Hygiene and sanitation among ethnic minorities in Northern Vietnam: does government promotion match community priorities?

Rural revival: Navigating environmental engineering and technology

The necessity for global engineering and technological solutions to address rural environmental challenges is paramount, particularly in improving rural waste treatment and infrastructure. This study presents a comprehensive quantitative analysis of 3901 SCI/SSCI and 3818 Chinese CSCD papers, spanning from 1989 to 2021, using tools like Derwent Data Analyzer and VOSviewer. Our key findings reveal a significant evolution in research focus, including a 716.67% increase in global publications from 1995 to 2008 and a 154.76% surge from 2015 to 2021, highlighting a growing research interest with technological hotspots in rural revitalization engineering and agricultural waste recycling. China and the USA are pivotal, contributing 784 and 714 publications respectively. Prominent institutions such as the Chinese Academy of Sciences play a crucial role, particularly in fecal waste treatment technology. These insights advocate for enhanced policy development and practical implementations to foster inclusive and sustainable rural environments globally.

Review of the slippage factors from open defecation-free (ODF) status towards open defecation (OD) after the Community-Led Total Sanitation (CLTS) approach implementation

Open-defecation (OD) is one of the most widespread sanitation practices in low-income countries. This practice often causes diarrheal diseases and 760,000 deaths per year. To eradicate OD, several approaches have been developed, including Community-Led-Total Sanitation (CLTS) which is a participatory and community approach. The specificity of CLTS is that it is managed by the community itself, as its name implies, and that no subsidies or financial contributions from outside the community are used in the construction of the facilities. Although, the CLTS is effective in the short-term for eradicating OD, the long-term results are not encouraging: Open-Defecation-Free (ODF) communities revert to OD or partially use latrines. The present research is based on literature review and authors investigation in Burkina Faso. It was conducted to provide a comprehensive understanding of the factors that affect the sustainability of ODF-status leading to slippage in communities. It was found that these factors can be grouped into five categories: behavioral and social, technological, organizational, and vulnerability factors. The last one, socio-political factors, is a contribution from the authors as it was not reported in the literature yet. The authors have proposed graphical synthesis of all the slippage factors and their associated categories in the ODF-communities. Finally, authors have suggested that to sustain ODF-status of communities: include all stages of the sanitation value chain (SVC) in the CLTS, the follow-up activities after achieving ODF-status must be planned well in advance, sanitation marketing should be developed and the sanctions against the practice of OD have to be reinforced. Governments and donors should pay particular attention to the following options: raising awareness and regular monitoring after ODF certification, encouraging research on sustainable and pro-poor sanitation technologies, and building the capacity of implementing actors including facilitators. While obtaining ODF status is materialized by a sign with the status on it, this paper drew the attention of CLTS implementers to the lack of materialization of slippage when it occurs, and the absence of studies on the evolution of the community sanitation scale after ODF-status.

The Indirect Impact of Smallholder Vegetable Production on Children's Nutrition Outcomes in Rural Vietnam

Childhood undernutrition, particularly stunting, wasting, and micronutrient deficiencies, remains a major health concern in rural Vietnam. While literature suggests leveraging agriculture to improve child nutrition via agricultural diversification, market engagement, and women's empowerment, very few studies have empirically explored how smallholder vegetable production can influence household nutrition. This paper examines the association of household-level vegetable diversity, market access, and market participation with nutrition outcome measures of children in smallholder households. We use a cross-sectional household dataset, collected in 2016 in northwest Vietnam, covering 234 children aged 6–60 months. We estimate and compare the results of regression models using three-stage least squares (3SLS), ordinary least squares (OLS), logistic regression, and seemingly unrelated regression (SUR), to explore variations in six nutrition outcome measures: height-for-age z-score (HAZ), weight-for-height z-score (WHZ), weight-for-age z-score (WAZ), stunting, wasting, and underweight. Our results suggest smallholder vegetable production has a significant indirect association with children's nutrition status via market participation. Market participation is an important factor in improving girls' HAZ and WHZ, and in reducing the probability of boys being stunted and underweight. The additional income from selling vegetables allows households to purchase nutritious food, which is likely to have a positive impact on children's nutrition outcomes.

A review of rural and peri-urban sanitation infrastructure in South-East Asia and the Western Pacific: Highlighting regional inequalities and limited data

Rural and peri-urban communities in developing countries rely on sanitation systems which are often unsafely managed. One of the major barriers to assess safely managed sanitation is a lack of data about the existing sanitation infrastructure and levels of containment safety. The aim was to review rural and peri-urban on-site sanitation studies in order to understand different infrastructure types, associated management practices and any impacts on human health. The scope was limited to South-East Asia and Western Pacific regions in order to better identify regional inequalities. Among the 155 reviewed articles, 73 studies (47%) linked sanitation infrastructure to poor human health. Nearly all articles reported latrine ownership (n = 149, 96%) while sanitation infrastructure types were covered less frequently (n = 104, 67%). In particular, there was a lack of published literature describing back-end characteristics (dimension and materials) (n = 12, 8%) and/or management practices (n = 4, 3%). This stems from a limited application of research methodologies that characterise sanitation infrastructure and faecal sludge management (containment, emptying and on-site treatment). Inequality between regions was prevalent with three quarters of the studies on latrine back-end infrastructure from Bangladesh and India in South-East Asia. A strategic research approach is needed to address the current knowledge gaps regarding sanitation infrastructure and safe faecal sludge management.

Double burden of malnutrition in ethnic minority school-aged children living in mountainous areas of Vietnam and its association with nutritional behavior

BACKGROUND/OBJECTIVES

Although children of ethnic minority groups are experiencing a transition from a predominance of undernutrition to overnutrition, there is little evidence of a dual-malnutrition burden. Therefore, this study examined the double burden of malnutrition among school-aged ethnic minority children living in mountainous areas and its association with their diets.

SUBJECTS/METHODS

A cross-sectional study was conducted from September 2019 to March 2020 in 3 mountainous areas of Northern Vietnam among 1,556 ethnic minority school-aged children. The prevalence of under-nutrition (stunting and thinness) and over-nutrition (overweight and obesity) were measured using the WHO 2006 child growth standards (height-for-age and BMI-for-age Z-score). Nutritional practices were evaluated by the frequency of food consumption based on a 4-level scale.

