SUMMARY
This randomized controlled study was performed to evaluate the effectiveness of an educational program entitled ‘Capacity building for community leaders in a healthy living environment,’ and to assess the usefulness of a participatory style of education and the applicability of an intersectoral approach in the educational process. An intervention group and a control group (consisting of 150 and 154 community leaders, respectively) were both evaluated, after the intervention group took part in a 5-day participatory-style educational program. Healthy living environment promotion competency (HPC) was evaluated by an instrument consisted of four competency areas: identifying the steps required for a healthy living environment; understanding the principles to reduce potential health risks; providing public health management to improve the living environment; and applying the principles of health communication skills. Scores between the intervention and control groups were examined to identify changes between the baseline and post-intervention periods. A qualitative evaluation of the educational program by participants and facilitators was conducted to assess the appropriateness of the intervention. The results indicated significant increases in the total HPC score and scores of individual HPC competency areas in the intervention group. Thus, the effectiveness of a capacity building program for community leaders in a healthy living environment was demonstrated. Qualitative evaluation revealed that the participatory-style and intersectoral collaboration approach facilitated the educational process. Community leaders, who are representatives of various sectors and mass organizations within the community, can be important implementers in the promotion of a healthy living environment.
INTRODUCTION
Health education is an essential component of efforts aimed at health promotion (Nutbeam, 2000). There are a number of studies on the effectiveness of community-based health educational programs on health outcomes focusing on specific health issues, including HIV/AIDS prevention (Poudel et al., 2005), antenatal care (Ohnishi et al., 2007), water and sanitation (Khandekar et al., 2006; Metwally et al., 2006), malaria control (Nonaka et al., 2008) and healthy lifestyles (Yajima et al., 2001). Also, it has been reported that community-based health educational programs are effective for specific target groups, including health professionals such as physicians (Clark et al., 1998; Maclure et al., 1998; Woodcock et al., 1999) and nurses (Brooker et al., 1994; Dalton et al., 1996; Ohnishi et al., 2007), patients (Chapman-Novakofski and Karduck, 2005; Baradaran et al., 2006; Tullmann et al., 2007), school children (Onyango-Ouma et al, 2005) and women (Metwally et al., 2006).
In the concept of Healthy Settings, the World Health Organization (World Health Organization, 2006) reported on the importance of the community-based intersectoral collaboration approach when responding to health needs and human resource development within the community. To develop strategies such as Healthy Village projects, there is a need to reveal the effectiveness of comprehensive health-education programs targeting community health and involving representatives from a wide range of groups within the community.
One of the model projects guided by the Western Pacific Regional Office (WPRO) of WHO has been implemented in Vietnam and involves sharing experiences in developing countries. In collaboration with the WPRO, the Vietnamese government has sponsored efforts to improve this situation and has initiated a Healthy Village project in 12 provinces throughout the country with the objectives of raising the awareness of people within the community regarding health issues, improving hygiene and sanitation conditions, and aiding in the prevention and control of communicable diseases (Prime Minister Decision, 2000; Ministry of Health of Vietnam, 2005). Increasing awareness within the general population is also a fundamental goal of this project, in recognition of the importance of health education. In the 2 years since its launch, the project has made significant achievements, including increased coverage of sanitation facilities (increases of 19.5% for hygienic toilets and 10.1% for clean water), reduced morbidity of common infectious diseases (e.g. reductions of 10.6, 35 and 43% in the prevalence of typhoid, dengue fever and meningitis, respectively), and strengthened commitment by local authorities to solve health-related problems (Ministry of Health of Vietnam, 2005).
However, there are a number of constraints curtailing the effective transmission of health messages to people in the general community, and in our study we focused on two major points as keys to improving the situation. First, health education and communication are managed in a top-down non-participatory style and that approach has been shown to be ineffective (Laverack and Tuan, 2001). Second, there is a lack of health communicators at the community level. Village health workers are considered the key conveyers of health messages in the community, yet they have had not sufficient opportunity to build capacity regarding health communication. To implement a Healthy Villages project effectively, efforts are necessary to transform a vertical style of information transmission to an interactive and participatory style of information sharing and to provide greater opportunities not only for health professionals but also for community leaders to share information as well as raise awareness.
‘Intersectoral collaboration’ is defined as a long-term partnership involving two or more organizations formed to benefit from the synergy of working together in an environment of trust and sharing information and resources in order to achieve a common objective (Sindall, 1997). Collaborative partnership has been increasingly recognized as an essential strategy in health promotion and public health (World Health Organization, 1997; Armstrong et al., 2006). Multi-disciplinary interprofessional training has been suggested as an effective and efficient way to build capacity in human resources able to solve complex health needs in a variety of community settings (Evans and Dowling, 2002; Andrus and Bennett, 2006; Perez et al., 2006).
In general, competencies can be defined as the knowledge, skills, abilities to deal with public health issues (Canadian Institute of Public Health Inspector) and to resolve problems in community, and communicate effectively with the people of the community (Centers for Disease Control and Prevention, 2001). At the community level, leaders are usually respected and give advice and encouragement to local residents (Flowers and Waddell, 2004). In any effective Healthy Village project, raising the skills and abilities of community leaders in identifying the concepts of a healthy living environment, controlling potential environmental health risks, managing environmental health issues and communicating effectively with people within the community is the key.
