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Evaluation of Avian Influenza Community Education Interventions in Rural Egypt Summary Report June 2010

Prepared for UNICEF by SPAN Consultants

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Summary Report on Evaluation of Avian Influenza Community Education Interventions in Rural Egypt Prepared for UNICEF by SPAN Consultants JUNE 2010

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Acronyms AI Avian Influenza CEP Community Education Programme C4D Communication for Development Programme CHL Communication for Healthy Living Project CHW Community Health Worker CSO Civil Society Organizations ERC Egyptian Red Crescent Society FAO Food and Agriculture Organisation FGD Focus Group Discussion GOE Government of Egypt HPAI Highly Pathogenic Avian Influenza KAP Knowledge, Attitudes and Practice MIS Management Information System MOA Ministry of Agriculture and Land Reclamation MOE Ministry of Education MOH Ministry of Health PHC Primary Health Care PPP Public Private Partnership RR Raedat Reefiat1 (Community Health Workers) SM/C Social mobilization and communication TOT Training of Trainers UNICEF The United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organisation

1 Raedat Reefiat is the plural for Raeda Reefia. The acronym used in this report (RR) is the phonetic transcription of the Arabic

name in plural form for rural community health workers. The word Raeda is used in the report when referring to a single community health worker.

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Acknowledgements SPAN Consultants’2 team of experts and field staff wish to express their appreciation for the support and encouragement received throughout the execution of this assignment. In particular, we wish to thank the housewives, schoolchildren, supervisors, teachers and community leaders, who took the time to reply to our questions and share their concerns. Furthermore, local authorities at the Governorate and District levels, as well as representatives of the Ministries of Health, Education, Agriculture, Environment and the Egyptian Red Crescent spared no effort to facilitate our task, for which we are grateful and appreciative. Special thanks also go out to the Raedat Reefiat team and their supervisors for their generous support and assistance throughout this undertaking. Thanks are due to Ms. Mona Ismail, Statisticians, for her effort in data management. Sincere acknowledgements are also due to valued partners and distinguished team of experts who have participated with their feedback and valuable advice on this study at different stages of the evaluation process.

Ministry of Heath: Dr Nasr El Sayed, Dr Amr Kndeel, Dr Amal Zaki, Dr. Samir Refai , Dr. Mohamed Gendi and Dr. Mohamed Amin

Ministry of Education: Mr Nabil El Demerdash and Ms Elham Abou El Kheir Egyptian Red Crescent Society Dr Magda El Sherbeeni and Dr Amal Emam

Ministry of Agriculture: Dr. Mona Mehrez and Dr. Shereen Galal Technical Experts and Consultants:

Dr. Elham Fateem, Prof Dr. Mohamed Hassan, Dr. Habiba Wassif, Prof Dr. Maha El Rabbat, Prof Dr. Fatma El Zanaty and Dr. Khaled Darwish.

UN Agenciers : Dr. Nasr El Tantawy WHO , Dr. Chadia Wannous, UNRC Office

Last but not least, the continued technical guidance and support provided by UNICEF’s Communication for Development team – headed by Dr. Sahar Hegazi - is greatly valued. Her significant contribution and guidance during the various stages of the evaluation were highly appreciated.

2 SPAN Consultants is an independent consulting firm based in The Netherlands, active in the field of development cooperation.

The firm has operations around the world and offers specialist services in the areas of communications, education and human resource development.

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Introduction Avian Influenza (AI) was first confirmed in Egypt in February 2006, and over 1,450 outbreaks have been reported since that time affecting more than 920 commercial and small farms along with 530 home breeders. These outbreaks have resulted in the culling of more than 40 million birds in Egypt. Reported outbreaks amongst poultry and human populations show a seasonal pattern of Avian Influenza with most cases occurring during the winter months (October – March). The first cases of Avian Influenza in Egypt were detected in poultry in several governorates of the delta region in February 2006. The first human case of AI H5N1 was confirmed on the 18th of March 2006 to a 30-year old housewife from Damietta governorate and resulted in her unfortunate death. Since then, a total of 109 human cases - 34 of which were fatal - were reported in 25 of the 29 governorates across the country. The incidents of AI amongst children under 18 accounted for more than 60% of all cases. Of the confirmed human cases, the number of women who contracted AI was relatively high as they accounted for roughly 68% of all confirmed cases (source: MOH AI Surveillance data 2009). As per May 2010, the AI H5N1 virus has infected poultry in 26 out of 29 governorates across Egypt. The Egyptian Government recognizes the seriousness of the AI threat and national response efforts are coordinated with UN agencies and the international community and led by several government ministries including the Ministry of Agriculture and Land Reclamation (MOA) and the Ministry of Health (MOH). As a response to the Avian Influenza epidemic, a high-level coordinating body – the Supreme National Committee for Combating Avian Influenza, was established after the outbreak upon the Prime Minister’s instruction to bring together interested organizations to contribute to national efforts for the prevention and control of AI. The approach of national and international partners remains to “catch and contain” the AI H5N1 virus in the bird population before it spreads to humans, as well as provide citizens with the necessary information on basic hygienic practices that will help them avoid AI infection. The social mobilization and communication component of the 2007 Integrated National Plan for Avian and Human Influenza (INPAHI) was formulated as a multilayered platform that uses several methods of communication to reach targeted populations. Implementation of different communication approaches at the ground level, especially to access hard-to-reach populations, was done against the backdrop of an ongoing public media campaign. Additionally, door-to-door visits by the Raedat Reefiat (community health workers), who were trained to implement the Avian Influenza community-based education program in addition to an intensive awareness raising program in communities and in primary schools were launched in mid 2006 by UNICEF, MOH and MOE. Other collaborators from international partners such as WHO, USAID, UNICEF, FAO, and the Communication for Healthy Living (CHL) project complemented this effort through other communication initiatives. To fortify efforts made by governmental and international actors, national civil society organizations – like the Egyptian Red Crescent (ERC) – also made important contributions towards the prevention and controlling of the spread of AI.

