HEALTH PROMOTION INTERNATIONAL
© Oxford University Press 2001. All rights reserved
Vol. 16, No. 1
Printed in Great Britain
Development of a national injury prevention/safe
community programme in Vietnam
LUAU HOAI CHUAN1,2, LEIF SVANSTRÖM, ROBERT EKMAN,
DUONG HUY LIEU1, NGUYEN OUANG CU1, GÖRAN DAHLGREN1
and HOANG PHUONG2
Karolinska Institutet, Department of Public Health, Division of Social Medicine, Stockholm, Sweden,
1
Health Policy Unit and 2Institute of Health Strategies and Policy, Ministry of Health, Hanoi, Vietnam
SUMMARY
The aim of this study is to describe the initiation of a
national programme on injury prevention/safe community
(IP/SC). Market economy, Doi Moi, was introduced in
Vietnam in 1986, and since then the injury pattern has been
reported to have changed. The number of traffic injury
deaths has increased three-fold from 1980 to 1996 and
traffic injuries more than four-fold. Injuries are now the
leading cause of mortality in hospitals. There are difficulties
in obtaining a comprehensive picture of the injury pattern
from official statistics and, in conjunction with the work
initiated by the Ministry of Health, a number of local reporting systems have already been developed. Remarkable
results have been achieved within the IP/SC in a very short
time, based on 20 years of experience. An organizational
construction system has been built from province to
local community areas. Management is based on administrative and legislative documents. IP/SC implementation
is considered the duty of the whole community, local
authorities and people committees, and should be incorporated into local action plans. The programme is a significant
contribution towards creating a safe environment in
which everybody may live and work, allowing the stability
for society to develop. Implementation of the programme
in schools is a special characteristic. The programme
will be developed in 800 schools with a large number of
pupils (25% of the population). This model for safer
schools is considerably concerned and is a good experience to disseminate. The recommendations are that more
pilot models of IP/SC should be conducted in other
localities and that the programme should be expanded to a
national scale. Furthermore, co-operation between sectors
and mass organizations should be encouraged and
professional skills of key SC members at all levels should
be raised.
Key words: injury prevention; intersectoral work; national programme; safe community
INTRODUCTION
Market economy, Doi Moi, was introduced in
Vietnam in 1986; since then the injury pattern has
been reported to have changed. The number of
traffic injury deaths has increased three-fold
from 1980 to 1996 and traffic injuries more than
four-fold. Injury is now the leading cause of
mortality in hospitals ahead of circulatory system,
infectious and parasitic diseases.
The authorities face many difficulties in
obtaining a comprehensive picture of the injury
pattern from official statistics and, in conjunction
with the work initiated by the Ministry of Health
under the title of injury prevention/safe communities (IP/SC), a number of local reporting
systems have been developed (Svanström, 1997;
Svanström, L., Hang, H. M., Ekman, R., Lieu,
D. H., Cu, N. Q., Chuan, L. H. and Phuong, H. T.,
manuscript submitted). The Ministry of Health
has also initiated a local surveillance system;
however, study and improvement of the quality
of the system is necessary. Another area in need
of development is research-oriented studies of
epidemiological character, such as householdbased surveys, to establish a more complete and
realistic picture of injuries in Vietnam. Recently,
an epidemiological field laboratory has been
47
48
L. H. Chuan et al.
established in the Bavi district, 60 km west of
Hanoi (Hang, 1999).
Traffic accidents in particular are becoming a
pressing and difficult problem, and are proving
a considerable danger to the people of Vietnam
(Chuan, 1999). According to injury statistics
for the period 1990–1999 in 61 provinces/cities
nationwide, there were 124 692 accidents, claiming the lives of 42 190 people and injuring
132 091. In 1990, there were only 6110 cases
(2268 deaths and 4956 injuries), whereas in 1998
there were 20 753 cases (6394 deaths and 22 989
injuries). Every day, traffic accidents result in
18 mortalities and 60 cases of serious injury,
resulting in huge losses of health, life and
property.
Accidents at work are also increasing. In 1998,
there were 3234 cases (362 reported deaths and
1084 seriously injured casualties), 1.4 times
greater than in 1997 (2257).
