Main Article Content
Background: Training of primary care practitioners is one of the most implemented interventions in medical international development programmes targeting non-communicable diseases (NCD). Yet in many cases their effectiveness is below expectations. One potential cause of this is that they struggle to account for local context, especially when working with ethnic minorities. Here we begin to address this gap through a qualitative case-study of how local contextual factors have impacted the success of a World Health Organization (WHO) healthcare training programme on Type 2 diabetes with an ethnic minority group in rural central Vietnam.
Design: A qualitative case-study collected data during 2018. We conducted 25 semi-structured interviews, two focus groups, and participant observation with patients, healthcare professionals, and members of a local non-governmental organisation involved in the programme. We used thematic coding to identify important contextual factors and how they helped or hindered programme delivery. Next, we synthesised each of these themes in a narrative style, drawing on the rich detail provided by respondents.
Results: We found that, despite using a notionally decentralised approach, the effectiveness of the training was hindered by social, political, and economic determinants of health which influenced the inhabitants’ relations to healthcare and diabetes. Particular barriers were the political perceptions of minorities, their economic access to services, the healthcare prejudices toward ethnic rural populations and the rigidity of medical training.
Conclusions: Given the similarity of our case with other WHO NCD programmes, we view that our findings are of wider relevance to global public health policy and practice. We suggest that better recognising and addressing local contextual factors would make such programmes more polyvocal, grounded, and resilient, as well as enabling them to better support long-term transformative change in public health systems. We conclude by discussing methods for implementing this in practice.
Kane J. et al. A systematic review of primary care models for non-communicable disease interventions in Sub-Saharan Africa. BMC family practice. 2017;18:1–12.
WHO. Package of essential noncommunicable disease interventions for primary health care in low- resource settings. Geneva: World Health Organization; 2010.
Jayanna K, et al. Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India. BMC public health. 2019;19:409.
Mlambo M, et al. Transformation of medical education through decentralised training platforms: A scoping review. Rural and Remote Health. 2018;18:4337.
Sharp A, et al. Decentralising NCD management in rural southern Africa: evaluation of a pilot implementation study. BMC Public Health. 2020;20:1-8.
Barko R, et al. Perceptions of diabetes symptoms and self-management strategies: A cross-cultural comparison. Journal of transcultural nursing. 2011; 22:274–281.
Fisher E, et al. Cross-cultural and international adaptation of peer support for diabetes management. Family practice. 2010;27:6–16.
De Pue JD, et al. Nurse–community health worker team improves diabetes care in American Samoa. Diabetes care. 2013; 36:1947–1953.
Alaofè H, et al. Community health workers in diabetes prevention and management in developing countries. Annals of global health. 2017;83:661–675.
WHO. Implementation tools Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings. Mscforum.Org. 2013;210.
Duc Son L, et al. Prevalence and risk factors for diabetes in Ho Chi Minh City, Vietnam. Diabetic medicine : a journal of the British Diabetic Association. 2004; 21:371–376.
Nguyen CT, et al. Prevalence of and risk factors for type 2 diabetes mellitus in Vietnam: A systematic review. Asia-Pacific journal of public health. 2015;27:588–600.
WHO. Diabetes country profiles; 2016a [online] Available:http://www.who.int/diabetes/country-profiles/vnm_en.pdf [Accessed 21 Feb. 2018].
WHO. The growing burden of diabetes in Viet Nam; 2016b. [online] Available:http://www.wpro.who.int/vietnam/mediacentre/features/feature_world_health_day_2016_vietnam/en/ [Accessed 21 Feb. 2018].
Miyakawa M, et al. Prevalence, perception and factors associated with diabetes mellitus among the adult population in central Vietnam: A population-based, cross-sectional seroepidemiological survey. BMC public health. 2017;17:1–8.
Binh TQ. Knowledge and associated factors towards type 2 diabetes among a rural population in the Red River Delta region, Vietnam. Rural and remote health. 2015;15:3275.
