Public Disclosure Authorized

Public Disclosure Authorized January 2019 Final Report

Situation Assessment and Analysis of Health Risk Communication in Vietnam Public Disclosure Authorized Public Disclosure Authorized

Development and Policies Research Center Address: Suite 305-307, 12 TrangThi Street, HoanKiem District, Hanoi. Phone: + 84 4 3935 1419 |Fax: +84 4 3935 1418 Website: http://www.depocen.org/ Email: [email protected]

TABLE OF CONTENTS ABBREVIATION ...... iii ACKNOWLEDGEMENT ...... iv EXECUTIVE SUMMARY ...... v SECTION I: INTRODUCTION ...... 1 1.1. Background ...... 1 1.2. Rationale for the Assessment ...... 2 1.3. Objectives and Scope of Work ...... 2 1.4. Methodology ...... 3 1.5. Limitations of the Study ...... 5 1.6. Demographic Information of the Quantitative Data ...... 5 SECTION II: KEY FINDINGS ...... 8 2.1. Overview of Risk Communication in Health Sector in Vietnam ...... 8 (i) Legal basis for risk communication in Vietnam...... 8 (ii) How the concept of risk communication is applied in the context of Vietnam ...... 9 (iii) Principles of risk communication and practical implementation of principles ...... 12 2.2. Situation of Risk Communication on EIDs and Public Health Events ...... 17 (i) Communication on EIDs and public health events ...... 17 (ii) Risk communication on infectious diseases ...... 24 (iii) Risk communication applied to food safety ...... 28 (iv) Communication on risk behaviors applied to NCDs ...... 29 2.3. Public concern and perceptions of health risks ...... 32 (i) Public interest / knowledge of infectious diseases ...... 34 (ii) Public interest / knowledge on unsafe food ...... 36 (iii) Public interest / knowledge on risk elements of NCDs...... 39 2.4. Public’s access to, exchange of, and feedback to health-related information ...... 43 (i) Mass media using habit ...... 43 (ii) Situation of information access and exchange among members of the public ...... 52 (iii) Feedback mechanisms regarding communicable diseases ...... 55 SECTION 3: CONCLUSIONS AND RECOMMENDATIONS ...... 57 3.1. Conclusion ...... 57 3.2. Recommendations ...... 59 ANNEXES ...... 62 Annex 1. Survey questionnaire ...... 62 Annex 2. Number of households participating in the survey by commune ...... 75 i

List of Figures Figure 1: Issues that raise health concerns of local people ...... 33 Figure 2: Proportion of people heard of the diseases taking place in the local areas in the last 03 years, by surveyed provinces ...... 34 Figure 3: The information about the disease outbreak that people are interested in ...... 36 Figure 4: People’s knowledge on unsafe food ...... 37 Figure 5: People's perceptions about the consequences of unsafe food consumption ...... 39 Figure 6: Proportion of respondents who believed that they and their families were exposed to the risks of NCDs, by gender ...... 39 Figure 7: People's perception on the risks of diseases caused by smoking ...... 41 Figure 8: People's perception on the risks of diseases caused by alcohol consumption ...... 41 Figure 9: Percentage of communication media accessed daily by gender and residence ...... 44 Figure 10: Percentage of communication media accessed daily by age groups ...... 45 Figure 11: Available technology devices at home ...... 46 Figure 12: Frequently accessed television channels ...... 47 Figure 13: Time frame of watching television ...... 48 Figure 14: Time frame of watching television by gender and residence ...... 48 Figure 15: Social networking sites used by respondents ...... 49 Figure 16: Frequency of access to social networking sites of respondents ...... 49 Figure 17: Frequently accessed online newspapers of respondents...... 50 Figure 18: Frequently accessed radio channels of respondents ...... 51 Figure 19: Time frame of listening to radio of respondents ...... 51 Figure 20: Time frame of listening to the radio by gender and residence...... 52 Figure 21: The rate of respondents who said that there had been communication programs about disease prevention or public health protection in the area where they reside during the last year ...... 53 Figure 22: Channels for communication programs of respondents ...... 54 Figure 23: Channels for epidemics-related information exchange and seeking ...... 54 Figure 24: Feedback strategies adopted by respondents to inform other people when a disease outbreak shows signs of spreading rapidly ...... 55 Figure 25: Reasons for not taking any action when an epidemic shows signs of spreading rapidly ...... 56 Figure 26: Assessment by respondents of government authorities’ reactions when informed by their people on epidemics ...... 56

List of Tables Table 1: Selected provinces by different criteria...... 4 Table 2: Sampling using ®STATA software (set seed) ...... 4 Table 3: Demographic profiles of survey respondents ...... 6 Table 4: The public’s perceptions of the degree of severity of communicable diseases ...... 34 Table 5: Response to infection of infectious diseases ...... 35 Table 6: People's actions to prevent disease risks ...... 40 Table 7: Use frequency of mass media ...... 44 Table 8: Main content that respondents often read/watch/listen to on the mass media ...... 46

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ABBREVIATION

APSED Asia Pacific Technical Advisory Group on Emerging Infectious Diseases

DEPOCEN Development and Policies Research Center

EID Emerging infectious disease

EOC Emergency Operations Center

EVD Ebola virus disease

FGD Focus group discussion

GDPM General Department of Preventive Medicine

GOV Government of Vietnam

HFMD Hand-foot-and-mouth disease

IHR International Health Regulations

INGO International non-governmental organizations

JEE Joint External Evaluation

KII Key informant interview

MERS-CoV Middle East respiratory syndrome coronavirus

MOH Ministry of Health

NCD Non-communicable disease

SARS Severe acute respiratory syndrome

WHO World Health Organization

WB World Bank

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ACKNOWLEDGEMENT

The Situation Assessment and Analysis of Health Risk Communication in Vietnam was conducted by Development and Policies Research Center (DEPOCEN) from August to December 2018. The research team would like give sincere thanks to project officers of the World Bank in Vietnam, Ministry of Health, Department of Communications and Reward, and the World Health Organization, for their valuable support during the progress of development of the assessment tools, the field work and the report production. We would like to extend our gratitude to leaders and officials of provincial Departments of Health and related agencies in 06 provinces, including Hanoi, Ho Chi Minh City, Lang Son, Da Nang, Quang Nam and An Giang; leaders and officials of the district and communal People’s Committees, and the local mass organizations in the surveyed areas; and especially the people for participating in the survey. We also thank individuals and organizations who have supported and provided the research team with valuable information that contribute greatly to the success of this study. On a final note, the opinions and assessments expressed in this report are those of the authors, and therefore not necessarily a reflection of the views of the World Bank, Ministry of Health, the World Health Organization and DEPOCEN.

The research team Dr. Nguyen Ngoc Anh, DEPOCEN Director Dr. Nguyen Minh Huong, expert in Risk Communication, et al.

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EXECUTIVE SUMMARY

Located in the region strongly influenced by the monsoon climate, tropical humidity as well as being highly populated, Vietnam is as a lower middle-income country facing both the burdens of infectious diseases and non-communicable diseases (NCDs). In addition, inadequate control of food safety and sanitation as risk factors to many diseases poses visible threats to public health, placing burdens on the national health care system. Under a commitment of the Communist Party of Vietnam and the Government of Vietnam (GOV) and the close international coordination and supports, Vietnam has made an encouraging progress in disease prevention and control. Practices of response to disease outbreaks in the past show that risk communication plays the central role in managing outbreaks as well as public health emergencies. Timely and smooth information exchange among relevant stakeholders in responding to diseases, particularly in health emergencies, is of critical importance. To fulfill its commitments in International Health Regulations (IHR) and Asia Pacific Technical Advisory Group on Emerging Infectious Diseases (APSED) as well as to proactively prevent and respond to risks of disease, the Government of Vietnam should be able to demonstrate its ability to perform risk communication. Effective risk communication will inform health management of disease situation, contributing to effective disease surveillance, reducing social confusion and enabling preventive behaviors in the community. Therefore, the Assessment and Situation Analysis of Health Risk Communication in Vietnam is conducted to collect inputs for defining practical and effective strategies for the 2019 – 2025 National Action Plan on Health Communication; in which, risk communication for four priorities are emphasized They are (i) risk communication on infectious diseases (dengue fever, measles, and HFMD) and EIDs (human avian influenza type A, Zika virus, and Mers-CoV); (ii) communication on risks of NCDs; (iii) risk communication on unsafe food and food poisoning; and (iv) risk communication on public health events (for example, health emergencies, medical issues, disease outbreaks after disasters, catastrophes, and severe weather). The study has the following objectives: Ø Situation assessment of risk communication from the central level to the local level in the four priority areas; Ø Public opinion survey on health risks and risk prevention practice in the four priority areas; Ø Analysis of the public’s receipt and exchange of information on health risks in the context of technology and Internet development; Ø Study of the feedback mechanism and public engagement in risk communication process; Ø Study of the coordination among levels, sectors and relevant stakeholders in implementation of risk communication; Ø Proposals on risk communication implementation steps for the four priority areas, which will be the basis for a practical, suitable and effective National Action Plan. To analyze the situation of risk communication through the views of both the public and the government at all levels, both quantitative and qualitative methods are employed. Six provinces/cities that are Hanoi and Lang Son in the North; Quang Nam and Da Nang in the Central; and Ho Chi Minh City and An Giang in the South are selected for the assignment. Those provinces/cities were selected based on the following criteria: low vs high risk of epidemic threats; low vs high risk of natural disasters; high vs low incidence of media coverage; rural vs urban areas; and close to border/ having international ports or not.

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For the qualitative survey, the research team conducted: (1) key informant interviews (KIIs) with representatives of international organizations, international non-governmental organizations (INGOs), renowned individuals in the social networks, and GOV officials from related ministries and media agencies; (2) focus group discussions (FGDs) with representatives of People Committee authorities, health communication staff, and of mass organizations (Women Unions, Farmer Associations, etc.) at all three levels (provincial/ district/ communal); and (3) FGDs with local people in six selected provinces; each group was selected by several specific characteristics. (See Annex 2 for further details) Qualitative data of KIIs and FGDs meetings with representatives of relevant stakeholders helps show the overall picture of current government’s risk communication activities from the central to local levels; understanding practices of risk communication principles; and mapping out coordinations within health sectors as well as between health sector and other state- and non-state actors. In addition, the results of FDGs with local people contribute to understanding the public perception of health risks and their experiences in dealing with health risks; as well as exploring their involvement in health risk communication process. For the quantitative survey, 1,009 households in six abovementioned provinces/cities were selected by the simple random sampling method. The survey contents were designed to colllect the public opinion on health risk related activities and assess results of current existing health risk activities. Data collected from questionnaire survey were cleaned before proceeding and analysing by STATA. Regarding legal basis for risk communication, according to the study results, Vietnam has established a legal framework and overarching mechanism for implementation of risk communication that covers its diverse aspects and facets. Although Risk communication was first introduced in Vietnam in 2011, it has become a priority topic in the National Program on Health for 2012 – 2015. Following that, the first National Action Plan on Risk Communication for the period 2013 – 2016 was developed. The Standard Operating Procedure (SOP) on risk communication in public health emergencies was completed in 2015; and a Manual Guide on risk communication for food safety was finalized in 2016. The Memorandum of Understanding (MoU) between the health sector and the agriculture sector in the One Health approach (prevention of diseases spread between animals and humans) has established a mechanism and provided guidance for information exchange among sectors. In addition, legal documents including a number of circulars and guidance are issued by Ministry of Health (MOH) to guide the implementation of risk communication components. However, a number of problems in implementation of risk communication activities at all levels have generated and required further discussion. Discussions with related agencies at all levels reveal a confusion in using the concept of risk communication in the health sector. The majority of grassroots health communication officials perceived risk communication as: informing people of the risks of each specific disease. This perception has affected the implementation of risk communication activities in the health sector at the grassroots level. Regarding the implementation of risk communication principles, the study results show that the MOH’s specialized agencies (such as General Department of Preventive Medicine, Department of Communications and Award, National Center for Health Education and Training, and Pasteur Institutes) have made positive changes in terms of applying risk communication principles in responding to disease outbreaks, from being inactive in communication about disease outbreaks and public health emergencies into actively cooperating with relevant stakeholders and press agencies. Achievements include: (1) these agencies have become active in cooperating with journalists to deliver communication messages to the public in health emergencies and disease outbreaks; (2) the health sector has developed an electronic reporting mechanism that allows real-time information exchange between vi the health management agencies and grassroots health officials about the disease situation in the community; (3) the National Center for Health Education and Training operates a daily news section to deliver information about disease outbreaks on its website – this is an innovation in the application of active listening principle; (4) the Ministry of Health’s management agencies follow closely the progress of disease outbreaks and are ready to respond to risks. Besides achievements, weaknesses do exist. Specifically, the content of risk communication programs for disease outbreaks and public health emergencies has not satisfied the public demand. The information on the websites of health specialized agencies is not updated or specific, and lacks a warning effect. MOH still focuses on combating outbreaks rather than controlling them. Moreover, communication agencies of MOH are overly cautious in delivering information to the public. Regarding situation of risk communication related to four priority areas, in communication about EIDs, the health sector has managed effectively a number of EIDs, particularly global ones. However, risk communication at present still focuses on handling outbreaks, without a comprehensive risk communication plan covering three stages: pre-outbreak stage, outbreak stage and post-outbreak stage. There is also a lack of systematic coordination among relevant sectors at the local level, which at current stage is a dependence on top-down instructions. Furthermore, due to the lack of a detailed communication plan for a specific disease outbreak and public health event, in some locations, disease prevention communication is considered only the health sector’s task; and thus, it is difficult to engage the participation of non-health agencies without a clear instruction of the authorities. Regarding risk communication on infectious diseases, communication agencies at all levels have actively developed communication plans for prevention of seasonal diseases before the disease season starts. MOH’s specialized agencies have diversified communication forms with the application of Information and Communications Technologies (ICTs) and social networks. Several health specialized agencies have considered social and cultural characteristics of the target groups, such as ethnicity, region, culture, etc. to develop suitable communication messages. An interesting example is the communication model on the prevention of dengue fever in pagodas in Hoc Mon district – Ho Chi Minh City. In terms of mobilizing resources for risk communication, several specialized agencies of MOH, e.g., Pasteur Institute of Ho Chi Minh City, cooperated with the private sector to implement the communication activities for the target group. Except for a few communication agencies that have had initiatives in applying diverse communication models to reach the target groups as mentioned above, communication activities regarding infectious diseases are generally rigid and mostly follow the health communication and education models that use conventional communication channels. Although MOH and its specialized agencies have endeavored to utilize diverse communication models using novel channels, such as posting information on their websites and fan pages in the social networks, they failed to identify the key audiences to design suitable communication messages and information. The grassroots communication agencies have focused only on the topics/diseases in line with the national target programs and the top-down instructions, and ignored rather than actively communicated the infectious diseases emerging locally (due to the unavailability of budgets and human resources). Regarding food safety risk communication, the study results show that the inadequate control of food safety is the biggest obstacle to food safety risk communication programs in Vietnam. The food safety communication program of the health sector for the public has been able to deliver the message: “Purchase and consume only products with clear origins” via the panels and slogans displayed in the public places. Nonetheless, these communication programs failed to point out places where people can purchase these products suitably with their geographical, economic, cultural and social conditions. Too vii many warnings on unsafe food without sufficient alternative suggestions cause confusion and damage public’s trust. In the surveyed areas, current communication activities have still targeted to street vendors and household- businesses in traditional outdoor markets or in small markets to enhance their awareness on processing/trading safe food products or “clean” food. At the central level, MOH, with the technical supports from international organizations, organized several training courses on “food safety risk communication” for representatives of related agencies. However, those training content and knowledge hardly have been applied in communication activities in practice. In brief, food safety risk communication is largely neglected while the people take all risks themselves without any other choices: “we are confusing but we still have to consume food”. Regarding risk communication on NCDs, the communication programs on NCDs still put an emphasis on intervention, screening and management of patients while a comprehensive communication program on disease prevention or promoting positive behaviors such as changing diets, taking physical exercise, and avoiding risk behaviors such as smoking or drinking alcohol remains absent. Some communication programs, such as the programs on prevention of adverse impacts of smoking and prevention of alcohol abuse and the nutrition programs, were conducted unsystematically without a connection among the programs or a comprehensive coordination among related sectors and implementing partners. The communication means mainly follow the health communication and education approach while behavioral change communication models that focus on the target groups have not been applied. In four priority areas, evaluation activities to assess the communication effectiveness is totally absent.

Regarding risk communication on infectious diseases, the communication programs on disease prevention at the local level are rigid and unadapted; and the message has not caught the public interest. About risk communication related to food safety, at the local level, communication activities target individuals and households doing business in outdoor markets and small markets to enhance their awareness on processing/trading safe food products or “clean” food. The food safety communication programs for the public were not indicated or implemented in the surveyed areas. Ministry of Health, with the technical supports from international organizations, organized several training courses on “food safety risk communication” for representatives of related agencies, such as provincial food safety departments, regional institutes of hygiene and epidemiology, Department of Communication, Competition and Award under MOH and related agencies of the Ministry of Agriculture and Rural Development. However, few training content and knowledge have been applied in communication activities in practice. In risk communication on NCDs, the communication programs on NCDs still put an emphasis on intervention, screening and management of patients while a comprehensive communication program on disease prevention or promoting positive behaviors such as changing diets, taking physical exercise, and avoiding risk behaviors such as smoking or drinking alcohol still remains absent. Several communication programs on risk elements of NCDs, such as the programs on prevention of adverse impacts of smoking and prevention of alcohol consumption and the nutrition programs are conducted unsystematically without a connection among the programs or a comprehensive coordination among related sectors and implementers. The communication means mainly follow the health communication and education approach while behavioral change communication models that focus on the target groups have not been applied. In all priority areas, evaluation of communication effectiveness is totally absent. In communication about public health events, risk communication procedures have not been carried out systematically and sufficiently in all public health events at all levels. In this priority area, efforts are spent on temporary solutions instead of a comprehensive and long-term plan. viii

Regarding public perception on health-related risks, the quantitative results in 06 surveyed provinces reveal that: the health issues related to infectious diseases and NCDs (or risk elements of NCDs such as smoking and alcohol abuse) are not of the people’s most concern. People pay more attention to risks related to consumption of unsafe food, garbage pollution, and environment pollution in their residential areas. Meanwhile, as infectious diseases, particularly emerging diseases, rarely or occasionally occur in the local areas, people generally do not pay much attention to the related risks. As a result, when a disease outbreak takes place, without timely warning from the health communication agencies, people can be incautious about the disease. Therefore, adequate understanding about the public concern of health risks is critical for the national and local communication programs to have preventive measures to each scenario.

Regarding the mechanism for access to disease related information, the study results show that television is the most widely accessed channel. However, there is a re-mapping of popular information channels for the public; according to which, television is no longer the dominant channel; on the other hand, the proportion of people with access to online channels such as online newspapers and social network is soaring; printed newspapers are losing their position.

Upon studying the public access to information in the mass media, the survey results reveal that new media means such as Facebook, Zalo and online newspapers have had high daily user rates. However, users access these channels mainly for entertainment purpose rather than searching for oriented information of more important areas such as health care. The practice reveals that new media means like Facebook, Zalo and online newspapers are potential information channels for the health management agencies to interact with the public, particularly the young audience. How the interaction should be carried out via these channels, and in which forms to achieve the effectiveness requires further study. For information about disease issues in the local areas, television, radio, printed newspaper, and recently online newspapers are convenient information sources. People also find direct channels such as their network of grassroots health workers, friends, neighbors, and acquaintances reliable and easy to access and exchange information. Nonetheless, our analyses also point out that people remain inactive as they mostly wait for information rather than be actively searching for information related to the disease outbreak in the local areas. In conclusion, risk communication for diseases is costly and requires long-term planning, which requires the active efforts of health specialized agencies, the strong leadership of government leaders at all levels, the engagement of the whole political system, and most importantly the close coordination between the health sector and relevant sectors. In addition, financial and technical supports of international organizations are needed. Regarding to public, it is critical that health specialized agencies understand the public’s demand on the types of information and their preferred sources to identify the suitable communication content and forms.

Based on the research results, we provide a number of suggest that may be used for the national program on risk communication in the period of 2020 – 2025 as: • Capacity building on risk communication for health communication officials at all levels; policy makers and leaders of relevant sectors should be a key activity in the design of the National Action Plan 2020 – 2025. In more details, communication officials, health managers and policy makers need to be informed on: (1) The circumstances and conditions under which each component of risk communication is applied to; ix

(2) Similarities and differences between risk communication and health education and health promotion; (3) How risk communication can be replaced or supplemented for general health education and communication in the four priority areas. • Some suggested improvements in application of risk communication principles include: v “Risk communication should be a step ahead and be active in preventive communication”. That is, there should be preparation in pre-outbreak, outbreak and post-outbreak communication planning, which includes input assessment (e.g., geographical, economic, cultural and social factors that affect the information access of the public and public perceptions of risks) to develop communication messages and select suitable interaction channels with the target groups. v Information delivered to the public should meet the public concern instead of generalized recommendations on prevention of specific disease; v “Blame” message such as “due to the people’s carelessness” and the messages “being indirect and hiding information about the outbreak to the public” should be avoided. These messages may have adverse impacts which damages the public trust in the health sector’s capacity to manage and control disease outbreaks. • To implement all components of risk communication in response the public health events or emergency infectious disease, the MOH’s communication units should: v Put SOP of Risk Communication in use; v Enhance the capacity for grassroot communication staff on the practical risk communication procedures based on SOP Guidelines: focusing on active listening skills and on implementing the principle of timely information to the public even in cases of uncertainty; v Strengthen the planning, monitoring and evaluating risk communication program regularly in all level; v Engcourage a opener announcement mechanism as well as more flexible expenditure mechanism in the situations of disease outbreak and/or public health emergency; v Promote the proactive and coordination with health journalist group and press agencies in order to provide information timely and accurately to the public. • To improve the behavior change communication in communicating both infectious diseases and NCDs, the health sector in general should have the comprehensive innovation: from developing communication plan, designing the communication messages, and choosing communication forms for each target group in each specific context of disease; avoid using either top-down communication or ‘one-to-fit-all’ messages. To improve health communication capacity at the grassroot level, MOH should decentralize their management and empower health communication units at local levels: v District or communal health centers must be (should be) active in choosing and applying communication models which could be suitable with geographic, economic, cultural and social situation of local people

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v Local health centers should also be allocated the budget appropriately and timely (both fixed budget and back-up budget) to actively plan and implement the communication program of their center, meet the condition of local culture, socio-economic, and intellectual level. • For NCD communication, the research results indicate that current NCD communication programs do not articulate with the public information demands. While NCD communication programs at local levels are focusing on the risks of high blood pressures, majority of respondents express their concerns more on risks of cancers, gastrointestinal problems, and hepatic-steatosis. Therefore, when planning a NCD program for each community at the grassroot level, health policymakers should consider baseline studies as an essential component of any NCD communication program. • For communicating threats of unsafe food to the public health, the health sectors should give more clear recommendations on how to select, process and consume safe foods that are appropriate with the economic, social and cultural situation of local people. Furthermore, more medical evidences on the correlation between consuming unsafe food and the incidence of cancer risk would be magnificent for communicating this theme to the public and to avoid the public anxiety. • About the communication channel to convey the message to the local people: v Based on the research findings on the public behavior of using mass media in daily life, the communication units of MOH could be able to choose the appropriate mean of media for the target group, and select the applicable time frame with the liking of the public. For example, with the target group of the adolecent and middle-aged, the multimedia communication (Facebook, Zalo and e-news) could be their favourite communication channels. Meanwhile, the radio is more appropriate with the people living in the rural area. v Maintaining the public trust is the key of effective risk communication; and other multimedia communication is a useful instrument to interact with the public. Therefore, communication units of health sector should strengthen their utilization of social media and multimedia: § Tracking the public concerns and interacting with public on social media such as Zalo, Facebook, …. § Cooperating with the key opinion leaders to interact with the public to avoid the fake news and confusing news, § Keep the active roles in the providing information timely, accurately and appropriately with the public’s concerns

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SECTION I: INTRODUCTION

1.1. Background

Located in the region strongly influenced by the monsoon climate, tropical humidity as well as being highly populated, Vietnam is as a middle-income country facing both the burden of infectious diseases and NCDs. Every year the country has to deal with various seasonal infectious diseases, such as dengue fever, hand- foot-and-mouth disease (HFMD), and acute respiratory infection. Its consistent progression of global integration in recent years carries the threats of EIDs such as severe acute respiratory syndrome (SARS), high pathogenic avian influenza A subtype H5N1 (HPAI), pandemic influenza A subtype H1N1, or avian influenza A subtype H7N9 virus infection, Zika virus infection, Middle East respiratory syndrome coronavirus (MERS-CoV), Ebola virus disease (EVD), among others. In addition, inadequate control of food safety and sanitation as a risk factor to many diseases, poses visible threats to public health, placing burdens on the national health care system. There is also an increasing impact of NCDs including cardiovascular disease, diabetes, cancer, and chronic respiratory diseases, along with a population aging. These burdens of diseases have been putting more stress on the health system as well as having economic, social and political impacts on Vietnam. With the high commitment of the Communist Party of Vietnam and the Government of Vietnam and close international coordination and supports, Vietnam has made an encouraging progress in disease prevention and control. Many severe disease outbreaks such as SARS, HPAI, Mers-CoV, were controlled and eradicated. Vietnam is recognized by the international community as a leading country in controlling SARS, a type of EID. Now over a decade since the SARS outbreak, the country has accumulated valuable experience in preparation and response to disease outbreaks, namely since the human avian influenza in 2003, HFMD in 2011, measles in 2013 and dengue fever in 2017. Lessons learnt from the recent outbreaks show that timely and smooth information exchange among relevant stakeholders in responding to diseases, particularly in health emergencies, is critical; the importance of which is stated in the International Health Regulations (IHR 2005) and the Asia Pacific Technical Advisory Group on Emerging Infectious Diseases (APSED) of which Vietnam is a strongly committed member. In these documents, risk communication is an important component of any disease risk response and management plans. In other words, risk communication is central to management and control of disease risks. To fulfill its commitments in IHR and APSED as well as to proactively prevent and respond to risks of disease, GOV should be able to demonstrate its ability to perform risk communication. Effective risk communication will inform health management of disease situation, contributing to effective disease surveillance, reducing social confusion and enabling preventive behaviors in the community. What are the requirements for risk communication? Within the framework of Vietnam’s commitments in IHR and APSEP, risk communication refers to the real-time, multi-faceted and multi-level process of information exchange between experts, policy makers and people at risk. This is done in order to help the stakeholders define risks, assess vulnerabilities, promote community resilience, and thereby promoting the capacity to cope with an unfolding public health emergency (JEE, 2017). In this process, risk communication requires organized and uninterrupted coordination among ministries, ministerial-level agencies, mass organizations, the private sector and international partners. Effective public risk communication should be done well timely and widely and by providing people with precise

1 and understandable information about the disease and its risk elements, promoting behavioral change for proactive prevention, sustaining public trust, and actively studying public opinions. As such, risk communication is consisted of three basic elements: (1) operational communication (frequent information exchange and update within the health sector and with relevant state management for timely decision making on risk responses); (2) behavioral change communication (interacting with the public and promoting public engagement for long-term objectives of protective behaviors); and (3) communication in health emergencies (communication for the affected group/area/community under the principles of actively studying public opinions, reducing confusion and sustaining public trust). To meet practical requirements on risk communication, the World Bank (WB) and World Health Organization (WHO) shall assist the MOH in developing a National Action Plan for Health Communication for period 2019-2023, vision to 2030 in which risk communication for infectious diseases and public health events is a key element. The Action Plan needs to provide clear directions for the health sector on effective usage of risk communication approaches and techniques for the whole healthcare sector, meeting requirements of innovation and being proactive. In order to provide experimental evidence for developing the Action Plan, it is urgent to have an Assessment and Situation Analysis of Risk Communication in Vietnam.

