The authors have declared that no competing interests exist.
Performed the experiments: TM TTH DML DTHV PTPT DTTH TTMP DHM JT NQC LQT KK. Analyzed the data: TM KK. Wrote the paper: TM.
Awareness of individuals’ knowledge and predicting their behavior and emotional reactions is crucial when evaluating clinical preparedness for influenza pandemics with a highly pathogenic virus. Knowledge, attitude, and practice (KAP) relating to avian influenza (H5N1) virus infection among residents in communities where H5N1 patients occurred in Vietnam has not been reported.
Face-to-face interviews including KAP survey were conducted in Bac Kan province, located in the northeast mountainous region of Vietnam. Participants were residents who lived in a community where H5N1 cases have ever been reported (event group, n = 322) or one where cases have not been reported (non-event group, n = 221). Data on emotional reactions of participants and healthcare-seeking behavior after the event in neighboring areas were collected as well as information on demographics and environmental measures, information sources, and KAP regarding H5N1. These data were compared between two groups. Higher environmental risk of H5N1 and improper poultry-handling behaviors were identified in the event group. At the time of the event, over 50% of the event group sought healthcare for flu-like symptoms or because they were scared. Awareness of the event influenced KAP scores. Healthcare-seeking behavior and attention to H5N1 poultry outbreaks diminished in the event group as time passed after the outbreak compared with the non-event group. Factors that motivated participants to seek healthcare sooner were knowledge of early access to healthcare and the risk of eating sick/dead poultry, and perception of the threat of H5N1.
Awareness of H5N1 patients in neighboring areas can provoke panic in residents and influence their healthcare-seeking behavior. Periodic education to share experiences on the occurrence of H5N1 patients and provide accurate information may help prevent panic and infection and reduce mortality. Local conditions should be taken into account when emphasizing the need for early access to healthcare.
Avian influenza A(H5N1) virus infection in humans remains rare and sporadic; however, it presents a continuous global pandemic threat associated with high mortality
Two laboratory-confirmed cases of H5N1 in humans were reported from a community in Bac Kan province, a mountainous region in northeastern Vietnam, in spring 2010
The study was performed in two communities: Nhu Co Commune in Cho Moi District and Minh Khai Ward in Bac Kan Township in Bac Kan province (
Bac Kan province is located in the mountainous region of northeast Vietnam. The white boxes denote study sites.
The study investigators included healthcare providers at Bac Kan General Provincial Hospital who worked closely with the health department in Bac Kan province. The population list of study communities were maintained by that health department and obtained by the investigators. From these lists, residents younger than age 18 and older than age 70 were excluded. A total of 400 participants 18–70 years of age were randomly selected from the reminder on the population lists in Nhu Co (event group) and Minh Khai (non-event group) using a random number generator. The sample size was chosen to allow the detection of an effect of 0.25 with a power of 0.8, even after a substantial number of dropouts.
The KAP survey was conducted in November 2011. The study subjects were invited to the survey by the letter from investigators and subjects who agreed to participate the survey received the face-to-face interview. The questionnaire was designed to assess KAP relating to H5N1 infection and emotional reactions to H5N1, and was back-translated. It collected information on the general background of participants, life environment in relation to household poultry, information sources on avian influenza, general knowledge of H5N1 infection, hygiene, and poultry handling, as well as emotional reactions to H5N1, including healthcare-seeking behaviors. The pilot survey was conducted at the Xuat Hoa Commune in Bac Kan Township, approximately one hour distance by motorbike from each study site, in September 2011, to identify suitable questions and interview methods for communities in Bac Kan province. All questions were either closed-ended or multiple-choice. The questionnaire was collected during face-to-face interviews conducted by previously-trained local healthcare workers. Interviews were held three times on a single day at meeting halls at each study site to avoid exchange of information among participants regarding the contents of the interviews. KAP associated with H5N1 infection were compared between the groups. A knowledge score was calculated according to correct answers. An attitude-practice score was also calculated to evaluate the factors influencing each score, including individuals’ healthcare behaviors. Economic conditions were classified according to quintiles of family income and were qualified on the basis of the possession of assets such as a television, radio, telephone, water server, refrigerator, buffalo/cow, bicycle, motorbike, car and air conditioner. Household poultry was defined as domesticated birds raised in backyards such as chickens, ducks, and musk ducks for the purpose of meet and eggs for daily meals and/or selling.
