The present study demonstrated that the occurrence of H5N1 in neighboring areas had an emotional impact, and also increased people’s attention to preventive measures and their knowledge about the necessity of early access to healthcare. Information and education delivery need to take into account the local conditions of the population.
Most human cases of avian influenza (H5N1) occur through direct or indirect contact with poultry 
. Contaminated water has also been identified as a potential risk factor 
. Bac Kan province is in a mountainous part of northeast Vietnam, with 95% of its area dominated by forest. The event group in Cho Moi District was located in a more deeply-forested area than the non-event group even though the districts are located side-by-side in Bac Kan province (). Along with the study participants, most residents in Cho Moi district were farmers and raised chickens, ducks, buffalo, and pigs. The non-event group lived in a more urban environment. Even though high awareness of H5N1 infection was observed in both groups, the event group had more chance to come into contact with poultry, thus increasing their risk for H5N1 infection compared with the non-event group. These results were compatible with a previous study in China that compared a typical urban area with a rural area in the middle of China 
. More participants in the event group had experienced H5N1 infection and unexplained sudden death in their household poultry, and a higher awareness of the importance of vaccination of poultry was observed. However, when their poultry died suddenly, participants in the event group were more likely than those in the non-event group to sell the rest of their live poultry, eat dead poultry, or throw carcasses into a river or pond. These results indicate that, participants in the event group maintained traditional habits and did not sufficient knowledge about the risks of H5N1 infection, with economic difficulties possibly contributing factor. Their economic difficulties in the event group might contribute for these behaviors. Although the role of water in transmission could not be confirmed, people’s behavior can contribute to the production of contaminated water. The results also indicated a lower knowledge score in the event group than in the non-event group. The main information sources about H5N1 infection for both groups were the television and radio. However, differences in economic conditions, which were qualified on the basis of household possessions, explained the difficulty in receiving information from television and radio, given that most participants in the event group did not have access to these. Educational background was also an important factor in understanding the information. Over 34% of participants in the event group had only an elementary school education, were illiterate, or had no educational background. Increased knowledge and appropriate attitude-practices relating to H5N1 infection were influenced by education, occupation, and economic conditions among the study population in an H5N1-affected community, as well as by the awareness of the presence of H5N1 patients in the community. These findings are compatible with previous surveys relating to H5N1 in China, Afghanistan, Laos, and Italy 
, and suggest that appropriate information delivery needs to be adjusted to local conditions 
More participants in the event group knew about the occurrence of H5N1 patients in neighboring areas (P
0.001) and were scared when they heard the news of an event (P<0.001). At the time of the event, 174 (54%) of participants in the event group and 168 (76%) of participants in the non-event group visited the hospital with flu-like symptoms such as cough, fever, and nasal discharge, or just because they were scared. The occurrence of H5N1 infection in humans in their neighbors caused the residents to panic and be unable to make calm decisions. They were unsure if their symptoms were attributable to H5N1 or to infection by another influenza virus, and their resulting behaviors made it more difficult for medical providers to take care of those who really needed medical intervention. After the event, almost all participants in the non-event group and over 90% in the event group sought healthcare early once they developed symptoms (e.g., fever). The event thus had an impact on their healthcare-seeking behaviors.
Logistic regression analysis identified factors influencing immediate access to healthcare once participants developed a fever after touching sick/dead poultry as knowledge about not eating such poultry, knowledge about the necessity for early access to healthcare, and recognition of H5N1 as a life-threatening disease. The results indicate that healthcare providers in high-risk areas need to stress the necessity of early access to healthcare, and promote proper knowledge about poultry handling to prohibit habits that favor H5N1 infection. Participants in the event group visited their local health center, while participants in the non-event group visited the provincial hospital. It is difficult to change behaviors and customs, especially in residents of rural areas. However, closer relationships between local healthcare providers and residents could promote early healthcare behaviors in people living in rural communities in deeply-forested regions. Educational programs conducted by local healthcare providers might be effective, but the attitudes of local residents must be taken into consideration when planning health education in communities with H5N1 patients in neighboring areas.
This study was limited to a comparison of participants living in one community affected and the other unaffected by the H5N1 outbreak in 2010, representing a rural and an urban setting in a province of Vietnam. Participants who did not have household poultry were included in the study participants and they need to answer some questions as if they have household poultry. Further investigations comparing subjects with similar socioeconomic conditions and common educational and environmental backgrounds are required to further assess the influence of an H5N1 outbreak.
Awareness of H5N1 patients in neighboring areas can cause panic in residents. However, it can also contribute to early healthcare-seeking behavior. Providing information from experiences of occurrence of H5N1 patients and clinical preparedness are crucial if further influenza pandemics occurred. Periodic educational interventions using locally-adjusted methods could contribute to preventing panic, motivating early access to healthcare, and reducing infection and mortality.