can spread to humans, with no treatment and death as a consequence. However, farmers are still unaware of some of the key measures, or unlikely to perform them, because they run contrary to ingrained habits.

Comparison of Baseline and Follow-up Data Following is a comparison of the 2006 baseline data with follow-up data from 2007 and 2009. Despite the barriers identified by the research, the numbers clearly illustrate that communication activities on AI have improved each of the four target indicators for awareness, knowledge and behavior:

INDICATOR

BASELINE KAP 2006

KAP 2009

1. Awareness

65%

99%

2. Knowledge of 3+ ways to protect poultry

32%

49%

3. Knowledge of 3+ ways to protect self/family

41%

73%

4. Practice 3+ ways to protect self/family

29%

50%

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Based on the follow-up KAP results, it was determined that more targeted behavior change programming was necessary to break ingrained habits, ensure strong concern and awareness of the severity of the disease, and clarify the full gamut of measures people should be taking to prevent and control AI. Ongoing roles for government stakeholders, NGOs and media were envisioned as being important to mobilize and raise awareness about AI at all levels, but greater frequency of communications was recommended. TV was deemed to be highly effective, especially using PSAs and other announcements during newscasts, and radio was cited as a good complement for more effective reach. Dovetailing community outreach with data gathering, the project also embarked on a participatory action research (PAR) project. AED and FAO collaborated on the eight-month PAR study with farmers, village authorities and district officials in four villages – two in Vientiane and two in Champassack – to determine the feasibility of changing behaviors related to biosecurity in preventing and controlling avian influenza. Use of a PAR, rather than other types of research, was deemed crucial in helping to

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change the behaviors of an entire community – and not just households or individuals. For each village, the team looked at: the importance of poultry; how seasonal events and climate influence poultry movement, use, and roles; gender roles regarding poultry; preferred information channels; how they protect themselves from poultry disease; and preferred village actions to prevent AI. These results were linked to village actions to prevent AI and led to the creation of a village action plan, signed by the village chiefs on behalf of the village. Observing community events also demonstrated that community education efforts were much more effective in conveying human health information than animal issues. As a result, the project created more materials to address animal issues, such as a low-literacy booklet addressing diseases in poultry, and the series of posters that outlined red, yellow, and green zones. In general, the project also collaborated much more closely with FAO to “co-produce” materials that would be more user-friendly and strengthen prevention and response at the animal transmission level. Concurrently, FAO led trainings for village veterinarians and farmers in response to KAP results that found people could not name a


credible source of information on animal health. The underlying goal of the training was to create a cadre of village veterinarians to serve as a source of reliable AI information. This tactic ultimately was successful, as several outbreaks were reported by village veterinary volunteers and district veterinary officials who were trained by the project. Following is a partial compilation of individuals who were trained as part of the AI-BCC project in Lao PDR.

NUMBER OF GOVERNMENT AND NON-GOVERNMENT PARTNERS AT VARIOUS LEVELS TRAINED IN AI AND BCC in lao pdr VILLAGE

YEAR

NATIONAL

PROVINCIAL DISTRICT

2006

48

114

34

2007

24

22

214

360

620

2008

493

60

179

978

1,710

2009

14

48

84

1,532

1,678

TOTAL

TOTAL 196

4,204

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The Role of Human Health Workers

Mid-Point Review: Growing the Program

Even though reaching out to and training animal health workers was a focus of the project, the role of human health workers was not neglected. AED collaborated with Ministry of Health/CIEH, WHO and U.S. Centers for Disease Control and Prevention (CDC) to implement two training sessions on AI outreach communication for health workers. AED and its partners trained a total of 78 health care workers in AI communications (56 at the district-level, 19 at the provinciallevel). The trained health educators were urged to provide ongoing education to the community as part of their regular health education sessions to outpatients and during other community outreach activities.

With follow-up data and months of activities under its belt, it became clear that the project was headed in the right direction by focusing on community engagement and interpersonal communication. It was important to delve deeper into communities, however, to reach the people who would influence behaviors and practices on a household level. In many cases, the influentials were village leaders and chiefs. This group was the initial target audience envisioned in the creation of an “AI Package,” a comprehensive collection of resources given to communities to help inform people before and during an outbreak.

Following an outbreak in Sayabouli, AED also collaborated with partners on a training program specifically for outpatient health care workers in that province. The training was intended to create an outreach team at each hospital at the provincial and district levels that provides AI education and communication to outpatients. It was deemed particularly important to target the outreach workers, as most patients reporting to hospitals with AI-type symptoms would be outpatients, and the workers needed to be empowered with information. The idea was that the outpatient workers could set up an orientation to AI for patients who were in the waiting rooms, as they would be a captive and interested audience. These same workers could venture out into the community with information during outbreaks. As it turned out, the outreach workers had an opportunity to practice their new AI education skills in the outpatient waiting room of the Sayabouli provincial hospital during an outbreak.

