2010: Egypt: Post-Assessment and Evaluation of Avian Influenza Community Education Program in Rural Egypt: Summary Report
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Avian Influenza (AI) was first confirmed in Egypt in February 2006. Over 1,450 outbreaks have been reported since, affecting more than 920 commercial and small farms and 530 backyard poultry keepers. Over 40 million birds have been culled. The reported outbreaks in poultry and occurrences of human cases have manifested a seasonal pattern with most of the cases occurring during the winter months. As of June 2009, the AI H5N1 virus had spread to infect the poultry population in 26 out of 29 governorates. The first human case of AI H5N1 was confirmed in March 2006. A total of 81 human cases of H5N1 infection - of which 27 were fatal - had been reported from the affected governorates. The incidence of AI among children under 18 years accounted for more than 60% of the total infected cases and 10 out of the last reported 11 cases in 2009 have been children less than 5 years of age. The proportion of confirmed human cases among women was also relatively high and accounted for 68% of confirmed cases (source: MOH AI Surveillance data 2009).
The Egyptian Government recognizes the seriousness of the threat and the national response efforts are coordinated in collaboration with the UN agencies, the international community and are led by the concerned ministries, in particular, the Ministry of Agriculture and Land Reclamation (MOA) and the Ministry of Health (MOH). A high level coordinating body, the Supreme National Committee for Combating Avian Influenza, chaired by the Minister of Health, was created bringing together the key partners involved in the national efforts for prevention and control of the AI epidemic. The national and international partners’ approach remains to be “catch and contain” the AI H5N1 virus in the bird population before it spreads to humans, and to arm humans with the information needed to modify their practices to protect themselves and avoid infection.
The social mobilization and communication component of the Integrated National Plan for Avian and Human Influenza of May 2007 (INPAHI) was formulated in consultation with the concerned sectors and the international community as a multilayered multiplatform plan that uses more than one means of communication to reach the targeted groups of the population. Implementation of different communication approaches at the targeted levels and/or groups of the population was done against a background of a continuing public media campaign, house to house home visits by the Raedat Reefiyat (community health workers) who were trained to implement the AI community-based education programme and an intensive awareness raising program in primary schools.
UNICEF’s main strategic communication for development objectives are:
• to support the Egyptian Government in controlling the spread of H5N1 virus;
• to minimize the likelihood of human exposure to infected poultry;
• to ensure early detection of human cases; and
• to take all necessary measures to prepare for a possible pandemic.
The overall goal of the present study is to provide an evaluation of the impact of the UNICEF supported Avian Influenza communication for development programme at the policy, program and household levels. The outcome of the analysis of the communication program will serve to support the design and implementation of future interventions. The specific objectives aimed to, (a) provide an assessment of the public knowledge, attitudes and practices regarding AI that resulted from direct exposure of households women and their children to the AI community education interventions in the 17 highest and medium risk governorates of UNICEF supported intervention, (b) strengthen the capacity of the community outreach teams and establish a management structure for a supervisory and technical support system that monitors their implementation of the program, and (c) minimize the risk of school children (6-12 years) becoming infected with AI.
The evaluation was designed to provide both quantitative and qualitative data. The former was generated from HH surveys and structured interviews with women in the households and with pupils at primary schools. The total number of interviewed households was 2763, 1361 in Lower Egypt districts, 1235 in Upper Egypt districts, and 167 as controls in Qassaseen District of Ismailia governorate.
The 27 primary schools selected for the school children KAP survey were situated in the same villages chosen for the household survey and represented schools that have already implemented the School AI Edutainment Programme. The sampling frame for the pupils included pupils aged 6-12 years from all grades (1st to 6th). Total number of interviewed primary school children
was 3240 (lower Egypt, 1440 while Upper Egypt was 1800).
According to the distribution of the households and schools, the focus group discussions in groups of 7-10 persons were held in districts and villages selected from the governorates included in the study. They involved the RR in 12 districts; teachers in 9 districts; and community leaders/men in 6 villages), to a total number of 27 focus group discussions.
The focus group discussions of the qualitative study were held separately with each of the different identified groups, namely, the RR, teachers and community men and leaders. The total number of FGD participants totaled 203 of which 91 were RR; 69 teachers (men & women); and 43 men and community leaders
Other data sources included review of documentation made available by UNICEF as well as face-to-face personal interviews with lead policy and program managers of the program.
Findings and Conclusions:
Most of the knowledge gained through RR was more appreciated by the targeted groups than the knowledge and practices disseminated through the mass media and other sources. The traditional networking among women in Egypt had a multiplier effect as it served to spread the message to other households.
The good level of gained knowledge about the protective measures required to prevent AI transmission among poultry and to human beings was translated to practice in most cases. This was evidenced in the KAP findings that were collected from the geographic areas covered by the RR communication program differed significantly from those collected from the control sites.