Ethical approval was provided by the Institutional Review Board of the Ministry of Health, Vietnam, Bach Mai Hospital and the National Center for Global Health and Medicine, Japan. All study participants provided either written informed consent or verbal consent if they were illiterate. This method was approved for the present study in Vietnam by ethical review boards. Consent was documented with the participants' signature or figure prints if they were illiterate, according to rules for scientific research in Vietnam.
Survey data were double-entered and analyzed using SPSS Statistics ver. 20 (IBM, Armonk, NY, USA). Continuous variables were compared using Mann-Whitney U or Kruskal-Wallis tests. Categorical variables were analyzed using chi-square tests and Fisher’s exact tests. A maximum of three points was assigned to the answer ‘agree’ for each question, two points were assigned to ‘undecided,’ and one point to ‘disagree,’ according to a three-point Likert-type scale. KAP scores were calculated according to the answers using factor analysis, adjusted to give a total score of 10. Factors influencing KAP scores were analyzed by logistic regression analysis. Independent factors influencing early access to healthcare were analyzed using a step-wise selection method to select variables from the baseline backgrounds of participants. For all analyses, significance levels were two-tailed, and a P value of <0.05 was considered significant.
Totals of 322 (median age, 36 [IQR 26–47] years) and 221 (median age, 40 [IQR 32–52] years) participants from the event group and non-event group, respectively, agreed to participate in the present study. The general backgrounds of the participants are shown in
Event group (Nhu Co) | Non-event group (Minh Kai) | P value | |
n = 322 | n = 221 | ||
No. (%) | No. (%) | ||
|
|||
Gender - male (%) | 103 (32.0) | 72 (32.6) | 0.926 |
Age –median (IQR) yr. | 36.0 (26–47) | 40.0 (32–52) | 0.001 |
Education, No. (%) | <0.001 | ||
Illiterate or only can read and write | 15 (4.7) | 2 (1.0) | |
Elementary school | 110 (34.2) | 11 (5.0) | |
Junior high school | 147 (45.7) | 63 (28.5) | |
High school | 39 (12.1) | 77 (34.8) | |
Specialty school | 2 (0.6) | 37 (16.7) | |
College/University | 9 (2.8) | 31 (14.0) | |
Occupation | <0.001 | ||
Farmer | 283 (87.9) | 27 (12.2) | |
Housewife | 6 (1.9) | 15 (6.8) | |
Government employee | 11 (3.4) | 67 (30.3) | |
Employed worker | 5 (1.6) | 44 (19.9) | |
Student | 2 (0.6) | 12 (5.4) | |
Unemployment | 0 (0.0) | 26 (11.8) | |
Others | 9 (2.8) | 30 (13.6) | |
Economic condition |
<0.001 | ||
1 | 95 (29.7) | 12 (5.4) | |
2 | 87 (27.2) | 30 (13.6) | |
3 | 66 (20.6) | 34 (15.4) | |
4 | 47 (14.7) | 68 (30.8) | |
5 | 25 (7.8) | 77 (34.8) | |
Health insurance | 290 (90.1) | 183 (82.8) | 0.014 |
|
|||
Number of participant owing household poultry | 298 (92.5) | 112 (50.7) | <0.001 |
Number of poultry raised at the participants’ house | |||
Chickens | <0.001 | ||
<10 | 43 (13.4) | 42 (19.0) | |
≥10 | 270 83.8) | 70 (31.7) | |
Ducks | <0.001 | ||
<10 | 19 (5.9) | 1 (0.5) | |
≥10 | 50 (15.6) | 3 (1.4) | |
Musk ducks | <0.001 | ||
<10 | 21 (6.5) | 3 (1.4) | |
≥10 | 56 (17.4) | 0 (0.0) | |
|
<0.001 | ||
Frequently | 264 (82.0) | 91 (41.2) | |
Sometimes | 53 (16.5) | 118 (53.4) | |
|
276 (85.7) | 174 (78.7) | 0.037 |
|
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Vaccination | 276 (85.7) | 174 (78.7) | 0.037 |
Clean or disinfect poultry cage | 150 (46.6) | 130 (58.8) | 0.005 |
Keep poultry in good condition | 114 (35.4) | 82 (37.1) | 0.716 |
Built fence around the area | 46 (14.3) | 79 (35.7) | <0.001 |
Do nothing | 10 (3.1) | 3 (1.4) | 0.257 |
|
110 (34.2) | 15 (6.8) | <0.001 |
|
162 (50.3) | 51 (23.1) | <0.001 |
Economic condition was qualified based on the possession of assets such as a television, radio, telephone, water server, refrigerator, buffalo, bicycle, motorbike, car and air conditioner, and was divided into quintiles according to family income. AI: avian influenza (H5N1) virus infection in humans.