RESULTS

The percentage of children with stunting and thinness were 14.0% and 5.4%, respectively, while the figure for overweight/obesity was 9.4%. The factors positively associated with stunting were living in a family with more than 2 children or being Muong/other ethnicities compared to the Tay ethnicity. Children who consumed fish/shrimps/crabs or milk weekly/daily were less likely to be undernourished compared to those who never consumed these foods. By contrast, children who never consumed foods rich in vitamin A precursors and vitamin A and fruit or consumed daily snacks/junk food were more likely to be overweight/obese.

CONCLUSIONS

Undernutrition remains a common issue among school-aged children and adolescents of ethnic minority groups, while over-nutrition exists simultaneously. Public health nutrition programs promoting adequate diets and positive lifestyle changes related to nutrition are essential to tackle the double burden of malnutrition among ethnic minority children.

The endemic Helicobacter pylori population in Southern Vietnam has both South East Asian and European origins

Background

The burden of Helicobacter pylori-induced gastric cancer varies based on predominant H. pylori population in various geographical regions. Vietnam is a high H. pylori burden country with the highest age-standardized incidence rate of gastric cancer (16.3 cases/100,000 for both sexes) in Southeast Asia, despite this data on the H. pylori population is scanty. We examined the global context of the endemic H. pylori population in Vietnam and present a contextual and comparative genomics analysis of 83 H. pylori isolates from patients in Vietnam.

Results

There are at least two major H. pylori populations are circulating in symptomatic Vietnamese patients. The majority of the isolates (~ 80%, 66/83) belong to the hspEastAsia and the remaining belong to hpEurope population (~ 20%, 17/83). In total, 66 isolates (66/83) were cagA positive, 64 were hspEastAsia isolates and two were hpEurope isolates. Examination of the second repeat region revealed that most of the cagA genes were ABD type (63/66; 61 were hspEastAsia isolates and two were hpEurope isolates). The remaining three isolates (all from hspEastAsia isolates) were ABC or ABCC types. We also detected that 4.5% (3/66) cagA gene from hspEastAsia isolates contained EPIYA-like sequences, ESIYA at EPIYA-B segments. Analysis of the vacA allelic type revealed 98.8% (82/83) and 41% (34/83) of the strains harboured the s1 and m1 allelic variant, respectively; 34/83 carried both s1m1 alleles. The most frequent genotypes among the cagA positive isolates were vacA s1m1/cagA + and vacA s1m2/cagA + , accounting for 51.5% (34/66) and 48.5% (32/66) of the isolates, respectively.

Conclusions

There are two predominant lineages of H. pylori circulating in Vietnam; most of the isolates belong to the hspEastAsia population. The hpEurope population is further divided into two smaller clusters.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13099-021-00452-2.

Sexual and reproductive health challenges facing minority ethnic girls in Vietnam: a photovoice study

This paper describes a study that examined the challenges faced by Vietnamese ethnic minority girls regarding their sexual and reproductive health. The study employed photovoice, a research method which treats photographs and the accompanying stories provided by participants as qualitative data. Twenty-six (26) minority ethnic girls took photographs of aspects of their lives as a way of documenting the challenges, difficulties and barriers that they faced in looking after their sexual and reproductive health. Findings indicated limited access to sexual health knowledge, the exclusion of young people from mainly adult-focused sexual and reproductive health services in minority ethnic communities and the prevalence of cultural beliefs and practices that negatively affected young people's sexual and reproductive health. The intersection of ethnicity, age and gender places Vietnamese ethnic minority girls at risk, as everyday practices informed by culture and tradition curtail their access to the limited sexual and reproductive health information and services available in their communities. Understanding these challenges is needed in developing appropriate policies, programmes and services aimed at enhancing the sexual and reproductive health of this segment of the population.

Evaluating Training Need for Epidemic Control in Three Metropolitans: Implications for COVID-19 Preparedness in Vietnam

Upon the outbreak of the COVID-19 pandemic, countries worldwide face a critical shortage of human resources in the health sector. Medical students are a potential task force with the capability to support the stretched health sector. This study aims to evaluate their training need for epidemic control in order to employ them effectively. A cross-sectional study was conducted using a web-based survey from December 2019 to February 2020. There were 5,786 observations collected using the snowball sampling technique. Logistic regression was applied to identify factors associated with training participation in epidemic prevention and disaster prevention. Multiple Poisson regression model was constructed to examine factors associated with the number of times they participated in sanitation training and disaster prevention activities in the previous 12 months. Sanitation and health education communication activities had the highest proportion of participants, with 76.5 and 38.4%, followed by examining and treating diseases in the community (13.4%). Those who participated in community activities had a higher number of times to participate in epidemic sanitation training and be involved in disaster prevention. This study informed the need for training programs to prepare medical students for COVID-19 epidemic responses. The training curriculum should include both theoretical approaches and contextual approaches to achieve efficient epidemic control.

Review of Public Financing for Water, Sanitation, and Hygiene Sectors in Vietnam

BACKGROUND

Vietnam declared its national roadmap towards Sustainable Development Goals number 6 by 2030. However, specific supporting programmes and financial means to proceed with the roadmap have not been passed on. Evidence on the financing for water, sanitation, and hygiene (WASH) being allocated or spent has not been well documented in Vietnam. This study aimed to obtain an overview and assessed the public funding across the WASH sector of Vietnam in 3 fiscal years 2016, 2017, and 2018.

METHODS

A cross-sectional study was conducted for information about the public financing for WASH at both national and sub-national levels. An activity-based costing approach was applied to determine WASH-related public expenditure. Fourteen focus group discussions with key stakeholders were used to identify the WASH activities and to access financial reports of these relevant institutions. TrackFin methodology was used to assemble the public financing for WASH in Vietnam.

