PUBLIC HEALTH IN VIETNAM: HERE'S THE DATA, WHERE'S THE ACTION?
Handwashing among schoolchildren in an ethnically diverse population in northern rural Vietnam
Le Thi Thanh Xuan1* and Luu Ngoc Hoat2
1Department of Environmental Health, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam; 2Department of Biostatistics and Medical Informatics, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
Abstract
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.
Keywords: handwashing with soap; schoolchildren; rural Vietnam; multiethnic population
Received: 29 May 2012; Revised: 21 December 2012; Accepted: 24 December 2012; Published: 31 January 2013
Glob Health Action 2013. © 2013 Le Thi Thanh Xuan and Luu Ngoc Hoat. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Glob Health Action 2013, 6: 18869 - http://dx.doi.org/10.3402/gha.v6i0.18869
Handwashing with soap (HWWS) is important for school-age children in the improvement of health and disease prevention (e.g. diarrhea and gastrointestinal infections), which in turn reduces absenteeism due to illness (1-10). Investing in HWWS is minimal and easy, and HWWS is effective in maintaining health. The practice is significant for schoolchildren, who might suffer a more severe burden of hygiene-related diseases compared to adults (11-13).
Previous studies showed that school-based HWWS promotion had significant effect on HWWS practices of schoolchildren (14) and also that those schoolchildren could act as 'HWWS messengers' to their family and community (1, 3, 15-18). However, the HWWS compliance of schoolchildren in the developing countries is still low (19-21). A study conducted in rural Senegal found that out of 3,797 primary pupils observed, only 7% washed their hands with soap after using the toilet. Rates were similar for boys and girls (21). A cross-sectional study among 669 students, grade 1-6, in rural Ethiopia showed that only 15% reported HWWS after defecation (19). A survey in 10 rural primary schools in Cambodia found the potential of public education campaigns, as children in higher grades had a greater tendency to improve on sanitation practices (20). Possible reasons for low rate of HWWS among schoolchildren could be lack of soap and water or absence of norms or culture at school, which could educate the schoolchildren on HWWS. Suggested interventions, thus, should be focusing on the physical environment at school, making water and soap available (22) and inculcating a culture of HWWS at the school level (21).
Policy recommendations
The public health designers and promoters should focus on creating school culture in HWWS by:
* Prioritization of the topic in the school curriculum
* Integration of the topic in the school activities, particularly extra-curriculum
* Encouragement of new teaching methods of HWWS to schoolchildren
* Motivation of the behavior at home through role model and peer-to-peer education
* Xa Phó and smaller children should be targeted in school hygiene promotional program
* Also, HWWS behavior measurement needs to be formulated.
In Vietnam, HWWS was taught to all first-grade schoolchildren as part of national curriculum through 1-hour sessions, titled 'Body hygiene'. There were some initiatives focusing on promoting HWWS compliance of schoolchildren in Vietnam (23). However, the HWWS rate among schoolchildren is still low. A survey conducted on hygiene practices at schools in Vietnam in 2007 found that only 12% of students washed their hands with soap after defecation, and the situation was even worse in northern Vietnam (24). Another study in 2008 found that no student washed their hands with soap at school (25). Some factors associated with the poor behavior were lack of availability of, and accessibility to, soap (26) and poor soap management (23). However, due to the large-scale social marketing, handwashing behavior, funded by the World Bank has been thoroughly investigated in the rural Kinh population in Vietnam, but not among the ethnic minority groups (EMGs) (27). This study was therefore carried out to analyze the HWWS compliance of schoolchildren in poor settings where they often suffer from the burden of hygiene-related diseases. This information will help policy makers and public health promoters to design an appropriate and effective hygiene program for the multiethnic population.
Methodology
Field sites
The study was carried out in two neighboring rural communities in a northern province of Vietnam that was piloting the national target program of water supply, sanitation, and hygiene. The two communities were chosen because they are worse off than others in the region and also because they are pilot sites for hygiene promotion activities, including the second phase (2006-2010) of school hygiene intervention of the Rural Water Supply and Sanitation National Target Program. The two communities consisted of about 10,000 people living in 39 lowland and highland villages. Eighty percent of the population in the two communities belonged to the EMGs, including the Dáy, Tày, Dao, Xa Phó, H'Mông, and Hoa. The highland villages, where the Xa Phó, H'Mông, and Hoa groups lived, were located farther away from the communal center and had less public services than the lowland villages.
