Background
In Laos, small backyard poultry systems predominate (90%). The first lethal human cases of highly pathogenic avian influenza (HPAI) occurred in 2007. Few studies have addressed the impact of outbreaks and education campaigns on a smallholder producer system. We evaluated awareness and behaviours related to educational campaigns and the 2007 HPAI outbreaks.

Methods
During a national 2-stage cross-sectional randomised survey we interviewed 1098 households using a pre-tested questionnaire in five provinces representative of the Southern to Northern strata of Laos. We used multivariate analysis (Stata, version 8; Stata Corporation, College Station, TX, USA) to analyse factors affecting recollection of HPAI educational messages, awareness of HPAI, and behaviour change.

Results
Of the 1098 participants, 303 (27.6%) received training on HPAI. The level of awareness was similar to that in 2006. The urban population considered risk to be decreased, yet unsafe behaviours persisted or increased. This contrasted with an increase in awareness and safe behaviour practices in rural areas.

Reported behaviour changes in rural areas included higher rates of cessation of poultry consumption and dead poultry burial when compared to 2006. No participants reported poultry deaths to the authorities. Overall, 70% could recall an educational message but the content and accuracy differed widely depending on training exposure. Washing hands and other hygiene advice, messages given during the HPAI educational campaign, were not recalled. Trained persons were able to recall only one message while untrained participants recalled a broader range of messages. Factors associated with an awareness of a threat of AI in Laos were: having received HPAI training, literacy level, access to TV, recent information, living in rural areas.

Conclusion
We report a paradoxical relationship between unsafe behaviours and risk perception in urban areas, as well as exposure to HPAI training and message misinterpretation. Future educational campaigns need to be tailored to specific target populations and farming styles, for example, small holder farms as compared to commercial farms. Special attention must be given to varying risk perceptions and the risk of misinterpretation of key messages, economic hardship, and real life consequences of reporting.