Do social isolation and neighborhood walkability influence relationships between COVID-19 experiences and wellbeing in predominantly Black urban areas?

Black Americans have been disproportionately affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) pandemic. Since the pandemic's start, we have observed compounded health, social, and economic impacts for communities of color, fueled in part by profound residential segregation in the United States that, for centuries prior to the pandemic, created differences in access to opportunity and resources. Based on a longitudinal cohort of Black residents living in two racially isolated Pittsburgh neighborhoods, we sought to: 1) describe the experiences of behavioral responses to COVID-19 conditions (e.g., closures of businesses, schools, government offices) and illness experiences reported by residents within these disinvested, urban areas and 2) determine if these experiences were associated with perceptions of risk, negative mental health outcomes, and food insecurity; and 3) examine whether any of the associations were explained by social isolation or modified by neighborhood walkability. We found direct associations between residents' experience with COVID-19-related closures and with the illness, with perceived risk, and change in psychological distress, sleep quality, and food insecurity from pre-COVID-19 levels. Social isolation was a statistically significant mediator of all of these associations, most strongly mediating the pathway to psychological distress. We found neighborhood walkability to be a significant moderator of the association between closure experiences and sleep quality. The results suggest that experiences of COVID-19 closures and illness were associated with serious threats to public health in Black, disinvested, urban neighborhoods, beyond those caused directly by the virus. Outcomes of the pandemic appear very much dependent on the extent to which social and physical resources are available to meet the demands of stress.

A longitudinal study of psychological distress in the United States before and during the COVID-19 pandemic.

The COVID-19 pandemic has caused financial stress and disrupted daily life more quickly than any prior economic downturn and on a scale beyond any prior natural disaster. This study aimed to assess the impact of the pandemic on psychological distress and identify vulnerable groups using longitudinal data to account for pre-pandemic mental health status. Clinically significant psychological distress was assessed with the Kessler-6 in a national probability sample of adults in the United States at two time points, February 2019 (T1) and May 2020 (T2). To identify increases in distress, psychological distress during the worst month of the past year at T1 was compared with psychological distress over the past 30-days at T2. Survey adjusted logistic regression was used to estimate associations of demographic characteristics at T1 (gender, age, race, and income) and census region at T2 with within-person increases in psychological distress. The past-month prevalence of serious psychological distress at T2 was as high as the past-year prevalence at T1 (10.9% vs. 10.2%). Psychological distress was strongly associated across assessments (X2(4) = 174.6, p < .0001). Increase in psychological distress above T1 was associated with gender, age, household income, and census region. Equal numbers of people experienced serious psychological distress in 30-days during the pandemic as did over an entire year prior to the pandemic. Mental health services and research efforts should be targeted to those with a history of mental health conditions and groups identified as at high risk for increases in distress above pre-pandemic levels.

Persistent Risk-Related Worry as a Function of Recalled Exposure to the Deepwater Horizon Oil Spill and Prior Trauma.

Large oil spills are disasters associated with psychological effects for exposed communities. The amount of worry that individuals experience after a disaster may be influenced by many factors, such as the type and extent of exposure to disaster impacts, prior trauma, and sociodemographic characteristics. This study examined the nature and predictors of worry about ongoing impacts of the 2010 Deepwater Horizon (DH) oil spill reported by Gulf of Mexico coastal residents. A random sample of 2,520 adult residents of Gulf of Mexico coastal counties were administered a telephone survey in 2016, including items about persistent worry and exposure to DH impacts, prior trauma, residence at the time of the spill, and sociodemographic characteristics. Respondents varied in the amount of worry they reported about ongoing health, social, and economic impacts. Controlling for sociodemographic characteristics, higher exposure to the DH oil spill was related to higher levels of worry about ongoing impacts, with past traumatic events related specifically to worry about health impacts. Unexpectedly, those who moved into the region after the spill showed similar levels of worry to residents exposed to the spill, and higher levels than residents who did not recall being exposed to the DH oil spill. This study highlights the impact of the DH oil spill on coastal residents many years after the DH disaster. The findings underscore the need to examine multiple pathways by which individuals experience disasters and for risk researchers to close knowledge gaps about long-term impacts of oil spills within a multi-dimensional framework.