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For a summary of work to reach out to village leaders, including the development of an AI Package of materials they could use to rapidly respond to outbreaks, see Capacity Building of Village Leaders: Villages Come Together to Improve Poultry Raising Practices and Fend off Avian Influenza Outbreaks. With AED’s support, village leaders in three provinces (Champassack, Savannakhet, and Luang Prabang) were trained, covering 23 districts, 250 villages, and reaching a population of approximately 125,000 people. The trained leaders were encouraged to use these materials to educate villagers and to prepare appropriately for a possible outbreak – human or animal – at the district and village-levels. This later stage of the project also continued with community outreach through festivals and special events, and maintained coordination with established partners while seeking additional collaborators to further the message’s reach.


Promotion of a Reporting Hotline To avoid another massive outbreak, as had happened in 2007, AI-BCC worked with key partners to further improve outbreak surveillance and response, through promotion of the emergency reporting hotline. The 166 toll-free hotline number was emblazoned on a variety of canvasses, from phone cards to billboards to stickers on tuk tuks (motorized rickshaws). The hotline was promoted successfully through phone cards carrying key AI messages. This promotion was enabled through an agreement between AED and ETL, the largest phone company in Lao PDR, and approved by NAHICO. Under the agreement, ETL printed seven million cards and made them available to their network of mobile phone users nationwide. Documentation of calls received showed that the phone cards were the second-highest source of hotline calls. To further promote the hotline, AI-BCC established five billboards in two provinces strategically located in high-risk areas, near landmarks such as markets, busy traffic areas, and bus stations. The hotline number was more widely transported, literally, through collaboration with tuk tuk and jumbo drivers in the Vientiane Capital area. Three key messages were fashioned on stickers that could be placed on tuk tuks and jumbos, two of the main sources of transportation in the urban area. Collaborating with the Ministry of Transport and Communication, the Tuk-Tuk Association, the National IEC Task Force, CIEH, and the Vientiane Health and Agriculture Department, the project held trainings along main transpor-

tation routes in Vientiane. During the training, drivers conducted a ‘risk mapping’ exercise in which they identified where they would encounter or transport poultry. They were trained in how to protect their communities, themselves, and their families from AI, and how to properly wash and disinfect their vehicles. AI-BCC trained 175 drivers in prevention and response to a suspected outbreak of the virus. The trained drivers also received distinctive SuperKai t-shirts, caps, and informational stickers for their vehicles.

More Targeted Mass Media Acknowledging that resources were better spent on community outreach, interpersonal communication and capacity building, the project engaged in relatively limited – but more targeted – mass media activities later in the project. Late in 2008, for example, AI-BCC partnered with CIEH to launch a one-hour weekly radio program titled, “We are together against AI.” The broadcast uses a fast-paced variety format interspersed with conversations to highlight important AI news, promote the AI toll-free hotline, air AI songs and spots, read listener letters, take calls, and answer questions. The project forged an agreement with Lao TV to air a series of 23 news segments on avian influenza, aiming to help people protect their poultry and families from the virus via oncamera announcers, “person-on-the street” interviews, expert interviews, as well as previously prepared spots to inform viewers of the latest AI developments. The first two weeks of the program covered the basics of “What

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is AI?” and “How is AI transmitted?” and featured interviews with the director and deputy director of the National Animal Health Center. Later editions of the 23-program series featured other technical experts and a range of AI themes and topics. WHO and FAO provided both technical expertise and financial resources for the series, while Lao TV donated its staff time to script, film, edit and produce the program, as well as provide free broadcast air time.

Insights from the Lao PDR Experience

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Overall, addressing avian influenza has forced ministries and organizations that have never before worked together to collaborate. The IEC Task Force, in fact, has been cited as one of the most successful cross-sectoral groups in the health BCC arena. The successful collaboration of the group and its activities can be attributed, in part, to the presence of NAHICO; the consensus-building culture common in Lao PDR; the ability to quickly refine strategies based on feedback and other data; and the collaborative and collegial atmosphere fostered by the project. Indeed, much of the project’s successes could be attributed to the unique situation in Lao PDR, which had the luxury of having an avian influenza-specific coordinating agency