RESULTS

The public expenditure of WASH declined by about 30.7% over the 3 fiscal years, from US $2016 million in 2016 to US $1397 million in 2018. Meanwhile, this expenditure allocated to the poor or mountainous areas increased by 3 folds. The highest proportion of WASH public funding was invested in sanitation through large network systems (59.07% of the total public expenditure), whereas the lowest was in hygiene promotion and handwashing facilities. The domestic budget was still the main source of public financing for WASH services, with 2 largest shares coming from government revenues (47.24%) and repayable loans (20.49%).

CONCLUSION

The main source of financing for WASH was from the government, yet its public expenditure has been decreased. A refined roadmap with specific steps for a sustainable WASH financing system in Vietnam, particularly to leverage government and private sector resources, is required to ensure no one is left behind.

Water usage, hygiene and diarrhea in low-income urban communities-A mixed method prospective longitudinal study

Epidemiological studies considered water use and hygiene practices as central risk factors for diarrhea. Few studies focused on independent association of water quantity with diarrheal diseases. This study aimed to describe the methodological protocol that adapted multidisciplinary and mixed-method research approach to assess how water usage including water quantity influences the attributable risk for diarrhea in a low-income urban community in Bangladesh.

The quantitative, anthropological and microbiological approaches were threaded together to provide a greater understanding of the infrastructural, behavioral and microbial interactions to fathom the dimensions of fecal oral transmission pathways within the households. The use of the 'Choleraphone' (i.e. a mobile phone based real time diarrheal reporting system) was a contemporary approach intended to cut down on resources, reduce research fatigue and provide more accurate data compared to the 'gold standard' (i.e. visiting a household of diarrhea cases within 48 hours) for measuring diarrhea incidence. Development of methods to measure water quantity using qualitative and quantitative approach within a setting where meter water connection is rare was another unique feature of this protocol. This protocol provided guidance and insight on how multiple methods of different disciplines can be combined to enrich understanding of waterborne diseases.

Leaving no one behind: Evaluating access to water, sanitation and hygiene for vulnerable and marginalized groups

Achieving equitable access to water, sanitation and hygiene (WASH) services requires paying special attention to the most disadvantaged segments of the population. Yet, despite all the progress made to evaluate the access of vulnerable and marginalized groups, important knowledge gaps still remain with respect to identifying their specific barriers and needs. At the global level, for example, the two monitoring mechanisms for SDG 6 - the Joint Monitoring Programme (JMP) and Global Analysis and Assessment of Sanitation and drinking-water (GLAAS) - face difficulties in understanding how, and to what extent, vulnerable and marginalized groups access WASH services. In this context, this work examines the UNECE/WHO-Europe 'Equitable Access Score-card' for assessing the access to WASH services by vulnerable and marginalized groups. In particular, we: (i) analyse its strengths and limitations as a tool for revealing the needs of these groups in accessing WASH services; and (ii) propose an extended variant of the score-card that addresses these limitations. We test this version in two local-level case studies: Lima (Peru) and Castelló de la Plana (Spain). The score-card diagnosis is found to be particularly useful for collecting information on the level of access of the different vulnerable and marginalized groups, as well as the specific public policies and funding mechanisms in place that address and support their needs. However, the score-card should be complemented with specific assessments of all five normative dimensions of the human rights to water and sanitation (access, availability, quality, acceptability and affordability) in order to have a better understanding of the concerns for service delivery for the different vulnerable and marginalized groups.

Demand for improved sanitation in an urban informal settlement in India: role of the local built environment

Sanitation uptake is a pressing challenge, especially in India, and sanitation demand in urban informal settlements and slums has been understudied relative to rural areas. Given the spatial and socioeconomic disadvantage of these settings, research suggests that the built environment may relate to sanitation demand, but this has not been tested. This study utilizes data on a large urban informal settlement in Maharashtra, India, examining built environment predictors including housing security, water access, and proximity to existing common sanitation, in association with sanitation demand. Results indicate that household size, home ownership, individual household water sources, and open defecation avoidance are significantly associated with interest in a toilet. Further, interactions between (1) water source and home ownership, and (2) open defecation and distance to shared sanitation, are associated with interest in a toilet. These findings support the role of the built environment in shaping sanitation demand in urban informal settlements.

Sustainable Sanitation Management Tool for Decision Making in Isolated Areas in Brazil

There is a worldwide range of technical sanitation guidelines focusing on small or traditional and isolated communities for ecological alternatives at the household level. However, a computational tool (software) that has a database and connects these guidelines in a single reference for resource-oriented sanitation concept decision making is still lacking. In this regard, an easy-to-use tool was developed using a participatory approach for the decision-making process from a choice of technical solutions to a type of system management. The results obtained from a pilot study indicate that the proposed tool in this paper will help with the decision-making process to aid in not only choosing sustainable sanitation solutions, but also sustainable operation and maintenance options for the systems. When presenting and discussing the tool with research groups and technicians, the potential for participatory application was noticed. The proposed tool can be used in the elaboration of municipal sanitation plans, assisting local technicians and environmental licensing agencies, designers and engineering students, among others. The software can be applied with other management tools, such as 5W2H and Canvas business model.

Can Sanitation Technology Play a Role in User Perceptions of Resource Recovery? An Evaluation of Composting Latrine Use in Developing World Communities in Panama

There remains a large unmet need for sanitation access throughout the world that compromises both human and environmental health. Opportunities exist to employ sanitation systems that better utilize and recover scarce resources from excreta such as water, energy, and nutrients. However, technologies such as a composting latrine may require more maintenance and close handling of feces compared to other sanitation technologies. This study aims to evaluate how use of on-site composting latrine technology and other demographic characteristics are associated with users' perceptions of excreta for resource recovery. Field observations and interviews of composting latrine users ( N = 201) and 200 perceptions surveys were administered to composting and non-composting latrine users in Indigenous and Latino communities in Panama. Of the completed composting latrines, 78% were in use and 65% of these were used properly. Compost latrine design and operational factors identified to improve were: anal wash capability, desiccant supply, children usage, and clogging urine tubes. Demographic categories associated with positive perceptions toward resource recovery ( p < 0.05) were ethnicity (14 out of 16 total statements) and sanitation type (11) then community origin (7), occupation (5), education (4), age (3), and gender (1).

