DSpace at VNU: An Exploration of How Perceptions of the Risk of Avian Influenza in Poultry Relate to Urbanization in Vietnam

DSpace at VNU: An Exploration of How Perceptions of the Risk of Avian Influenza in Poultry Relate to Urbanization in Vie...

EcoHealth DOI: 10.1007/s10393-014-0906-2 Ó 2014 International Association for Ecology and Health Original Contribution An Exploration of How Perceptions of the Risk of Avian Influenza in Poultry Relate to Urbanization in Vietnam Melissa L Finucane,1,2 Tuyen Nghiem,3 Sumeet Saksena,1 Lam Nguyen,4 Jefferson Fox,1 James H Spencer,5 and Trinh Dinh Thau4 East-West Center, 1601 East-West Rd, Honolulu, HI 96848 RAND Corporation, 4570 Fifth Ave, Pittsburgh, PA 15213 Vietnam National University, Hanoi, Vietnam Hanoi University of Agriculture, Hanoi, Vietnam Clemson University, Clemson, SC 29634 Abstract: This research examined how perceptions of outbreaks of highly pathogenic avian influenza (HPAI) subtype H5N1 in poultry are related to urbanization Via in-depth interviews with village leaders, household farmers, and large farm operators in modern, transitional, and traditional communes in the north of Vietnam, we explored behaviors, attitudes, cultural values, and traditions that might amplify or attenuate HPAI outbreaks We also explored conceptualizations of urbanization and its impacts on animal husbandry and disease outbreaks Qualitative theme analyses identified the key impacts, factors related to HPAI outbreaks, and disease prevention and management strategies The analyses also highlighted how urbanization improves some aspects of life (e.g., food security, family wealth and health, more employment opportunities, and improved infrastructure), but simultaneously poses significant challenges for poultry farming and disease management Awareness of qualitative aspects of HPAI risk perceptions and behaviors and how they vary with urbanization processes may help to improve the prevention and management of emerging infectious diseases Keywords: risk perception, urbanization, avian influenza, HPAI, poultry, Vietnam INTRODUCTION Highly pathogenic avian influenza (HPAI) subtype H5N1 emerged in Southeast Asia in 2003, with repeated outbreaks causing poultry and economic losses on a large scale Anthropogenic and ecological studies suggest that the spread of HPAI may be related to the ongoing process of replacing traditional farming methods (e.g., multispecies livestock husbandry) with industrial, mass-production-oriented Correspondence to: Melissa L Finucane, e-mail: Melissa.Finucane@EastWestCenter org operations (e.g., Mallin and Cahoon 2003); especially when the number of poultry houses and other connected establishments increases without proper planning (Capua and Marangon 2000) Opportunities for disease transmission increase with industrial poultry production because of increases in livestock pools, intensive rearing of multiple species, and semi-vertical integration systems where, for instance feed trucks, abattoir delivery, and other vehicles, may visit several farms daily (Dent et al 2008) Gilbert et al (2008) demonstrated that a few key factors, such as human population density, rice cropping intensity, and poultry density, explain a large proportion of the spatial variation in HPAI Melissa L Finucane et al disease risk The same study also highlighted that a considerable variation remains unexplained and factors, such as poultry production, marketing systems, or other dimensions of human behavior, should be considered Only a few studies have examined the perceived risk of HPAI in poultry Studies in Thailand (Takeuchi 2006), Laos (Barennes et al 2007), and Cambodia (Ly et al 2007) suggest that few people are aware of HPAI symptoms in poultry and that many think it is unlikely to occur in their flocks Few people report that they would notify authorities of poultry deaths, despite believing that it is important to report the deaths The most common reasons for non-reporting include lack of knowledge about or inaccessibility of the reporting procedure, fears of culling, and fears of being unable to sell the remaining poultry The above studies were sampled from areas reflecting different levels of urbanization but did not report differences among urban, semi-urban, and rural subsamples, even though the level of urbanization may be related to avian influenza outbreaks (Spencer 2013) Thus, we not know (1) whether perceived risk varies with levels of urbanization and (2) how people conceptualize urbanization and its impacts on animal husbandry and disease outbreaks Vietnam provides an excellent site for this research because as a result of its rapidly growing economy (5% GDP real growth rate for 2012; Central Intelligence Agency 2013) it is experiencing rapid environmental transformations Urbanization in Vietnam has substantially changed farmers’ interactions with natural systems For example, transportation has become motorized, increasing the potential for disease to spread further and more easily from one farm or commune to another via feces on moped or truck tires Understanding perceptions of urbanization and its relationship with HPAI outbreaks in poultry is important because urbanization and the resulting infrastructure create a filter which distances people from the environment and affects their ability to perceive changes in natural resources (Lilian et al 2007) Failing to perceive change potentially threatens a community’s ability to respond appropriately To fill the gap in knowledge about whether and how HPAI outbreaks are related to urbanization, we conducted two exploratory studies with village leaders, household farmers, and large farm operators in the north of Vietnam METHODS Research Design A qualitative research design was used to allow participants to describe beliefs and experiences about HPAI in poultry and urbanization in their own words, rather than as a choice between the predetermined survey responses (Morgan 1998; O’Brien 1993; Pope and Mays 1995) We established sampling frames (see below) that included traditional settings (customary agricultural practices, housing, and water sources), modern settings (agricultural modernization, industrial cities, and modern water sources), and transitional settings (a mix of traditional and modern agricultural practices, housing, and water sources) The variables we used to identify these settings were reported previously as metrics of urbanization potentially associated with outbreaks of HPAI in poultry (e.g., Spencer 2013; Pfieffer et al 2007; Fang et al 2008; Gilbert et al 2008) Participants For both Studies and 2, a research assistant from Hanoi University of Agriculture arranged permissions and scheduled people to attend the interviews Individuals were recruited using a purposive sampling technique with the goal of obtaining diverse samples regarding age, gender, and farming activities Participants were informed about the purpose of the study, the nature of the questions, and that they could refuse to answer questions or withdraw from the study at any time Each participant was paid 30,000–200,000 VND (approximately $1.44–$9.60 USD) to compensate for their time and travel expenses The sample for Study included 43 people recruited from four communes1 in Bac Ninh Province, Vietnam The communes were selected as representative of different levels of urbanization based on an index of water source coherence (Spencer 2013) calculated from variables in the 1999 Vietnam census The index reflects the amount of ‘‘mixing’’ of different types of household-level water supply (well, rain, bottled, or surface water) Table shows the demographics and other characteristics of the sample To identify participants for Study 2, we created a sampling frame using the 2006 Vietnam agricultural census following the methods developed by Saksena et al (2013) All the communes were classified into three groups reflecting different levels of urbanization (traditional, transitional, or modern) using hierarchical cluster analysis with the following criteria: (1) percent of houses whose main income is from agricultural, fishing, or forestry activities and (2) percent of houses that have a modern The smallest administrative unit in Vietnam is usually the commune, but in more urban areas they may be called a ward or town Perceived Risk of AI in Poultry and Urbanization in Vietnam Table Study Participant Characteristics (n = 43) Table continued Commune, Province (urbanization level), n (%) Thai Bao, Bac Ninh (modern) 14 (32.6) Quang Pho Thanh, Bac Ninh (transitional) 15 (34.9) Ninh Xa, Bac Ninh (transitional) 10 (23.3) Dai Dong, Bac Ninh (traditional) (9.3) Participant type, n (%) Village leader 15 (34.9) Household farmer 13 (30.2) Large farm operator 15 (34.9) Gender, n (%) Male 32 (74.4) Female 11 (25.6) Age, years, range (mean) 29–61 (46.57) Ethnicity, n (%) Kinh 43 (100) Education, n (%) High school or less 27 (62.8) Vocational school or some college 11 (25.6) Completed 4-year college or more (11.6) No response (4.7) Primary profession, n (%) Manager/Deputy Manager (7.0) Professional (e.g., lawyer, doctor, teacher) (2.3) Industrial worker (2.3) Agricultural laborer 31 (72.1) Retired (4.7) Other (Head of Village (4.7) and Agricultural Extension Officer) No response (7.0) Annual household income, 150,000– VND, range (mean) 300,000,000 (49,335,135) Housing, n (%) Solid (concrete walled) 19 (44.2) Semisolid (bamboo or concrete) (14.0) Wood frame with cottage roof 11 (25.6) (bamboo, thatch) Temporary one-floor house (11.6) Two- or three-floor strong house (4.7) Type of latrine, n (%) Household septic latrine 31 (72.1) Pour-flush filtered latrine (4.7) Eco-latrine (2.3) Ventilated improved pit latrine (18.6) Other latrine (0) No latrine (0) No response (2.3) Main source of fresh water, n (%) Tap water (7.0) Purchased water (tank, jar, bottle, etc.) (0) Rain water 16 (37.2) Drilled well water 24 (55.8) Constructed well water (0) Other well water (0) River, lake, pond water (0) Spring water (0) Other sources (0) Animals farmed in the previous 12 months, (n participants raising animal), livestock count range (mean) Chicken (n = 36) 5–10,000 (972.6) Duck (n = 17) 4–2,000 (181.6) Other bird (n = 3) 10–1,200 (28.6) Pigs (n = 33) 2–200 (33) Fish (n = 13) 300–30,000 (1757.9) Other animals (e.g., dog, goose) (n = 4) 1–50 (2.6) Crops, n farming crop (percent) Rice 40 (47.1) Other cereals (e.g., corn) 18 (21.2) Fruits (8.2) Vegetables 14 (16.5) Industrial trees (2.4) Other crops (4.7) toilet system The resulting characteristics of these three groups are shown in Table The Study sample included a total of 33 participants from communes at all the three levels of urbanization, but with an emphasis on transitional areas because of our interest in understanding perceptions of change Table shows the demographics and other characteristics of the sample Materials and Procedures For both studies, individual and small-group interviews followed a semi-structured protocol Study participants were asked first to comment on their experience of avian influenza in poultry (e.g., ‘‘Tell me what you know about avian influenza in birds and how it affects you, your family, Melissa L Finucane et al Table Characteristics of three groups (traditional, transitional, and modern) of communes Type of commune Traditional Transitional Modern Percent of houses whose main income is from agricultural, fishing, or forestry activities Percent of houses with modern toilets 81 53 12 11 56 90 and your community?’’) Then more specific probes asked about their understanding of risk exposure processes, HPAI effects, risk assessment and management, and Vietnamese values and traditions relevant to animal husbandry and disease management (e.g., ‘‘What role spiritual beliefs play in preventing or managing disease outbreaks among your animals?’’) Study participants were asked to comment on their understanding of ‘‘rural’’ and ‘‘urban’’ (e.g., ‘‘What does rural mean to you?’’) and how urbanization affects: the built and natural landscapes, farming practices, livelihoods, quality of life, waste management systems, and HPAI in poultry The interviews were facilitated jointly by the first author (asking questions in English) and the second author (translating questions and responses) During individual and small-group interviews, the facilitators and two assistants recorded by hand the information about participants’ remarks and nonverbal responses Audio recordings were not made because the topic was deemed too sensitive Each interview took 1–2 h For Study 1, nine small-group interviews (with 3–6 individuals per group) were held with 43 participants over days (May 25–27, 2010) in meeting rooms at the commune headquarters of each of the three communes in Bac Ninh Province: Thai Bao (Day 1), Quang Pho Thanh (Day 2), and Ninh Xa (Day 3) Three groups were interviewed each day One group comprised village leaders, one group comprised household farmers, and one group comprised large farm operators For Study 2, three small-group interviews (with 5–12 individuals per group) were held with 23 participants over days (July 25–27, 2011) at each of the three communes in Quang Ninh Province: Viet Hung (Day 1), Bang Ca (Day 2), and Cam Tay (Day 3) Two groups were held in meeting rooms at the commune headquarters and one was held at a farmer’s house Individual interviews were held with ten participants Data Analysis For Study 1, qualitative theme analysis (Bernard and Ryan 1998; Crabtree and Miller 1999) using ATLAS.ti (version 5) was used to distinguish the salient constructs and to identify words commonly used to describe attitudes and experiences Following the guidelines presented by Fereday and Muir-Cochrane (2006), the coding template was developed using a hybrid of the data-driven inductive approach of Boyatzis (1998) and the deductive a priori template of codes approach outlined by Crabtree and Miller (1999) Core themes that repeatedly appeared in notes of the interview discussions were identified by the lead author and confirmed by a research assistant Consensus was achieved via discussion For Study 2, the key-words-incontext technique (Tesch 1990) was used to find instances of key words in field notes Themes were then identified by sorting the examples into groups of similar meaning, retaining information about the sources of the examples Given that this research focused largely on identifying perceptions that not necessarily have a correct answer, respondents’ trustworthiness was assessed by asking knowledgeable locals (e.g., village veterinarian) or