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Purpose of the Intervention The communication for development strategy in the national communication plan draws on UNICEF’s earlier experience implementing the social mobilization and communication interventions. The overall aim of UNICEF’s AI-related community education has been to target high risk vulnerable groups who handle poultry in rural Egypt to minimize the chances of infection in humans, especially among breeding families. While the wider public is the main target, high risk vulnerable groups include women and children in households that breed poultry under unsafe conditions, and primary school children between the ages of 6-12. To reach this goal UNICEF’s main strategic C4D objectives are to:

Support the Egyptian Government in controlling the spread of the H5N1 virus among poultry;

Minimize the likelihood of human exposure to infected poultry;

Ensure early detection of human cases; and,

Take all preparatory measures for a possible pandemic. Overview of UNICEF- Supported Avian Influenza Interventions 2006 – 2009:

UNICEF has been the leading agency on communication for development for AI given the organizational global commitment. UNICEF-supported interventions can be grouped in three phases starting from 2006 until the end of 2009 as described below:

The first phase was initiated in the period mid 2006 to mid 2007 whereby the most affected 7 governorates were covered with social mobilization and awareness campaigns as well as house-to-house educational activities on the villages’ level. Additionally, a school program was implemented targeting primary school children in the same areas. A national radio campaign which included celebrity drama, mini drama, educational spots, children song, and Q and A talk shows which echoed the same messages disseminated on the community level. Policy advocacy on the governorates level was a key strategy in addition to networking with NGOs and the civil society.

The second phase of UNICEF-supported interventions was expanded to 17 governorates by mid 2007 till end of 2008. Interventions included building a new monitoring and supervision system for community outreach program of MOH (Raedat Reefiat), intensifying social mobilization and community awareness to support the community education and the launch of a strong and wide edutainment school program. These activities covered about 4.8 million households through 11,000 Raedat Reefiat (RR) and more than 3.8 million children in primary schools of the rural areas with the support of almost 9000 teachers3. Partnership to realize this effort also expanded to include Ministry of Education (MOE), and The Egyptian Red Crescent (ERC). Several creative communication approaches were introduced including the edutainment school kit that

3 School program was implemented under phase 2 in 13 governorates only for funding limitations.

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combines games and activities in delivering the protective messages. Celebrities like the renowned actress Karima Moukhtar were also tapped on to appeal to rural women in their adherence to hygienic practices.

The third stage started in 2009 and expanded the implementation of the same interventions to 24 governorates (out of 29) both for the community and school program. In addition to rural areas, slum neighbourhoods of greater cities were also targeted as part of the intervention sites. However, the most significant result of this phase was the completion, testing and application of the community outreach system of MOH’s RR, which proved to be quite instrumental in the management of the community education program and in transforming its system into a data-driven program.

The four main messages for schoolchildren were: Wash (regular hand washing), Stay away (do not handle or play with poultry), Separate (separate different types of poultry and separate breeding from living places) and Notify (report sick and/or dead poultry to the appropriate authority). For the households, the critical practices also included hand-washing after handling poultry, keeping children away from poultry, caging poultry and separating them from living and sleeping areas as well as safe slaughtering and buying from safe sources.

Previous Studies UNICEF undertook a number of research activities to plan, monitor and evaluate different phases of the AI program. The Knowledge, Attitudes and Practice (KAP) study related to AI, which was implemented by El-Zanaty (2007) among women over the age of 15 years before the interventions, was used as a baseline for the household survey. Similarly, a qualitative study carried out by El Rabbat in 2007 was used to assess the progress made through the AI community education intervention among the RR. Findings obtained from this study were used to support the development and revision of the RR supervisory Management Information System (MIS). The outcomes also served as a basis for adapting AI-related health communication and education strategies, especially among women raising backyard poultry in rural areas, as well as for the improvement of RR systems. Another study, the 'School Edutainment Intervention Baseline Survey' was conducted by ERC in cooperation with UNICEF Egypt in 2008. The survey was carried out in 13 governorates in the first phase of the intervention and included a sample of 5,900 pupils in Lower and Upper Egypt. The results of this survey served later as the baseline data for the schools in this evaluation study and were used for comparison purposes. Finally, a qualitative study was conducted by UNICEF and MOE in 2008 to plan the school intervention and its findings were employed as the basis for the development of the school kit.

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Objectives of the evaluation The overall goal of this evaluation was to assess the outputs, outcomes and impact of UNICEF’s Avian Influenza Communication for Development Program at the family and community levels. This analysis of the communication program will serve to support the planning, design and implementation of future interventions. The specific objectives:

Provide assessment of the public knowledge, attitudes and practices (KAP) regarding AI that were affected by direct exposure to the community education intervention on the household level.

Provide an evaluation of the overall outcome of the UNICEF-supported AI program.

Highlight strengths and weaknesses of the intervention and draw key lessons learned.

