The threat posed by a potential avian influenza/pandemic influenza (AI/PI) outbreak has prompted a range of agencies to promote planning and response-preparedness around the World.  UNICEF is focusing on communication and other supportive measures that inform, educate and enable families and communities to protect themselves from illness and death caused by bird flu or its consequences, as part of the UN response to the threat of AI/PI.  UNICEF recognises that every aspect of children’s lives could be seriously threatened by a pandemic. UNICEF is putting its extensive communication expertise and its global on-the-ground presence to the service of national governments and partners to control bird flu and to prepare for a possible pandemic.

As part of this work in the Pacific, UNICEF commissioned Dialogue to undertake a baseline study in Kiribati (and subsequently a follow-up study in Fiji).  Dialogue worked closely the Kiribati Ministry for Health and Medical Services and enormous thanks are due to the Chief Public Health Inspector Tianuare Taeuea who provided the researchers with invaluable assistance and advice in undertaking the research in the Gilbert Group.

The work programme for the baseline research in Kiribati was designed to achieve six objectives within the context of the local social and economic systems:

1. describe cultural, social, political and economic factors impeding or enhancing key behavioural interventions in relation to: reporting (animal and human cases); fowl and other animal handling, marketing, farming, and disposal; personal and family hygiene; food storage, preparation, and cooking; home management and treatment-seeking behaviour in response influenza-like illnesses;
   

2. identify risk groups and risk behaviours;
   

3. ascertain community health information needs, credible sources of information, potential sources of negative rumours, and knowledge gaps;
   

4. explore community suggestions for control and containment;
   

5. determine baseline measures of key behavioural interventions; and
   

6. examine advocacy, social mobilisation and communication components of the existing preparedness and response plan including quarantine procedures, disaster planning, legal authority and organizational characteristics including potential for civil society engagement.
   

The research identified that the current situation in Kiribati is a mixture with some factors which will enhance and others that will impede the implementation of the behavioural interventions that are key to preparedness and response for avian influenza/pandemic influenza. 

Knowledge of AI/PI is starting from an unsurprisingly low base but factors such as  a well developed system of health centres and clinics with nurses recognised as an important/credible source of health information; a simple media structure with relatively high proportion listening to radio which is already in use to communicate health messages; significant evidence of well developed personal hygiene practices; and limited significance of local chickens (except to young boys) are all positive.  In terms of social mobilisation there are also strong networks in communities used to provide information and training, with traditional structures still operating in the Outer Islands.

On the downside there are range of factors which present challenges including the existing very high incidence of flu-like illnesses making detection of bird flu potentially difficult; a high frequency of formal and informal gatherings in maneaba and other settings as a regular part of the way of life of I-Kiribati; the traditional extended family living arrangements; the practices of sending children to school when showing mild flu symptoms, and of

going to work with mild flu symptoms (but probably when infectious); the lack of reporting of chicken deaths; cock fighting by younger boys; and the common experience of I-Kiribati of “learning the hard way” rather than taking preventative measures could make it difficult to turn awareness into action. Survey results show strong discontinuities between what people say they have done in relation to past illnesses and what they say they will do in the event of an outbreak of dangerous flu.

This qualitative and quantitative research with caregivers, students, NGOs, public servants and other stakeholders undertaken in September-October 2007 provides direction for the development of preparedness and response communications for AI/PI at both the strategic and tactical level. There are a number of implications for the development of communications strategy development that can be drawn from the research including the need for:

1. a multi-channel approach to achieve full coverage rather than reliance of single/few channels (includes health professionals, health promotion unit, women’s groups, church groups, schools and radio);
   

2. a long term programme is required because the MH&MS and UNICEF are seeking behavioural change -  Kiribati has considerable experience with short-term programmes which  end when donor funding runs out and before desired behavioural change is entrenched;
   

3. appropriate resourcing to sustain programmes over time and to meet requirements of specific settings, e.g. mweaka (donation) for meetings at the maneaba and transport to workshops for attendees from outer villages;
   

4. learn from experience of KFHA of “quote from the Bible” in terms of preparing/positioning messages;
   