Cost and effectiveness of water, sanitation and hygiene promotion intervention in Ghana: the case of four communities in the Brong Ahafo region

Knowledge of cost and effectiveness of Ghana's main hygiene promotion intervention (HPI), Community-Led Total Sanitation (CLTS), is critical for policy direction. Cost and resultant effect of HPI is examined using a case study of four communities. Surveys were conducted with 300 households, CLTS implementers and relevant agencies during the study period (May 2012 to February 2014). The HPI produced marginal but statistically significant effect (8%, p < 0.001). Improvement in hygiene behaviour was statistically associated with both government investments (p < 0.001) and household investments (p < 0.001). Actual HPI cost is US$ 90 per household: US$ 51 and 39 from government and households respectively. Cost-effectiveness of the HPI is US$ 106.42 per capita of improved hygiene behaviour.

Determination of Appropriate Service Delivery Level for Quantitative Attributes of Household Toilets in Rural Settlements of India from Users' Perspective

Improvement of quality of sanitation services in rural settlements is an important development goal in developing countries including India and accordingly several strategies are adopted which promote the demand and use of household toilets through creating awareness and providing subsidies to poor people for construction of household toilets with service-level standards specified from experts' perspective. In many cases, users are unsatisfied with the quality of toilets constructed using subsidies and the same remain unused. Users' satisfaction depends on their perceptions of service quality of individual attributes and overall service quality of the household toilets, which is an important determinant of sustainability and sustained use of toilets. This study aims to assess and benchmark the appropriate service delivery level for quantitative attributes of rural household toilets based on user perception. The service quality is determined with the help of level of service (LOS) scales developed using successive interval scaling technique, the zone of tolerance (ZOT), and users satisfaction level (USL) which relates service delivery levels with user satisfaction directly. The study finds that the service quality of most of the attributes of household toilets constructed using subsidies is perceived as poor. The results also suggest that most of the users expect to have a toilet with the service level of attributes ranging between LOS A and LOS B.

Toilet Talk: Eliminating Open Defecation and Improved Sanitation in Nepal

Globally, 2.4 billion people lack adequate sanitation, and open defecation remains common. In this article, I present the qualitative findings from an evaluation of a water, sanitation, and hygiene intervention in remote, mid-West Nepal. The evaluation, conducted in 2014, involved villagers from eight wards in Kotgaun Village Development Committee. Drawing on the concept of the "toilet tripod," I argue as follows: multi-scalar political will provide an important foundation for construction and sustained use of toilets, proximate social pressures contributed significantly to toilet adoption and efforts to eliminate open defecation, and water insecurity constrained improved sanitation and hygiene.

Switching to sanitation: Understanding latrine adoption in a representative panel of rural Indian households

Open defecation, which is still practiced by about a billion people worldwide, is one of the most compelling examples of how place influences health in developing countries. Efforts by governments and development organizations to address the world's remaining open defecation would be greatly supported by a better understanding of why some people adopt latrines and others do not. We analyze the 2005 and 2012 rounds of the India Human Development Survey (IHDS), a nationally representative panel of households in India, the country which is home to 60% of the people worldwide who defecate in the open. Among rural households that defecated in the open in 2005, we investigate what baseline properties and what changes over time are associated with switching to latrine use between 2005 and 2012. We find that households that are richer or better educated, that have certain demographic properties, or that improved their homes over this period were more likely to switch to using a latrine or toilet. However, each of these effect sizes is small; overall switching to latrine use from open defecation is low; and no ready household-level mechanisms are available for sanitation programs to widely influence these factors. Our research adds to a growing consensus in the literature that the social context should not be overlooked when trying to understand and bring about change in sanitation behavior.

Health care waste management in community-based care: experiences of community health workers in low resource communities in South Africa

Background

In South Africa, community health workers (CHWs) working in community-based care (CBC) programmes provide care to patients most of whom are living with HIV/AIDS and tuberculosis (TB). Although studies have shown that the caregiving activities provided by the CHWs generate health care waste (HCW), there is limited information about the experiences of CHWs on health care waste management (HCWM) in CBC. This study explored HCWM in CBC in Durban, South Africa from the perspectives CHWs.

Methods

We used three ethnographic approaches to collect data: focus group discussions, participant observations and informal discussions. Data was collected from 85 CHWs working in 29 communities in the Durban metropolis, South Africa. Data collection took place from July 2013 to August 2014.

Results

CHWs provided nursing care activities to patients many of whom were incontinent or bedridden. Some the patients were living with HIV/AIDS/TB, stroke, diabetes, asthma, arthritis and high blood pressure. These caregiving activities generate sharps and infectious waste but CHWs and family members did not segregate HCW according to the risk posed as stipulated by the HCWM policy. In addition, HCW was left with domestic waste. Major barriers to proper HCWM identified by CHWs include, lack of assistance from family members in assisting patients to use the toilet or change diapers and removing HCW from homes, irregular waste collection by waste collectors, inadequate water for practicing hygiene and sanitation, long distance between the house and the toilets and poor conditions of communal toilets and pit latrines. As a result of these barriers, HCW was illegally dumped along roads or in the bush, burnt openly and buried within the yards. Liquid HCW such as vomit, urine and sputum were disposed in open spaces near the homes.

Conclusion

Current policies on primary health care (PHC) and HCWM in South Africa have not paid attention to HCWM. Findings suggest the need for primary health care reform to develop the competencies of CHWs in HCWM. In addition, PHC and HCWM policies should address the infrastructure deficit in low resource communities. In order for low-and-middle-income-countries (LMICs) to develop effective community health worker programmes, there is a need for synergies in PHC and HCWM policies.

The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis

BACKGROUND

An estimated 2.4 billion people still lack access to improved sanitation and 946 million still practice open defecation. The World Health Organization (WHO) commissioned this review to assess the impact of sanitation on coverage and use, as part of its effort to develop a set of guidelines on sanitation and health.