Evaluation Design and Data Sources The evaluation study was designed to provide both quantitative and qualitative data. Quantitative inputs were generated from a new KAP survey with structured face-to-face interviews with women at home and pupils at primary schools. In parallel, qualitative input was generated from focus group discussions (FGDs) held with the RR, teachers and male community members/leaders. The quantitative sample consisted of 2,763 households (1,361 in Upper Egypt (44%), 1,235 in Lower Egypt (49.3%), and 167 in Ismailia (6.0%) as a control group). The schoolchildren sample consisted of 3,240 pupils (1,440 in Lower Egypt and 1,800 in Upper Egypt). The qualitative sample consisted of 203 respondents (91 RR, 69 teachers, and 43 men as community members/leaders). Table 1. Households Sample Distribution

Region Governorate Households

interviewed Percentage

%

Lower Egypt

Dakahlia 427 15.5

Menoufia 254 09.2

Sharkia 253 09.1

Damietta 217 07.9

Beheira 210 07.6

Total 1361 49.3

Upper Egypt

Beni Sweif 233 08.4

Minia 212 07.7

Assiut 419 15.2

Aswan 190 06.9

Qena 181 06.5

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Total 1235 44.7

Control Ismailia 167 6.0

Total 11 2,763 100.0

The majority of household respondents (HH) were females (99.2%) between 15 and 75 years of age, with an average age of 35 years. Half of the respondents were illiterate (50.3%) and only one third (31%) received education beyond the mandatory 9 years of basic schooling. Less than half of all the households (43.6%) had children under the age of 10. Table-2 Schoolchildren Geographical Distribution

Region School Children

Percentage %

Lower Egypt 1,440 44.4

Upper Egypt 1,800 55.6

Total 3240 100.0

The total number of schoolchildren surveyed (3240) was divided equally among males and females. Children almost equally varied between grades one and six with ages ranging from 6 to 12 years. Five target groups were identified for the qualitative and quantitative segments of this study and were divided as follows:

1- Women in households 2- Schoolchildren 3- Community health workers (Raedat Reefiat) 4- Teachers who received training as AI communication providers 5- Male community members and leaders

Women in households were included in the survey to demonstrate the results of community-based AI communication activities. The aim was to examine their knowledge and behaviour regarding AI practices as well as assess how well they absorbed safe AI-related attitudes and behaviours. Furthermore, an appraisal of the IEC tools specifically developed for the school program was conducted The sample was representatively drawn in 10 governorates of various geographical locations out of the total of 17 governorates in Upper and Lower Egypt where the intervention was implemented. One district in Ismailia governorate (Qassassin) was selected as the control group. This particular district was selected as a ‘control’ since it was not covered by the intervention program and due to its similarity to the experimental group in its demographic and environmental characteristics. Other segmentation of data included households divided into

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breeders and non-breeders, visited and non-visited by RR, comparison of KAP among schoolchildren before and after the interventions and a comparison between households and schoolchildren concerning knowledge and practice. Schoolchildren were also covered by the KAP survey that examined their gained knowledge of key program messages and any reported behavioural changes. Children’s preferences for activities and games utilized to facilitate information outreach on AI were also investigated. These schools were selected from the same villages where household surveys were conducted, and represent schools that have already implemented the School AI Edutainment4 Program. Pupils, aged 6 – 12 years from all the grades of primary education were sampled for interviews. There was no control group selected for the school survey given the availability of pre-intervention baseline data. The aim of the qualitative study with community health workers was to evaluate the AI educational materials used by the RR and to assess the overall community awareness and any perceived change of the behaviour and practices among the target group (mainly women in the households). Equally, the discussions with teachers covered their role as implementers of the AI-related School Program, the training they received, the cooperation with colleagues on the implementation of the AI School Program, use of the materials received, and suggestions for improvement of similar interventions in the future. Meanwhile the main aim of the FGDs with community leaders/ men was to obtain their general opinion on the implemented AI community based interventions and their suggestions for the development and implementation of such activities in the future. Other data sources for the study included a desk study of the documents and reports made available by UNICEF, as well as face-to-face interviews with leading policy and program managers of various institutions participating in the initiative. Results of the quantitative KAP surveys in households and at schools, and the qualitative FGDs, are presented in this English summary that highlights the main findings from the discussions, which were conducted in Arabic. The results of qualitative research are incorporated within the quantitative analysis to confirm or deny findings. Additionally, the outcomes of the quantitative studies were also compared with findings presented in reports of earlier conducted baseline surveys in households and at schools.

Qualitative Sample

Table-3 Number of focus group sessions and number of participants

Governorate

# of RR sessions

# of RR Participants

# of Teachers’ sessions

# of Teacher Participants

# of Men sessions

# of Men Participants

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4 Edutainment is short for educational entertainment and activities that fall under this definition are used to educate, as well as

entertain children on a host of different issues. Different types of edutainment include the use of film, radio, TV, computer software, museum exhibits and hands-on workshops.

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Lower Egypt

Menoufia 1 7 1 8 1 8

Dakahlia 2 15 - - 1 7

Sharkia 1 7 1 8 - -

Beheira 1 8 1 7 1 8

Damietta 1 8 1 7 -

Total 6 45 4 30 3 23

Upper Egypt

Beni Sweif 1 8 - - - -

Minia 1 8 1 8 1 7

Assiut 2 14 2 15 1 6

Qena 1 8 1 9 1 7

Aswan 1 8 1 7 - -

Total 6 46 5 39 3 20

Total 12 91 9 69 6 43

Evaluation Design and Data Sources 1. General Findings The graph below (Graph – 1) shows that the experimental group (Upper & Lower Egypt) values information obtained from the RR and the Health Unit more than information received via other information channels, while the control group (Ismailia) values information received through the TV more than any other channel. This confirms that information is better obtained through the RR followed by the Health Unit than other information channels.