(NAHICO) and unusually collaborative partners. NAHICO has since become a model agency due to its cross-sectoral and inter-ministerial cooperation and communication. Part of the effectiveness of NAHICO is that it does not reside in a specific ministry, but rather operates independently under the Office of the Prime Minister, with representation from all relevant ministries. The people assigned to NAHICO were ultimately NAHICO workers who happened to have different areas of AI-relevant expertise. NAHICO’s multi-sectoral composition ensured buy-in from a variety of government ministries and led to an overall sense of inclusion among the different groups involved. NAHICO, as a coordinating body, streamlined approvals and made a significant difference in expediting actions in response to outbreaks and other priorities. At the beginning of the project, coordination mechanisms were weak, but following the formation of NAHICO, coordination received increasing attention. In addition, the presence of NAHICO led to respect of both formal channels and practical, informal channels that are necessary for coordinating communications among key government partners and donors. Another enabling factor in Lao PDR was the “legitimacy” conferred upon AED due to MOUs with the FAO and the Lao PDR government. This legitimacy was important because, unlike many other developing countries, there are very few NGOs operating international donorsponsored programs in Lao PDR, and USAID does not have a Mission presence. Working on the MOU with Ministry officials bestowed a certain level of trust on AED, and allowed the

project to forge agreements and collaborations with other organizations. Indeed, the development of initial channels of communication and a strong, formalized relationship with the government was key to many of the project’s successes. Helping matters was the spirit of openness and collegiality in Lao PDR. The country has, at its core, a collaborative culture, where people prefer to reach consensus rather than staunchly argue opposing viewpoints. This atmosphere was complemented by project staff members who were either Lao PDR nationals or embodied these cooperative traits. Organizations such as the LWU noted that they felt a spirit of openness and good intentions from the project staff from the beginning, and appreciated that all of their questions or concerns along the way were met with a prompt and gracious reply. This responsiveness increased their comfort level with the project and allowed for smooth planning and implementation, as well as a willingness and make changes along the way, if warranted. The various members of the IEC Task Force, influenced by the openness of NAHICO and impressed by the access to fairly senior-level officials, were also put at ease from the get-go. This allowed for an open, collaborative environment where organizations were open to learning from each other and not competing for attention. In addition, finding opportunities for the group to work together on an event or product was important and led to the team appreciating the skills and expertise of one another. Good examples of this were the festival booths and the AI Package.

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A significant ongoing obstacle in Lao PDR was how to address the myriad ethnic communities in Lao PDR, where 64 groups are officially registered as minorities with their own languages, cultures and beliefs. The participation of the Lao Front on the IEC Task Force has helped to ensure that those voices are taken into account, but resources have not always allowed for materials and activities to be tailored to so many different languages and belief systems. The project could not solely rely on mass media – often a significant component of BCC campaigns. Because Lao broadcast and print media have limited reach, the project had to use creative alternatives, including working with Lao journalists directly to improve their capacity and production; targeting media buys during timeslots which have high listenership/ viewership and incorporating messages into popular news programs; and finally, investing significantly in “direct-to-the-community” events and activities. Indeed, the project has affirmed an old lesson that bears repeating: “word of mouth” (i.e., interpersonal communication) is a much stronger (and often faster) medium than electronic broadcast media. Work with the LWU and, more recently, village chiefs, has borne this out.

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In the end, most of the partners have acknowledged that the activities and materials have benefited from trial and error, and a willingness to refine things that were not deemed successful. Rather than waiting for the perfect materials to emerge, materials were created, used in practical, real-world environments, and then improved based on listening carefully to feedback from the field and end-users. This approach was used in everything from the development of booklets to distributing materials through certain organizations. The project learned that building consensus from the bottom - (village) level up was helpful. After listening to farmers, for example, it was discovered that fencing and other earlystage prevention messages were disregarded by them. To create subsequent messages, the group listened to the farmers, their families, and village leaders to determine what messages were realistic and feasible.


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C a mbodia

AI-BCC began operations in Cambodia in late 2005, working in close collaboration with the Government of Cambodia, the Ministry of Agriculture, Forestry and Fisheries (MAFF) and the Ministry of Health (MOH); the NGO community; and various UN organizations, including FAO, UNICEF, and WHO. Based on research and with the assistance of two main local NGOs, Centre d’Etude et de Development Agricole Cambodgien (CEDAC )and Centre for Livestock and Agriculture Development (CelAgrid), training, behavior change communication, materials development, and community-based approaches such as community theater were the foci of AI prevention and control activities. 32

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As in Vietnam and Lao PDR, work in Cambodia was launched with a KAP survey and a BCC workshop with all stakeholders. Four posters (on fencing, quarantine, hand washing, and cleaning up feces) and two leaflets (one on safe poultry selling and transport and another on how to build low-cost fencing to contain poultry) were quickly developed.

