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 . 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 . 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 . 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 ) . 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 ) . 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 . 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% ] ;   30.0 , p<0.001 ) . provinces exposed to avian influenza and intensive information , education , and communication campaigns ( kabul , march 2007 , and nangahar , february 2007 ) . seq was positively associated with kap score above the median ( lowest vs. highest : adjusted odds ratio [ aor ] 14.3 , 95% confidence interval [ ci ] 5.239.9 ) , as was provincial exposure to avian influenza iec campaigns ( aor 9.5 , 95% ci 4.918.6 ) . backyard poultry ownership ( nonowners vs. owners : aor 0.3 , 95% ci 0.20.7 ) and older age group ( 1520 years vs. > 40 years : aor 0.3 , 95% ci 0.10.8 ) were both negatively associated . for secondary analysis , mean kap score differed between seq ( p<0.001 , by analysis of variance ) and was higher in provinces previously exposed to iec campaigns ( 50.2% vs. 40.1% ; p<0.001 , by t test ) . reporting of sick or dead poultry to authorities was less frequent among lowest seq ( 8/47 [ 13% ] ) than highest seq ( 20/49 [ 37% ] ;  6.6 , p = 0.02 ) where selling poultry in the event of a local outbreak was more commonly reported ( 21/66 [ 66% ] vs. 10/51 [ 18% ] ;  27.2 , p<0.001 ) . presence of coops was less frequent in lowest seq ( 9/49 [ 18.4% ] ) than in highest seq ( 21/46 [ 45.6% ] ;  8.2 , p = 0.004 ) . human cases of avian influenza ( h5n1 ) have resulted from contact between humans and infected backyard poultry ( 4 ) . risk to humans is also related to frequency of disease occurrence in the avian population ( 5 ) . recently , human - to - human transmission has been reported in the neighboring northwest frontier province of pakistan ( 2 ) . overall knowledge was low , although in provinces exposed to intensive iec campaigns , kap scores of the population were higher . the level of concern generated by the campaign , government response , media reports , and proximity to the outbreak are all likely to contribute to this association . despite this encouraging evidence , level of knowledge was far higher among persons with higher socioeconomic status . our results can be broadly generalized to the population , although we did not have access to unsafe districts ( most of the districts in southern and eastern afghanistan ) . this limitation may introduce selection bias , which would underestimate the effect of socioeconomic status because those living in inaccessible areas likely have a lower status than persons in accessible areas . preintervention and postintervention surveys would provide a more robust measure of effectiveness . in the immediacy of an outbreak , although there are limitations to the study design in concluding intervention effectiveness , the results provide evidence to support further intensive campaigns as a response to influenza outbreaks in poultry . several reports have examined kaps and behavior related to avian influenza ( h5n1 ) ( 69 ) . similar to the finding in the lao people s democratic republic ( 6 ) , our study suggests that conventional education and behavior change messages have a limited effect in populations with highest exposure . efforts to ensure that iec messages are suitable for lower socioeconomic groups should be adopted , specifically by improving the knowledge of community leaders , designing messages in a suitable format for the poor and illiterate , and ensuring that the most accessible channels are used . messages should carefully balance the risk for human disease against potential nutritional and economic consequences of high population concern ( e.g. , food scares ) . successfully promoting behavior change is a lengthy process and requires frequent reinforcement . the acuteness of avian influenza ( h5n1 ) outbreaks requires a concerted effort to enhance knowledge and change behavior among those most at risk in low - income countries .
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 .