0

10

20

30

40

50

60

Unit RR TV Physician

44.0

57.6

16.0

3.5

43.740.0

24.7

10.2

42.8

4.2

44.6

18.1

Regions

Information Sources

Graph-1: Sample Opinion of Information Source

Lower Egypt

Upper Egypt

Ismailia

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Children were asked to recall the four key messages taught in the AI Edutainment School Program; and the majority of schoolchildren were able to remember them all. While in Lower Egypt the order of the four messages came as follows: Wash, Stay Away, Separate, and Notify, in Upper Egypt, the order was slightly different: Wash, Stay Away, Notify, and Separate. It is clear that all four messages are known to almost all the children. As for the messages order by gender, the messages were recalled in identical order by both genders. Preference of Edutainment School Kit Table-4 Popularity of School Kit by Grade

1-2 3-4 5-6 Total

Games and Activities

# of Cases

Percentage %

# of Cases

Percentage %

# of Cases

Percentage %

# of cases

Percentage %

Snake and Ladder 560 23.7 858 36.3 948 40.1 2366 100.0

So Koko 248 18.1 524 38.2 601 43.8 1373 100.0

Healthy Home 64 27.8 37 16.1 129 56.1 230 100.0

Koko Woawa 260 29.5 274 31.1 347 39.4 881 100.0

Story of Abdel Sabour

262 22.6 407 35.1 491 42.3 1160 100.0

Cartoon Film 433 29.2 467 31.5 583 39.3 1483 100.0

Others 52 36.9 45 31.9 44 31.2 141 100.0

Table-4 demonstrates the opinion of pupils on the edutainment school kit. The Healthy home

activity (a drawing of a home where good breeding practices are exercised which could be used

mainly in art classes for drawing and modelling), was the most popular game with grades 5-6

because it helps them to understand the importance of staying away from the birds. Teachers

0

10

20

30

40

50

60

70

80

90

100

Wash Stay away Separate Notify

91.7 90.2

76.373.4

94.0 92.6

86.189.2

Regions

Messages

Graph-2: AI Message Retention by School Children in Intervention Areas

Lower Egypt

Upper Egypt

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consider it one of the most important activities and find that it is essential for the children to

learn the meaning of “healthy home” and the idea of ‘separation’.

معنى فيما بيحبه سادست خامست سنت يف انتالميذ. جديدة حاجت األطفال بيعهم ألنو األنشطت أحسن من يانصح انمنزل

. انمعيشت يف بينيم بينا انفصم انطير عن انبعد أىميت فكزة يانصح انمسكن

Sokoko, a pictorial mental game inspired from the Japanese numerical game Soduko, on the other hand, was the most popular game with grades 3-4 because of its competitiveness and group play, while Koko Wawa was the favourite among the children in grades 1-2, an activity that displayed the sick birds’ symptoms and according to teachers children enjoyed working with the thermometer very much.

يبسط بشكم انشسائم بخششح كا يافست فيا جاعيت نعبت ألا انسكك نعبت بيحبا سابعت ثانثت ست حالييز يخخصش

صسة حبا األطفال ،انشض أعشاض بخششح ألا حايت أنى ست يف األطفال ي يحببت اا انفشخت كك انفشخت يعبشة ألا انخشييخش

2. Overall Knowledge, Attitudes and Practices

Table-5 AI Symptoms in Humans (HH)

RR visited RR did not visit Total Intervention area Control area Total

Symptoms # of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

%

Fever 841 73.1 309 26.9 1150 100.0 1897 95.0 99 5.0 1996 100.0

Cough & Difficult Breathing

426 74.1 149 25.9 575 100.0 961 94.5 56 5.5 1017 100.0

Sore Throat 141 75.4 46 24.6 187 100.0 335 94.9 18 5.1 353 100.0

Muscle Ache 215 77.1 64 22.9 279 100.0 414 95.2 21 4.8 435 100.0

Sneezing 631 72.1 244 27.9 875 100.0 1418 95.0 75 5.0 1493 100.0

Others 46 73.0 17 27.0 63 100.0 110 100.0 - - 110 100.0

Responses obtained from HH visited by RR are at least 50% higher than in not visited households, which yet again confirm the positive role the RR fulfilled in educating women in households about the symptoms. More significantly, the intervention areas showed knowledge of AI symptoms by 90% higher than the control area. This is an obvious confirmation of the contribution of the program to the increase of general awareness of AI symptoms. The overall effect of the program is reflected in Table-5 which compares the household knowledge of AI symptoms among those visited and not visited by the RR and subsequently it also compares the results obtained in the intervention areas with those achieved in the control area.

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The general impact of the program is reflected in the percentages of vaccinations in the intervention areas of Lower & Upper Egypt which reached 95.6%, while this was 4.4% in the control district of Ismailia. Accordingly, RR and community men asked for more involvement of veterinary units to support

the role of RR.

Table-6 Can we protect ourselves from AI? (schoolchildren)

Baseline Post-survey

# of Cases Percentage % # of Cases Percentage %

Yes 4436 77.7 3096 97.9

No 1270 22.3 66 2.1

Total 5706 100.0 3162 100.0

The post-intervention survey shows a higher awareness of protective measures, as 97.9% of the respondents believe they can protect themselves from AI as opposed to 77.7% in the baseline (Table-6). Both the baseline survey and the post-intervention study show that in perception of the respondents the number one protective practice is to stop playing with poultry and the score increased from 33.0% to 58.4%. Finally, the share of respondents who had no idea how to protect themselves against AI in the baseline survey (7,4%) decreased in the study after the interventions significantly (0.9%). Separating poultry from living areas came in third in the post-intervention study and was not that significant in the baseline survey. This proves yet another increased awareness in protective practices. Mothers are usually responsible for raising the poultry which was proven in both the baseline survey and the post-intervention study. Sisters are usually next in line in both measurements. Only 8.4% of the respondents in the baseline survey were responsible for raising the poultry themselves and this share increased in the post-intervention study to 11.1%. Teachers mentioned that some pupils said that they stopped helping their mothers in poultry

breeding. They also confirmed a positive response from girls in 5th and 6th grades who stated

covering their mouth and nose and changing their dress when helping their mothers deal with

poultry.

