201 JOURNAL OF SCIENCE, Hue University, N 0 61, 2010 RESEARCH ON ACTIONS OF COMMUNITY MOBILIZATION TO IMPROVE SANITATION ENVIRONMENT FOR ETHNIC MINORITIES IN ESPECIALLY DIFFICULT REGION OF DONG HY DISTRICT, THAI NGUYEN Dam Khai Hoan Thai Nguyen University of Medicine and Pharmacy Hoang Anh Tuan Thai Nguyen Medical College SUMMARY A two year- study on community mobilization for improving people’s behavior on environmental hygiene in minority ethnic community at remote and disadvantage region in Cay Thi Commune, Dong Hy district, Thai nguyen province. The findings are (1) the model of inter- branches in community and responsibility shared with health personnel in communicating to improve the people’s behavior on environmental hygiene, combine the task of each member of stake holder. The model had been set up the concrete duties and tasks to ensure their task as well as the integration of communication of environmental hygiene, (2) the findings show that there are the changes in people’s behavior on environmental hygiene in Cay Thi Commune, the knowledge is increased 63%, attitude is increased 33, 2%, practice is increased 14, 5%. The interventional effectiveness is knowledge on environmental hygiene (323%), practice (253%) and attitude (206%). After intervention in Cay Thi Commune, there are changes clearly, especially in building and using hygiene latrines, built hygiene latrines are increased (26, 5% households), the interventional effectiveness is 217, 22%. The recommendations: This model is good solution, feasibility and need to be applied and continue to study by certain local authority and health system. Key words: The community mobilization; the environmental hygiene; the minority ethnic community. 1. Introduction Environmental hygiene is a problem that is not only of interest in the scope of a country or a region, but also a matter of concern on a global scale because of its importance to human health. Implementing good environmental hygiene to improve the health and living conditions of rural people contributes to poverty alleviation, especially in the uplands, deep and difficult areas as well as ethnic minority areas. However, economic development, culture and society in these areas is still poor, the common 202 people's living standards are low, their educational level has not improved, transportation is difficult, and health care conditions and social welfare are still lacking. In Dong Hy district, Thai Nguyen province, the behavior of environmental hygiene is a problem. Therefore, we deem it necessary to improve environmental sanitation. Mobilizing the community to participate in improving the behavior of environmental hygiene is considered a good approach for solving these problems. Thus this research is conducted to describe the actual situation of environmental hygiene behavior of ethnic minorities in particularly difficult communes of Dong Hy district, Thai Nguyen province, to build a model of community mobilization to improve environmental hygiene behavior for people in Cay Thi commune, Dong Hy district, Thai Nguyen province and to assess the effectiveness of the model for improving sanitation behavior for ethnic minorities in Cay Thi commune after two years of implementation. 2. Methods 2.1. Subjects: All households, government leaders, government departments, unions and medical workers. 2.2. Location: 4 communes (Cay Thi, Hop Tien, Van Lang and Tan Long) of Dong Hy district, which are mountainous communes, in which Cay Thi is a intervention commune and Hop Tien is a control commune 2.3. Time: From January 2006 to December 2007 2.4. Methods: A cross-sectional method was used to describe the actual situation of environmental hygiene behavior and find the factors related to environmental hygiene behavior. An Epidemiological intervention to build models to improve sanitation behavior was also conducted. 2.4.1. Descriptive study Design: The combination of the properties. The sample size was calculated for a cross-sectional survey of 800 but the actual survey sample was 830. Four communes of Dong Hy district were chosen intentionally, because they are considered extremely difficult communes in Dong Hy. 200 households of ethnic minorities in remote areas (the town center from 5 km) were selected from each commune. Each household randomly selected one adult representative (as family leader) from the list of households. 2.4.2. Intervention study design: The following interventions are confronting the sample size was calculated based on a formula of epidemiological intervention n = 194, so the number of households in each commune was 200. We decided to choose Cay Thi commune and Hop Tien commune because they have similar social characteristics. 