1.2. Rationale for the Assessment

Risk communication was introduced in Vietnam in 2011 and a risk communication plan was developed and realized in 2013. Nonetheless, there has been no overall assessment to assess the coverage and effectiveness of the risk communication plan. Although the Joint External Evaluation (JEE) conducted a capacity assessment of risk communication in Vietnam, the assessment focused on the organizational process of risk communication rather than a public survey on risk assessment. According to the JEE on the implementation of the International Health Regulations (IHR) (which was jointly conducted by the government, led by MOH, and partners including WHO and external partners in 2016), Vietnam has demonstrated its risk communication capacity in controlling newly emerging communicable diseases such as bird flu or Zika virus. However, there are unequal capacities among different levels of management, different present diseases and different events of public health. Risk communication is carried out unsystematically and lagging behind in the context of technology development. Therefore, an assignment on Situation of Health Risk Communication in Vietnam is urgent to collect inputs for defining practical and effective strategies for the 2019 – 2025 National Action Plan.

1.3. Objectives and Scope of Work

In this study, four areas are prioritized: (1) risk communication on infectious diseases (dengue fever, measles, and HFMD) and EIDs (human avian influenza type A, Zika virus, and Mers-CoV); (2) communication on risks of NCDs; (3) risk communication on unsafe food and food poisoning; and (4) risk communication on public health events (for example, health emergencies, medical issues, disease outbreaks after disasters, catastrophes, and severe weather). The assignment has the following objectives: Ø Situation assessment of risk communication from the central level to the local level in the four priority areas; Ø Public opinion survey on health risks and risk prevention practice in the four priority areas;

2 Ø Analysis of the public’s receipt and exchange of information on health risks in the context of technology and Internet development; Ø Study of the feedback mechanism and public engagement in risk communication process; Ø Study of the coordination among levels, sectors and relevant stakeholders in implementation of risk communication; Ø Proposals on risk communication implementation steps for the four priority areas, which will be the basis for a practical, suitable and effective National Action Plan. In addition to survey with relevant stakeholders at central level, the assessment was conducted in six provinces that are Hanoi and Lang Son in the North; Quang Nam and Da Nang in the Central region; and Ho Chi Minh City and An Giang in the South. Those provinces/cities were selected based on the following criteria: low vs high risk of epidemic threats; low vs high risk of natural disasters; high vs low incidence of media coverage; rural vs urban areas; and close to border/ having international ports or not.

1.4. Methodology

To analyze the situation of risk communication through the views of both the public and the government at all levels, both quantitative and qualitative methods are employed. For the qualitative survey, we have conducted: ü 20 KIIs with representatives of international organizations, international non-governmental organizations (INGOs), and officials of related ministries and media agencies such as General Department of Preventative Medicine, Vietnam News Agency, National Agricultural Extension Center, National Center for Health Communication and Education, Vietnam Food Administration (please see Annex 2 for details). ü 38 group discussions (with the total of about 300 participants), who are representatives of People Committee authorities, health sector, health communication staff, and of mass organizations (Women Unions, Farmer Asssociation,…) at all three levels (provincial/ district/ communal) (please see Annex 2 for details) ü 12 FGDs with local people in six selected provinces; each group was selected by a specific characteristic (people living in rural vs. urban area/ high vs. low education attainment/ high vs. low income/ Kinh vs. ethnic group/ elderly vs. youth/ family with small children). The details date and number of participants in the FGDs are listed in the Annex 2. It is noted that the FGD with representatives of Department of Health, of provincial People Committee, and mass organizations in Hanoi could not be organzied because of the short time announcement, they could not invite participants as planned. Therefore, the research team changed to conduct a key informant interview (KII) with the representative of Hanoi Department of Health. Qualitative data of KIIs and group discussion meetings with representatives of relevant stakeholders helps showing the overall picture of current government’s risk communication activities from the central to local levels; understanding practices of risk communication principles; and mapping out coordinations within health sectors as well as between health sector and other state- and non-state actors. The results of FDGs with local people contribute to understanding the public perception of health risks and their experiences in dealing with health risks; as well as exploring their involvement in health risk communication process.

3 For the quantitative survey, 1,009 households in six abovementioned provinces/cities were selected by the simple random sampling method. The survey contents were designed to colllect the public opinion on health risk related activities and assess results of current existing health risk activities. Data collected from questionnaire survey were cleaned before proceeding and analysing by STATA. Table 1: Selected provinces by different criteria

Criterion Risk of Risk of Incidence Urban/ rural Nearby Regions epidemics Natural of Media areas borders or

disasters coverage international ports Proposed High Low High Low High Low Urban Rural Yes No North Central South provinces risk risk risk risk

Hanoi X X X X X X

Lang Son X X X X X X

Da Nang X X X X X X

Quang Nam X X X X X X

Ho Chi Minh X X X X X X City

An Giang X X X X X X

In each province, we selected two districts: one in urban area and one in rural area. In each selected district two communes were also identified by the simple random method also (see Table 2). Then, we selected 40 – 451 households in each commune to survey. Sample selection is done by using a statistical software, ®STATA. We also set a seed number to ensure reproducibility of our sample selection. The sampling process is well recorded to calculate sampling weights, which are used for statistical analysis and national aggregation. The research team tries to attain a sufficient number of respondents for gender- based data-disaggregated analysis. The practical lists of households in each commune were finalized with consultation from the designated local guide. In the case that a selected household was absent or refused to participate in the survey, the team requested the local guide to choose another household nearby for alternative replacement. Table 2: Survey sites (Using ®STATA software for set seed) Hanoi Da Nang Ho Chi Minh City

Districts Commune Districts Commune Districts Commune

Phuc Loi Hoa Cuong Bac Thanh Loc Long Bien Hai Chau District 12 Thach Ban Hoa Thuan Dong Tan Hung Thuan Nam Son Hoa Chau Tan Hiep Soc Son Hoa Vang Hoc Mon Phu Minh Hoa Bac Xuan Thoi Son Lang Son Quang Nam An Giang

1 We selected 45 households in each commune in Ha Noi and Ho Chi Minh City; and 40 households in each commune in other provinces.

4 Hanoi Da Nang Ho Chi Minh City

Districts Commune Districts Commune Districts Commune

Districts Commune Districts Commune Districts Commune

Lang Son Tam Thanh Truong Xuan Long Dong Xuyen Tam Ky City Hoang Van Thu Hoa Huong Xuyen Binh Duc Yen Vuong Tam An Dinh Thanh Huu Lung Phu Ninh Thoai Son Yen Son Tam Thai Binh Thanh

Quantitative data is used to test the public perception of health risks as well as their protective behaviors. It is also analyzed to know about their access to health risk communication via different types of media; and about their ways to communicate health risk information with others.

1.5. Limitations of the Study

(1) Ambitious objective within limited time frame A major challenge to this study is its widely-covering objective within a limited time frame. The study analyzes the situation of risk communication in four priority areas, including: (1) risk communication on infectious diseases and EIDs); (i2) communication on risks of NCDs; (3) risk communication on unsafe food and food poisoning; and (4) risk communication on public health.. Each priority area requires its own risk communication principles and approaches. For example, in the area of infectious diseases, there are certain risks and uncertain risks of infectious elements, which accompany with their own requirements on the steps and their specific orders of the risk communication process. This is a challenge to designing the research tool and data analysis. Therefore, a situation assessment of risk communication provides only a preliminary view of how risk communication is being carried out in the surveyed provinces. rather than an in-depth effectiveness analysis of each health communication program for each specific disease. (2) Generalization of quantitative data Due to the seasonal immigration practice in the rural areas of Vietnam, young adults in working ages of many rural households often temporarily migrate to large cities or adjacent industrial zones to work. Therefore, a survey using systematic sampling (with the list of households in each commune) may not be able to reach this group of population. In addition, office employees, who are often absent from home during the daytime, are difficult to meet in the later time of the day as they spend time taking care of their children and housework. Hence, there may be discrepancy between the occupation structure of the sample and that of the total population. (see Table 3 below).

1.6. Demographic Information of the Quantitative Data

The Situation Assessment and Analysis on Health Risk Communication in Health sector was conducted in 06 provinces and cities of Vietnam. It engaged 1009 respondents distributed evenly among local areas. Specifically, there are 180 respondents in Hanoi, 161 respondents in Lang Son province, 160 respondents in Da Nang city, 163 in Quang Nam, 183 in Ho Chi Minh City, and 162 in An Giang province.

In terms of gender, 70% of 1009 respondents are female while the rest are male. The male - female ratio varies around 30 – 70 in the surveyed provinces. In Hanoi, the ratio is 33.3 – 66.7; 34.2 – 65.8 in Lang Son

5 province; 29.4 – 70.6 in Da Nang city; 30.7 – 69.3 in Quang Nam province; 25.7- 74.3 in Ho Chi Minh city; and 27.2 – 72.8 in An Giang.

Regarding the age of respondents, 62.3% of respondents are 24 – 55 years old; 27.3% are 55 - 64 years old. The youngest age group of 18 – 24 years old and the oldest age group of 65 years old and older account for 3.2% and 7.2%, respectively. All surveyed provinces share the same age structure. Specifically, the largest age group is 25 – 55 years old, followed by 55 – 64 years old; the group 18 – 24 years old and the group 65 years old and older account for the smallest.

About residential area, there is an equal proportion of respondents residing in the urban area and those in rural area, which are 50.1% and 49.9% respectively. All surveyed provinces have the same ratio: Hanoi has the smallest difference between the proportion of urban respondents and that of rural respondents (both 50%) and the largest difference is in Quang Nam (51.5% and 48.5% respectively). Table 3: Demographic profiles of survey respondents Hanoi Lang Son Da Nang Quang Nam Ho Chi Minh An Giang Total % No. % No. % No. % No. % No. % No. % No. Gender Male 33.3 60 34.2 55 29.4 47 30.7 50 25.7 47 27.2 44 30 303 Female 66.7 120 65.8 106 70.6 113 69.3 113 74.3 136 72.8 118 70 706 Total 100 180 100 161 100 160 100 163 100 183 100 162 100 1009 Age 18 - 24 1.7 3 3.7 6 3.1 5 1.2 2 2.2 4 7.4 12 3.2 32 25 - 34 13.9 25 21.7 35 11.3 18 9.2 15 12.6 23 19.1 31 14.6 147 35 - 44 16.1 29 27.3 44 20.6 33 16.6 27 23.5 43 23.5 38 21.2 214 45 - 54 25 45 17.4 28 32.5 52 31.3 51 24.6 45 29 47 26.6 268 55 - 64 34.4 62 26.1 42 23.1 37 34.4 56 26.8 49 17.9 29 27.3 275 65 + 8.9 16 3.7 6 9.4 15 7.4 12 10.4 19 3.1 5 7.2 73 Total 100 180 100 161 100 160 100 163 100 183 100 162 100 1009 Urban - Rural Rural 50 90 49.7 80 50.6 81 48.5 79 49.7 91 50.6 82 49.9 503 Urban 50 90 50.3 81 49.4 79 51.5 84 50.3 92 49.4 80 50.1 506 Total 100 180 100 161 100 160 100 163 100 183 100 162 100 1009 Occupation Formal area 16.7 30 5.6 9 18.8 30 18.5 30 22 40 29 47 18.5 186 Informal area 22.8 41 24.2 39 33.8 54 28.4 46 30.2 55 29.6 48 28.1 283 Agriculture 35 63 45.3 73 16.3 26 36.4 59 2.2 4 9.9 16 23.9 241 Do not work / 25.6 46 24.8 40 31.3 50 16.7 27 45.6 83 31.5 51 29.5 297 Have not worked Total 100 180 100 161 100 160 100 162 100 182 100 162 100 1007 Highest attained education level Do not attend 0.6 1 1.9 3 2.5 4 4.3 7 4.9 9 4.3 7 3.1 31 school Below elementary 2.2 4 9.9 16 3.8 6 3.7 6 10.9 20 21.6 35 8.6 87 education Elementary 7.2 13 18 29 27.5 44 28.2 46 29.5 54 30.9 50 23.4 236 education

6 Hanoi Lang Son Da Nang Quang Nam Ho Chi Minh An Giang Total % No. % No. % No. % No. % No. % No. % No. Secondary 40 72 30.4 49 31.9 51 34.4 56 24 44 13.6 22 29.1 294 education Upper-secondary 30 54 24.2 39 20 32 20.2 33 19.1 35 16.7 27 21.8 220 education Vocational training/ 15.6 28 8.7 14 8.1 13 3.7 6 7.1 13 3.7 6 7.9 80 Intermediate training/College University/High 4.4 8 6.8 11 6.3 10 5.5 9 4.4 8 9.3 15 6 61 er education Total 100 180 100 161 100 160 100 163 100 183 100 162 100 1009

In regard to occupation, the respondents in the formal sector, who work for registered establishments, account for the smallest part (18.5%), followed by those in the agriculture sector (23.9%) and the informal sector (28.1%) (small business owners, seasonal workers, or self-employers). The respondents who do not have a job, make up the largest part (29.5%). As explained above, this 29.5% group include people of retirement ages - age 55+ (30%), students and housewives/househusbands.

In terms of education level, the highest attained education level of most respondents are primary education, secondary education and high school education, at 23.4%, 29.1% and 21.8% respectively. Those who did not attend school, did not complete primary education or graduated from universities or higher education account for less than 10% of the survey sample. The respondents who did not attend school make up the smallest part, at 3.1%. Lang Son province, Da Nang city, Quang Nam province, and Ho Chi Minh city share similar education structure of respondents. In Hanoi, the respondents whose highest education level are secondary education, high school education, and vocational / college education, account for the largest parts: 40%, 30% and 15.6%, respectively; the proportions of respondents who did not complete primary education, completed primary education and those have higher education level are all below 10%; the respondents not attending school have the smallest proportion (0.6%). In An Giang, the proportions of respondents who did not complete primary education, completed primary education, and completed high school education are the largest at 21.6%, 30,9% and 16,7%; followed by the proportion of respondents at secondary school education level at 16.7%. The respondents who did not attend school, those completing vocational school/college and those with higher education level account for the smallest proportions, all below 10%.

7 SECTION II: KEY FINDINGS

2.1. Overview of Risk Communication in Health Sector in Vietnam

(i) Legal basis for risk communication in Vietnam

Risk communication was first introduced in Vietnam in 2011 and has become a priority topic in the Health National Program for 2012 – 2015. Specifically, the first National Action Plan on Risk Communication for the period 2013 – 2016 was developed. The Standard Operating Procedure (SOP) on risk communication in public health emergencies was completed in 2015; and a Manual Guide on risk communication for food safety was finalized in 2016. The Memorandum of Understanding (MoU) between the health sector and the agricultural sector in the One Health approach (prevention of diseases spread between animals and humans) has established a mechanism and provided guidance for information exchange among sectors.

The Law on Prevention and Control of Infectious Diseases issued on 21st November 2007 clearly states that: (1) prevention is the key and infectious disease information, education and communication and surveillance are regarded as major measures; (2) organizing inter-sector coordination and implementing social mobilization in the prevention and control of infectious diseases; integrating activities of prevention and control of infectious diseases into socio-economic development programs; (3) publicizing in a timely manner accurate information on epidemics. Therefore, health communication activities in general and risk communication in particular always consider as the most priority function in the prevention and control activities of infectious diseases. In addition, legal documents including a number of circulars and guidance are issued by Ministry of Health (MOH) to guide the implementation of risk communication elements. For example, Circular No. 54/2015/TT-BYT dated 28th December 2015 guiding the mechanism for informing, reporting and declaring infectious disease outbreaks is a fundamental legal document which regulates the obligations and tasks as well as the procedure of exchanging information in the health agencies. About the communication of infectious diseases originating from zoonotic diseases, Joint Circular No. 16/2013/TTLT-BYT-BNNPTNT on guidelines for the coordinated prevention and control of zoonotic diseases was issued on 15th July 2013 so as to consolidate the coordination, information sharing, and partnership between health sector and veterinary sector in risk monitoring and evaluation, reaction and disease outbreaks investigation.

Regarding organizational structure, three units under MOH are assigned to work as focal points in risk communication, including the Department of Communications and Award (in charge of press relation), the General Department of Preventive Medicine (GDPM) (in charge of communication on health emergencies), and the National Center for Health Communication and Education (in charge of behavioral change communication). During disease outbreak, MOH takes the key responsibility for information publication; the GDPM is assigned to be the mouthpiece of MOH. For the local contact point of risk communication at the provincial level and lower, Circular No. 51/2014/TT-BYT, issued on December 29, 2014, and regulated the functions, accountabilities, jurisdictions and organizational structure for the City/Provincial Center of Preventive Medicine under management of central level stated that these centers (center of preventive medicine) is the focal contact point to implement the risk communication activities and cooperate with relevance units to develop the sharing information - communication – education in the field of preventive medicine. In addition, to respond to the public health events and emerging infectious outbreak, Vietnam has also established various national steering committees, namely the National Steering Committee on influenza pandemic and emerging diseases, the National Steering Committee on natural disaster prevention, the

8 National Steering Committee on food safety (JEE, 2017). Component of Prevention and Control Disease Steering Committee includes: health sectors, finance sectors, information – communication sectors, military, polices, and other relevance sector in the corresponding level. The responsibility of Prevention and Control Disease Steering Committee was regulated in Article 46 of The Law on Prevention and Control of Infectious Diseases: developing and implementing the prevention method and overcoming the consequences of epidemic, setting up the mobile emergency teams to implement the epidemic emergency, treatment and handling. As stated, the responsibility of Prevention and Control Disease Steering Committee is worked during the epidemic outbreak. As a member of the National Steering Committee on influenza pandemic, the communication board includes participants from various agencies and has been completed at all levels of government to serve as the key agent for operational communication element in risk communication. Moreover, a team specialized in training and education on risk communication for the grassroots level has been formed with members from National Center for Health Communication and Education, GDPM, and relevant ministerial departments. Vietnam has established a legal framework and overarching mechanism for implementation of risk communication that covers its diverse aspects and facets. However, the existential problems in implementation of risk communication activities at all levels require further discussion that will present in the section 2.2 of this report.

(ii) How the concept of risk communication is applied in the context of Vietnam

The concept of risk communication was first introduced in Vietnam in 2011. However, until now, this concept has been understood and used heterogeneously within the health sector and among the other sectors, organizations and the public. First of all, this section explores the concept of risk communication and how this concept is being understood and used in the practice. According to the 2003 Ministry of Health’s guiding documents on risk communication and international documents (IHR 2005 and APSEP), risk communication refers to the real-time, multi-faceted and multi- level process of exchange of information among relevant stakeholders (including people at risks) in order to reach unified understanding of risks, to verify risks, and to cooperate to reduce risks. Risk communication requires organized and uninterrupted coordination among ministries, ministerial-level agencies, mass organizations, the private sector and international partners. Effective public risk communication should be performed via widely and timely providing people with precise and understandable information about the disease and its risk elements, promoting behavioral change for proactive prevention, sustaining public trust, and actively studying public opinions.

9 Box 1: A number of fundamental concepts related to risk communication

Hazards: is any event or phenomenon that has the ability to cause damage to humans and natural / social environment. Risk: is the probability of unexpected consequences as the hazard affects the public. Public Perception: the perception of individuals, groups, and the public on the probability of risk or the perception of scale, degree and amount of time of risk impact. Risk perception is dependent of cultural, social and economic characteristics of individuals such as education level, personal experience, public opinions, receipt information, etc. Therefore, different individuals or social groups have different risk perceptions of the same event/issue. Risk communication: Is the process of connecting relevant stakeholders (including people at risks) in order to reach unified understanding of risks, to verify risks, and to join hands to reduce risks. (Training manual guide on risk communication of Ministry of Health, 2013)

According to the results from consultations with health officials from the central level to grassroots level, few representatives of provincial Department of Health possessed basic understanding of the concept of risk communication while others participated in the trainings without remembering the details of concepts or principles of risk communication. The majority of officials from the district level and lower levels had never heard of risk communication. This situation indicated trainings on risk communication within the health sector were not widely or adequately implemented (had not reached health communication staff at grassroots level). Training programs on risk communication have been carried out since 2013 for provincial officials and several relevant central agencies; yet, the trainings were conducted unsystematically and the content of the training were not sufficiently applicable. As shared by a representative of National Center for Health Communication and Education, the training document on risk communication was first developed in combination with the National Program on Avian Flu Prevention. As the document was drafted for the first time (‘anything notable was included’), its content was complicated and confusing for the grassroots staff and difficult to apply in local practice. Similarly, a number of health communication officials at the provincial level revealed that they had participated in training courses or heard of training programs on risk communication a few years ago; however, the training courses took place only occasionally and unsystematically and were often made shorter (e.g., a 5-day training is cut down to 2-day training or even to 1-day training) from the central level to provincial level and the provincial level to grassroots level. In addition, related agencies did not have any specific plan in regards to sending their staff to training courses; i.e., each training has different participating staff from the same agency, rendering it ineffective; the practical situation was not suitable for application of the learnt knowledge that makes it forgettable. “Risk communication is not only warning people about the risk…” During the discussions about risk communication with grassroots health staff and officials of relevant sectors, the majority of them perceived risk communication as: informing people of the risks of each specific disease. This perception has affected the implementation of risk communication activities in the health sector at the grassroots level. In our later analysis on risk communication at the local level, the research team pointed out that the health risk communication programs, particularly at the grassroots level, were currently unsystematically carried out. The programs were mistaken as simply Information, Education and Communication (IEC) or the programs were limited within public awareness enhancement

10 approaches. In other ways the approach was a one-way delivery of information without the public perception being taken into account. “… yet requires cooperation to resolve risks” According to the training document on risk communication of Ministry of Health in 2013 (see Box 1), risk communication should not be a single effort of any agency, individual or organization; it is rather a connection between relevant stakeholders to resolve risks. In risk communication, cooperation and quick delivery of sufficient information among stakeholders is critical for making suitable decisions.