METHODS AND FINDINGS

We systematically reviewed the literature and used meta-analysis to quantitatively characterize how different sanitation interventions impact latrine coverage and use. We also assessed both qualitative and quantitative studies to understand how different structural and design characteristics of sanitation are associated with individual latrine use. A total of 64 studies met our eligibility criteria. Of 27 intervention studies that reported on household latrine coverage and provided a point estimate with confidence interval, the average increase in coverage was 14% (95% CI: 10%, 19%). The intervention types with the largest absolute increases in coverage included the Indian government's "Total Sanitation Campaign" (27%; 95% CI: 14%, 39%), latrine subsidy/provision interventions (16%; 95% CI: 8%, 24%), latrine subsidy/provision interventions that also incorporated education components (17%; 95% CI: -5%, 38%), sewerage interventions (14%; 95% CI: 1%, 28%), sanitation education interventions (14%; 95% CI: 3%, 26%), and community-led total sanitation interventions (12%; 95% CI: -2%, 27%). Of 10 intervention studies that reported on household latrine use, the average increase was 13% (95% CI: 4%, 21%). The sanitation interventions and contexts in which they were implemented varied, leading to high heterogeneity across studies. We found 24 studies that examined the association between structural and design characteristics of sanitation facilities and facility use. These studies reported that better maintenance, accessibility, privacy, facility type, cleanliness, newer latrines, and better hygiene access were all frequently associated with higher use, whereas poorer sanitation conditions were associated with lower use.

CONCLUSIONS

Our results indicate that most sanitation interventions only had a modest impact on increasing latrine coverage and use. A further understanding of how different sanitation characteristics and sanitation interventions impact coverage and use is essential in order to more effectively attain sanitation access for all, eliminate open defecation, and ultimately improve health.

It's not only what you say, it's also how you say it: communicating nipah virus prevention messages during an outbreak in Bangladesh

BACKGROUND

During a fatal Nipah virus (NiV) outbreak in Bangladesh, residents rejected biomedical explanations of NiV transmission and treatment and lost trust in the public healthcare system. Field anthropologists developed and communicated a prevention strategy to bridge the gap between the biomedical and local explanation of the outbreak.

METHODS

We explored residents' beliefs and perceptions about the illness and care-seeking practices and explained prevention messages following an interactive strategy with the aid of photos showed the types of contact that can lead to NiV transmission from bats to humans by drinking raw date palm sap and from person-to-person.

RESULTS

The residents initially believed that the outbreak was caused by supernatural forces and continued drinking raw date palm sap despite messages from local health authorities to stop. Participants in community meetings stated that the initial messages did not explain that bats were the source of this virus. After our intervention, participants responded that they now understood how NiV could be transmitted and would abstain from raw sap consumption and maintain safer behaviours while caring for patients.

CONCLUSIONS

During outbreaks, one-way behaviour change communication without meaningful causal explanations is unlikely to be effective. Based on the cultural context, interactive communication strategies in lay language with supporting evidence can make biomedical prevention messages credible in affected communities, even among those who initially invoke supernatural causal explanations.

Effectiveness of group discussions and commitment in improving cleaning behaviour of shared sanitation users in Kampala, Uganda slums

RATIONALE AND OBJECTIVE

Access to and use of hygienic shared sanitation facilities is fundamental in reducing the high risk of diseases such as diarrhoea and respiratory infections. We evaluated the effectiveness of group discussions and commitment in improving the cleaning behaviour of shared sanitation users in three urban slums in Kampala, Uganda. The study follows the risk, attitudes, norms, abilities and self-regulation (RANAS) model of behaviour change and some factors of the social dilemma theory.

METHODS

A pre-versus post-intervention survey was conducted in three slums of Kampala, Uganda, between December 2012 and September 2013. From the pre-intervention findings, users of dirty sanitation facilities were randomly assigned to discussions, discussions + commitment and control interventions. The interventions were implemented for 3 months with the aim of improving cleaning behaviour. This paper provides an analysis of 119 respondents who belonged to the intervention discussion-only (n = 38), discussions + commitment (n = 41) and the control (no intervention, n = 40) groups.

RESULTS

Compared to the control, discussions and discussions + commitment significantly improved shared toilet users' cleaning behaviour. The rate of improvement was observed through behavioural determinants such as cleaning obligation, cleaning ease, cleaning approval and affective beliefs.

CONCLUSION

Our study findings show that group discussions and commitment interventions derived from RANAS model of behaviour change are effective in improving the shared sanitation users' cleaning behaviour.

Shared toilet users' collective cleaning and determinant factors in Kampala slums, Uganda

Background

Dirty shared toilets are a health risk to users in urban slum settlements. For health and non-health benefits among users of shared toilets to be guaranteed, their cleanliness is important. The objective of this study was to investigate the cleanliness situation of shared toilets in Kampala’s slums and the psychological and social dilemma factors influencing users’ cleaning behaviour and commitment by using the risks, attitudes, norms, ability and self-regulation (RANAS) model and factors derived from the social dilemma theory.

Methods

We conducted a cross-sectional study in three slums of Kampala between December 2012 and January 2013. Data were collected from 424 household respondents that were primarily using shared toilets. Semi-structured questionnaires administered through face-to-face interviews were used in data collection. Linear regression was done for the multivariate analysis to test for the association between respondent cleaning behaviour and a combination of RANAS and social dilemma predictors.

Results

Out of 424 respondents interviewed, 44.3% reported cleaning the shared toilet daily, 34.4% cleaned once or several times a week, 1.4% cleaned every second week, 5.4% cleaned once or several times a month and 14.4% did not participate in cleaning. The main RANAS factors significantly associated with respondents’ cleaning behaviour were: attitudinal affective belief associated with cleaning a shared toilet (β = −0.13, P = 0.00) and self-regulating factors, such as coping planning (β = 0.42, P = 0.00), commitment (β = 0.24, P = 0.00), and remembering (β = 0.10, P = 0.01). For social dilemma factors, only the social motive factor was statistically significant (β = 0.15, P = 0.00). The R square for the linear model on factors influencing cleaning behaviour was 0.77 and R square for factors influencing cleaning commitment was 0.70.

