MINISTRY OF EDUCATION AND TRAINING UNIVERSITY OF THAI NGUYEN HOANG ANH TUAN THE STATUS OF DAO’S SANITARY BEHAVIORS IN SOME PARTICULARLY DIFFICULT COMMUNES IN THAI NGUYEN AND TESTING INTERVENTION MODELS Major: SOCIOLOGY AND SANITATION HEALTH ORGANIZATION Code: 62.72.01.64 SUMMARY OT Ph.D THESIS THAI NGUYEN - 2014 The work has been completed in University of Medicine & Pharmacy – Thai Nguyen University Science Superviors: 1. Assoc.Prof.,Dr Dam Khai Hoan 2. Assoc.Prof.,Dr Nguyen Van Hien Opponent 1: Opponent 2: Opponent 3: The thesis will be protected in Thesis Committee in National Level held in University of Medicine and Pharmacy - Thai Nguyen University at in , 20 The information from this thesis can be found: Library of Thai Nguyen University of Medicine and Pharmacy Learning Resource Center – Thai Nguyen University National Library LIST OF PUBLISHED WORKS RELATED TO THESIS 1. Hoang Anh Tuan, Dam Khai Hoan, Nguyen Van Hien (2014), “The reality of knowledge, attitude and practice of environmental sanitation in some of the Dao extremely difficult communes in Thai Nguyen Province", Journal of Science and Technology, Journal of Agriculture, Biology-Medicine, Thai Nguyen University, vol 123 (09)/2014, p. 3-10. 2. Hoang Anh Tuan, Dam Khai Hoan, Nguyen Van Hien (2014), "A number of factors related to environmental hygiene behavior in 4 of the Dao extremely difficult communes in Thai Nguyen," Journal of Practical Medicine, (7; 925), p. 149-152 3. Hoang Anh Tuan, Dam Khai Hoan, Nguyen Van Hien (2014), "Effective interventions on environmental sanitation of the Dao in communes with special difficulties of Vo Nhai, Thai Nguyen," Journal of Practical Medicine, (7; 924), p. 58-61  1 BACKGROUND Northern mountainous Vietnam is the main living area of the minority ethnic communities in Vietnam ethnic groups such as Tay, Nung, Thai, Muong, Dao, H'mong These are the areas with difficult transportation, low literacy levels by existing many outdated traditions, many potential risks of environmental pollution caused by man himself. The percentage of households with clean water, sanitary latrines is very low, the main cause is being not good at environmental hygiene behaviors. Dao people mainly live in the remote areas throughout Vietnam-China border from Lai Chau to Ha Giang province. General characteristics of Dao people are underdeveloped economic, cultural, society, and poor environmental hygiene. The question is what the status of the Dao sanitary behaviors in some particularly difficult communes of Thai Nguyen province now is? What factors affect Dao’s sanitary behaviors? And whether the communication models of health and education can improve sanitary behaviors or not? To answer above questions, we conducted a research on "The Status of Dao’s sanitary behaviors in some particularly difficult communes in Thai Nguyen and testing intervention models" with the objectives: 1. Assess the situation of the Dao’s sanitary behaviors in some extremely difficult communes in Thai Nguyen 2011. 2. Describe some factors related to Dao’s sanitary behaviors in some extremely difficult communes in Thai Nguyen province. 3. Assess the result of the testing the communication models in changing sanitary behaviors for Dao people in Vu Chan commune, Vo Nhai district, Thai Nguyen province. 2 THE NEW CONTRIBUTIONS OF THE THESIS 1. The result of the thesis has described the overall big picture of the current status of the Dao’s sanitary behavior living in particularly difficult communes in Thai Nguyen province. 2. This is the first intervention study in the Dao community which has provided the evidence, factors related to environmental hygiene behaviors of the Dao living in particularly difficult communes in Thai Nguyen province. 3. The Model "Communication in changing sanitary behaviors for the Dao in Vu Chan commune" has been mobilizing the resources of the community, the prestigious Dao people participating in the programe to improve the sanitary behavior for them. The research model is integrated into The primary Health care Committee of the commune, functions and duties assigned specificly and clearly with the pivotal role which is the Fatherland Front. This is the basis for the model to develop sustainably and feasibility. STRUCTURE OF THE THESIS The main thesis with 126 pages is composed by the following parts: Introduction: 2 pages Chapter 1 - Overview: 31 pages Chapter 2 - Objects and methods of research: 18 pages Chapter 3 - Findings: 39 pages Chapter 4 - Discussion: 34 pages Conclusion and Recommendation: 2 pages The thesis has 126 references, including 82 Vietnamese documents and 44 English ones. The thesis consists of 24 quantitative result tables, 5 charts, 4 diagrams, 1 figures and 5 qualitative result boxes. The appendix includes 7 appendixes, 25 pages. 3 Chapter 1. OVERVIEW 1.1. Current status of sanitary behaviors of the Dao in Vietnam According to WHO "Human behavior is a complex set of actions, but these actions are influenced by many inside and outside, subjective and objective factors." Behaviors are influenced by internal factors such as knowledge, attitudes, beliefs, values, personal experience of practice, behavior and external factors such as legislation, regulations, family, friends, the reputed people The activities have repeated several times, gradually become a lifestyle. Lifestyle is also influenced by anthropology, culture, society, psychological factors Lifestyle is a set of behaviors, creating a human life, including many specific issues such as practice personal hygiene and the use of sanitary facilities, living habits of individuals, families and communities, customs Every behavior is a specific expression outside and affected by many elements that are knowledge, attitude, practice (KAP) and the belief of people in a certain work or situation. 