2.4.3. The research indicators: Using Knowledge, Attitudes and Practice, (KAP) on environmental sanitation as indicators. The KAP level distributed into three types of variables, such as knowledge (K), attitude (A) and practice (P) for each problem will be 203 studied. The total of points for each variable was 10 points. The classification of KAP levels are as follows: Total points from 10-70 points: Good; from 5 to 6 points: average; <5 points : weak 2.4.4. Build models of intervention. - Establish a Steering Committee to adopt the model in Cay Thi (intervention commune) - Train participants in basic issues of hygiene and environmental media and methods of operation in the model (duration of the training course is one week). - Assign functions and specific tasks to the participants - The Steering Committee meets monthly to review the implementation progress of the model and supplement and update the knowledge of some of its members - Activities of the team: Conduct a surveillance to review progress on implementating models and to detect additional problems which require direct support every two months. - The activities of the model are continuous for about two years. 2.4.5. Information gathering techniques * Quantity: Interview households: investigators conducted interviews directly to householders. Interviews were recorded on pre-printed forms which were designed in accordance with the procedures and requirements of the research. These forms were pre-tested at Cay Thi commune, then revised again before printing. Observations in homes and information collected from health centre reports. * Identification: Focus group discussions were used to explore cultural aspects, hygiene habits of the people and the acceptability of the community model: There were two discussion groups (one before and the one following the intervention) with the steering committee members and community representatives (approximately 10 people for each). 2.4.6. Assessment methods. Comparisons of KAP about environmental sanitation change in Cay Thi and Hop Tien before and after intervention. Results were ranked based on intervention effectiveness index and effective interventions. 2.4.7. Method of processing data. The software EPIINFO 6:04 was used. 3. Results 3.1. Knowledge attitude practice (KAP) about environmental sanitation of people in the researched communes 204 Table 3.1. KAP of the people who undertook water and management of water distribution. KAP n % Source water agreements: good knowledge 249 30. Behaviour 176 21.20 Good Practice 134 16.14 Distribution management: good knowledge 168 20.24 Behaviour 159 19.16 Good Practice 89 10.72 The results revealed the KAP of people concerning water is very low: The percentage of people with good knowledge only reached 30%, good attitudes and good practices account for only 21.2% and 16.14 %. Concerning water management, the percentage of people who had good knowledge of management was 20.24%, the percentage of good attitudes and good practice was also lower: 19.16% and 10.72% respectively In the community, before our intervention was implemented a panel discussion with local leaders and residents of Cay Thi was conducted. When discussing water issues, according to Mr. K - Farmer's Market "local water sources are mainly used, as dug wells, which are not sanitary, the cause of pollution is caused by grazing and deforestation at the watershed "Mr. X - President of the National Social Front, said:" As neighbors get water vascular plants from the mountain town to households and three neighbors used deep troughs using water from streams to their homes The cause of water pollution was due to mining, a few households also raise stock, sanitation as water wells near food. There are not hygienic latrines by customs still optimistic Miss. When discussing the management of water sources, Mr. C – Cay Thi commune said "Look at the toilet hygiene of the households in eight neighborhoods, I found most of the households have sanitary latrines ". Mr. H – from the commune health center said: " There are no hygienic latrines in four remote hamlets of Cay Thi, this is caused by backward habits of sanitation. The solution for this is to communicate in order to change people's behavior ". In summary, water sanitation in the communes is not good, polluted by negative behaviors of people like the indiscriminate exploitation of mineral, water near the latrines, cattle pens People also use the slots, spring water and largely indiscriminate release UE is common due to no hygiene toilet Table 3.2. KAP of the people who had cattle pens and chemical plant protection KAP n % Animal cages: good knowledge 289 34.82 205 Behaviour 249 30. Good Practice 176 21.20 Chemical plant protection: good knowledge 166 20. Behaviour 158 19.04 Good Practice 89 10.72 In the KAP Synthesis of people on blankets, drop, construction of animal barns we saw that: good knowledge of the people on these issues is still low, reaching only 34.82%. The scores of attitudes, and practice of the people was also low, only 30% and 21.2%. Knowledge, attitudes and practices of the population with chemical plant protection is not yet possible. In our study, the proportion of people with good knowledge of 20%, good attitudes and good practices as 19.04% and 10.72% respectively According to Ms. M – Cay Thi primary school: "The farm animals and do not just drop hygienic ". According to Mr. K - Commune Farmer Association: "The raising of cattle and cattle ranching also no longer present if the neighbors are mostly in remote areas. The rate of latrine use is low due to the habits and practices " Table 3.3. KAP of the people about sanitation KAP n % Good knowledge 179 21.57 Behaviour 157 18.92 Good Practice 79 9.52 