Baseline KAP Study

CARE INTERNATIONAL IN VIETNAM
AVIAN INFLUENZA LOCAL RISK REDUCTION PROJECT
BASELINE KAP STUDY
August 2006
Disclaimer: The views expressed herein are those of CARE Viet Nam and do not
necessarily reflect the official position of the Australian Government, the
Australian Agency for International Development (AusAID) or any other Party.
Table of Contents
CARE INTERNATIONAL IN vIETNAM.................................................................0
Disclaimer: The views expressed herein are those of CARE Viet Nam and do
not necessarily reflect the official position of the Australian Government, the
Australian Agency for International Development (AusAID) or any other
Party.Table of Contents....................................................................................0
Table of Contents .............................................................................................1
Introduction.......................................................................................................2
Avian influenza in Vietnam .............................................................................2
CARE’s STOP AI program .............................................................................2
Aim..................................................................................................................3
Methods ............................................................................................................3
1. Study population.........................................................................................3
2. Data collection ............................................................................................4
3. Statistical analysis ......................................................................................4
Results..............................................................................................................4
1. Part 1: General information ........................................................................4
Attitudes towards AI.........................................................................................5
2.1. Part 2A: Knowledge of AI transmission and symptoms in poultry ..........6
21.1.1 Question 10: Transmission routes among poultry..........................6
2.1.2 Question 11: Symptoms of AI in chickens .........................................7
2.1.3 Question 12: Symptoms of AI in ducks...............................................7
2.2 Part 2B: Knowledge of AI transmission and symptoms in humans .........7
2.2.1 Question 13: Transmission of AI in humans......................................7
2.2.2 Question 14: Symptoms of AI in humans...........................................8
3. Part 3: Knowledge of AI practices ..............................................................8
3. Part 3: Knowledge of AI practices ..............................................................9
3.1 Question 14: Prevention methods against AI for family ......................9
3.2 Question 15: Protection methods for AI when slaughtering poultry ..9
3.3 Question 16: Protection methods for AI when cooking poultry ........10
3.4 Question 17: Prevention methods against AI for poultry ..................11
3.5 Question 18: What do you do when you suspect AI in your poultry?
..........................................................................................................................11
3.6 Question 19 and 20: Reporting suspect AI .........................................12
3.7 Question 21: Vaccination of poultry......................................................13
4. Part 4: Direct Observation ........................................................................13
Conclusion......................................................................................................14
Annexes..........................................................................................................16
Annex1. Study Protocol for KAP ..................................................................17
Methods ...............................................................................................................17
Study population.................................................................................................17
Data collection ....................................................................................................17
Statistical analysis..............................................................................................18
Timeline ...............................................................................................................18
Annex 2. KAP Tools .....................................................................................20
1
Introduction
Avian influenza in Vietnam
The H5N1 avian influenza virus (AI) is a particularly virulent poultry disease that
has caused billions of dollars of livestock losses in Asia and is now considered
endemic in Vietnam. It is a zoonotic disease that has already caused deaths in
humans, and threatens to mutate into a human infection with potential
consequences larger than the scale of the 1918 influenza pandemic.
Direct losses from the 2003-2004 outbreaks in Vietnam resulted in 44 million

birds either dying or being destroyed. Vietnam has been “ground zero” for
human cases of avian influenza, reporting the highest number of human AI
infections in any country by a substantial margin until just recently. Vietnam has
experienced 93 cases resulting in 42 deaths as of 11 August 2006. Almost all the
human cases to date have had presumed contact with infected birds. The most
important exposures have been from handling sick or dead birds, although
limited human-to-human transmission through close contact with infected
relatives has recently been confirmed in Indonesia.
The nature of the threat to humans persists so long as birds and other animals
continue to be infected with highly pathogenic AI. The effective management and
control of AI is critical not only for the livelihoods and food security of the rural
poor in Vietnam, but because of the potential of the virus to mutate and become
capable of human-to-human transmission.
CARE’s STOP AI program

CARE in Vietnam has been working with communities since 2004 to address the
major gap in AI awareness, prevention, and outreach support and, based on
considerable experience, has developed a successful AI model to be replicated
and expanded to the most vulnerable communities. CARE couples Behaviour
Change Communication (BCC) with creative new approaches to develop the IEC
messaging through both formal and informal community structures. CARE’s
model encourages partnership and a multi-sectoral approach to community
mobilization for understanding of and response to AI.
CARE initially conducted a Knowledge, Attitude and Practice survey in

December 2004- January 2005 in Long An, An Giang, Binh Dinh and Son La
provinces to obtain an in-depth understanding of mainly small-scale rural
farmers’ knowledge, attitude and practices (KAP) on poultry rearing in order to
inform health education in regards to AI. Using the results from this report, CARE
developed the STOP-AI program (Strengthening Training, Outreach and
Prevention services for the ongoing Avian Influenza response), which was
funded by NZAID and implemented in four districts in Binh Dinh and Long An
Provinces, between May 2005 and February 2006. An independent evaluation of
the STOP-AI project was favourable, and concluded that the project effectively
contributed to raising the awareness of Avian Influenza for small-scale poultry
producers in Binh Dinh and Long An provinces.
Further funding from McDonalds in early 2006 allowed CARE to expand the
program to four districts in Hai Phong, Bac Ninh, Dong Thap and An Giang
provinces (STOP-AI2). This project has been conducted in 64 communes and is
2
due for completion in September 2006. In June 2006 AusAID also provided
funding to expand STOP-AI2 in four different districts in these same four
provinces (referred to as Local Risk Reduction project (LRR) from now on). This
phase will reach an additional 32 communes. One of the additional components
of the STOP-AI2 program is to conduct a knowledge, attitude and practices
(KAP) survey of households in all four provinces at the beginning and towards
the end of the project cycle in order to evaluate the effectiveness of the program.
Aim
To conduct a baseline knowledge, attitude and practices (KAP) survey of
households in Hai Phong, Dong Thap, Bac Ninh and An Giang before
conducting CARE’s Local Risk Reduction project in these provinces.
Methods
The study design is a cross-sectional survey, administered at the beginning of
the project cycle. The same survey will be administered towards the end of the
project cycle and compared to the results of this baseline. This report includes
the baseline survey results only.
1. Study population
The baseline study was conducted in one commune in each of the four
provinces of the LRR project – Hai Phong, Bac Ninh, An Giang and Dong Thap.
The participating communes were randomly selected from the eight communes
in each province that will be involved in the LRR project.
The total number of households to be interviewed in each commune was 100.