Emerging infectious disease, the household built environment characteristics, and urban planning: Evidence on avian influenza in Vietnam.

Recent concerns with pandemic outbreaks of human disease and their origins in animal populations have ignited concerns regarding connections between Emerging Infectious Diseases (EID) and development. As disasters, health, and infectious disease become part of planning concern (Matthew & McDonald, 2007), greater focus on household infrastructure and EID disease outbreaks among poultry is warranted. Following Spencer (2013), this study examines the relationship between the mix of household-scale water supplies, sanitation systems, and construction materials, and Highly Pathogenic Avian Influenza (HPAI) among poultry in a developing country: Vietnam. Findings of our multivariate logistic regressions suggest that a non-linear, Kuznets-shaped urban transition (Spencer, 2013) has an independent effect on the outbreak of HPAI, especially as it relates to household-level sanitation infrastructure. We conclude that the Kuznets-shape development of household infrastructure characteristics in Vietnam play a significant role in explaining where poultry outbreaks occur. Using secondary data from the Census of Population and Housing, and the Agricultural Census at the District and Commune levels for the country of Vietnam, we performed logistic regression to test the relationship between outbreaks of HPAI in poultry and newly-developed "coherence indices" (Spencer, 2013) of household water supply, sanitation, and construction materials that measure nonlinear, transitional development. Results show that district-scale coherence indices are negatively and independently correlated with HPAI outbreaks, especially for sanitation. Findings also suggest that community-scale coherence of urban infrastructures is a powerful tool for predicting where HPAI poultry outbreaks are likely to occur, thereby providing health planners new tools for efficient surveillance.

Improving Patients' Choice of Clinician by Including Roll-up Measures in Public Healthcare Quality Reports: an Online Experiment.

BACKGROUND: Public reports on healthcare quality typically include complex data. To lower the cognitive burden of interpreting these data, some report designers create summary, or roll-up, measures combining multiple indicators of quality into one score. Little is known about how the availability of roll-ups affects clinician choice. OBJECTIVE: To determine how presenting quality scores at different levels of aggregation affects patients' clinician choices. DESIGN: We conducted a simulated clinician-choice experiment, randomizing participants to three versions of a public reporting website and comparing their clinician choices. One version aggregated all clinician-level quality measures into roll-ups, the second provided disaggregated (drill-down) scores only, and the third offered both roll-ups and drill-downs. PARTICIPANTS: Five hundred fifty panelists drawn from a probability-based Internet panel. MAIN MEASURES: We assessed the amount of effort participants exerted by tracking the length of time spent on the website and the number of concrete actions taken on the website (e.g., clicking items). We evaluated decision quality by measuring whether participants selected a clinician who performed more poorly than others and incongruence between participants' stated preferences for dimensions of quality and their chosen clinician's performance on those dimensions. KEY RESULTS: Participants seeing drill-downs alone (mean = 14.9) or with roll-ups (mean = 19.2) took more actions than those who saw roll-ups alone (mean = 10.5) (ps < 0.05). However, participants seeing only drill-downs made poorer choices than those who saw roll-ups alone or with drill-downs. More participants seeing drill-downs chose a clinician who was outperformed (36.3% versus 23.4% [roll-up] and 25.6% [drill-down + roll-up], ps < 0.05) and made choices incongruent with stated preferences (51.2% versus 45.6% [roll-up] and 47.5% [drill-down + roll-up], ps < 0.05). The distinction between roll-up and drill-down was somewhat stronger for sicker participants. CONCLUSIONS: Our results suggest that roll-ups in healthcare quality reports, alone or as a complement to drill-downs, can help patients make better decisions for themselves.

What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement.

Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers' patients, and health system administrators can identify and respond to patterns in patients' accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement. CONTEXT: For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement. METHODS: Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders. FINDINGS: The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements. CONCLUSIONS: In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

Aging and Emotional Well-Being After Disasters: Vulnerability and Resilience.

BACKGROUND AND OBJECTIVES: Climate change threatens well-being and has increased the prevalence of weather-related disasters. We investigated age differences in emotional well-being among adults who had experienced hurricane-related, unavoidable stressors. Socioemotional selectivity theory (SST) posits that age-related motivational shifts buffer older adults against psychological distress, whereas the strength and vulnerability integration model (SAVI) posits that unavoidable stressors are more detrimental to older adults' well-being compared to younger adults. RESEARCH DESIGN AND METHODS: We used existing self-report data from a life-span sample of adults (N = 618, M age = 58.44 years, standard deviation = 16.03, 18-96 years) who resided in the U.S. Gulf Coast region. The sample was recruited in 2016 to examine the sequelae of the Deepwater Horizon oil spill and contacted again after the 2017 and 2018 hurricane seasons. In 2016, participants reported their depression, anxiety, and trauma history. After the 2017-2018 hurricane seasons, participants reported their depression, post-traumatic stress, exposure to hurricane-related adversities, injuries and casualties, self-efficacy, and perceived health. RESULTS: In line with SST, older age was associated with reporting significantly fewer depression and post-traumatic stress disorder symptoms, even after controlling for exposure to hurricane-related adversities, injuries and casualties, health, self-efficacy, pre-hurricane depression, anxiety, and trauma. The association between older age and fewer depression symptoms was stronger among those who experienced hurricane-related adversities compared to those who had not, in contrast to predictions based on SAVI. DISCUSSION AND IMPLICATIONS: We discuss the implications of age-related strengths in emotional well-being for policy and practice in the context of the ongoing climate crisis.

Perceived Need for Mental Health Treatment and the Mental Health Response to the COVID-19 Pandemic in the United States.

Objective: Population-based information on the extent of perceived need for mental health treatment and clinically significant psychological distress can help inform strategies for responding to the mental health impact of the COVID-19 pandemic.Methods: A representative sample of U.S. adults, age 20 and over (N = 1,957), completed surveys in May and June 2020. Potential target populations were distinguished based on perceived need for mental health treatment and psychological distress, assessed by the Kessler-6, among those without perceived need. Populations were characterized with respect to demographic characteristics and prior mental health treatment history using logistic regression models.Results: The prevalence of perceived need for mental health treatment was 21%. Perceived need was strongly associated with pre-pandemic treatment history; compared to those with no treatment history, perceived need was dramatically higher among those in treatment when the pandemic began (OR = 53.8 95% CI 28.2-102.8) and those with pre-pandemic treatment history (OR = 9.3, 95% CI 5.1-16.8). Among the 79% who did not perceive need, moderate or greater distress was reported by 19% and was associated with younger age and Hispanic ethnicity (OR = 2.1, 95% CI 1.2-3.6).Conclusions: In the U.S., where mental health treatment is relatively common, mental health treatment response during the pandemic, and perhaps other crises, should target people with a history of mental health treatment. Outreach to people less likely to seek care on their own despite clinically significant distress should target Hispanic populations.

Nationally Representative Sample Shows an Increase in Domestic Conflict Early in the COVID-19 Pandemic.

OBJECTIVE: The coronavirus disease (COVID-19) pandemic and associated social distancing increased stressors related to risk for domestic conflict, but increases in domestic conflict early in the pandemic have yet to be studied in community samples. METHODS: Increase in domestic conflict (verbal or physical fights) since the beginning of the pandemic was assessed in 1196 partnered and cohabitating respondents, drawn from a nationally representative sample, in May 2020. Chi-square tests and logistic regression analyses were used to estimate associations of demographic characteristics and financial worry with domestic conflict. RESULTS: An increase in domestic conflict was reported by 10.6% (95% CI: 7.7-13.4) of the sample. Domestic conflict increase was significantly associated with younger age, lower education, and financial worry. CONCLUSION: Increases in domestic conflict were seen in certain vulnerable groups and in those who report financial worry. Policies ensuring financial stability, particularly early in the disaster conditions, could reduce domestic conflict during continued COVID-19 conditions or other disasters.