General knowledge of environmental sanitation of the people is at a very low level, at 21.57%. The results of good behavior and good practice on environmental hygiene is also very low (18.93% and 9.52% respectively). When discussing sanitation issues in general, according to Mr. T – Cay Thi People’s Community: "Now latrines and hygiene of the households in the most remote hamlets are a problem. The reason is their habits. The knowledge people have about hygiene is very limited. Particularly in three remove hamlets people still feed free pigs " So the proportion of households who have clean water, sanitary latrines, and bathrooms are very low. The leading cause is due to the customs and obsolete traditions, and poverty communication on sanitation is necessary. The party, government, departments should motivate the active participation on the medical basis to ensure the success 206 3.2. Building a model of intervention 3.2.1. The results of model intervention. The model was built with the participation of key community organizations. Members of the model were assigned proper tasks 3.2.2. Operation results of the model: * Results of model training Table 3.4. Results of model training Time Level Pretest Postest p n % n % Pretty, Good 14 33.33 28 66.66 <0.05 Average 15 35.71 12 28.57 Weak 13 30.95 2 9.52 Total 42 42 After training, the participant's knowledge about environmental sanitation increased markedly, to an especially good level (p <0.05). * Implementation: The model has been in operation since September 2006. The content and implementation plan are designed as a specific model. On the basis of assigned duties, the commune health center staff supervised professional activities. The Commune People’s Committee had a resolution on the implementation of sanitation projects for the implementation of each Party member. CPC documents guided the implementation of the sanitation department and send it to the village chief. The departments have guidelines made by members. The implementation of the sanitation standard promoted an emulation among party members, union members, many members of mass organizations Every week, the health volunteers, the collaborators and nutritionists, with the support of village leaders, youth in the village have taken to visit households and combine health education. On the last day of each month, members send reports to the leader of commune health centers (CHC). He reviewed and provided information to the members what has been done, and what should be added to next month for better performance * Supervision: The right process, the team will supervise and inspect the actual activities of the village members. The supervisors consider the reports of health volunteers, collaborators and teachers, reviews of economic growth while listening to the leader of CHC reflects the opinions of people in the original. Every two months, the team meets the CPC and the leader of CHC to evaluate the activities of members in villages and discuss additional issues that need more direct support. The leader of the 207 CHC supervises the health volunteers and collaborators’ daily work in the medical professional field. * Results of communication activities Table 3.5. The results of specific activities of the participants concerning the model indicators Indicators Member Number of sessions transmitted through meetings Number of communicati on sessions in households Number of listeners Commune health station staff 10 105 198 Village health workers 51 423 982 Women 8 120 379 Youth Union 42 387 1.235 Farmer 8 45 125 Teachers 'plug' 13 78 234 University medical student 24 490 678 The other mass organizations 12 24 132 Total 168 1.672 3.963 The above results show the organizations involved in communication on sanitation works. the leading groups are health staff, medical students, youth union and teachers are plugging the organizations most active. 3.3. Effective models of intervention in changing people's environmental sanitation behavior Cay Thi and Hop Tien, Dong Hy district, Thai Nguyen province Table 3.6. Change KAP on environmental sanitation of the people to conform to social Time hygiene environment Before intervention After intervention Difference (%) performance indicators (%) p n % n % Good knowledge 39 19.5 165 82.5 63. 323. p<0.05 Behaviour 32 16. 98 49. 33.2 206. p<0.05 Good Practice 19 9.5 67 33.5 14.5 253. p<0.05 208 After the intervention the change in people's KAP on environmental sanitation is illustrated in table 3.6. Clearly the most effective interventions are knowledge of sanitation (323%), followed by sanitation practices (253%) and attitudes (206%) with p <0.05. Table 3.7. Behavior change using the people's communes CTVS Tree Market Time hygienic work Before intervention After intervention Difference (%) performance indicators (%) p n % N % Clean Water 95 47.5 115 57.5 10 20 >0.05 Sanitary latrines 21 10.5 74 37.0 26.5 252 <0.05 Bathroom 90 45. 