members of the local research team to corroborate the plausibility of responses Confirmability was assessed, where possible, by asking respondents to verify some statements (e.g., that there is no place to take dead animals) via a tour of their vicinity Credibility was assessed frequently during interviews by checking respondents’ agreement with paraphrasings of their comments FINDINGS Study 1: HPAI Risk Perceptions Key Impacts Overall, participants were very concerned about HPAI outbreaks, referring to the disease as an ‘‘epidemic,’’ ‘‘a scary disease,’’ ‘‘a big worry,’’ and ‘‘very dangerous,’’ particularly because of the relatively high fatality rate of HPAI in poultry One participant described the death of chickens from HPAI as ‘‘equal to robbing because it takes away our Perceived Risk of AI in Poultry and Urbanization in Vietnam Table Study Participant Characteristics (n = 33) Commune, Province (urbanization level), n (%) Mo Lao, Ha Dong (modern) (3.0) Cam Tay, Quang Ninh (modern) (24.2) Viet Hung, Quang Ninh (transitional) 13 (39.4) Phu Luong, Ha Dong (transitional) (3.0) Quoc Oai, Ha Tay (transitional) (3.0) Phung Xa, Thach That (transitional) (6.1) Bang Ca, Quang Ninh (traditional) (21.2) Participant type, n (%) Village leader (9.1) Household farmer 30 (90.9) Gender, n (%) Male 11 (33.3) Female 22 (66.7) Age, years, range (mean) (n = 29) 25–69 (47.9) Ethnicity, n (%) Kinh 23 (69.7) Dao (21.2) No response (9.1) Education, n (%) High school or less 26 (78.8) Vocational school or some college (9.1) Completed 4-year college or more (0) No response (12.1) Primary profession, n (%) Agricultural laborer 14 (42.4) Non-agricultural wage laborer (9.1) Manager/Deputy Manager (3.0) Professional (e.g., lawyer, doctor, teacher) (0) Retired (3.0) Other (e.g., student, homemaker) (24.2) No response (18.2) Annual household income, 10,000,000– VND, range (mean) (n = 22) 168,000,000 (49,154,545) livelihood with no warning or reason.’’ Participants from all the communes agreed that the most worrisome aspect of HPAI was at the household level when substantial investments and their main income source were lost Factors Related to HPAI Outbreaks Modernization and Pollution Participants varied in the factors they emphasized as important in the spread of HPAI in poultry, but many focused on the process of modernization and associated increase in pollution problems Participants from all the communes observed that rapid population increase and economic development had a detrimental impact on their environment The increased volume of waste from livestock and household garbage, which was perceived to be poorly managed and hard to control, was viewed as a key source of air, land, and water pollution (e.g., dead chickens are thrown onto the street or into fish ponds) Many participants noted the importance of keeping a clean farm to prevent disease One participant (from a transitional commune) indicated that he kept his farm clean; but that he could not control the whole system, which he observed to be increasingly interdependent Participants from the traditional commune emphasized the role of transportation in spreading the virus (e.g., trucks spread disease via their tires when transporting feed and international movement of livestock) Farming Practices The trade-offs of new versus old farming practices were emphasized For instance, some participants (modern commune) commented that the new, industrial way is good because ‘‘the feed is more relaxing’’ (i.e., farmers not have to collect or prepare the feed) and the livestock have more economic value However, they also noted that the industrial feed may use too many chemicals, be moldy, or cause chickens to put on weight too fast, causing the livestock to be more prone to disease Farm Size Participants had differing opinions on the role of the farm size Some participants (modern and transitional communes) tended to believe that small and large operations were equally likely to experience an outbreak of disease Some participants in transitional communes, however, emphasized that the high-volume farming operations caused environmental problems because the chicken density was too high and that small-scale operations posed fewer problems Others noted that large operators were more cautious and thus more likely to vaccinate their livestock, but that small-scale farmers were more able to check each chicken and to detect a problem early Poultry Varieties Most participants agreed that traditional Vietnamese chickens have a higher resistance (and not require much care) than industrial broiler or layer chickens, but that the latter were more profitable Some noted that compared with broiler chickens, layer chickens were probably less vulnerable because they were kept on a high floor (for easy egg retrieval) Melissa L Finucane et al Seasonal Variation Most participants noted