قانا أمياتيم ابيساعد يانم سادست خامست سنو يف يانم انبناث. انطير عشت ماما مع نطهع بطهنا إحنا ننا بيقنا األطفال

بإيشارب مناخيزىم بقيم يغطا بقا إنيم

Table-7 Raising poultry at home can transfer AI (schoolchildren)

Baseline Post-survey

# of Cases

Percentage %

# of Cases

Percentage %

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Yes 4433 78.1 3055 97.0

No 1245 21.9 96 3.0

Total 5678 100.0 3151 100.0

The awareness of the poultry raising effect increased significantly from 78% to 97% as evident in Table-7 above. Results of both studies (baseline and post-intervention survey) show that schoolchildren believe that playing with poultry is the number one opportunity for getting infected with AI at percentages increasing from 33.7% to 59% respectively. The second cause of infection in the baseline survey was cleaning the breeding place at 21.6% and in the post-intervention study at 47%. Diseased poultry came in third. Table-8 Vaccination of Poultry (HH)

RR visited RR did not visit Total

# of Cases

% # of Cases

% # of Cases

%

Yes 625 79.8 158 20.2 783 100.0

No 153 50.8 147 49.2 300 100.0

The RR’s role is greatly apparent in the vaccination (Table-8) as it shows that almost 80% of the visited households vaccinate their reared poultry. In the non-visited sample it was 20%. Table-9 Cooking Birds (HH)

Preventive message

RR visited RR did not visit Total Intervention area Control area Total

# of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

%

Clean with Soap/

Vinegar/Flower/Salt

1062 70.1 452 29.9 1514 100.0 2350 94.2 144 5.8 2494 100.0

Boiling 1098 69.2 488 30.8 1586 100.0 2491 93.9 161 6.1 2652 100.0

Others 2 66.7 1 33.3 3 100.0 6 100.0 - - 6 100.0

70% of the households (HH) visited by RR mentioned washing poultry with soap, vinegar, flour

and salt, while this practice was reported by only 30% of those not-visited by RR. The same

difference is evident in proper boiling as it reached 69% among those visited by RR, and less than

half of that percentage among those not-visited. Table-9 above confirms these findings and

sheds more light on the practices in intervention areas versus control area, which confirms the

positive effect of the awareness program.

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Table-10 Behaviour with Dead Birds (HH)

Behaviour RR visited RR did not visit Total Intervention area Control area Total

# of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

%

Cover Nose 36 65.5 19 34.5 55 100.0 95 92.2 8 7.8 103 100.0

Cover Hands 111 77.6 32 22.4 143 100.0 277 98.6 4 1.4 281 100.0

Cover bag with Phenol

380 85.0 67 15.0 447 100.0 848 97.6 21 2.4 869 100.0

Burry bag safely

285 69.0 128 31.0 413 100.0

696 88.9 87 11.1 783 100.0

Notify 62 83.8 12 16.2 74 100.0 124 100.0 - - 124 100.0

Table -10 confirms the impact of the intervention program on HH as the comparison between respondents visited and not visited shows a significant variation in practices involving handling dead poultry. The same finding is confirmed when comparing the intervention and control areas’ responses. 3. Critical AI Knowledge, Attitudes and Practices:

I. Change in AI specific Knowledge

Table-11 Protective Measures

RR visited RR did not visit Total Intervention area Control area Total

Preventive message

# of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

%

Separate Children

616

207 25.2 823 100.0

1300 94.5 75 5.5 1375

100.0

Separate Elderly 18 72.0 7 28.0 25 100.0 36 92.3 3 7.7 39 100.0

Separate Pregnant

17 77.3 5 22.7 22 100.0 37 100.0 - - 37 100.0

No House Rearing

313 66.9 155 33.1 468 100.0

784 95.6 36 4.4 820 100.0

Separate Different Poultry Types

37 84.1 7 15.9 44 100.0

94 100.0 - - 94 100.0

Boil Chicken 350 73.8 124 26.2 474 100.0 837 97.3 23 2.7 860 100.0

Ware Gloves on Slaughtering

187 83.1 38 16.9 225 100.0

405 98.3 7 1.7 412

100.0

Special Dress 461 88.1 62 11.9 523 100.0 1002 98.4 16 1.6 1018 100.0

Continuous Soap Hand Wash

700 70.4 295 29.6 995 100.0

1614 94.2 99 5.8 1713 100.0

Cover Nose & Mouth

382 83.6 75 16.4 457 100.0

761 96.5 28 3.5 789

100.0

Disposal of Ill Birds

75 71.4 30 28.6 105 100.0

162 89.5 19 10.5 181 100.0

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The positive effect of the program is confirmed further in the above table (Table-11) as it shows the much higher awareness of protective measures acknowledged in intervention areas and specifically when visited by RR. When households (HH) were asked on their knowledge concerning handling poultry, they particularly highlighted the following protective knowledge ordered by importance:

Soap hand-wash

Cover mouth & nose

Special footwear

Cleaning of breeding place The following graph (Graph-3) illustrates all their responses