Despite the problems of assessing the real injury
picture in Vietnam there is sufficient information
available for the Vietnamese authorities to recognize this social problem. This paper aims to
describe the initiation of a national programme
to deal with it.
BACKGROUND
Vietnam became an independent state on
2 September 1945 and is a socialist republic.
Vietnam covers an area of 329 560 km2 and in a
decade, from 1986 to 1996, the population density
has increased from 184 to 227 persons per km2
(Ministry of Health, 1996a). The population consists of 38 582 000 females and 36 773 000 males.
Approximately 60 million of the total population
live in rural areas. The growth rate is now 1.88%
(1996), having decreased from 2.07% in 1986.
The fertility rate has decreased from 3.8 to 3.1%
in the same period. About half of the population
is ,25 years of age and ~3% are .65 years of age.
Life expectancy has been reported to be 64
years for males and 69 years for females
(1996). The infant mortality rate was 38 per 1000
live births in 1996. There were, however, large
reported geographical differences; 31.2 in the
south-eastern regions and 71.6 in the central
highlands. Immunization rates among children
,1 year of age have improved substantially over
the last 10 years and are now ~95%. The number
of cases and deaths due to vaccine-preventable
diseases such as diphtheria, pertussis, polio-
myelitis, tetanus, tuberculosis and measles has
consequently decreased.
Health and drug policy for the period 1996–2000
A government resolution was adopted on 20 June
1996 on ‘strategic orientation for people’s health
care and protection for the period of 1996–2000’
(Ministry of Health, 1996b).
Health care and protection is the responsibility of
every individual, family, authority at all levels, mass
organizations and social organization … The Ministry
of Health is responsible for formulation of a concrete
plan providing guidance for implementation and
supervising, and speeding up the implementation
of this resolution by other sectors. The Vietnam
Fatherland Front and other mass organizations within
the Front are requested to collaborate …
In the resolution, equity in, and access to,
health care is included. Also in the resolution,
injuries are recognized as a Public Health problem:
Efforts should be redoubled to early detect and reduce
the harmful effects of … injuries due to traffic
accidents, mental disorders and occupational diseases
etc., which are common to the morbidity pattern of
developed countries and are a growing problem in
Vietnam.
The local health network should be strengthened with
the local authority exercising management over health
activities in the community. … Health programmes in
the community shall be guided by various levels of
authority and implemented by the health authorities
and other sectors with the participation of all members
of the community.
It is also stated that:
Programmes for the protection and control of cancer,
cardio-vascular diseases and injuries due to traffic
accidents should be implemented.
In order to implement these action points, cooperation was established between Vietnam and
Sweden from 1994 to 1999 in the health policy
area.
The third annual plan of operation
According to the Specific Agreement of Vietnam–
Sweden Health Co-operation 1994–1999, the
objective of support to the Health Policy Unit
(HPU) is to increase the capacity of the Ministry
A national injury prevention/safe community programme in Vietnam
of Health (MoH) to formulate effective and appropriate health policies in the context of market
economy.
The third annual plan of operation (Ministry of
Health, 1997a) is focusing on the following
objectives:
1. To promote and enhance the implementation
of the government resolution on long-term
health policy and strategy from 1996 to 2000
and in the run up to 2020.
2. To continue to strengthen the policy-making
capacity of the MoH and to consolidate the
HPU.
3. To implement appropriate policies to deal
with urgent health problems, most of which
are continuations of those initiated last year.
In all activities, the issue of gender will be
considered.
Under point 3 (above), it is stated:
Accidents and injuries in production and in daily life. In
1996, a two-community pilot study of safe community
and an intersectoral committee on injury prevention
were launched. However, this is only the first step of a
long process to solve an increasingly serious health
problem for all age groups, including both men and
women, which is now the fourth most-likely cause of
death and hospital admission.
Furthermore, the plan includes:
Indicators: (1) Effective expansion of the safe community model in three provinces based on pilot studies
in 1996. Introduction of integrated family health care
in two pilot communities. (2) A short term adviser for
evaluating whether a safe community is effective.
And finally:
4.3.0.1. Expand to three provinces the model of ‘safe
community/injury prevention’ based on pilot studies in
1996 and maintain two pilot communities in Hanoi.