SuperChicken Saves the Day All of these initial posters incorporated SuperChicken, or SuperMoan, as he was called in Cambodia, a poultry “superhero” who advised people on how to prevent and control AI. SuperChicken, which was initially created in Cambodia, was also adapted and used with much success in neighboring Lao PDR. Two radio and two TV spots were developed, with the television ads starring SuperMoan. Copies of the radio and TV spots were made available to all 108 district offices and to NGOs that agreed to integrate them in their animal health activities. AED’s media partner Media Consulting and Development (MC&D) conducted a brief survey among 11 rural, backyard farmers to determine their impressions of

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SuperMoan. Results showed that 100 percent of the farmers were aware of SuperMoan and regarded him highly. One-hundred percent remembered the message of quarantine and 70 percent remembered the messages related to fencing. For a summary of the experience with SuperMoan, see SuperChicken: Using an Icon in the Fight against Avian Influenza. AED and its media partner MC&D developed strategy plans for advocacy and for branding Super Chicken. When AED subsequently met with Dr. David Nabarro, senior UN systems coordinator for avian and human influenza, he praised the Government of Cambodia and its partners for creating the SuperMoan icon, and requested access to the design so that SuperMoan could be shared with other countries. By late 2006, Dr. Nabarro secured government approval to have Super Chicken serve as the icon for all avian influenza prevention and transmission messages in the region. AED worked with MC&D to develop two additional TV spots featuring the Super Chicken character on reporting outbreaks and quarantine. The TV spots were broadcast during the Khmer New Year period. Overall, messages for all materials developed were identified with the input of all relevant stakeholders. With 25 technical, communication, and practical experts, including village chiefs and village animal health workers from outbreak areas, a one-day discussion was organized by AED, FAO and UNICEF to identify the most important messages government officials would

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communicate to the public in the event of an outbreak. As one of the engines behind the National Coordination Committee for AI-IEC, AED helped to host a two-day workshop in November 2007 to review AI prevention messages and promoted behaviors and determine the content of key AI outbreak messages. AI-BCC also adapted the Lao PDR outbreak materials for Cambodia, including three posters and a farmer’s guide. The project also developed five outbreak posters with Khmer messages.

Building Capacity As with AI-BCC activities in Vietnam and Lao PDR, a focus of the work in Cambodia also involved building the capacity of key actors using well-connected partner organizations. One example was a series of communication training workshops for almost 100 journalists that was organized by UNICEF and AED together with Ministry of Information. Much of the notable capacity building in Cambodia involved AED’s partner, Centre d’Etude et de Development Agricole Cambodgien (CEDAC). One of the first activities by CEDAC led to the training of 287 village promoters who came from 326 villages (covering 90 communes) on AI prevention and control tactics. In turn, these village promoters – model farmers that share AI prevention messages in the village – organized 201 village meetings, reaching 5,000 farmers directly and about 20,000 indirectly. These numbers continued to grow throughout the project as CEDAC and AED reached increasingly more villages.


As part of the work with village promoters, CEDAC helped with a study on low-cost fencing alternatives. A leaflet on how to create low-cost fencing was developed as a result, and was disseminated at the village meetings. CEDAC also published nine articles in the Farmer Magazine, a farmers’ bulletin distributed at subsidized cost. Other leaders who were educated and trained on AI messages in collaboration with CEDAC included commune members and village chiefs. In the end over 1,000 villages were reached with messages on improved chicken raising, reaching over 40,000 farmers and 200,000 of their family members. CEDAC also conducted seven trainings attended by 467 chicken producers at the district-level, 35 trainings attended by 671 chicken producers at the commune-level, and another 36 trainings attended by 281 chicken raisers at the village-level. In collaboration with CEDAC, AED conducted two advocacy forums, one in Takeo province and one in Kompot province, with 58 farmers attending, as well as village promoters, leaders of poultry producer groups, and officers and members of management committees of villagebased farmer associations. Twelve participants provided testimonials of their experience applying AI content to ecological poultry-raising training. CEDAC also conducted six workshops aimed at government officials and farmers regarding new ideas on low-cost fencing solutions based on their fencing research. Another significant partner for the Cambodia project was the Centre for Livestock and Agriculture Development (CelAgrid).

