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January 3, 2007

Muppets, Pharmacists and Media Aid Avian Flu Prevention

safiStaff at the Bloomberg School of Public Health’s Center for Communication Programs (CCP) are working closely with partners in over 30 countries to promote behaviors and practices that could help prevent the spread of avian influenza (H5N1). The behavior change campaigns they have developed, which include everything from printed flyers to children’s television programs, are tailored to the specific cultural needs of each country.

Basil Safi, MPH, CHES, EIT, oversees CCP’s avian flu projects in the Near East, Europe and Eurasia regions. He is currently working on programs in Azerbaijan, Ukraine and Egypt. Safi also co-chairs CCP’s center-wide avian flu communication taskforce. Tim Parsons, director of Public Affairs, spoke with Safi about some of CCP’s avian flu prevention programs.

Question: CCP is using children’s television in Egypt as part of a campaign to inform the public about the risk of avian flu. How are you educating kids?

Answer: We have a joint venture with the Sesame Street Workshop. Alam Simsim is the Egyptian version of what we see in the United States as Sesame Street. Kids are often the family messengers in that they learn something at school or through television and they pass it on to the rest of the family. (Watch Alam Simsin video spot 1 and spot 2.)

To target the youth in Egypt, we thought it would be a good idea to use this very popular program to teach messages about general hygiene, safe water and hand washing. One of the transmission routes for avian flu is hand-to-mouth contact. If we can instigate a hand washing campaign or hygiene program it will not only benefit avian influenza transmission, but also reduce the spread of typhoid fever and diarrhea, which are very common in children under age 5. As a matter of fact, roughly 40 percent of all childhood deaths in Egypt are the result of typhoid fever and diarrhea. Any pro-hygiene messages that we can stress in our programs will contribute to the overall public health disease burden.

Hand washing is one of these “heath competent” behaviors, meaning that it is a normative behavior that affects more than one disease. By providing individuals and communities with the proper skills, knowledge and attitudes, we facilitate the sustainability and success of our health programs. This is important because even if a family isn’t affected by avian flu, then we’ve still improved their general health and advanced other national health outcomes.

Question: What are you doing to reach adults in Egypt?

Answer: To reach adults, we’ve used an integrated mass-media campaign that is complemented by various other public and private-sector activities.  You can reach a great deal of people with public service announcements on the TV and radio, but the message dissemination is not complete without more community-level efforts. To reach those without phones or televisions, newspapers and magazines reprinted hundreds of thousands of prevention brochures as inserts. These publications continue to cooperate with our efforts to spread public awareness on avian influenza. In addition, volunteers in our community programs organized to address the avian influenza threat in their villages by holding meetings in homes, setting up committees to screen all the houses breeding domestic birds, and even closing shops that sold live birds

In my opinion, one of the most exciting activities is our use of the AskConsult pharmacy network. In Egypt, because the health care system is so poor, the majority of people go to their pharmacist instead of their doctor to receive health information. There are roughly 21,000 pharmacies in the country and about 15,000 of those are part of our AskConsult network.

Through the AskConsult network, we can tap into this large pool of trained professionals who are a great resource for citizens around the country, even in remote areas. By distributing huge numbers of behavior change materials, like brochures and posters, through the pharmacists themselves, we multiply our capacity to inform local residents about the disease. Not only does the pharmacist learn more about avian flu, but the brochures and posters become conversation pieces whereby the customer and pharmacists can talk things out, regardless of what they came in to buy.  People notice the national branding that we’ve attached to all the print materials and know that it’s the same that was used on our national TV spots.  This provides our program with a level of credibility and assurance that the messages come from a trusted source.

Question: What are you telling adults about avian flu?

Answer: We have nine messages we are stressing. The messages all have to do with spotting the symptoms of avian flu in humans and in animals, transmission routes, protective strategies, and how to take the next step, such as knowing who to contact if someone is sick or has sick chickens in the home.

A lot of this information was transmitted by way of national public service announcements on the TV and radio. In addition to an initial TV spot with general information on modes of transmission of avian flu and basic preventive measures, our office collaborated on the production of three other TV spots. The additional spots included more specific messages on modes of transmission, hygiene and safe preparation of poultry for consumption, safe handling of live poultry, keeping children safe and promoting a national avian flu hotline. The avian flu hotline is housed within the Ministry of Health Promotion and received close to 300,000 calls within the first three months of establishment

Question: How effective are these behavior change programs?

Answer: In Egypt, we did an impact evaluation survey of adults age 15 to 49 with a representative sample of 1,500 households across 21 governorates. Seventy percent of the people surveyed said they had adopted at least one of the nine protective behaviors as a result of the messages they received. Over 51 percent of those surveyed had avoided chickens and birds as a primary change in behavior. The most difficult behavior to change turned out to be the number of people who reported washing their cooking utensils more carefully than usual after preparing poultry.  Only 26 percent changed their behavior with respect to this and it’s a particular area of concern because several international studies have shown that improper sanitation around the kitchen increases the likelihood of H5N1 transmission. Those who heard two or more of the messages were far more likely to be practicing more preventative behaviors. What we showed is that the more campaign messages someone is exposed to, the more likely they are to change their behavior.