Thus, we introduced a new educational program called ‘Capacity building for community leaders in a healthy living environment’ (CCH) which applied the participatory approach. Its aim is to promote the healthy living environment and to mobilize human resources in rural communities. The Kim Son district of Ninh Binh province was defined as a model setting for the CCH program. We assessed an educational program designed to implement health and environmental education, increase information sharing and raise awareness on the part of intersectoral actors in the community. The target participants of this educational program were community leaders who strive to help the community gain a better understanding of issues related to health and illness and who work to maintain a level of cohesion and connectedness designed to improve health within the population. The participants were political leaders (village leaders), village health workers, teachers and representatives of various organizations within the community (Women's Union, Youth Union, Farmers’ Union and the Red Cross Association). The effectiveness of the educational program was evaluated by measuring the level of improvement in the competencies of the participants.
METHODS
Study area, subjects and design
The randomized community-based intervention study was conducted in the Kim Son district of Ninh Binh province, a rural area in the Red River Delta region of Northern Vietnam, in which the livelihood of 90% of the population is based on agriculture. This district has a lack of clean water and hygienic latrines, problems with garbage around houses and on roads and unhygienic habits that include drinking water that has not been boiled and eating raw river fish (Kim Son District Health Center, 2005). In addition, the community has no participatory-style educational programs. The commune is the lowest administrative unit in Vietnam. Fourteen such units satisfying all of the following criteria were selected for the present study: a population between 4000 and 10 000 inhabitants; established before 2004; and not equipped with a water station providing a clean, piped water supply to individual households. Eight of the eligible communes were selected at random, and four were assigned randomly into each of the intervention and control groups. A total of 160 community leaders were selected at random for each group based on organization memberships, including village leaders, village health workers, Women's Union members, Youth Union members, primary school teachers, Red Cross Association members and Farmers’ Union members. The sample size of the study was calculated to detect expected differences of 30% between the intervention and control groups using the t-test with a significance level of 5%, power of 90% and a 20% possibility of loss of follow-up estimated based on the observations of previous educational programs conducted in rural communities of Vietnam. Finally, 150 community leaders in the intervention group (94%) and 154 in the control group (96%) participated fully in the study and were included in the analysis (Figure 1). Sixteen cases dropped out of the study because they were sick or had to attend a community event, e.g. a funeral or wedding ceremony, at the time of the assessment tests.
Flowchart of subjects included in the study.
Flowchart of subjects included in the study.
Intervention
In August 2006, each intervention commune hosted a 5-day CCH educational program to enable community leaders to improve their knowledge and skills regarding a healthy living environment, to understand potential health risks of unsanitary conditions, to provide counseling and promote a healthy living environment and to apply effective health communication skills. The control group received no such intervention.
Standardized educational materials
The written training materials were developed based on the guidelines of the World Health Organization (World Health Organization, 1998; World Health Organization, 2002), UNICEF Vietnam (United Nations Children's Fund, 2004) and the Ministry of Health of the Government of Vietnam (Ministry of Health of Vietnam, 2004). The materials were designed to provide simple but useful messages for the community leaders. The topics covered by the educational program were as follows: house and village sanitation; use and maintenance of clean water and hygienic toilets; garbage treatment and disposal; personal hygiene; prevention of diseases related to water and sanitation; and basic health communication concepts and skills applied in the context of a healthy living environment.
Participatory educational style
A participatory style was employed in the educational program with a participant-centered solution-based approach with activities such as small group discussions, brainstorming, role-playing, demonstrations, games, case studies and field visits. In addition, other audiovisual materials, including blackboards, flip charts, photographs and overhead projectors, were used as supporting facilities in the educational program.
Application of intersectoral collaboration approach
The participants in the educational program were community leaders who were representatives of various sectors and mass organizations in the village. During the 5-day educational program, participants worked not only as part of the whole group but also in smaller groups of seven to eight people representing all organizational memberships. They learned and practiced together and had many opportunities to share their experiences and to practice the knowledge and skills they had gained.
Procedures
Assessment of community leaders’ competencies
A structured pre-assessment questionnaire was used to assess the baseline knowledge of community leaders in both the intervention and control groups prior to the beginning of the educational program. The questionnaire consisted of 25 questions originally developed to assess four required competency areas for community leaders, called healthy living environment promotion competencies (HPCs): (i) identifying the steps required for a healthy living environment, (ii) understanding the principles to reduce potential health risks, (iii) providing public health management to improve a healthy living environment and (iv) application of the principles of health communication skills. The questionnaire consisted of three types of questions: multiple choice, open-ended and true-or-false. The answers were categorized as correct or incorrect and given a score. The theoretical total score of each test ranged from 0 (lowest) to 100 (highest). The pre-assessment questionnaire was tested (n = 25) prior to the actual test to ensure that participants could correctly understand all questions and have sufficient time to answer. A post-assessment questionnaire, developed in the same way as the pre-assessment test, was also used to determine the knowledge of the two groups after the intervention. The scores of all participants in both the intervention and control groups were double-marked using the developed answer sheet and checked by both a researcher and an independent expert from the Ministry of Health of Vietnam.
