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Designing and implementing anintegrative research project: lessonslearned from a case study in VietnamDr. Hung Nguyen-Viet...
Content• Context and conceptual framework development• Case study in Vietnam–Environment–Health–Socio-economic research• T...
2.6 billion peopleworld-wide still donot have anyimproved sanitation
MDG
Water and Sanitation intervention• Reduces child diarrhea by 22%-36%.• Reduces 9,1% burden of disease for humans (DALYs)• ...
World Toilet Organization (WTO)
Rational for conceptual framework development• Lack of integrated framework of assessment ofhealth, environment and societ...
Interdisciplinary team
Interdisciplinary teamEpidemiologist EngineerAnthropologist BiologistMedical doctor
Objective: to develop a conceptualframework for improving environmentalsanitation and healthby combining assessment of hea...
Interventions (biomedical, systems, engineering, behavioral or in combination):Efficacy, effectiveness and equity studies ...
Thailand VietnamCase studies to test the conceptual frameworkCôte d‘Ivoire
Case study in Northern Vietnam• Issue of wastewater and excreta reuse inagriculture and aquaculture• Health risk and envir...
Study site: Nhat Tan and Hoang Taycommunes, Kim Bang district, HanamCase study in VietnamHa Nam province
Interventions (biomedical, systems, engineering, behavioral or in combination):Efficacy, effectiveness and equity studies ...
1) Physical environment: Material flow analysisMFA has been used for analyzing environmental sanitation and agriculturesys...
Scenario development10935199711153210035020406080100120140160180200Nitrogen PhosphorusWastewater to drainage systemTonnesp...
Cross-sectional surveyPrevalence and risk factors for helminth infections• 1,834 individuals, 540 randomly selected househ...
2. Risk factorsAny helminths A. lumbricoides T. trichiuraOR 95% CI OR 95% CI OR 95% CIHousehold use of tap waterYes versus...
Risk factorsMatchedOR 95% CIAttributablefraction% exposedcontrols1. Exposure to excretaComposting of human excreta ( ≤ 3 v...
2) Health: Quantitative microbial risk assessmentObjective: assess diarrhea risk of contact with wastewater andexcreta in ...
Estimated annual risks of diarrhoea0.4150.2080.5030.1270.3950.6570.1010.0390.1520.004 0.0000.2340.1450.238 0.2400.0430.250...
3) Social and economic research of sanitation• Study the perception and behavior related to theuse of wastewater and human...
Measuring awareness and perceptions of of farmersand the practical aspects of wastewater reuseusingProtection Motivation T...
Economic benefits associated with diarrhea cases preventedas a result of improvement in access to clean water andhygienic ...
Willingness to pay in Kim Bang district, Ha NamSẵn sàng chi trả để xâynhà vệ sinh tự hoại Sẵn sàng chi trả để xâydựng hệ t...
Willingness to pay for in Kim Bang district, Ha Nam16,464.001,530.00Mức sẵn sàng chi trả để xây nhà vệsinh tự hoại-nhà tắm...
Physical environment Social, cultural andeconomic environmentImpact of wastewaterand excreta useEPI & QMRACase study in Vi...
• Close links with graduate school and schedulefor students• Commitment of students: risk• Administrative barriers (regist...
Interventions (treatment at household level, behavioral, hygiene practice):Efficacy, effectiveness and equity studies meas...
Communication strategy and policy impact•Publication in both internationaland national• International peer-reviewed papers...
Communication strategy and policy impact•National Workshop fordissemination•Workshop with communities
Partnership
Conclusions 1• A conceptual framework was developed and case studies launched.• Physical environment: onsite sanitation an...
Is it really an Ecohealth research?• What are people actually doing when theysay they are doing ecohealth?• Identify enabl...
Our Proposal• Proposal was based on conceptual framework• Investigation of ecohealth by asking questions about thepillars ...
Approach• Case study- Identification of case/boundaries, sources of information,context• Bottom-up approach: nature of int...
Methods – Selection Process• Identifying the system- NCCR project, project documents, project team• Entry into project sit...
Study Design – Data CollectionGathering and analysis of data• Data collection– interviews/focus groups– English/Vietnamese...
Study Design - Analysis• Translation & transcription– Questions, responses, validation• Data analysis– Analysis Method Fra...
Results of interview and focus groups• Identified over a 100 themes including severalenablers and impediments• Reported on...
Results: Themes from Interviews and Focus Groups3 of the 18 themes:•“integration not clear”•“don’t understand”•“limits par...