that outbreaks were more likely around Teˆt, the Vietnamese New Year, which usually falls in the western calendar months of January or February and is a period when more chickens are raised and exposure is more likely One participant noted that the powder of xoan (Melia azedarach) flower (which flowers in spring) causes HPAI Wild Birds When asked about the role of wild birds, some said that they had heard about this issue in the media, but thought it was unlikely to be an important factor because of a lack of wild birds in their area (in part because villagers shoot them) Others suggested that wild birds may play a role in disease outbreaks Disease Management Strategies Vaccination Vaccination was generally thought to be effective, though problematic when poultry are already sick Some participants from the traditional commune indicated that they might not buy the vaccine until their poultry was sick because it was too expensive Both the household farmers and large operators in transitional and traditional communes expressed reservations about vaccine effectiveness Some participants stressed the problems in obtaining high-quality vaccines (e.g., distributors might dilute it, not keep it cool during transportation, or sell expired bottles) and that the availability of too many brands of unknown quality was confusing Waste and Disease Management Systems Participants discussed the need for better waste and disease management systems Several noted that there was no place to take dead animals (so they were buried in the paddy fields near the communes with lime) and there was little systematic guidance about how to deal with waste or disease One participant in a transitional commune stressed that there was noone to identify and quarantine the source of an outbreak and that sometimes quarantine restrictions were implemented too late One participant (modern commune) observed that people not always report poultry deaths Another participant (transitional commune) stressed that reporting deaths brought little extra support Some participants indicated that they were not willing to make reports because they did not want to precipitate in new culling campaigns Uncertainty, Knowledge, and Training In general, participants expressed a desire for more knowledge and training about disease management options and more consultation opportunities (e.g., about which vaccine to use) One participant (transitional commune) suggested that an early warning system would be helpful (e.g., providing forecasts about when each province will be most likely to experience an outbreak) Others reflected on the importance of mass media (television and newspapers) as a source of information about HPAI origins and impacts Support Systems Key sources of support for understanding and managing HPAI included village veterinarians, village leaders, and faculty at the Hanoi University of Agriculture When asked about the role of spirituality, some participants said it did not play an important role in disease management, but others noted that they thought it was important to put food on their altars or to pray internally to ask their ancestors for good health and production Figure schematically depicts these qualitative themes and their relationships as described in the interview discussions Study 2: Perceptions of Urbanization and its Impacts Characteristics of Rural and Urban Settings Participants from all the communes agreed that the key characteristics of a rural setting include: good or supportive, sharing relationships and emotional ties among residents; a feeling of coolness and clean, pure air; and agricultural activities (using the land for farming to produce food and raise livestock) They also noted that rural houses were spacious with old-style (pit) toilets In contrast, key characteristics of an urban setting include: weaker emotional ties among residents; large-scale industrial development; better quality houses with more furniture; a closed sewage system; piped water for cooking; less space (e.g., to raise children); and more closed doors and private spaces Participants noted that income in urban areas typically comes from trading and selling services, that there are a lot of jobs, and that it is easier to make money Process of Urbanization Participants from the traditional commune of Bang Ca said that the process of urbanization had been mostly worth- Perceived Risk of AI in Poultry and Urbanization in Vietnam Figure A mental model of highly pathogenic avian influenza (HPAI) outbreaks as reflected in interview discussions with village leaders, household farmers, and large farm operators in modern, transitional, and traditional communes in Bac Ninh Province, Vietnam while, but that it came with both positive and negative aspects (e.g., the modernization of agriculture increased the spraying of chemicals to improve