1.1.1. Behavior in using clean water of Dao people Results of the survey of Preventive Medicine and Environment Department in 2010, on the environmental hygiene conditions of some ethnic minorities in Vietnam showed that the Dao mainly used headwater streams and wells, very few people use tap water, rain water and wells: 57.6% of households using water from headwater streams, 18.3% of households using water from wells; few households using other water sources (0.7% of households using well water); not any households use tap water and rain water. However, 2.1% of households still use water from rivers, lakes, and 21.4% are using other sources of water which is not clean. Nearly half of Dao households in the survey (49.7%) admitted drinking (unboiled) water. 1.1.2. Behavior in using Latrine of the Dao Some studies of Hoan, D.K (2003), Hoc, N.D (2003) showed that the proportion of the Dao households who have latrines accounted for 50.4% of the surveyed households, but the proportion of households with suitable latrines were very low, only 5.8%. Of which there were only 5.1% of two separated compartment latrines, 0.3% of septic latrines, 0.3% of absorbed flush toilets. The Dao households who have no latrines defecate to the gardens and forests (85.5%), use the others’ households 4 (4.5%) or to the barn (10%). Reasons for not building latrine of the Dao is like the other minorities, mostly "no money" (76.9%); "no need" (21.3%) and "do not like" (1.2%). 1.2. The affects of habits on the sanitation health of the Dao According to the census of population and houses in 2009, the Dao in Vietnam has a population of 751,067 people, accounting for 0.87% of the whole national population, ranking 9th in ethnic groups, ranking 2nd in countries where the Dao live, residing in 61 out of 63 provinces and cities. The Dao (other names: Man, Dong, Trai, Diu Mien, Kim Mien, Lu Gang, Lan Ten, Dai Ban, Tieu Ban, Coc Ngang, Coc Mun, Son Dau etc) usually live in the valleys, low hills, surrounding foothills or along streams, where has headwater. They live in clusters, small separate hamlets and people gathered around the theocratic, with particular characteristics on the traditions and the most evidence is on their clothes such as Red Dao, Dao Quan Chet, Dao Thanh Y, Dao Ao Dai, Dao Quan Trang Although they have many different groups, their language is united to connect the close relationship between the Dao communities with each other. Dao groups have similarities in customs, habits, economic patterns and beliefs. 1.3 Some models of communication in changing sanitary behaviors * Model of community health workers in Zimbabwe: Community health workers selected are respected, literated and trained in the community. Health care models demonstrate the role of the prestigious leader in the community. * Approach "Total Sanitation owned by the community - CLTS - Community led Total Sanitation": CLTS approach is to achieve and maintain the status that does not defecate indiscriminately through guiding community to analysis hygiene, toileting habits and its aftermath, from which putting out collective action not to defecate indiscriminately into the environment (UNICEF -2009). * Approach "Marketing toilet - SanMark": access to market- oriented in order to take advantages of non-governmental organizations, the private sector, and state management agencies to assess and improve sanitation for households in poor rural areas in a sustainable way. The Capital course of the program will not be used to sponsor on purchasing materials and building latrines, but to focus on the implementation of activities in order to develop Sanitary market (IDE - USA). 5 * Mobilizing model community into communication - health education some contents of primary health care to the people of Long Tan - Dong Hy – Thai Nguyen: Mobilizing the community to participate in health education programme implementating the primary health care under the direction of the steering sanitation committee of the commune (Dam.K.H -2010). * Approach "Mobilizing communication communities to improve sanitation behavior in the remote and isolated areas of Cay Thi commune, Dong Hy District, Thai Nguyen Province": using educational methods and communication to change the people behavior from which they make the investment in building clean water project and sanitation of the family, no funding for latrines (Hoan,D.K, 2007). Chapter 2. SUBJECTS AND METHODS OF THE STUDY 2.1. Subjects of study - The Dao households (both husband and wife are the Dao), live in the Dao hamlets, not intermingled with other ethnics. - Commune and village health workers, population collaborators, the nutritional staffs in the village. - Government officials and departments, organizations in the communes - Teachers and primary students in the village. - Students of Thai Nguyen Medical College and Thai nguyen Medicine and Pharmacy College. 