The organization implemented a 16-week Farmer Field School (FFS) program, training 777 farmers in 28 villages on chicken-raising, with an introduction to AI prevention related to both animal and human health. At the FFSs, 25-30 farmers committed to attending 12 biweekly sessions on improving poultry production. After completing the FFSs, model demonstration farms were established in the community to increase awareness and model best practices. In addition to completing the FFSs, CelAgrid created 28 demonstration farms based on the practices learned in the training program. CelAgrid organized a field day in these 28 communities to invite the village chiefs, members of commune councils, village animal health workers, commune health center workers and neighboring village farmers to view the demonstration farms. At the farms, the owners explained the importance of improved poultry management, how to care for and feed hens, and shared knowledge on preventing AI through improved biosecurity activities. Village animal health workers provided information on AI risks and prevention in poultry and humans. CelAgrid also completed AI orientations to introduce appropriate ways to reduce the risk of avian influenza and demonstrate alternative practices to improve production of backyard poultry farmers in Kandal, Takeo, and Pursat provinces. Overall, the village orientation program and farmers’ field schools benefited 1,848 families. Agronomes et Veterinaires sans Frontieres (AVSF) was another key partner in Cambodia, and provided training of trainer (ToT) workshops to district and provincial government staff in five provinces. The focus

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of this training was the epidemiological investigation and diagnosis of AI. AED contributed a communication component to the ToT, a modification that enabled the government to better communicate clearly about AI to their target audiences. The keystone of AED’s capacity building activities in Cambodia was the development and production of a training video on Good ChickenRaising Practices. AI-BCC partnered with the Government of Cambodia, FAO and several local and international NGOs, including AVSF, CEDAC, CelAgrid and Heifer International on the video, which was intended to serve as a tool to reinforce good poultry raising, highlight poultry health issues, and contain clear messages on how to manage the AI epidemic. The video targeted village animal health workers (VAHWs) and NGOs were working with farmers with information presented in four modules: (1) the disease; (2) feeding; (3) fencing; and (4) human-to-human transmission. The video was used to train government district veterinarians, who then were tasked with reaching more than 10,000 village animal health workers with community education. The video was also reproduced in DVD formats to benefit other NGOs and local partners with the intention of conducting community education on AI. In the end, this video was used as a model in several other countries.

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Providing Information in an Entertaining Way with Community Theater Another focus of the work in Cambodia centered on the use of community theater to get AI messages across to a variety of audiences. AED, in collaboration with its partners, the U.N. Food and Agriculture Organization (FAO) and UNICEF, conducted community-based theater, karaoke, and other musical activities in 350 rural villages along the border areas with Thailand and Vietnam, reaching approximately 700,000 viewers who had limited access to radio and television. The community plays featured AI prevention messages, and performers distributed posters, soap with a graphic of SuperMoan on it, leaflets and booklets on prevention, and t-shirts. There also were quiz games, with prizes awarded to those with correct answers about prevention of avian influenza. AI-BCC worked with three community theater groups on the creation of this drama-based nationwide awareness program: the Fine Arts Association (FAA), Sovanna Phum, and Action IEC. Each of the groups covered a different geographical area: one theater group covered the border with Thailand, one covered the border with Vietnam, and one followed the Mekong River. AED and UNICEF also organized avian influenza training for key actors in each theater group.


In the villages where Sovanna Phum performed, 88% of those interviewed recalled messages about not eating dead/sick poultry and using gloves and masks, 37% knew messages about quarantining for 14 days, and 30% knew hand washing messages. In addition, 96% said they knew that AI is spread through touching of sick poultry, while 44% and 11% knew it was spread by uncooked meat and by inhalation, respectively. Observational visits found that 82% of homes visited had bars of soap, and 55% had fenced areas or chicken houses for their poultry. A puppet karaoke video with key avian influenza messages and a humorous traditional karaoke song starring two famous television personalities was developed in conjunction with Resource Development Institute (RDI). The RDI mobile road show program reached up to 1,000 people daily with direct house-to-house communication and AI karaoke songs. There was also a hand washing demonstration, culminating with a gathering of viewers singing AI- and hygiene-themed karaoke songs with the mobile performers. RDI visited over 20 villages and 30,000 households, predominantly concentrated on and around the main poultry transport roads in the province, reaching an estimated 213,000 people. The community theater groups also played a large role in outreach at special events, such as the annual Pchum Ben Festival and Water Festival. In most cases, Sovanna Phum conducted promotional activities during the day and held shows in the evening featuring SuperMoan. Oftentimes, these performances were broadcast on national TV. For the Pchum Ben Festival, the troupe performed at five bus and taxi stations in Phnom Penh, reaching an

estimated 38,250 people as they travelled to their homelands to celebrate. In addition to stickers distributed to the travelers, AED offered a special-edition avian influenza newspaper insert, pocket calendars, and other educational materials. Festival booths offered materials and the opportunity for festival attendees to have their pictures taken with SuperMoan. The superhero character also participated in the Government’s Independence Day celebration by conducting awareness-raising campaigns and joining a parade. Special events and holidays were also used as markers to launch mass media. AI-BCC aired two 60-second TV PSAs focusing on recognizing AI symptoms and sudden death in poultry and reporting of sick or dead birds in the event of an outbreak. These spots were aired over 240 times.