Box 2: Risk communication elements

Operational communication: is the process of timely internal exchange of information among leaders and managers, including health managers, clinicians, testers, policy makers and relevant sectors, to give timely decisions to respond to outbreaks and other public health emergencies. Behavioral change communication: is the process of development and implementation of health improvement programs to prevent public health risks, including: promoting self- protective behaviors and pubic engagement in health emergencies. Health emergency communication: is quick delivery of risk information and messages to people at risks and the public during the health emergency; to respond to public concerns and support actions in health emergencies. (Training manual guide on risk communication of Ministry of Health, 2013)

On such basis, risk communication under the guidance of WHO and Ministry of Health should include three fundamental elements: ((1) operational communication (frequent information exchange and update within the health sector and with relevant state management for timely decision making on risk responses); (2) behavioral change communication (interacting with the public to promote protective behaviors and promoting public engagement in long run with follow-up actions); and (3) communication in health emergencies (communication for the affected group/area/community under the principles of actively studying public opinions, reducing confusion and sustaining public trust). At present, the three basic terms in risk communication were ambiguously referred to in the communication programs on emerging severe diseases or in health emergencies even though these communication elements have been implemented (unsystematically). Whether these elements are suitable for application in all four priority areas (mentioned in the study objectives) is yet unclear. In practice, most health communication officials were not aware of or rarely mentioned these terms in the discussions about annual communication program planning and implementation. Three fundamental elements of risk communication (operational communication, behavioral change communication and emergency communication), according to the training manual of Ministry of Health, can/should only be applied in communication for outbreaks of infectious diseases, EIDs and health emergencies. Regarding the other two priority areas which are risk communication for food safety and foodborne disease outbreaks, and risk communication for NCDs, behavioral change communication should be emphasized. Therefore, it is difficult to have a one-size-fits-all action program for all priority areas. During the Assessment, the research team noticed a confusion in the use of risk communication terminologies among participants. As such, communication officials, health managers and policy makers

11 need to be informed on: (1) the circumstances and conditions under which risk communication is applied to; (2) similarities and differences between risk communication and general health education and communication; (3) how risk communication can be replaced or supplemented for general health education and communication in the four priority areas. To conclude, training on risk communication for health communication officials at all levels, policy makers and leaders of related agencies should be a key activity in the design of the National Action Plan 2019 – 2025.

(iii) Principles of risk communication and practical implementation of principles

Ministry of Health, with the support of WHO, has drafted an important document called Standard Operational Procedure of Risk Communication in Health Emergencies based on 05 fundamental principles of risk communication (see Box 3) and has guidance on specific implementation steps to ensure the compliance with these 05 principles. However, the document has not been disseminated widely and communicated to all levels in the health sector, which results in few officials having heard of the matter. Therefore, following these risk communication principles remains a problem.

Box 3: Five fundamental principles of risk communication

Early notice: Actively inform people at risks of actual or potential risks on public health; early notice should be conducted even before sufficient information is available; prevent rumors and false information. Ensuring transparency: Relevant communities or communities at risks are informed with precise, easily understandable information and in a timely manner on the actual and potential health risks. The necessary practice to prevent and control disease spread, and control measures issued by health management should also be communicated. Active listening: Understanding public perceptions on risks, public opinions and concerns is key to effective communication and better management of health emergencies. Detail planning (for each disease outbreak phase/public health emergency) Ensuring public trust Disseminating information via approaches that build, sustain and restore public trust towards management agencies.

(“Standard Operational Procedure of Risk Communication in Health Emergencies” - SOP, 2016) Principle 1_Early notice: actively informing relevant stakeholders and the public of risks (including certain risks and uncertain risks) is critical in health emergencies and disease outbreaks. If information of health risks is not publicized early by specialized agencies and competent authorities, doubts and unwanted rumors will form and damage the public trust. As a result, the situation might be difficult for the health management to control.

(+) Achievements

v Department of Communication Competition and Award and GDPM have made positive change in terms of information delivery “from being inactive in communication about disease outbreaks and public health emergencies into actively cooperating with relevant stakeholders and press agencies”. Leaders of communication units under Ministry of Health no longer avoid reporters;

12 furthermore, a closer relationship with the network of health reporters were shown. As shared by a WHO representative, Director General of GDPM had an address book of health reporters and maintained responsive relationship with them. v Creating “Reporter group” and direct interaction in the social media: these units actively connect with the network of health reporters; specifically, they create a “reporter group” in the social networking sites and frequently interact with the network. On one hand, this activity helps Ministry of Health’s specialized agencies share real-time information to the reporter group in order to deliver the messages to the public most effectively. On the other hand, this channel helps Ministry of Health’s communication units be informed of issues, events and information of public concerns. Therefore, the forming of reporter group is a crucial step in the relation between Ministry of Health and press agencies. Press agencies serve as the bridge between managers, policy makers, and experts to the public.

“Actively communicating information is beneficial to the health sector. The press will deliver information in a suitable manner and in compliance with the purpose of MOH”. – Interview with a health reporter –

v The health sector has developed an electronic reporting mechanism that allows real-time information exchange between the health management agencies and grassroots officials. (-) Non-achievements

v Delivered information has not satisfied the public’s demand: in health emergencies, the public should be informed of the risks they are facing with and which actions can be performed to protect the life and ensure the health and safety of themselves, their families and communities. However, at present risk communication has not been able to meet such needs.

“For example, at present while the public is greatly concerned with the hand-foot and mouth disease in Ho Chi Minh City, they [specialized agency of Ministry of Health] should update necessary information such as the number of recorded cases of new infections and number of deaths in the country (or of each locality), etc. We [communication agency of Ministry of Health] may announce that: there is a risk of disease outbreak in location ABC; however, the health sector is responding to the outbreak and the people should do the same to prevent the disease ”. – Interview with a health reporter –

v Specialized agencies of Ministry of Health including GDPM, Office of Ministry of Health, provincial Departments of Health, Center for Health Communication and Education, among others, have their own websites and share information on the websites; however, the information is not updated or specific, and lacks a warning effect. “We expect the health sector to build a website with sufficient and updated information, which is highly accessible to the people such as CDC website of the United States. However, we have not been able to do that.” – Focus group discussion with representatives of departments in Da Nang city –

v Although the health sector, particularly communication agencies of Ministry of Health, have made positive moves in risk communication, they still follow the media rather than taking a proactive

13 role in preventive communication. Ministry of Health’s agencies deliver information about the disease outbreaks and health events only when the events are popular topics in the mass media. “Risk communication should take a step ahead”

“In Vietnam, there is a habit of doing what is seen rather than doing what is yet to be seen; and the communication is taking the same approach. Preventive action against NCDs is commendable since it can be performed gradually. Preventive action against infectious diseases is very difficult.” – Interview with a health reporter –

v Many reporters said they often had to be the ones to initiate contact with specialized agencies of Ministry of Health and found it considerably difficult to get a response and especially precise information. Contacting the communication unit of Ministry of Health is easier than contacting the departments; the latter is quite difficult, they often refused to provide information right away without any later appointment. We had to ask the communication unit to ask for information; if there is any information available, much forth-and-back exchange is made before information reaches the press. In many cases, the information is already outdated. For example, in the case of HIV infection in Phu Tho province, we contacted the Vietnamese Administration of HIV/AIDS Control many times; yet, they replied that they had not had any official information. This was because they had not reached a conclusion with what information to share publicly. – Interview with a health reporter –

Principle 2_ Transparency: To ensure transparency of information in risk communication, particularly in uncertainties, there needs to be a clear mechanism for information delivery, feedback and information classification within the health system as well as outside the health sector for effective use of information by management and leaders in early detection and control of disease outbreaks. A difficult challenge to the health sector is sharing information in a timely and transparent manner while reducing public confusion and other disruptions in economic, political and social spheres. “Over-caution in information delivery” v According to several leaders of relevant departments and representatives of international organizations and press agencies, at present, communication agencies of Ministry of Health are overly cautious in delivering information to the public.

Here is an issue: they [leaders of Ministry of Health] are overly cautious before giving answers and hesitant to give precise information about an outbreak, specifically by saying “waiting for test results” rather than being straightforward as “there is ABC case at present, or there is a disease outbreak in that location”. After that, in order to avoid confusion, they [communication agencies of Ministry of Health] should affirm that “We are conducting investigations, researches, and tests, and the results will be available on date abc, etc.” At least, such information should be available to the press. –Interview with a representative of health reporter group –

v As explained by the stakeholders outside the health sector, the managers, particularly health managers, were “being obsessive of achievement and fear of responsibility”. Some practical examples were a hesitation to announce data about the actual cases of infection in the outbreaks,

14 such as vaccinable diseases such as measles and diphtheria. Health specialized agencies were afraid of affecting the vaccination achievements. “If the politicians were not overly obsessed with achievements, transparency would be possible” – Interview with a representative of an international organization –

v A “hidden” issue about information transparency lies at the grassroots level. When a disease outbreak was announced, many teams came to the area to work and check, etc. The grassroots health unit at the affected area was short of time and human resources to host the teams as they were fighting the outbreak. v “Being indirect and hiding information about the outbreak to the public” would cause unexpected consequences. A health reporter noted that, although the central-level agencies have become more active in information delivery, local agencies, including grassroots health agencies of large cities such as Hanoi, still avoided to provide actual information about the outbreaks. An example is the 2017 dengue fever outbreak in Hanoi.

We visited a commune where blanket production is a popular business in Thuong Tin district, Hanoi. They [authorities] said only a few people got infected and no one had any problem. When we took a drink in a nearby drink vendor, we heard all the households had infected people, that is, the disease spread in the whole village. When we brought this to the commune People’s Committee, we were told that villagers did not have the disease and the disease came from the outside. The issue here is that whether the disease came from the outside or the villagers had it, it had become a great outbreak. To prevent the outbreak, it should have been communicated with the public so they were aware of the dengue fever outbreak which is easily infectious, how one catches infections, what should be done. In this case, they tried to hide it; once it got worse, they became worried. – Interview with a representative of media –

Principle 3_ Listening: Active listening to the public might help health management understand the public perception, awareness, and concern about risks. On such basis, suitable messages could be delivered to promote self-protective behaviors within the public to handle the outbreak situation and other public health emergencies. v National Center for Health Communication and Education has a daily news section about disease outbreak information, which is posted on the Center’s website. This is considered an initiative of active listening. v The wide and strong network of grassroots health collaborators in all communes / wards across the country is a great asset of the health sector which enable it to reach each household and listen to the public opinions. v The 2016 Standard Operational Procedure on Risk Communication in Public Health Emergencies of MOH provides detail guidance on the active listening procedure. v However, this document has not been introduced to grassroots health units; therefore, guidance on specific steps of active listening for the grassroots officials and a clear public feedback mechanism are not available. Results from the focus group discussions with grassroots health officials showed that active listening skills of the grassroots officials were lacking in many areas.

Principle 4 _ Detail planning: According to the training manual on risk communication of Ministry of Health, communication planning includes the following basic steps: (1) evaluation of inputs, for example,

15 public accessibility and public perception; (2) development, completion and sharing of information and communication messages; (3) evaluation of communication effectiveness. Evaluation and monitoring of communication activities are mostly neglected v Although monitoring and evaluation of communication effectiveness is crucial in risk communication planning, and despite a number of leaders of the provincial Departments of Health expressing a desire to follow the planned steps, actions were yet to be implemented in almost all areas. v It is important to conduct rapid evaluations, which are performed before designing the communication program. This is as to develop communication plans that targets the beneficiaries. Yet, rapid evaluations have not been performed systematically from the provincial level to the grassroots level. Evaluation and monitoring have only been carried out for a few communication and community-development combined projects., which engage the participation of international organization(s). v After implementing a communication program, evaluation of its effectiveness is an important step; yet, this activity has been mostly neglected. v According to a representative of the GDPM, “good planning, yet restricted implementation” is a fundamental issue in risk communication planning. Some causes were noted as: o Inadequate cooperation among stakeholders; o Limited capacity of grassroots officials; o Limited budget: budget is unavailable in some places while in others budget is difficult to get imbursement; o Lack of a monitoring mechanism so that failure to implement the plan does not carry any consequences.

Principle 5 _ Ensuring public trust: information should be disseminated via the means that build, sustain and restore public trust in management agencies. Avoid “blame” messages Upon a disease outbreak or public health emergency, health management and health specialized agencies often send the messages such as “due to low vaccination rates in the areas” and “due to public incaution”. These kinds of messages might have adverse impacts, reducing public trust in health authorities’ capacity to handle and control the disease outbreak in public health. The 2013 measles outbreak in some areas is a typical example. In 2013, the measles outbreak in the Yen Bai province (later cross infection in National Children’s Hospital) is a harsh lesson for hiding information. When the event took place, it was agreed that people were not vaccinated and called it “areas of low vaccination rates”. However, the vaccination rate in all mountainous provinces is 99%; thus, this could not be 1% of risk in the context of such high figure. The question is whether the health sector hid information or whether the province made false reports. Another question is if they have always reported those numbers, why did they blame the vaccination rate? – Interview with a health reporter –

However, the KIIs with the representatives from MOH’s risk communication key agencies demonstrated quite a different view on the disclosure and transparency principles of risk communication. MOH’s specialized agencies have taken an active role in responding to the risk of disease outbreaks, and follow up closely the disease situation. They also show preparedness in their response measures; however, the

16 extent of information disclosure should be considered: “based on the assessments of the disease spread, risk elements of infection cases, means of infections, the possibility of disease related information creating an information crisis or unexpected rumors in the social networks” and “we have to answer the public with general advices, which focus on prevention of disease rather than disclose information that causes confusion” (KII with a communication official of MOH’s specialized agency). However, the specialized agencies have not been able to provide specific measures or assessment methods. It is important to note that MOH’s specialized agencies, press agencies and non-health agencies/organizations currently have different perceptions on the principle of timely and transparent delivery of information to reduce public confusion in risk communication. In conclusion, to promote compliance with the 05 principles of risk communication in emerging disease outbreaks, the National Action Plan on Risk Communication should focus on: Ø Enhancing the capacity of grassroots communication officials on the risk communication procedure. This should be in accordance with the Standard Operational Procedure on Risk Communication. Focus should be on the skills related to active listening and active delivery of information even in the situations where information is insufficient; Ø Promote suitable mechanisms to carry out regular monitoring and evaluation of risk communication programs at all levels. Ø Open a more flexible mechanism (expenditure mechanism, information disclosure mechanism, etc.) in risk communication in disease outbreaks and health emergencies. A non-health manager had the following suggestion to promote timely and transparent delivery of information even in the situations of uncertain risks: “Communication mechanism about outbreaks and health emergencies should have “rooms for errors” [upon announcement of uncertain risks]; which would make managers feel less pressured in publicizing information” – Interview with a non-health management official –

2.2. Situation of Risk Communication on EIDs and Public Health Events

(i) Communication on EIDs and public health events

In this report, assessment about risk communication on seasonal infectious diseases is presented in a separate section while that on EIDs and public health events is combined in this section due to the features and characteristics of each disease. As the infectious diseases normally have certain risks or are vaccine- preventable, MOH generally emphasizes behavioral change communication and pays a degree of attention to operational communication in its communication means. At the same time, emerging severe infectious diseases have uncertain and ambiguous risks, are urgent, quickly emergent and difficult to control that could lead to public health emergencies. Hence, risk communication programs for emerging severe infectious diseases and public health events, under MOH’s direction and guidance of WHO, focus on all three elements of risk communication, which are operational communication, behavioral change communication and emergency communication. “Effective management of a number of EIDs, particularly global ones” Previous assessments and studies showed that Vietnam has effectively performed risk communication both in terms of organizational capacity and coordination for emerging diseases such as H1N1, Zika, Ebola

17 and Mers-CoV (see Bao, Lan, Tien & Lien 2012; JEE, 2017). Results from FGDs with local agencies revealed that risk communication for global emerging severe diseases, such as H1N1, Ebola and Zika had been well implemented at the central level and large cities including Hanoi, Da Nang and Ho Chi Minh City. The relevant agencies actively responded to the situation; the inter-sectoral coordination was systematically carried out; the People’s Committee and People’s Council gave directions to relevant sectors; the “whole political system” was engaged at the maximum” – FGD with provincial departments in Ho Chi Minh city –

Regarding the guiding documents, the research team considered the Standard Operational Procedure for Risk Communication in Public Health Emergencies an important document that directed the implementation of communication activities in public health emergencies (including disease outbreaks). The document provides detailed instructions on the following issues:

• Coordination among the health sector and between the health sector and its communication partners. How to collect and exchange information before during and after the health emergency takes place; • Procedure for active listening (including information collection and feedback in the community, and getting updated and processing information in the mass media); • Procedures for development, finalization and exchange of information and communication messages; and the procedure for communication effectiveness assessment after announcing the end of a disease outbreak / health emergency. About the focal contact point, being responsible for coordinating such activities as: receiving, summarizing, analysing and sharing the information of urgent epidemic situations, MOH has established the Vietnam’s Ministry of Health Emergency Operations Center (EOC) under the supervision of MOH’s Steering Committee for the Prevention and Control of Emerging Infectious Diseases according to Decision No. 1424/QD-BYT Regarding the establishment of the Emergency Operation Center issued on May 2, 2013. EOC serves as the national coordination hub, run by the board of representatives of the GDPM, relevant representatives of MOH’s departments, agencies, offices as well as those from other agencies and units from related ministries, sectors and international organizations in Vietnam. Leaders and members of the EOC work concurrently with their current jobs and the Director of GDPM is undertaken as an EOC Chief. Beside the National EOC at the GDPM, Northern Vietnam EOC was established at NIHE (Hanoi) in 2016, and Southern Vietnam EOC was built at the Pasteur Institute Ho Chi Minh City (HCMC) in 2017. These EOCs play an important role in collecting, managing data and sharing the updated information about the status of a disease outbreak or other public health emergency affecting any of cities, provinces in the region, and timely announcing the warning about the unusual event of epidemic. For example, the EOC could track the situation of dengue outbreak and be able to recognize the unusual. Based on the analyse of data, experts could timely announce the focal contact point in the provinces/cities, and appoint epidemiological staff to work in the detected outbreak locations so as to control the outbreak. Additionally, the EOC also contributes on connecting the local health experts in Vietnam and international health experts and relevant units/organizations in order to enhance the prevention and response of disease outbreak emergencies capacity.

18 The One Health Communication Network (OHCN), whose members include specialized agencies of Ministry of Agriculture and Rural Development2 and Ministry of Health3, coordinated by the Secretariat Office of One Health Partnership, has facilitated a legal framework for inter-sectoral coordination in risk communication on EIDs transmitted from animals to humans (or from the interaction of humans – animals – ecological system), to engage the domestic and international resources at the maximum level and avoid overlaps among members. Regarding the coordination between health sector and other state- and non-state actors Operational communication has been executed with positive results at the central level. The Pasteur Institute in the South shared experiences about operational communication as follows: “Information related to disease outbreaks in the Southern area is directly shared with the provincial authorities to get verified. Based on their verification, the provinces identify whether there is a disease outbreak or a risk; if it is a risk, operational communication will be implemented systematically at the provincial level. For communication on disease outbreaks, Pasteur Institute of Ho Chi Minh city has developed a questionnaire related to EIDs and re-emerging ones. This document is consisted of questions (and answers) that help the local health system answer the questions raised by the government, press agencies and the public. The main content includes pathological mechanisms, disease transmission means, disease impacts, and recommendations to the public. When a disease outbreak occurs, this document is sent to the provincial authorities via email. The Institute might also use the questionnaire to answer and respond to the public via text messages; the Institute Director also uses the document to timely respond to the press”. – KII with a representative of Pasteur Institute of Ho Chi Minh city –

The sharing of the representative of Ho Chi Minh Pasteur Institute indicates a good coordination between city/provincial center of health and specialized agencies of MOH in management and sharing the internal information, as well as preparation for the speech mechanism in the emergency public health event, outbreak in the cities/provinces. However, the prepared documents only provide the general information on a disease (such as pathology mechanism, transmission, consequences, and some advises for the public). It is not easy at applying for all the situations of disease/epidemic/outbreak in the city/province. Therefore, if spoken persons at the grassroot level rigidly use these documents to provide information for the public, the provided information will not meet the public demand such that health journalists have reported. When discussing the internal and external coordination between local health centers and other related sectors, our research teams found that the local health communication officials at both the district and communal levels seem to be passive in implementing health communication program. They often implement communication activities when receiving the guidance of the upper level. Many centers of preventive medicine at district and communal levels only participated in the monitoring and managing

2 Specialized agencies of Ministry of Agriculture and Rural Development include: National Agriculture Extension Center, Department of Animal Health, Department of Livestock Production, National Institute of Veterinary Research, Management Authorities of CITES, Vietnam National University of Agriculture 3 Office of Ministry of Health, Department of Communication Competition and Award, General Department of Preventive Medicine, National Center for Health Communication and Education, and Agency of Health Examination and Treatment

19 information of the cases and clusters of case in the local when being informed from provincial or central level about the case of people living in the local. Currently, the local health sector in several surveyed areas is conducting the organizational restructure such as establishing the CDC by merging the local center for preventive medicines, the center for health education and communication and education, the center for primary healthcare and the center for population and family planning. Besides, some other district health units merged the center for preventive medicines and unit of medical examination and treatment into District Health Center. Those organizational restructure are implemented with attempts to enhance the coordination among specialized units of health sector in each level. Nonetheless, the merger is not consistent among districts and it was starting to merge in some districts at the surveyed time. Therefore, it is not enough practical evidences to evaluate the effective of the coordination before and after the merger. Several officials in the provincial health center expressed their concerns about the effective of communication activities after merging. The process of organizational restructure is narrowing down the health communication unit, which has been suffered from the shortage of human resource. Furthermore, the voice of communication units would be more restrained and the financial autonomy would be reduced after merging. In addition, the district communication units also shared their concerns about the human resource problems after merging with unit of medical examination and treatment: “…the number of staff working in preventive medicine would be reduced because no-one want to work in this unit due to lower income in comparison with working in medical examination and treatment units. Therefore, after merging process, several staff in the preventive medicine unit may try to move to the unit of medical examination and treatment because of much higher income”. – KII with a representative of Pasteur Institute of Ho Chi Minh city – Regarding to the coordination mechanism of health sectors and relevant units/departments of other sectors in the public health event and newly infectious diseases, the research results indicate that guidelines about the coordination procedure (which is precisely mentioned in the SOP) is not applied particularly and concretely in practical activities. Although there are some legal documents inside and outside the health sectors, during and after the public health events, these documents did not disseminate in whole health sector. Besides, developing the overall risk communication plan, containing the component of coordination mechanism between health sector and other state- and non-state actors, did not implement in almost surveyed area. Therefore, they were not ready to coordinate in the specific communication activities. Moreover, according to opinions of some representatives of specialized departments of health sectors, the relevant departments/units also believed that health risk communication is responsible by health sectors only (except some cases with the steering guideline of Government and/or of Minister). Currently, the risk communication activities of some epidemic still have some problem in the coordination between Department of Health, Department of Agriculture or aerial port at the airport, as shared in the previous meeting, the general reason is because of no detailed local coordination procedure, and lack of evaluation activtiies to identify what are the missing points, to help us improve our performance. – FGD with officials of Da Nang International Health Quarantine Center –

20 About disease prevention issues in the private sector (such as in industrial zone and large manufacturing factories with large employees) preparing and monitoring the early warnings of infectious diseases in these areas is important, to avoid the risk of out-of-control disease outbreaks. However, according to the sharing of the representative of Pasteur HCM, the coordination between Provincial Center of Preventative Medicine and the private sectors in the monitoring and sharing information about the status of diseases, and the outbreak is currently difficult. A reason is that there are no detailed legal documents or regulation on the coordination between the local center of preventive medicine and the board of industrial zone management. Relating to the level of management, the management board of industrial zone is under the management of the Government, the local center of health could not directly request for the monitor coordinating and sharing the updated information. Regarding to planning and implementing the procedure of risk communication Risk communication procedures have not been carried out systematically and sufficiently in all public health events at all levels. However, as pointed out by this study, the SOP on risk communication in health emergencies has been carried out only at the central level; health communication agencies at the provincial level and lower levels were still not active enough in planning and depended greatly on the central level’s instruction. “The SOP for 03 elements and 05 principles has been available since 2015; yet, it was not applied widely on the local level. When a health emergency or EID outbreak took place, it took several days for a few steps of the SOP to be implemented at the local level. And this was only after the Minister gave direction”. - FDG with relevant provincial departments in Da Nang city.