Disposal of Dead Birds

59 70.2 25 29.8 84 100.0

134 89.9 15 10.1 149 100.0

Disposal of Remnants

114 80.9 27 19.1 84 100.0

214 95.1 11 4.9 225

100.0

Do Not Eat Birds 11 42.3 15 57.7 26 100.0 34 87.2 5 12.8 39 100.0

Immunization of Poultry

209 80.7 50 19.3 259 100.0

367 95.3 18 4.7 385 100.0

Avoid Migratory Birds

34 82.9 7 17.1 41 100.0

60 96.8 2 3.2 62

100.0

Notify Ill & Dead Birds

48 61.5 30 38.5 78 100.0

103 89.6 12 10.4 115 100.0

Others 46 73.0 17 27.0 63 100.0 99 100.0 - - 99 100.0

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Breeding practices (Graph-4) A comparison of breeding practices in household visited by RR versus those not-visited is shown in the graph above (Graph-4). When households (HH) were asked what they actually do when handling poultry, those visited by RR mentioned “wearing special dress” as the most significant practice, while the not-visited mostly gave a reply falling under “Other practices” which signifies their disagreement over the most important practices. The second most important practice mentioned by those visited by RR was “clean footwear”, while those non-visited mentioned “hand-washing with soap”. This demonstrates the impact the RR had in anchoring information among visited HH versus the confusion and lacking awareness among those non-visited. As mentioned earlier, UNICEF-supported AI community intervention focused on five practices. Three of them were most critical: hand-washing with soap, keeping children away from poultry and separating poultry from living area. The two other important messages were safe slaughtering practices and purchasing poultry from known sources.

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II. HANDWASHING:

Table-12 Hand-washing (schoolchildren)

Baseline Post-survey

# of Cases

Percentage %

# of Cases

Percentage %

Yes 5552 97.5 3189 99.7 No 74 1.3 4 .1 I do not know 71 1.2 4 .1

Total 5697 100.0 3197 100.0

Table-12 above shows clearly that washing hands among school children increased overall by almost 2% when comparing the results of the post-intervention survey with those of the baseline. When asked why they thought hand washing is important, 93.8% of the children answered it is important to protect themselves from diseases in the post-intervention survey. This share was 64.9% in the baseline survey. This is evident in Table-12a below. Table-12a Hand Washing is important because (schoolchildren)

Baseline Post-survey

Reason # of Cases

Percentage %

# of Cases

Percentage %

Protect us from diseases 3603 64.9 3006 93.8

Cleaning our nails 2120 38.2 181 5.6

Always clean - - 1600 49.9

‘Tahara’ (cleanliness) - - 282 8.8

Part of our tradition 77 1.4 64 2.0

Learn that from my family and school 359 6.5 294 9.2

I do not know 177 3.2 23 .7

Others 10 0.1 67 2.1

Germs, pollution,…etc. 385 6.9 - -

The following table (Table-13) illustrates that washing hands after waking up increased significantly (from 40% to 68%). However, this seems a logical conclusion to general increase in hygiene awareness. Washing hands before and after eating came second, also increasing remarkably from 50.3% to 63%. In addition, washing hands doubled after handling the garbage and quadrupled after cleaning the breeding place.

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Table-13 When to wash hands (schoolchildren)

Baseline Post-survey

Timing # of Cases

Percentage %

# of Cases

Percentage %

Wake up in the morning 2268 39.9 2195 68.2

Before eating 1191 21.0 792 24.6

After eating 1076 18.9 866 26.9

Before and after eating 2855 50.3 2024 62.9

After playing with birds 238 4.2 320 9.9

After cleaning the birds cage 196 3.5 390 12.1

After get rid of garbage 183 3.2 186 5.8

After WC 367 6.5 597 18.5

Any time I found my hand not clean 918 16.2 1232 38.3

At the end of the day 363 6.4 783 24.3

At Wodoo 755 13.3 1072 33.3

When go to sleep 433 7.6 732 22.7

There is no particular time 289 5.1 38 1.2

Others 115 1.9 98 3.0

III. Caging and Poultry Separation

Table-14 Location of Poultry in the House (schoolchildren & HH)

Table-14 above confirms the actual poultry raising location. Having a cage in the home yielded 12.5% in the baseline study and reduced to 5% in the post-intervention survey, which was also consistent with the HH responses: 26.8% said keeping poultry caged on the roof, while 9.9% said having birds free outside home. This means that the “Separate” message is becoming clearer in reality. RR reported in FGDs that they witnessed the impact they had on the general awareness. While they used to be greeted by running birds when visiting houses before, they have noticed some

Baseline Post-survey HH

Location # of Cases

Percentage %

# of Cases

Percentage %

# of Cases

Percentage %

Cage on Roof 2737 62.8 1667 61.8 511 26.8 Un-caged on Roof - - - - 204 10.7

Cage on Home 543 12.5 131 4.9 126 6.6

In Certain Room 573 13.1 501 18.6 433 22.7

Free in the Home 82 1.9 29 1.1 181 9.5

Free Outside the Home 109 2.5 58 2.2 190 9.9

Caged outside - - - - 316 16.5

Others 360 8.3 311 11.5 - -

Total 4360 100.0 2697 100.0 1910 100

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improvement because they do not longer see birds running freely in the houses or on the streets as frequently as in the past. Preventing the birds from roaming in the street was one of the indicators of the ‘separate’ message. When comparing results of the survey in the intervention and control areas, it showed that almost 86% of the HH in the intervention areas don’t let their poultry out, compared to only 14% in control area.

