Community-based rehabilitation workers in Vietnam need assistance to support communication and swallowing: Sustainable Development Goals 3, 4, 8, 10, 17

Abstract

Purpose

Communication and swallowing disabilities (CSwD) impact health and well-being (Sustainable Development Goal SDG 3), educational attainment (SDG 4) and employment (SDG 8) and contribute to poverty (SDG 1). In Vietnam, community-based rehabilitation (CBR) workers are often the first point of contact for people with CSwD. This commentary reports research exploring the knowledge, experiences and training needs of CBR workers and their preparedness to provide services to people with CSwD and their families living in a province of Vietnam.

Method

Two hundred and five CBR workers completed a written survey and eight participated in a semi-structured interview. Quantitative survey data were analysed using descriptive statistics and content analysis was used to analyse the qualitative data.

Result

Most participants were female, aged over 30 and worked in a variety of health settings. Multiple challenges to the delivery of services to people with CSwD were described, including lack of training and limited understanding of CSwD by CBR workers, communities and their leaders.

Conclusion

Limited knowledge and preparedness of CBR workers is threatening the achievement of the SDGs for people with CSwD in Vietnam. There is a need for comprehensive education, training and the raising of awareness of the cause and impact of CSwD, and for this to be in partnership with people who experience CSwD and their families, local speech-language pathologists, and international collaborators. Future research exploring the needs of people with CSwD in Vietnam is critical to guiding the development of contextually relevant services and support. This commentary focuses on good health and well-being (SDG 3), quality education (SDG 4), decent work and economic growth (SDG 8), reduced inequalities (SDG 10) and partnerships for the goals (SDG 17), and indirectly addresses no poverty (SDG 1).

Keywords:

• sustainable development goals
• good health and well-being (SDG 3)
• quality education (SDG 4)
• decent work and economic growth (SDG 8)
• reduced inequalities (SDG 10)
• partnerships for the goals (SDG 17)
• communication disability
• swallowing disability
• Vietnam
• community-based rehabilitation (CBR)

Introduction

The Sustainable Development Goals (SDGs, United Nations, 2015) aim to reduce poverty, alleviate the effects of climate change and environmental degradation and provide equitable access to education, good health, and safe settlement by 2030. People with disabilities (PWD) are explicitly referred to in the SDGs: good health and well-being (SDG 3), quality education (SDG 4), decent work and economic growth (SDG 8), reduced inequalities (SDG 10) and sustainable cities and communities (SDG 11). In this commentary, the knowledge, experiences and training needs and hence preparedness of community-based rehabilitation (CBR) workers to meet the needs of people with communication and swallowing disabilities (CSwD) in Vietnam are examined, leading to suggestions regarding initiatives to better support the health and well-being, educational attainment, and employment of people with CSwD in Vietnam.

Disability in Vietnam

In 2016, Vietnam conducted its first National Survey on People with Disabilities (Vietnam General Statistics Office, 2016). An estimated 7.1% (approx. 6.2 million people) of the population of 92 million people aged 2 years and older identified as having a disability; an additional 13% (nearly 12 million people) lived in a household with a PWD. Disability prevalence was almost 1.5% higher in rural areas and increased with age. With regard to types of disabilities, communication disabilities ranked third after motor and mental health disabilities, with 7.8% of children and adults reporting disabilities in more than one of the domains of hearing, cognition, psychosocial functioning, and communication. Data collected in 2015 by Global Disability Rights Now (2017), an international non-governmental organisation promoting the rights of PWD, suggested that of 5,203,180 people in Vietnam who identified as having a disability in 2015, 410,000 had a speech disability, 550,000 experienced difficulties with hearing, and 820,000 lived with cognitive disabilities.

Communication and swallowing disabilities may impact general health, well-being and relationships (SDG 3), quality education (SDG 4), access to decent work (SDG 8), and equity of access (SDG 10). Relative to the wider population, PWD in Vietnam have a higher probability of unemployment and reduced income, contributing to poverty, social isolation, and poorer physical and mental health outcomes (Palmer et al., 2015).