crop productivity but posed a human health risk) Participants in the traditional settings noted that there has been no change in the type of toilets or home gardens, but that forested areas have decreased (the land is being used for roads, houses, and mines) and environmental pollution has increased One man noted that the environment was ‘‘cooler’’ in the past when their houses were made from wood (rather than cement) and were placed lower in the valley (rather than higher up the hillside) Residents in the traditional areas can now take advantage of more and different (nonfarm) income sources (e.g., making baskets), but some people still did not have enough money to cover the basic living expenses They reported that ‘‘civilization is more accessible’’ (e.g., through television, which is available in every house), but that the traditional customs (praying, ceremonies, and shamans) remained the same Participants in the transitional communes (Viet Hung, Phu Luong, Quoc Oai, and Phung Xa) noted rapid change over the past 20 years They highlighted not only improv- ing food security and food diversity, but also new environmental and health problems (e.g., pesticides and diabetes) One female farmer said that urbanization brought more needs (e.g., her children want to go out for breakfast instead of staying at home like they used to) and that it is more difficult to earn money Another participant noted that the number and types of houses were changing (‘‘no more bamboo fences or simple tile roof houses’’) and that the environment felt ‘‘hotter.’’ Participants described how land value has decreased because it was rezoned for industry; but then industries were not developed, leaving them in ‘‘suspense,’’ not knowing how long they can keep farming their land Participants mentioned that there are more nonfarm income sources and that people now worked for individuals or households rather than the cooperative Despite the negative aspects of transition, participants generally agreed that transition is worthwhile because their living standard and well-being has improved and they have more time to rest Participants in the modern communes (Cam Tay and Ha Dong) thought that in general urbanization is worthwhile, but that sometimes people cannot keep up with a Melissa L Finucane et al rapid rate or high number of changes They noted how urbanization has changed the ‘‘coolness’’ of their environment, primarily by the removal of trees Other participants reported that the amount and type of housing was changing in their area (e.g., from thatched or tile roofs to brick roofs), but not too fast Every house now has its own toilet and reliable electricity Stream flow has decreased so residents buy trucked water for cooking and use catchment water for washing Participants noted that food security has improved and there is less hardship Human health is also better because of improved access to health care and awareness of disease prevention strategies Families have fewer children Also, relationships among neighbors have changed, with more private spaces and less visits because people are spending more time working Impact of Urbanization on Poultry and Disease Outbreaks Participants in the traditional commune reported difficulty in controlling poultry disease, especially when poultry are bought from outside the commune and have an unknown vaccination record They said that their poultry’s health was not affected by water pollution or human waste, but was affected by increasing animal density and chemicals in the environment Modern treatments were available to deal with disease, but there was uncertainty about what is most effective One farmer said that they cannot prepare effectively because they not know what is needed In contrast, participants in transitional communes commented that their ability to raise poultry has improved because they have more medicines and training from the government on how to use those medicines and deal with disease They reported vaccinating frequently, so their exposure to disease is less They felt that it is easier to quarantine sick animals with the increases in fences and walls Participants in the modern communes noted that animal and human waste can cause disease, but that it does not happen in their commune Air and water pollution were identified as causing poultry disease One participant said that it was easier for poultry to get sick now because the weather was unstable (changing between extremely hot to extremely cold) and food is now freely exchanged among areas (e.g., sickness spreads across the commune easily when a sick chicken is brought in from another commune) Animal density was also thought to cause disease because there was less air for the poultry to breathe DISCUSSION HPAI is Perceived as Risky and Disease Management is Linked with Urbanization Processes Across the