In communication of EIDs and health emergencies, the active role of each communication agency is crucial. The health communication and management agencies at provincial level and at lower levels should be acquainted with the SOP. An example of this was how the Da Nang International Health Quarantine Center carried out risk communication programs for EIDs and health emergencies. This was due to the Center’s leaders having a strong understanding of risk communication principles and being active in every activity rather than relying on the top-down instruction. The officials actively studied SOP online and gradually applied the knowledge in the Center’s communication. It was the only provincial agency that was well accustomed with the SOP and the IHR. When there was an early sign of a disease outbreak, before the Minister of Health gave directions, we actively developed a preventive plan; however, our plan is not as detailed as in the SOP. I think the SOP is very good, but it has not been applied in the area. I do not know why. The SOP explains each component, each phase and promotes inter-agency coordination. If we understand the SOP, we can take an active role right at the beginning and make a step-by-step plan. It would be better. Then we conduct a re-assessment. – FGD with officials of Da Nang International Health Quarantine Center –

Another question is: why has risk communication been performed well only in some specific public health events rather than systematically in all disease outbreaks? This could be due to EIDs being urgent events and difficult to control. They pose threats to national/ global health security; which would attract international and public attention. Communication on these diseases could mobilize financial and technical resources of relevant stakeholders, including, international organizations, get the attention of government leaders and potentially engage the whole political system.

21 “In our country, risk communication sometimes receives too much attention while other times is neglected. For example, during the Ebola outbreak, Ebola was mentioned everywhere. MERS- CoV, on the other hand, was also a severe disease; we saw it having higher contamination rates than Ebola. If a person carrying Ebola virus was detected, he/she would be timely isolated then it would be ok. However, those who carried MERS-CoV were difficult to detect and we could not identify them. The passengers went everywhere while we could not control it. Yet, communication about MERS-CoV was not conducted adequately. We even had to call the GDPM and Mr. Q [provincial Center for Health Communication and Education] to supplement leaflets about MERS-CoV to give to the passengers. Thus, I think we still respond to specific emerging issues rather than taking an active approach in communication” – FGD with representatives of relevant departments of Da Nang city –

As shown in FGDs with communication officials from grassroots health agencies, communication and sectoral coordination for the issue/event/disease outbreak that receives the attention and direct instruction of Ministry of Health’s leaders and government leaders at all levels are generally unproblematic and likely to be successful. The previous experiences in responding to EIDs in Vietnam showed that communication in health emergencies has been able to respond quickly to the situation thanks to the rapid engagement of the whole political system and top-down instruction from the central level to the grassroots level. However, such strength has not been enforced in all disease outbreaks or public health events. Operational communication activities as well as the coordination between different units within the health sector and between the health sector and other relevant sectors was implemented in the central level and in some provincial health departments, and became key element but these activities are not implemented consistently at the lower levels. Efforts are spent on temporary solutions instead of a comprehensive and long-term plan. This comment was made by a representative of a Ministry of Health’s research institute on risk communication situations. This opinion was agreed by several non-health partners: “the current communication programs on infectious diseases still focuses on the stage “when the disease outbreak has occurred”, that is, focusing on responding to the situation when a disease outbreak has happened with emphasis on outbreak combat rather than outbreak management. Hence, the current situation of risk communication in public health events in Vietnam, as described by the representative of an international disease control agency, is “responding to specific emerging issues rather than taking an active approach in communication”. The coordination mechanism among relevant departments in communication for public health events and EIDs has not been applied sufficiently or focused. Although there are official documents on coordination within the health sector and between the health sector and non-health agencies before, during and after the public health events take place, these documents have not been delivered to all communication units of the health sector. In addition, comprehensive planning for risk communication, including planning on sectoral and inter-sectoral coordination, has not been implemented in almost all surveyed locations. Hence, non-health agencies were often unwilling to cooperate in specific communication activities. Several leaders of health specialized agencies also noted that relevant agencies still considered risk communication for disease outbreaks as only a task for the health sector (except for when the central government or relevant ministers give an official instruction).

22 At present, the problem with risk communication for disease outbreaks lies in coordination between the provincial Department of Health, the provincial Department of Agriculture and Rural Development and the International Airport. As previously mentioned, the reason is the lack of a specific coordination procedure as well as a need for re-assessing work in the area; because of this, we do not know which step of the SOP have been overlooked, and we do not know how to improve our work. – FGD with officials of Da Nang International Health Quarantine Center –

Regarding to the finance for communication activities in the emergency health event, the representatives of health department at the central level and some unit at the provincial level such as Hanoi Center of Preventive Medicines, Center of International Medical Quarantine, and representatives of communication units at the central level shared: the current rigid financial mechanism made the communication activities difficult in the public health event. For example, regulation on bidding with the expenses from 20 million VND is not adequate for the current implementation of emergency public health events, or there are some situations which do not promulgate the epidemic disease but the grassroots health staff members have to work in communication section as promulgated epidemic disease, but they do not receive the extra grant or do not have the detailed regulations in the mobile finance budget for the unit working in health communication of emergency public health events; … In conclusion, risk communication for EIDs and public health events is costly and requires long-term planning, which requires the active efforts of health specialized agencies, the strong leadership of government leaders at all levels, the engagement of the whole political system, and most importantly the close coordination between health specialized agencies, the health sector and relevant sectors. Therefore, financial and technical supports of international organizations are needed. The study also pointed out the strengths of current risk communication programs, which is a favourable legal framework, the quick engagement of the political system, and the sectoral top-down instruction in emergencies. However, risk communication at present still focuses on handling outbreaks, without a comprehensive risk communication plan covering three stages: pre-outbreak stage, outbreak stage and post-outbreak stage. There is also a lack of systematic coordination among relevant sectors at the local level, which at current stage is an inactive dependence on top-down instruction. Without a clear coordination mechanism or specific assignment to each health and related non-health agency in every communication plan, an active coordination is almost impossible. Moreover, planning, monitoring and evaluation of risk communication activities have been largely neglected. Furthermore, the inflexible finance mechanism would obstruct the communication activities in the emergency health events. Several recommendations have been made for enhancing risk communication in public health events and EIDs as follows: Ø MOH’s communication agencies should actively construct scenarios; Ø Develop corresponding plans; Ø Discuss and reach agreement with relevant stakeholders and grassroots health agencies about necessary response steps for each scenario; Ø After that, provide instructions to grassroots agencies and relevant sectors (according to the issued regulations, instructions and other documents) for each scenario; Ø Develop communication messages for each scenario; Ø Select the target group; select the communication channels and messages suitable with the target group; Ø More importantly, carry out monitoring and evaluation of risk communication implementation.

23 (ii) Risk communication on infectious diseases

Behavioral change communication is considered the main communication mean to promote people’s active use of preventive behaviors against seasonal infectious diseases in Vietnam. According to the Risk Communication Plan for 2013 – 2016 of MOH, key behavioural change communication activities include: developing communication materials, distributing them to the public via the extensive health network, delivering communication messages in the mass media (before and during the outbreak), and conducting direct communication in the community to promote preventive behaviors in the public. At present, behavioural change communication in the community is executed via three extensive health networks that cover the whole country and is capable of reaching every community and even household. The three networks are: (1) health communication and education network at all levels, (2) preventive health network at all levels, (3) grassroots collaborator network (village/hamlet). In addition, when an outbreak occurs, mass media and social networks are selected as the main channels to quickly deliver necessary information to the public. For information to be delivered consistently, precisely and coherently, MOH uses press releases drafted by its Communication Board in the form of official documents sent to relevant stakeholders and press agencies. At the local level, based on the messages delivered by Ministry of Health’s specialized agencies and instructions of the National Steering Committee on disease prevention, grassroots communication networks execute communication activities in the community, which are developing and distributing the communication materials suitable with local characteristics, or organizing public engaged communication events. The survey results showed that the popular communication means for infectious diseases include: - Loudspeaker system and local broadcasting outlets; mobile communication means are also utilized in several remote areas; - Panels and slogans in public places; - Household visits for providing direct consultation and delivering leaflets; - Direct communication sections in the community. However, behavioural change communication is not only the delivery of recommendations and warnings about the diseases or the dissemination of preventive measures to the community at risk, it also includes the strategies that promote self-protective behaviors of the people as well as their responsibility to public health. Therefore, behavioral change communication has a long-term nature with regular follow-up activities. As previously discussed, the majority of grassroots health officials and officials of related sectors understand risk communication as informing the people of the risks of a specific disease. Such an understanding has greatly affected the selection and application of risk communication models in practice. The results from FGDs with local departments of 06 surveyed provinces show that current communication activities on prevention of seasonal diseases at the grassroots level currently focus on enhancing public awareness. As a result, these activities follow the health communication and education model, which does not facilitate the exchange of information, rather than applying the participatory approach in behavioural change communication. Moreover, as public perception of risks is not taken into account in these activities, the delivered recommendations might not suit all of the target groups or fail to attract public interest/engagement. However, in recent years, risk communication on infectious diseases has progressed to a certain degree:

24 v In terms of planning, communication agencies at all levels have actively developed a communication plan for prevention of seasonal diseases before the outbreak. v The coordination within the health sector in monitoring, sharing and managing information about the diseases at the local level has significantly improved thanks to the application of an online reporting system. o As an example, the representative of the provincial Center for Preventive Health of An Giang province provided detailed information about the procedure base on which mouth-and-foot infection cases were verified quickly from the provincial level to the commune level within the health sector, the identification of the radius of the surveillance zone, and the control and exchange of information with the communities where the infection cases were detected. o Area-at-Risk management model in preventive health and “focused on-site communication” are successful examples of the combination between grassroots health communication and risk management in the community:

When the disease spreads in an area, on-site risk communication will be conducted right away, for example, hanging panel with the message “This is a disease affected area, the following behaviors are recommended…”. At first, people reacted negatively. However, after a while, the disease outbreak was eliminated. As the outbreak had ended within 15 days, this method gained people’s trust and support. - FGD with provincial departments of Ho Chi Minh city – v Ministry of Health’s specialized agencies have actively applied diverse communication means, such as application of information computer technologies and social networks. Several examples are: o Display behavioral change communication messages on the specialized agencies’ websites; o Connect with Viettel Group to run a software that reminds mothers of young children to get them vaccinated according to the recommended schedule via SMS; o Form groups on social networking sites to carry out behavioral change communication for the target groups. For instance, in a new model executed in Ho Chi Minh city, a Zalo group was formed to communicate about disease outbreaks and organize offline member meetings. v Regarding communication messages, several health specialized agencies have considered social and cultural characteristics of the target groups, such as ethnicity, region, culture, among others, to develop suitable communication messages. An interesting example is the communication model on the prevention of dengue fever in pagodas in Hoc Mon district – Ho Chi Minh city.

25 Box 4: Behavioral change communication model for the target group

In the dengue-fever prevention program in Ho Chi Minh city, a contest on behavioral change communication model was organized for grassroots health communication agencies. The first prize came to the commune health station of Truong Xuan commune – Hoc Mon district for persuading the Buddhist monks of Hoang Phap pagoda in eliminating larvae to prevent dengue fever. Hoang Phap pagoda is a large pagoda in Hoc Mon district, where a large number of monks, nuns, and lay Buddhists reside and visit for spiritual cultivation. Therefore, the pagoda is at high risk of a dengue-fever outbreak when a few people get infected. The grassroots communication group of Truong Xuan commune’s health station saw the concept of killing living beings in Buddhism as a cultural obstacle to behavioral change communication for this group. Specifically, the monks believed eliminating mosquito larvae is killing and a Buddhist taboo. To persuade the monks to eliminate mosquito larvae in the water-logged areas in the pagoda such as miniature landscapes (tiểu cảnh non bộ), gardens, among other, the grassroots communication group applied direct communication skills based on their knowledge of religion and culture in the pagodas.

o The communication mean applied in Binh Thanh commune – Thoai Son district – An Giang province is also a good example. The communication staff of the commune health station and relevant departments applied people meetings and group meetings in the coffee shops in the village and provided leaflets in the shops. In this example, communication activities were customized to suit the local populations habit of hanging out in coffee shops, whilst utilizing the large number of these shops in the local area (around 10 shops/village). However, as most of the customers are male, this on-site communication mean might cause an imbalance in access to health communication between male and female groups. v In terms of mobilizing resources for risk communication, Pasteur Institute of Ho Chi Minh city cooperated with the private sector to implement the communication activities for the target group. Details as follows: o The Institute collaborated with Sanofi (a private health care group) to communicate with students – a target group - about dengue fever, in high schools via direct communication in computer science classes. o In addition, the Institute cooperated with the schools to reach the parents (the majority of whom work in industrial zones) via SMS based on the electronic parent-school communication platform. Besides the achievements, the communication programs on infectious diseases have limitations for which improvements are needed in the future: “The communication programs on disease prevention at the local level are rigid and unadapted” v Except for a few communication agencies that have initiatives in applying diverse communication models to reach the target groups as mentioned above, communication activities regarding infectious diseases are generally rigid and mostly follow the health communication and education models that use conventional communication channels. v At the district and commune levels, risk communication activities still focus on outbreak elimination and one-way (increased) communication which is underlined by the idea that a disease spreads quickly due to the public being incautious.

26 v Even in several surveyed provinces, districts and communes, health communication and education is conducted weakly and oftentimes neglected. Several reasons were mentioned: o The limited capacity of grassroots officials who generally handle multitasks and run various programs at the same time, particularly those of commune health stations. o In recent years, as the National Center for Health Communication and Education has merged with the Department of Communication, Competition and Award in terms of operation mechanism, grassroots communication officials at the provincial level and lower levels have tended to not participate in any training / capacity building activity. o The budget for preventive area in general and for epidemic prevention communication in specific restrictive; and suffers substantial budget cuts. “The message has not caught the public interest” v As the concern, knowledge and perception on risks of the target groups are generally not considered in the communication programs, they fail to catch the public’s interest. They usually use a one-size-fits-all message. o For example, the communication program on prevention of dengue fever in the central wards of large cities failed to persuade the better-off households to practise preventive behaviors, despite the fact that the program was launched extensively with relevant departments’ effort to persuade every household. v Although MOH and its specialized agencies have endeavored to utilize diverse communication models using novel channels, such as posting information on their websites, they failed to identify the key audiences to design suitable communication messages and information. v The grassroots communication agencies focus only on the topics/diseases in line with the national target programs and the top-down instructions, and ignore rather than actively communicate the infectious diseases emerging locally (due to the unavailability of related programs). o For example, in several areas in Quang Nam province, a toxocariasis-related disease in humans was detected, causing public concern. Many households formed groups to / several private organizations in the local areas directly sent the suspected infected people to get examinations in local hospitals such as Quy Nhon hospital and Pasteur Institute of Nha Trang city. The grassroots health agencies knew about the disease situation; yet, they mostly had not received any action to communicate about this new infectious disease. To conclude, behavioral change communication programs on infectious diseases require comprehensive improvements on communication planning, design of communication messages, selection of suitable communication means for each specific disease and target group, taking into account the factors such as geographic features, economy, culture, ethnicity, language and especially the public interest and demand of each specific location. Regarding communication messages, grassroots communication agencies should identify which information should/must be shared and to whom rather than using a one-size-fits-all message. Furthermore, we should know that designing message contents is a must, but BCC needs much more than that. BCC requires many other important activities such as setting up informal community networks and feedback channels to interact with the public in community; identifying cultural, social and economic factors that may affect behavior change; and creating appropriate stakeholder coordination. Therefore, regular capacity building for grassroots health officials and training on risk communication skills for officials at the district level and lower levels are critical for effective implementation of the National Action Plan on Risk Communication in the community.

27 (iii) Risk communication applied to food safety

Food safety and the disease risks resulting from consumption of unsafe products is foremost concern of consumers at present. “Dirty food” is a term commonly used by the public to refer to unsafe types of food. How to choose safe types of food and how consumption of unsafe food affects health and its associated disease risks, particularly cancer risks, are the topics that attract people’s interest in FGDs. However, the current communication programs on food safety have not provided adequate answers or solutions to this concern. Too many warnings on unsafe food without sufficient alternative suggestions cause confusion and damage public’s trust. Opinions of the people participating in FGDs and those of grassroots health officials demonstrated a high level of concern in the community: people are worried because food is sold everywhere without examination. Consumers are unable to distinguish and also have no tool to distinguish between safe food and unsafe food. The information of unsafe source of food but no solution for alternative source makes the public confused and disbelieved.

Box 5: Warnings about unsafe food without alternative suggestions add confusion and damage public’s trust

Never before has the phase “unsafe food” mentioned that much. Every day, the media constantly covers this issue. For example, the information about pigs with exceeded salbutamol residues, chicken with antibiotics residues, bleached tofu and plaster-mixed tofu, artificially ripened fruits, beverages made from chemicals, confectionery production using color agents without a clear origin, among others. This is the reason why people are always confused and worried about the origins of their daily consumed food. All types of food products are sold everywhere and it is very difficult to distinguish between safe food and unsafe food.

– Health and Live Magazine dated 24/2/2018 –

The goals of food safety risk communication are to enable people to protect their health from food safety risks by providing information that enables them to make informed food safety decisions4. However, the key obstacle to food safety risk communication in Vietnam is the inadequate control for food safety. Processed or non-processed food products that are fake, expired, having low-quality or containing toxic chemicals are prevalent. The state management agencies have not had any feasible or effective mechanism to manage this issue. The majority of current food products in the market are produced by individuals, households and small businesses in the informal sector. There is over 500,000 food processing establishments, most of which are small-size businesses and households that have their products made by hands and only in a certain time of the year. In addition, their operations are generally not checked, supervised, or required to comply with specific procedures on food safety and sanitation. Hence, MOH’s communication agencies will find it particularly difficult to design a message with clear instructions on how people should do to avoid unsafe food.

4 WHO, Handbook: Risk Communication applied to Food Safety, 2016.

28

A Photo taken in the commune health station of Hoa Bac commune, Hoa Vang district, Da Nang As the research team observed, the food safety communication program of the health sector for the public has been able to deliver the message: “Purchase and consume only products with clear origins” via the panels and slogans displayed in the public places. Nonetheless, these communication programs failed to point out which are “products with clear origins”, where people can purchase these products suitably with their geographical, economic, cultural and social conditions, and whether the “products with clear origins” (e.g., poultry meat with veterinary certificate) are trustworthy or not. Before 2014, in combination with the Avian Flu Prevention Program, MOH and grassroots health agencies collaborated with local food safety and sanitation departments communicated to people about the consequences of consuming infected poultry meat and instructed people how to choose, process and cook poultry meat to avoid disease transmission from poultries. With the technical and financial supports from various sources (both from international sources and national project budgets), the communication program was well executed and complied with most of the behavioral change communication principles for each target group. Moreover, the message “boil it, cook it” that prevent disease risks is still disseminated via several communication means, such as panels, posters, and flyers in some rural and remote areas of the surveyed provinces. In FGDs with local departments, regarding communication related to food safety, the representatives of local departments and the agencies in charge of food safety management often mentioned their experiences in communicating to individuals and households doing business in outdoor markets and small markets to enhance their awareness on processing/trading safe food products or “clean” food. The main communication means were direct communication and training. The food safety communication programs for the public were not indicated or implemented in the surveyed areas. MOH, with the technical supports from international organizations, including WHO and Food and Agriculture Organization of the United Nations (FAO), organized several training courses on “food safety risk communication” for representatives of related agencies, such as provincial food safety departments, regional institutes of hygiene and epidemiology, Department of Communication, Competition and Award under MOH and related agencies of the Ministry of Agriculture and Rural Development. However, few training content and knowledge have been applied in communication activities in practice. In conclusion, food safety risk communication is largely neglected while the people take all risks themselves without any other choice: “we are confusing but we still have to consume food”.

(iv) Communication on risk behaviors applied to NCDs

The prevention of NCDs (including cancer, cardiovascular disease, diabetes, chronic obstructive pulmonary disease, asthma and other NCDs) is the predominant focus of a national target program in the health sector. The national strategy on the prevention of NCDs between 2015 – 2025, was approved by the Prime Minister on 20th March 2015, and listed specific objectives on communication as follows:

29 (1) Enhance public knowledge (with a focus on adults) about NCDs and their impacts on public health and the socio-economic aspects of the country, as well as related prevention principles; (2) Reduce main risk behaviors that lead to cancer, cardiovascular disease, diabetes, chronic obstructive pulmonary disease and asthma; The identified risk elements of NCDs include smoking, alcohol abuse, inadequate nutrition, unsafe food, and lack of physical exercise. In addition to the specific objectives, several measures for communication and social engagement are pointed out in the national strategy as follows: o Use the communication and information network from the central level to the local level to disseminate information and promote governments at all levels, sectors, social organizations and encourage people to follow the strategies, policies, legislations, and recommendations on the prevention of NCDs. o Develop communication materials. o Promote health improvement communities suitable with specific region and target group, with a focus on schools /work places /cities for health. o Propose launching the campaign all the people live healthier lives, incorporated with prevention of non-communicable communicable diseases.

A photo taken in the district health center of Hoa Vang district – Da Nang city The research team observed that, in the study results, MOH has not had any comprehensive program on risk communication (or communication on risk behaviors) for NCDs according to the direction of the

30 National Strategy on Prevention of NCDs. This finding is supported by the opinion shared by the representative of an INGO which has been carrying out many supports for the prevention of NCDs.

For the programs on prevention of NCDs to have long-term effectiveness, the community interventions should focus on a comprehensive approach that affects the risk elements and on communication for people to understand about risk elements, besides the macro-level policies. At present, interventions are conducted only when the disease occurs while preventive measures are unsystematic. Specifically, a lack of connection is noted: preventive measures are executed only for single risk element; and each agency is in charge of communication on a specific risk element. For example, the nutrition institute takes responsibility for nutrition; the agency in charge of recommendations for promoting physical exercise is still unknown; it should not be the agencies in the areas of culture, sport and tourism. Communication on risk elements is executed unsystematically without a focal point. - KII with the representative of an INGO –

A communication official in charge of NCDs in Da Nang city also noted the limitations of this activity: “at present, we have data on the situation of in-infectious diseases in the city. However, we do not have any solution for communication on risk elements of these diseases to the people or promoting elimination and reduction of alcohol consumption and smoking. We, as the communicators, do not even know the effectiveness of our communication work, despite making tremendous efforts for it”. At the district and commune levels, many officials noted that there have been instructions for implementing communication programs on NCDs in recent years; however, few activities have been carried out due to the lack of budget and time. As the research team observed, in 06 surveyed provinces, communication activities on NCDs currently focuses on the National Program on Prevention of High Blood Pressure. The program’s objective is informing people about strokes and the importance of blood pressure control, promoting health screening tests and blood pressure monitoring, and providing screening measures for people at risk of high blood pressure and cardiovascular disease, etc. High blood pressure prevention activities have been performed adequately in all surveyed areas; yet, they mainly emphasize screening and management of high blood pressure patients in communes / wards. Regarding communication means, the communication program on prevention of high blood pressure still focus on enhancing public awareness on hypertension and control measures via health communication and education approach (or information – education – communication). At the grassroots level, main communication activities are: o Print communication materials: display of panels and slogans in health agencies. o Broadcast warning programs about hypertension on the local television channels o Disseminate knowledge about hypertension via the loudspeaker system in all communes o Distribute leaflets and flyers to all the people At the central level, the communication programs on hypertension prevention are conducted via coverage and periodical sections on Vietnam Television channels (VTV), the Radio Voice of Vietnam (VOV), newspapers, magazines, and local media. Some examples of communication content are “for a strong heart”, “live healthily”, “being happy, healthy and helpful”, and “the hour for the heart” Communication activities on NCDs conducted by grassroots health agencies still focus on screening (screening test and monitoring); comprehensive preventive communication programs on risk behaviors remain unavailable.