For each of the selected communes, information was gathered about the
structure of the commune and this was used to determine the selection method
of households for that commune.
In Bach Ninh, the selected commune was Tam Giang, which consists of five
villages. Each of these villages had a different number of hamlets (streets), and
these were divided to allow for twenty interviews from each village as follows:
1. Hamlet 1 – 5 interviews in all 4 sub villages
In Hai Phong, the selected commune was Lai Xuan, which consists of four
villages. Each of these villages has twelve hamlets and five of these were
randomly selected. Five interviews were conducted in each hamlet to give the
total of 100 interviews (5×5×4). For these two provinces, the first house in each
hamlet was selected, followed by every fifth house until all interviews were
completed.
In Dong Thap, the selected commune was My Ngai, which consists of three
villages. As there were five interviewers to conduct twenty interviews each, forty
interviews were conducted in the two large villages and twenty in the smaller
village. As there are 740 households in the village, every seventh house was
3
selected for interview. In An Giang, the selected commune was My Hoa Hung,
which consists of 106 groups of houses. One house per group was interviewed.
2. Data collection
Data was collected through a knowledge, attitude and practice (KAP)
questionnaire. The questionnaire was developed during a CARE AI team
meeting whereby the team brainstormed all the AI prevention messages that
form the basis of the LRR project, under the three headings of knowledge,
attitude and practice. From these the most important twelve were chosen for
inclusion in the questionnaire. The questions were then based on previous KAP
studies conducted in Vietnam by CARE and the Academy of Educational
Development (AED), with new questions developed where necessary. The
questions were either of yes/no format or open, with the interviewers selecting
responses from a list provided in the questionnaire and recording those not on
the list as “other”. These “other” responses were then recoded. The
questionnaire is attached in Appendix 1.
Five interviewers were recruited in each province from the Provincial Women’s
Union (PWU) and the District Women’s Union (DWU). A CARE staff member
conducted training in each province which included working through each
question and receiving feedback from the interviewers. The interviewers then
took turns interviewing each other for practice. Each interviewer was responsible
for conducting 20 interviews. The head of the household or an adult member
was interviewed. The interviewer also made some direct observations as
indicated in the questionnaire. Once all interviews were completed they were
sent to the team leader in each province for checking and any missing data was
re-collected. The forms were then sent to CARE.
3. Statistical analysis
All data was entered into an Access database designed for this survey. The data
was then exported and analysed in Stata where basic frequencies were
calculated. Tables and graphs were then developed in Excel.
Results
1. Part 1: General information
• 67.2% (n=267) of respondents were female and most were aged between
30 and 59 (Figure 1). Male respondents were mostly aged over 40.
• Most respondents (74.3%) were of middle income, this proportion ranged
from 57% in Bac Ninh to 88% in Hai Phong. Bac Ninh had the highest
proportion of rich respondents, at 38% and Dong Thap had the highest
proportion of poor and very poor respondents, at 12% (Figure 2).
4
Figure 1: Age and sex distribution of Figure 2: Economic status of participants by
participants province
50 Male Female 100

80
40
Percent
60
Percent
30
40
20 20
10 0
0 An Giang Bac Ninh Don Hai
10-19 20-29 30-39 40-49 50-59 60+ Thap Phong
Age group Poor Middle income Rich Unspecified
• 71.5% (n=276) of participants reported raising poultry at their home. This

ranged from 37.6% in An Giang to 92.9% in Bac Ninh.
• For those respondents that reported raising poultry, the numbers that they
raise are shown in Table 1. The most common size of poultry farm was
10-99.
Table 1: Number of poultry raised by participants

No. of poultry Frequency Percent
Less than 10 62 22.5
10-99 166 60.1
100-999 42 15.2
More than 1,000 6 2.2
Total 276 100.0
• One respondent (0.3%) reported having a previous human case of AI in

their household; 7.1% (n=27) reported having a previous case of AI in
their poultry. 24 of these 27 reported still raising poultry at their home.
• 96.5% of participants (n=386) had heard of AI. The 14 people that hadn’t
were all from Hai Phong province. These 14 were excluded from the
analysis making total sample size 386.
Attitudes towards AI
• 59.6% (n=229) of participants reported that they thought AI would occur
again in Vietnam, 22.7% (n=87) reported they didn’t think AI would occur
again and 17.7% (n=68) answered “Don’t know”.
• 77.1% (n=296) reported that they thought it was possible to prevent AI
from spreading; 7.0% (n=27) thought it was not possible and 15.9%
(n=61) answered “Don’t know”.
• Seven participants (1.8%) reported having attended an AI community
event sponsored by CARE, 81.5% reported they hadn’t and 16.7% (n=64)
answered “Don’t know”.
• Of those that reported raising poultry (n=276), half (48.2%) believed that it
is very unlikely that their poultry will be infected with AI (Figure 3). A tenth
(9.8%) reported thinking it is very likely that their poultry will be infected
with AI.
5
Figure 3: How likely do you think it is that your poultry
will be infected with AI?
(1=Very unlikely to 7=Very likely)
48.2
50
40
Percent 30
20 13.8
10.9 10.5 9.8
10 3.6 1.8
0
1 2 3 4 5 6 7
Ranking
2.1. Part 2A: Knowledge of AI transmission and symptoms in poultry
21.1.1 Question 10: Transmission routes among poultry