The total and HPC scores in the pre- and post-assessment tests were used to assess the community leaders’ improvement in knowledge regarding a healthy living environment. We calculated the scores of each HPC area and then converted them to relative scores, on a scale of 0 to 100, for correlative comparison of the changes between the four areas.
Assessment of the educational program
The educational program was assessed by an evaluation questionnaire just after completion of the intervention. Questions with five different rating scales, ranging from ‘strongly agree’ to ‘strongly disagree,’ were applied for quantitative evaluation of program content, teaching methodology, materials, facilitator's competence and time management; ‘strongly agree’ was given the highest score of 5, and the score was reduced by 1 for each descending level of agreement. In addition, open-ended questions were used for qualitative evaluation of the importance of the educational program to the participants’ work and to examine the features of the educational program that participants liked the most and those that required improvement. All of the community leaders in the intervention group were asked to complete the questionnaire. The facilitators of the educational program and research team members recorded their observations about each participant's motivation, participation and educational progress.
Informed consent
The Ministry of Health of Vietnam and Ninh Binh province health authorities gave their consent to the study after being informed regarding the research activities and procedures planned. All participants in both study groups participated voluntarily in the study with informed consent.
Analysis
The pre- and post-test totals and HPC scores in the intervention and control groups were compared by the paired t-test. The differences between the total scores and between the HPC scores of the intervention and control groups were examined using the independent-samples t-test. Moreover, analysis of variance (ANOVA) was performed to compare score means between different categories of demographic factors in each group. In addition, the χ2-test was applied to examine the differences between demographic factors of the two groups and the one-sample t-test was used to evaluate the educational program. Finally, linear regression analysis was used to obtain the regression coefficients and to determine the strengths of associations between the effects of demographic factors and study outcomes. The distribution of the total pre- and post-test scores was checked for their normal distribution before linear regression analysis. All analyses took into account the clustering of subjects in the study design. Significance was accepted at P < 0.05. All data were analyzed using the Statistical Package for Social Science (SPSS for Windows, version 14; SPSS Inc., Chicago, IL, USA).
RESULTS
Baseline characteristics of the study population
Table 1 shows the baseline characteristics of the study population. There were no significant differences with respect to any of the variables compared regarding gender, age, educational background or organizational membership between the intervention and control groups. The mean age and standard deviation of the intervention and control groups were 43.9 ± 9.0 and 42.2 ± 9.7, respectively.
Baseline characteristics of the subjects
| Characteristics | Intervention group (n = 150), n (%) | Control group (n = 154), n (%) |
|---|---|---|
| Sex | ||
| Male | 76 (50.7) | 75 (48.7) |
| Female | 74 (49.3) | 79 (51.3) |
| Age | ||
| 20–29 | 14 (9.3) | 22 (14.3) |
| 30–39 | 28 (18.7) | 31 (20.1) |
| 40–49 | 59 (39.3) | 61 (39.6) |
| 50–59 | 49 (32.7) | 40 (26.0) |
| Education | ||
| Secondary school | 58 (38.7) | 66 (42.9) |
| High school | 64 (42.7) | 60 (39.0) |
| Higher education | 28 (18.7) | 28 (18.2) |
| Organizational membership | ||
| Village health worker | 38 (25.3) | 40 (26.0) |
| Village leader | 31 (20.7) | 32 (20.8) |
| Women's union member | 20 (13.3) | 19 (12.3) |
| Youth union member | 16 (10.7) | 18 (11.7) |
| Primary school teacher | 19 (12.7) | 19 (12.3) |
| Red Cross member | 11 (7.3) | 12 (7.8) |
| Farmers’ union member | 15 (10.0) | 14 (9.1) |
| Characteristics | Intervention group (n = 150), n (%) | Control group (n = 154), n (%) |
|---|---|---|
| Sex | ||
| Male | 76 (50.7) | 75 (48.7) |
| Female | 74 (49.3) | 79 (51.3) |
| Age | ||
| 20–29 | 14 (9.3) | 22 (14.3) |
| 30–39 | 28 (18.7) | 31 (20.1) |
| 40–49 | 59 (39.3) | 61 (39.6) |
| 50–59 | 49 (32.7) | 40 (26.0) |
| Education | ||
| Secondary school | 58 (38.7) | 66 (42.9) |
| High school | 64 (42.7) | 60 (39.0) |
| Higher education | 28 (18.7) | 28 (18.2) |
| Organizational membership | ||
| Village health worker | 38 (25.3) | 40 (26.0) |
| Village leader | 31 (20.7) | 32 (20.8) |
| Women's union member | 20 (13.3) | 19 (12.3) |
| Youth union member | 16 (10.7) | 18 (11.7) |
| Primary school teacher | 19 (12.7) | 19 (12.3) |
| Red Cross member | 11 (7.3) | 12 (7.8) |
| Farmers’ union member | 15 (10.0) | 14 (9.1) |
Competency development of community leaders
As shown in Table 2, the intervention group showed a significant improvement from the pre-test score of 32.0 ± 11.9 to the post-test score of 75.8 ± 14.4 (P < 0.001), whereas no statistical change was observed in the control group.