Conclusion

The RANAS factors provide a more robust understanding of shared toilet users’ cleaning behaviour than social dilemma factors. Self-regulating factors and changing the negative affective cleaning feelings are shown to be very important for interventions to increase shared toilet users’ collective participation in their cleaning. In addition to RANAS, social dilemma factors have an important influence on slum residents’ commitment to clean their shared toilets.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1260) contains supplementary material, which is available to authorized users.

Early childhood diarrhoeal diseases and cognition: are we missing the rest of the iceberg?

Risk factors which interfere with cognitive function are especially important during the first 2 years of life - a period referred to as early child development and a time during which rapid growth and essential development occur. Malnutrition, a condition whose effect on cognitive function is well known, has been shown to be part of a vicious cycle with diarrhoeal diseases, and the two pathologies together continue to be the leading cause of illness and death in young children in developing countries. This paper reviews the burden of early childhood diarrhoeal diseases globally and the emerging evidence of their relationship with global disparities in neurocognitive development. The strength of evidence which indicates that the severe childhood diarrhoeal burden may be implicated in cognitive impairment of children from low- and middle-income counties is discussed. Findings suggest that greater investment in multi-site, longitudinal enteric infection studies that assess long-term repercussions are warranted. Furthermore, economic analyses using the concept of human capital should play a key role in advancing our understanding of the breadth and complexities of the health, social and economic ramifications of early childhood diarrhoeal diseases and enteric infections. This broadened awareness can serve to help advocate for more effective interventions, particularly in developing economies.

Anti-Trichinella IgG in ethnic minorities living in Trichinella-endemic areas in northwest Vietnam: study of the predictive value of selected clinical signs and symptoms for the diagnosis of trichinellosis

The objective of this study was to assess the presence of anti-Trichinella IgG in the serum of persons from ethnic minorities from northwest Vietnam with clinical signs and symptoms that are compatible with trichinellosis. A total of 645 persons were enrolled, of which 200 people lived in two villages where outbreaks of human trichinellosis had been documented in 2004 and 2008, and 445 people who were hospitalized in the Dien Bien and Son La provincial hospitals without a definitive diagnosis. Presence of anti-Trichinella IgG was demonstrated in serum samples by a standardized Enzyme-linked Immunosorbant Assay (ELISA); positive serum samples were subjected to Western blot (WB) for confirmation. Seven (3.5%; 95% CI: 1.4-7.1) persons from the villages and seven (1.6%; 95% CI: 0.6-3.2) hospitalized patients, tested positive by both ELISA and WB. Fever (N=13), eosinophilia (N=12), myalgia (N=9), facial edema (N=9) and leukocytosis (N=8) were the most common clinical signs and symptoms in the serologically positive persons. The concomitant occurrence of facial edema and myalgia among the enrolled persons from the villages, accounted for 75% of the positive predictive value (PPV) and 99.5% of the negative predictive value (NPV), suggesting that they could be used for suspecting trichinellosis when serology is not available. The high prevalence (1.6-3.5%) of anti-Trichinella IgG in persons from Vietnamese provinces where Trichinella spiralis is circulating in pigs strongly supports the need to develop control programs to eliminate the infection from pigs and for consumers' education and protection.

Controlling parasites, understanding practices: the biosocial complexity of a One Health intervention for neglected zoonotic helminths in northern Lao PDR

A parasitological survey in northern Lao PDR showed a remote ethnic minority village to be hyper-endemic for Taenia solium, a Neglected Tropical Disease (NTD) that impacts human and pig health. An intervention combining human Mass Drug Administration (MDA) with porcine vaccination and antihelmintic treatment was then implemented, targeting both T. solium and other soil-transmitted helminths. To understand the biosocial complexity of this integrated One Health intervention, we conducted a rapid ethnographic study exploring the transmission dynamics of T. solium and locally acceptable long-term control options. Informed by two years of project work in the village, this included six focus group discussions, 35 semi-structured interviews, a latrine survey, a school-based education meeting, participant observation and many unstructured interviews conducted over two weeks in October 2013. We found that risk behaviours were mediated by various social determinants including limited market access, interrelationships between alcohol, ancestral sacrifices and the consumption of raw pork, seasonal variations and poor latrine coverage. Only sixteen percent of households had latrines, attributed to the unacceptability of dry latrines, lack of water access, poor building techniques and poverty. Whilst women could explain T. solium transmission, most men and children could not, revealing that distributed posters/leaflets relied too heavily on text and ambiguous images. Compliance with MDA was high due to trust between project staff and village leaders. However understandings of pharmacology, minor side effects, human migration and children's fear of worms may lead to resistance in future programmes. Our research highlights the complexities of controlling T. solium and other soil-transmitted helminths in a remote ethnic minority village and the need to integrate biomedical and participatory approaches. Although we showcase the heuristic value of using rapid ethnography to inform intervention strategies as part of a One Health/NTD agenda, we also identify several possible paradoxes and conundrums in embedding locally-grounded biosocial analysis into NTD programmes. These need to be acknowledged and negotiated by multidisciplinary teams.

Context and group dynamics in a CBPR-developed HIV prevention intervention

This paper will explore in detail the effects of context and group dynamics on the development of a multi-level community-based HIV prevention intervention for crack cocaine users in the San Salvador Metropolitan Area, El Salvador. Community partners included residents from marginal communities, service providers from the historic center of San Salvador and research staff from a non-profit organization. The community contexts from which partners came varied considerably and affected structural group dynamics, i.e. who was identified as community partners, their research and organizational capacity, and their ability to represent their communities, with participants from marginal communities most likely to hold community leadership positions and be residents, and those from the center of San Salvador most likely to work in religious organizations dedicated to HIV prevention or feeding indigent drug users. These differences also affected the intervention priorities of different partners. The context of communities changed over time, particularly levels of violence, and affected group dynamics and the intervention developed. Finally, strategies were needed to elicit input from stakeholders under-represented in the community advisory board, in particular active crack users, in order to check the feasibility of the proposed intervention and revise it as necessary. Because El Salvador is a very different context than that in which most CBPR studies have been conducted, our results reveal important contextual factors and their effects on partnerships not often considered in the literature.