Question: What are you doing in other countries?

Answer: In Azerbaijan, we were brought in to assist UNICEF through a USAID-funded program on building a national communication program for the government. Azerbaijan had an H5N1 outbreak in March 2006 and a situational analysis conducted by the World Health Organization revealed that improvements were needed on both the surveillance and communication sides of avian flu.

When avian influenza started to spread within the aviary species, many of the beautiful white geese that Azerbaijan is known for were left dead on the side of the road. We learned that some of the people who became infected had been poor young women who would pluck feathers from these dead geese in an effort to sell feather-based goods, such as pillows. Given this risky behavior and the economic benefit that drives it, one of the messages we needed to develop for Azerbaijan was to tell people to stay away from sick or dead birds and call the proper authorities for proper clean-up.

Question: Were there any obstacles you needed to overcome?

Answer: In Azerbaijan, there were about 12 groups within the country that had developed avian flu information for the public. Some did better than others, but many put together their education messages without really understanding their target population. For instance, some of these brochures had messages relating to cooking chicken until it had an internal temperature of 68 degrees Celsius. That works fine in a gourmet restaurant where the chef has a meat thermometer in his back pocket, but if you’re a rural Azerbaijani you’re not going to be able to tell if the meat is the proper temperature. We therefore suggested the language be changed to say the meat be cooked until it’s a “consistent color” inside and “no longer pink” or to cook your eggs until they are “no longer runny.” Subtle changes like these are very important because advice can often be misinterpreted, or worse, the people follow a well-intentioned, but misinformed source that results in an adverse effect. Either way, the credibility of the messages and the institutions that provided them, can be compromised if they’re disseminated without attention to detail.

Another problem in Azerbaijan was that most of the information about avian flu outbreaks and containment strategies came from the news media. This group was not entirely knowledgeable about the disease and fed the public information that was based on hearsay, not fact. In one instance, the media reported on a culling operation in which the cleanup crew wasn’t wearing any personal protective equipment. What message does that give to a farmer sitting at home watching TV? Is he therefore more or less likely to dawn a mask and gloves when he cleans up his own dead chickens? To improve this general practice of uninformed avian flu reporting, we worked with local counterparts to conduct several workshops for journalists and spokespeople on how to get the important avian flu messages across.

Overall, CCP’s communication efforts in this area have developed increased transparency between the various implementing partners and instituted behavior change materials and programs for those underserved audiences. This communication-based streamlining is now providing the cohesion necessary for all parties involved in the avian flu campaign to work more harmoniously under one umbrella.

To understand behavior change communication as an art, you really need to understand the culture, what the people have been exposed to in the past and what mistakes have been made.  This takes research, scientific application, and program implementers who understand the field of public health communication.

Question: Is CCP doing any avian flu communication in the United States?

Answer: Yes. We will be developing an internal communication plan for the entire Johns Hopkins enterprise system to inform and prepare employees, students and other constituents about a possible avian influenza pandemic. CCP is working with the Johns Hopkins Office of Critical Event Preparedness and Response (CEPAR) and is addressing the myriad issues involved with maintaining operations for a large institution like Hopkins with all of its various branches and functions, should a pandemic occur. These issues range from how to deal with patients at Johns Hopkins hospitals, to students in classrooms, to employees working at all levels in all Hopkins facilities—here and abroad. Needless to say, this is a huge operational challenge for which communication will play a vital role. Once materials and messages are disseminated, we'll be collecting feedback in a methodical fashion to help evaluate effectiveness and guide future communication efforts.

Baltimore represents a high risk area for avian influenza. Roughly 70 percent of the broiler chickens raised in the United States come from the Maryland-Delaware-Virginia shore. The area is also home to two of the biggest migratory stops for birds heading north and south. That combination presents a potential problem, because these migratory birds could carry disease from one region to another and could meander to the poultry feeding farms.

We are working with the Howard County Health Department (one of counties near Baltimore) to develop an avian flu communications plan. We are conducting a series of community discussions with Howard County, which has an ethically diverse population, to assess their individual needs in developing a strategy. At this point, the Howard County Health Department is focusing on preparation messages, including a reminder to people about the importance of getting a seasonal flu vaccine, which could potentially reduce the severity of an avian influenza outbreak.

Additional information about CCP's avian flu campaigns

Public Affairs media contacts for the Johns Hopkins Bloomberg School of Public Health: Tim Parsons or Kenna Lowe or at 410-955-6878 or paffairs@jhsph.edu.