Pre- to post-test changes in total score according to demographic factors
| Variables | Intervention group (n = 150) | Control group (n = 154) | P-value | ||||
|---|---|---|---|---|---|---|---|
| Pre-test (mean ± SD) | Post-test (mean ± SD) | Changes† | Pre-test (mean ± SD) | Post-test (mean ± SD) | Changes† | ||
| Mean score | 32.0 ± 11.9 | 75.8 ± 14.4 | 43.7** | 36.3 ± 10.5 | 37.8 ± 9.1 | 1.5 | <0.001 |
| Sex | |||||||
| Male | 30.2 ± 9.8 | 71.6 ± 14.5 | 41.4** | 35.7 ± 9.7 | 35.5 ± 9.2 | −0.2 | <0.01 |
| Female | 33.9 ± 13.5 | 80.1 ± 1.9 | 46.2** | 36.8 ± 11.3 | 40.0 ± 8.6 | 3.2 | <0.01 |
| Age | |||||||
| 20–29 | 30.2 ± 9.0 | 77.2 ± 12.5 | 46.9** | 33.5 ± 11.8 | 39.7 ± 8.9 | 6.3 | <0.05 |
| 30–39 | 38.3 ± 11.9 | 82.8 ± 11.0 | 44.4** | 42.1 ± 9.9 | 42.6 ± 6.9 | 0.5 | <0.01 |
| 40–49 | 31.8 ± 12.6 | 75.2 ± 16.1 | 43.4** | 35.7 ± 10.7 | 37.3 ± 8.8 | 1.6 | <0.01 |
| 50–59 | 29.2 ± 10.5 | 72.0 ± 14.5 | 42.6** | 34.2 ± 8.5 | 33.8 ± 9.5 | −0.4 | <0.01 |
| Education | |||||||
| Secondary school | 24.6 ± 10.3 | 67.6 ± 14.3 | 43.0** | 32.5 ± 8.5 | 34.9 ± 8.5 | 2.4 | <0.01 |
| High school | 34.5 ± 9.7 | 78.2 ± 11.5 | 43.7** | 35.7 ± 9.6 | 37.6 ± 7.7 | 1.9 | <0.01 |
| Higher education | 41.8 ± 9.9 | 87.2 ± 10.1 | 45.4** | 46.5 ± 10.3 | 45.0 ± 7.0 | −1.4 | <0.01 |
| Organizational membership | |||||||
| Village health worker | 30.9 ± 11.6 | 75.0 ± 11.4 | 44.0** | 33.4 ± 10.1 | 38.6 ± 8.6 | 5.2 | <0.01 |
| Village leader | 28.3 ± 10.0 | 70.1 ± 13.9 | 41.8** | 34.9 ± 8.4 | 32.9 ± 8.8 | −2.0 | <0.01 |
| Women's union | 27.8 ± 13.4 | 75.8 ± 15.3 | 48.0** | 33.8 ± 11.5 | 37.3 ± 9.5 | 3.6 | <0.05 |
| Youth union | 31.3 ± 9.6 | 76.1 ± 9.7 | 44.9** | 35.3 ± 11.5 | 38.3 ± 7.4 | 3.0 | <0.05 |
| Teacher | 46.4 ± 7.0 | 90.9 ± 4.3 | 44.5** | 45.9 ± 7.2 | 44.8 ± 6.0 | −1.1 | <0.01 |
| Red Cross | 34.5 ± 10.5 | 79.3 ± 18.6 | 44.9* | 41.2 ± 12.2 | 43.7 ± 8.1 | 2.4 | <0.05 |
| Farmers’ union | 28.9 ± 9.2 | 67.4 ± 16.6 | 38.4* | 35.0 ± 9.0 | 32.2 ± 8.2 | −2.8 | <0.05 |
| Variables | Intervention group (n = 150) | Control group (n = 154) | P-value | ||||
|---|---|---|---|---|---|---|---|
| Pre-test (mean ± SD) | Post-test (mean ± SD) | Changes† | Pre-test (mean ± SD) | Post-test (mean ± SD) | Changes† | ||
| Mean score | 32.0 ± 11.9 | 75.8 ± 14.4 | 43.7** | 36.3 ± 10.5 | 37.8 ± 9.1 | 1.5 | <0.001 |
| Sex | |||||||
| Male | 30.2 ± 9.8 | 71.6 ± 14.5 | 41.4** | 35.7 ± 9.7 | 35.5 ± 9.2 | −0.2 | <0.01 |
| Female | 33.9 ± 13.5 | 80.1 ± 1.9 | 46.2** | 36.8 ± 11.3 | 40.0 ± 8.6 | 3.2 | <0.01 |
| Age | |||||||
| 20–29 | 30.2 ± 9.0 | 77.2 ± 12.5 | 46.9** | 33.5 ± 11.8 | 39.7 ± 8.9 | 6.3 | <0.05 |
| 30–39 | 38.3 ± 11.9 | 82.8 ± 11.0 | 44.4** | 42.1 ± 9.9 | 42.6 ± 6.9 | 0.5 | <0.01 |
| 40–49 | 31.8 ± 12.6 | 75.2 ± 16.1 | 43.4** | 35.7 ± 10.7 | 37.3 ± 8.8 | 1.6 | <0.01 |
| 50–59 | 29.2 ± 10.5 | 72.0 ± 14.5 | 42.6** | 34.2 ± 8.5 | 33.8 ± 9.5 | −0.4 | <0.01 |
| Education | |||||||
| Secondary school | 24.6 ± 10.3 | 67.6 ± 14.3 | 43.0** | 32.5 ± 8.5 | 34.9 ± 8.5 | 2.4 | <0.01 |
| High school | 34.5 ± 9.7 | 78.2 ± 11.5 | 43.7** | 35.7 ± 9.6 | 37.6 ± 7.7 | 1.9 | <0.01 |
| Higher education | 41.8 ± 9.9 | 87.2 ± 10.1 | 45.4** | 46.5 ± 10.3 | 45.0 ± 7.0 | −1.4 | <0.01 |
| Organizational membership | |||||||
| Village health worker | 30.9 ± 11.6 | 75.0 ± 11.4 | 44.0** | 33.4 ± 10.1 | 38.6 ± 8.6 | 5.2 | <0.01 |