More Social Mobilization In addition to theater performances, AI-BCC forged social mobilization activities with Buddhist monks. AI-related training was provided to three Buddhist monks who spoke about avian influenza during the 17th Dharmayietra Peace Walk in March 2007. AED/USAID sponsored transportation for materials and equipment (with USAID stickers on the trucks) during the walk. Again, in 2008, AI-BCC provided training and IPC materials to Buddhist monks for use during their annual Peace walk across 18 districts in the Takeo province. The monks distributed AI booklets, leaflets, and four-message posters. The monks also gave hand washing demonstrations with

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active participation from the children present. After properly washing their hands, the children received bars of soap with the SuperMoan image printed on them.

trainings, 22 participants were selected to participate in a Master Trainers session so they could lead additional trainings among other animal and health workers.

Targeting the school population, AED advised the Ministry of Education’s School Health Department on the development of AI teaching materials for secondary schools. The Ministry chose AED’s Zandi’s Song as a starting point for developing a Cambodian storybook and teaching materials on AI called Rumduol and Hope, which was produced by UNICEF. The booklet received some media attention, with the Ministry of Education being interviewed on Rumduol and Hope.

The project also used Sovanna Phum to promote AI messages at the U.S. Pacific Airlift Medical Mission in Ou Reang Ov, Kampong Channang province using a live appearance by SuperMoan, and collaborated with FAO on the distribution of materials at the U.S. Navy medical mission in Sihanoukville.

Going beyond working with just animal health workers, the AI-BCC project also collaborated with MEDICAM at the National Institute of Public Health to discuss how NGOs in Cambodia could implement health projects, seek opportunities to strengthen AI messages within health interventions, and identify organizations with an interest in collaborating with the AI-BCC project. The project also worked with the Angkor Hospital for Children (AHFC) based in Siem Reap province to educate and build the capacity of various audiences on interpersonal communication related to AI to enhance dialogue. This included training: 21 medical staff of Angkor Hospital for Children and district personnel from Siem Reap province (this was organized in close collaboration with MOH); 25 animal health workers from FAO, agricultural extension agents from MAFF, and community volunteers from CARE International, Cambodia Red Cross, Ministry of Rural Development, CEDAC, and CelAgrid; and 21 animal health workers, agricultural extension workers, and community organizers from CEDAC and CelAgrid. From these 38

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Follow-up KAP Surveys AED and its research partner, Indochina Research Limited (IRL), conducted a second Knowledge, Attitudes and Practices (KAP) Survey in mid 2007 in a total of six provinces in Cambodia. In collaboration with FAO, the KAP covered six provinces in Cambodia and included 1,454 interviews with backyard farmers in July and August 2007. The KAP II showed that there were continuing gains in awareness and knowledge (99% of the survey participants had heard of AI) and some reported gains in hand washing practices. Some other key behaviors, such as cleaning feces from the yard regularly, declined from the first KAP survey in 2006. However, there was an increase in reported willingness to undertake changes, which is a positive step in the process of behavior change. Final reports of a 2008 KAP Survey and other qualitative research conducted in Cambodia revealed that: • Awareness of AI and related programs was nearly 100%, but knowledge on preventive behavior remained relatively low.


• • •

Preventive actions were not practiced because of finance and space reasons, and because people had not experienced the impact of an AI outbreak. Responses to different preventive measures varied, indicating that campaigns should tailor messages to the immediate concerns of each target audience. Mass media proved effective in generating message recall, but results implied looking beyond media campaigns to more interpersonal, community-led interventions.

To assess the potential of integrating animal and human influenzas (AHI) into other USAID health projects in Cambodia, AI-BCC conducted a simple assessment of current and recently concluded USAID projects to: revisit the health programs, principal partners, and strategies of USAID partners and identify commonalities; identify key areas in the program implementation of the USAID projects where AHI could be strategically integrated; and recommend possible technical assistance to encourage integration. Using a simple questionnaire to interview officers and program staff of 15 USAID partners, AI-BCC identified some avenues for integration of activities and resources of partners and their stakeholders under the existing organizational and political structure. These areas were: strengthening the capacity of health care providers, social mobilization, and strategic communications – including research, messages and materials development, and media. In December 2008, AED conducted a technical assistance meeting with other USAID health projects and contractors such as Reproductive and Child Health Resource Center (RACHA), Reproductive Health Association of Cambodia (RHAC), URC, the A2Z Micronutrient and Child Blindness Project, the USAID ACCESS project, and Population Services International (PSI) to assist them in integrating avian and human influenza in their activities. AED AI partners also attended the meeting, including participation from CEDAC, CelAgrid, Sovanna Phum, CARE International, Cambodia Red Cross and Market Strategy Development. The partners shared their experiences and lessons learned from working with the AI-BCC project.