• 18.3% (n=73) participants did not know how AI was spread amongst
poultry. Figure 4 shows the responses for 313 participants that did
respond to this question. Respondents could provide more than one
transmission route.
• “Other” responses included: airborne transmission (n=11), from the H5N1
virus (n=9), weather or environment (n=6), wild birds (n=8), transport
(n=3), large scale farms (n=1), small scale farms (n=1) and storing
chickens and geese together (n=1).
• Half (49.2%) of respondents reported one transmission route, 28.4%
reported two, 15.7% reported three and 6.7% reported more than three
transmission routes.
Figure 4: Transmission routes of AI in poultry (n=313)
Contact with contamination clothing or footware 2.9
Contact with contaminated farming equipment 9.3
Other 12.8
Free-ranging chickens or ducks 18.5
Contact with infected manure 25.9
Purchase of unidentified poultry 27.5
Contact with contaminated environment/feed 34.5
Contact with infected/sick birds 51.8
0 10 20 30 40 50 60
Percent
6
2.1.2 Question 11: Symptoms of AI in chickens
• 67.9% (n=262) reported that you can always see when chickens are
infected with AI. This proportion was higher in those reported raising
poultry compared with those that did not report raising poultry (74.2%
compared with 53.2% respectively).
• Figure 5 shows the most commonly reported symptoms of AI from the 262
participants that reported that you can always see when chickens are
infected with AI.
• Less commonly reported symptoms (not on Figure 5) included fast
breathing (n=15), excessive thirst (n=13), fever (n=12), stop laying eggs
(n=11) and bleeding (n=10).
• “Other” responses were varied and have been grouped into the following
categories: symptoms in the leg (n=15), symptoms in the neck/head
(n=12), drooping wings (n=5), cough (n=4).
• 21.3% of participants reported one symptom, 34.1% report two, 24.3%
reported three and 20.3% reported more than three symptoms. Two
people reported nine different symptoms.
Figure 5: Reported symptoms of AI in chickens (n=262)
Discoloured manure 7.6

Diarrhoea 9.9
Swollen and puffy looking eyes 10.3
Sudden death in large number 11.1
Other 15.6
Sudden onset of illness or death 17.9
Dark/red/blue combs and wattles 21.0
Loss of appetite 31.3
Discharge from eyes and nose 31.7
Ruffled feathers 32.1
Sleepiness 47.7
0 10 20 30 40 50 60
Percent
7
2.1.3 Question 12: Symptoms of AI in ducks
• 44.5% (n=172) reported correctly that you cannot always see when ducks
are infected with AI. This proportion was higher in those reporting not
raising poultry at home compared with those that did report raising poultry
(54.1% compared with 41.5% respectively).
• Due to a sequencing error in the questionnaire, only those participants
that answered “yes” to Question 12a (Can you always see the symptoms
of AI in ducks?) were then asked to list the symptoms of AI in ducks
(n=109). Figure 6 shows the most common responses.
• Less commonly reported symptoms (not on Figure 5) included diarrhoea
(n=9), bleeding (n=9), fever (n=7), excessive thirst (n=6) and fast
breathing (n=4).
Figure 6: Reported symptoms of AI in ducks (n=109)
Swollen and puffy looking eyes 11.9
Dark/red/blue combs and wattles 12.8

Sudden death in large number 13.8
Stop laying eggs 17.4
Discharge from eyes and nose 21.1
Other 22.0
Sudden onset of illness or death 24.8
Ruffled feathers 25.7
Loss of appetite 33.9

Sleepiness 38.5
0 10 20 30 40 50 60
Percent
• “Other” responses included drooping wings (n=4), discoloured manure

(n=3), symptoms in the leg (n=3), symptoms in the neck/head (n=3) and
cough (n=2).
• 15.7% of participants reported one symptom, 35.2% report two, 31.5%
reported three and 17.6% reported more than three symptoms.
2.2 Part 2B: Knowledge of AI transmission and symptoms in humans
2.2.1 Question 13: Transmission of AI in humans

• 87.0% (n=334) of participants correctly responded that humans can be
infected with AI; 6.0% (n=23) reported they could not be infected and
7.0% (n=27) reported “Don’t know”.
• Of the 334 participants, 16 (4.8%) responded “Don’t know” to the question
about transmission routes of AI in humans. The responses from the
remaining 318 participants are shown in Figure 7.
• “Other” responses included no personal protection (n=5), killing poultry
(n=4), lack of hygiene (n=2), pollution (n=2) and airborne route (n=2).
7
• 44.2% of participants reported one transmission route, 33.4% reported
two, 14.8% reported three and 7.6% reported more than three
transmission routes.
Figure 7: Transmission routes of AI in humans (n=318)
Other 6.9
Contact with contaminated farm equipment 7.9
Contact with humans infected with AI 11.9
Contact with infected poultry feces 16.0
Eating raw poultry product 28.9
Eating undercooked infected poultry/eggs 36.2
Contact with infected poultry 75.5
0 10 20 30 40 50 60 70 80 90 100
Percent
2.2.2 Question 14: Symptoms of AI in humans

• Of the 334 participants that responded that humans could be infected with
AI, 61 (18.3%) responded “Don’t know” to the question about symptoms
of AI in humans. Responses from the remaining participants (n=273) are
shown in Figure 8.
• “Other” responses included headache (n=6), runny nose (n=5), loss of
appetite (n=3) and vomiting (n=3).
• 38.6% of participants reported one symptom, 35.7% reported two, 15.1%
reported three and 8.4% reported more than three symptoms.
Figure 8: Symptoms of AI in humans (n=273)
Eye infection 4.0
Tiredness 4.8
Sore throat 5.1
Diarrhoea 11.7
Other 14.7
Muscle Ache 18.3
Difficult/fast breathing 49.1
Cough 49.8
Fever 85.7
0 10 20 30 40 50 60 70 80 90 100
8 Percent
3. Part 3: Knowledge of AI practices
3.1 Question 14: Prevention methods against AI for family

