Susan Mackay, Senior C4D Specialist (Health) UNICEF

Partner Insights FAO Risk Communication Seminar

“Business unusual”

AI - What was learned (or not!)

• Multiple KAP studies conducted between 2006-2007 (Unicef research in at least 16 countries)

• Different methodology and designs made it impossible to compare or generalize results

• Interesting insights for designing communication strategies, and general planning

• However insufficient qualitative or participatory research to help address the critical „WHY‟ question

What the KAPs showed

• High awareness but low understanding

– High media coverage likely to be a significant

factor

• Low level of knowledge about

transmission (at best one or two modes of

transmission) and many „incorrect‟ beliefs

Challenges

• Rural and less educated populations less

knowledgeable and less aware

• Studies largely descriptive

– Lacking plausible explanations for

demographic variables or varying levels of

knowledge about different forms of

transmission

– Lack of nuanced analysis unfortunate as

would have been key to improving design

Impact

• Communication campaigns did contribute to

increased awareness

• Knowledge (transmission, symptoms, methods of

disposal, and prevention) increased after exposure

or participation in communication interventions eg

– Meetings and outreach activities increased perceptions

of the seriousness of AI in Laos

– Substantial knowledge increases recorded (transmission

modes and prevention) between 2006 and 2007 in

Thailand and Egypt

Significant knowledge-practice gap

• Although awareness and knowledge of prevention and transmission behavioural change was much lower

– Some actions (cooking and handwashing) easier to implement than others (biosecurity and reporting behaviours) – also linked to low perception of risk

– Need for a much deeper understanding of social, economic and political barriers to change

Risk perception

• Even though awareness and understanding increased, risk perception and sense of urgency generally remained low

• However in urban areas sudden drops in consumption reported during outbreaks – Yet in rural areas consumption even increased

suggesting low risk perception

• AI “only has relative importance”, “people are used to it”

• Lower risk perception than issues such as dengue, malaria, malnutrition, diarrheal diseases and limited access to sanitation

Challenges

• Studies identified variations in risk perception

but did not (or were not sensitive enough) to

investigate highs and lows

– a better understanding of the drivers and timings

of changing attitudes and behaviours is needed

– more „dynamic‟, innovative approaches needed to

tracking changing perceptions of risk

– need to explore relationship with media coverage

(animal and human cases) and of economic

drivers

“… tools are still needed

to address the

challenges of

communicating in these

difficult circumstances.

These tools can be

developed by looking at

alternative paradigms of

risk that exist within the

social sciences.”

Abraham, T, Bull World Health Organ 2009;87:604–607

“Psychometric

paradigm”

Slovic et al.; Covello and

Sandman

“Risk Society” Beck, Giddens etc

Strong

Epidemic

Psychology

Culture, Risk and

Blame Douglas

Social

Amplification of

Risk

(See Murdoch et al.)

But how does this translate in

low resource settings?

Behaviours

Studies showed that the four behaviours are

rarely practices in high risk communities in

„real life‟

But too much emphasis on „educating‟ rather

than finding the „locks‟ and „keys‟ to

behaviour change

– Lack of link with „programme‟ and community

developed solutions

Reality check (1)

Reality check 2

“The idea that one should have to protect oneself from one’s poultry is literally exotic”

“birds and humans have mingled for generations without any negative impact as far as they could see ….”

We must constantly work within peoples social, cultural, political and economic realities.

Reality check (2)

Reality check 1

“AI prevention and control faces formidable obstacles, including disbelief in the existence of the disease, lack of economic means to implement recommended practices, and distrust of the authorities and health services.

“It is important to distinguish between obstacles that can be addressed through communication alone, and those that need different and complementary programme interventions””

Reality check (3)

If we were starting again …

• Much more emphasis on addressing

attitudes, such as low risk perception and

stigma around reporting

• Total integration with technical programming

to reduce structural obstacles that discourage

health practices (eg grant subsidies,

economic aid to strengthen bio-security, as

well as incentives to promote community

surveillance and reporting)

Design shortcomings

• Not enough adjustment of the four key

behaviours to local settings and realities –

need for dialogue and consensus

• Initial outbreak responses were inevitably

„general‟, but later interventions should

have been more tightly focused and

nuanced to address specific needs and

concerns (or lack of!) in segmented high

risk populations

Potential solutions

Participatory approaches to build local

perspectives into design of activities and

solutions

Lessons learned

• Too much emphasis on promoting the actual behaviour but not enough on „selling‟ the benefits and / or risks eg

– Local beliefs

– Social attitudes eg stigmatization

– Agreeing feasible, low cost solutions

– Encouraging self and collective efficacy

– Credibility - understanding the context of trust in local authorities

Social determinants

• Interesting gender, religious and cultural

insights, but in many cases the data was

available only after the bulk of communication

interventions had been designed or

implemented eg

– Women primary handlers of poultry and eggs

spending more time with backyard poultry

– Men involved in handling slaughter, and cock-fighting

in particular countries

– Particular ethnic and or religious practices

Some highlights

Innovative work with schools eg. Thailand,

Indonesia, Turkey

What worked

• High level advocacy with government officials and decision makers

• Training of print and broadcast journalists at national and subnational levels

• Training frontline workers and volunteers, rapid response teams and poultry farmers

• Orientation and training of government spokespersons, school teachers and community influencers

• Folk theatre and rural media

• TV and radio campaigns featuring public service announcements

Limitations

• Frantic pace of activities

– Emergency response to outbreaks

– Pressure from donors to implement quickly

when more time was needed for participatory

research, design and implementation

– Lack of existing capacity at all levels

We were aware of most (if not all) of the

limitations at the time but limited capacity to

change course!

Institutional context

• Level of government commitment, ownership and capacity varied

• Coordinating committees a problem in some areas

• Working relationships within and between agencies varied – where it was good generally the quality of work and impact was higher

– These relationships work best where they are built in advance

• Participatory planning processes involving multiple stakeholders was greatly appreciated

Resource issues

• Some programmes had much more than

funding than they were used to, others had

to work with very limited resources

• Limited human resources within country

offices and country teams – some had to

be pulled from other teams, others had to

be recruited quickly without the necessary

experience or training

AI and Pandemic Influenza

• Much of the AI surge capacity was no longer in place when the H1N1 pandemic emerged

• Confusion about the differences between AI response and pandemic preparedness – should have been delinked!

• Much longer term investment is required in building „C4D‟ capacity – best way to be ready for an emergency

Wish list (1)

• Interagency vision and leadership required to

make long term communication investments

towards „One Health‟

• Capacity for evidence based communication

planning and implementation in all agencies

– correct balance of quantitative and qualitative

research (including PLA, rapid surveys),

implementation, monitoring and evaluation

Wish list (2)

• More emphasis on achieving change

through analysis of „locks‟ and „keys‟ to

change, as well as careful use of

appropriate risk communication approaches

for developing country settings

• Stronger partnership between the agencies

– understanding each others roles,

responsibilities, strengths and weaknesses

Thank

you