Short-Term Solutions to a Long-Term Challenge: Rethinking Disaster Recovery Planning to Reduce Vulnerabilities and Inequities.

In the immediate aftermath of disaster, governments usually act quickly to reduce risk and to recover their communities' socio-economic functioning. Policy makers in these situations need-but may not have the capacity or time for-substantial analysis and public debate about how to balance short- and long-term societal needs. Inadequate attention to this challenge may result in a deepening of the inequities that increase vulnerability to disaster impacts. We review case examples to illustrate how post-disaster policies may influence the nature, pace, and inclusiveness of community recovery. We then apply a vulnerability/inequity framework to conceptualize how to enhance disaster recovery and avoid perpetuating inequities when weighing the diverse needs of communities across long time horizons.

On the Need for Prospective Disaster Survey Panels.

Disasters are typically unforeseen, causing most social and behavioral studies about disasters to be reactive. Occasionally, predisaster data are available, for example, when disasters happen while a study is already in progress or where data collected for other purposes already exist, but planned pre-post designs are all but nonexistent. This gap fundamentally limits the quantification of disasters' human toll. Anticipating, responding to, and managing public reactions require a means of tracking and understanding those reactions, collected using rigorous scientific methods. Oftentimes, self-reports from the public are the best or only source of information, such as perceived risk, behavioral intentions, and social learning. Significant advancement in disaster research, to best inform practice and policy, requires well-designed surveys with large probability-based samples and longitudinal assessment of individuals across the life-cycle of a disaster and across multiple disasters.

A Rigorous Approach to Large-Scale Elicitation and Analysis of Patient Narratives.

Patient narratives have emerged as promising vehicles for making health care more responsive by helping clinicians to better understand their patients' expectations, perceptions, or concerns and encouraging consumers to engage with information about quality. A growing number of websites incorporate patients' comments. But existing comments have fragmentary content, fail to represent less vocal patients, and can be manipulated to "manage" providers' reputations. In this article, we offer the first empirical test of the proposition that patient narratives can be elicited rigorously and reliably using a five-question protocol that can be incorporated into large-scale patient experience surveys. We tested whether elicited narratives about outpatient care are complete (report all facets of patient experience), balanced (convey an accurate mix of positive and negative events), meaningful (have a coherent storyline), and representative (draw fulsome narratives from all relevant subsets of patients). The tested protocol is strong on balance and representativeness, more mixed on completeness and meaningfulness.

Reaching vulnerable populations in the disaster-prone US Gulf Coast: Communicating across the crisis lifecycle.

Delivering risk and crisis communication to US Gulf Coast residents poses a unique challenge to individual and organizational responders. The region has endured several natural and man-made disasters, spanning Hurricane Katrina, the Deepwater Horizon oil spill, and more recently Hurricanes Harvey and Irma. In the future, the US Gulf Coast is expected to remain susceptible to a range of disasters. At the same time, the region is experiencing a growing population, struggles with systemic disparities between residents, and is home to major energy, tourism, fishing, and shrimping industries. Engaging in pre-crisis planning with vulnerable populations, and assessing response strategies, can help the region prepare for future disasters. In support of understanding vulnerabilities in the US Gulf Coast, the authors conducted a survey in 2016 of n = 2,520 adult residents of the targeted geographic region. The authors examine how demographic characteristics affect communication channel preferences (ie, television, Internet, print [newspapers, magazines], radio, word-of-mouth, or another specified channel) and trust in sources (ie, the national news media, local news media, business leaders and organizations, religious leaders and institutions, academics and academic institutions, friends and family, and doctors) in the US Gulf Coast. Weighted prevalence estimates or similar summary statistics (mean, standard deviation) are provided for both outcomes. Findings for channel preferences and trust in sources are examined by sex, race/ethnicity, age, and education. Weighted multinomial logistic regression is used in a multivariate model. Weighted linear regression is used to examine differences in trust in each source of information. Results highlight significant differences in channel preferences and trust across respondents. The authors also place these results in context to more readily accessible national estimates of these outcomes, emphasizing takeaways for the region.