Garabiles MR, et al. Cultural adaptation of a scalable world health organization E-mental health program for overseas Filipino workers. Journal of Medical Internet Research Formative Research. 2019;3:e11600.
Ngai PBY. NGO interpretation of participatory communication for rural Cambodia: what is lost in ‘translation’? The Journal of International Communication. 2017;23(2):231-251.
Baah FO, et al. Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health—An integrative review. Nursing Inquiry. 2019;26:12268.
Kok MC, et al. How does context influence performance of community health workers in low-and middle-income countries? Evidence from the literature. Health Research Policy and Systems. 2015;13:13.
Lynch JW, et al. Why do poor people behave poorly? Variations in adult health behaviors and psychosoocial characteristics by stages of the socioeconomic life course. Social Sciences and Medicine. 1997;44:809–819.
Browne AJ, et al. Enhancing health care equity with Indigenous populations: Evidence-based strategies from an ethnographic study. BMC Health Services Research. 2016;16:544.
Hirst JE. et al. Women with gestational diabetes in Vietnam: A qualitative study to determine attitudes and health behaviours. BMC Pregnancy and Childbirth. 2012; 12:81.
Arhem N. Forests, spirits, and high modernist development. A study of cosmology and change among the Katuic people in the Uplands of Laos and Vietnam. PhD diss., Univeristy of Uppsala; 2014.
Khetan AK, et al. The effectiveness of community health workers for CVD prevention in LMIC. Global Heart. 2017; 12(3):233-243.
Ballinger, C. The SAGE encyclopedia of qualitative research methods. Sage. 2008; 781–783.
De Vault ML, Gross G. Feminist Qualitative Interviewing: Experience, Talk and Knowledge. In Handbook of Feminist Research: Theory and Praxis, edited by Sharlene Nagy Hesse-Biber. Sage; 2015.
Colorafi KJ, Evans B. Qualitative descriptive methods in health science research”. Health Environments Research and Design Journal. 2016;9:16–25.
Harrison H, et al. Case study research: Foundations and methodological orientations. Forum qualitative Sozialforschung. 2017;18(1).
Yin RK. Case Study Research Design and Methods (5th Ed.). Thousand Oaks, CA: Sage; 2014.
Song M, Parker D. Dynamics of disclosure in depth interviewing. Sociology. 1995; 29:241-256.
Bernard HR. Interviewing: unstructured and semistructured. In Research methods in anthropology: Qualitative and quantitative approaches, edited by Alta Mira 210–250. 4th ed. Rowman and Littlefield Publishers; 2006.
Yeong ML, et al. Interview protocol refinement: Fine-tuning qualitative research interview questions for multi-racial populations in Malaysia. The Qualitative Report. 2018;23:2700-2713.
Temple B, Edwards R. Interpreters/ Translators and cross-language research: reflexivity and border crossings. International Journal of Qualitative Methods. 2002;1:1–12.
Bujra J. Lost in translation? The use of interpreters in fieldwork. Doing Development Research. 2006;172–179.
Pigg S. The credible and the credulous: The question of “villagers’’ beliefs” in Nepal. Cultural Anthropology. 1996;11: 160–201.
Pigg S. Found in most traditional societies: Traditional medical practitioners between culture and development. International development and the social sciences: Essays on the history and politics of knowledge. 1997;259–290.
Pigg SL. On sitting and doing: Ethnography as action in global health. Social Science & Medicine. 2013;99:127-134.
Porterfield A. Shamanism: A psychosocial definition. Journal of the American Academy of Religion. 1987;55:721–739.
Thompson M. Vietnamese traditional medicine: A social history. NUS Press; 2015.
Fang DM, Stewart SL. Social–cultural, traditional beliefs, and health system barriers of hepatitis B screening among Hmong Americans: A case study. Cancer. 2018;124:1576–1582.
Thapa S, Aro AR. Strategies to integrate community-based traditional and complementary healthcare systems into mainstream HIV prevention programs in resource-limited settings. Globalization and Health. 2018;14:64.