انبيج ج بيجشا يقابالا انفشاخ يبالق انبيث ذخم نا كا صيا, يعضنت عشش يف انطيس يشبا احعها دنقج اناط .انشاسع يف يجشا سايبيى أ األض فى

IV. The Role of Children in Poultry Breeding

Table-15 Children Help Raising Poultry (schoolchildren &HH)

Baseline (schools) Post-survey (schools) Post-survey (Households)

# of Cases

Percentage %

# of Cases

Percentage %

# of Cases

Percentage %

Yes 2381 54.6 985 39.6 205 10.8

No 1981 45.4 1505 60.4 1692 89.2

Total 4362 100.0 2490 100.0 1897 100.0

Table-15 above shows a large variation between schoolchildren and households in answering the same question which is whether or not the child participates in raising poultry. While 39.6% of the children responded positively, women/mothers responded to the same question positively at 10.8%. This variation in answers versus the consistency of children’s answers in the baseline and post-intervention survey favour the children’s responses and could indicate that mothers are aware of the risks involved in asking children to assist which may have led them to provide a pleasing answer. This is positively confirmed by the RR’s observation that in spite of the fact that the majority of those responsible for the breeding are the women in the households, children, especially girls, still help feeding the poultry and cleaning the breeding places. However, it is noticeable that some of the families are concerned about the dangers of AI and try to prevent children from assisting.

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Table-16 How are children helping with the poultry

Baseline Post-survey

How children help # of Cases

Percentage %

# of Cases

Percentage %

Cleaning the cage 380 16.0 335 27.5

Collect Eggs 552 23.2 517 42.5

Selling Poultry 38 1.6 10 .8

Feeding 1598 67.1 1049 86.3

Slaughtering 53 2.2 11 .9

Throw Remnants 180 7.6 63 5.2

Others 35 1.3 6 .5

Table-16 shows that most children mentioned helping by feeding birds when asked in the school survey. The percentage of children who mentioned participating in slaughtering poultry decreased from 2.2% in the baseline to 0.9% in the post-intervention study.

V. Safe Slaughtering

Table-17 Behaviour on Slaughtering (HH)

RR visited RR did not visit Total Intervention area

Control area Total

Behaviour # of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

% # of Cases

%

Wash Hands w Soap Before

174 83.3 35 16.7 209 100.0 333 94.9 18 5.1 351 100.0

Special Dress 129 91.5 12 8.5 141 100.0 292 99.3 2 .7 294 100.0

Cover Nose & Mouth

80 94.1 5 5.9 85 100.0 193 98.5 3 1.5 196 100.0

Use Deep Utensil

368 85.6 62 14.4 430 100.0 799 98.3 14 1.7 813 100.0

Cover Utensil After

225 87.5 32 12.5 257 100.0 450 98.5 7 1.5 457 100.0

Bag Remnants & Feathers

407 75.9 129 24.1 536 100.0 874 94.6 50 5.4 924 100.0

Put Chlorine/ Phenol in Bag

88 90.7 9 9.3 97 100.0 187 96.9 6 3.1 193

100.0

Wash Hands w Soap After

420 76.8 127 23.2 547 100.0 865 95.2 44 4.8 909 100.0

Clean Utensils After

203 72.2 78 27.8 281 100.0 413 91.6 38 8.4 451 100.0

Clean Place After

266 77.6 77 22.4 343 100.0 480 92.7 38 7.3 518 100.0

Others 28 80.0 7 20.0 35 100.0 62 100.0 - - 62 100.0

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The role of the RR is clearly evident in safe slaughtering as demonstrated in Table-17 above. The households in the intervention areas - and those visited by the RR specifically - adopted the proper slaughtering practices in high percentages. Being asked what they actually do when slaughtering poultry, they mentioned washing hands before and after, covering mouth and nose, using deep utensils for slaughter and covering it after slaughtering the birds. The control areas and those not visited by RR showed notably low percentages on these practices. RR confirmed in FGDs observing households now placing birds in deep utensils after slaughtering them and covering the utensils. Previously, the slaughtered birds were often left on the floor.

دنقج (.حخفط/ حفشفش) حشكا ربحا بعذ األسض عهى انطيس سيى عذو يا انسيذاث عذ احغيشث سهكياث في .ييخغط غيط إاء يف بيذبحا

VI. Buying from Known Source5

Table-18 Source of Poultry Purchasing:

Source # of Cases

Percentage %

House 232 12.2

Neighbors 22 1.2

Shop 95 5.0

Market place 300 15.8

Known vendor 653 34.4

Unknown vendor 376 19.8

Other 349 18.4

Total 1900 100

Table-18 above confirms the concern that almost 20% of the HH still purchase poultry from unknown vendors. This is not a small percentage and should be reduced with further awareness raising activities on purchasing from known sources.

5 Buying from a known source is to be understood as not buying from street vendors or buying from someone who

sells vaccinated chicks.