| Village leader | 28.3 ± 10.0 | 70.1 ± 13.9 | 41.8** | 34.9 ± 8.4 | 32.9 ± 8.8 | −2.0 | <0.01 |
| Women's union | 27.8 ± 13.4 | 75.8 ± 15.3 | 48.0** | 33.8 ± 11.5 | 37.3 ± 9.5 | 3.6 | <0.05 |
| Youth union | 31.3 ± 9.6 | 76.1 ± 9.7 | 44.9** | 35.3 ± 11.5 | 38.3 ± 7.4 | 3.0 | <0.05 |
| Teacher | 46.4 ± 7.0 | 90.9 ± 4.3 | 44.5** | 45.9 ± 7.2 | 44.8 ± 6.0 | −1.1 | <0.01 |
| Red Cross | 34.5 ± 10.5 | 79.3 ± 18.6 | 44.9* | 41.2 ± 12.2 | 43.7 ± 8.1 | 2.4 | <0.05 |
| Farmers’ union | 28.9 ± 9.2 | 67.4 ± 16.6 | 38.4* | 35.0 ± 9.0 | 32.2 ± 8.2 | −2.8 | <0.05 |
*P-value of pair t-test of comparisons between pre- and post-test scores <0.01.
**P < 0.001.
†Score changes were compared using independent samples t-test.
‡P-value of the independent samples t-test.
In the intervention group, women showed higher post-test scores and gains than men (post-test score 80.1 ± 12.9 versus 71.6 ± 14.5, respectively, P < 0.01; score gain 46.2 ± 9.4 versus 41.4 ± 12.4, respectively, P < 0.01) (Table 2). Community leaders, who ranged in age from 30 to 39, had higher pre- and post-test scores than the other groups (pre- and post-test scores of 38.3 ± 11.9 and 82.8 ± 11.0, respectively, P < 0.05; ANOVA) (Table 2). A significant association was observed between a higher educational level and higher pre- and post-test scores; the group of community leaders with a higher education level had the highest post-test score of 87.2 ± 10.1, while the other groups, i.e. those with only a high school and secondary school levels, had post-test scores of 78.2 ± 11.5 and 67.6 ± 14.3, P < 0.01 (ANOVA), respectively (Table 2). Among the seven categories of organizational membership, primary school teachers had the highest pre- and post-test scores (46.4 ± 7.0 and 90.9 ± 4.3, respectively, P < 0.01; ANOVA) (Table 2).
After the adjustment for these demographic factors by linear regression analyses, only educational background in the intervention group retained its effect on the pre- and post-test score differences (correlation coefficients were 0.4 and 0.5, respectively, P < 0.001, data not shown). Women showed higher post-test scores and higher gains (correlation coefficients were 0.2 for both, P < 0.05, data not shown). Membership in various organizations within the community had no significant effect on score improvement. In the control group, only educational background affected the changes from pre- to post-test scores (data not shown).
Table 3 shows the changes in HPC scores in both the intervention and control groups. In the intervention group, the competency for identifying the steps required for a healthy environment showed the highest improvement (pre- and post-test scores were 27.0 ± 11.8 and 82.4 ± 17.3, respectively, P < 0.001). The pre- and post-test competencies in this group for understanding the principles to reduce potential health risks were relatively high (59 ± 24.4) and very high (93.7 ± 11.8), respectively, P < 0.001. The competencies on the provision of public health management to improve a healthy living environment and on health communication skills showed smaller improvements than those mentioned above, with pre- and post-test scores of 17.9 ± 20.4 versus 41.3 ± 24.1 and 35.6 ± 21.1 versus 64.0 ± 21.2, respectively. However, all of these improvements were statistically significant (P < 0.001).