Assessment of ecohealth in practiceEcohealthcomponents:• Participation• ComplexitySource• Interview themes:“collected data...
Major Findings• Reporting on those aspects of ecohealth practice: notjust technical results but process results (networks)...
Conclusions 2: is it an ecohealth study?• Our research emphasized the importance of negotiatingindicators for success of t...
General conclusions: Lessons learnedfrom ecohealth application• Many levels of being ecohealth – integrative research• Hav...
Acknowledgement• Dr Pham Duc Phuc, NIHE• Do Thu Nga, PhD student (AIT), Vu Van Tu, PhD student (HSPH)• Nguyen Cong Khuong,...
Thank you for your attention!
Designing and implementing an integrative research project: Lessons learned from a case study in Vietnam
Designing and implementing an integrative research project: Lessons learned from a case study in Vietnam
Designing and implementing an integrative research project: Lessons learned from a case study in Vietnam
Designing and implementing an integrative research project: Lessons learned from a case study in Vietnam
Designing and implementing an integrative research project: Lessons learned from a case study in Vietnam
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Designing and implementing an integrative research project: Lessons learned from a case study in Vietnam

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Presentation by Hung Nguyen-Viet at the EcoZd-FBLI One Health/Ecohealth training course held at Hanoi, Vietnam, 27-30 May 2013.

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  1. 1. Designing and implementing anintegrative research project: lessonslearned from a case study in VietnamDr. Hung Nguyen-VietHanoi School of Public Health (HSPH)EcoZD-FBLI Ecohealth/One Health courseHanoi, Vietnam, 27-30 May 2013
  2. 2. Content• Context and conceptual framework development• Case study in Vietnam–Environment–Health–Socio-economic research• Training/involvement student by/for research• Is it really Ecohealth research?• Lessons learns and perspectives
  3. 3. 2.6 billion peopleworld-wide still donot have anyimproved sanitation
  4. 4. MDG
  5. 5. Water and Sanitation intervention• Reduces child diarrhea by 22%-36%.• Reduces 9,1% burden of disease for humans (DALYs)• Reduces 6.3% deaths worldwide each year
  6. 6. World Toilet Organization (WTO)
  7. 7. Rational for conceptual framework development• Lack of integrated framework of assessment ofhealth, environment and society• Optimizing natural resource use and healthimprovement• Understand local need from different perspectives(cultural, perception, willingness to change/pay)• Target most effective interventions to archive MDGgoals on water, sanitation and health
  8. 8. Interdisciplinary team
  9. 9. Interdisciplinary teamEpidemiologist EngineerAnthropologist BiologistMedical doctor
  10. 10. Objective: to develop a conceptualframework for improving environmentalsanitation and healthby combining assessment of health,physical environment, and socialenvironment, leading to extendedcharacterization of risks for health,physical and social environments andfinally proposing integral interventions
  11. 11. Interventions (biomedical, systems, engineering, behavioral or in combination):Efficacy, effectiveness and equity studies measured in relation to risksCritical control points: comprehensive biomedical, epidemiological, ecological, social,cultural and economic assessmentAnalysis of interrelations between environmental sanitation systems, health status and well-beingHealth statusExposure to pathogens (viruses, bacteria,protozoa, helminths)Health related and help seeking behaviorFood chainExcreta, Wastewater, WaterNutrients: N, PChemical pollutantsEcological risks and useof resourcesMFAHealth risks-impacts,Affected populationQMRAVulnerability, resilienceand equity patternsSSAStructure of societyEmpowermentEconomic statusEPIPhysical environment Social, cultural andeconomic environmentbetween systems andinterventionsDynamic interactions(Water and Sanitation)
  12. 12. Thailand VietnamCase studies to test the conceptual frameworkCôte d‘Ivoire
  13. 13. Case study in Northern Vietnam• Issue of wastewater and excreta reuse inagriculture and aquaculture• Health risk and environmental risk• People’s perception on waste reuse andhealth risk, economic assessment, healtheconomics of sanitation