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Lessons learned The continuous involvement of UNICEF in the formulation and design of the communication strategy to prevent and control AI in rural Egypt since its first outbreak in 2006, has established a foundation for a dynamic C4D programming jointly with MOH, MOE and ERC. The approach as chosen proved capable of evolving to respond to emerging challenges and changing needs, and of addressing them timely and effectively. This is facilitated by the nationwide coverage of the closely monitored RR outreach program. Their feedback is channelled into a Management Information System in order to compile the data provided by the RR into a database making it more accessible, as well as facilitating the analysis of the data provided from the field. The UNICEF SM/C has also resulted in a large scale school awareness and education program that builds on the presence of focal points for promoting environmental and population-related activities in every school. The teachers’ efforts to engage children in an educational process to protect themselves from AI and avoid infection was effectively managed by ERC through a tight and well planned monitoring system that allowed problem solving and facilitated implementation in a swift manner. This study has resulted in several lessons learned to be considered when planning sustainability, expansion, and re-implementation of the AI Intervention Program. The following is a summary of said results: 1- Evaluation results demonstrated the effectiveness and impact of the RR’s role in delivering information as well as changing some practices concerning handling poultry and healthy home breeding. The qualitative part of the evaluation shows that in some cases, RR carry out individual initiatives and innovative ways to gain the households’ trust in order to motivate them or teach them to adopt new practices, they also innovate ways to improve their work. Such individual initiatives ought to be encouraged when re-planning the Intervention Program by providing RR with more space to innovate and facilitate their own methods, tools, and personal experiences to cater for cultural diversity and variety amongst governorates. 2- It has been proven that public information and communication campaign and social mobilization are critical when behaviour changes are the goal of interventions. The interpersonal outreach (respectively between RR and women in the households and between the teachers and schoolchildren) is providing the best results, as this way of information transfer also allows for asking and answering questions, and for adapting the information to the specific domestic situation. The already existing relationship between the disseminator and the recipient of the information, affects the impact of the intervention in a positive way. 3- During the special training workshop conducted for teachers and supervisors, participants have demonstrated their ability to use their practical experiences to create new ideas for the educational game kit. Because they contributed to the program, the sense of ownership had motivated them and their colleagues to implement the program. This sense of ownership is what is needed to create buy-in within program participants.

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4- The experience shows that tailor-made capacity building aimed at enhancing the professional knowledge and skills of the intermediates (such as RR, teachers and supervisors) can be considered the essential part of the program which helps in achieving the impact desired. 5- It has been confirmed that when direct supervision is provided by an NGO, there is a greater probability of program success. This was evident in the role of the Egyptian Red Crescent in this program as it maintained both direct supervision and continuous follow-up of the implementation. This gave school administrators and teachers the sense of seriousness of supervision and follow-up which created the attention to the program implementation as required. 6- The pilot phase of the program followed by expansion to more areas as introduced proved that a step-by-step approach provided the possibility to benefit from the initial first experiences and to improve the communication/education means developed in order to enhance the tailor-made approach of the activities. 7- It proved crucial to initiate a baseline survey in order to be able to measure the final impact and achievement of the different kinds of interventions and the program as a whole. 8- It is also evident that target audiences can be seen as important actors and multipliers, passing-on the information obtained to other members of the target groups in their surroundings (schoolchildren distributed the information received through the school program to their family members, as well as did the women in the households to their neighbours). 9- Not all the recommended behaviours have been implemented by the target group (women in HH) immediately or to a satisfactory degree and some of them seem harder to be put in practice. For that reason, the messages need to be disseminated to the target audiences repeatedly and the households need to be frequently visited for further refinement. Recommendations 1. Build technical and educational skills for program participants: RR, Teachers, Heads of Schools and Community Leaders in addition to other community representatives such as those in veterinarian services, agricultural supervisors, and NGOs. Capacity building can be performed through interactive training to provide space for participation and innovation. 2. Enlarge the network of organizations involved with the implementation of the community-based AI-related communication and education program. For instance, closer co-operation with the Ministry of Agriculture and its institutions and allies in the community outreach can contribute to a wider spin-off of the UNICEF-supported interventions, resulting in a deeper and broader impact. Coordination with other entities participating in various AI programs will avoid overlapping and gain credibility with target audience. This can also prevent or reduce duplicating the work done inside one organization or by various organizations.

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3. Build on the existing RR system to cover all the governorates and to include all outreach workers as well as workers from all sectors and the local governorates in order to support the work system of RR, making it more systematic, co-ordinated and efficient. 4. Create and train male groups of RR to educate men in villages and help female RR in covering larger numbers of people in villages and especially rural/remote areas. Men, being often the decision makers in the households, justify an extension of the campaign to target this group directly. Male RR can also co-operate with agricultural supervisors to enhance their role in the program. 5. Involve veterinarian specialists in training programs for RR, teachers and others due to their important contribution to the program. Using the experience accumulated to date, develop protocols and training manuals on methodologies of dissemination and scope of IEC materials adapted for use by different communicators and stakeholders, including, among others, veterinarians, agricultural workers, religious, traditional and community leaders, media, teachers/educators. 6. Include local NGOs already existing in the covered areas to conduct supervision and follow-up in order to enhance their role in execution as did the Egyptian Red Crescent in prior phases of the intervention.

7. Create a mass-media communication plan that guarantees continuity and that is realistic and appealing to various types of audiences. This is important because target audiences need information to be presented in various ways. 8. In the upcoming phases, more focus is needed on an important and main message towards families to educate them on the dangers of children participating in poultry-raising. Another important new focus should be on purchasing poultry from safe sources so that existing poultry production isn’t negatively affected nor is the health of the home and family. Thus, it is important to analyze the outcomes of the study to identify which of the critical messages haven’t lead to satisfactory results yet and find out the reasons behind the lack of impact. This will, subsequently, lead to focus on the improvement of the situation/ behaviour changes in the future activities. 9. A further extension of the school program could be considered in the future: develop additional educational materials for other school subjects than it was the case to date. It is also possible to organize project-oriented activities at schools, involving the entire school population with AI-related education activities during one or several days. For this occasion, experts/professionals can be invited to schools as lecturers (e.g. GPs or nurses from the community health centres, vets and others). 10. Initiate policy changes which can lead to less resistance among people concerning reporting sick and dead poultry such as reimbursement of lost income and a more efficient process for vaccination of poultry among the relevant audiences.