31 In addition to the program on hypertension prevention, WHO coordinated with MOH to implement several communication activities on the prevention of the adverse impacts of smoking at the central level and in large cities. For example, a media campaign on respecting non-smokers was carried out to promote a non-smoking environment for the respect of oneself and for others. Furthermore, several non- governmental organizations have conducted some communication activities on preventing the adverse impacts of smoking and alcohol consumption on the public health, and programs on promoting physical exercise and changing diets for disease prevention. However, these efforts were carried out without a comprehensive program or coordination among implementers.

WHO’s supports for communication are very helpful. However, a comprehensive program on risk communication or risk elements for NCD is still absent.

In the coming time, WHO should focus on preventive measures rather than interventions as at

present. They should focus resources to resolve those risks, carry out pilots in the communities so that a specific community be able to resolve all those risks, and conduct communication to enhance public awareness on risk elements to resolve local issues. The pilot should be carried

out in several provinces. After that, if the pilot proves to be effective, the Government will scale it up. – KII with the representative of an INGO –

The existential problems in risk communication programs on NCDs include: - The communication programs on NCDs still put an emphasis on intervention, screening and management of patients while a comprehensive communication program on disease prevention or promoting positive behaviors such as changing diets, taking physical exercise, and avoiding risk behaviors such as smoking or drinking alcohol remains absent. - The communication programs on risk elements of NCDs, such as the programs on prevention of adverse impacts of smoking and prevention of alcohol abuse and the nutrition programs. are conducted unsystematically without a connection among the programs or a comprehensive coordination among related sectors and implementers. - The communication means mainly follow the health communication and education approach while behavioral change communication models that focus on the target groups have not been applied. - Similar to the communication programs on the priority areas as discussed above, the communication programs on NCDs totally lack evaluation activity to assess the communication effectiveness.

2.3. Public concern and perceptions of health risks

This section analyzes the quantitative results of the study which has been conducted in 06 provinces to give a practical view on the public perceptions of health risks. In the survey, people were asked about the local issues affecting people’s health without giving them a set of answers to choose from. As a result, the majority of respondents (64.3%) said that there was currently no issue in their communities. Some mentioned issues include environment pollution (smoke pollution, water pollution and especially pollution of domestic waste). In addition, a few people showed concern about unsafe food. However, infectious diseases, NCDs (or risk elements of NCDs such as smoking and alcohol consumption) were no issues of concern among the respondents.

32 Figure 1: Issues that raise health concerns of local people

70% 64.3% 60% 50% 40% 30% 20% 10% 0% … … …

Other No issue Air pollution Soil pollution Unsafe food Noise pollutionWater pollution

-communicable diseases

Environmental hygiene at the… Non Do not know / Do not remember Alcohol consumption and smoking Newly emerging infectious epidemics Seasonal epidemicsNatural disaster/extreme (dengue, influenza…) weather event

This finding is consistent with the people’s opinions in FGDs. They often raised concerns and paid great attention to two main issues in the discussions which were environment pollution and consumption of unsafe food. Specifically, these two issues were affecting their daily lives and contained many health risks; yet, they were not aware of the degree of impact or related preventive measures. Two issues that people are most concerned about are food safety and environment pollution. People are confused about which food products are safe and which are not. People do consume their home grown/raised products; however, they account for only a small part of people’s diets. Therefore, food consumption may result in disease infection. The more development, the more pollution. Women, both old and young, suffer from hypertension, breast cancer, ovarian cancer, or liver problems.

In recent years, the environment is polluted; waste is disposed indiscriminately. When a disease is detected in animals, they throw the dead animals to the river. People are only aware of the issue during the communication section; after that, they come back to their normal habits. We are worried about the impact of herbicides on our future generation. In this mountainous area, overuse of herbicides is prevalent; it will be a serious problem if all people use it in their fields. When the authorities communicated about using the natural herbicides made of chili pepper, people followed the instruction only for a while. After that, they still used chemical herbicides. People have not got any disease from this overuse yet, so they do not follow what is communicated. Or they listen to it for a moment, only to ignore it later.

– FGD in Huu Lung district – Lang Son province –

As infectious diseases, particularly EIDs, rarely occur and do not occur on a regular basis in the local areas, people are generally not very worried and pay little attention to these issues. When a disease outbreak takes place, without timely warnings from the health communication agencies, people easily

33 underestimate the threats of infection. In this context, an active studying and thorough understanding of people’s concerns about health risks is critical for the preparation of suitable contingency plans in the national communication and local communication plans.

(i) Public interest / knowledge of infectious diseases

The survey studied people’s interest in the infectious diseases that occurred in the local areas in the last 05 years. According to the results, dengue fever was mentioned by a significant proportion of respondents (see Figure 2). Figure 2: Proportion of people heard of the diseases taking place in the local areas in the last 03 years, by surveyed provinces

40 31.1 30 27.5 25.9

18.4 18.9

% 20

9.4 10 2.2 3.7 3.8 2.2 3.3 3.7 2.6 1.1 0.6 1.2 0 0.6 1.2 0.6 1.4 0 Hanoi Lang Son Da Nang Quang Nam Ho Chi Minh An Giang Total Measles - Rubela Dengue fever Hand-foot and mouth Chickenpox Figure 2 shows that 31.1% of respondents in Ho Chi Minh city, 27.5% in Da Nang, 25.9% in An Giang, and 18.4% in Quang Nam acknowledged the present of dengue fever outbreak in their residential areas. However, the incidence was quite low in Hanoi and Lang Son in recent years. It should be noted that the proportions of respondents who mentioned other seasonal infectious diseases such as hand-foot and mouth disease and measles are extremely low, despite the fact that the numbers of reported infection cases of these diseases are much higher than that of dengue fever. Such contradiction indicates that: (1) people’s perception of risks is based on their experience rather than the nature of threats; and (2) the data suggest that the extensive communication programs on prevention of dengue fever at the local level have greatly influenced people’s interest in the disease outbreak. For details of public’s perception of the degree of severity of communicable diseases, the survey shows that majority believe that diseases that are at risk of rapid spread such as H1N1, Measles - Rubella, Dengue fever or HFMD are dangerous. Meanwhile, although Zika virus has been widely reported in big cities and mentioned in national media, up to 44.5% of respondents did not know about this disease (Table 4). Table 4: The public’s perceptions of the degree of severity of communicable diseases

Not severe Severe Do not know Human influenza type 4.1% 86.8% 9.1% A H1N1 Measles - Rubella 11.4% 79.4% 9.2% Zika virus 1.8% 53.7% 44.5% Dengue fever 5.7% 92.1% 2.2% HFMD 11.0% 84.7% 4.3% Chickenpox 23.2% 73.8% 3.0%

34 This result confirms that: communication on EIDs is conducted mostly at the central level and in large cities, and very little at the community level via the grassroots health network. These diseases have not occurred in local areas; and thus, people showed little interest or concern about the possibility of such an outbreak. However, when being asked about what to do if they got infected, 80% of respondents chose to go to health facilities to get check-ups; among the selected facilities, the one that are chosen the most are commune health stations and district hospitals (see Table 5). Table 5: Response to infection of infectious diseases

Do Buy the Get a Go to a Go to the Ask for Consult Look for Other Do nothing, medication doctor nearby provincial / support opinions treatments not wait for themselves, to check private central from the from on the social know self- and stay at at health health local friends and networking Disease recovery home (do home clinic or facilities Preventive relatives sites or in not see a district / Health for the internet doctor commune Team or treatment health outbreak center prevention agencies Human influenza 0.2% 2.4% 0.0% 65.5% 30.8% 2.0% 0.1% 0.0% 12.1% 4.5% type A Measles - 0.4% 12.7% 0.1% 63.9% 19.9% 0.7% 0.8% 0.0% 8.7% 7.2% Rubella Zika virus 0.3% 0.9% 0.1% 43.5% 19.0% 0.4% 0.4% 0.1% 1.7% 37.7%

Dengue 0.2% 7.7% 0.3% 71.4% 27.1% 0.5% 0.6% 0.2% 6.5% 2.4% fever HFMD 0.4% 8.0% 0.0% 67.7% 24.0% 0.6% 0.5% 0.1% 10.7% 3.9%

Chicken- 0.3% 20.8% 0.5% 63.0% 18.1% 0.5% 1.3% 0.4% 10.6% 3.6% pox Rabies 0.2% 1.5% 0.0% 58.6% 23.8% 12.6% 0.5% 0.0% 4.9% 5.6%

Upon the occurrence of a disease outbreak, the majority of respondents were interested the most about how to prevent the disease for themselves and their families (60.5%), followed by the disease causes (26.9%), and the situation of disease outbreak in the community (16.7%). The data reveals that the people care most about preventive measures when a disease outbreak takes place in the local area while they pay less attention to what happens to the community. Therefore, in designing communication messages for a disease outbreak, the local communication programs should focus on: the areas where the outbreak takes place, its impacts to the infected people’s health, the disease causes, and the preventive measures. Moreover, the communication programs on infectious diseases should also integrate information about individual responsibilities in the community to prevent the spread of diseases.

35 Figure 3: The information about the disease outbreak that people are interested in

80.0 60.5 60.0

% 40.0 26.9 16.7 20.0 5.7 7.8 5.1 6.8 2.3 1.3 0.0 …

Other

Disease progress

Medication/treatments The possibility of outbreak Signs/SymptomsPreventative of disease measures for… The prestigious address for… The causes of the diseases or The consequences if not treated…

(ii) Public interest / knowledge on unsafe food

As analyzed in Section 2.2, food safety and the disease risks originating from consumption of unsafe food products is the foremost concern of the people at present. However, while safe food risk communication is neglected, the mass media delivers too much information on unsafe or “dirty” food products without any alternative suggestion of safe products. As a result, people are worried the most about this issue. “Many diseases come from mouth” Vegetables can be grown and consumed domestically. However, we are still worried about the origins of meat because it is delivered from elsewhere. We avoid unsafe food based on experiences. The authorities do not have any inspection activity. If we do not eat food, we do not have anything to eat. We are worried about food safety; but we still have to eat. We grow vegetables ourselves, so we are not worried. But pork is purchased so we are not so sure. – FGD with the people in Lang Son –

Among the most worrying issues at present are the use of preservatives and prohibited chemicals in food products, chemical residues exceeding the legal limits in food products, consumption of expired food products, and rancid food being processed then sold in the market (see Figure 4)

36 Figure 4: People’s knowledge on unsafe food

40 35.8 36.3 30.6 30 21.5

% 20

10 0.1 0.6 1.2 1.1 0

Too cheap food Food produced in… Unknown-origin food Food containing natural… Stale/expired foodGenetically which… modified food Food using prohibited/toxic…Food using higher chemical…

Upon being asked: what is unsafe food? 35.8% respondents believed unsafe food products were the food products that contain chemical residues exceeding the legal limits, and 36.3% referred to expired food products and transformed rancid food being, sold in the market. This result is consistent with the opinions shared by the people in FGDs.

37 Box 6: Warnings on unsafe food without alternative suggestions causing more confusion and damaging public trust

Mr. Ly, born in 1963, having a Cao Xang business in Hoang Van Thu ward, shared that he had food poisoning from crabs due to the crab seller adding chemical substances in the crabs. Normally, he trusted the food products sold in the village because these products were produced by the villagers and hence should be clean products. However, after having eaten the crap soup, he had diarrhea and suffered from vomiting. Crabs were sold a lot in the market, at only VND 15,000 per bag and they looked delicious. He got poisoned after having a crab soup. After that, he talked to the villagers and accidentally found out that there was a kind of substance that people sprinkled over the field. After one night, crabs came up and people could catch them easily. This substance might have its origin in China, not Vietnam.

There is information that even the commune health stations do not know. Especially, villagers used pesticides to catch fish. They used pesticides provided by the government for other purpose. The government provided 10 kgs of pesticides to eliminate pests and insects; people used only 06 kgs and kept 04 kgs to sprinkle it over the field to kill fish and catch them later to sell them. If the pesticides can kill pests then they can also kill fish. These people sold those fish but did not consume them – Mr. Ly shared.

Another story is about "sau sau" leaf - a special type of wild leaf in Lang Son. According to Ms. Hau - a noodle seller, when sau sau leaf was cheap, it was ok. When the price climbed up, the villagers picked the leaves, and soaked them with chemical stimulants. After a few days, the leaves looked better but caused stomachache. As a result, people stopped eating them. We lost a delicacy and trust in food products. People are so greedy. I asked them just to know the information.

Chemical substance is used for another special fruit plan of Lang Son - custard apple plant. Without the substance, a tree yields only 5 -7 custard apples. The substance made the fruits look bigger and nicer. It would be ok if the farmers followed the regulations which allowed the fruits to be harvested and sold 20 days after the substance use. However, they are harvested and sold only 10 days after the substance use; which is why the substance was still in the fruits.

– The story was shared by Ms. Hau –

These findings indicate that the large coverage of information about unsafe food products, for which forbidden and toxic chemicals were used in preserving food and stimulating food ripening, has strongly affected the public awareness on the threats of unsafe food products or foodborne diseases. On the other hand, the communication programs on food safety for the public have only delivered the message: "purchase and consume only food products with clear origins" without indicating any alternatives. As such, they fail to meet the public concern. In this area, the people have to take their all responsibility to manage foodborne risks or consume unsafe food in fear. In the discussion about the disease risks from consuming unsafe food, the participants showed great concern about how the soaring rate of cancer in recent years is linked to consumption of "dirty" food or unsafe food. In addition, worries about the impacts of unsafe food to functional disorder symptoms with uncertain causes such as early puberty and infertility, were also mentioned repeatedly in the FGDs. Moreover, the visible impacts of unsafe food consumption to the risk of gastrointestinal diseases were frequently indicated, particularly in the quantitative survey (see Figure 5 below).

38 Figure 5: People's perceptions about the consequences of unsafe food consumption

No Yes

Other No, 75.22% 24.78% Unknow-cause functional disorders (infertility, No, 97.22% 2.78% teratogenesis, …)

Cancer No, 63.23% 36.77%

Mental health symptoms (comatose, drowsy, …) No, 93.26% 6.74%

Digestive disorders, diarrhoea (choleara, typhoid, …) No, 34.09% 65.91%

In conclusion, food safety risk communication to the public remains a difficult puzzle for the health management and relevant sectors.

(iii) Public interest / knowledge on risk elements of NCDs

According to the quantitative results, the issues of most concern among the respondents are the risks of gastrointestinal problems (such as gastritis, gastro-paresis, and ulcerative colitis) as this is raised by 62.1% of male respondents and 53% of female, hepatic steatosis (high liver enzymes) by respectively 41.6% of male and 36.7% of female, cardiovascular diseases by 51.2% and 49%, and respiratory diseases by 39.6% and 33.4%. Figure 6: Proportion of respondents who believed that they and their families were exposed to the risks of NCDs, by gender

80

62.1 60 51.2

39.6 41.6 40 31.7

23.4 21.5 20 11.9

0

Other Diabetes Cancer Hepatic diseases Respiratory diseases Cardiovascular diseases Mental health diseasesGastrointestinal diseases

Male Female

39 Figure 6 shows that cardiovascular diseases receive great attention from the people. They are also among the priorities of the health sector in communication on NCDs. However, while gastrointestinal diseases, such as erosive gastritis and ulcerative colitis, are of most concern to the people, they have not been adequately focused on risk communication on NCDs. Furthermore, the proportion of male respondents showing concern about getting infectious diseases is higher than that of female respondents. This can be explained by the cultural and social context of Vietnam that risk behaviors such as smoking, alcohol consumption and unhealthy diets, are more common among men than women; as such, men are more worried about the risks of diseases such as hepatic steatosis, respiratory diseases, and gastrointestinal diseases, etc. When being asked about what to do to prevent NCDs, a substantial number of respondents chose to buy the medications or food supplements by themselves. This result is well supported by the practice. In FGDs, many participants shared that most companies cooperated with the commune health station or a local administrative unit to approach local people to sell the products advertised as helping to prevent diseases. Some examples are anti-osteoporosis milk or supplements, the meditation equipment (VND 42 million) that helps preventing cancer in Quang Nam and RO water filter that prevents diseases from contaminated water and protects family's health. Information about these disease prevention measures are normally disseminated verbally through experiences shared by friends, relatives and neighbors. This situation suggests people's special attention to disease prevention, which is quickly recognized and responded to by these companies via the communication channels most trusted by the people such as local mass organizations, friends, relatives and neighbors. However, while the equipment and food supplements in the market are advertised as having disease prevention and curing effects, these effects are not yet verified by health specialized agencies. Table 6: People's actions to prevent disease risks

Do Do Take regular Reduce Eat and Consult Look for Purchase Other Do not nothing exercises medical alcohol drink friends and preventive medications know / or don’t regularly examination consumption safely relatives measures on and food refuse to Disease know or stop about social supplements answer what to smoking preventive networking by oneself to do measures sites and in improve the internet health Cardiovascular 3.8% 29.3% 21.0% 13.4% 0.4% 0.4% 8.0% 29.7% 53.2% 9.7% diseases Diabetes 4.1% 18.4% 12.6% 4.8% 0.0% 1.7% 4.1% 30.3% 9.5% 72.5% Chronic obstructed pulmonary 3.1% 4.2% 4.8% 50.0% 0.6% 0.3% 4.5% 42.4% 9.3% 14.9% disease & asthma Cancer 7.8% 4.9% 16.6% 5.9% 0.0% 0.5% 2.0% 24.9% 22.0% 28.0% Mental 3.5% 9.5% 6.0% 4.5% 0.0% 1.0% 4.5% 52.8% 20.0% 2.0% diseases Hepatic diseases (high liver enzyme, 4.2% 4.7% 6.0% 45.5% 0.8% 0.8% 8.1% 20.0% 35.4% 8.6% hepatic steatosis)

40 Notably, regarding prevention of risks of respiratory diseases, 50% of respondents chose to reduce alcohol consumption and smoking. Similarly, 45.5% of respondents chose the same to prevent hepatic diseases (see Table 6). This data is consistent with the results about people's perceptions on the risks of diseases caused by smoking and alcohol consumption (see Figure 7 and Figure 8 below) In this survey, upon studying people's perceptions on the risk behaviors towards NCDs, the majority of respondents (90.49%) believed that smoking resulted in respiratory diseases and lung cancer, and excessive consumption of alcohol led to hepatic diseases and liver cancer (79.9%). Only a few respondents said that smoking and excessive use of alcohol results in cardiovascular diseases and hypertension. The above figures demonstrate that people's perceptions still rely on their personal observation and experiences of the infected cases in their communities. In addition, MOH's hypertension prevention communication programs have not substantially affected people's knowledge about the disease risks despite being executed in all the provinces and cities across the country. Figure 7: People's perception on the risks of diseases caused by smoking

Other 11.79 88.2 Gastrointestinal diseases (erosive gastritis, ulcerative colitis, …) 1.09 98.9 Hepatic diseases (high liver enzymes, hepatic 17.54 82.5 steatosis, …) Mental health diseases (mental disorders, 1.78 98.2 depression, aniety disorder, autism, ...)

Cancer 35.68 64.3 Respiratory diseases (asthma, chronic obstructed pulmonary disease) 90.49 8.5

Diabetes0.40 99.6 Cardiovascular diseases (myocardial infarction, 10.70 89.3 stroke, dyslipidemia, …)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

Yes No

Figure 8: People's perception on the risks of diseases caused by alcohol consumption

Other 90.3 9.7

Gastrointestinal diseases 78.3 21.7

Hepatic diseases 21.0 79.0

Mental health diseases 88.5 11.5

Cancer 87.0 13.0

Respiratory diseases 85.0 15.0

Diabetes 98.3 1.7

Cardiovascular diseases 88.4 11.6

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

No Yes

41 In addition, as pointed out by the FGD results, although the majority of respondents are knowledgeable of risk behaviors, such as that smoking and alcohol consumption may lead to NCDs, the practice of preventing NCDs depends largely on the cultural, economic, and social conditions of each individual and community. For example, Lang Son is characterized by mountainous terrain and is home to a large proportion of ethnic minorities who have the custom of drinking alcohol daily. The local people are aware that drinking alcohol is a cause of liver cancer. However, they cannot break this habit as it is considered a culture feature and a local custom. Many more men there have liver cancer than women because of their drinking habit.

Liver cancer may result from alcohol consumption. Alcohol consumption has been communicated in transportation safety programs. However, these programs only help people to reduce alcohol use; people still cannot stop it. A habit dies hard. Liver cancer is caused by alcohol abuse and also inherited genes. (an official of the Youth Union – chairman of the Farmer’s Union) There are no methods to improve people’s awareness. The worse people’s health becomes, the more alcohol they drink. Even they know drinking alcohol is harmful, they get addicted to it. Today they are hospitalized; later they come back home and continue drinking; tomorrow they are hospitalized again. If the wife does not buy alcohol, the husband will nag her. Women sometimes get drunk. When I approached them to communicate about this issue, they answered that they would die anyway. (a commune official in charge of cultural affairs – chairwoman of the Women’s Union) We fear the consequences of alcohol abuse; but we cannot stand living without it. During meals, not drinking alcohol makes me so irritated. It became a deeply-rooted habit. (a male participant of FGD)

Drinking habit could not be broken. During holidays, the ethnic minorities must have it. – FGD with the people in Lang Son –

In order to change risk behaviors of the community, some people and health officials suggested that changing communication means, and delivering the message on stopping alcohol abuse in combination with communicating about legal punishment forms against alcohol abuse (e.g., punishment against using alcohol before driving), might increase people’s attention.

If I hear about it on the television, I will trust the information and quit drinking. If I hear about it on the radio, I will reduce my drinking. If my wife takes the alcohol bottle away, I will keep drinking. (a man, of Tay ethnicity, having gout) If they hear about it on the television, they may reduce their drinking. If men hear about it, they may cut down the alcohol use; but they cannot stop drinking. (a woman, of Tay ethnicity, retired) I heard on television that if we drive, we are not allowed to drink; otherwise, we will get a punishment; drinking makes it easy to cause traffic accidents. So people avoid drinking when they have to drive. However, when they get home, they still drink a lot. (a man, of Tay ethnicity, farmer) – FGD with the people in Lang Son –

42 Moreover, the practice of preventive behaviors related to NCDs still depends on the economic conditions and the situation of the family, as well as the age group. For example, immigrants with low income often talked about their worries of getting diseases; yet, they only got treatment after they were infected due to the lack of necessary conditions for prevention:

“We get treatment only after we get infected; this is because we lack necessary conditions for prevention. Now I am still young, I utilize my time to work all day: working in the field and working as a construction worker to earn money to pay my children’s tuition fee. I am worried about diseases, but I am still ok now (no disease has been detected); so I focus on working to take care of my children; our life is still difficult. Of course, we are worried; if we get diagnosed with a disease, we will try to get cured. We will get a health check-up when we get sick.” – FGD with the people of low-income group in Hanoi –

On the contrary, opinions from the elderly people of high-income group in Quang Nam and Hanoi reveal that the people from better-off households, the elder people and those living in the cities generally know how to take care of oneself and actively perform preventive behaviors against NCDs, which are enhancing physical health, taking regular exercise, creating travelling groups to reduce stress and sustain a happy, healthy and useful life. This fact indicates that if the risk communication programs on NCDs focus only on enhancing people’s awareness without adequate attention to influential factors such as cultural customs, consumption habits, economic and social conditions of each target group and each community, the behavioral change communication could hardly bring the expected results. At present, the communication programs on NCDs in 06 surveyed provinces still focus on hypertension prevention communication. However, FGDs with the people show that the foremost concern of the people about NCDs is cancer, and they pay great attention to the potential causes, the linkage between the increasing prevalence of cancers with consumption of unsafe food products, environment pollution, water pollution, smoke, etc. Nonetheless, for this issue, there has been no specific communication program of the health sector that adequately responds to the people’s worries about the prevention methods. Some people even expressed impotence towards cancer risks “when the heavens appoint, one must obey” as they did not know clearly about the causes of cancer and how to prevent it effectively.

“In recent years, the diseases including diabetes, hypertension, stroke, and cancer, are spreading quickly; there is a cancer patient in every village. Is it because of food or which causes? Many people are worried but do not know what to do.” – FGD with the people of low-income group in Hanoi –

2.4. Public’s access to, exchange of, and feedback to health-related information

To provide recommendations on the communication channels suitable with the public, the research team carried out the quantitative survey to study the public’s access to information channels on health-related issues.