The toilet tripod: understanding successful sanitation in rural India

Building toilets and getting people to use them is critical for public health. We deployed a political ecology approach specifically to identify the multi-scalar political, economic, and environmental factors influencing toilet adoption in rural India. The research used ethnographic and technical methods in rural villages of West Bengal and Himachal Pradesh over the period September 2012 to May 2013. The elements of successful sanitation adoption depended on three factors (i.e., toilet tripod): (1) multi-scalar political will on the part of both government and NGOs over the long term; (2) proximate social pressure, i.e., person-to-person contact between rural inhabitants and toilets; (3) political ecology, i.e., assured access to water, compatible soil type, and changing land use. This research contributes to studies of sustainable development and global public health by developing a theory and framework for successful sanitation.

Teaching minority children hygiene: investigating hygiene education in kindergartens and homes of ethnic minority children in northern Vietnam

OBJECTIVES

Ethnic minority children in Vietnam experience high levels of hygiene- and sanitation-related diseases. Improving hygiene for minority children is therefore vital for improving child health. The study objective was to investigate how kindergarten and home environments influence the learning of hygiene of pre-school ethnic minority children in rural Vietnam.

DESIGN

Eight months of ethnographic field studies were conducted among four ethnic minority groups living in highland and lowland communities in northern Vietnam. Data included participant observation in four kindergartens and 20 homes of pre-school children, together with 67 semi-structured interviews with caregivers and five kindergarten staff. Thematic analysis was applied and concepts of social learning provided inputs to the analysis.

FINDINGS

This study showed that poor living conditions with lack of basic sanitation infrastructures were important barriers for the implementation of safe home child hygiene. Furthermore, the everyday life of highland villages, with parents working away from the households resulted in little daily adult supervision of safe child hygiene practices. While kindergartens were identified as potentially important institutions for improving child hygiene education, essential and well-functioning hygiene infrastructures were lacking. Also, hygiene teaching relied on theoretical and non-practice-based learning styles, which did not facilitate hygiene behaviour change in small children. Minority children were further disadvantaged as teaching was only provided in non-minority language.

CONCLUSIONS

Kindergartens can be important institutions for the promotion of safe hygiene practices among children, but they must invest in the maintenance of hygiene and sanitation infrastructures and adopt a strong practice-based teaching approach in daily work and in teacher's education. To support highland minority children in particular, teaching styles must take local living conditions and caregiver structures into account and teach in local languages. Creating stronger links between home and institutional learning environments can be vital to support disadvantaged highland families in improving child health.

An improved tool for household faeces management in rural Bangladeshi communities

OBJECTIVE

To explore child defecation and faeces management practices in rural Bangladesh with the aim to redesign and pilot a tool to facilitate removal and disposal of faeces.

METHODS

We conducted six group discussions, six short interviews and three observations of practices and designed the new tool. We piloted the new tool and elicited feedback through two in-depth interviews and two observations.

RESULTS

Until three years of age, a child commonly defecates in the courtyard and occasionally inside the house. A heavy digging hoe was commonly used to remove child faeces. Mothers preferred a redesigned 'mini-hoe' and found it easier to use for removal and disposal of liquid faeces.

CONCLUSIONS

Promoting modified local tools may contribute to improving environmental sanitation and health.

Ethnic minority health in Vietnam: a review exposing horizontal inequity

BACKGROUND

Equity in health is a pressing concern and reaching disadvantaged populations is necessary to close the inequity gap. To date, the discourse has predominately focussed on reaching the poor. At the same time and in addition to wealth, other structural determinants that influence health outcomes exist, one of which is ethnicity. Inequities based on group belongings are recognised as 'horizontal', as opposed to the more commonly used notion of 'vertical' inequity based on individual characteristics.

OBJECTIVE

The aim of the present review is to highlight ethnicity as a source of horizontal inequity in health and to expose mechanisms that cause and maintain this inequity in Vietnam.

DESIGN

Through a systematic search of available academic and grey literature, 49 publications were selected for review. Information was extracted on: a) quantitative measures of health inequities based on ethnicity and b) qualitative descriptions explaining potential reasons for ethnicity-based health inequities.

RESULTS

Five main areas were identified: health-care-seeking and utilization, maternal and child health, nutrition, infectious diseases, and oral health and hygiene. Evidence suggests the presence of severe health inequity in health along ethnic lines in all these areas. Research evidence also offers explanations derived from both external and internal group dynamics to this inequity. It is reported that government policies and programs appear to be lacking in culturally adaptation and sensitivity, and examples of bad attitudes and discrimination from health staff toward minority persons were identified. In addition, traditions and patriarchal structures within ethnic minority groups were seen to contribute to the maintenance of harmful health behaviors within these groups.

CONCLUSION

Better understandings of the scope and pathways of horizontal inequities are required to address ethnic inequities in health. Awareness of ethnicity as a determinant of health, not only as a covariate of poverty or living area, needs to be improved, and research needs to be designed with this in mind.

Handwashing among schoolchildren in an ethnically diverse population in northern rural Vietnam

Background

Handwashing with soap (HWWS) is a simple and effective measure to prevent transmission of fecal–oral disease and other infectious diseases in school-age children. To promote the behavior, we need to understand their HWWS compliance. The aim of this article is to describe handwashing behavior and HWWS compliance and to identify associated factors among schoolchildren in the multiethnic rural area of northern Vietnam.

Methods

The study was conducted in six primary and secondary schools and in the homes of four ethnic villages in northern Vietnam. Quantitative methods included face-to-face interviews with, and demonstration of handwashing protocol to, 319 schoolchildren in first, fourth, and seventh grades. Qualitative methods included structured observations at six schools and 20 homes comprising 24 children. The dependent variable was the self-reported HWWS behavior (yes/no). The independent variables included grade, school type, gender, ethnicity group, owning home latrine, and household assets. Logistic regression modelling was performed to examine associations between HWWS behavior and demographic factors.