communes, HPAI in poultry was viewed by the participants as a dangerous epidemic with worrying economic consequences The role of change in agriculture in the spread of HPAI was recognized Both new and old farming practices were perceived as having advantages and disadvantages Participants were sensitive to the roles of farm size, type of chicken, seasonal variation, and wild birds in the spread of HPAI The most prominent disease management strategies focused on vaccination, quarantine, and farm and commune hygiene; with calls for better information and training programs to assist farmers These findings are not only consistent with Fielding et al.’s (2009) description of lay explanations for the cause of HPAI in humans, but also extend our understanding of risk mental models to explain the perceived causes of HPAI in poultry The present results are consistent with studies finding a reluctance to report poultry deaths to authorities because of fears of culling and economic impacts (Barennes et al 2007; Ly et al 2007; Sultana et al 2012; Takeuchi 2006) However, participants in our study seemed to express more motivation for improving waste and disease management practices compared with the previous studies The results of the present research support the notion that urbanization changes people’s ability to respond appropriately to variations in their environment The inability to respond is not necessarily because of an inability to perceive change (cf Lilian et al 2007) Rather, our participants described a rapid and extensive change that poses different challenges for poultry management as communes move from rural to transitional to urban settings Limitations The first limitation of this research is that samples were drawn from people willing and able to participate in a 2-h interview and may not represent the general population of farmers in Vietnam in terms of sociodemographic variables such as age, education, and income There is also a gender imbalance in each study, potentially biasing the perspectives obtained toward issues most relevant to the majority gender However, the consistency of the findings from this Perceived Risk of AI in Poultry and Urbanization in Vietnam study with those reported elsewhere encourages the confidence that many of the observations are generalizable A second limitation concerns the small size of samples in these studies It is possible that additional information would have been obtained with a broader sample of individuals Within this sample, however, we believe that the questions posed were thoroughly addressed at least by modern and transitional commune participants because little new information was obtained in the final interviews This phenomenon is called saturation in qualitative research and indicates that a topic has been adequately sampled (i.e., enough interviews conducted) Another limitation of the small sample sizes is that they not permit statistical differences to be analyzed and thus conclusions are restricted to the descriptive statements elicited Finally, the topic of avian influenza is a sensitive issue that participants may have been reluctant to discuss openly, especially in a group setting Other research suggests that farmers are reluctant to report cases of animal illness because of fears of culling and loss of income (e.g., Sultana et al 2012) This is a limitation of most investigations relying on self-report, but was minimized in the present research by building good rapport and selecting a diverse sample to increase the chance of including some more open participants Nonetheless, constrained responses limit our capacity to draw conclusions FUTURE DIRECTIONS The exploratory nature of this research established preliminary qualitative information about a topic poorly documented to date, namely how perceptions of HPAI risk in poultry relate to urbanization in Vietnam The research findings offer a first step toward understanding mental models of disease risk and urbanization in a developing country context The findings raise several interesting questions for future research: What research methods (e.g., anonymous surveys) are effective at capturing representative perspectives of a sensitive issue in a rapidly changing environment? How well risk perceptions correspond with the actual outbreaks of disease in poultry and does the relationship vary with setting (traditional, transitional, modern)? What analytic methods are needed to identify the components of urbanization that best predict the perceived risk and the actual outbreaks of avian influenza in poultry? Addressing these and other questions will help policymakers be better informed about the optimal risk prevention and management strategies in diverse settings ACKNOWLEDGMENTS The authors are grateful to colleagues at the Hanoi University of Agriculture for assistance in conducting