‘Integrated family health care’ will be included, in collaboration with the Centre of Social Sciences in Health
and three provincial health bureaus. Gender issues will
also be taken into consideration. Regular meetings of
the National Committee on Injury Prevention to be
continued and the pilot project will be assessed before
expanding to other areas.
The IP/SC plan was introduced after a
delegation of Vietnamese representatives from
the health policy area to Sweden in September
1995 and the subsequent participation of Dr Cu
in the Third International Conference on Injury
Control in Melbourne and the Fifth International
49
Conference on Safe Communities in the City of
Hume and Latrobe Valley Municipality. Dr Cu
also participated in one of the SC. Travelling
seminars, in February 1996, were organized by
the WHO Collaborating Centre on Community
Safety (Karolinska Institutet, Department of
Public Health Sciences) in collaboration with
Australian SCs. The plan was to set up
programmes in two communities in 1996, and in
three provinces and a secondary school in 1997.
Outlines of the report of the study on
‘prevention of accidents and injuries, and
building the model for a safe community’
The Head of the IP/SC project is Professor
Nguyen Van Thuong, the Vietnamese ViceMinister of Health, and the Vice-Head is Mr Luu
Hoai Chuan.
In the resolution, injuries are recognized as a
public health problem (Ministry of Health,
1997b):
Efforts should be redoubled to detect and reduce the
harmful effects of … injuries due to traffic accidents,
mental disorders and occupational diseases etc., which
are common to the morbidity pattern of developed
countries and are a growing problem in Vietnam.
The local health network should be strengthened with
the local authority exercising management over health
activities in the community. … Health programmes
in the community shall be guided by various levels
of authority and implemented by the health sector
and other sectors with the participation of all of the
community. … Programmes for the protection and
control of cancer, cardio-vascular diseases and injuries
due to traffic accidents should be implemented.
The authorities face a large number of difficulties in obtaining a comprehensive picture of
the injury pattern from official statistics such as
those reported above. As yet, no comprehensive
studies have been made of the injury problem
either at the national or local level. In conjunction with the work initiated by the Ministry
of Health under the name of IP/SC, a number of
local reporting systems have been developed.
The aim of this paper is to describe some of the
results from such community studies and to discuss the quality of the data represented (Ministry
of Health, 1999a).
Recently, a new planning document for 1999–
2001 has been developed with respect to health
policy (Ministry of Health, 1999b).
50
L. H. Chuan et al.
The Ministry of Health requests SIDA [Swedish
International Development Cooperation Agency] to
be the main donor with respect to strategic policy
development within the health sector. The aim of the
support is to strengthen the capacity of the Ministry of
Health to lead the health sector reform process—
including foreign aid resources—towards the overall
objectives for the health sector as stated by the
Vietnamese Government.
Policy development for health services and
national health policy and programmes is the key
component for future development. The four
areas suggested in the field of public health are
IP/SC, tobacco control, adolescent health and
reduction of perinatal mortality.
The aim of the IP/SC is that ‘all inhabitants,
both male and female in the community would
live and work more safely’. Eleven activities
are suggested to strengthen the intersectoral
IP work at the national level and to implement
the community-oriented SP/IP programme on all
other levels. Factors to ensure sustainability for
the programme are suggested: policy supports,
appropriate technology, environment protection,
economic analysis and financial sustainability.
A budget for the period July 1999 to December
2001 is suggested.
The programme components
1. Local safe community demonstration
programmes
In the first year’s implementation (1996), the
programme was piloted in the two communities
of Thinh Liet (Thanh Tri District) and Co Nhue
(Tu Liem District) in the suburb of Hanoi. After
1 year, preliminary positive results and experiences
were summarized and the organizational structure for the sake of supervision as well as
improving the awareness of the community about
injury prevention was formulated. Results were
also positive with respect to the possibility of
changing the behaviour of individuals to
encourage self-prevention of possible injuries in
order to create a safe community and a safe
society in every aspect (Ministry of Health,
1999c).
Based on the experiences drawn from the two
pilot studies, the programme was expanded in
1997 to all communities of the Thanh Tri and
Tu Liem districts. There was also expansion of
the programme to other districts such as Chau
Giang (Hung Yen province), Cam Pha town
(Quang Ninh province) and Le Quy Don
secondary school (Ha Dong town, Ha Tay
province). During 1998 and for the first 6 months
of 1999, the programme was continued in the
above localities and expanded to the whole
province of Long An and Hung Yen.