The study was carried out in 6 of 23 schools and 4 of 39 villages in the two communities. Six schools for the study included two secondary schools, two main primary schools, and two satellite primary schools. In each community, the primary school system included one main school located at the center of the community and several smaller branches or satellite schools located in the villages. The selection of schools aimed at diversifying the school type (two secondary and four primary schools, four main schools and two satellite schools), lowland and highland schools (five lowlands and one highland). Table 2 indicates that most children in the six schools belonged to the Tày, Dáy, Xa Phó, and Kinh ethnic groups. The four villages selected for home observation were representatives of the four different ethnic groups (Kinh, Tày, Dáy, and Xa Phó) (Table 1).
[Table omitted -see PDF.]
Shading denotes significant results.
All observation notes were recorded and analyzed using a thematic approach. The theme included 1) physical environment for HWWS (availability of soap and water) and 2) school and home activities enable schoolchildren to practice HWWS.
This study was approved by the Ministry of Health; the Ethical Committee of National Institute of Hygiene and Epidemiology; and the authorities at the school, community, and village levels. In this article, names of all schools, villages, and communities are concealed, and schools are referred to by the area they belong to (main or branches) to ensure the anonymity of informants.
Results
HWWS compliance
In this study, individual interviews demonstrated that schoolchildren did not commonly wash their hands, even with water (Table 3). The common time for HW was before eating (60%). Only 23% of schoolchildren reported HW after defecation. Very few did before cooking (only 7 students out of 319; generated 2% reported). Only four students (three female and one male student at the secondary school level) reported to HW at all critical times (before cooking, after defecation, and before eating).
Table 3 also demonstrated that 66% of respondents did HW with soap the previous day. HW is similar for both male and female students but significantly different with regard to grade and ethnicity; higher the grade, the higher the tendency to HW (32% among grade 1 and 80% among grade 7), with p <0.05. Likewise, the students belonging to the Xa Phó group did not practice this much (39%), compared to the other groups (Kinh-Tay, 71% and Day, 66%), p <0.05.
Observation both at school and home revealed that almost all students did clean the playground with their hands for playing certain games (exposure to dirt/soil) but did not HW after these activities. School observation results show that about half of more than 1,000 students observed at school snacked before school hours (probably breakfast) and during break time (from a vendor near the school) without HW before eating. Furthermore, some students did HW but with unclean water (visibly seen) from drains and water holes in the school playground.
Through demonstration protocol, children demonstrated low level of HWWS skills. Table 4 shows that the percentage of students who demonstrated HWWS was 78%. However, out of 319 participants, only 10 schoolchildren could do HWWS correctly, as per the guidelines of the Ministry of Education and Training (28). The actions less frequently done by children included: drying hands with towels (46%), washing the backs of both hands, and rinsing hands with water before using soap (Table 4).
Table 5 shows that the average HWWS time was 45 sec (±26.63). The HWWS time significantly differed by gender. The percentage of students washing their hands in the recommended time (30-60 sec) was 58%, and it increased by grade (from 34% among grade 1 to 67% among grade 7; p <0.05). Interestingly, male students washed their hands longer than the female students (49 sec vs. 41 sec; p <0.05).
Table 6 presents the logistic model analysis between the self-reported HWWS rate and relevant demographic factors. Grade and EMG were associated with the behavior significantly. Older children reported more frequent HWWS [grade 4 vs. grade 1: OR=4.14 (2.00-8.56), grade 7 vs. grade 1: OR=7.76 (3.67-16.4)], and the behavior was less common among the students belonging to the Xa Phó group [Xa Phó vs. Kinh-Tay: OR=0.28 (0.11-0.70)].
The physical environment for HWWS at both school and home settings
Observation at school shows that out of six schools, HWWS station was absent or not functional at four schools. In two schools with HWWS station installed outside the latrines, only one had water supply. All six schools did not have soap for HW. All six schools had no specific lesson on HWWS for schoolchildren or guidelines for them to practice during the 6-week observation at school, as stipulated in the national routine school program or curriculum.
Observation at home found that children had good opportunity to access water and soap for HW. All 20 households of schoolchildren had soap and water available for HW. Eight households had latrine; however, the location of the latrine was not close by. In addition, schoolchildren were not reminded to HW with soap during observation time.