• The purpose of this question was to determine what participants are
currently doing to prevent AI in humans. However, a lot of responses were
focused on poultry prevention methods. These have been included in the
“other” section, as they did not correspond to the prepared list of
responses.
• 8.0% of participants (n=31) responded “Don’t know” to the question about
prevention methods currently being conducted by the family. Figure 8
shows the responses from the remaining 355 participants.
Figure 9: Prevention methods currently being conducting by the family

(n=355)
Do / Done Nothing 5.4

Change and wash clothes after taking care of poultry 9.3
Do not let children handle poultry eggs 10.1
Wash hand with soap before handling/ preparing food 14.6
Wash hand with soap before/after contact with poultry 18.3
Don't eat birds that fall dead; bury or burn them instead 20.8
Do not eat duck or geese blood pudding 29.3
Other 36.3
Do not eat under cooked poultry and egg 37.7
0 5 10 15 20 25 30 35 40 45 50
Percent
• “Other” responses included cleaning the farm/equipment (n=51), using

PPE (n=30), spraying chemicals (n=23), not eating sick or dead poultry
(n=16), isolating poultry rearing from the home (n=11), using lime (n=5),
vaccination (n=7) and medicine (n=5).
• 54.3% of participants reported one prevention method only, 24.7%
reported two, 9.7% reported three and 10.9% reported more than three
prevention methods.
• An additional question asked if there were any other prevention methods
that the family was planning to adopt to prevent AI. This question was not
well understood as many participants repeated those methods they are
currently doing (eg repeating answers from Question 14a). Only a small
proportion mentioned different prevention methods, therefore this
question was not included in this report.
3.2 Question 15: Protection methods for AI when slaughtering poultry

• 9.8% of participants (n=38) responded “Don’t know” to the question on
protection methods against AI when slaughtering poultry. The responses
from the remaining 348 participants are shown in Figure 10.
• “Other” responses included using boiling water (n=5), slaughtering poultry
from known sources (n=5), using other PPE (n=5) and using salt (n=3).
9
• 29.2% of participants reported one protection method for AI when
slaughtering poultry, 44.8% reported two, 19.1% reported three and 6.7%
reported more than three protection methods.
Figure 10: Protection methods against AI when slaughtering poultry (n=348)
Other 8.9
Do it away from the

9.5
house
Wash hands afterwards 21.6
Clean area afterwards 26.1
Wear gloves 60.1
Wear a mask 76.4
0 10 20 30 40 50 60 70 80 90 100
Percent
3.3 Question 16: Protection methods for AI when cooking poultry

• 8.5% of participants (n=33) responded “Don’t know” to questions about
protection methods against AI when cooking poultry. The responses from
the remaining 353 participants are shown in Figure 10.
• “Other” responses included wearing a face mask (n=14), not eating
poultry (n=5), embalming poultry with ginger or other spices (n=6),
keeping the pot covered while cooking (n=2), not eating the viscera (n=2)
and not eating the water the poultry is cooked in (n=2).
• 48.4% of participants reported one protection method for AI when cooking
poultry, 29.5% reported two, 13.9% reported three and 7.7% reported
more than three protection methods.
Figure 11: Protection methods against AI when cooking poultry (n=353)
Keep kitchen clean 5.7
Other 8.5
Wash hands before/after preparing food 10.8
Use a separate chopping board 12.7
Do not eat poultry with suspected AI 22.7
Do not drink ducks blood 34.3
Cook the poultry completely 86.7
0 10 20 30 40 50 60 70 80 90 100
Percent
10
3.4 Question 17: Prevention methods against AI for poultry
• The remainder of the questions were asked to those households that
reported raising poultry in their home (n=276).
• When asking about prevention methods against AI in poultry, five (1.8%)
responded “Don’t know”. The responses from the remaining 271
participants is shown in Figure 11.
• There were 120 “Other” responses to this question, and when analysed
some of these were more commonly reported that those in the set list.
These were added to Figure 11. Less common responses to this question
included controlling entries to the farm (n=8), feeding garlic to poultry
(n=8), keeping all new poultry separate (n=5) and changing clothes after
being at another farm (n=4).
• 53.0% of participants reported one prevention method, 23.7% reported
two, 16.2% reported three and 5.3% reported more than three prevention
methods.
• Similar to question 14, we also asked if there were any other prevention
methods the family was planning to adopt for prevention of AI in poultry.
Again this question was not well understood as many participants
repeated those methods they were currently doing (eg repeating answers
from Question 17a). Only a small proportion mentioned different
prevention methods and so these results have not been presented.
Figure 12: Prevention methods currently being conducting for poultry (n=271)
Do / Done Nothing 4.4
Washs hands before/after contact with poultry 4.4
Separate the chickens from the ducks 5.2
Use lime 6.3
Spray disinfectant 6.6
Keep poultry in a protected environment 14.4
Keep poultry in good condition 16.6
Use medicine 17.0
Clean cages/farm 19.2
Vaccinate poultry 76.4
0 10 20 30 40 50 60 70 80 90 100
Percent
3.5 Question 18: What do you do when you suspect AI in your poultry?
• 2.9% of participants (n=8) responded “Don’t know” in regards to what to
do when suspecting AI in poultry. The remaining 268 responses are
shown in Figure 13.
• “Other” responses included kill them and throw them into the river (n=5),
vaccinate them (n=3), eat them (n=2), monitor them (n=2) and do nothing
(n=1).
• 59.8% of participants reported one action, 28.4% reported two, 9.2%
reported three and 1.5% reported more than three actions.
11
Figure 13: What to do when you suspect AI in your poultry (n=268)
Give them medicine 9.7
Keep them separate 11.6
Kill them and burn them 15.7
Follow instructions from

26.1
Official
Report to an authority 38.8
Kill them and/or bury

41.4
them
0 10 20 30 40 50 60
Percent
3.6 Question 19 and 20: Reporting suspect AI