HPC score changes from pre- to post-test by four competency areas (calculated by using the maximum scale of 100 score)
| Competency areas | Intervention group (n = 150) | Control group (n = 154) | P-value‡ | ||||
|---|---|---|---|---|---|---|---|
| Pre-test (mean ± SD) | Post-test (mean ± SD) | Changes† | Pre-test (mean ± SD) | Post-test (mean ± SD) | Changes† | ||
| Identify the steps required for a healthy living environment | 27.0 ± 11.8 | 82.4 ± 17.3 | 55.4** | 33.2 ± 11.0 | 33.7 ± 9.9 | 0.5 | <0.001 |
| Understand the principles to reduce potential health risks | 59.0 ± 24.4 | 93.7 ± 11.8 | 34.7** | 63.1 ± 19.0 | 69.7 ± 19.7 | 6.7 | <0.05 |
| Provide public health management to improve a healthy living environment | 17.9 ± 20.4 | 41.3 ± 24.1 | 23.3** | 19.6 ± 19.8 | 19.3 ± 19.0 | −0.3 | <0.05 |
| Apply the principles of health communication skills | 35.6 ± 21.1 | 64.0 ± 21.2 | 28.3** | 36.1 ± 18.7 | 38.2 ± 16.2 | 2.1 | <0.05 |
| Competency areas | Intervention group (n = 150) | Control group (n = 154) | P-value‡ | ||||
|---|---|---|---|---|---|---|---|
| Pre-test (mean ± SD) | Post-test (mean ± SD) | Changes† | Pre-test (mean ± SD) | Post-test (mean ± SD) | Changes† | ||
| Identify the steps required for a healthy living environment | 27.0 ± 11.8 | 82.4 ± 17.3 | 55.4** | 33.2 ± 11.0 | 33.7 ± 9.9 | 0.5 | <0.001 |
| Understand the principles to reduce potential health risks | 59.0 ± 24.4 | 93.7 ± 11.8 | 34.7** | 63.1 ± 19.0 | 69.7 ± 19.7 | 6.7 | <0.05 |
| Provide public health management to improve a healthy living environment | 17.9 ± 20.4 | 41.3 ± 24.1 | 23.3** | 19.6 ± 19.8 | 19.3 ± 19.0 | −0.3 | <0.05 |
| Apply the principles of health communication skills | 35.6 ± 21.1 | 64.0 ± 21.2 | 28.3** | 36.1 ± 18.7 | 38.2 ± 16.2 | 2.1 | <0.05 |
**P-value of paired t-test of comparisons between pre- and post-test scores <0.001.
†Score changes were compared using independent samples t-test.
‡P-value of the independent samples t-test.
The changes in total score and in HPC scores were statistically significant between the intervention group and the controlled group (Tables 2 and 3).
The participants rated the educational program highly with regard to educational objectives (4.8 ± 0.3, P < 0.001), methods (4.8 ± 0.3, P < 0.001), learning atmosphere (4.9 ± 0.2, P < 0.001), the facilitators (5.0 ± 0.2, P < 0.001), time management (4.7 ± 0.4, P < 0.001) and training materials (4.8 ± 0.3, P < 0.001).
The qualitative evaluation of the importance, strengths and weaknesses of the educational program is described in Table 4. Most of the community leaders stated that the educational program was important and provided useful knowledge on a healthy living environment and health communication skills, which proved helpful in their daily work. Participant-centered learning and the problem-solving approach were rated highly by the participants. The participatory methods applied in the program, including small group discussions, role-playing and games, were important in facilitating the learning process. The educational topics were useful and necessary. The participants suggested that the educational program could be improved in the future by the addition of a half-day for field visits, more references for self-study and clearer regulation for participants to encourage punctuality. Table 4 also shows the community leaders’ motivation, participation and educational progress from the viewpoint of the facilitators; most of the community leaders showed strong motivation, active participation and made good progress during the educational program.