Rehabilitation in Vietnam

Rehabilitation services are provided at all levels of the Vietnam health system (i.e. central, provincial, district and commune); however, the number of rehabilitation practitioners, their training, and the scope of services is limited (World Health Organization, 2016). Professional service providers are mostly university-trained rehabilitation doctors and physiotherapists; a cadre of mid-level health workers such as therapy assistants and volunteers also provide rehabilitation services.

Vietnam first implemented CBR in 1987 following the 1981 World Health Organization model (World Health Organization, 2010). Rehabilitation services are provided under five domains: health, education, livelihood, social, and empowerment. CBR provides access to rehabilitation services in contexts of limited human and other resources, and where services to PWD are restricted by poverty, limited transport and geographical location (World Health Organization, 2016). CBR may include rehabilitation in the home, support with education and employment, career guidance, and legal aid and counselling (World Health Organization, 2010). A priority is that CBR is available in the communities in which PWD live, and delivered by personnel, including PWD and their families who are supported by governmental and non-governmental organisations and infrastructure.

In its 2014–2020 National Plan of Rehabilitation Development (Vietnam Ministry of Health, 2014), the Vietnam government reinforced its commitment to CBR and also committed to prioritising the development of a professional rehabilitation workforce that included speech-language pathologists (SLPs). International funding provided by the United States Agency for International Development (USAID) and technical assistance from non-government organisations that include Medisch Comite Nederland-Vietnam (MCNV) and Trinh Foundation Australia (TFA) has now supported the first cohort of speech-language pathology graduates from Baccalaureate and Master degrees across Vietnam (Trinh Foundation Australia (TFA), n.d.). At the time of writing this commentary, four further degrees were under way in Vietnam, with more planned.

Whilst the speech-language pathology profession is growing in Vietnam (Atherton et al., 2020; TFA, n.d.), the current workforce cannot meet the needs of people with CSwD and this will not change in the short term given university degrees and other education opportunities have only just commenced. Previous researchers suggest that CBR may be a viable and contextually relevant way for people to access speech-language pathology services in poorly resourced contexts similar to Vietnam (Deepak et al., 2011; Yeap et al., 2017); however, the utility of CBR to meet the needs of people with CSwD in Vietnam is unknown.

This paper comments on findings and implications from research we conducted exploring the preparedness of CBR workers in one province in Vietnam to provide services to people with CSwD. Three key research questions were posed:

1. What is the understanding of CBR workers about CSwD?

2. What are the experiences of the CBR workers when working with people with CSwD and their families?

3. What are the training and support needs of the CBR workers who provide services to people with CSwD and their families?

Because this is a commentary paper, we only briefly summarise our research methods and highlight key results central to our commentary. For more detail on Methods and Results, see Atherton, McAllister, Van and Trang (forthcoming).

Method

The research employed a mixed methods approach conducted in two stages. Stage 1: a cross-sectional survey to collect information from CBR workers at district and commune levels in Tỉnh province (pseudonym) about their understanding of CSwD, the content and extent of their training to work with people with CSwD, their experiences of working with people with CSwD, and their future training needs. Stage 2: semi-structured interviews with eight self-nominated CBR workers who completed the survey, to further explore these topics. Quantitative data from scaled questions and closed-ended survey questions was subjected to descriptive statistical analysis to yield frequency counts. Qualitative data was analysed using inductive content analysis (Elo & Kyngäs, 2008). Research approval was obtained from the Medical Ethics Council of the University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam (Approval No: 533/HDDD-DHYD).

Result

This paper reports results pertaining to three key categories identified in the survey data and in content analysis of the interview data: Characteristics of CBR workers and their readiness to work with people with CSwD; Experiences working with people with CSwD; Training needs and preferences. Note that the device (P#) at the end of quotes refers to participant number.

Characteristics of CBR workers and their readiness to work with people with CSwD

Two hundred and five CBR workers completed the survey. Females comprised 68% of the sample; 89% of the sample were 30 years or older. Only 12% had post-secondary education, and 91% worked part-time in CBR, at commune level (20.5%) or village level (79.5%). Demographics were similar for interview participants. Only 119 of 205 survey participants had received training in CBR and this training ranged from one week to three months. For those who had received CBR training, this was about general awareness and rehabilitation intervention for PWD (43.1%), followed by general rehabilitation training for children with developmental delay, autism, cerebral palsy (17.5%), and palliative care and care for people with mobility difficulties (10.9%). Only five of the 205 participants (3.6%) had completed any formal training in CSwD.

Survey participants were asked to self-assess their understanding of communication disability. On the scale of I have no/some/good understanding of communication disability, 21.5% of survey participants reported no understanding, 73.7% reported some understanding, and 4.9% reported good understanding. For swallowing disability, 33.2% reported no understanding, 63.9% had some understanding, and 2.9% had good understanding. Half of the interview participants reported no knowledge of the causes of CSwD: “[I don’t know] what the pathological mechanism is” (P7). Training was described as often theoretical, not practical, and some trainers reported they were “…not familiar with speech and language therapy” (P3).

Experience of working with PWD

Survey participants reported working with people with physical, sensory, cognitive and mental health disabilities across a broad age range and that most of their work focussed on the CBR domain of “Health”. When asked to rate how often they worked with people with CSwD, on a scale of seldom, sometimes, regularly and very frequently, for communication disabilities, the majority of participants (60.5%) opted for sometimes while 7.8% rated this as seldom. For swallowing disabilities, 50.7% of participants opted for sometimes while 32.7% rated this as seldom. Services provided for people with communication disabilities were mainly detection and reporting to CBR service managers (82.8%), encouraging participation by PWD and their families (71.1%), training at home (40.2%), and other services that included providing advice (7.4%). Similar services and figures were reported for working with people with swallowing disabilities.

Factors affecting participants’ capacity to provide CBR services included limited knowledge about management strategies: “I only know a little bit about how to help them, for example, practice speaking slowly, practice pronunciation, practice massaging the mouth, but I don’t have a clear direction” (P7). A lack of time, resources and limited salary were also reported. Interview participants discussed reduced confidence in their work: “I don’t have the ability to guide, so I don’t dare to just casually point this and that [out], I don’t have experience so I don’t know” (P4), and feelings of inadequacy about their work because they could see interventions were not resulting in progress. One participant said, “… every day… the baby is exactly the same” (P3). Frequent negative experiences were encountered, including resentment and resistance … “[the client] ran away, he didn’t cooperate, and I couldn’t help at all” (P4); “… [people] say harsh words to me…. so when I came, some people were angry, even kicked me out of the house” (P1). Participants further noted that lack of community and leadership understanding about the nature of their work and inadequate funding contributed to limited participation of people with CSwD and their families in CBR services.

Training needs and preferences

The majority (96%) of participants expressed a need for further training to work with people with communication disabilities, and 97.6% for working with people who had swallowing disabilities. The training content proposed related to knowledge and skills to detect CSwD and to work directly with people with CSwD and their families, as well as skills for community awareness-raising. With respect to modes of training, participants preferred short courses about the full range of conditions impacting on communication and swallowing, but most frequently about stroke, cerebral palsy, head injury and aging/dementia. Half indicated a preference for face-to-face training. “As for online learning, it is not very good [because] it is more difficult to ask for advice than studying [face to face]” (P4). But some saw value in online learning: “If you study online, you can study outside of school hours” (P7). Almost all interview participants emphasised the need for practical training as well as theory: “[I want] both practice and theory, I want to learn more by practice” (P7).

Discussion

The findings of this research highlight a CBR workforce ill prepared to meet the needs of people with CSwD and their families in Tỉnh province, Vietnam. Incomplete understanding and awareness of CSwD, and limited training and resources are preventing people with CSwD accessing services that would improve their quality of life by supporting engagement in education (SDG 4) and income generation (SDG 8) (and thereby reduce poverty SDG 1), improve their health and well-being (SDG 3), and afford equity of access to services and life participation (SDG 10). The demographic profile of the research participants (age, gender, primary qualifications) reflected that previously reported for CBR workers in Vietnam and similar contexts (Sharma & Deepak, 2003; Yeap et al., 2017). Further, a predominance of training in the management of physical disabilities reflects previous findings (Wickenden, 2013) that CBR services often focus upon the visible aspects of a disability, with communication and intellectual disabilities largely unaddressed.

CBR workers in Tỉnh province require theoretical knowledge and practical skills to support their work. Education that builds capacity could be accessed through the strengthening of local partnerships, for example, collaboration with the growing numbers of Vietnamese SLPs (Atherton et al., 2020) (SDG 10). This may improve access to contextually relevant training specific to the needs of people with CSwD in Tỉnh province and may be relevant throughout Vietnam. The content of future training may also include skill development in advocacy that has the potential to enhance community awareness and capacity building (SDG 10). Further, multidisciplinary training in CSwD would support a broad range of rehabilitation providers to focus on aspects of CBR that address inclusion and human rights (SDG 10, SDG 17).

The participants sought training that was delivered flexibly, including via the internet. This finding is consistent with research by Yeap et al. (2017) who noted that CBR workers value training that accommodates their individual circumstances. As has occurred globally, the development and use of technology in Vietnam because of the COVID-19 global pandemic has supported greater access to online learning and communication for both local and international collaboration (SDG 17). Whilst a standardised approach to training of CBR workers has been proposed (Jansen-van Vuuren & Aldersey, 2019), there is a need for further research to support understanding of the education needs of CBR workers within the individual contexts in which they practice and in relation to the diverse range of CBR programmes and contexts.

Given the speech-language pathology workforce in Vietnam is still small, international collaboration and partnerships will be important (SDG 17). This could involve collaboration with international non-governmental organisations, professional associations, universities and SLPs to provide education at local and national levels through lectures, workshops and skill development sessions under supervision. To support community and government understanding and awareness of the causes and impact of CSwD, education and training in awareness-raising and advocacy is required. It will however be critical that these initiatives are developed in collaboration with people with CSwD. People with disabilities and their families are well positioned to identify the knowledge and skills required of CBR workers, and their involvement would enhance community understanding of the challenges they face and “practically demonstrate empowerment in action” (Jansen-van Vuuren & Aldersey, 2019, p. 21).

Finally, the lack of CBR training focussed on working with people with CSwD affected the participants’ knowledge, ability and confidence to provide services and also led to a perceived lack of trust in and respect for their abilities by services users. Self-efficacy or confidence in the ability to perform one’s work has been identified as a key factor in contributing to the workplace success, satisfaction and retention of CBR workers (Sharma & Deepak, 2003). It is therefore important that capacity building include professional development, supervision, support and mentoring which is provided locally and in collaboration with local and international partners (SDG 17).

Summary and conclusion

CBR has the potential to improve the lives of people with CSwD in Vietnam; however, our study has shown that CBR workers in one province (and likely others) do not have the necessary knowledge, skills and leadership support to assist people with CSwD. We do not know if our results are generalisable throughout Vietnam, and we recommend the research be repeated in other provinces to obtain a national picture. Lack of knowledge, skills and leadership compromises the ability of people with CSwD to achieve SDG 3, SDG 4, SDG 8 and SDG 10. Participants recognised the need for education and training, and we have suggested ways in which this could be achieved in line with the SDGs. It is critical that research seeking to inform the development of contextually relevant services and supports in Vietnam include people with CSwD and their families.

Acknowledgements

The authors thank the managers of the CBR service who supported this research and also the many CBR workers who participated in the surveys and interviews.

Disclosure statement

No potential conflict of interest was reported by the author(s).