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Emergency Response Activities With governmental agency assistance, AED developed risk and outbreak communication materials for first responders. SuperMoan was present on May 17, 2007 at the “Handover Ceremony” of USAID personal protective equipment and disinfectants to Cambodia’s Ministry of Agriculture so that first responders would be well equipped in the case of outbreaks. This event, organized by the U.S. Embassy in Phnom Penh, received much media attention. AI-BCC also conducted an AI Emergency Risk Communication Training in November 2008 for 11 FAO trainers and two MAFF trainers. This activity was timely due to its proximity both to the Government of Cambodia’s outbreak simulation exercise, which also took place in November 2008, and to an AI outbreak in December of that year. The training oriented task force members and familiarized them to their roles during an outbreak. Participation included provincial veterinarians, district veterinarians, village chiefs and village animal health workers from Pursat and Kampong Chhnang provinces.

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Indonesia

AED’s work in Indonesia was brief, but set a solid foundation on which future projects could operate. An overall communication strategy and media strategy were put in place, and initial creative products were developed and began field testing.

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Initial Messaging and Media Work During the first quarter of the Indonesia AI-BCC program, multiple stakeholders met to consider different approaches, materials and channels to convey AI prevention and control messages. Drawing upon the collaboration and field work with the FAO/Tufts staff and their Ministry of Agriculture/Animal Health counterparts, AED circulated among stakeholders a message guideline for review by the multiple stakeholders. In addition, AED and its local advertising/public relations partner, Hotline, prepared illustrative creative concepts to review with stakeholders. The result was general agreement that the first phase of AI communications should focus on prevention messages for Sectors 3 and 4 farmers. Specifically, it was decided that initial behavioral messages would target caging and separating of chickens and ducks, followed by messages about vaccination and proper home/farm hygiene. In addition, based on the FAO/Ministry of Agriculture experience in Java, messages included attempts to address the social stigma of having sick or dead birds (e.g., AI is nobody’s fault, but everybody’s responsibility; and “Together, we can overcome the challenge of AI”).

To launch these new ideas, AED chose radio as the initial medium. Three jingles and a series of 10 radio mini-dramas each contained two to three messages, ranging from caging and separating poultry, to safe handling and disposal of sick and dead birds, as well as the importance of reporting sick and dead birds to authorities. At the same time, local radio broadcasters were provided with an AI “Broadcaster’s handbook” designed to interest and enable the broadcaster contribute to add to the AI dialogue. The handbook included fact sheets, suggested talk-show formats and, where available, local contact information for health and veterinary services and support. Broadcasters also received a complete set of messages that could be read as 10-30 second “fillers” on air. Each broadcaster was encouraged to invite local animal and human health personnel to participate in talk shows on selected themes. In preparation for working with the press, AED undertook an analysis of the content of the most-recent three months of print media coverage on AI (nearly 200 articles in 24 publications). The major findings included that no print media provided any information on how to prevent AI in animals or humans; no scientific information on animal or human risks was included in the

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coverage; and few articles offered analysis and commentary on the evolving AI situation. UNICEF later invited AED to collaborate in the planning and implementation of an initial journalist training and field visits. AED had identified a “positive deviance” instance in a community involving a group of 14 farmers who had adopted key prevention behaviors in rearing poultry (caging, separating, vaccinating, maintaining clean environments and using protective equipment). This group of farms was free of AI despite being located in a district with a high number of reports of AI. AED escorted journalists to the site, leading to published articles on the community.

Research Findings AED worked with the international research firm, Synovate, to begin building a foundation for monitoring and evaluation activities and to help pre-test materials in preparation for a national communication launch slated for June 2006, which was ultimately cancelled. Pretesting of products and messages, however, provided some interesting insights: namely that respondents resisted accepting most prevention practices unless they received “official” confirmation that there was AI in their local area. Although they accepted that AI was present in Indonesia, and acknowledged unexplained poultry deaths in their communities, there was a belief that there was no AI in their area until authorities conducted official tests. Respondents also indicated a low level of understanding of AI in general, and an unwillingness to undertake preventive behaviors that were difficult and offered

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little guarantee of success. Although the simplicity of the messaging was welcomed, most respondents stated a need to have a much greater understanding of avian influenza and how it is transmitted before they would act on prevention advice. As stated by the research team in the summary report: “It was observed that a low degree of self relevance and distance exists with respect to AI. Most [respondents] exhibit a mind set of denial.”