Hand washing and keeping children away from poultry and separating poultry from living and sleeping areas was the most noticed knowledge improvement. To a lesser extent wearing protective gloves, buying from a trusted peddler, and handling of sick or dead poultry on their own without reporting.
Some gaps in knowledge (and in means for its application) were found in recognizing manifestations of human AI disease and of the appropriate referral sites and protective measures such as washing eggs before consumption and preparing birds for cooking. Knowledge gaps also existed in the steps required for rebreeding. The gaps in knowledge were far more pronounced among the households with families that had not been visited by the RR.
The involvement of children in poultry breeding as reported by the households was found to be 10.2% as is shown in the following figures which also provide details of the tasks in which children are involved. The children on the other hand reported more involvement in home breeding in their responses to the same questions in the school survey where 39.6 of the children admitted being involved in breeding tasks. The underlying reasons for this difference in perception of child involvement in poultry breeding between the HH and the children may need to be further pursued. The involvement, reported by children, in the tasks of cleaning the coup and in slaughtering of birds exposes them to a very high risk of infection. Though the post intervention results may show some improvement, the children continue to be involved.
The knowledge of the interviewed household members about the source of human infection by AI are shown in Fig. x. Despite the presence of some misconceptions about the transmission of the infection, yet the majority of the HH respondents gave correct answers. A significant positive outcome of the UNICEF interventions was the recognition by 48 % of women in HH that dealings with healthy looking live birds can be a source of infection. This was an improvement on the El Zanaty (2007) findings where there was no mention of dealings with live birds as a source of infection.
The proportion of knowledge in general between households with and without children was equal, except for the item regarding the separation of children from the birds. The proportion of women who were aware of the need of child separation was twice in the households with children compared to the figure for households with no children.
School children had a good idea about the source of human AI infection, as only 2.7% did not know if birds play a role or not, and 3% stated frankly that birds has no role in human AI infection.
The four key messages disseminated through the AI-related school programme (Edutainment programme) were remembered by the majority of the school children.
They were the following (see Fig x):
1- Wash (means hand washing)
2- Stay away (means do not play or deal with poultry)
3- Separate (means separation of different poultry types)
4- Notify (means reporting sick and dead poultry)
Attitudes were found to be variable alternating between a positive feeling of security and negative ones caused by the progressive evolution in the existing AI situation in the country and at community level. The negative ones are further complicated by the burden of the serious financial difficulties that the families suffer as a result of loss of income from poultry breeding.
The demand for veterinary services and vaccination exceeds by far their availability which is a liability that can seriously undermine the impact of prevention and control programs.
The FGDs with the RR confirmed that they would like more coordination with the veterinary services and believe in the usefulness of jointly organized CBE sessions. They appreciate the technical support provided by their supervisory system that notes the important feedback information and they provide from the field. This could be for urgently needed interventions such as system for collection and disposal of AI infected refuse, or to overcome the barriers that continue to stand in the way of notification of dead birds. Making available the diagnostic tests for human avian influenza free of charge was requested by the RR.
The school teachers expressed general appreciation of the work of the RR and of the school based interactive learning by playing approaches in the FGDs sessions. They commented that the older children of Grades 4,5 and 6 benefited more from the messages than the younger children. They requested that the number of kits per school be increased and that the duration of their training be longer, with involvement of a veterinary specialist.
The community leader’s FGDs revealed that the Government was expected to do more for control of the AI epidemic. They appreciated the CBE programmes and have noted the result changes in the traditional methods of poultry breeding. Familiarity with the work of the RR was variable. The school based AI educational programmes were appreciated and the relay of the messages by the children to their families was commented. They were of the opinion that the RR and school based programmes must be continued and sustained and the school teachers could additionally assume a community based outreach role for dissemination of the AI messages outside the HHs and the schools. The TV programmes topped the list of public sources of information.
The Raedat and their work
• Much will be gained from the expansion of the RR programme to cover all the governorates. Institutionalization of outreach system worker will allow breaking off dependence on the vertical programmes and integration of her health related tasks. Reorganization of the work of the RR to integrate AI messages with the related health education component of programmes such as mother and child health, nutrition, and childhood illnesses is expected to avoid repetition and increase the usefulness of the messages promoted through the RR.
• There is a need to involve the community level outreach workers from all sectors, as well as the Local Government, in discussions for identification of modalities for coordination of their respective AI related interventions so as to satisfy the needs identified by the households and to better serve the principal objective of containment of the spread of the AI infection.
• Serious efforts need to be made to communicate the health information and education tasks of the RR in an integrated manner and not to deliver it in the form of compartmentalized messages produced by separate vertical programmes. Environmental sanitation, hygiene, nutrition and mother and child health and childhood illnesses all have related messages that can be integrated in comprehensive health education messages, hence avoiding repetition and shortening the duration of the home visit as well as increasing their effectiveness and pertinence, thus increasing her popularity.