(i) Mass media using habit

Table 7 shows that television is still the most accessed channel with 75.9% of respondents watching television daily and 13.9% watching it several times a week. Notably, the proportions of respondents that

43 access information via social network, online newspapers, and websites (both domestic and international) are relatively high: 30.2% use social networks daily and 8.5% use it several times a week; 21.1% read online newspapers or daily news websites. Table 7: Use frequency of mass media

Several Several Several times times Not Daily times Never per per available per year week month Television 75.9% 13.9% 3.3% 1.1% 4.7% 1.2%

Printed newspapers 6.8% 5.6% 4.9% 2.5% 64.7% 15.6%

Radio 17.4% 5.5% 3.2% 1.5% 51.1% 21.3% Online newspapers, domestic 21.1% 12.9% 4.0% 0.7% 41.6% 19.7% and international websites Social network (Facebook, 30.2% 8.5% 2.1% 0.3% 37.4% 21.5% Zalo, etc.) Other 3.5% 1.7% 1.5% 0.8% 3.4% 89.2%

Comparing by residence, Figure 9 shows that there are a small significant different between rural and urban in the proportion of daily watching TV. However, the percentage of people living in the rural and listen to the radio regularly (24.5%) is higher than the one living in the urban (10.5%). In the contrast, the percentage of people reading the e-newspaper and access the social media in the urban area (26.7% and 35.6% respectively) is higher than the one in the rural area (corresponding to 15.5% and 24.9%) Figure 9: Percentage of communication media accessed daily by gender and residence

90 82.2 77.9 80 73.2 74 70

60

50

40 35.6 32 28.4 29.5 30 24.5 24.9 26.7 19.8 16.418 20 13.2 15.5 8.510.5 10 4 5.2 0 Male Female Rural Urban

Television Printed newspapers Radio Online newspapers Social Network

Figure 9 presents the different in accessing almost popular public media by gender. The percentage of men listening to the radio, reading newspapers/magazines, watching TV as well as accessing multimedia are higher than women’. In real, in Vietnam, women have less spare time than men because of double burden because of gender different.

44 When comparing by the age groups, the data collected shows that higher percentage of respondents in the age group of older than 55 years old like watching TV than the one of younger people. Figure 9 presents more than 80% of middle-aged people and seniors watching TV daily, while only about 55% of adolescent (18 – 24 years old) watching TV daily. Otherwise, the proportion of younger aged group accessing the social media and new media are significant higher (81.3% for age group 18-24 years old, and 67.3% for age group 25-34 years old) than the seniors’ one (comparing to 12.7% for age group 55-64 years old and only 6.8% for age group older than 65). The statistical results express the actual current social life, when social media is becoming more and more popular and the younger aged group is the most sensitive group accessing to the social media. Figure 10: Percentage of communication media accessed daily by age groups

100.0 88.7 90.0 84.9 81.3 79.9 80.0 69.2 70.0 67.3

60.0 56.3 54.4 50.0 46.9 38.8 40.0 37.4

30.0 26.027.4 23.8 22.4 17.9 20.4 20.0 15.9 16.8 11.6 12.712.7 13.7 8.4 10.0 5.2 6.8 3.13.1 2.0 4.2 0.0 18-24 25-34 35-44 45-54 55-64 > 65

Television Printed newspapers Radio Online newspapers Social Network

The survey results also show a significant incidence of respondents having smartphones or high-tech equipment in their house, connected to the internet, such as laptops, tablets and other electronic devices (see Figure 11). This finding suggests a re-mapping of popular information channels for the public; according to which, television is no longer the dominant channel; on the other hand, the proportion of people with access to online channels such as online newspapers and social network is soaring; printed newspapers are losing their position as only 6.8% of respondents read printed newspapers daily.

45 Figure 11: Available technology devices at home

90% 80.2% 80%

70% 62.2% 58.8% 60% 50% 40% 33.9% 30% 23.7% 20% 17.2% 9.0% 10% 6.4% 0%

Laptop Tablet Personal… Internet… Smartphone Other high-… Digital/satellit… No high-tech…

People’s demand for information varies among channels (see Table 8). For example, the public accesses mass media such as television, printed newspapers, radio and online newspapers to watch/listen to daily news or information in the areas of sport, fashion, entertainment and beauty. Only a few respondents access social networks, newspapers and television to get information related to health care. Meanwhile, the proportion of respondents using radio to access health care information is the highest among the incidence of other means, at 31.5%. Moreover, online newspapers and other online information websites are potential information channels to deliver disease prevention messages to the public. Table 8: Main content that respondents often read/watch/listen to on the mass media

Information Issues of about sport, Information public Daily news fashion, related to Other concern and entertainment, health care interest beauty Television 80.5% 64.6% 21.2% 11.6% 2.1%

Printed newspapers 63.3% 17.6% 21.6% 42.2% 12.4%

Radio 67.7% 12.2% 31.5% 13.3% 16.8% Online newspapers, domestic and 62.3% 30.0% 27.9% 31.3% 13.6% international information websites Social network 38.8% 37.6% 22.4% 20.7% 27.2% (Facebook, Zalo, etc.) Hence, the survey results on the people’s information access via mass media show that the new communication channels such as social networks (Facebook, Zalo, etc.) and online newspapers have high rate of daily users; however, users access these channels mainly for the topics other than health care. Specifically, the public accesses these channels for entertainment purpose rather than searching for

46 oriented information of more important areas. It is critical that health specialized agencies understand the public’s demand on the types of information and their preferred sources to identify the suitable communication content and forms. The practice shows that new media such as Facebook, Zalo, and online newspaper are highly potential for the health management agencies to interact with the public, particularly the youth. Nonetheless, how the interaction should be carried out, and in which forms to achieve the effectiveness requires further study.

The information access habit of the public via each communication channel will be analysed further in the following sections. Access to television channels Television is the most accessed medium. Table 7 shows that 75.9% of respondents watch television daily and 13.9% watch television several times a week. The survey also reveals that VTV1 and VTV3 are the most watched channels, which are accessed by 43.6% and 35.5% of the respondents, respectively. In addition, local channels have relatively high rates of users: 26.6% of respondents often watch the local channels of their provinces and 27.2% often watch the channels broadcasted by adjacent provinces. Figure 12: Frequently accessed television channels

VTC7 4.6

VTV6 5.7

VTV2 9.4

Cable television: VTVCab, K+, SCTV,… 11.5

Other 20.5

Local television channels 26.6

Local television channels of other areas 27.2

VTV3 35.5

VTV1 43.6

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0

Other channels (VTV2, VTV6, VTC7, etc.) have small proportions of users, ranging from 5% to below 10%. Some channels, which are VTC1, VTC2, VTC6, VTC7, VTV7, VTV8, VTV9, and international channels also have insignificant user rates, under 2%. Although there are a variety of television channels in Vietnam, VTV1 (a channel specialized in delivering news, reports and events) and VTV3 (specialized in entertainment) are the two most popular. This fact confirms the statement that people generally watch news on the television. Moreover, they also use television to access entertainment programs. The knowledge dissemination programs on VTV2 attract few public attention. This finding informs the health communication agencies of the suitable choices of communication channels to communicate with the general public. The television time frame that has the highest proportion of viewers according to the survey is the night time, from 18:00 to 22:00, with 74.3% of television viewers. This is also the most popular time frame in television broadcasting during which the people often watch news. The viewer rate during 20:00 – 22:00 is relatively high, at 48.9%, with most viewers watching entertainment programs and movies during these

47 hours. In addition, the time frame at noon, which is 12:00 - 14:00, attracts a considerable number of viewers, at 25.9%. Figure 13: Time frame of watching television

80.0 74.3 70.0 60.0 50.0 48.9 40.0 30.0 25.9 20.0 21.2 16.8 10.0 10.8 7.3 7.5 6.3 0.0 2.9

–12:00 0:00 - 6:00 6:00- 8:00 8:00- 10:00 10:00 12:00- 14:0014:00 -16:0016:00 - 18:0018:00 - 20:0020:00 - 22:0022:00 - 24:00

The collected data presents there is no statistically significant different between the male and female group, urban and rural group in the time frame of watching TV. The most popular time frame of watching TV from 18:00-20:00. Figure 14: Time frame of watching television by gender and residence

90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

–12:00 6:00- 8:00 0:00 - 6:00 8:00- 10:00 10:00 12:00- 14:0014:00 -16:0016:00 - 18:0018:00 - 20:0020:00 - 22:0022:00 - 24:00

Male Female Rural Urban

Access to social network The second most popular channel is social network, with 30.2% of respondents using social network daily and 8.5% several times per week. To study about the social networking sites most accessed by the people, the research team listed 10 popular social networking sites in Vietnam, which include 08 international networking sites (Facebook, Youtube, Instagram, Google+, Twitter, Linkedln, Flickr and Vimeo) and 02 Vietnamese sites (Zalo and Zing me) in the questionnaire. According to the results, Facebook is the most favorite site as used by 91% of social network users, followed by Zalo at 80.3%. Youtube is also accessed widely, by 47.8% of social network users. Moreover, some social networking sites are used by few respondents, including Vimeo, Linkedln, Flickr and Twitter, with a user rate below 1%. These results are consistent with the data from international studies, which identify Facebook as the most popular social

48 networking site in Vietnam and in the world5. The number of Facebook users in Vietnam is ranked 7th in the global ranking, with 64 million users, accounting for 3% of the total number of Facebook accounts6. Figure 15: Social networking sites used by respondents

Vimeo 0.3 Linkedln 0.3 Flickr 0.5 Twitter 0.8 Others 2.6 Zing me 2.6 Instagram 5.6 Google+ 16.9 Youtube 47.8 Zalo 80.3 Facebook 91.0

0.0 20.0 40.0 60.0 80.0 100.0

A closer view on respondents’ frequency of access to the networking sites reveals that the majority of the respondents accesses social networks several times per day or several times per week. Specifically, 77.8% of respondents use Facebook several times per day and 19.4% use it several times per week. About using Zalo, the corresponding figures are 60.5% and 33.1%. Figure 16: Frequency of access to social networking sites of respondents

90.0 77.8 80.0 70.0 65.2 60.5 60.0 51.5 50.0

40.0 33.1 32.1 33.3 30.0 19.4 20.0 12.1 10.0 5.7 2.5 0.3 0.6 2.7 3.0 0.0 Facebook Zalo Youtube Google+

Several times/day Several times/week Several times/month Several times/year

Department of Communication and Awards and grassroots communication agencies of Ministry of Health are on the right path as they have initiated new communication channels to the public. Specifically, they create Facebook fanpages and form communication target groups in Zalo. Moreover, with a large number

5We are Social (2014), Social Digital & Mobile in Asia- pacific region in 2014: 16/1/2014 (tr 208) 6 https://e.vnexpress.net/news/business/data-speaks/vietnam-climbs-to-seventh-worldwide-for-number-of- facebook-users-report-3614034.html

49 of Youtube users, using video clips to deliver risk communication messages on Youtube might prove to be an effective approach to attract the public attention, particularly of the young audience. Access to online newspapers Online newspaper is currently a popular information channel. It can deliver information quickly with diverse types of information; however, a negative feature is its sole focus on the number of views. According to the survey results, 343 respondents access online newspapers several times per week, equivalent to 34%, which is considerably higher than the incidence of printed newspapers. Zing.vn is the most accessed newspaper with 76.8% of the respondents, followed by docbao.vn with 24% of respondents. Hence, the people access online newspapers mostly for quick news about daily social issues and entertainment information. Figure 17: Frequently accessed online newspapers of respondents

Dantri.com.vn 1.6 Baomoi.com 3.2 Vietnamnet.vn 3.2 Kenh 14.vn 4.8 Vnexpress.net 8.8 24h.com.vn 9.6 Tin247.com 11.2 Afamily.vn 12 Docbao.vn 24 Zing.vn 76.8

0 10 20 30 40 50 60 70 80 90

Access to radio The proportion of people using radio has increased in recent years. In this survey, 231 respondents listen to the radio several times per week, accounting for 22.9%. The majority – 75.8% - often listen to the local channels; other channels, including VOV and Xone FM, have low rates of users, below 10%.

50 Figure 18: Frequently accessed radio channels of respondents

80.0 75.8

70.0

60.0

50.0

40.0

30.0

20.0 8.2 10.0 5.6 6.1 3.5 0.0 VOV2 VOV XoneFM VOV1 Local channels Transportation

Unlike television, radio is accessed mostly in the morning, during the time frame 06:00 – 08:00, by 42.4% of the respondents. Moreover, the afternoon period from 16:00 – 18:00 also has a high rate of users, at 33.3%. Figure 19: Time frame of listening to radio of respondents

45.0 42.4 40.0 35.0 32.9 33.3 30.0 25.0 20.0 15.0 13.4 10.0 10.4 8.2 9.5 8.7 5.0 6.1 6.1 0.0

–12:00 0:00 - 6:00 6:00- 8:00 8:00- 10:00 10:00 12:00-14:0014:00 -16:0016:00 - 18:0018:00 - 20:0020:00 - 22:0022:00 - 24:00

When deeply analysing the different between males and females and between people living in rural and urban about the time they often listening to the radio, the data shows that the period from 6:00-8:00 is the “golden time frame” for the rural to access the radio, while for the urban, the time frame from 16:00- 18:00 is the most popular time which they listening to the radio.

51 Figure 20: Time frame of listening to the radio by gender and residence

60.0

50.0

40.0

30.0

20.0

10.0

0.0

–12:00 0:00 - 6:00 6:00- 8:00 8:00- 10:00 10:00 12:00- 14:0014:00 -16:0016:00 - 18:0018:00 - 20:0020:00 - 22:0022:00 - 24:00

Male Female Rural Urban

Access to printed newspapers Printed newspapers are the less accessed mass medium, with 6.8% or respondents reading newspaper daily. To understand the popular printed newspapers, the survey listed 12 printed newspapers; however, most respondents read the newspapers that are not listed. Only Tuoitre Newspaper is mentioned most often among the listed ones, by 24% of printed newspaper users. In conclusion, the survey results show people’s demand and usage pattern of the mass media. In general, television is used by the majority of respondents; other new information channels, such as social networks, also have high user rates. The results also reveal an overview of the public demand on information in different communication channels and in different time frames. Television is still the most popular and quick information channel to communicate with people about the disease outbreak situation, public health events and preventive measures. According to the survey results, this information reaches the public most efficiently via the news programs broadcasted at noon (12:00) and in the evening (18:00 – 20:00). Moreover, local television channels are better than national channels in terms of cost efficiency and probability of reaching people. Social networks are a relatively effective communication channel. Although the user rate of social networking sites is high, the rate of people that access information about health issues and diseases is negligible. Hence, health management should utilize social networks to interact with the public based on its highly interactive feature compared to the traditional channels, particularly through Facebook and Zalo – the two most popular sites. Radio still has a considerable rate of users. The health care program in the radio still dominates other channels’ similar programs. Printed newspaper is less used by the surveyed people. Therefore, communication on other channels such as television, social networks, and radio will be more effective than on printed newspaper.

(ii) Situation of information access and exchange among members of the public

In order to understand the situation of access to information of the public on health risks, first of all, the research team examined whether the public get to know or remember disease prevention communication programmes which have been implemented in the area where they reside. Survey results show that

52 62.6% of respondents said that there had been communication programmes on these topics in the area where they resided during the last one year. This figure means that a large part of the population did not know about communication campaigns on disease prevention of each particular surveyed province and the healthcare sector in general. Of all the surveyed provinces, Hanoi had the highest rate of people who knew about communication programmes on disease prevention and health protection, which was 76.1%. In contrast, despite being the biggest province in Viet Nam in terms of economic output and the population and urbanization rate, this rate for Ho Chi Minh city was only 58.5%. In addition, the rate for Lang Son was only 51.6%, the lowest of all the surveyed provinces. Figure 21: The rate of respondents who said that there had been communication programs about disease prevention or public health protection in the area where they reside during the last year

90 81.6 80 72.2 71.8 69.2 68.2 70 64.1 60 56.5 50 40 30 20 10 0 Overall Ha Noi Da Nang An Giang Quang Ho Chi Lang Son Nam Minh

The low rate of people who knew about disease prevention communication programs for Lang Son can be explained by the fact that this is a border province located in the northern mountainous region, with large ethnic minority populations and transport difficulties, which causes limitations for communication activities in communities. Indeed, the main means of health communications and public education in remote areas is mobile loudspeakers. HCMC also had a low rate of people who knew about disease prevention communication programs in communities. This can be explained by fast-changing populations in most surveyed districts in HCM. As mentioned by leaders of Hoc Mon district Health Centre, a large portion of the district’s population are migrant families of factory workers who work in nearby industrial zones and stay in rental accommodations. Therefore, the fast population shift in suburban HCMC is an obstacle to the traditional direct communication models (for example, talks during neighborhood meetings). Disease prevention communication campaigns in communities thus need to be improved by employing communication channels that cater to specific audiences in different localities so as to attract public attention better. When asked through which channels they knew about disease prevention communication programs, 56.6% mentioned village/neighborhood/hamlet meetings, which was the highest rate for all listed channels. This was followed by local loudspeaker broadcasts, with 29.9%. Other channels such as community events (community art shows and contests), marches and public gatherings had relatively low rates, of 1.6% and 2.8%, respectively. To sum up the findings, among the communicative channels at the local level (loudspeaker broadcasts, leaflets, banners and community events), loudspeaker broadcasts is still the most common channel. However, the effectiveness of each communicative channel for each local rea, community and audience

53 vary; and there should be concrete assessments to develop communication programs that suit each local area. Figure 22: Channels for communication programs of respondents

Community events (community art shows, contests…) 1.6

Marches and public gatherings 2.8

Training, seminars, workshops 9.2

Banners, posters and leaflets 17.4

Other channels 19.6

Local loudspeaker broadcast 29.9

Village/neighbourhood/hamlet meetings 56.6

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Figure 22 demonstrates information channels which the public preferred and found convenient as they sought for information on epidemics. The most popular source of information was “traditional mass media channels” with 35.7%, followed by online newspapers, with 23.8%. The rate of those who sought for information through medical professionals was relatively high, with 21.5%. Notably, the public found it less convenient to exchange and seek for information on epidemics through local government authorities (4.3%), or family members and relatives (4.3%). Information access through mass organizations staff at the local level had a higher rate (7.9%). Figure 23: Channels for epidemics-related information exchange and seeking

Not interested 3.0 Not sure 7.2 Other 8.0 Consulting/talkig to members of groups/clubs/associations 2.8 Consulting/talking to local authorities 4.3 Consulting/talking to family members and relatives 4.3 Consulting/talking to representatives of mass… 7.9 Seeking for/following/sharing information on social media 9.2 Consulting/talking to friends or acquaintances 19.9 Consulting medical professionals at medical facilities 21.5 Seeking for information/follow online newspapers 23.8 Following mass media 35.7

0 5 10 15 20 25 30 35 40

This result shows that when epidemics-related problems happened in a local area, traditional mass media channels such as television, radio, print newspapers, and recently online newspapers are convenient for the public to get a sense of the situation. In addition, direct information channels such as local healthcare

54 networks and social networks of friends, acquaintances and neighbors play an important role as convenient platforms for the public to exchange and seek for information on epidemics in local areas. These results also imply that the public was quite passive in seeking for information on epidemics that happened in local areas; they tended to follow the news rather than actively seeking formation when epidemics happened.

(iii) Feedback mechanisms regarding communicable diseases

In the case of a disease outbreak that is showing signs of spreading rapidly or a complicated development, the most common initial reaction and way to inform other people was informing friends and family, with the rate of 72.1%, much higher than other kinds of reactions listed in the questionnaire. On the other hand, 7.9% of respondents said that they were not sure what to do, and 4.8% said they would not do anything. Figure 24: Feedback strategies adopted by respondents to inform other people when a disease outbreak shows signs of spreading rapidly

Reporting to journalists, reporters and press agencies 0.1

Calling hotlines of government authorities-in-charge 0.1

Posting comments/sharing information on social media 1.6

Other 2.7

Not taking any action 4.8

Not sure 7.9

Reporting to village health staff or commune/ward… 8.4

Reporting to medical units and organisations 10.5

Reporting to local authorities (ward/commune level) 13.2

Informing family members, relatives and friends 72.1

0 10 20 30 40 50 60 70 80

For those who said that they did not take any action, the most commonly cited reason was that they thought that informing other people about the acute situation of a disease outbreak is “not their responsibility”, with 31.3%. 37.5% cited other reasons such as “not sure what to tell other people”, “not sure what to do”, “not knowing about the disease”, “that no one would listen”, or “one only minds his/her own business”.

55 Figure 25: Reasons for not taking any action when an epidemic shows signs of spreading rapidly

40.0 37.5

35.0 31.3 30.0

25.0

20.0

15.0 12.5 12.5 10.4 10.0

5.0

0.0 Someone else Not sure who Not my Even if I report, Other already and how to responsibility the problem will reported inform not be solved

Only 275 respondents, equivalent to 27.3%, said that they adopted at least one out of the four feedback strategies related to government authorities, which included “informing healthcare agencies and institutions”, “informing local authorities”, “informing healthcare professionals” and “calling the hotlines of government authorities”. Moreover, the survey got respondents to assess government authorities’ reactions when they contacted these authorities to provide information. 65.8% of respondents said that the authorities quickly came to check endemic situations in reported areas, yet 5.5% said that government authorities took too many days to respond or did not respond. Figure 26: Assessment by respondents of government authorities’ reactions when informed by their people on epidemics

70.0 65.8

60.0

50.0

40.0 29.1 30.0

20.0

10.0 4.0 1.5 0.0 Quickly checked Took too many Did not respond Not sure epidemic situation days to respond in reported areas

To sum up, most respondents demonstrated an inward tendency in terms of disease prevention and did not have an adequate awareness of their own responsibility for public health protection in their communities. Indeed, they were still hesitant to raise their voice because they thought it is “not their responsibility” or “it would not make any difference”. Therefore, it is important to raise people’s awareness about their responsibility as individuals in public health protection as well as to promote their willingness to participate in the implementation of preventative measures.