End of AI-BCC Operations in Indonesia By July 2006, less than a year after operations began in Indonesia, AED was advised that USAID/Jakarta had made a new bilateral award for avian influenza to Development Alternatives Inc. (DAI) and requested that AED turn its attention toward closing out a list of pending activities. One of these activities was the purchase of radio airtime in North Sumatra following an outbreak, with four prevention-oriented radio jingles accompanied by live announcements to be read by broadcasters from a handbook prepared by AED. In light of the low level of general public awareness and understanding of AI, USAID requested AED to produce a comprehensive video instructional piece, both for mass media broadcast and for use in a modularized form as part of community-based education. The modular form allowed for individual segments to be used as brief television PSAs. The 30-minute video and support materials, which featured a physician as a narrator, were


developed by AED and Ogilvy/PR, and all materials was transitioned to DAI/JHU (CBAIC), including four TV spots, three sets of posters and leaflets, and a booklet. The Indonesian video ended up being adapted by the AI-BCC project in Lao PDR and Pakistan for use in training and mass media. Another activity that AED participated in after operations officially ceased was the design and implementation of a baseline survey for a tripartite AI program between the governments of Singapore, Indonesia and the U.S. AED completed the KAP survey and provided topline reports and a detailed analysis plan in response to the results.

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ke y insights from the AI-BCC e xperience

The experience of almost four years in Southeast Asia has yielded several key learnings that have implications for future work on outbreak prevention and control. Time and again, it was shown that communication can play a critical and positive role in outbreak prevention and control, but cannot achieve behavior change if there are other systemic factors which constrain this behavior (e.g., the absence of an effective compensation policy and practice for culling, or the lack of a nationallevel entity and resources to provide guidance and buy-in to activities).

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Communication needs to work closely with the other aspects of a country’s AI program to determine how it can be used to address issues like delay in reporting of poultry outbreaks by farmers, what to do if an AI outbreak occurs in specific areas, delay in human cases presenting at health facilities, and communication issues to enable effective outbreak response or case management by animal and human health workers. Advocacy is also essential, particularly for government officials to set in place guidelines or policies for more effective outbreak response or case management. Although TV and radio are useful in many cases, face-to-face channels are even more important to respond to questions and address misconceptions on AHI. Developing and nurturing a network of village-based workers and volunteers who can incorporate AHI in their regular activities is crucial to the sustainability of AHI communication. Collaboration with mass organizations and NGOs with extensive networks at local levels and good relationships with government were key in effectively developing the capacity of field workers or volunteers for AI communication and reaching a large number of the population

within a short time frame, as was shown in Vietnam. Participatory training and simple modules are very effective in catching attention and improving learning gains. Local trainers can skillfully learn and use these approaches, but need time to hone skills through on-thejob coaching. One challenge in many of the AI-BCC countries was the feeling that they were “playing catch-up� from the beginning. Unlike many communication or behavior change programs, they did not have the luxury of testing materials extensively before rolling them out. Due to the outbreak situation, messages and materials were developed and disseminated quickly, particularly in the beginning. Partners had to rapidly disseminate information to people who needed it. Adding another wrinkle was the overall lack of literacy and low education levels among one of the main target audiences, backyard poultry farmers. Although low-literacy materials were developed, it was nevertheless challenging to convey complex information related to proper disinfection, personal protective equipment or disease transmission through these materials. Even with higher-literate audiences, comprehension of new concepts related to AI prevention

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and containment was difficult, and often required reinforcement with training, orientation, or other methods of interpersonal communication. All of these approaches, unfortunately, require a high level of resources, human and otherwise.

Steps toward the Future In most of the AI-BCC countries, although farmers and supply chain actors considered avian influenza to be a serious disease, they also believed that infections were not likely to occur among their poultry or in themselves or their families. Even when outbreaks occurred in the same district, farmers were not necessarily worried enough to take concrete actions. This low personal risk perception made it difficult to use AI as a persuasive argument to promote biosecurity practices, especially because most of these entail significant financial or other costs. It has become increasingly important, as a result, to study other entry points which would be more effective behavior change “drivers” for AI prevention and control. Work in identifying these points has continued beyond the AI-BCC project and the AI.COMM project, also implemented by AED. As part of USAID/RDM/A’s Greater Mekong Region Project, AED is continuing its work in the region in avian influenza and transferring many of these approaches to malaria, dengue, and other emerging infectious diseases. Building on the network of donors, international NGOs, local NGOs, and the private sector, AED has helped nurture an informal but sturdy structure that leverages resources and forms a collective unit to work toward containment and prevention of emerging infectious diseases.

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Photography Eleanora de Guzman/AED; Berengere de Negri/AED; Cecile Lantican/AED; and Anton Schneider/AED This publication was prepared by AI-BCC, managed by AED, and funded by USAID under contract number GHS-I-00-03-00036. It does not necessarily represent the views of USAID or the U.S. Government. www.avianflu.aed.org 2010


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