Backgrounds on education (a), occupation (b), and economic condition (c) of study participants are compared between the event group and the non-event group. *Economic condition was qualified based on the possession of assets such as a television, radio, telephone, water server, refrigerator, buffalo, bicycle, motorbike, car and air conditioner, and was divided into quintiles according to family income.
Participants who possessed household poultry were more common in the event group (92.5%) than in the non-event group (50.7%). Furthermore, significantly more participants in the event group had contact with poultry as part of their daily work (P<0.001). Significantly more participants in the event group had experienced H5N1 infection and sudden death in household poultry compared with the non-event group (P<0.001).
Most participants had heard about avian influenza (H5N1) (event group 97.2%, non-event group 98.2%, P = 0.263). Sources of their information relating to avian influenza (H5N1) are listed in
Event group (Nhu Co) | Non-event group (Minh Kai) | P value | |
(n = 322) | (n = 221) | ||
No. (%) | No. (%) | ||
|
313 (97.2) | 217 (98.2) | 0.263 |
|
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Information source | |||
Television | 238 (73.9) | 202 (91.4) | <0.001 |
Radio | 191 (59.3) | 106 (48.0) | 0.011 |
Newspaper | 13 (4.0) | 61 (27.6) | <0.001 |
Poster | 2 (0.6) | 25 (11.3) | <0.001 |
Friend | 29 (9.0) | 30 (13.6) | 0.122 |
Healthcare worker | 100 (31.1) | 77 (34.8) | 0.402 |
Advertisement of women’s association | 82 (25.5) | 79 (35.7) | 0.013 |
Others | 3 (0.9) | 7 (3.2) | 0.099 |
Ever attended any educational programs relating to H5N1? | 216 (67.1) | 161 (72.9) | 0.130 |
Requested more information on AI | 303 (94.1) | 213 (96.4) | 0.262 |
|
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Know about the news |
280 (87.0) | 168 (76.0) | 0.001 |
Scared if get AI | 287 (89.1) | 160 (72.4) | <0.001 |
Visited hospital with some symptoms | 174 (54.0) | 87 (39.4) | 0.001 |
Kind of symptoms that you got | |||
Fever | 149 (46.3) | 61 (27.6) | <0.001 |
Dyspnea | 33 (10.2) | 10 (4.5) | 0.015 |
Cough | 145 (45.0) | 48 (21.7) | <0.001 |
Sneezing | 39 (12.1) | 39 (17.6) | 0.081 |
Nasal discharge | 54 (16.8) | 43 (19.5) | 0.427 |
Just scared | 17 (5.3) | 9 (4.1) | 0.548 |
|
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Pay more attention to dead/sick poultry | 297 (92.2) | 213 (96.4) | 0.066 |
Seek healthcare earlier once get symptoms | 293 (91.0) | 220 (99.5) | <0.001 |
Occurrence of H5N1 patients in Cho Moi District, Bac Kan province in the spring of 2010. AI: avian influenza (H5N1) virus infection in humans.