Discussion
This study demonstrated the low rate of HWWS among schoolchildren and the poor physical environment at school and home that inhibited them from practicing the behavior.
The study found that the schoolchildren did HWWS more commonly before eating but very few did so after defecation and before cooking. The HWWS rate was similar for boys and girls. A poor rate of HWWS was in line with what other studies previously had shown in rural Senegal (21) and Ethiopia (19). In this study, the HWWS increased significantly by grade, with the lowest at grade 1 (32%) to the highest at grade 7 (80%). The significant difference in HWWS with regard to grade or age group of schoolchildren can be explained with the fact that the students in higher graders have greater exposure to public and school hygiene promotion, as found in rural Cambodia (20). The finding underlines the importance of targeting the younger schoolchildren in HWWS education at school.
The study also found that ethnicity also had an impact on self-reported HWWS, with this behavior less common among highlanders or Xa Phó (Tables 3 and 6). In fact, in the highland communities where the Xa Phó ethnic group lives, the parents of the schoolchildren often go far away from home for farming activities, work long hours, and have limited opportunities to remind their children about hygiene practices (31, 32). Thus, not only ethnicity but also economic conditions have a negative impact on the HWWS compliance of schoolchildren in the multiethnic population.
The study also found that physical environment at school was poor, while all homes visited had water and soap. Similarly, availability of water and soap had a great influence on HWWS compliance of schoolchildren, as found in previous studies (22, 26). In addition, the study also found that HWWS was not a part of school and home schedule, where nobody reminded schoolchildren to HWWS, such as requesting them to HWWS before eating or cooking. It might reflect failure of adults (teachers and parents) to reinforce HW behavior. The findings implied that there was a need to prioritize HWWS among schoolchildren in the multiethnic population to reduce the high-burden of hygiene-related diseases among them. An intervention can be made in school settings, through a provision of soap and water facilities at a low-cost, with new HWWS lessons placed in the curriculum for grade 1. In addition, there should be motivation for schoolchildren to HWWS at home, where soap and water are available, by reminding them 'clean hand to be a good child' or through peer-to-peer education.
Some authors argued that studies on hygiene using only questionnaire-based surveys often have limited value (5, 33). However, others found that hygiene studies of smaller schoolchildren can be done with questionnaires because students express their practice truthfully and not provide desired answers or answers influenced by adults (34). Children are often a more reliable source of information than adults (35) as they are not aware of what is socially desirable (21). Furthermore, some authors have argued that hygienic behaviour could be less varied at a population level than at an individual level (36, 37). Therefore, this study applied triangulation to describe the HWWS compliance of schoolchildren, including face-to-face interviews, demonstration protocol, and observation. The results from these methods could complement each other, for example, using questionnaire to describe HWWS behavior, demonstration for exploring HWWS skills, and observation of physical environment and support at school and at home. The consistency of the results of HWWS before eating between Questionnaire and Observation recommend using the questionnaire to explore the hygiene behaviours of schoolchildren, particularly for 4th graders (Questionnaire: 57%; Observation: 50%). However, the HWWS of two key players, teachers and parents, might have a great influence in shaping the hygiene behavior of schoolchildren, and it should be further studied.
In sum, the study demonstrated the poor level of HWWS among schoolchildren in the multiethnic population of rural Vietnam, which needs more attention from policy makers. Education on handwashing needs to be prioritized to multiethnic children at school.
Acknowledgements
The study was supported by the Danish International Development Assistance (Danida) through the project, SANIVAT 'Water supply, sanitation, hygiene promotion and health in Vietnam' (www.sanivat.com.vn; 104.DAN.8.L.711). Thanks are due to the staff at the National Institute of Hygiene and Epidemiology, local partners at the provincial center for preventive medicine, and all the research assistants for their support and work. Finally, we thank all schoolchildren who participated in this research.
Conflict of interest and Funding
The authors have not received any funding or benefits from industry or elsewhere to conduct this study.
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*Le Thi Thanh Xuan
Department of Environmental Health
Institute for Preventive Medicine and Public Health
Hanoi Medical University, No 1 Ton That Tung, Dong Da
Hanoi, Vietnam.
Email: [email protected]
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Copyright Co-Action Publishing 2013
Abstract
Background: Handwashing with soap (HWWS) is a simple and effective measure to prevent transmission of fecaloral 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.
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer