CHILILAB DESS VIETNAM The HANOI SCHOOL OF PUBLIC HEALTH VIET NAM HAI DUONG CHI LINH Hai Duong Province Chi Linh District LOCATION OF CHILILAB DESS SITE, VIETNAM: Monitored population 64,000 Le Vu Anh, Tran Huu Bich, Pham Viet Cuong, Pham Huy Tuan Kiet, Le Cu Linh et al. 1
1. CHILILAB DESS SITE DESCRIPTION 1.1. Physical geography of the CHILILAB DESS The CHILILAB is located in Chi Linh district of Hai Duong province in the northern part of Vietnam. Chi Linh spreads out in an area of 300.54 square kilometers, bordering Bac Giang province in the north, Bac Ninh province in the West and Quang Ninh province in the North East. The site is about 60 km northeast of Hanoi, Vietnam s capital city. The climate in the site is typically tropical, although the winters are cool and mild. The CHILILAB facility can be accessed from Hanoi by National Road No.183 connecting with Highway No. 5. Chi Linh also connects with Quang Ninh province via National Road No. 18 and with Bac Giang via National Road No.37. 1.2 Population characteristics of the CHILILAB DESS At the 1999 national census, Chi Linh district had a population of 142,278 inhabitants, of whom 71,580 were female, accounting for 50.3%. The majority of the population are Kinh people, although there are small numbers of people from different ethnic groups, including the San Diu, Chinese, H'Mong, Tay, Nung minorities. The population is widely dispersed across 17 communes and 3 townships, of which 13 communes are in mountainous areas. The population that forms the basis for this surveillance system is approximately 53,000, spread across 3 townships and 5 commune which are under rapid process of urbanization. Adolescents and young adults (aged 15-24 years) make up nearly 20% of the total district population. The health system in Chi Linh consists of a district health center, a regional health clinic (in Pha Lai) and 20 commune health stations. There are 150 health staff categorised as follows: 5 specialised doctors with specialisation degree 1 (2 internal/paediatricians, 1 obstetrician and 2 public health workers}; 25 doctors of other specialisations; 30 management officials and 80 staff working at commune health stations; and 224 hamlet health workers. The existing health care services in the district are diverse, consisting of health centers and health stations which are public medical facilities, licensed private specialized health clinics and traditional medicine clinics. Apart from those formats of health care services, the health staff in the district also provide home-based health care services outside the working hours As far as natural resources are concerned, the district has 4,700 ha for rice cultivation, 4,200 ha for subsidiary dry crop food, and 14,200 ha of hill forest under exploitation. The Kinh Thay river runs through the district and creates favorable conditions for waterway transport and agricultural irrigation. The main food crops in the district are rice, 2
subsidiary dry crops such as ground-nuts and maize. The growing of commercial fruit trees such as lychee, longan and custard-apple has expanded over the past 10 years.. The electricity supply network is functioning all over the district. The funding for accessibility of electricity comes from the state budget, and in some areas, people spend their own money in getting access to the services. Information supply is from different channels: All communes are covered by the loud-speaker system and all households have their own radio receivers. About 60% of households have TVs. A TV relay station and an FM radio station were built in the district. 2. THE CHILILAB DESS PROCEDURES 2.1. Introduction to the CHILILAB DESS CHILILAB is a field laboratory belonging to the Hanoi School of Public Health (HSPH). The idea of field laboratory development was originally generated during the first years of implementation of the existing field site system, which is used to support the community-health activities of Masters students at HSPH. This system was based on the Public Health Schools Without Walls model fostered by the Rockefeller Foundation since 1996. The Board of Directors of the HSPH decided to develop a field laboratory for the purpose of implementing high quality, sophisticated public health studies, strengthen research capacity of academic staff and provide training opportunities for PhD students in the future. In 1998-1999, several exploratory studies and baseline surveys were carried out in the district of Chi Linh. The result of those studies provided the staff of the HSPH with a clear picture about the socio-demographic characteristics and health situation of the district. Late in 1999, the project proposal for development of a field laboratory was written by the Vice Dean (now Dean) and submitted to the China Medical Board of New York for approval. After gaining support in 2000, more than ten studies in the areas of reproductive health, injuries, non-communicable disease, HIV/AIDS, health care service delivery, food poisoning and environmental health were carried out by HSPH staff and MPH students in the three year period from 2000-2002. The information from baseline surveys and other specific studies have been effectively used as background information for establishment of the field laboratory in Chi Linh district. To build capacity for the CHILILAB, in the same three year period, a group of HSPH staff were selected and sent for PhD training in the USA and Australia. These staff have made significant contributions to the process of field laboratory development. The team responsible for the site development was also sent to Matlab, ORP (Bangladesh), Yogyakarta (Indonesia) and the Africa Center (South Africa), to investigate the design, management and day-to-day functioning of field labs. Based on the experiences gained and other improvements in human resource capacity at HSPH, it was decided to establish 3
the field laboratory in full scale from early 2003. In the design stage, the responsible team at the HSPH has worked with international experts from Johns Hopkins University, Tulane University and the INDEPTH network to draft out the design of the system. After consideration of the current health situation in Vietnam and in the Chi Linh district, the HSPH research team decided that the CHILILAB-DESS should be designed in such a way that it can focus on studying adolescent health and patterns and trends of noncommunicable diseases. The1999 census data indicated that 53% of the 80 million inhabitants of Vietnam were under the age of 25 and 32% were aged between 10 and 24 (nearly the same figure for Chi Linh). Adolescents and young adults are often sensitive to social changes and are at high risk for sexually transmitted diseases, especially HIV/AIDS, other reproductive health problems, accidental injury and mental health problems.. Those are the justifications for the construction of a surveillance system with a focus on young people. However, other population groups, diseases and public health problems will be taken into account for research as specific issues emerge in response to social changes. In March 2003, the population of 3 townships (urban) and 4 communes (rural and potentially be urbanized in 2006) that are geographically representative of the Chi Linh district was identified as the population base for the Demographic-Epidemiologic Surveillance System of CHILILAB. In early 2003 the office of CHILILAB was set up in the health center of the district. At the operational level, 2 field coordinators together with 49 field surveyors, 9 supervisors and 5 data capturers have responsibility for day to day project management including community liaison, data collection, quality control and entering the data into the computers. Before expanding the system to cover the whole population of 64.000 inhabitants, the system has been piloted in two small areas (one urban and one rural) with a total population of 2824 households (9540 inhabitants). Basic descriptive data from this survey are summarized at the end of this document. After reviewing the procedures and activities from several preliminary studies, the system will be expanded in June 2004, including a formal initial census of the entire 18.000 households. The CHILILAB DESS will be continuously operational for a long period of time and the implementation of activities will be a closely integrated with the community (among inhabitants, local authorities and the health sector). The lab will be the co-ordinating centre for specialised field research activities, particularly involving PhD students and their academic supervisors. As far as possible, this work will be integrated with routine health activities in the district. The objectives of the CHILILAB DESS are as follows: General objective: The goal of the CHILILAB DESS is to collect, on a regular basis, demographic and health indicators that are important for public health research and training, which can 4
serve as a basis for policy making and capacity building in order to enhance the local community health and Vietnam public health. Specific objectives 1. To identify patterns and trends in morbidity and mortality in the district population periodically and longitudinally. 2. To identify socio-economic patterns in the population and the influence of these variables on population health. 3. To provide specific data on adolescent health (reproductive health, STI and HIV/AIDS, injury, mental health), as well as risk and protective behaviours 4. To implement community health intervention strategies in order to form a basis for developing health policies in the locality and elsewhere. 5. To improve procedures for data collection, analysis and application at the community level in a reliable and effective manner. 6. To strengthen the capacity of public health professionals by implementing public health researches conducted by PhD students. 2.2. CHILILAB DESS data collection and processing activities 2.2.1 Field procedures a) Baseline survey: (once/2years ) In the baseline survey, the demographic and epidemiologic surveillance system collects general demographic, socio-economic and cultural conditions of the household. This information will be collected every two years from all households under the surveillance system. b) Periodical update: (every 3 months) General information regarding household demography and health status will be collected and updated every 3 months by using a set of data collection instruments. Collected information will relate mainly to population immigration (in and out) of the households, outcomes of pregnancy, delivery, marriage and divorce, general morbidity, mortality and injury cases. c) Specialised module: (every 2 years) Information regarding specialised modules on health of adolescents and young adults (as well as information relating to risk behaviour and protective factors) will be gathered through interviews. Furthermore, identification of biological markers for diagnosis of diseases will be conducted. d) Field supervision and quality control 5
Quality control is performed during field work and during the process of data entry at the computer centre located in the CHILILAB's Office. In order to control data quality, the field supervisors review all questionnaires collected from the group of surveyors under his or her supervision. Detected errors will be given to the responsible surveyors as feedback so that they can correct the errors (if possible) and re-interview participants if necessary. In addition, the field supervisors will conduct cross-check re-interviews randomly with 5% of participants. The field coordinators, at the same time, are responsible for supervising activities being conducted by the field supervisors. This quality control process is conducted by comparing interview outcomes of the surveyors and supervisors. All errors and inconsistent results will be recorded and used as feedback to staff and research students in regular progress meetings. Those surveyors who have multiple errors will be given feedback, comments and more training and supervision. The data entry program is developed in such a way that there is automatic detection of out-of-range values or logically inconsistent responses. In case the data sets are detected with errors by the data entry clerk or software, the relevant surveyor and supervisor will be informed by the field lab office manager to examine in detail the reasons for the errors. Data will be entered into the database and regularly backed up at several sites to ensure excellent data security against equipment failure, accidents, theft or other damage. 2.2.2 Data management and data analysis Periodically, the checked questionnaires will be given to the Operational Field Coordinator and then forwarded to data capturers for entry into the computer at the office. After finishing the data entry process, the questionnaires will be kept in separate, locked filing cabinets. The computer based data management system of CHILILAB consists of a main server used for storing the database and other work-stations that are used for data entry. MS SQL database management software has been used to develop data maintenance under Windows NT/Windows Server 2003 environment. In the work-stations, software designed for DESS data entry works under a WindowsXP environment. The DESS software in the work station is directly connected with the central data base in the main server. As a result, the database in the server is continuously updated when data is entered in the work-station. To access data from the SQL database, the SQL client tool such as Microsoft Access is used. The researcher can also use other statistical software packages supported with ODBC such as SPSS, Stata and EpiInfo 2002 to access the database. 6
3. CHILILAB DSS: BASIC DEMOGRAPHIC DATA FROM TWO PILOT AREAS, 2003. 3.1. Population Structure The currently surveyed areas of the Chi Linh Demographic Surveillance System include An Lac Commune and 3 population clusters of the District Town Sao Do. To date, 2824 households have been approached to provide information on membership, housing and living conditions. Data from 9540 people, structured by gender and age, are described in the following figure: Figure 1: The population pyramid Female Male 80.00 60.00 40.00 20.00 0.5% 1.0% 1.5% 2.0% 2.5% In general, the population pyramid reflects the typical structure of the population in a developing country. Existence of concaveness in ages of 30-ies in both female and male may be due to labor out-migration, where there are more outgoing males than outgoing females. One question raised by Hanoi School of Public Health in this context is whether the current definition of household membership should be changed to capture temporary out-migrants for labor or not. This distortion may affect research design, conduct and outcomes, especially those related to migration or investigation of migration. 7
Table. 1: Population distribution in gender and age groups Age groups <5 Count 5-9 Count 10-14 Count 15-19 Count 20-24 Count 25-29 Count 30-34 Count 35-39 Count 40-44 Count 45-49 Count 50-54 Count 55-59 Count 60-64 Count 65-69 Count >=70 Count Female 280 47,6% 5,6% 355 48,0% 7,1% 486 48,7% 9,8% 532 50,3% 10,7% 312 53,4% 6,3% 356 56,1% 7,1% 338 53,7% 6,8% 367 54,3% 7,4% 443 53,2% 8,9% 412 53,8% 8,3% 276 52,9% 5,5% 177 52,5% 3,6% 171 50,6% 2,3% 113 50,9% 2,3% 364 63,1% 7,3% Sex Male 308 52,4% 6,8% 384 52,0% 8,5% 512 51,3% 11,3% 525 49,7% 11,6% 272 46,6% 6,0% 279 43,9% 6,2% 292 46,3% 6,5% 309 45,7% 6,8% 390 46,8% 8,6% 354 46,2% 7,8% 246 47,1% 5,4% 160 47,5% 3,5% 167 49,4% 3,7% 109 49,1% 2,4% 213 36,9% 4,7% Total 588 6,2% 739 7,8% 998 10,5% 1057 11,1% 584 6,1% 635 6,7% 630 6,6% 676 7,1% 833 8,8% 766 8,1% 522 5,5% 337 3,5% 338 3,6% 222 2,3% 577 6,1% 8
3.2. Distribution of Gender and Ethnicity The proportions of males and females are 47.5 to 52.5 respectively. This is also the outmigration effect for labor where more men went for work than women. The ethnic majority in this particular area is the Kinh (99.8%). Data for 6 people are missing. Other ethnic groups are in absolute minority with less than 0.2%. The ethnic diversity in other areas of Chi Linh district is likely to be different. 3.3. Main Occupation Table. 2: Situation of main occupation Occupation Frequency Percent Farmer Civil Servant Worker Handcraft Trade/ Service Retired Small Children School Children Household Unemployed Elderly Others Total 2681 774 140 60 1026 659 801 2344 85 83 437 450 9540 28,1% 8,1% 1,5% 0,6% 10,8% 6,9% 8,4% 24,6% 0,9% 0,9% 4,6% 4,7% 100% Agriculture, trade and services are the most important occupational categories, while 8.1% of the population work as civil servants for the state. Less than 1% is unemployed. 3.4. Educational background Table. 3: Education situation Education Frequency Percent Analphabet Reading/ Writing Primary/ Intermediate Training University Degree Master/ Doctor Small Children Others Total 176 231 7804 522 12 786 9 9540 1,8% 2,4% 81,8% 5,5% 0,1% 8,2% 0,1% 100% 9
Most of the people had reached the level of primary or intermediate education. Only 5.5% were university graduates. There were very few people at the lowest and highest ends of the spectrum of educational achievement, with master or doctoral qualifications, and illiteracy (ananalphabet) being quite rare. 4. ACKNOWLEDGEMENT The research activities carried out in the Chi Linh district and establishment of the CHILILAB DESS are funded by grant from the China Medical Board of New York. Partial support for the CHILILAB's team to gain experience in field development also came from the Ford Foundation and the Atlantic Philanthropies. 10