5. appropriate respect to the unimane when undertaking promotions at the village level.  This would imply a range of tactics to avoid confrontations when what is required goes against tradition. Kireata Ruteru already employs a range of useful techniques for this, including briefing of selected unimane before the formal presentation so that there is already an advocate among the elders (or even a constituency) for what is being promoted;
   

6. distinguish between the specific circumstances of South Tarawa and other locations including access to media, the role of traditional leaders, infrastructure, lifestyle, and resources; and
   

7. carefully consider nature of visual aids support for campaigns including exploring possible hand-bill-style displays for vans/buses where exposure would be high.
   

There are a number of key messages that will need to be conveyed in the AI/PI communications including:

1. affirmation/reinforcement of existing personal hygiene practices to achieve high levels of consistent behaviour, not simply a strong behavioural intention;
   

2. building the profile of nurses/nurse aides/doctors as the first point of contact for all heath information and treatment (NB it is important that there be no denigration of traditional healers or remedies);
   

3. need for reporting of unusual numbers of chicken deaths;
   

4. need for use of personal protection equipment especially for hands, feet and airways particularly on poultry farms and by animal health workers;
   

5. risks associated with cock fighting;
   

6. risks associated with the poaching of wild birds on Kiritimati; and
   

7. need to cook chicken properly.
   

These messages need to be set into a broad context of healthy living not treated as yet another one-off, single-issue campaign which stops when the funds run out. 

The proposed communications programme development supported by UNICEF can play a vital role in enhancing information; promoting the desired behavioural changes; and encouraging preparedness.  This is necessary but not sufficient to ensure consistent adoption of new or changed behaviours. 

Engagement with civil society, in particular the churches, NGOs and traditional leaders will be essential in translating awareness, knowledge, positive attitudes and behavioural intention into consistent practice of the four key behavioural interventions.  It is also essential to ensure that other required behaviours such as the reporting of significant numbers of chicken deaths are undertaken consistently.  These various groups will act as “agents” of the programme using their existing authority and networks in the community to deliver some messages, reinforce others and, most importantly, to facilitate and support behaviour change.

If there are no “agents” to play this supportive role in the programme there is a serious risk of what may be called the “New Year Resolution Problem” – when the behavioural intention is not turned into action!  Agents can support change through the regular contacts they have with people, be they a village leader, clergy, teacher or a nurse.

Engagement across civil society at the village and island scales also changes the emphasis from the individual to their community, which is inherently more sustainable. Effective reduction of incidence of cock fighting, for instance, will require positive measures such as promotion of alternative activities (like canoe building and sailing which seems to have declined) as well as sanctions.  This can best be delivered in a group setting where the participants reinforce one another.  Similarly, villagers who keep free-range chickens will not go to the expense of fencing and feeding chickens (even if they can afford it, which in many cases is unlikely) without changing the social perception of the practice so that other villagers are less accepting of it. 

In general in Kiribati, where there are limited incomes and much poverty, actions which require significant extra expense are likely to be difficult to promote.  That said, it is clear that on South Tarawa some people do cage their chickens, despite the expense, for protection from roaming dogs and theft.  An expectation anyone other than the commercial farmers on South Tarawa could be persuaded to use personal protective gear when handling poultry, however, is likely to be disappointed.

There will be opportunities to gain synergies with the existing activities of a range of groups on both South Tarawa and the outreach programmes to the Outer Islands but ultimately there will need to be some resourcing made available to them as they are ultimately a very potent mechanism for both training in, and reinforcement of, the desired behaviours.  There also needs to be a serious look at the infrastructure.  Schools which do not have toilets or washrooms do not provide an appropriate environment for large numbers of children for the whole of the school day.  Neither, for that matter, does it set an appropriate model for people at home.

One of the encouraging findings from the research is that the organisations who could act as “agents” for behavioural change are strong.  Carefully targeting linking the measures to the capabilities of different groups, such as reporting to the unimane and hygiene to the churches and NGOs, could go a long way to ensuring appropriate behavioural change. 

A copy of the report can be obtained from the Downloads page.

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