  14. 14. Study site: Nhat Tan and Hoang Taycommunes, Kim Bang district, HanamCase study in VietnamHa Nam province
  15. 15. Interventions (biomedical, systems, engineering, behavioral or in combination):Efficacy, effectiveness and equity studies measured in relation to risksCritical control points: comprehensive biomedical, epidemiological, ecological, social,cultural and economic assessmentAnalysis of interrelations between environmental sanitation systems, health status and well-beingHealth statusPhysical environment Social, cultural andeconomic environmentbetween systems andinterventionsDynamic interactionsImpact of wastewaterand excreta useEPI & QMRACase study in VietnamNutrient (N, P) flowin Env. SanitationsystemMFAPerception of reuseand health risk PMTHealth economics ofsanitationWTP, CBA
  16. 16. 1) Physical environment: Material flow analysisMFA has been used for analyzing environmental sanitation and agriculturesystems with the emphasis on nutrient flow of nitrogen (N) and phosphorus (P)Onsite sanitation and crop production discharge the largest flows of N into water bodiesthrough drainage systems (CCPs)
  17. 17. Scenario development10935199711153210035020406080100120140160180200Nitrogen PhosphorusWastewater to drainage systemTonnesperyearYear 2008Year 2020Year 2020 with improved on-sitesanitationYear 2020 with reuse wastewaterPollution scenario for the study site in the year 2020 (Unit: ton/y)
  18. 18. Cross-sectional surveyPrevalence and risk factors for helminth infections• 1,834 individuals, 540 randomly selected households• Questionnaires on household & individual level• Stool examinations: Kato-Katz & FECTCohort studyIncidence rate of diarrhoea• Subjects: 867 adults, both of sex, aged 16-65 years• Diarrhoea status was collected weeklyNested case-control studyRisk factors for diarrhoea• 232 cases were detected & selected by morbidity interview• Controls were selected from all cohort subjects (ratio: 1:1)• History of exposure was defined as a previous week2) Health: Epidemiology
  19. 19. 2. Risk factorsAny helminths A. lumbricoides T. trichiuraOR 95% CI OR 95% CI OR 95% CIHousehold use of tap waterYes versus No 0.6 0.4-0.9 N.A. - 0.6 0.4-0.9Use of human excreta for application in fieldYes versus No 1.3 0.9-2.0 1.3 0.8-2.0 1.5 1.0-2.3Direct contact with Nhue River during field workaYes versus No 1.5 1.1-2.2 2.1 1.4-3.2 1.1 0.8-1.5Washing hands with soap after field workaYes versus No N.A. - 1.3 0.9-2.0 0.8 0.6-1.1Use protective measures at workaYes versus No 0.9 0.5-1.5 1.0 0.6-1.7 N.A. -Notes: OR: odds ratio, CI: confidential interval, N.A. not applicable1. Prevalence: any helminths (47%), A. lumbricoides (24%), T. trichiura (40%), hookworm (2%).2) Health: Epidemiology: Intestinal helminthinfections
  20. 20. Risk factorsMatchedOR 95% CIAttributablefraction% exposedcontrols1. Exposure to excretaComposting of human excreta ( ≤ 3 versus > 3 months) 2.5 1.4-4.3 0.51 72Handling human excreta in field work (Yes versus No) 5.4 1.4-21.1 0.07 2Handling animal excreta in field work (Yes versus No) 3.3 1.8-6.0 0.36 252. Exposure to water from Nhue River and local pondDirect contact with Nhue River water during fieldwork (Yes versus No) 2.4 1.2-4.7 0.27 26Close contact with local pond water (Yes versus No) 2.3 1.2-4.3 0.14 133. Personal hygiene practicesNot use of protective measures at work (Yes versus No) 6.9 3.5-13.9 0.78 61Close contact with people having diarrhoea (Yes versus No) 3.7 1.4-10.3 0.08 3Washing hands with soap in general (Sometime versus frequently) 2.5 1.3-4.9 0.27 25Washing hands with soap in general (Never or rarely versus frequently) 3.3 1.8-6.3 0.51 454. Food and water consumptionEating raw vegetables the day before (Yes versus No) 2.4 1.2-4.6 0.12 10Water source for drinking (Rainwater versus tap water) 5.4 2.4-12.1 0.77 782) Health: Epidemiology: Risk factors for diarrhoeain adults
  21. 21. 2) Health: Quantitative microbial risk assessmentObjective: assess diarrhea risk of contact with wastewater andexcreta in agriculture using QMRA.CompostingWatersourceHousehold(wastes)SolidwastesExcreta/ManuresFoodWastewaterSewagesSanitationIrrigationsystemPonds CropLandfillLivestockRiver6355124
  22. 22. Estimated annual risks of diarrhoea0.4150.2080.5030.1270.3950.6570.1010.0390.1520.004 0.0000.2340.1450.238 0.2400.0430.2500.0030.00.10.20.30.40.50.60.7Harvestingvegetables inNhue RiverCleaning thehouseholdsewageFishing in thelocal pondsGrowing rice Application ofexcreta in thefieldsCombined allexposuresAnnualrisksofdiarrhoea(pppy)G. lamblia C. parvum Diarrheagenic E. coli