2.2. Study sites 4 Dao specially difficult communes in Thai Nguyen province are: Lien Minh, Vu Chan, Phuong Giao in Vo Nhai district and Cay Thi commune in Dong Hy district. 2.3. Study time From 7/2011 to 7/2014, 18-month intervention period from 8/2011 to 4/2013. 6 2.4. Research Methodology 2.4.1. Study Design Using a cross-sectional descriptive and intervention studies, then control method in combination with quantitative and qualitative methods. 2.4.2. Sample sizes and sampling methods 2.4.2.1. Sample sizes and sampling methods for cross-sectional study * Sample size: Estimated sample size based on the ratio of the Dao who use sanitary latrines, according to the results of previous studies was 0.25, the belief level is 95% and d = 0.03. 2 2 2/1 d pq Zn    From the formula above, calculating n equals to 801, rounded up to 840. Sample size is apportioned equally to 4 communes, each commune consists of 210 people. * Sampling Technique: Choose intentionally Dao communes in the list of specially difficult communes according to the Decision No.164/2006/Decision-Prime Minister of the government Prime Minister. Getting Dao households as sampling units, each commune selects 210 households according to accidental method. 2.4.2.2. Sample sizes and sampling methods for intervention research * Sample size: Estimated sample size based on the ratio of the Dao who use the sanitary latrines previous intervention (p1) is 25% and expecting to achieve 40% post-intervention (p2) with a level of belief is 95% , the capacity is 90% . 2 21 2211 2 )( )( pp qpqp Zn     From the formula, n = 203, getting 210 people per commune. * Sampling Technique: Choose intentionally Vu Chan commune (Vo Nhai) to intervene and choose one commune with similarities social, geographical, economic and health condition among specially difficult communes described in previous cross-sectional studies to act as controls. And Lien Minh commune (Vo Nhai) is chosen. Intervention was conducted on the entire Dao households living mainly in five hamlets of Vu Chan communes: Khe Noi, Khe Cai, Cao Son, Khe Ria 7 and Khe Rac. The subjects were selected for evaluation after intervention by accidental methods similarly sampling in cross-sectional descriptive study before intervention. 2.4.2.3. Sample sizes and sampling methods tested Ascaris eggs in soil * Sample size: Estimated sample size based on the density of the average Ascaris eggs in soil under 1kg previous studies ( 1 ) is 145 eggs per kg of soil and expecting to reduced to 115 eggs per kg soil after intervention ( 2 ) with a confidence level is 95%, power is 90%     2 21 2 11 2 2        ZZ n Based on the formula, n = 99, rounded up to 100 samples/commune. * Sampling Techniques: In the households interviewed, 100 households in each commune were randomly selected to test soil sampling in many diferent positions: in the house, in the yard, on the way to the toilet and around the toilet. Sample Ascaris eggs in soil were conducted in two communes, Vu Chan (intervention) and Lien Minhh (control) at 2 diferent periods, before and after intervention. 2.4.2.4. The sample size for qualitative research: - Discussion: Each commune conducts two discussions at 02 periods, before and after intervention with the leaders of community groups and the representing people of Dao community. - Further interview: 5 prestigious people in the Dao villages. 2.4.3. Content intervention 2.4.3.1. Construction intervention model Methods Step 1: Define the content to be mobilized to solve the problems of sanitation behavior. Step 2: Study the problem and collect the data. Step 3: Develop general and specific objectives to mobilize communities to improve priority sanitation behavior . Step 4: Determine the solution and specific actions to carryout the models. Step 5: Develop monitoring and evaluating tools to measure the results of operations of research models. [...]... effectiveness of intervention of 21.0% and contaminated soil samples decreased with the effectiveness of intervention of 11.1% Chapter 4 DISCUSSION 4.1 Situation of sanitation behavior of the Dao in some extremely difficult communes in Thai Nguyen, in 2011 4.1.1 Behavior of domestic water use In this study, the behavior of water use of Dao people in extremely difficult communes has not achieved, only... the other 23 hand, thisstudy has not assessed the impact of the change in sanitationbehavior to the illnesses of the Dao, thusIt’snecessary to have furtherresearches, whichimplement interventions in the longer period CONCLUSION After 18 months of construction and testing intervention models with the content of mobilizing community participate in sanitation communications for Dao people in especiallydifficultregions,... about sanitation closely relate to general sanitation behavior of the Dao (PR> 1, p . communes in Thai Nguyen and testing intervention models& quot; with the objectives: 1. Assess the situation of the Dao s sanitary behaviors in some extremely difficult communes in Thai Nguyen. MINISTRY OF EDUCATION AND TRAINING UNIVERSITY OF THAI NGUYEN HOANG ANH TUAN THE STATUS OF DAO S SANITARY BEHAVIORS IN SOME PARTICULARLY DIFFICULT COMMUNES IN THAI NGUYEN AND TESTING. the overall big picture of the current status of the Dao s sanitary behavior living in particularly difficult communes in Thai Nguyen province. 2. This is the first intervention study in the