• 78.0% of participants (n=215) responded that they would report
suspected cases of AI in their poultry. The remaining 58 (22.0%)
responded that they would not report it.
• Of those that would report suspect cases, the person they would report to
is shown in Figure 14.The two “other” are to a “neighbour”, and “not sure
who to report to”. Local authorities included village/hamlet leaders (n=64),
commune leaders (n=7), village officers (n=4), commune committee
(n=1), head of police (n=1) and farmer association member (n=1).
• Reasons for not reporting include: have small number of poultry (n=39),
would burn/bury instead (n=8), do not know who to inform (n=3), no vets
in village (n=2) and will lose money (n=1).
Figure 14: Who to report suspect cases of AI in poultry to (n=215)
Others 0.9
Mass organisation 2.8
Commune/village health
4.7
worker
Local Authority 48.4
Animal Health Worker 69.8
0 20 40 60 80 100
12 Percent
3.7 Question 21: Vaccination of poultry
• 67.7% of participants (n=187) reported that they had had their poultry
vaccinated.
• Of the 28.2% of participants (n=78) that reported that their poultry had not
been vaccination, reasons this included:
- Poultry too young for vaccination (n=15)
- Only have a small number of poultry (n=11)
- Vaccinator did not come (n=7)
- Not home when vaccinators came (n=5)
- Did not know when vaccinators were coming (n=5)
- Poultry are healthy (n=5)
- Could not catch them (n=4)
- Gave medicine instead (n=4)
- Can not eat poultry for a long time after vaccination (n=4)
- Don’t know (n=2).
4. Part 4: Direct Observation

• Table 2 shows the results for the direct observations. Most participants
(78.6%) had soap for hand washing and nearly two-thirds (60.3%) of
those with chickens kept them in a closed-off area. This proportion was
less for those with ducks, at 34.6%.
• Interestingly in 78.3% of those households with poultry, the poultry were
let free in the backyard and were able to go outside. This contradicts the
result referring to poultry being kept in closed-off areas and reasons for
this are unclear.
• A large proportion of households with poultry (77.0%) allowed their poultry
to have contact with other animals. This again contradicts the result
referring to poultry being kept in closed-off areas and again, reasons for
this are unclear.
• Two-thirds of households with poultry (62.4%) had feces lying on the
ground outside the area where the poultry were kept, which again
suggests poultry were not being kept in closed-off areas.
• Not many households (12.1%) with poultry kept a manure composting pit.
Table 2: Results for Direct Observations

Percent
Direct observation Yes No Total yes
Can you show me if you have soap for
hand washing? 291 79 370 78.6
Are all chickens kept in a closed building
or fenced-in area? 158 104 262 60.3
Are all ducks kept in a closed building or
fence-in area? 18 34 52 34.6
If poultry are let free in the backyard, can
they go outside? 188 52 240 78.3
Are there other animals which can come in
contact with the poultry? 187 56 243 77.0
Is there poultry faeces lying on the ground
outside the area where the poultry is kept? 156 94 250 62.4
Is there a poultry manure composting pit? 29 210 239 12.1
13
Conclusion
Most of the households involved in the study reported raising poultry and most of
the participants had heard of AI. However, the fourteen respondents in Hai
Phong province that had not heard of AI is worrying. Two thirds of participants
think that AI will occur again in Vietnam, but reassuringly most (77%) believe that
it is possible to prevent AI from spreading. Half of the respondents that raise
poultry believe that their poultry is unlikely to be infected with AI.
With regards to knowledge about AI, most participants were able to report at
least one transmission route and symptom of AI in poultry and one transmission
route and symptom of AI in humans. The most commonly reported transmission
route in poultry was contact with infected birds, and the most commonly report
symptoms were sleepiness, ruffled feathers and discharge from eyes and nose.
In humans, the most common transmission route reported was contact with
infected poultry and eating undercooked infected poultry/eggs and the most
common symptoms reported were fever, cough and difficulty/fast breathing.
Nearly all participants reported one prevention method that their family is
currently conducting to prevent AI. The most common were not eating
undercooked poultry/eggs and not eating blood puddings. Washing hands was
not commonly reported. The most common protection methods reported when
slaughtering chickens was wearing a mask and gloves and the most common
prevention method when cooking was to cook poultry completely.
All but five participants that raised poultry reported at least one prevention
method they are currently doing to protect their poultry from AI. Vaccination was
by far the most commonly reported prevention method, all other prevention
methods were reported by less that a fifth of participants. Most participants were
also able to report what they would do if they suspected their poultry had AI.
Killing and/or burying them was the most common response, followed by
reporting to an authority. Two-thirds of participants that raise poultry reported
having their poultry vaccinated. There was a variety of reasons given for not
having poultry vaccinated.
One fifth of participants that raise poultry reported they would not report
suspected cases of AI in their poultry. Reasons for this included only having a
small number of poultry, burning or burying instead and not knowing who to
inform or not having a vet in their village to inform. Only one participant reported
compensation as a reason for not reporting. For the remainder that said they
would report, animal health workers and local authorities were the person to
report to.
Most households were able to show the interviewer that they had soap for hand
washing. The results from the remainder of the direct observations were
somewhat contradictory. Although two-thirds of poultry rearing households were
observed as keeping their chickens in a closed-off area, higher proportions were
observed having poultry let free in the backyard that were able to go outside,
poultry having contact with other animals and having feces lying on the ground
outside the area where the poultry were kept. Reasons for this are unclear. Few
households were observed having manure composting pits.
14
In conclusion, this study shows that most households in these communes have
some knowledge about avian influenza and are conducting some prevention
methods. However, there are gaps in knowledge and prevention methods and
these should be addressed by the LRR project.
15
Annexes
16
Annex1. Study Protocol for KAP
Methods
The study design is a cross-sectional survey, administered at the beginning of
the project cycle (pre-test), and then repeated at the end of the project cycle
(post-test). Comparisons between the two studies will provide evidence for
increase awareness, knowledge and improved practices in relation to avian
influenza as a result of the STOP-AI (AusAID) project.
Study population
The baseline study will be conducted in each of the four provinces the AusAID
project will be conducted – Hai Phong, Bac Ninh, An Giang and Dong Thap.
All Provinces
1 of 4 districts (RS)
1 of 4 communes (RS)
Figure 1: Study selection process
5 Villages (RS)
5 Hamlets / sub-villages (RS)
4 households (SS)
The study will be conducted in one commune in each of the four provinces. The
study selection process is shown in Figure 1. One district per province and one
commune per district will be randomly selected (RS). In each commune, five
villages will be randomly selected and in each village, five hamlets/sub villages
will be randomly selected. Four households will be interviewed in each and these
households will be selected using systematic sampling (SS), whereby the first
house in each hamlets/sub village will be interviewed, followed by every fifth
house until four interviews are completed. Information on the lay out of each
village will be provided by the commune women’s district, and CARE staff will
undertake the random selection at each level.
Therefore, there will be four interviews per hamlets/sub villages, giving twenty
interviews per village, 100 interviews per commune, with a total sample size of
400 over the four provinces.
Data collection
Data will be collected through a knowledge, attitude and practice (KAP) study.
The questionnaire will be developed based on previous KAP studies conducted
in Vietnam by CARE and AED, in consultation with CARE Vietnam staff. The
17
questionnaire will consist of twelve key questions and four behavioural
observations.
There are two options for administering the questionnaire at the commune level:
1. Women’s Union only
CARE will train three WU members per commune to conduct the interviews.
Training will take approximately two hours. After this the interviewers will be
given four days to conduct their interviews (33 each). These will be handed in
to the District Women’s union at the end of each day, who will check that
each interview form has been filled in correctly. Any that are not, will be
followed up. Forms will then be sent to CARE.
2. University students
As it is university holidays, we could use Public Health students as our
interview trainers and quality control officers. CARE would train these
students in the methodology of the study, and then they would train three WU
members per commune. The students will remain in the commune for the
interview period, to observe the interviewers for consistency, and to conduct
the checking of forms before they are submitted to CARE.
The head of the household or an adult member will be interviewed. The