Lock M, et al. Biomedical Technologies in Practice. An Anthropology of Biomedicine. 2010;17–31.
Yeh GY, et al. Use of complementary and alternative medicine among persons with diabetes mellitus: Results of a national survey. American Journal of Public Health. 2002;92:1648–1652.
Wahlberg A. Bio-politics and the promotion of traditional herbal medicine in Vietnam. Health. 2006;10:123–147.
List J, Health G. For someone who’s rich, it’s not a problem’. Insights from Tanzania on diabetes health- seeking and medical pluralism among Dar es Salaam’s urban poor. Globalization and Health. 2010;6:1–9.
Lunyera J, et al. Traditional medicine practices among community members with diabetes mellitus in Northern Tanzania: An ethnomedical survey. BMC complementary and alternative medicine. 2016;16:282.
Latt TS, et al. Traditional Medicine and Diabetes Care in Myanmar. Journal of Social Health and Diabetes. 2019;7:16-21.
Luedke T, West H. Borders and Healers: brokering therapeutic resources in southeast Africa. Bloomington: Indiana University Press; 2006.
Marsland R. The modern traditional healer: Locating “hybridity” in modern traditional medicine, southern Tanzania. Journal of Southern African Studies. 2007;33:751–765.
Handley J. et al. Living with type 2 diabetes- Putting the person in the pilots’ seat. Australian Journal of Advanced Nursing. 2010;27:12–19.
Broom D, Whittaker A. Controlling diabetes, controlling diabetics: Moral language in the management of diabetes type 2. Social Science and Medicine. 2004; 58:2371–2382.
Yates‐Doerr, E. The weight of the self: Care and compassion in Guatemalan dietary choices. Medical Anthropology Quarterly. 2012;26:136-158.
Krahn J. The dynamics of dietary change of transitional food systems in tropical forest areas of Southeast Asia. The contemporary and traditional food system of the Katu in the Sekong Province, Lao PDR. PhD diss., Universitäts-und Landesbibliothek Bonn; 2005.
Gross L. et al. Increased consumption of refined carbohydrates and the epidemic of type 2 diabetes mellitus in the United States: An ecological assessment. American Journal of Clinical Nutrition. 2004;70:466–473.
Popkin BM, Nielsen SJ. The sweetening of the world’s diet. Obesity Research. 2003; 11:1325–1332.
Gulliford MC, Mahabir D. Utilisation of private care by public primary care clinic attenders with diabetes: Relationship to health status and social factors. Social Science & Medicine. 2001;(53):1045-1056.
Rao KD, Sheffel A. Quality of clinical care and bypassing of primary health centers in India. Social Science & Medicine. 2018; 207:80-88.
Miewald C. Is Awareness Enough? The Contradictions of Self-Care in a Chronic Disease Clinic. Human Organization. 1997; 56:353–362.
Nakata C. et al. Chronic illness medication compliance: A liminal and contextual consumer journey. Journal of the Academy of Marketing Science. 2019; 47:192-215.
De Villiers M. et al. Decentralised training for medical students: A scoping review. BMC Medical Education. 2017; 17(1):196.
Baumann L. et al. A training program for diabetes care in Vietnam. Diabetes Educator. 2006;32:189–194.
Pulvirenti M. et al. Empowerment, patient centred care and self-management. Health Expectations. 2014;17:303–310.
Checkley W. et al. Management of noncommunicable disease in low- and middle- income countries. Global Heart. 2014;9:431–443.
Aflague TF, et al. Examining the Influence of Cultural Immersion on Willingness to Try Fruits and Vegetables among Children in Guam: The Traditions Pilot Study. Nutrients. 2020;12(1):18.
Endrizal CL, et al. Dietetics Practice in the Unique, Culturally Diverse Pacific Island Region. Hawai'i Journal of Medicine & Public Health. 2018;77(6):135.