DOI: 10.3201/eid1409.071382 Suggested citation for this article:…

DOI: 10.3201/eid1409.071382
Suggested citation for this article: Leslie T, Billaud J, Mofleh J, Mustafa L, Yingst S.
Knowledge, attitudes, and practices regarding avian influenza (H5N1), Afghanistan. Emerg
Infect Dis. 2008 Sep; [Epub ahead of print]



           Knowledge, Attitudes, and Practices
            regarding Avian Influenza (H5N1),
                       Afghanistan
               Toby Leslie, Julie Billaud, Jawad Mofleh, Lais Mustafa, and Sam Yingst

Author affiliations: Ministry of Public Health, Kabul, Afghanistan (T. Leslie, J. Mofleh, L. Mustafa); US Naval Medical
Research Unit 3, Cairo, Egypt (T. Leslie, S. Yingst); London School of Hygiene and Tropical Medicine, London,
United Kingdom (T. Leslie); Sayara Media Communication, Kabul (J. Billaud); and United Nations Food and
Agriculture Organization, Kabul (S. Yingst)



From February through April 2007, avian influenza (H5N1) was confirmed in poultry in 4 of 34 Afghan
provinces. A survey conducted in 2 affected and 3 unaffected provinces found that greater knowledge
about reducing exposure was associated with higher socioeconomic status, residence in affected
provinces, and not owning backyard poultry.



         Avian influenza (H5N1) has been reported in southern Asia (1). In Afghanistan, avian
cases were confirmed from February through April 2007 in 4 of 34 provinces (1). No human
cases have been detected, although limited human-to-human transmission has been reported from
Pakistan (2). Backyard poultry (chickens) were affected in 20 of 22 outbreak sites in 4 eastern
provinces. No outbreaks have been reported from commercial facilities. The response in
Afghanistan was to cull all poultry within a 3-km radius, restrict poultry movement and
importation, and conduct intensive influenza-like illness surveillance and information, education,
and communication (IEC) campaigns within affected provinces. IEC campaigns included leaflets
distributed in affected areas and broadcast media coverage on local television and radio. The
campaign was designed to inform the public through messages aimed at reducing exposure to
disease, preventing spread in poultry, and encouraging reporting. Additional IEC messages were


                                                     Page 1 of 6
aired nationally and outbreaks were widely reported by local news media. We conducted a
survey of knowledge, attitudes, and practices (KAPs) regarding avian influenza in Afghanistan.
The aim was to assess factors associated with KAPs.


The Study

       Five provinces in Afghanistan were selected as a convenience sample (accessibility) that
included both affected and unaffected areas. Two accessible districts in each province were
randomly selected by using a random number generator. Random transects were used to select
10 households per village. To give an approximately equal male:female ratio, either the head of
household, spouse (woman), or the oldest person available at the time was selected. Participants
provided informed consent. Ethical approval was provided by the Institutional Review Board,
Ministry of Public Health, Afghanistan.

       A standardized, structured questionnaire collected information on demographic and
socioeconomic measures, avian influenza information sources and knowledge of appropriate
preventive measures, poultry and animal handling, food and generic hygiene, and human
influenza knowledge and treatment seeking. Questions related to KAPs were scored by a panel
of experts in related disciplines. The questions were ranked for importance in preventing avian
influenza transmission in poultry or reducing human exposure and awarded 5 points, 3 points, or
1 point for correct answers. For each respondent, the sum of scores for correct answers divided
by the sum of available points generated a percentage score. Blank responses to questions were
counted as such and not included in individual denominators. The questionnaire was back-
translated and pilot-tested. The survey was conducted in May 2007, by trained Afghan surveyors.
Data were double-entered by using Microsoft Access (Microsoft, Redmond, WA, USA) and
analyzed by using Stata 8 software (Stata Corporation, College Station, TX, USA).

       KAP scores provided a weighted measure of KAPs related to prevention of avian
influenza. Percentage scores for each respondent were ranked and classified as above or below
the median. The primary analysis was conducted to compare factors (age, sex, socioeconomic
status, provincial exposure to avian influenza IEC campaigns, and poultry ownership) associated
with knowledge above the median. Socioeconomic quintiles (SEQs) were defined by principle
components analysis using employment, education, and household assets as indicators (3).



                                           Page 2 of 6
Factors independently associated by univariate regression at the 95% confidence level were
included in a stepwise multivariate logistic regression model. To numerically evaluate KAP
levels, a secondary analysis assessed differences between mean percentage scores, stratified by
factors identified by logistic regression analysis.

       Data for 304 respondents were included in the analysis. Of the 5 provinces, Kabul and
Nangahar had had influenza outbreaks in poultry in 2007. Enrollment characteristics are shown
in the Table. Median age of respondents (38 years) was high, but it reflected the age of heads of
households and spouses. Poultry ownership was reported by 65.2% of households (>95%
backyard ownership) and differed significantly between SEQs (poorest 53/62 [85.5%] vs. least
poor 20/55 [36.4%]; 2 30.0, p40 years: AOR 0.3, 95% CI 0.1­0.8) were both negatively associated.

       For secondary analysis, overall mean KAP score was 44.4%. Mean KAP score differed
between SEQ (p