interviewer will also ask to observe the behaviours as indicated in the
questionnaire. Once the interviews have been completed, the interviewer will
give their forms to the District Women’s Union/University student for checking,
and once these are all completed, they will be returned to CARE office for data
entry and analysis.
The study will be repeated at the end of the project cycle. The same hamlet/sub
villages will be interviewed, although different households will be selected.
Statistical analysis
A database will be designed by CARE staff to facilitate data entry and analysis.
This will be compiled in Excel. Basic frequencies will be reported from the pre-
test, and upon completion of the post-test comparisons between the two studies
will conducted.
Reports for each commune and a comparison across all communes will be
produced and disseminated to the communes. These results can then be used
to assist in the planning of community events.
Timeline
Activity July August October
10-14 17-21 24-28 01-04 07-11 14-18 21-25
Develop methodology
X
and questionnaire
Liaise / organise with
X X
Women’s Union
Conduct KAP in Cao
X
Lanh (Don Thap)
Conduct KAP in An
Giang province (TBA)
Conduct KAP in Yen
X
Phong (Bac Ninh)
18
Conduct KAP in Thuy
X
Nguyen (Hai Phong)
Surveys returned to
X
CARE, follow up
Analysis undertaken X X X
Repeat KAP XXX
19
Annex 2. KAP Tools
20
AVIAN INFLUENZA KAP SURVEY
Interviewer Name:
Date of Interview
Region: Province District Commune Village
Respondent's Name:
Address:
Gender: Male: 1 Female: 2
Economic indicator:
Please circle the level of household economic status based on the following criteria:
Very poor No electricity
Poor Has electricity, no TV, no bicycle
Middle Has electricity, has TV, has motorbike/bicycle
Rich Has electricity, has TV, has motorbike, has refridgerator - at lower standard
Very rich Has electricity, has TV, has motorbike, has refridgerator - at higher standard
Good morning/ afternoon, my name is ............................I am an interviewer for CARE Vietnam.

We are conducting a study on Avian Influenza in Vietnam and would like to interview for our study.
The interview will take approximately 30 minutes. You do not have to participate in the Interview
if it is inconvenient for you. May we talk with you now?
Please be assured that any information you provide will be anonymous and no personal information
collected will appear in any documents or reports based on this survey.
PART 1: GENERAL INFORMATION

1 How old are you?
2 Have you heard of Avian Influenza?
21
2 Have you heard of Avian Influenza?
Yes ……………. 1 If no, prompt with "I'm talking about the

poultry disease that caused many
No ……………. 2 outbreaks in 2004 and 2005", If still say
no then thank them and terminate the
interview
3 Do you raise poultry at your home?

Yes ……………. 1 If yes implement interview with
No ……………. 2 all available questions.
If no skip Questions 4 and 5,
then continue the interview from
Question 6, terminate the
interview at Question 16
PART 1: GENERAL INFORMATION
4 How many of the following poultry do you have?
Chicken ……………
Duck ……………
Other poultry such as geese, turkeys, quails etc. ……………
Total
5 How likely do you think it is that poultry on your farm will be infected with AI?
(rate from 1-7. 1 means very unlikely and 7 means very likely of catching AI)
SHOW SCALE CARD
Very Unlikely>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>Very likely
Your poultry risk 1 ………. 2 ………. 3 ………. 4 ………. 5 ………. 6 ………. 7
6 Have any humans or poultry in your household previously been infected with AI?
Humans Poultry
Yes …………… 1 ……………. 1
No …………… 2 ……………. 2
Don't know …………… 98 ……………. 98
22
7 Do you think that AI will occur again in Viet Nam?
Yes ……………. 1
No ……………. 2
Don't know ……………. 98
8 Do you think that it is possible to prevent AI from spreading?