More participants in the event group knew about the occurrence of H5N1 patients in Cho Moi District in the spring of 2010 (event) compared with participants in the non-event group (P = 0.001) (
Some of the KAP results are shown in
Event group (Nhu Co) | Non-event group (Minh Kai) | P value | |
(n = 322) | (n = 221) | ||
No. (%) | No. (%) | ||
AI† is a kind of infectious disease | 303 (94.1) | 216 (97.7) | 0.042 |
People get AI by touching sick poultry | 293 (91.0) | 214 (96.8) | 0.003 |
AI can be prevented | 292 (90.7) | 214 (96.8) | 0.001 |
AI can be cured | 276 (85.7) | 198 (89.6) | 0.001 |
People can die of AI | 298 (92.5) | 214 (96.8) | 0.021 |
Do not eat sick/dead poultry | 165 (51.2) | 158 (71.5) | <0.001 |
Early access to healthcare is the key to treat AI | 312 (96.9) | 215 (97.3) | 0.805 |
What is the most serious disease that you concern | |||
Diarrhea | 57 (17.7) | 38 (17.2) | 0.909 |
Cough/pneumonia | 38 (11.8) | 18 (8.1) | 0.197 |
Avian influenza (H5N1) | 236 (73.3) | 157 (71.0) | 0.625 |
Malaria | 50 (15.5) | 19 (8.6) | 0.018 |
Tuberculosis | 52 (16.1) | 20 (9.0) | 0.020 |
Others | 10 (3.1) | 11 (5.0) | 0.003 |
AI: avian influenza (H5N1) in humans.
Event group (Nhu Co) | Non-event group (Minh Kai) | P value | |
n = 322 | n = 221 | ||
No. (%) | No. (%) | ||
|
|||
Use soap when you wash your hands | 318 (98.8) | 220 (99.5) | 0.766 |
Use clean water when you wash your hands | 245 (76.1) | 208 (94.1) | <0.001 |
What would you do if your household poultry suddenly die? (multiple choices) |
|||
Sell rest of live poultry | 10 (3.1) | 1 (0.5) | 0.032 |
Eat them | 3 (0.9) | 1 (0.5) | 0.649 |
Throw them in a river or pond/outside | 6 (1.9) | 2 (0.9) | 0.482 |
Bury them | 301 (93.5) | 177 (80.1) | <0.001 |
Disinfect poultry cage | 137 (42.5) | 101 (45.7) | |
Report to government authorities | 173 (53.7) | 149 (57.4) | 0.002 |
Do nothing | 2 (0.6) | 0 (0.0) | 0.516 |
When slaughtering poultry, how can you protect yourself from AI? (multiple choices) | |||
Wear gloves | 155 (48.1) | 142 (64.3) | <0.001 |
Wear mask | 159 (49.4) | 123 (55.7) | 0.162 |
Do it away from house | 40 (12.4) | 60 (27.1) | <0.001 |
Wash hands afterwards with soap | 279 (86.6) | 195 (88.2) | 0.603 |
Clean area afterwards… | 110 (34.2) | 160 (72.4) | <0.001 |
|
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After touching sick or dead poultry, if you are sick with fever, how fast do you seek treatment? | 0.002 | ||
Immediately | 250 (77.6) | 200 (90.5) | |
1–2 days after onset | 55 (17.1) | 16 (7.2) | |
If get really sick | 11 (6.4) | 3 (1.4) | |
Nothing | 1 (0.3) | 1 (0.5) | |
Which organization do you seek treatment at first? | |||
Community health center | 291 (90.4) | 56 (25.3) | <0.001 |
District hospital | 52 (16.1) | 30 (13.6) | 0.465 |
Provincial hospital | 2 (0.6) | 137 (62.0) | <0.001 |
AI: avian influenza (H5N1) virus infection in humans.
participants who did not have household poultry answered as if they have household poultry.
Many participants in both groups said that they buried household poultry if that died suddenly, but some participants in the event group said that they sold the remainder of the live poultry (3.1%), ate the dead poultry (0.9%), or threw the carcasses into rivers or ponds (1.9%). When they slaughtered their poultry, significantly fewer participants in the event group compared with the non-event group said that they wore gloves (p<0.001) and did it away from their house (p<0.001).
Significantly fewer participants in the event group compared with the non-event group said that they sought healthcare immediately if they developed a fever after touching sick poultry (P<0.001). The preferred healthcare organization that they accessed first when they got a fever was the commune healthcare center in the event group (90.4%) and the provincial hospital in the non-event group (62.0%).
