Effect Measure

It is an unconscious assumption of many public health officials, experts and most health educators that The Truth Shall Make you Free. We know it won’t, not even in something as simple as understanding what to do and not do about bird flu. A paper this month in CDC’s scientific journal, Emerging Infectious Diseases, is a case in point. Public health workers at the Pasteur Institute in Cambodia, the London School of Hygiene, the Cambodian Ministry of Agriculture and the UN’s FAO undertook a survey about the knowledge, attitudes and practices among rural villagers in Cambodia, a southeast asian country that has suffered periodic poultry outbreaks with influenza A/H5N1 (bird flu) since 2003. There have been 6 human cases, as well, all fatal. Cambodian public health authorities maintain that human infections are the result of close contact with infected poultry and they began a vigorous public education campaign. It has been half successful. The results of the survey show the message has been received and understood. It also shows that there continues to be widespread risky interactions between people and poultry in rural Cambodia (“AI,” below, is avian influenza):

Twenty-three villages were included in Kampong Cham and Prey Veng Provinces. Four hundred sixty respondents from 269 households completed the questionnaire. Most were women (60%), farmers (88%), and persons who had completed less than primary schooling (57%). The median number of household members was 5 (range 1-16), and 77% of all households included children <15 years of age.

Many households owned chickens (97%) and ducks (39%), although the size of most poultry flocks was small. Almost all poultry were free ranging (100% of chicken flocks; 96% of duck flocks), and mixing of the poultry with pigs and other domestic animals was common. Respondents reported that they use poultry feces for manure (77%), touch sick/dead poultry with bare hands (75%), eat poultry that died from illness (45%), eat wild birds (33%), let children touch sick/dead poultry with bare hands (20%), and gather dead wild birds for consumption (8%).

During the previous 6 months, of the 260 households that owned poultry, 162 (62%) experienced poultry deaths; however, only 18 (7%) reported these deaths to local authorities. Half of the respondents (n = 231) believed that it was important to report any poultry deaths because the death may be due to AI (61%) or because the poultry owners may receive management advice from the village veterinarians (39%). Among these 231 respondents, many did not report poultry deaths because they did not know how (41%), were in the habit of not reporting poultry deaths (31%), believed they would have a problem selling poultry if they reported deaths (18%), did not know the risks of AI (7%), or feared poultry culling (5%). Among those respondents who did not believe reporting deaths was important, the reasons provided included the following: "the number of poultry deaths were too few" (62%), "poultry are not as important as cattle" (18%), "no help would be provided from veterinary staff or authorities" (13%), or "because mortality was similar to previous years" (7%). Of respondents that experienced poultry deaths, 62% buried or burned dead poultry, 53% prepared them for food, 22% threw away the dead poultry, 3% used them to feed other animals, and 2% prepared them for sale or gave them to their neighbors. (Soarth Ly et al., Emerging Infectious Diseases, cites omitted)

Very few (7%) of the respondents gave ignorance of the dangers as reason. Indeed 81% had learned about bird fu from TV and 78% from radio, one in three could even describe the symptoms of bird flu and more than 7 in 10 knew that it was a fatal disease of birds that could infect humans.

Most respondents believed it is unsafe to touch sick or dead poultry with bare hands (67%), eat wild birds (70%), let children touch sick or dead birds with bare hands (83%), and eat meat or eggs that are not fully cooked (86%). Sixty-one percent of respondents mentioned at least 1 of the recommended behavioral practices that protect against AI infection.

This is both a stunning success and an equally stunning failure. People knew, understood and still practiced risky behavior. Why?

Anecdotally, we also reported that family members of H5N1-infected patients, who knew about AI risks, still prepared dead or sick poultry for household consumption during massive die-offs, because they observed that neighbors with the same behavior did not become sick (Institute Pasteur in Cambodia, unpub. data). These findings provide evidence that high awareness does not necessary lead to behavior change. Behavior change involves comprehensive and multidisciplinary intervention, which combines risk perception communication and feasible and practical recommendations, including economic considerations. We speculate that it is hardly feasible to sustain good poultry-handling practices if access to personal protective equipment is cost prohibitive, particularly when disease occurrence poultry die-offs are common.