56 SECTION 3: CONCLUSIONS AND RECOMMENDATIONS

3.1. Conclusion

1. The study reveals an overview of the risk communication situation of the health sector, including: (1) the degree to which risk communication elements have been performed and the application of risk communication principles in practice; (2) achievements / non-achievements and the obstacles to risk communication practice on infectious diseases, EIDs and public health emergencies, as well as risk communication on consumption of unsafe food and risk elements of NCDs; (3) public concerns of disease risks in comparison with the communication content delivered by the health sector to the community; and (4) information access and exchange of the public about disease risks. The analysis situation on risk communication also points out: (5) achievements in coordination within the health sector, and between the Ministry of Health’s communication agencies and the press, and between the grassroots health communication agencies and local organizations / agencies. Moreover, the study also shows the problems in inter-sectoral coordination between the health sector and other sectors due to the lack of a detailed plan for each communication program of a specific disease. 2. Regarding implementation mechanism of risk communication in the health sector, in general, Vietnam has established a legal framework and overarching mechanism for implementation of risk communication that covers its diverse aspects and facets. The achievements expressed the remarkable attempt of specialized departments at the central level such as GDPM, Department of Communication and Reward, and Pasteur Institutes in improving health risk communication activities in Vietnam. However, in practice, grassroots health officials and officials of related agencies do not have an adequate understanding of and are confused in the use of risk communication concepts. Most officials still perceive risk communication as informing people of the risks of each specific disease. However, according to the training document of Ministry of Health, risk communication should not be simply warning people about the risks but requires cooperation among relevant stakeholders to resolve risks. 3. In its analysis of risk communication at grassroots level, the report shows that, the health risk communication programs at the grassroots level are currently unsystematically carried out. The programs are mistaken as simply Information, Education and Communication (IEC) or the programs are limited within public awareness enhancement approaches. In other ways the approach was a one-way delivery of information without the public perception being taken into account. In addition, the communication programs at the grassroots levels (district level and lower level) still depend largely on the top-down instruction. In health communication at the local level, assessment of inputs is not conducted, which otherwise could help develop communication programs suitable with each target group, as well as the geographical, economic, cultural and social conditions of each community. The post-outbreak assessment on communication effectiveness is almost neglected. 4. The obstacles to implementation of risk communication elements in disease outbreak prevention include: (1) the grassroots health communication staff are multi-tasked and can be periodically transferred to other positions; (2) in recent years, with the merging of various health units, training and capacity building for health communication staff are neglected; as a result, they are barely trained about risk communication principles and skills; (3) the budget for risk communication in disease outbreaks and public health events is limited; many agencies do not have contingency budget to spend on emergencies while in others budget spending is hindered by the financial principles imposed by the State ( e.g., an expenditure of over VND 20 million must be open for bid); (4) Standard Operational Procedures on Risk communication is not widely disseminated or applied in practice; (5) a supervision mechanism on risk communication implementation and detailed planning following the instructions of the Standard Operational Procedures on Risk Communication are absent; (6) as a result, inter-sectoral coordination between the health sector and other sectors remain problematic due to the lack of an adequate coordination mechanism. 5. Regarding implementation of the fundamental principles of risk communication, the study results show that the Ministry of Health’s specialized agencies (GDPM, Department of Communication and Award, Pasteur Institutes) have made positive change in terms of applying risk communication principles in responding to disease outbreaks. Achievements include: (1) these agencies have become active in cooperating with the reporters to deliver communication messages to the public in health emergencies and disease outbreaks; (2) the health sector has developed an electronic reporting mechanism that allows real-time information exchange between the health management agencies and grassroots health officials about the disease situation in the community; (3) the National Center for Health Education and Training operates a daily news section to deliver information about disease outbreaks on its website – this is an innovation in the application of active listening principle; (4) the Ministry of Health’s management agencies follow closely the progress of disease outbreaks and are ready to respond to risks. However, as health specialized agencies, press agencies and non-health agencies currently have different understanding and views of the information disclosure and transparency principle in risk communication, there exists a gap between the public expectation on disclosure of information on disease outbreaks and the intention of the health management. 6. Regarding coordination mechanism between the health sector and related agencies, in risk communication about disease outbreaks and public health emergencies, the results reveal that: the current risk communication programs enjoy a favorable legal framework for coordination mechanisms, quick engagement of the political system and timely top-down instructions upon emergencies. However, there lacks a detailed planning for coordination among relevant agencies for specific disease in specific location following three stages: pre-outbreak, outbreak and post- outbreak; the coordination in fact still relies on the top-down instruction. Therefore, without an adequate coordination mechanism or specific task assignment for each health and non-health agency in the communication plan for specific event, good coordination among relevant agencies can hardly be achieved. 7. Regarding public perceptions on health related risks, the people show an increasing concern for disease risks related to consumption of unsafe food and risks from garbage pollution and environment pollution in the residential areas. Meanwhile, as infectious diseases, particularly emerging diseases, rarely or occasionally occur in the local areas, people generally do not pay much attention to the related risks. As a result, when a disease outbreak takes place, without timely warning from the health communication agencies, people can be incautious about the disease. Therefore, adequate understanding about the public concern of health risks is critical for the national and local communication programs to have preventive measures to each scenario. 8. Upon studying the public access to information in mass media, the study results show that: television is the most widely accessed channel. However, there is a re-mapping of popular information channels for the public; according to which, television is no longer the dominant

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channel; on the other hand, the proportion of people with access to online channels such as online newspapers and social network is soaring; printed newspapers are losing their position. 9. Regarding the mechanism on information access of the people related to disease prevention, upon disease issues in the local area, mass media such as television, radio, printed newspaper, and recently online newspapers are convenient information sources. The people also find the direct channels such as the network of grassroots health officials, friends, neighbors, and acquaintances, reliable and easy to access and exchange information about the disease outbreak taking place in the locality. Nonetheless, our analyses also point out that people remain inactive in looking for information related to the disease outbreak in the local area as they mostly wait for information rather than actively search information when a disease outbreak takes place. 10. The practice reveals that new media such as Facebook, Zalo and online newspapers are potential information channels for the health management agencies to interact with the public, particularly the young audience. However, users access these channels mainly for the topics other than health care. Specifically, the public accesses these channels for entertainment purpose rather than searching for oriented information of more important areas. Therefore, how the interaction should be carried out via these channels, and in which forms to achieve the effectiveness requires further study. In conclusion, risk communication for diseases is costly and requires long-term planning, which requires the active efforts of health specialized agencies, the strong leadership of government leaders at all levels, the engagement of the whole political system, and most importantly the close coordination between the health sector and relevant sectors. In addition, financial and technical supports of international organizations are needed. Regarding to public, it is critical that health specialized agencies understand the public’s demand on the types of information and their preferred sources to identify the suitable communication content and forms.

3.2. Recommendations

• Capacity building on risk communication for health communication officials at all levels; policy makers and leaders of relevant sectors should be a key activity in the design of the National Action Plan 2020 – 2025. In more details, communication officials, health managers and policy makers need to be informed on: (1) The circumstances and conditions under which each component of risk communication is applied to; (2) Similarities and differences between risk communication and health education and health promotion; (3) How risk communication can be replaced or supplemented for general health education and communication in the four priority areas. • Some suggested improvements in application of risk communication principles include: v “Risk communication should be a step ahead and be active in preventive communication”. That is, there should be preparation in pre-outbreak, outbreak and post-outbreak communication planning, which includes input assessment (e.g., geographical, economic, cultural and social factors that affect the information access of the public and public perceptions of risks) to develop communication messages and select suitable interaction channels with the target groups. 59

v Information delivered to the public should meet the public concern instead of generalized recommendations on prevention of specific disease; v “Blame” message such as “due to the people’s carelessness” and the messages “being indirect and hiding information about the outbreak to the public” should be avoided. These messages may have adverse impacts which damages the public trust in the health sector’s capacity to manage and control disease outbreaks. • To implement all components of risk communication in response the public health events or emergency infectious disease, the MOH’s communication units should: v Put SOP of Risk Communication in use; v Enhance the capacity for grassroot communication staff on the practical risk communication procedures based on SOP Guidelines: focusing on active listening skills and on implementing the principle of timely information to the public even in cases of uncertainty; v Strengthen the planning, monitoring and evaluating risk communication program regularly in all level; v Extend the flexibleannouncement mechanism as well as expenditure mechanism in the situations of disease outbreak and/or public health emergency; v Promote the proactive and coordination with health journalist group and press agencies in order to provide information timely and accurately to the public. • To improve the behavior change communication in communicating both infectious diseases and NCDs, the health sector in general should have the comprehensive innovation: from developing communication plan, designing the communication messages, and choosing communication forms for each target group in each specific context of disease; avoid using either top-down communication or ‘one-to-fit-all’ messages. To improve health communication capacity at the grassroot level, MOH should decentralize their management and empower health communication units at local levels: v District or communal health centers must be (should be) active in choosing and applying communication models which could be suitable with geographic, economic, cultural and social situation of local people v Local health centers should also be allocated the budget appropriately and timely (both fixed budget and back-up budget) to actively plan and implement the communication program of their center, meet the condition of local culture, socio-economic, and intellectual level. • For NCD communication, the research results indicate that current NCD communication programs do not articulate with the public information demands. While NCD communication programs at local levels are focusing on the risks of high blood pressures, majority of respondents express their concerns more on risks of cancers, gastrointestinal problems, and hepatic-steatosis. Therefore, when planning a NCD program for each community at the grassroot level, health policymakers should consider baseline studies as an essential component of any NCD communication program. • For communicating threats of unsafe food to the public health, the health sector should give more clear recommendations on how to select, process and consume safe foods that are appropriate with the economic, social and cultural situation of local people. Furthermore, more medical

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evidences on the correlation between consuming unsafe food and the incidence of cancer risk would be magnificent for communicating this theme to the public and to avoid the public anxiety. • About the communication channel to convey the message to the local people: v Based on the research findings on the public behavior of using mass media in daily life, the communication units of MOH could be able to choose the appropriate mean of media for the target group, and select the applicable time frame with the liking of the public. For example, with the target group of the adolecent and middle-aged, the multimedia communication (Facebook, Zalo and e-news) could be their favourite communication channels. Meanwhile, the radio is more appropriate with the people living in the rural area. • Maintaining the public trust is the key of effective risk communication; and other multimedia communication is a useful instrument to interact with the public. Therefore, communication units of health sector should strengthen their utilization of social media and multimedia: v Tracking the public concerns and interacting with public on social media such as Zalo, Facebook, …. v Cooperating with the key opinion leaders to interact with the public to avoid the fake news and confusing news, v Keep the active roles in the providing information timely, accurately and appropriately with the public’s concerns

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ANNEXES

Annex 1. Survey questionnaire

KAP SURVEY ON THE HEALTH RISK COMMUNICATION IN VIETNAM

Good morning/afternoon, my name is …………………………………….., from Development and Policy Research Center (DEPOCEN). We are conducting a survey about your perception and behavior relating to health risk and health risk communication. The information collected from this survey would be used for the recommendation for risk communication programs in the future. Your participation is completely voluntary. The provided information will be aggregated to the community group and used for research purposes only. Refusing to answer any questions or stopping the interview will not affect your rights and current work. At the end of the interview, the team will give you a small thank you gift. The questionnaire completion time is about … minutes. Do you have any question about this survey? Do you agree to participate in this survey? (For the enumerator: The interview will only start when the respondent agrees to participate)

Province code District code Commune code Village code Household code

Enumerator code Name of enumerator Name of supervisor Date of interview Starting time: …………………………......

Respondent code Name of respondent Mobile phone number Is your telephone able to access the ☐ Yes 2. ☐ No internet?

SECTION A1. RESPONDENT’S DEMOGRAPHY Please provide the following information of yourself A1.1. Gender? ☐ 1. Male ☐ 2. Female ☐ 3. Other A1.2. Year of birth? ……………………….. A1.3. The highest level of formal education completed? ☐ 1. Did not attend school ☐ 5. High school ☐ 2. Pre-school ☐ 6. Vocational School/College ☐ 3. Primary school ☐ 7. University/Higher education ☐ 4. Secondary A1.4. Marriage status?

62 ☐ 1. Single ☐ 4. Separated ☐ 2. Married ☐ 5. Widowed ☐ 3. Divorced A1.5. How many children do you have? ...... child(ren) A1.6. In that, how many children under 18 years old are there?...... child(ren) A1.7. What is your main occupation? ☐ 1. Wage worker (for more than 1 year) ☐ 2. Seasonal worker ☐ 3. Business owner ☐ 4. Self-employed ☐ 5. Work at home (handicraft) ☐ 6. Farming/livestock/aquaculture ☐ 7. Freelancing (driver of motorbike/taxi, ticket sellers, …) ☐ 8. Unemployed ☐ 9. Do not work (attending school, old, sick, have no need to work, …) ☐ 10. Other, specify… SECTION A2. HOUSEHOLD’S CONDITION A2.1. Which type is your household’s residence? ☐ 1. Villa/ luxury apartment ☐ 4. Hut, cob house, … ☐ 2. Lock house/budget apartment ☐ 5. Other, specify… ☐ 3. One-floor house/old tenement A2.2. Which high-technology devices of your household are? ☐ 1. Smartphone ☐ 5. Digital television/Satellite ☐ 2. Laptop ☐ 6. Internet connected device ☐ 3. Desktop ☐ 7. Other, specify… ☐ 4. Tablet ☐ 8. None of high-technology device A2.3. How many members of your household you are living with? ...... (person/people) A2.4. In last 12 months, how much is the total of your household’s expenses per month in these parts? (Write 0 if the respondent’s household does not spend money on the object, do not leave it empty) Expenses Amount of money (millions/month, can be noted in the decimal number) Food …………………. Living (electricity, water, gasoline, internet, mobile, living stuff …) …………………. Study (tuition, semi-boarding tuition, extra-class cost, learning tools, living …………………. expense for child(ren) studying if he/she/they live(s) far from home for studying….) Healthcare (health care, medical examination and treatement, medicines, …………………. hospitalization, ….) Entertainment (promenade, travel, …) …………………. Other (please, specify):………………………………………. …………………. TOTAL …………………. A2.5. Do your household members have the health insurance? ☐ 1. All household members have

63 ☐ 2. Only some household members have ☐ 3. None of household members has ☐ -99. Don’t know A2.6. In last 12 months, do you take the regularly medical examination? ☐ 1. Yes ☐ 2. No ☐ -99. Don’t know A2.7. In the last 5 years, which disasters/extreme events have occurred in your locality (village, district)? ☐ 1. None of natural disaster ☐ 5. Drought ☐ 2. Inundation due to flood, rain ☐ 6. Storm ☐ 3. Tornado ☐ 7. Front cold ☐ 4. Flash flood ☐ 8. Other, specify… A2.8. If there was any natural disaster occurred, how was your household members’ health affected? ☐ 1. Not be affected ☐ 2. Be affected a little ☐ 3. Be affected neutral ☐ 4. Be affected much ☐ -99. Do not know SECTION B. RESPONDENT’S HABIT IN ACCESSING INFORMATION B1. Which channels do you often access to update information in general (about life, economics, social, cultural, educational, … situation) and how often? ☐ 1. ☐ 2. ☐ 3. ☐ 4. ☐ 5. ☐ 6. Do Every Several Several Several Never not have -day times times times this per per per year informa- week month tion source Television Printed newspapers, magazines Radio E-newspapers, Vietnamese and/or international websites Social network (Facebook, Zalo,...) Other, specify… B2. If you often read newspaper/listen to the radio/watch TV or access to social network or Internet, which contents do you regularly follow up or are interested in? No 1. News 2. Sports, 3. 4. Concerned, -99. Other of current fashion, Information Pressed issues events entertainment, related to in society beauty health 1 Television ☐ ☐ ☐ ☐ ☐ 2 Newspapers, ☐ ☐ ☐ ☐ ☐ Magazines 3 Radio ☐ ☐ ☐ ☐ ☐

64 4 E-newspapers, Vietnamese and/or ☐ ☐ ☐ ☐ ☐ international websites 5 Social network ☐ ☐ ☐ ☐ ☐ (Facebook, Zalo,...) B3. [If you watch TV several times per week or more frequently] B3.1 Which TV channel do you often watch? (Choose up to 3 choices) ☐ 1. VTV1 ☐ 7. VTV9 ☐ 12. VTC6 ☐ 2. VTV2 ☐ 8. Local TV Channel (which is of ☐ 13. VTC7 ☐ 3. VTV3 living province) ☐ 14. Cable TV Channel: VTVCab, K+, ☐ 4. VTV6 ☐ 9. Local TV Channel (which is not SCTV, Mobifone/AVG, NextTV, ☐ 5. VTV7 of living province), Please, specify ..... MyTV, FPTPlay, … ☐ 6. VTV8 ☐ 10. VTC1 ☐ 15. International Channel, please ☐ 11. VTC2 specify, …. B3.2. When do you often watch TV? (May select multiple choices) ☐ 1. 6:00- 8:00 ☐ 3. 10:00–12:00 ☐ 5. 14:00 -16:00 ☐ 7. 18:00 - 20:00 ☐ 9. 22:00 - 24:00 ☐ 2. 8:00- 10:00 ☐ 4. 12:00-14:00 ☐ 6. 16:00 - 18:00 ☐ 8. 20:00 - 22:00 ☐ 10. 0:00 - 6:00 B4. [If you listen to the radio several times per week or more frequently] B4.1. Which radio station do you often listen to? (Select up to 3 choices) ☐ 1. VOV1 ☐ 4. VOV4 ☐ 7. VOV English 24/7 ☐ 2. VOV2 ☐ 5. VOV5 ☐ 8. VOV FM 89 ☐ 3. VOV3 ☐ 6. VOV Transportation ☐ 9. Local radio station ☐ 10. Xone FM ☐ 11. Do not aware which channel is 12. Other, specify… B4.2. When do you often listen to radio? (May select multiple choices) ☐ 1. 6:00- 8:00 ☐ 3. 10:00–12:00 ☐ 5. 14:00 -16:00 ☐ 7. 18:00 - 20:00 ☐ 9. 22:00 - 24:00 ☐ 2. 8:00- 10:00 ☐ 4. 12:00-14:00 ☐ 6. 16:00 - 18:00 ☐ 8. 20:00 - 22:00 ☐ 10. 0:00 - 6:00 B5. [If you read the newspapers several times per week and more frequently Which newspapers do you often read? ( Select up to 3 choices ) ☐ 1. Anninhthudo ☐ 5. People’s newspaper ☐ 10. Women & ☐ 13. Other printed ☐ 2. Anninhthegioi ☐ 6. Tienphong Family newspaper newspaper (please, ☐ 3. Sport and Culture ☐ 7. Tuoitre ☐ 11. Law and Life specify): …….

☐ 4. Lifestyle and health ☐ 8. News ☐ 12. Vietnam News ☐ 9. Weekly news B6. [If you read the e-newspapers several times per week and more frequently] Which e-newspapers do you often read? (Select up to 3 choices) ☐ 1. Vnexpress.net ☐ 6. Baomoi.com ☐ 11. 24h.com.vn ☐ 16. Tuoitre.vn ☐ 2. Dantri.com.vn ☐ 7. Docbao.vn ☐ 12. Vietbao.vn ☐ 17. Laodong.com.vn ☐ 3. Vietnamnet.vn ☐ 8. Giadinh.net.vn ☐ 13. Zing.vn ☐ 18. Doisongphapluat.com ☐ 4. Kenh14.vn ☐ 9. Dailyinfo.vn (tiin) ☐ 14. Ngoisao.net ☐ 19. Other Vietnamese e- ☐ 5. Tin247.com ☐ 10. Afamily.vn ☐ 15. Soha.vn newspapers (Please, specify): ……. ☐ 20. International e-newspapers B7. [If you access to the social network several times per week and more frequently] Which social network do you often access to? (Select up to 3 choices ) ☐ Facebook ☐ Google + ☐ Twitter

65 ☐ Youtube ☐ Skype ☐ Instagram ☐ Zalo ☐ Viber ☐ Other (please, specify) …….. SECTION C. RESPONDENT’S CONCEPTION OF HEALTH RISKS C1. The concern/conception of health issues in general In your opinion, which issues are seriously affecting the local people’s health? (May select multiple choices) ☐ 1. None ☐ 2. Air pollution ☐ 3. Noise pollution ☐ 4. Water pollution ☐ 5. Soil pollution ☐ 6. Environmental hygiene at the residence/domestic waste ☐ 7. Unsafe food ☐ 8. Alcohol, tobacco use ☐ 9. Newly emerging infectious epidemics (H1N1, Ebola, Mers-CoV, …) ☐ 10. Seasonal epidemics (dengue, influenza…) ☐ 11. Natural disaster/extreme event (storm, flood, front cold, …) ☐ 12. NCDs (Cardiovascular diseases, diabetes, cancer, …) ☐ 13. Other (please, specify) … ☐ -99. Don’t know/ Don’t remember C2. The concern/conception of Communicable diseases C2.1. In the last 3 years, which epidemic diseases in human (which rapidly spread in the community) have occurred in your residence? (Do not read out the options) ☐ 1. None ☐ 8. Avian Influenza H5N1,H1N1,… ☐ 2. Measles – Rubella ☐ 9. Fasciola gigantica ☐ 3. Zika virus ☐ 10. Rabies ☐ 4. Dengue ☐ 11. HIV/AIDS ☐ 5. Hand, foot and mouth disease (HFMD) ☐ 12. Other, please specify… ☐ 6. Varicella ☐ -99. Don’t know/ Don’t remember ☐ 7. Hepatitis B C2.2. [If C2.1>1] Which information sources have you awared of these diseases from? (May select multiple choices) ☐ 1. Doctors and medical staff at the clinic/ hospital ☐ 2. Television ☐ 3. Radio ☐ 4. Local loudspeaker ☐ 5. Newspaper ☐ 6. E-news portal (e-newspaper, website,…) ☐ 7. Social (Facebook, Zalo, Twitter, Google+...) ☐ 8. Relatives, friends or neighbors, ... ☐ 9. Village meetings ☐ 10. Posters, leaflets ☐ 11. Other, specify…

66 ☐ -99. Don’t know/ Don’t remember C2.3. In your opinion, Which the following communicable diseases are considered dangerous? 1. Dangerous 2. Not dangerous -99. Don’t know 1. Influenza H5N1,H1N1,… ☐ ☐ ☐ 2. Measles – Rubella ☐ ☐ ☐ Zika ☐ ☐ ☐ Dengue ☐ ☐ ☐ HFMD ☐ ☐ ☐ Varicella ☐ ☐ ☐ 7. Hepatitis B ☐ ☐ ☐ 8. Janpanese encephalitics ☐ ☐ ☐ 9. Fasciola gigantic ☐ ☐ ☐ 10. Rabies ☐ ☐ ☐ 11. HIV/AIDS ☐ ☐ ☐ 12. Other,specify… ☐ ☐ ☐ C2.4. If one of your household members have the following disease, what would you do (or which medical help would you seek) (*)?(May select multiple choices) Diseases (1) (2) (3) (4) (5) (6) (7) (8) (9) (- 99) 1. Avian Influenza H5N1, ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ H1N1,… 2. Measles - Rubella ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 3. Zika ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 4. Dengue ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 5. HFMD ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 6. Janpanese encephalitis ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 7. Fasciola gigantica ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 8. Rabies ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 9. Other (please, specify) … ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ (*) In that, ☐ 1. Do nothing, wait until the body heals itself ☐ 2. Self-medicate, heal the disease at home (without asking the doctor or anyone else) ☐ 3. Ask the doctor to go to your house for the disease treatment ☐ 4. Go to the near private clinic or the commune health center ☐ 5. Go to the central health facility ☐ 6. Ask for help from the Preventive Medicine Team or local epidemics prevention agency ☐ 7. Ask the relatives and/or friends about the treatment ☐ 8. Search information about the treatment through internet, social network ☐ 9. Other, specify... ☐ -99. Don’t know C3. The concern/conception about NCDs C3.1. In your opinion, which diseases could be resulted in by the following habits? Habits Disease could be resulted in

67 ☐ 1. Cardiovascular diseases (myocardial infarction, stroke, dyslipidemia, …) ☐ 2. Diabetes ☐ 3. Respiratory diseases (asthma, chronic obstructed pulmonary disease) ☐ 4. Cancer a. Smoking ☐ 5. Mental health diseases (mental disorders, depression, aniety disorder, autism, ...) ☐ 6. Hepatic diseases (high liver enzymes, hepatic steatosis, …) ☐ 7. Gastrointestinal diseases (erosive gastritis, ulcerative colitis, …) ☐ 8. Other, specify... ☐ -99. Don’t know/Don’t remember ☐ 1. Cardiovascular diseases (myocardial infarction, stroke, dyslipidemia, …) ☐ 2. Diabetes ☐ 3. Respiratory diseases (asthma, chronic obstructed pulmonary disease) b. Drinking ☐ 4. Cancer too much ☐ 5. Mental health diseases (mental disorders, depression, aniety disorder, autism, ...) alcohol/beer ☐ 6. Hepatic diseases (high liver enzymes, hepatic steatosis, …) ☐ 7. Gastrointestinal diseases (erosive gastritis, ulcerative colitis, …) ☐ 8. Other, specify... ☐ -99. Don’t know/Don’t remember

C.3.2. Which diseases do you think that you or your household members could be at risk? 1. Yes 2. No -99. Do not know 1. Cardiovascular diseases (myocardial infarction, stroke, ☐ ☐ ☐ dyslipidemia, …) 2. Diabetes ☐ ☐ ☐ 3. Respiratory diseases (asthma, chronic obstructed pulmonary ☐ ☐ ☐ disease) 4. Cancer ☐ ☐ ☐ 5. Mental health diseases (mental disorders, depression, aniety ☐ ☐ ☐ disorder, autism, ...) 6. Hepatic diseases (high liver enzymes, hepatic steatosis, …) ☐ ☐ ☐ 7. Gastrointestinal diseases (erosive gastritis, ulcerative colitis, …) ☐ ☐ ☐ 8. Other, specify... ☐ ☐ ☐

C.3.3. What would you do to prevent the risk of the following diseases? (May select multiple choices) Diseases (1) (2) (3) (4) (5) (6) (7) (8) (-99) 1. Cardiovascular diseases ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 2. Diabetes ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 3. Asthma, chronic obstructed pulmonary ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ disease 4. Cancer ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 5. Mental health diseases ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 6. Hepatic diseases ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 7. Gastrointestinal diseases ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

68 8. Other, specify… ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ (*) In that, ☐ 1. Do nothing or don’t know what to do ☐ 2. Do exercises regularly ☐ 3. Take the regularly medical examination ☐ 4. Reduce alcohol/beer use or do not smoke ☐ 5. Eat clean, drink clean ☐ 6. Ask the relatives and/or friends about the prevention ☐ 7. Search information about the prevention through internet, social network ☐ 8. Buy drugs and functional foods by yourself to strengthen your health ☐ 9. Adjust the living, eating regime ☐ 10. Other, specify... ☐ -99. Refuse to answer C4. The concern/conception of medical adverse events relating to medical services and treatment C4.1. In the last 5 years, which medical adverse events have you awared of? ☐ 1. Complication after vaccination ☐ 2. Using the out-of-date drug/ unsafe quality administration of drug ☐ 3. Complication due to vaccination or use of wrong drug ☐ 4. Infections in hospital (postoperative wound infection, infection with other diseases from the hospital, …) ☐ 5. Intraoperative or immediately postoperative/postprocedure death ☐ 6. Adverse events associated with the use or function of a device in patient care and treatment (eg: in hemodialysis, …) ☐ 7. Other, specify… ☐ 8. Do not know any medical adverse events C4.2. Which information sources have you awared of these medical adverse events from? (May select multiple choices) ☐ 1. Doctors and medical staff at the clinic/ hospital ☐ 2. Television ☐ 3. Radio ☐ 4. Local loudspeaker ☐ 5. Newspaper ☐ 6. E-news portal (e-newspaper, website,…) ☐ 7. Social network (Facebook, Zalo, Twitter, Google+...) ☐ 8. Relatives, friends and neighbors, ... ☐ 9. Village meetings ☐ 10. Posters, leaflets ☐ 11. Other, specify… ☐ -99. Don’t know/ Don’t remember C4.3. How do you feel when heard about the above medical adverse events? ……………………………………………………………………………………………………….