128 64.0 19 42 >0.05 Move animal cages away from housing 35 17.5 45 22.5 5 29 >0.05 After intervention in Cay Thi, there was a significant change in building and using sanitary latrines, effective intervention is 252% (p <0.05), but other issues had low efficiency and are not statistically significant (p> 0.05). Table 3.8. Change KAP on environmental sanitation of Hop Tien commune Time hygienic work Before intervention After intervention Difference (%) performance indicators (%) p n % N % Good knowledge 32 16 76 38 22 138 p<0.5 Behaviour 30 15 40 20 5 33 p>0.5 Good Practice 20 10 30 15 5 50 p>0.05 After nearly two years in Hop Tien commune without intervention, there was the significant change in people's knowledge of environmental hygiene, with the index reaching 138% of efficiency (p <0.05). Other issues have also changed and are at less effective (p> 0.05). 209 Table 3.9. Change of use CTVS of Hop Tien commune Time hygienic work Before intervention After intervention Differenc e (%) performanc e indicators (%) p n % N % Clean Water 83 41.5 98 49.0 7.5 18.07 >0.05 Sanitary latrines 23 11.5 31 15.5 4 34.78 >0.05 Bathroom 95 47.5 113 56.5 9 18.95 >0.05 Move animal cages away from housing 39 19.5 47 23.5 4 20.51 >0.05 After nearly two years, Hop Tien commune had no significant change in the use of latrines. The percentage of CTVS in Hop Tien increased but this is small and had low efficiency (p> 0.05). Table 3.10. KAP on environmental sanitation after intervention Time Hygienic Work Cây Thị (n.200) Hợp Tiến (n.200) Difference (%) work efficiency p n % n % Good knowledge 165 82.5 76 38 44.5 185 p<0.05 Behaviour 98 49 40 20 29 176 p<0.05 Good Practice 67 33.5 30 15 18.5 133 p<0.05 After intervention there was a dramatic change in KAP. The KAP of the people in Cay Thi is significantly higher in number of effective and efficient sanitation interventions than Hop Tien. The change in social and Tree Town were also clearly higher than in Cay Thi (p <0.05) Table 3.11. Change of use CTVS people between the two communes Time hygienic work Cây Thị (n.200) Hợp Tiến (n.200) Difference (%) work efficiency p n % n % Clean Water 115 57.5 98 49.0 8.5 12. >0.05 Sanitary latrines 74 37.0 31 15.5 21.5 217.22 <0.05 210 Bathroom 128 64.0 113 56.5 7.5 33. >0.05 Move animal cages away from housing 45 22.5 47 23.5 1. 18. >0.05 After nearly two years in Cay Thi commune, hygiene work increased more than in Hop Tien commune, but only indicators of sanitary latrines are clear and significantly (p <0.05). Effective intervention on hygienic latrines was much higher and clearer (217.22%). Other interventions are effectively unknown. After nearly two years of research, we conducted a panel discussion with representatives of community leaders. The discussion focused on issues such as: changes in behavior of people on sanitation, the performance of the model and how to maintain the operation of the model. We have obtained the following results: According to Mrs. H- Hoan Hamlet Secretary: "Although Hoan Hamlet has poor environmental sanitation,after implementing the program, sanitation issues of neighborhood schools has improved a lot. The program has combined with neighborhood groups and people to support implementation of sanitation activities under the guidance of officials and medical students. Awareness of the people improved. Implementation of sanitation activities is expected to continue in the commune ". According to Mr. H – CHC "the rate of households with hygienic works has improved remarkably. Households should be supported to improve sanitation of one compartment into sanitation of two compartments, the water tank to create sanitary, landfill site. Local leaders and organization should be leading implementation. People want more development in the local " So the opinions of community members were focused on model studies that were effective in improveing people's behavior in sanitation very well. Practically, building of latrines and hygiene is the most obvious changes. 4. Discussion 4.1. Organization: Community mobilization means that many organizations are mobilized to educate people about environmental sanitation. If organizations work separately, the power and efficiency of interventions will be reduced. Hence involving organizations in a Steering Committee is critical to these models. Activities of the committee are fluent, owing to a close relationship, , proper responsibilities and clear communication among organizations and departments. Our organization emphasizes the principle of mainstreaming as recommended by primary health care. The general activities of the community are integrated into each activity separately in each department organization. 4.2. The authorities missions: We determined the Sanitation Steering Committee is part of primary health care in the commune. The main task of the Steering Committee was to organize and mobilize the public sector on environmental sanitation . cross-sectional survey of 800 but the actual survey sample was 830. Four communes of Dong Hy district were chosen intentionally, because they are considered extremely difficult communes in Dong Hy. 200. epidemiological intervention n = 194, so the number of households in each commune was 200. We decided to choose Cay Thi commune and Hop Tien commune because they have similar social characteristics. 2.4.3 attitudes and good practices as 19.04% and 10.72% respectively According to Ms. M – Cay Thi primary school: "The farm animals and do not just drop hygienic ". According to Mr. K - Commune