Reaching vulnerable populations in the disaster-prone US Gulf Coast: Communicating across the crisis lifecycle.

Delivering risk and crisis communication to US Gulf Coast residents poses a unique challenge to individual and organizational responders. The region has endured several natural and man-made disasters, spanning Hurricane Katrina, the Deepwater Horizon oil spill, and more recently Hurricanes Harvey and Irma. In the future, the US Gulf Coast is expected to remain susceptible to a range of disasters. At the same time, the region is experiencing a growing population, struggles with systemic disparities between residents, and is home to major energy, tourism, fishing, and shrimping industries. Engaging in pre-crisis planning with vulnerable populations, and assessing response strategies, can help the region prepare for future disasters. In support of understanding vulnerabilities in the US Gulf Coast, the authors conducted a survey in 2016 of n = 2,520 adult residents of the targeted geographic region. The authors examine how demographic characteristics affect communication channel preferences (ie, television, Internet, print [newspapers, magazines], radio, word-of-mouth, or another specified channel) and trust in sources (ie, the national news media, local news media, business leaders and organizations, religious leaders and institutions, academics and academic institutions, friends and family, and doctors) in the US Gulf Coast. Weighted prevalence estimates or similar summary statistics (mean, standard deviation) are provided for both outcomes. Findings for channel preferences and trust in sources are examined by sex, race/ethnicity, age, and education. Weighted multinomial logistic regression is used in a multivariate model. Weighted linear regression is used to examine differences in trust in each source of information. Results highlight significant differences in channel preferences and trust across respondents. The authors also place these results in context to more readily accessible national estimates of these outcomes, emphasizing takeaways for the region.

Choosing Doctors Wisely: Can Assisted Choice Enhance Patients' Selection of Clinicians?

We conducted a simulated clinician-choice experiment, comparing choices and decision-making processes of participants (N = 688) randomized among four experimental arms: a conventional website reporting only quantitative performance information, a website reporting both qualitative (patient comments) and quantitative information, the second website augmented by a decision aid (labeling of patient comments), and the decision-aided website further augmented by the presence of a trained navigator. Introducing patient comments enhanced engagement with the quality information but led to a decline in decision quality, particularly the consistency of choices with consumers' stated preferences. Labeling comments helped erase the decline in decision quality, although the highest percentage of preference-congruent choices was seen in the navigator arm. Engagement with the quality information and satisfaction with choices available were likewise highest in the navigator arm. Findings held for high- and low-skilled decision makers. Thus, navigator assistance may be a promising strategy for equitably promoting higher quality choices in information-rich contexts.

Making diabetes self-management education culturally relevant for Filipino Americans in Hawaii.

PURPOSE: The purpose of this study was to identify the cultural values, traditions, and perceptions of diabetes risk and self-care among Filipino Americans in Hawaii with type 2 diabetes that facilitate or impede engagement in diabetes self-management behaviors and education classes. METHODS: This qualitative study used 2 rounds of semistructured focus groups and interviews. Participants included 15 patients with type 2 diabetes recruited from a large health-maintenance organization in Hawaii and 7 health care and cultural experts recruited from the community. The taped and transcribed focus groups and interviews were coded thematically. Participants evaluated example materials for diabetes self-management education (DSME) with Filipino Americans. RESULTS: Several aspects of Filipino American culture were identified as central to understanding the challenges of engaging in self-management behaviors and DSME: (1) undertaking self-management while prioritizing the family and maintaining social relationships, (2) modifying diet while upholding valued symbolic and social meanings of food, (3) participating in storytelling in the face of stigma associated with diabetes, and (4) reconciling spiritual and biomedical interpretations of disease causality and its management. Respondents also emphasized the role of several qualitative aspects of perceived risk (eg, dread, control) in moderating their behaviors. Participants suggested ways to make DSME culturally relevant. CONCLUSIONS: Awareness of cultural values and qualitative aspects of perceived risk that influence Filipino Americans' engagement in diabetes self-care behaviors and classes may help to improve teaching methods, materials, and recruitment strategies.