It is now expected that the SC model will be
introduced into many other provinces/cities
nationwide and become a national programme
on injury prevention and safe community, based
on the experiences gained after 3 years’ implementation.
2. The central level
A support organization is needed to strengthen
and improve the organizational structure of
SC. This must act on the central level between
sectors, but also give support from the central to
local level.
The central SC programme has been
strengthened and its operation has been widened
in co-operation with a number of central sectors
(Chuan, 1999). These are: the National Committee
on Traffic Safety, Traffic Warden Department,
Security Ministry; the Flood Prevention and
Diving Management Department, Ministry of
Agriculture and Rural Development; the Social
Evil Control Department, Ministry of Social, War
Invalid and Labour Affairs; the Universal Education Department, Ministry of Education and
Training; the Labour Protection Institute, Vietnam
General Labour Confederation; and the Vietnam
Women’s Union.
The SCs established as pilot projects (five
communities of the Thanh Tri district, five of the
Tu Liem district, six of the Chau Giang district,
four pilot wards of Cam Pha town and the
Le Quy Don Secondary School, Ha Tay, where
the IP/SC programme has been in operation
since 1997) have been strengthened. SCs in the
remaining communities of these districts/towns
have also been established, including 19 communities of the Thanh Tri district, 11 of the
Tu Liem district, 33 of the Chau Giang district,
and 12 communities and areas of Cam Pha town.
SCs in all districts and communities of two
provinces of Long An and Hung Yen have also
been formed (one provincial, six district/town
and 122 community SCs in Hung Yen province;
one provincial, 14 district/town and 182 community/ward SCs in Long An).
Members of SCs, from the provincial to
community level, are representative of different
authorities, inter-sectors and social organizations:
Health, Education, Security Social, Labour, War
A national injury prevention/safe community programme in Vietnam
51
The future IP/SC training plan
1.1 Overall objective
To improve the IP/SC knowledge of all members
of society in order to change their behaviour, as
well as environment and social structure.
1.2 Specific objectives
• To improve knowledge of IP/SC promotion
(focusing on the objectives, significance, content and requirement of IP/SC) for all members of the programme at all levels (central/
provincial/district/community).
• To master task, role and organizational model
as well as the operation mechanism of the
management system (steering committees).
• To provide key members of district and
community SCs with skills associated with information and data collection and processing,
accident/injury identification, report writing,
management and communication.
• To learn from IP/SC experiences in other
countries.
Fig. 1: The organizational structure of an IP/SC
steering committee from central to provincial
district/town–community levels in Vietnam.
Invalid and Social Affairs, Women, Information
and Culture, Fatherland Front, War Veterans,
Farmers, Youth, the Red Cross and the Elderly.
All SCs are headed by a Vice-Chairman in
charge of cultural and social affairs of the People’s
Committee at equivalent levels. Permanent Vice
Directors of SCs are Directors of Provincial
Health Bureaus and District Health Centers or
Commune Health Stations.
3. Organizational structure
The overall organizational structure of the
programme on all its levels is clarified in Figure 1.
Throughout the analysis, both internally and
through expert external judgements, the Ministry
of Health has indicated that it is very satisfied
with the organizational aspects of the programme
but has identified an urgent need for training of
personnel at all levels of the system.
2 Content
2.1 Definitions, concepts and terms in the field
of accident/injury prevention and safety
promotion.
2.2 Objective, significance, content and requirement of IP/SC programme.
2.3 Organization model and operation mechanisms of SCs at all levels.
2.4 Accident/injury situation in Vietnam and the
world causes and influences on the stable
development of countries.
2.5 To uncover accident/injury problems in
Vietnam in order to prioritize intervention in
fields such as:
• traffic (including road, airline, water);
• work places with cases of occupational or
other such injury (falls, electrocutions, explosions, fire/burns, and drowning, poisoning, violence etc.);
• public places (communities, schools etc.);
• homicide: falls, burns/fires, electrocutions,
poison, violence, suicide; and
• social evils: prostitution, gambling, drug
using, drinking.
2.6 Skills with respect to international systems
for collection, synthesis and classification of
injuries.
2.7 Skills with respect to information, education
and communication for different target
groups of the community.
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L. H. Chuan et al.