Clearly the lack of a compensation policy has a major effect on willingness to report. This paper points to Vietnam’s apparent success as an indication that poultry vaccination should be seriously considered. But persistent concerns that vaccination leaves birds still infectious yet apparently healthy, if true would not solve the problem of risky poultry handling practices but perhaps even exacerbate it.

Knowledge and understanding are important, but as this paper indicates once again, not sufficient. But we know that. Many readers of this site are acutely aware of the dangers of climate change but haven’t sold their big cars for hybrids or bicycles, haven’t insulated their houses, stamp the earth with unconscionably large carbon footprints and much more. We understand but fail to act.

Just thought I’d mention it.


  1. #1 G in INdiana
    December 26, 2006

    Of course awareness doesn’t lead to behavioral change. Take smoking, over using powerful illegal (or legal) drugs or overindulging in alcohol. We all KNOW those things are bad for us, but we do them any way.
    I’d say the Cambodians have a more pressing problem since the afore mentioned bad habits are not, in most cases, part of the regular person’s livelihood or survival. The handling of ducks and chickens, whether they are ill or well, is to these folks.
    I sold the truck, insulated the house, and planted over 5400 trees, but I still over indulge the alcohol. Stupid me.

  2. #2 M. Randolph Kruger
    December 26, 2006

    I dont know about insulating the houses but Beijing has thousands of bicycles and the worst air on this planet. They are now trading those bicycles in on new Benz’s. We have a fairly informed and warned population about bird flu here. They have getting warned more and more in Cambodia about it and they hasnt done anything to change the mindset there. Neither is prepared, and as you say Revere the poor will suffer the most. But then again they are generally the most populated parts of the planet. We will likely take a bigger hit from a four month event from starvation than they will. We are too stretched along the food chain. There are people here who cant even use a manual can opener, that is if the food was there.

    They handle poultry, we handle cans. You can get cut by both and they will be taken out by birds and we will because of a lack of cans.

  3. #3 Ron
    December 26, 2006

    Cambodia has a population of nearly 14 million people, living in close quarters with each other and their poultry. Eighty percent of poultry production is rustic smallholder ‘backyard’ production with high percentage of native breeds. Poverty is rampant and sanitary conditions are horrible,bacterial and protozoal diarrhea, hepatitis A, and typhoid fever are rampant. Infant mortality it nearly 70/1000 live births. Dengue fever, malaria, and Japanese encephalitis are also prevalent in some regions. But only 6 people have died from H5N1?! Can you really blame them for being unconcerned, perhaps more concerned about their kids dying from diarrhea,say?

    We should be studying Cambodia to find out how peoples’ habits and behavior are contributing to there *not* being a high risk of H5N1 in the country.

  4. #4 Rich
    December 28, 2006

    Knowledge doesn’t lead to behavior change? Not exactly news, but infectious disease practitioners and epidemiologists can’t seem to get beyond information giving and dow what is more difficult–understand how people live and figutre out how to integrate evidence-based best practices with cultural practices. As a social scientist whose worked with MDs and epis for years, I’ve seen this over & over agin. Collectively, you guys are just pathetic.

  5. #5 revere
    December 28, 2006

    Rich: In my experience it is social scientists who push the idea that health education and health promotion works. You’ve erected complex bulwarks about what affects compliance and health belieef and god knows what else. Why blame us for your failure to find a way to do this? We’d listen to you if you had anything useful to offer. Since our not listening hasn’t lead to your behavior change, I guess you are a self-fulfilling prophecy. Yet you keep trying to work with us. Go figure.

    What “beyond information giving” are you referring to? We’ve tried a lot of things beyond information giving but you haven’t provided anything that works, it seems. I’m actually with you on the information giving side of things, since it has always been obvious that there are barriers to act that are social in nature. But why blame us? If you’ve got the answer, then go ahead and implement it (and we both know why you or we haven’t). You guys are also pathetic. Too. Evidence based practice? LOL.