Using "roll-up" measures in healthcare quality reports: perspectives of report sponsors and national alliances.

OBJECTIVES: To understand the views of prominent organizations in the field of healthcare quality on the topic of reporting roll-up measures that combine indicators of multiple, often disparate, dimensions of care to consumers. STUDY DESIGN: This study used a semi-structured, qualitative interview design. METHODS: We conducted 30- to 60-minute semi-structured telephone interviews with representatives of 10 organizations that sponsor public healthcare quality reports and 3 national alliances representing multiple stakeholder groups. We conducted a thematic analysis of interview transcriptions to identify common issues and concerns related to reporting roll-up measures. RESULTS: Among sponsors reporting roll-up measures, current practices for calculating and reporting these measures are diverse. The main perceived benefit of reporting roll-up measures is that they simplify large amounts of complex information for consumers. The main concern is the potential for consumers to misunderstand the measures and what associated roll-up scores communicate about provider performance. Report sponsors and national alliances feel that more guidance and research on the methods for producing and reporting scores for roll-up measures are needed. CONCLUSIONS: The results of the interviews elucidate the need for research focused on construction and reporting of roll-up measures. Studies are needed to determine if roll-up measures are indeed perceived by consumers as being less complex and easier to understand.

CAHPS and Comments: How Closed-Ended Survey Questions and Narrative Accounts Interact in the Assessment of Patient Experience.

OBJECTIVES: To investigate whether content from patient narratives explains variation in patients' primary care provider (PCP) ratings beyond information from the closed-ended questions of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey and whether the relative placement of closed- and open-ended survey questions affects either the content of narratives or the CAHPS composite scores. METHODS: Members of a standing Internet panel (N = 332) were randomly assigned to complete a CAHPS survey that was either preceded or followed by a set of open-ended questions about how well their PCP meets their expectations and how they relate to their PCP. RESULTS: Narrative content from healthier patients explained only an additional 2% beyond the variation in provider ratings explained by CAHPS composite measures. Among sicker patients, narrative content explained an additional 10% of the variation. The relative placement of closed- and open-ended questions had little impact on narratives or CAHPS scores. CONCLUSION: Incorporating a protocol for eliciting narratives into a patient experience survey results in minimal distortion of patient feedback. Narratives from sicker patients help explain variation in provider ratings.

Perceived Risk of Avian Influenza and Urbanization in Northern Vietnam.

Highly pathogenic avian influenza (HPAI) is an important public health concern because of potential for widespread morbidity and mortality in humans and poultry and associated devastating economic losses. We examined how perceptions of the risk of HPAI in poultry vary across communes/wards in the north of Vietnam at different levels of urbanization (rural, peri-urban, urban). Analyses of questionnaire responses from 1081 poultry raisers suggested that the perceived risk of HPAI in poultry was highest in peri-urban and rural settings. We also found that perceived risk was higher when respondents rated settings in which they did not live and that the process of change is related to perceived risk. Compared with others, respondents in peri-urban areas reported less disease management planning; respondents in rural areas reported less ability to separate infected poultry. These findings are consistent with, and add to, the limited previous research on the perceived risk of HPAI in poultry in developing countries. What is new in the present findings is that we describe how urbanization is related to people's perceptions of and ability to respond appropriately to variations in their environment. In particular, the inability to respond is not necessarily because of an inability to perceive change. Rather, rapid and extensive change poses different challenges for poultry management as communes move from rural to peri-urban to urban settings. Our results suggest that health promotion campaigns should address the perceptions and needs of poultry raisers in different settings.