2.8 Skills with respect to monitoring and supervising the progress of implementation.
2.9 Skills with respect to periodical report writing at central/provincial/district/community
level (monthly, quarterly, annually).
2.10 Methods of making rapid assessment,
periodical assessment (quarterly and yearly).
The 12 WHO SC criteria have been developed in
line with the current Vietnamese situation.
The target groups for the planned training
courses are: (i) Central Steering Committee
leaders and all staff; (ii) Provincial Steering Committee leaders and all staff; (iii) District Steering
Committee leaders and all staff; and (iv) Commune Steering Committee leaders and all staff. It
is also possible to invite other key persons from
equivalent bodies to attend these courses.
Teachers for the different levels are recruited
as follows:
• for central and provincial levels, national and
international experts;
• for district level, experts from the MoH,
Health Policy Unit, Health Strategy and Policy
Institute, School of Public Health, Hanoi
Medical University; and
• for community level, experts from central
level, but mainly people who have been
trained in district training courses.
DISCUSSION
Evaluation is based on the 12 WHO IP/SC criteria
and the characteristics of the localities.
1. After 3 years of implementation, the programme has yielded some preliminary achievements contributing to the formulation of useful
activities aimed at making changes towards a
better social environment. It is possible to affirm
that the IP/SC programme has changed the way
in which organizations and authorities at different levels view the importance and significance
of developing the IP/SCs in their areas. IP/SC
implementation is considered the duty of the
People’s Committee at all levels and the whole
community—not of any individual or organization. Therefore, SCs at all levels have involved
the participation of other sectors and mass
organizations.
2. Information, education and communication
(IEC) activities play an important role in changing attitudes and behaviour of people in the
community towards IP/SCs. It is now believed
that ‘injury is preventable and avoidable’.
3. A network of collaborators has been set up to
conduct surveys and collect data analysing the
injury situation and submit timely and suitable
intervention methods to the SC at higher levels.
High-risk groups in the communities have been
paid attention to (e.g. those at risk of traffic
injury).
4. The programme has attracted the involvement
of other sectors, and mass organizations and the
health sector play the key role. This sector is in
charge of data monitoring and data analysis as
well as preparing tools for first aid and treatment
at health and local facilities. Commune health
workers at all facilities are also excellent propagators for the programme.
5. Some interventions have been made such as
IEC, training, competence and IP/SC professional
skill development for the programme’s officers
(Svanström, 2000). The programme is considered
a community-based direct intervention programme (together with other initiatives) to
reduce the rate of injuries. The community’s
intervention is very important because it can
change the struggle against the increasing
mortality rate caused by injuries in developed as
well as developing countries.
These interventions cannot replace the existing activities of the programme with the same
purpose, but are considered complementary as a
new way of solving problems that are not solved
by traditional methods (from the top level
down). The new method is mobilizing the power
of the whole community to make changes in the
attitude and behaviour of society.
6. Experiences have been drawn on to serve as
the basis for improving the effectiveness of the
programme in pilot-study localities and in expanding the programme nationwide in the future.
It is necessary to develop the programme on the
larger scale.
7. A ‘Guideline on IP/SC’ has been compiled
(first draft), focusing on the areas of: traffic,
work, and public and daily life. Publication is
planned for 2000.
One of the constraints of the programme so far
has been lack of experience, especially with SCs
in localities where the programme has only
recently been developed. Members of SCs are
leaders of party organizations or representatives
of other professional sectors, therefore they
cannot spend all their time on the programme.
A national injury prevention/safe community programme in Vietnam
This partly affects the quality and effectiveness of
the programme.
In some SCs at local level, the work of
supervising and monitoring is still not up to the
required standard, leading to missing information, especially with respect to data processing
and analysis. Furthermore, the programme’s
activities have not yet been integrated effectively
into other local activities, for example primary
health care programmes. Financial resources
from local organizations have not been mobilized
to support timely intervention measures.
CONCLUSIONS
Remarkable results have been achieved within
this project in a very short period of time. There
is 20 years of experience of IP/SC programmes in
other countries (Ekman and Svanström, 1999) to
base this judgement on. Achievements have been
made in a very short time, from the first visit of
the MoH to Sweden and the Karolinska Institute,
Department of International Health and Social
Medicine (now Department of Public Health
Sciences, also appointed The World Health
Organization’s Collaborating Centre on Community Safety Promotion) in September 1995
and participation in the Seventh Travelling
Seminar on Safe Communities in February 1996.
