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

Abstract

Improving sanitation and hygiene to prevent infectious diseases is of high priority in developing countries. This study attempts to gain in-depth understanding of hygiene and sanitation perceptions and practices among four Ethnic Minority Groups (EMGs) in a rural area of northern Vietnam. It is based on extensive participatory observations in 4 villages and 20 case households over a period of six months (May–October 2008). In addition, 10 key informants and 60 household-members were interviewed and 4 focus group discussions conducted.

The study found that among the four selected EMGs the cultural perceptions of hygiene and sanitation which inform everyday hygiene practices did not differ substantially and were similar to hygiene explanations found in the rural majority population elsewhere in Vietnam. However, the difficult living conditions, particularly in highland communities, reinforce a sense of marginalization among the EMGs, which had great impact on how they perceive and respond to government sanitation interventions.

The enclosed latrines promoted by authorities are met with reluctance by the EMGs due to cultural perceptions of the body as permeable and therefore, vulnerable to ’dirty air’ such as bad smells from human faeces. In addition, the prioritization of specific sanitation hardware solutions by the central government aimed at increasing coverage creates expectations and dependency among the EMGs that hygiene ’comes from the outside society’, resulting in low levels of community initiated actions.

Based on these findings, we suggest that future hygiene promotion strategies aim for a closer match between community priorities and government hygiene policies, e.g. by allowing for a larger diversity of low-cost sanitation solutions. Scaling up participatory community-based hygiene promotion is also recommended to curb dependency and spark initiatives in ethnic minority communities. Finally, interventions should focus on hygiene “software” - promoting hygiene behaviour changes known to effectively prevent hygiene related diseases.

Introduction

Vietnam is characterized by having a strong state and health is a key objective of state policies and governance (London, 2008). Hygiene has been a top priority since President Ho Chi Minh, in 1961, stressed for all children to ‘maintain very good hygiene’ (Giu gin ve sinh that tot), a phrase still being taught in schools all over Vietnam (Ho Chi Minh, 1961). In 1999, the focus on improving environmental health was boosted by initiating the donor supported National Target Programme for Rural Water and Sanitation. It focuses heavily on the construction of safe water supply and sanitation facilities in villages. To increase affordability of sanitation, the government is currently relying on subsidy-driven sanitation, by offering financial or hardware subsidies (around 0.5 million Vietnamese Dong, app. 28 USD) to households constructing nationally approved and standardized models of latrines (Ministry of Health, 2005). The cheapest variation and a frequently advocated type of latrine in rural areas is the composting latrine with a closed concrete superstructure, slab and underground vaults for storing the faecal matter. It costs approximately two million Vietnamese Dong (app. 115 USD) to construct. The traditional overhung fishpond latrine used by rural residents in Vietnam for centuries, has recently been banned due to fears of transmitting parasite infections from fish to humans. In 2005, hygiene promotion was added as a programme component, to boost the previously low priority given to ‘software’ interventions. The promotion methods presently used consist mainly of information materials (posters, flyers and guidelines) and training hygiene advocators such as village health workers to advocate sanitation and safe water use. Thus, improving hygiene and sanitation is now firmly stated as part of public health policies in Vietnam, in what could be called a ‘body politics’ (Scheper-Hughes & Lock, 1987) understood as government intentions aimed at governing, regulating and monitoring hygiene behaviour.

Vietnam hosts a total of 53 officially recognized EMGs according to government classifications, making up 14.5 percent of the total population, and 44.7 percent of the population categorized as poor (The World Bank, 2009). These groups live mainly in rural uplands and mountainous areas of the country. During the last decades, the Vietnamese government has implemented various economic and social reforms targeting ethnic minorities to improve their living standards. But data show that ethnic minorities still experience increasing poverty and economic disparities compared with the Vietnamese majority population (the Kinh group) (Teerawichitchainan & Phillips, 2008). Also, uptake of water and sanitation facilities is slowest in areas with high concentrations of ethnic minorities. Official statistics from 2004 concluded that 71% of the population in the north east had no or substandard pit latrines and only 18% had safe water supplies (General Statistics Office, 2006). The burden of hygiene-related diseases is also particularly high in the northern region with high levels of diarrhoea, helminth and trachoma infections (DPME, 2009, Khandekar et al., 2006, Shaikh et al., 2008). Health surveys shows that minority children in the northern and central highlands consistently experience higher risks of malnutrition than Kinh children (General Statistical Office, 2003), which can be partly ascribed to poor hygiene and sanitation.

Poor socio-economic factors and access to water and soap influence hygiene practices (Schmidt et al., 2009). But research has also shown that motivations for individuals to practice hygiene are often not based on biomedical knowledge or rational calculations of risk. Health and hygiene initiatives therefore need to be culturally and socially appropriate to be successful (Panter-Brick, Clarke, Lomas, Pinder, & Lindsay, 2006). Douglas underlines such socio-cultural hygiene factors when defining dirt as things classifiable as ‘out of order’ according to local norms (Douglas, 2002). Dirt and pollution avoiding behaviour can therefore be interpreted as ways of maintaining order and protecting bodily, social and spatial borders. Campkin and Cox (2007) further highlight dirt avoidance in relation to domestic, urban and rural borders. Hence, socially constructed perceptions of hygiene and dirt operate metaphorically to suggest borders between clean and dirty places.

Many studies also highlight symbolic, social and cultural driving forces for hygiene practices, such as indicating a higher social status by having a latrine or signalling good motherhood when keeping children hygienic (Jenkins and Curtis, 2005, Scott et al., 2007). Similarly, Rheinländer et al. (2008) found that the social desire for neat appearances was more important for street-food vendors than biomedical food hygiene. A recent review of hand washing interventions summed up factors such as disgust, nurture, and comfort to be among the key drivers for hand washing across 11 developing countries (Curtis, Danquah, & Aunger, 2009).

Few in-depth studies have been published on hygiene perceptions in Vietnam. One such study highlights social norms of hygiene as very influential for caregivers’ child hygiene behaviour (Dearden et al., 2002). Other studies highlight the influence of miasmatic beliefs inscribed into Vietnamese medicine, according to which wind, air and smells are able to permeate the body and cause diseases. This results in disgust towards smells from human and animal wastes and stresses the importance of well-aired living premises (Craig, 2002, Knudsen et al., 2008). Hence, social and cultural values of hygiene are embodied in everyday hygiene practices. Using Scheper-Hughes & Lock’s expression (1987), local perceptions of hygiene are inscribed in the ’social body’ and hygiene initiatives are therefore expected to be most effective when building on in-depth understandings of social practices and the specific cultural context.

This study aims to gain an in-depth understanding of hygiene and sanitation perceptions and practices among four EMGs in a rural area of northern Vietnam, with the goal of informing and matching future hygiene interventions and policies in Vietnam with community priorities.