Qualitative evaluation of the educational program
| Importance of the educational program to the work of community leaders (voice from participants) |
| The program provided useful knowledge on a healthy living environment and communication skills, and so I feel more confident in working with people in my community |
| I believe that with useful knowledge and skills learned in this program, I can be an active health communicator for water, sanitation and hygiene |
| The knowledge gained in the educational program is necessary not only for my work but also for myself and my family to protect and promote our health |
| The program helped me to find good partners. I will collaborate with them to develop and implement an action plan for the promotion of a healthy living environment |
| I think I have learned a lot from this program. I will use the information gained here to give advice and support community authorities to carry out regular activities to promote water, sanitation and hygiene in the community |
| The contents of the educational program and learning methodology were really helpful for me—a primary school teacher. I will apply what I have learned in my daily teaching work and guide my students to protect our environment |
| Features of the educational program that participants liked the most (voice from participants) |
| The educational method was very good, which allowed me to easily understand and receive new knowledge. This is the first time for us to experience the participatory method |
| The learning atmosphere was very friendly and active. The participants were very interested in the educational program's activities |
| Role playing and small group discussions were effective. We did not feel shy and could easily share our opinions and then summarized the best solution for each case study |
| The topics covered by this program are necessary for my village. I was very interested in finding appropriate solutions to solve existing problems to create a healthy living environment in my village |
| In this class, I worked with various community representatives. We already developed a good action plan for our own village with the participation of the group members |
| Games were great and made everybody feel happy in learning new knowledge |
| ‘Learn to play and play to learn’ is right in this class. I have gained good knowledge and skills to apply in my current work |
| The educational materials were clear and useful. Sets of pictures for case studies were interesting |
| Facilitators showed good knowledge regarding a healthy living environment and were effective in disseminating their knowledge and skills to us |
| I liked all aspects of the educational program, e.g. the training methods, program's topics and the facilitators. I would be happy to participate in additional training courses in the future |
| Features of the educational program that require improvement in the future (voice from participants) |
| An additional half day for a practical field visit |
| Provide more documents as references for self-study |
| Clearer regulation for participants is needed to encourage punctuality |
| Community leaders’ motivation, participation and educational progress in the educational program (voice from facilitators) |
| Community leaders participated actively in the educational program |
| They became confident to express their ideas even though some initially felt shy |
| Although the participants came from different organizations, they gathered closely for discussions and demonstrations. The diverse backgrounds of community leaders led to good opportunities for rich discussions |
| Peer influence encouraged participants to complete the learning tasks. All groups in the class completed the educational tasks, and most of them went to great efforts in developing their own action plans to promote a healthy living environment for their villages |
| At the end of the program, neither participants nor facilitators wanted to say goodbye to each other. This demonstrates the willingness to attend further participatory training like this program |
| Importance of the educational program to the work of community leaders (voice from participants) |
| The program provided useful knowledge on a healthy living environment and communication skills, and so I feel more confident in working with people in my community |
| I believe that with useful knowledge and skills learned in this program, I can be an active health communicator for water, sanitation and hygiene |
| The knowledge gained in the educational program is necessary not only for my work but also for myself and my family to protect and promote our health |
| The program helped me to find good partners. I will collaborate with them to develop and implement an action plan for the promotion of a healthy living environment |
| I think I have learned a lot from this program. I will use the information gained here to give advice and support community authorities to carry out regular activities to promote water, sanitation and hygiene in the community |
| The contents of the educational program and learning methodology were really helpful for me—a primary school teacher. I will apply what I have learned in my daily teaching work and guide my students to protect our environment |
| Features of the educational program that participants liked the most (voice from participants) |
| The educational method was very good, which allowed me to easily understand and receive new knowledge. This is the first time for us to experience the participatory method |
| The learning atmosphere was very friendly and active. The participants were very interested in the educational program's activities |
| Role playing and small group discussions were effective. We did not feel shy and could easily share our opinions and then summarized the best solution for each case study |
| The topics covered by this program are necessary for my village. I was very interested in finding appropriate solutions to solve existing problems to create a healthy living environment in my village |
| In this class, I worked with various community representatives. We already developed a good action plan for our own village with the participation of the group members |
| Games were great and made everybody feel happy in learning new knowledge |
| ‘Learn to play and play to learn’ is right in this class. I have gained good knowledge and skills to apply in my current work |
| The educational materials were clear and useful. Sets of pictures for case studies were interesting |
| Facilitators showed good knowledge regarding a healthy living environment and were effective in disseminating their knowledge and skills to us |
| I liked all aspects of the educational program, e.g. the training methods, program's topics and the facilitators. I would be happy to participate in additional training courses in the future |
| Features of the educational program that require improvement in the future (voice from participants) |
| An additional half day for a practical field visit |
| Provide more documents as references for self-study |
| Clearer regulation for participants is needed to encourage punctuality |
| Community leaders’ motivation, participation and educational progress in the educational program (voice from facilitators) |
| Community leaders participated actively in the educational program |
| They became confident to express their ideas even though some initially felt shy |
| Although the participants came from different organizations, they gathered closely for discussions and demonstrations. The diverse backgrounds of community leaders led to good opportunities for rich discussions |
| Peer influence encouraged participants to complete the learning tasks. All groups in the class completed the educational tasks, and most of them went to great efforts in developing their own action plans to promote a healthy living environment for their villages |
| At the end of the program, neither participants nor facilitators wanted to say goodbye to each other. This demonstrates the willingness to attend further participatory training like this program |
DISCUSSION
The effectiveness of a community-based educational program targeting community leaders with diverse organizational backgrounds was clearly demonstrated by this randomized community-based intervention in rural Vietnam. Consistent increases in the competencies of the participants in leading a healthy living environment in rural villages were observed. Mutual learning within community leaders with diverse backgrounds was achieved. The use of various methods of learning, including lectures, small group discussions, brainstorming, role-playing, demonstrations, games, case studies and field visits, were new experiences for the participants, facilitated the participant-centered and solution-based approach. Participants found this approach and combination of various teaching methods relevant and useful in their work as health promotion community leaders.
The appropriate design of the educational program led to improved capacities on the part of the participants. The objectives and the content of the program addressed the urgent health needs of the community. Therefore, community leaders participated actively in the educational activities involved in this comprehensive Healthy Village project. A large number of issues were introduced and discussed that focused not only on healthy living environments but also on effective communication skills. The information provided was reinforced several times during the educational process to help community leaders better understand the issues involved and to remember what they learned.