interviews; to Boonyarit Itsara and Charles Nguyen for assistance in verifying and analyzing data The authors also thank Michael DiGregorio, Nancy Lewis, and Bruce Wilcox for assistance in developing the interview protocol This work was funded by the National Science Foundation Grant # DEB-0909410 REFERENCES Barennes H, Martinez-Aussel B, Vongphrachanh P, Strobel M (2007) Avian influenza risk perceptions, Laos (letter) Emerging Infectious Diseases 13(7):1126 Bernard HR, Ryan GW (1998) Text Analysis: Qualitative and Quantitative Methods In: Handbook of Methods in Cultural Anthropology, Bernard HR (editor), Walnut Creek: Altamira Boyatzis R (1998) Transforming qualitative information: thematic analysis and code development, Thousand Oaks: Sage Capua I, Marangon S (2000) The avian influenza epidemic in Italy, 1999–2000: a review Avian Pathology 29:289–294 Central Intelligence Agency (2013) The World Factbook https://www.cia.gov/library/publications/the-world-factbook/ geos/vm.html Accessed 25 July 2013 Crabtree B, Miller W (1999) A template approach to text analysis: developing and using codebooks In: Doing Qualitative Research, Crabtree B, Miller W (editors), Newbury Park: Sage, pp 163–177 Dent JE, Kao RR, Kiss IZ, Hyder K, Arnold M (2008) Contact structures in the poultry industry in Great Britain: exploring transmission routes for a potential avian influenza virus epidemic BMC Veterinary Research 4:27 Fang L, de Vlas SJ, Liang S, Looman CWN, Gong P, Xu B, et al (2008) Environmental factors contributing to the spread of H5N1 avian influenza in mainland China PLoS One 3(5):e2268–e2268 Fereday J, Muir-Cochrane E (2006) Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development International Journal of Qualitative Methods 5(1):1–11 Fielding R, Leung GM, Lam WWT, Jiang CQ, Sitthi-Amorn C, Ahn LV, et al (2009) A pan-Asian survey of risk perception, attitudes and practices associated with live animal markets Hong Kong Medical Journal 15(5):17–20 Gilbert M, Xiangming X, Pfeiffer DU, Epprecht M, Boles S, Czarnecki C, et al (2008) Mapping H5N1 highly pathogenic avian influenza risk in Southeast Asia Proceedings of the National Academy of Sciences 105:4769–4774 Lilian A, Kliskey A, Williams P (2007) The distancing effect of modernization on the perception of water resources in Arctic communities Polar Geography 30(3–4):175–191 Ly S, Van Kerkhove MD, Davun Holl D, Froehlich Y, Vong S (2007) Interactions between humans and poultry, rural Cambodia Emerging Infectious Diseases 13(1):130–132 Mallin MA, Cahoon LB (2003) Industrialized animal production? A major source of nutrient and microbial pollution to aquatic ecosystems Population and Environment 24:369–385 Melissa L Finucane et al Morgan D (1998) The Focus Group Guidebook, Thousand Oaks: Sage O’Brien K (1993) Improving Survey Questionnaires Through Focus Groups In: Successful Focus Groups: Advancing the State of the Art, Morgan D (editor), Newbury Park: Sage, pp 105–117 Pfieffer DU, Minh PQ, Martin V, Epprecht M, Otte MJ (2007) An analysis of the spatial and temporal patterns of highly pathogenic avian influenza occurrence in Vietnam using national surveillance data The Veterinary Journal 174:302–309 Pope C, Mays N (1995) Researching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research British Medical Journal 311:42–45 Saksena S, Trinh DT, Pham NL, Sultana N, Finucane ML, Fox JM (2013) Animal husbandry and farm-level bio-security practices across the rural to urban gradient in Vietnam and their rela- tionship to avian influenza Paper presented at the American Association of Geographers, Los Angeles, CA, April 11, 2013 Spencer JH (2013) The urban health transition hypothesis: empirical evidence of an avian influenza Kuznets curve in Viet Nam? Journal of Urban Health 90(2):343–357 Sultana R, Rimi NA, Azad S, Islam MS, Khan MSU, Gurley ES, et al (2012) Bangladeshi backyard poultry raisers’ perceptions and practices related to zoonotic transmission of avian influenza Journal of Infection in Developing Countries 6(2):156–165 Takeuchi MT (2006) Avian influenza risk communication, Thailand (letter) Emerging Infectious Diseases 12(7):1172–1173 Tesch R (1990) Qualitative research: analysis types and software tools New York: Falmer ... DIRECTIONS The exploratory nature of this research established preliminary qualitative information about a topic poorly documented to date, namely how perceptions of HPAI risk in poultry relate to urbanization. .. urbanization in Vietnam The research findings offer a first step toward understanding mental models of disease risk and urbanization in a developing country context The findings raise several interesting... methods are needed to identify the components of urbanization that best predict the perceived risk and the actual outbreaks of avian influenza in poultry? Addressing these and other questions will