Yes ……………. 1
No ……………. 2
9 Have you attended any events about Avian Influenza that have been sponsored by CARE?
Yes ……………. 1
No ……………. 2
PART 2A: KNOWLEDGE - AI TRANSMISSION AND SYMPTOMS OF POULTRY
10 In your opinion, how is AI spread among poultry/birds?

DON'T READ OUT ANSWERS. Let respondent answer and circle the appropriate answer below.
If the response is not in the list, please write in Other section
Contact with another infected/sick birds .……… 1

Contact with infected manure .……… 2
Contact with other contaminated environment, feed .……… 3
Contact with infected farming equipment .……… 4
Purchase of unidentified poultry .……… 5
Free-ranging chickens or free-ranging ducks .……… 6
ntact with virius brought in by people, their clothing or footware .……… 7
Other Specify:_____________________________ .……… 8
Don't know .……… 98
11a Can you always see the symptoms of illness in chickens when your chickens are infected with AI ?
ASK EVEN IF THEY HAVE NO CHICKENS
Yes ……………. 1 Go to 11b
No ……………. 2 Go to Q12
Don't know ……………. 98 Go to Q12
23
11b How can you tell?
Sudden onset of illness or death .………….... 1

Sudden death in large number .………….... 2
Sleepiness .………….... 3
Stop laying eggs .………….... 4
Dark/red/blue combs and wattles .………….... 5
Excessive thirst .………….... 6
Swollen and puffy looking eyes .………….... 7
Discharge from eyes and nose .………….... 8
Diarrhea .………….... 9
Fast Breathing .………….... 10
Fever .………….... 11
Loss of appetite .………….... 12
Reffled feathers .………….... 13
Bleeding .………….... 14
Other Specify:_____________________________ ……………. 15
12a Can you always see the symptoms of illness in ducks when they are infected with AI ?
ASK EVEN IF THEY HAVE NO DUCKS
Yes ……………. 1 Go to 12b
No ……………. 2 Go to Q13
PART 2A: KNOWLEDGE - AI TRANSMISSION AND SYMPTOMS OF POULTRY (Cont'd)

12b How can you tell?
Sudden onset of illness or death .…………... 1

Sudden death in large number .…………... 2
Sleepiness .…………... 3
Stop laying eggs .…………... 4
Dark/red/blue combs and wattles .…………... 5
Excessive thirst .…………... 6
Swollen and puffy looking eyes .…………... 7
Discharge from eyes and nose .…………... 8
24 Diarrhea .…………... 9
Swollen and puffy looking eyes .…………... 7
Discharge from eyes and nose .…………... 8
Diarrhea .…………... 9
Fast Breathing .…………... 10
Fever .…………... 11
Loss of appetite .…………... 12
Reffled feathers .…………... 13
Bleeding .…………... 14
Other Specify:_____________________________ ……………. 15
PART 2B: KNOWLEDGE - AI TRANSMISSION AND SYMPTOMS OF HUMANs

13a Can humans get AI?
Yes ……………. 1 Go to 13b,c
No ……………. 2 Go to Q14
13b How can humans catch AI?

Contact with infected poultry .…………... 1

Contact with infected poultry feces .…………... 2
Eating undercooked infected poultry/eggs .…………... 3
Eating raw poultry product (ie. Blood Pudding) .…………... 4
Contact with humans infected with AI .…………... 5
Contact with contaminated farm equipment .…………... 6
Other Specify:_____________________________ .…………... 7
Don't know .…………... 98
13c What are the signs and symptoms of AI among humans?

Difficult/fast breathing .…………... 1

Fever .…………... 2
Cough .…………... 3
Muscle Ache .…………... 4
Sore throat .…………... 5
Eye infection .…………... 6
Diarrhoea .…………... 7
Other Specify:_____________________________ .…………... 8
Don't know .…………... 98
25
PART 3: KNOWLEDGE OF PRACTICES
14a What are you/your family currently doing to protect you and your family from getting AI?
Wash hand with soap before and after taking care taking care of poultry …………1
Wash hand with soap before handling/ preparing food …………2
Change and wash clothes after taking care of poultry …………3
Do not let children handle poultry eggs …………4
Do not eat duck or geese blood pudding …………5
Do not ean under cooked poultry and egg …………6
Don't eat birds that fall dead; bury or burn them instead …………7
Do / Done Nothing …………8
Other Specify:___________________________________________ …………9
Don't know …………10
14b Are there any other things you can do to protect you and your family from getting AI?
Wash hand with soap before and after taking care taking care of poultry …………1
Wash hand with soap before handling/ preparing food …………2
Change and wash clothes after taking care of poultry …………3
Do not let children handle poultry eggs …………4
Do not eat duck or geese blood pudding …………5
Do not ean under cooked poultry and egg …………6
Don't eat birds that fall dead; bury or burn them instead …………7
Do / Done Nothing …………8
Other Specify:___________________________________________ …………9
Don't know …………10
15 When killing poultry, how can you protect yourself from AI

Wear gloves …………… 1

Wear a mask …………… 2
Do it away from the house …………… 3
Wash hands afterwards …………… 4
Clean area afterwards …………… 5
Other Specify:___________________________ …………… 6
Don't know …………… 7
26
PART 3: KNOWLEDGE OF PRACTICES CONT'D
16 When cooking poultry how can you protect yourself and your family from AI?
Use a separate chopping board …………… 1

Cook the poultry completely …………… 2
Do not drink ducks blood …………… 3
Wash hands before and after preparing food …………… 4
Do not eat sick or dead poultry with suspected AI …………… 5
Keep kitchen clean …………… 6
Other Specify:___________________________ …………… 7
FOR NON-POULTRY FARMING HOUSEHOLDS TERMINATE QUESTIONNAIRE

AND CONDUCT THE FOLLOWING DIRECT OBSERVATION QUESTION
Can you show me if you have soap for handwashing? Yes No

….. 1 ….. 2
17a What are you/your family currently doing to protect your poultry from getting AI?
Vaccinate poultry against AI …… 1