C5. The concer/conception about Environmental issues affecting health

69 C5. Which environmental/sanitary issues in your locality makes you feel worried? (DO NOT READ OUT THE ANSWERS) ☐ 1. No issue ☐ 7. Uncontrolled domestic waste ☐ 2. Water pollution ☐ 8. Garbage, wastewater from nearby industrial ☐ 3. Noise pollution areas ☐ 4. Air pollution ☐ 9. Unhygienic latrine ☐ 5. Soil pollution ☐ 10. Other, specify… ☐ 6. Garbage, wastewater from the nearby ☐ -99. Don’t know household business production C6. The concern/conception about food safety C6.1. In your opinion, what is unsafe food? (DO NOT READ OUT THE OPTIONS – May select multiple choices) ☐ 1. Unknown-origin food ☐ 2. Food using prohibited/toxic chemical substances ☐ 3. Food using out-of-bounds chemical substances ☐ 4. Stale/expired food still be consumed ☐ 5. Genetically modified food ☐ 6. Food containing natural toxins (snakehead, toard, ...) ☐ 7. Food produced in contaminated land ☐ 8. Very cheap price food ☐ 9. Other (please, specify) … ☐ -99. Don’t know C6.2. In your opinion, which food safety issues affect the local people’s health the most? (May select multiple choices) ☐ 1. Unknown-origin food ☐ 2. Food using prohibited/toxic chemical substances ☐ 3. Food using higher chemical substances amount than permitted ☐ 4. Stale/expired food which are still consumed ☐ 5. Genetically modified food ☐ 6. Food containing natural toxins (snakehead, toard, ...) ☐ 7. Food produced in contaminated land ☐ 8. Other, specify… ☐ -99. Don’t know C6.3. In your opinion, which health consequences could unsafe food use cause? (DO NOT READ OUT THE OPTIONS) ☐ 1. Digestive disorders, diarrhoea (choleara, typhoid, …) ☐ 2. Mental health symptoms (comatose, drowsy, …) ☐ 3. Cancer ☐ 4. Unknow-cause functional disorders (infertility, teratogenesis, …) ☐ 5. Other (please, specify) … ☐ -99. Don’nt know C6.4. In the last 1 year, have any members of your household ever had foodborne?

70 ☐ 1. Yes ☐ 2. No ☐ -99. Don’t know/Don’t remember C6.5. What is your experience to avoid unsafe food? ☐ 1. Buy wellknown-origin food ☐ 2. Buy food at certificated stores (Supermarkets, branded stores, ...) ☐ 3. Buy hand-carried imported/imported food ☐ 4. Buy food from acquaintance’s supply ☐ 5. Get food from the countryside ☐ 6. Self raising/planting ☐ 7. Process food hygienicly, use boiled water and cooked food ☐ 8. Steep food in salt water, pemanganat water ☐ 9. Refer to the information to select/buy safe food ☐ 10. Other, specify … ☐ 11. Do not have any experience

SECTION E. RECEPTION AND EXCHANGE OF INFORMATION RELATING TO HEALTH RISKS E1. National communication campaigns E1.1. In the last 1 year, was there any communication program on disease prevention or people’s health protection? ☐ 1. Yes ☐ 2. No ☐ -99. Don’t know E1.2. [If yes], which channels are those communication programs performed through? ☐ 1. Meetings, community events ☐ 2. Banners, posters or leaflets at residence/working place/health center ☐ 3. Community activities (public performance, competitions, …) ☐ 4. Training, seminars, conferences ☐ 5. Local loudspeaker ☐ 6. Community meeting ☐ 7. Other, please specify... E1.3. Do you remember the topic of those communication programs? ……………………………………………………………………………………………………………… ……… E1.4. [If yes], After hearing about/listen to the information on the above preventive measures, do you follow the guidelines that you have been disseminated/communicated? ☐ 1. Implement all preventive behavior for diseases in accordance with guidelines which you have been disseminated/communicated ☐ 2. Follow some guidelines on prevention that reasonable and consistent with the reality of your locality ☐ 3. Do not follow any preventative instructions for diseases propagated ☐ 4. Other, specify… E2. Reception and exchange of information relevant to communicable diseases E2.1 When you began to hear about a local outbreak, you concern/find out which information? (May select multiple choices) ☐ 1. Disease progress

71 ☐ 2. The possibility of outbreak ☐ 3. The causes of the diseases or risk factors (alcohol using, not sleeping in mosquitonet, …) ☐ 4. Signs/Symptoms of disease ☐ 5. Preventative measures for disease ☐ 6. Medication/treatments ☐ 7. The consequences if not treated promptly ☐ 8. The prestigious address for medical examination ☐ -99. Do not know E.2.2. When you want to FIND OUT/EXCHANGE information about the epidemic diseass, which information channels do you often use or refer to? ☐ 1. Follow up information on mass media (television, radio, printed newspaper, …) ☐ 2. Fint out/follow information on the e-newspaper ☐ 3. Find out/follow/share information on social network (Facebook, Zalo, Twitter, ... ) ☐ 4. Share/talk with other family members and relatives ☐ 5. Ask/talk with/to friends or acquaintances ☐ 6. Ask/talk with/to local staffs in your villages/wards (the local health councils/ women's union, veterans association ...) ☐ 7. Ask the doctor/health staffs at the medical facilities ☐ 8. Ask/talk with local authorities (Head of Households, staff of People's Committee, Party Committee, Departments ...) ☐ 9. Ask/talk with members of the association/group through meetings (group meetings, clubs, etc) ☐ 10. Other, specify... E2.3. How do you assess the level of trust of the following sources when looking for information relating to health (1. Unreliable - 4. Trustworthy) 2. Partially 3. Pretty 4. Trust -99. Don’t Information sources 1. Unreliable reliable reliable worthy know The state agencies and ☐ ☐ ☐ ☐ ☐ organizations International organizations ☐ ☐ ☐ ☐ ☐ (WHO, UN, ....) Union officials ☐ ☐ ☐ ☐ ☐ Doctors and medical specialists ☐ ☐ ☐ ☐ ☐ Hot Facebookers, Bloggers and ☐ ☐ ☐ ☐ ☐ famous/reputable individuals Vietnamese electronic

information sites Foreign electronic information ☐ ☐ ☐ ☐ ☐ sites Other, specify… ☐ ☐ ☐ ☐ ☐

SECTION F. MECHANISM OF INFORMATION FEEDBACK F1. Respondent’s feedback to communicable diseases F1.1 When there is the signal of increasing spread or complicated development of epidemics in your locality, what did you do to warn people? (May select multiple choices) ☐ 1. Report to the medical units, organisations (commune/ward health center, department of health, ….)

72 ☐ 2. Report to the local authorities (ward/commune level) ☐ 3. Report to the village health staffs/ward preventive health staffs ☐ 4. Call the telephone hotline to report ☐ 5. Inform the journalists, reporters, press agencies ☐ 6. Tell the relatives/friends ☐ 7. Post/comment/share the information on social network (Facebook, Zalo, Twitter, ...) ☐ 8. Other (please, specify) … ☐ 9. Do nothing ☐ -99. Don’t know F1.2 [F1.1 = 9] Why didn’t you do anything? ☐ 1. Someone has already reported to government units ☐ 2. I don’t know who and how to report ☐ 3. It’s not my business ☐ 4. Even if I report, it will not be solved ☐ 5. Other, specify… F1.3. [F1.1 <5] If you notified, what is the reaction of the local authorities or medical organisations after notified? (Only select 1 choice) ☐ 1. Quickly check the epidemic situation in the locality ☐ 2. Slowly response (After serveral days) ☐ 3. Not response/Ignore ☐ 4. Don’t know F2. Respondent’s feedback to unsafe food F2.1. In the last 1 years, are there any local production and business establishments producting unsafe food? ☐ 1. Yes ☐ 2. No ☐ -99. Do not know F2.2. [F2.1 = 1] What did you do? ☐ 1. Immediately report to the local authorities ☐ 2. Call the hotline to report ☐ 3. Inform the journalists, reporters, press agencies ☐ 4. Post/comment/share the information on social network (Facebook, Zalo, Twitter, ...) ☐ 5. Other, please specify… ☐ 6. Will never buy the product/use service of that bussiness ☐ 7. Inform friends, relatives, neigbour to know about this bad business ☐ 8. Do not do anything F2.3. [F2.2 = 6] If not do anything, why? ☐ 1. I am afraid of being intimidated, revenged ☐ 2. Someone has already reported ☐ 3. I don’t know who and how to report ☐ 4. It’s not my business so I don’t care ☐ 5. Even if I report, it will not be solved ☐ 6. Other, please specify… F2.4. [F2.2 <4] If report to the authorities, organization, telephone hotline, what is their reaction?

73 ☐ 1. The authorities promtly and timely visit/inspect the reported situation ☐ 2. The authorities visit/inspect the reported situation lately ☐ 3. The authorities do not have any reponses ☐ 4. Other (please, specify) ……………. ☐ -99. Do not know

74 Annex 2. Number of households participating in the survey by commune

Table i. Number of representatives of Central Department participating in the survey

No. Department/Center Participant Date

1 WHO Representative Office in Health Emergencies and 03/08/2018 Vietnam Communicable Disease Control

2 WHO Representative Office in Health Emergencies and 07/08/2018 Vietnam Communicable Disease Control

3 WHO Representative Office in Vaccine Preventable Diseases 08/08/2018 Vietnam

4 WHO Representative Office in Malaria and Other Vector-borne and 09/08/2018 Vietnam Parasitic Diseases

5 General Department of Preventive Head of Communication Department 24/08/2018 Medicine

6 Vietnamnews Agency Official, Team of Domestic Cutural 30/08/2018 Social News, in Medicine

7 Department of Livestock Production Vice-director of department 31/08/2018

8 Center for Health Communication and - Vice-director of center 13/09/2018 Education - Communication officials

9 Department of Food Safety Head of Control Food Safety 13/09/2018 Management Management Unit

10 HCMC Pasteur Institute Communicaiton official 19/09/2018

11 Agency of Health Environment Vice-head of medical environment 21/09/2018 Management management unit

12 Secretariat Office of Onehealth - Head of Secretaria Board 26/09/2018 Partnership - Secretary of Board - Communication Official

13 HealthBridge Canada Communication Official 27/09/2018

14 Health Strategy and Policy Institute Vice-director of institue 28/09/2018

15 Key Opinion Leaders Bloggers 28/09/2018

75 16 National Hospital of Tropical Spokesperson – Head of Department 2/10/2018 Diseases of Planning

17 Reporter VOV 8/10/2018

18 Reporter Health and Life Newspaper 8/10/2018

Table ii. Number of local authorities participating in the survey by local Province District Form Participants Date 1. Head of Unit of Health Communication and Education, Hanoi Center of Health KII 27/08/2018 2. Communication Official (T4G), Hanoi Center of Health 1. Vice-head of Long Bien Department of Health 2. Communication Official, Long Bien Preventive FGD Center 30/08/2018 3. President of Long Bien Women’s Union Long 4. Vice-president of Long Bien Youth Union Bien 1. Vice-president of Thach Ban People’s Committee Ward 2. Vice-secretary of Thach Ban Youth Union 3. Head of Thach Ban Health Center FGD 31/08/2018 Hanoi 4. Vice-president of Thach Ban Women’s Union 5. Head of culture unit, People’s Committee 6. Vice-president of Veterans’ Association 1. Vice-head of Soc Son’s Department of Health 2. Vice-head of Soc Son’s Center of Health 3. Communication Official, Center of Health FGD 28/08/2018 4. Vice-president of Soc Son Farmers’ Association 5. Vice-president of Soc Son Women’s Union Soc Son 6. Vice-Secretary of Soc Son Youth Union 1. President of Phu Minh People’s Committee 2. Head of Phu Minh Health Center FGD 29/08/2018 3. President of Phu Minh Women’s Union 4. Secretary of Phu Minh Youth Union 1. Head of Communication Department, Lang Son Preventive Medicine Center 2. Vice-head of Lang Son Food Safety Administration 3. Vice-head of Business Unit, Lang Son Women Lang Son FGD Union 04/09/2018 4. Official, Lang Son People’s Committee 5. Head of Medical Operation, Lang Son Department of Health 6. Vice-head of Commucation Section, Lang Son Youth Union

76 Province District Form Participants Date 1. Vice-director of Lang Son International Medical Quarantine Center KII 05/09/2018 2. Official, Unit of Administration – Operation, Lang Song International Medical Quarantine Center 1. Vice-head of Lang Son City Center of Health 2. Secretary of Lang Son City Youth Union 3. Vice-president of Lang Son City Farmers’ FGD 04/09/2018 Association 4. Staff, Lang Son City Women’s Union Lang 5. Official, Lang Son City People’s Committee Son City 1. Vice-president of Hoang Van Thu People’s Committee 2. President of Hoang Van Thu Women’s Union FGD 05/09/2018 3. Secretary of Hoang Van Thu Youth Union 4. President of Hoang Van Thu Farmers’ Association 1. Vice-president of Huu Lung’s Women’s Union 2. Staff, Huu Lung’s Youth Union FGD 3. 2 Officials of Huu Lung People’s Committee and 06/09/2018 Council of People 4. Official, Huu Lung Center of Health Huu 1. President of Yen Son People’s Committee Lung 2. President of Yen Son Women’s Union 3. Vice-president of Yen Son Women’s Union FGD 4. Representative of Yen Son Youth Union 07/09/2018 5. President of Yen Son Farmer’s Association 6. 2 officials, Culture Unit, Yen Son People’s Committee 1. Vice-director of Ho Chi Minh City (HCMC) Department of Health 2. Head of Medical Operation Unit, HCMC Department of Health 3. Vice-director of HCMC Center for Health Communication and Education 4. Head of Planning Unit, HCMC Preventive Ho Chi Medicine Center FGD 05/09/2018 Minh 5. Vice-director of HCMC International Medical City Quarantine Center 6. Vice-head of Communication Unit, HCMC International Medical Quarantine Center 7. Vice-Secretary of HCMC Youth Union 8. Vice-head of HCMC Management Board of Food Safety Administration 9. Vice-president of HCMC Women Union KII 1. Vice-director of City Children’s Hospital 06/09/2018

77 Province District Form Participants Date 2. Communication Official 1. Vice-head of management board of Kim Bien Market KII 2. Head of Customer Services Management Unit 06/09/2018 3. Head of 13 Ward Health Center 4. Officials of District 5 Center of Health A doctor working in Communication, Tan Son Nhat KII 07/09/2018 Airport’s International Medical Quarantine Center 1. Head of Department of Communication, KII Cholimex Food JSC. 07/09/2018 2. Head of Medical Unit, Cholimex Food JSC. 1. Vice-head of District 12 Unit of Health, People’s Committee 2. Vice-director of District 12 Preventive Medicine Center 3. Comminucation Official, District 12 Preventive FGD Medicine Center 05/09/2018 4. Vice-president of District 12 Farmers’ Association 5. Vice-president of District 12 Women Union District 6. Vice-head of District 12 Cuture – Information 12 Unit, People’s Committee 1. Vice-president of Tan Hung Thuan Associaion of the Elderly 2. Vice-secretary of Tan Hung Thuan Youth Union 3. Vice-president of Tan Hung Thuan Women FGD 06/09/2018 Union 4. Head of Tan Hung Thuan Health Center 5. Communication Official, Tan Hung Thuan People’s Committee 1. Vice-director of Hoc Mon Preventive Medicine Center 2. Comminucation Official, Hoc Mon Preventive Medicine Center FGD 3. Vice-chief of Hoc Mon People’s Committee 07/09/2018 Secretariat 4. Vice-president of Hoc Mon Farmers’ Association Hoc 5. Vice-president of Hoc Mon Women Union Mon 6. Vice-secretary of Hoc Mon Youth Union 1. Vice-president of Xuan Thoi Son People’s Committee 2. Head of Xuan Thoi Son Health Center FGD 08/09/2018 3. President of Xuan Thoi Son Farmers’ Association 4. Vice-president of Xuan Thoi Son Women Union 5. Staff, Xuan Thoi Son Youth Union

78 Province District Form Participants Date 1. Vice-director of An Giang Department of Health 2. Vice-head of Medical Operation Unit, An Giang Department of Health 3. Vice-director of An Giang Preventive Medicine Center 4. Vice-director of An Giang Center for Health Communication and Education FGD 10/09/2018 5. Vice-director of An Giang Board of Food Safety Administration 6. Vice-president of An Giang Women Union 7. Secretary of An Giang Youth Union 8. Vice-president of Committee of An Giang Fatherland Front 9. Vice-president of An Giang Farmers’ Association 1. Vice-head of Unit of Health, Long Xuyen People’s Committee 2. Vice-president of Long Xuyen Preventive Medicine Center FGD 10/09/2018 3. Vice-president of Long Xuyen Women Union 4. Vice-secreatry of Long Xuyen Youth Union 5. Vice-president of Long Xuyen Farmers’ Long Association Xuyen An Giang 1. Vice-president of Binh Duc People’s Committee City 2. Head of Binh Duc Health Center 3. Communication Official, Binh Duc Health Center 4. Vice-president of Binh Duc Women Union FGD 5. Vice-president of Binh Duc Farmers’ Association 6. Vice-president of Committee of Binh Duc Fatherland Front 7. 3 Heads of village/Group 1. Vice-director of Thoai Son Center of Health FGD 2. Secretary of Thoai Son Youth Union 12/09/2018 3. Vice-president of Thoai Son Women’s Union 1. Vice-president of Dinh Thanh People’s Committee 2. Official of Dinh Thanh Health Center 3. Head of Dinh Thanh Health Center Thoai FGD 12/09/2018 4. Vice-president of Dinh Thanh Farmers’ Son Association 5. Vice-president of Dinh Thanh Red Cross 6. Official of Thoai Son Center of Health 1. Head of Binh Thanh Health Center 2. Communication Official, Binh Thanh Health FGD 13/09/2018 Center 3. Vice-president of Binh Thanh Women Union

79 Province District Form Participants Date 4. President of Binh Thanh Farmers’ Association 5. Secretary of Binh Thanh Youth Union 6. Justice official, Binh Thanh People’s Committee 1. Vice-president of Danang Department of Health 2. Vice-president of Danang Center for Communication and Education 3. Vice-president of Danang Preventive Health Center 4. President of Danang International Medical Quarantine Center 5. Official of Danang Board of Food Safety Administration FGD 11/09/2018 6. Journalist – Editor of media and newspaper news, Danang Center for Communication and Health 7. Head of Testing Unit, Danang International Medical Quarantine Center 8. Head of Family – Society Unit, Danang Women’s Union 9. Head of Communication Unit, Danang Youth Union Danang International Medical Quarantine Center 1. Director of Center 2. Communition Official (T3G), writing news on Da Nang website FGD 12/09/2018 3. Head of Testing Unit 4. T3G Official working in the airport 5. Planning Official, working in post the news, Website Management Team Official in Danang Board of Food Safety 13/09/2018 Adminitration 1. Team leader of preventive medicine team, Hai Chau Center of Health 2. Official of Planning and Operation Unit, Hai Chau FGD 11/09/2018 Center of Health 3. Vice-president of Hai Chau Women Union 4. Vice-secretary of Hai Chau Youth Union Hai 1. Vice-president of Hoa Thuan Dong People’s Chau Committee Ward 2. Secretary of Hoa Thuan Dong Youth Union 3. Head of Communication Board, Hoa Thuan Dong FGD 12/09/2018 Party Executive Committee 4. Official, Hoa Thuan Dong Party Executive Committee 5. Official, Hoa Thuan Dong Health Center

80 Province District Form Participants Date 6. Vice-president of Control Party Committee 7. Cutural Social Work Official, Hoa Thuan Dong People’s Committee 1. Director of Hoa Vang Center of Health 2. Vice-president of Hoa Vang Center of Health 3. Team leader of Preventive Medicine Team, Hoa Vang Preventive Medicine Center FGD 4. Vice-secretary of Hoa Vang Youth Union 13/09/2018 5. Vice-president of Hoa Vang Farmer’s Association 6. Official of Hoa Vang Farmer’s Association Hoa 7. Official of Hoa Vang Women Union Vang 8. Public Health Official, Preventive Medicine Team 1. Vice-president of Hoa Vang People’s Committee 2. Secretary of Hoa Vang Youth Union 3. Head of Hoa Vang Health Center FGD 4. Vice-head of Hoa Vang Health Center 14/09/2018 5. Vice-president of Hoa Vang Women’s Union 6. Vice-president of Farmers’ Association 7. Head of Culture Unit, People’s Committee 1. Communication Official – Quang Nam Center for Communication and Education 2. Official of Quang Nam Board of Food Safety, Department of Health 3. Head of Medical Operation, Quang Nam FGD 17/09/2018 Department of Health 4. Head of Medical Examination, Quang Nam Center of Malaria and Thyroncus Preventation 5. Head of Medicine Executive – Quang Nam Preventive Medicine Center 1. Head of Preventive Medicine, Tam Ky Center of Health Quang 2. Vice-director of Tam Ky Center of Health FGD 17/09/2018 Nam 3. Medical Offcial, Unit of Health, Tam Ky People’s Tam Ky Committee City 4. Communication Official, Tam Ky Center of Health 1. Official of Hoa Huong Health Center 2. Official of Hoa Huong Farmers’ Association FGD 18/09/2018 3. Official of Hoa Huong Youth Union 4. Official of Hoa Huong People’s Committeee 1. Head of preventive medicine unit, Phu Ninh Center of Health Phu 2. Preventive Medicine Doctor, Phu Ninh Center of FGD 19/09/2018 Ninh Health 3. Official of Phu Ninh Farmers’ Association 4. Vice-president of Phu Ninh Women Union

81 Province District Form Participants Date 5. Official of Phu Ninh Youth Union 1. Head of Tam Thai Health Center FGD 2. Vice-secretary of Tam Thai Youth Union and 20/09/2019 Vice-president of Tam Thai Women Union

Table iii. Number of local people focus group discussion by local No. of No. Participants Date participant Group of local people who have low education and low 1 06 29/08/2018 salary in Phu Minh, Soc Son, Hanoi Group of local people who have high education and high 2 07 30/08/2018 salary in Phuc Loc, Long Bien, Hanoi Group of local business owners in Hoang Van Thu, Lang 3 07 05/09/2018 Son City, Lang Son 4 Group of ethnic people in Yen Son, Huu Lung, Lang Son 08 07/09/2018 Group of Elderly in Tan Hung Thuan, District 12, Ho 5 09 06/09/2018 Chi Minh City Group of Youth in Tan Hiep, Hoc Mon, Ho Chi Minh 6 07 07/09/2018 City Group of family with children form 0-18 years old Binh 7 08 11/09/2018 Đuc, Long Xuyen, An Giang Group of family with children form 18-25 years old in 8 06 13/09/2018 Binh Thanh, Thoai Son, An Giang Group of local people working in tourism services in 9 06 13/09/2018 Danang City 10 Group of local farmers in Hoa Bac, Hoa Vang, Đa Nang 07 14/09/2018 Group of local people with high incomes in Hoa Huong, 11 06 18/09/2018 Tam Ky City, Quang Nam Group of local poor people in Tam Thai, Phu Ninh, 12 06 20/09/2018 Quang Nam

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