• In addition to providing effective communication training to enhance the performance of the RR, the training programme needs to also prepare the Raeda for dealing with newly emerging AI related needs that are now being expressed by the women in the households. Though the issue may impact on health, the solution may not be strictly in the health domain, such as the requested guidance on how to apply measures for bio-safety. Since the Raeda is the only outreach worker with access to the homes she may need to work in tandem with the veterinarians to satisfy the knowledge and guidance gaps on matters that represent a direct health hazards.
• The involvement of men in the household surveys was observed in a minority of homes. It may be opportune to consider means of engaging with them when present at home based education sessions or at community based activities attended by both men and women. Community leaders enjoying broad respec and influencet could also be invited to support interventions that target men especially in rural Egypt.
Gender related issues
• Analysis of AI related activities from a gender perspective will need to be included when trying to understand and overcome identified barriers to KAP. One example is the issue of buying birds from “unsafe/unreliable” sources. To reduce the figure recorded in the survey for procurement of birds from unsafe vendors the reasons underlying this observation may need further clarification. This may well be attributed to disruption of the habitual purchasing channels by the aggressive AI epidemic control measures and the resulting diminished offer.
The school AI Edutainment programme
• Attention will need to be given to the demand expressed by teachers, and evidenced by the survey, to exclude the first two grades from the edutainment programme as their knowledge retention capacity was significantly lower than the last three grades, 4, 5, and the 6th grade. An alternative is to design activities that are suited to their age.
• Including an item in the training programme of the teachers on the “constraints and/or barriers” encountered in the course of implementation of the edutainment programme and on ways and means to overcome them will help them devise solutions as appropriate to overcome them. An example is how to organize an edutainment session in an overcrowded class. Such an item can be presented by one of the earlier groups of teachers who had gained experience in the “Learn by Playing” programme.
• Investigate how to involve the parent-teacher associations in disseminating the AI messages to reach the families, as was proposed in the FGDs.
• Investigate possibilities for sustainability and self sufficiency of the Edutainment programme through CSO involvement or public private partnerships (PPP) so as to be able to satisfy the demand made for its progressive scaling up of the programme to all primary schools.
• Encourage the organization of the Edutainment programme in those schools that are open during the summer holidays for community based activities.Continue to support initiatives implemented already by some of the teachers for integrating the AI education knowledge in the relevant school subjects. Successfully implemented examples of AI education projects contributed to reinforcing the AI-related knowledge and a better understanding of the AI messages.
Developmental needs of households
• Now that the CBE programme is becoming well established, the RR will need to be prepared to help the households to cope with the emerging complications of the AI epidemic such as child malnutrition that is already affecting children in the infected governorates as a consequence of the loss of family income and the precious source of animal protein. The RR will need to be able to provide advice on balanced low cost diets for children and on measures to prevent the onset of malnutrition.
• The lack of coordination between the sectors working at the community level has been evoked by the Director General for Epizootics and Poultry Diseases of the MOA the matter needs to be further investigated and measures taken to activate the already established multi-level intersectoral AI coordination committees.
Communication for Behaviour Change Messages and their Dissemination
• Harmonization of media messages and the respect of the agreed policies that govern and guide AI related activities has been listed as a recommendation in earlier assessment reports and remains outstanding. UNICEF may be well placed to follow it up being a member of the ad hoc AI Media and Communication Committee. However it should be viewed as the full responsibility of the GOE.
• The “peer” education modality for dissemination of AI related information to colleagues in other schools and to parents was evoked by some teachers as an example for relaying the AI messages received through AI CBE interventions. The women in the surveyed households also mentioned passing on the messages to their neighbours. This dissemination by “relay” communicators may create a multiplier effect and increase the numbers of the population who are exposed to AI messages.
Lessons Learned (Optional):
The present assessment has achieved the set purpose of designing a tool for qualitative and quantitative assessment of the impact of the AI CEP interventions and has demonstrated the gains in knowledge, attitudes and practices as an outcome of the intensive, integrated and accelerated multi-channel communication inputs that were deployed since early 2007. It is considered that the present evaluation undertaken with the community and at the community level has provided an insight to how the community conceives the respective roles for its key players as expressed in their own words in the qualitative studies and in the feedback reports from the RR. It is believed that there is enough material at present to re-adjust and re-programme the social mobilization and the communication and education components of the national AI prevention and control plan and to transform it from an emergency management model to a sustained, efficient and well targeted programme. The evaluation also served to identify a number of issues and domains for action that are considered basic to any effort or programme that aims at taking the national AI and C4D programmes forward. The study served to highlight issues and domains for action that have been revealed in the course of the qualitative studies and others that were the outcome of a developmental reading and analysis of the study findings. They are presented under headings that represent the domain of an action and not the action itself.
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