Results

Among the 319 schoolchildren interviewed, 66% reported HWWS. Through the demonstration protocol, only 10 out of 319 schoolchildren, performed HWWS satisfactorily. The percentage of students who washed their hands at recommended times (30–60 sec) was 58%. This proportion increased by grade (from 34% among grade 1 to 67% among grade 7; p<0.05). Correlates of self-reported HWWS were more common in higher grades [grade 4 vs. grade 1: odds ratio (OR)=4.14 (2.00–8.56), grade 7 vs. grade 1: OR=7.76 (3.67–16.4)] and less common in ethnic minority groups [Xa Phó vs. Kinh-Tay: OR=0.28 (0.11–0.70)]. All 20 homes of schoolchildren visited had soap and water but none of the six schools had soap for handwashing.

Conclusions

This article describes poor compliance of schoolchildren with HWWS in a multiethnic population in Vietnam. Education on handwashing needs to be prioritized among multiethnic children at school.

Sanitation behavior among schoolchildren in a multi-ethnic area of Northern rural Vietnam

Background

In Vietnam, efforts are underway to improve latrine use in rural and remote areas with particular focus on increasing coverage of sanitation in schools. However, there is a lack of information on how the school program affects latrine use by schoolchildren and at community level. This paper analyzes sanitation use among schoolchildren in a multi-ethnic area to inform future school-based sanitation promotion programmes.

Methods

A combination of quantitative and qualitative methods was applied during a 5 months period in six primary and secondary schools and in the homes of schoolchildren in four different ethnic villages in Northern rural Vietnam. Using a structured questionnaire, 319 children were interviewed face-to-face to collect quantitative data. Qualitative methods included extensive observations at schools and in the homes of 20 children, a single day's diary writings of 234 children, in-depth interviews with children (20), their parents (20) and school staff (10), and focus group discussions with parents (4) and teachers (6), and picture drawing with children (12).

Results

All surveyed schools had student latrines. However, the observed schoolchildren most commonly urinated and defecated in the open. Main barriers for latrine use included inadequate number of latrines, limited accessibility to latrines, lack of constant water supply in latrines and lack of latrine maintenance by school management. Programs promoting latrine use for children were not conducted in either schools or communities and were not established as a preferred social norm in such settings. Children perceived existing school latrines as unappealing and expressed a wish to have basic, functional, clean, and colorful school latrines with privacy.

Conclusions

The paper shows that the current school based sanitation promotion is insufficient to change sanitation behavior of school children irrespective of their ethnicity. It is important that schools, households and communities work more closely together to increase use and uptake of latrine use among schoolchildren. Also, the contractors of latrine facilities must work more closely with local school management when constructing latrines, including identifying location, design and appropriate systems of water supply. A separate budget needs to be allocated to allow the school to maintain the sanitation infrastructure and keep it hygienic and appealing for users.

Hygiene and sanitation promotion strategies among ethnic minority communities in northern Vietnam: a stakeholder analysis

Effective rural hygiene and sanitation promotion (RHSP) is a major challenge for many low-income countries. This paper investigates strategies and stakeholders' roles and responsibilities in RHSP implementation in a multi-ethnic area of northern Vietnam, in order to identify lessons learned for future RHSP. A stakeholder analysis was performed, based on 49 semi-structured individual interviews and one group interview with stakeholders in RHSP in a northern province of Vietnam. Participants came from three sectors (agriculture, health and education), unions supported by the Vietnamese government and from four administrative levels (village, commune, district and province). The study villages represented four ethnic minority groups including lowland and highland communities. Stakeholders' roles, responsibilities and promotion methods were outlined, and implementation constraints and opportunities were identified and analysed using thematic content analysis. Effective RHSP in Vietnam is severely constrained despite supporting policies and a multi-sectorial and multi-level framework. Four main barriers for effective implementation of RHSP were identified: (1) weak inter-sectorial collaborations; (2) constraints faced by frontline promoters; (3) almost exclusive information-based and passive promotion methods applied; and (4) context unadjusted promotion strategies across ethnic groups, including a limited focus on socio-economic differences, language barriers and gender roles in the target groups. Highland communities were identified as least targeted and clearly in need of more intensive and effective RHSP. It is recommended that the Vietnamese government gives priority to increasing capacities of and collaboration among stakeholders implementing RHSP activities. This should focus on frontline promoters to perform effective behaviour change communication. It is also recommended to support more participatory and community-based initiatives, which can address the complex socio-economic and cultural determinants of health in multi-ethnic population groups. These lessons learned can improve future RHSP in Vietnam and are also of relevance for health promotion in other minority population groups in the region and globally.

Perspectives on child diarrhoea management and health service use among ethnic minority caregivers in Vietnam

BACKGROUND

In Vietnam, primary government health services are now accessible for the whole population including ethnic minority groups (EMGs) living in rural and mountainous areas. However, little is known about EMGs' own perspectives on illness treatment and use of health services. This study investigates treatment seeking strategies for child diarrhoea among ethnic minority caregivers in Northern Vietnam in order to suggest improvements to health services for EMGs and other vulnerable groups.

METHODS

The study obtained qualitative data from eight months of field work among four EMGs in lowland and highland villages in the Northern Lao Cai province. Triangulation of methods included in-depth interviews with 43 caregivers of pre-school children (six years and below) who had a case of diarrhoea during the past month, three focus group discussions (FGDs) with men, and two weeks of observations at two Communal Health Stations (CHGs). Data was content-analyzed by ordering data into empirically and theoretically inspired themes and sub-categories assisted by the software NVivo8.

RESULTS

This study identified several obstacles for EMG caregivers seeking health services, including: gender roles, long travelling distances for highland villagers, concerns about the indirect costs of treatment and a reluctance to use government health facilities due to feelings of being treated disrespectfully by health staff. However, ethnic minority caregivers all recognized the danger signs of child diarrhoea and actively sought simultaneous treatment in different health care systems and home-based care. Treatments were selected by matching the perceived cause and severity of the disease with the 'compatibility' of different treatments to the child.

CONCLUSIONS

In order to improve EMGs' use of government health services it is necessary to improve the communication skills of health staff and to acknowledge both EMGs' explanatory disease models and the significant socio-economic constraints they experience. Broader health promotion programs should address the significant gender roles preventing highland mothers from seeking health services and include family elders and fathers in future health promotion programs. Encouraging existing child health care practices, including continued breastfeeding during illness and the use of home-made rehydration solutions, also present important opportunities for future child health promotion.