Keep poultry in good condition (access to clean water, and adequate food/housing) …… 2
Keep poultry in a protected environment (enclosed building/ fenced area) …… 3
Separate the chickens from the ducks …… 4
Keep all poultry brought to the farm separate from other poultry for at least 2 weeks …… 5
Was hand with soap before and after taking care of poultry and other animals …… 6
Change clothes/shoes/sandals when coming from another farm or market …… 7
Control entries into the farm (do not let middleman/visitors enter the farmyard etc.) …… 8
Store manure from another farm for at least 3 weeks …… 9
Do / Done Nothing …… 10
Other Specify:___________________________________________ ………… 11
Don't know …… 12
27
17b Are there any other things you think you could do to protect your poultry from getting AI?
Vaccinate poultry against AI …… 1

Keep poultry in good condition (access to clean water, and adequate food/housing) …… 2
Keep poultry in a protected environment (enclosed building/ fenced area) …… 3
Separate the chickens from the ducks …… 4
Keep all poultry brought to the farm separate from other poultry for at least 2 weeks …… 5
Was hand with soap before and after taking care of poultry and other animals …… 6
Change clothes/shoes/sandals when coming from another farm or market …… 7
Control entries into the farm (do not let middleman/visitors enter the farmyard etc.) …… 8
Store manure from another farm for at least 3 weeks …… 9
Do / Done Nothing …… 10
Other Specify:___________________________________________ ………… 11
Don't know …… 12
PART 3: KNOWLEDGE OF PRACTICES CONT'D

18 What do you do with poultry that you suspect of having AI?
Keep them in a closed building/separate from other poultry & animals …………… 1
Sell them …………… 2
Eat them …………… 3
Kill them and throw them away in the river/pond …………… 4
Kill them and throw them outside/ garbage …………… 5
Kill them and bury them …………… 6
Kill them and burn them …………… 7
Report to an authority …………… 8
Follow Animal Health Dept (or other official) instructions …………… 9
Do nothing …………… 10
Other Specify:___________________________________ …………… 11
Don’t know …………… 12
19a If you thought you had an outbreak of AI in your poultry, would you report it?
Yes …………1 Go to Q19b

No …………2 Go to Q20
Refuse …………3 Go to Q20
28
19b To who would you be most likley to report an outbreak of AI in your poultry to?
Animal Health Worker ………. 1

Commune/village health worker ………. 2
Local Authority (Village Chief, Police etc.) ………. 3 >> specify:__________________________
Mass organisation (womens/farmers union) ………. 4
Others ………. 5 >> specify:__________________________
20 Why would you choose not to report the case?
21a Have your poultry been vaccinated against AI
Yes …………… 1 Go to 21b

No …………… 2
21b Why not?

Vaccinator did not come …………… 1

Note home when vaccinators came …………… 2
Did not know vaccinators were coming …………… 3
Not enough vaccines …………… 4
Vaccination make poultry sick / died / not lay egg …………… 5
Can not eat poultry for long time after vaccination …………… 6
Can not sell poultry for long time after shot …………… 7
Other …………… 8
PART 4: DIRECT OBSERVATION
22 Can you show me if you have soap for handwashing Yes No
….. 1 ….. 2
23 Can I see where you keep your chicken, duck and other animals to check some details
Do not ask the questions. Observe and check off the answer after having observed the situation
Yes No
a Are all chickens kept in a closed building or fence-in area? ….. 1 ….. 2
b Are all ducks kept in a closed building or fence-in area? ….. 1 ….. 2
c If poultry are let free in the backyard, can they go outside? ….. 1 ….. 2
d Are there other animals (such as pig) which can come in contact with the po….. 1 ….. 2
e Is there poultry feces lying on the ground outside the area where the poultry….. 1 ….. 2
f Is there a poultry manure composting pit? ….. 1 ….. 2
29

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CARE INTERNATIONAL IN VIETNAM

AVIAN INFLUENZA LOCAL RISK REDUCTION PROJECT

BASELINE KAP STUDY

Direct losses from the 2003-2004 outbreaks in Vietnam resulted in 44 million

CARE’s STOP AI program

CARE initially conducted a Knowledge, Attitude and Practice survey in

The total number of households to be interviewed in each commune was 100.

50 Male Female 100

Age group Poor Middle income Rich Unspecified

• 71.5% (n=276) of participants reported raising poultry at their home. This

Table 1: Number of poultry raised by participants

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

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

21.1.1 Question 10: Transmission routes among poultry

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

Contact with contamination clothing or footware 2.9

Contact with contaminated farming equipment 9.3

Free-ranging chickens or ducks 18.5

Contact with infected manure 25.9

Purchase of unidentified poultry 27.5

Contact with contaminated environment/feed 34.5

Contact with infected/sick birds 51.8

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

Discoloured manure 7.6

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

Swollen and puffy looking eyes 11.9

Dark/red/blue combs and wattles 12.8

Discharge from eyes and nose 21.1

Ruffled feathers 25.7

Loss of appetite 33.9

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

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

2.2.1 Question 13: Transmission of AI in humans

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

Contact with contaminated farm equipment 7.9

Contact with humans infected with AI 11.9

Contact with infected poultry feces 16.0

Eating raw poultry product 28.9

Eating undercooked infected poultry/eggs 36.2

Contact with infected poultry 75.5

2.2.2 Question 14: Symptoms of AI in humans

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

Eye infection 4.0

Sore throat 5.1

Muscle Ache 18.3

Difficult/fast breathing 49.1

3.1 Question 14: Prevention methods against AI for family

Figure 9: Prevention methods currently being conducting by the family

Do / Done Nothing 5.4

Do not eat duck or geese blood pudding 29.3

Do not eat under cooked poultry and egg 37.7

• “Other” responses included cleaning the farm/equipment (n=51), using

3.2 Question 15: Protection methods for AI when slaughtering poultry

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

Do it away from the

Wash hands afterwards 21.6

Clean area afterwards 26.1

Wear gloves 60.1