The median knowledge and attitude-practice scores in the event and non-event groups were 8 vs. 9, and 6.9 vs. 7.4, respectively, out of a total of 10. The differences between the groups in terms of both scores were significant (P<0.001) (
Median | Range | Z |
P value | |
|
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Event group (Nhu Co)(n = 322) | 8 | 1–10 | −4.542 | <0.001 |
Non-event group (Minh Kai) (n = 221) | 9 | 2–13 | ||
|
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Event group (Nhu Co)(n = 322) | 6.9 | 3–10 | −6.482 | <0.001 |
Non-event group (Minh Kai) (n = 221) | 7.4 | 4–9 |
The Z statistic was obtained from the Mann-Whitney test for two independent samples.
In the logistic regression analysis using baseline background data of the participants, factors that influenced early access to healthcare once participants developed symptoms were knowledge about the necessity of early access to healthcare for treating avian influenza, not eating sick and dead poultry, and considering avian influenza to be a life-threatening disease (
Coefficient | Standard error | P value | Odds ratio | 95% confident interval | |
Constant | 0.382 | 0.735 | 0.603 | 1.465 | |
Know that early access to healthcare is the keyto treating AI* | 2.000 | 0.740 | 0.007 | 7.390 | 1.731–31.529 |
Know not to eat sick/dead poultry | 1.146 | 0.557 | 0.040 | 3.145 | 1.056–9.367 |
AI is the most life-threatening disease | 1.233 | 0.526 | 0.019 | 3.433 | 1.225–9.624 |
AI: avian influenza (H5N1) virus infection in humans.
The present study demonstrated that the occurrence of H5N1 in neighboring areas had an emotional impact, and also increased people’s attention to preventive measures and their knowledge about the necessity of early access to healthcare. Information and education delivery need to take into account the local conditions of the population.
Most human cases of avian influenza (H5N1) occur through direct or indirect contact with poultry
More participants in the event group knew about the occurrence of H5N1 patients in neighboring areas (P = 0.001) and were scared when they heard the news of an event (P<0.001). At the time of the event, 174 (54%) of participants in the event group and 168 (76%) of participants in the non-event group visited the hospital with flu-like symptoms such as cough, fever, and nasal discharge, or just because they were scared. The occurrence of H5N1 infection in humans in their neighbors caused the residents to panic and be unable to make calm decisions. They were unsure if their symptoms were attributable to H5N1 or to infection by another influenza virus, and their resulting behaviors made it more difficult for medical providers to take care of those who really needed medical intervention. After the event, almost all participants in the non-event group and over 90% in the event group sought healthcare early once they developed symptoms (e.g., fever). The event thus had an impact on their healthcare-seeking behaviors.
Logistic regression analysis identified factors influencing immediate access to healthcare once participants developed a fever after touching sick/dead poultry as knowledge about not eating such poultry, knowledge about the necessity for early access to healthcare, and recognition of H5N1 as a life-threatening disease. The results indicate that healthcare providers in high-risk areas need to stress the necessity of early access to healthcare, and promote proper knowledge about poultry handling to prohibit habits that favor H5N1 infection. Participants in the event group visited their local health center, while participants in the non-event group visited the provincial hospital. It is difficult to change behaviors and customs, especially in residents of rural areas. However, closer relationships between local healthcare providers and residents could promote early healthcare behaviors in people living in rural communities in deeply-forested regions. Educational programs conducted by local healthcare providers might be effective, but the attitudes of local residents must be taken into consideration when planning health education in communities with H5N1 patients in neighboring areas.
This study was limited to a comparison of participants living in one community affected and the other unaffected by the H5N1 outbreak in 2010, representing a rural and an urban setting in a province of Vietnam. Participants who did not have household poultry were included in the study participants and they need to answer some questions as if they have household poultry. Further investigations comparing subjects with similar socioeconomic conditions and common educational and environmental backgrounds are required to further assess the influence of an H5N1 outbreak.
Awareness of H5N1 patients in neighboring areas can cause panic in residents. However, it can also contribute to early healthcare-seeking behavior. Providing information from experiences of occurrence of H5N1 patients and clinical preparedness are crucial if further influenza pandemics occurred. Periodic educational interventions using locally-adjusted methods could contribute to preventing panic, motivating early access to healthcare, and reducing infection and mortality.
We thank the residents of Bac Kan province, Vietnam, who participated in the present study, as well as the medical providers and healthcare workers in Bac Kan provincial hospitals and in the commune health centers in Cho Moi and Minh Kai for assisting with the survey.