  23. 23. 3) Social and economic research of sanitation• Study the perception and behavior related to theuse of wastewater and human excreta, healthrisk, coping appraisal and intention to act basedon Protection Motivation Theory (PMT)• Cost-benefit (CBA) of sanitation• Willingness to pay (WTP) for improved sanitation
  24. 24. Measuring awareness and perceptions of of farmersand the practical aspects of wastewater reuseusingProtection Motivation Theory frameworkFear of diseaseSelf-efficacyResponse-efficacySeverityVulnerabilityMotivationHygiene practiceHygiene practice inrelation to wastewateruse0.350.320.300.300.180.110.19
  25. 25. Economic benefits associated with diarrhea cases preventedas a result of improvement in access to clean water andhygienic sanitation in Nhat Tan commune, Kim Bang, Ha NamUsing the service (%) Unit Cost(VND)Total cost(VND)Self-treatment 8% 31,294 157,723Health Station 26% 101,246 1,658,416District Hospital 24% 868,878 13,137,439Provincial Hospital 19% 1,334,612 15,975,302Central Hospital 6% 2,102,244 7,946,481Pharmacies 10% 31,294 197,154Private Health 7% 688,476 3,036,177Total cost (VND) avoided/year 42,108,693
  26. 26. Willingness to pay in Kim Bang district, Ha NamSẵn sàng chi trả để xâynhà vệ sinh tự hoại Sẵn sàng chi trả để xâydựng hệ thống cốngchung67.6%79.5%Willingness to pay for flushtoilet Willingness to pay for publicsewer
  27. 27. Willingness to pay for in Kim Bang district, Ha Nam16,464.001,530.00Mức sẵn sàng chi trả để xây nhà vệsinh tự hoại-nhà tắm (nghìn)Mức sẵn sàng chi trả để xây dựnghệ thống cống chung (nghìn)Mean of WTP for flush toilet(Thousand)Mean of WTP for public sewer(Thousand)
  28. 28. Physical environment Social, cultural andeconomic environmentImpact of wastewaterand excreta useEPI & QMRACase study in VietnamNutrient (N, P) flowin Env. SanitationsystemMFAPerception of reuseand health risk PMTHealth economics,of sanitationWTP, CBA•PhD Phuc•MSc Khuong•MSc Toan•MSc Tung•MSc Nga (AIT), now PhD in Tokyo•MSc Tam (AIT) •MSc Tu (HSPH), now PhD•MSc Thanh (HMU)•Postdoc Minh (HMU)Training students within research project
  29. 29. • Close links with graduate school and schedulefor students• Commitment of students: risk• Administrative barriers (registration, finance…)• Investment for coaching, supervision with moto• Training vs. Project purposesTraining students within research project
  30. 30. Interventions (treatment at household level, behavioral, hygiene practice):Efficacy, effectiveness and equity studies measured in relation to risksCritical control points: Health (specific exposure and health impact), Environmental (on-sitesanitation, crop), Socio - economic (PMT, WTP, CBA)Physical environment Social, cultural andeconomic environmentImpact of wastewaterand excreta useEPI & QMRACase study in VietnamNutrient (N, P) flowin Env. SanitationsystemMFAPerception of reuseand health risk PMTHealth economics,of sanitationWTP, CBA•PhD Phuc(Basel & NIHE)•MSc Khuong(HSPH)•MSc Toan(HSPH)•MSc Tung(HSPH)•MSc Nga (AIT), now PhD in Tokyo•MSc Tam (AIT)•MSc Tu (HSPH),now PhD•MSc Thanh (HMU)•Postdoc Minh(HMU)Combined assessment and future intervention…
  31. 31. Communication strategy and policy impact•Publication in both internationaland national• International peer-reviewed papers• National publication on VietnamJournal of Public Health: special issueon Health and Sanitation• Policy briefs, Outcome Highlight
  32. 32. Communication strategy and policy impact•National Workshop fordissemination•Workshop with communities
  33. 33. Partnership
  34. 34. Conclusions 1• A conceptual framework was developed and case studies launched.• Physical environment: onsite sanitation and crop production contribute largepart of N and P discharge to water bodies through drainage systems (CCPs).Options for mitigating environmental impact• Health risk (helminth infection and diarrhea diseases) are related to the useof wastewater and excreta use in agriculture. Specific exposure activitiesidentified• Socio-economic assessment: Perception, behavior of health risk and abilityof people to prevent risk caused by wastewater and excreta reuse.• Method development for health combined assessment by EPI and QMRA• Detailed research on health impact (exposure, pathogens…) and socialresearch (software) of health and sanitation + Intervention• Training students and partnership: linkage with graduate school, multi-institution and interdisciplinary, investment for supervision and admin.Barriers
  35. 35. Is it really an Ecohealth research?• What are people actually doing when theysay they are doing ecohealth?• Identify enablers and impediments ofproject approach and to assess conformityof practice with conceptsMSc thesis of Vi Nguyen, University of Guelph, Canada, 2010
  36. 36. Our Proposal• Proposal was based on conceptual framework• Investigation of ecohealth by asking questions about thepillars of ecohealth as defined by CoPEH-Can, IDRC- Transdisciplinarity- Equity- Participation- Sustainability• Challenges: research in-progress, languageVi Nguyen (2010)
  37. 37. Approach• Case study- Identification of case/boundaries, sources of information,context• Bottom-up approach: nature of interactions, howknowledge was shared• Definition of a “stakeholder”, “involvement”Vi Nguyen (2010)
  38. 38. Methods – Selection Process• Identifying the system- NCCR project, project documents, project team• Entry into project site- Jan-May 2010, Hanoi School of Public Health,sampling visits, interaction with community• Selection and recruitment of participants- snowball/chain sampling, perspectives: NCCR team,health station staff, research participantsVi Nguyen (2010)
  39. 39. Study Design – Data CollectionGathering and analysis of data• Data collection– interviews/focus groups– English/Vietnamese– questions: stakeholder roles, research process, typeof participation, opinions on approachVi Nguyen (2010)
  40. 40. Study Design - Analysis• Translation & transcription– Questions, responses, validation• Data analysis– Analysis Method Framework– Management: Atlas.ti
  41. 41. Results of interview and focus groups• Identified over a 100 themes including severalenablers and impediments• Reported on 18 themes (groundedness of 20+)• Themes grouped into 5 categories according tocommonalities
  42. 42. Results: Themes from Interviews and Focus Groups3 of the 18 themes:•“integration not clear”•“don’t understand”•“limits participation”Some enablers and impediments:•enablers: networks, evidence (if used)•impediments: “not comfortable”, “they just ask, no results”Vi Nguyen (2010)
  43. 43. Assessment of ecohealth in practiceEcohealthcomponents:• Participation• ComplexitySource• Interview themes:“collected data”,“limitedparticipation”• project documentsVi Nguyen (2010)
  44. 44. Major Findings• Reporting on those aspects of ecohealth practice: notjust technical results but process results (networks)• Interview and focus group insights → ecohealthreporting guidelines → inform reporting, designing,evaluatingVi Nguyen (2010)
  45. 45. Conclusions 2: is it an ecohealth study?• Our research emphasized the importance of negotiatingindicators for success of the research, within a participatoryapproach, since they may differ among different stakeholdergroups. Furthermore, ecohealth practice involves collectionof data from multiple scales and sectors. The challenge ofhow to integrate these must be considered at the designstage and throughout the research.• We recommend that ecohealth research teams include aself-investigation of their process in order to facilitate acomparison of theory-to-practice. This may serve as a bestpractice for ecohealth research and may also offer insightsinto how to evaluate the process.
  46. 46. General conclusions: Lessons learnedfrom ecohealth application• Many levels of being ecohealth – integrative research• Having a systematic thinking when designing andimplementing, involvement of stakeholders andcommunication with them are important.• Really try to have intervention, even small. AvoidNATO…• Student involvement and support by seniors and donorsare important for capacity building in ecohealth• Challenges ahead … but future is bright
  47. 47. Acknowledgement• Dr Pham Duc Phuc, NIHE• Do Thu Nga, PhD student (AIT), Vu Van Tu, PhD student (HSPH)• Nguyen Cong Khuong, CPV Hanam• Nhung, Thao, Toan, Tung, HSPH• Vi Nguyen, Guelph University• Ha Nam province, Hoang Tay and Nhat Tan communes• Prof. Jakob Zinsstag, Dr. Peter Odermatt Swiss TPH• Mr. Roland Scherteinleb, Chris Zuebrugg, Eawag/Sandec• Prof. Phung Dac Cam, NIHE• Profs. Thanh Huong, Bich, Linh, Vu Anh, HPSH• Ms. Huong, Hanh, Bich• Others
  48. 48. Thank you for your attention!
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