By September 1996, the programme had started
by establishing a national Steering Committee
and during the rest of 1996 three districts and one
school were involved.
From a pilot project in 1996–1997, IP/SC has
now (at the end of 1999) been developed as a
programme in the whole of two provinces with
24 districts, 400 communities and 2 981 669
inhabitants. An organizational construction
system has been built from provincial level down
to community areas. Management is based on
administrative and legislative documents. IP/SC
implementation is considered the duty of the
whole community, of local authorities and of
People Committees, and should be included
in the action plans of localities. The programme
is a significant contribution towards creating a
safe environment in which everybody may live
and work, allowing the stability for society to
develop.
Implementation of the programme in school
(under the leadership of the Education and
Training Department or Chamber) is a special
characteristic. The programme will be developed
53
in 800 schools with a large number of pupils
(25% of the population). This model for safer
schools is considerably concerned and is a good
experience to disseminate.
Intersectoral work is the key factor of success.
The programme has involved the participation of
the whole community and its sectors. Each sector
or organization is in charge of a different task
consistent with their main professional function.
The health sector plays the key role.
IEC is one of the successful factors of the
programme, which has helped to elevate its
popularity with the close co-operation of mass
organizations and sectors. It has created a large
change, first in attitude and then in behaviour
with the slogan ‘each individual must protect
himself and his family, then their community’. As
a result of these efforts, a reduction in injury rate
has been reported. The programme therefore is
much appreciated due both to its humanitarian
and economic elements.
These achievements are only the first to
emerge. In order to improve the programme’s
scientific effectiveness, SCs at all levels should
focus further on working out concrete, useful and
feasible activities, action plans and purposes
parallel to strengthening management. It is very
important to develop feasible activities to develop a national IP/SC programme in the future.
We recommend that more pilot studies should
be conducted in other localities and the programme should be extrapolated to the national
scale. Furthermore, the co-operation between
sectors and mass organizations should be encouraged and the professional skills of key
members of SCs at all levels should be improved.
Based on administrative mechanisms, the
programme should be strengthened further and
organization structures and management must
be improved. Responsibility of different sectors
at different levels should be clearly identified and
put into resolution by equivalent bodies. The
IP/SC programme should further mobilize the
contribution (financial, human and technological) of individuals and organizations, both
within the programme and outside it.
There are some specific areas in need of
improvement. First, quality control should be
established on ‘missing cases’. Over time a
decrease could reflect on more unreported cases
instead of a real decrease in numbers and success
of the programme. The establishment of a kind of
‘quasi-experimental’ evaluation design would
then be possible. Intervention areas could be
54
L. H. Chuan et al.
compared with control areas where injuries are
recorded but as yet there is no programme. In
that case a historical or secular trend on injuries
could be estimated and any change could be
attributed to the programme components.
In these matters, the value of involving universities more in both qualitative studies on the
processes of intervention as well as development
of measure must be emphasized. In general it
must be stated that from a scientific point of view
it is impossible to establish programme effects so
short a time after the programmes started. That
does not exclude the possibility of the local as
well as the national Steering Committee talking
about successes already based on their own
experiences—short-term safety policy making.
Long-term safety policy making needs a scientifically sound basis—therefore, evidence-based
safety promotion is most valuable.
With respect to the role of the health sector,
the development of injury surveillance systems is
crucial. There are reasons to introduce (as pilot
studies) a trial version of the global WHO classification of the International Classification for
External Causes of Injuries (ICECE). Quality
control is crucial. Today most injuries reported in
the pilot studies are from in-patients and a few
out-patients. For this reason there might be
reasons to consider concentration on in-patient
reports alone in order to obtain similar
definitions of what kind of cases we are talking
about.
A final objective to add would be to focus
particularly on equity for vulnerable groups in
future programmes and especially to plan taking
gender issues into consideration.
Address for correspondence:
Professor Leif Svanström
Karolinska Institutet
Department of Public Health Sciences
Division of Social Medicine
Norrbacka
SE 171 76 Stockholm
Sweden
E-mail: [email protected]
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