The teaching methods used in the educational program were new to the participants, and the learning capacities of community leaders were enhanced. As mentioned above, previous health-education programs had been top-down and non-participatory, a style that previous studies have shown reduces the transmission of knowledge (Shereen and Susan, 2000). The present study applied a participatory style to maximize the effectiveness of the educational program. Although this method was introduced many years ago (World Health Organization, 1998), it is still a novel approach in the developing world, especially at the grassroots level. The interactive methods used in the training played an important role in facilitating understanding and the recall of new knowledge by the participants (Lankard, 1995). Moreover, the encouraging atmosphere in the classroom stimulated learning, fostered teamwork and encouraged participants to share ideas freely. In addition, materials with demonstrative pictures and simple messages as well as other visual aids used in the training helped participants gain an understanding of the topics faster. The participatory style used in this program has been demonstrated elsewhere to be a useful tool for effective learning (Brown and Fleming, 1998; Clark et al., 1998; World Health Organization, 2000; Onyango-Ouma et al., 2005; Griscti and Jacono, 2006; Ohnishi et al., 2007).
The unique character of our educational program lies in the fact that those invited to participate were recognized leaders representing various sectors and organizations within a rural community. That allowed us to examine the role of intersectoral collaboration of community leaders from a diverse range of organizations in the educational process at the community level. Our results indicate that, regardless of differences in organizational membership, community leaders showed a great deal of improvement thanks to the educational program. The facilitators and research team members noted that most of the participants worked closely with each other and actively shared opinions and experiences. The training provided a good opportunity for them to have open and equal discussions and to support each other in finding ways to improve their living environment. This sharing process facilitated learning by the community leaders. Our results are consistent with previous studies indicating the important role of community collaboration in effective health interventions (Roussos and Fawcett, 2000; World Health Organization, 2000; Sanchez et al., 2005; Khandekar et al., 2006). In addition, the community leaders showed a high degree of motivation because they understood that they were representatives of their community and were therefore driven to acquire new knowledge and skills. The formation of a group of people from diverse backgrounds and sectors facilitated mutual learning and allowed for spontaneous intersectoral collaboration during the learning process.
The facilitators of the educational program also played a role in making the program effective. When the community leaders were asked to name the two things they liked best about the program, this was the most common answer: ‘Facilitators showed good knowledge regarding a healthy living environment and were effective in disseminating their knowledge and skills to us.’ In our study, the facilitators promoted dialogue, suggested action strategies, and put barriers into perspective. Onyango-Ouma et al. (Onyango-Ouma et al., 2005) also highlight the role of facilitators in improving knowledge on health-related hygiene issues and fomenting positive changes in the behavior of school children.
In the present study, participants with higher education level achieved higher test scores than those with either a high school or secondary school education, most likely due to their greater literacy level. Teachers, the most highly educated participants, with either a university or college degree, had the highest scores in both pre- and post-assessments. The involvement of such educated people is a key in promoting a healthy living environment in any community.
Considering the following three HPC areas: competency in identifying the steps required for a healthy living environment; competency in understanding the principles to reduce potential health risks; and competency in providing public health management to improve the living environment, the first and second areas relating to general knowledge of a healthy living environment and the prevention of potential health risks improved greater than the third area. The reason is the first two areas involve issues about the surrounding environment, which were very familiar to the community leaders in their daily lives. Participants’ knowledge in the first two areas was high and their scores reflected that. Moreover, these groups’ questions had a low cognitive level, e.g. questions asked about capacity to remember and understand issues of healthy living environment, which facilitated community leaders to recall and understand new knowledge gained through an educational program (Anderson et al., 2001). The third area, which includes technical issues and requires the capacity to apply and analyze healthy living environment issues, had lower scores in our study. Consequently, an additional half-day should be arranged that focuses on the third competency area in future programs.
Communication skills are an important tool for community empowerment. In the present study, health communication skills remained a challenge for community leaders, including village health workers, and that must be addressed in detail, in both theory and practice, in future training courses. Such training should contribute to shaping communities that allow for greater empowerment and information sharing.
In conclusion, the present study demonstrates the effectiveness of an educational program on capacity building for the promotion of a healthy living environment for community leaders in a rural setting in Vietnam. More widespread implementation of the program, involving participants with diverse membership and cross-cultural backgrounds, would likely prove an effective educational strategy for mobilizing competent human resources in the area of healthy living environment. A participant-centered and problem-based approach is a useful and appropriate method of public health leadership at the community level, and this participatory-style training worked well in this rural village in Vietnam. Maximization of the use of this program is expected to contribute to the capacity development for community leaders and mobilize human resources to promote community health.
FUNDING
Grants-in-Aid for Scientific Study by Japan Society for Promotion of Science.
ACKNOWLEDGEMENTS
We are grateful to the staffs from Ministry of Health of Vietnam, Ninh Binh Health Authority and Kim Son district People Committee for their close cooperation. We thank all the community leaders who were voluntarily and patiently participate in this study.
Conflict of interest: none declared.
