Article Text

Download PDFPDF

Enabling factors and barriers to the sustainability and scale-up of drowning reduction interventions in Vietnam: a qualitative assessment
  1. Jagnoor Jagnoor1,
  2. Aliki Christou1,2,
  3. Cuong Pham3,
  4. Rebecca Q Ivers1,4,
  5. Ha Nguyen1,5
  1. 1 Injury Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
  2. 2 Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
  3. 3 Centre for Injury Policy and Prevention Research, Hanoi School of Public Health, Hanoi, Vietnam
  4. 4 School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
  5. 5 John Walsh Centre for Rehabilitation Research, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Jagnoor Jagnoor, Injury Division, George Institute for Global Health, Sydney, NSW 2042, Australia; jjagnoor{at}george.org.au

Abstract

Background Vietnam has some of the highest rates of drowning deaths in the Western Pacific Region, particularly among children aged 19 years or younger. Several policies aimed at drowning prevention have been developed over the last decade; however, despite policy support, generally these have not been sustained beyond a pilot phase or have been limited to small geographical regions. The present study aims to explore barriers and facilitators for sustainability and scale-up of drowning prevention initiatives in Vietnam, identifying ways forward for future implementation.

Methods This was a qualitative study using semistructured indepth interviews with key stakeholders (n=12) engaged in drowning prevention in Vietnam. The Framework Method was used to analyse the data drawing on Schell’s theoretical framework for public health programme sustainability. The Framework Method is most commonly used for the thematic analysis of semistructured interview transcripts, particularly as the data were fairly homogeneous.

Results Four key factors were identified that facilitated implementation of drowning reduction activities in Vietnam. Strong political support at all levels, underpinned by policy; effective partnerships with the community; widespread communication; and programme adaptation to local contexts and application of innovative approaches, for example, strengthening organisational capacity in limited resource settings, were the key enablers. Barriers include the instability of the funding sources; inadequate programme evaluations to generate evidence of effectiveness and lack of consistent and timely data collection; and insufficient strategic planning for long-term implementation of drowning prevention interventions.

Conclusion Ensuring the sustainability and scale-up of drowning prevention programmes in Vietnam requires a continued focus on enablers such as on community engagement, communication activities and partnership approaches, and importantly concerted efforts to mobilise resources for continued long-term funding, improvements in planning and intersectoral coordination, and ensuring that future programmes are robustly evaluated for effectiveness.

  • drowning
  • low-middle income country
  • qualitative research
  • policy
  • implementation / translation
View Full Text

Statistics from Altmetric.com

Introduction

Drowning is one of the leading causes of death in Vietnam, particularly among children.1 2 Data from the injury mortality surveillance system showed that between 2009 and 2013 there was only a marginal decline in all-ages drowning mortality, from 7.1 per 100 000 to 6.6 per 100 000.1 3 This is approximately three times the drowning mortality rate that exists in high-income countries, and is higher than the age-standardised rate of the WHO Western Pacific Region, in which Vietnam is located.4 Childhood mortality rates from drowning in Vietnam are even higher; a study using the WHO mortality database found that among children aged 19 years or younger, the drowning mortality rate was 10.9 per 100 000 in Vietnam. This is around twice the mortality rates in Thailand and the Philippines, neighbouring countries with similar exposure to water bodies.5

The high drowning mortality rate in Vietnam is due to a combination of environmental, socioeconomic and individual factors. With over 3000 km of coastline and a wide network of rivers, lakes and ponds, the level of exposure to water bodies in Vietnam poses a significant risk of drowning. Further, frequent flooding, particularly flash flooding in mountainous areas, and typhoons during the monsoon season result in hundreds of drowning deaths every year.6

Socioeconomic factors such as poverty, lack of child supervision and large families are known risk factors for drowning.7 The lack of childcare centres in socioeconomically disadvantaged, rural and remote areas, and the inability to afford childcare result in many working parents leaving children at home under the supervision of older siblings. A 2014 report found that 53.4% of children in the poorest quintile attend early years education compared with 85.7% from the richest; 67.8% of children aged 3–5 years old attend childcare in rural areas of Vietnam.8 Lack of water survival skills is also an important risk factor for drowning; an intervention study of a swimming lesson programme in Danang, a central coast city in Vietnam, reported that 80% of children over 5 years of age could not swim.9

The complexity of drowning risk factors and the circumstances that surround drowning events often make it difficult to prioritise and implement effective drowning prevention interventions. A review of major drowning prevention interventions and policies in Vietnam, following the development of the First National Policy on Injury Prevention (2002–2010) in 2001, identified several supportive policies promoting drowning prevention (online supplementary appendix 1, table S1) and an increase in drowning prevention activities and programmes in Vietnam (online supplementary appendix 1, table S1). These activities and programmes included a range of information, education and communication campaigns to improve awareness of drowning risks, lessons for school children on survival swimming skills and efforts to improve data collection on drowning mortality.

There are a paucity of examples in the low-income and middle-income country context, where sustainable drowning reduction has been achieved. Although Bangladesh has no national policy to support drowning reduction, it has seen significant sustainability of drowning prevention research, and more recently success in programme implementation. This is largely attributable to ongoing funder-driven investment in this area.10 This funder-driven partnership in Bangladesh has produced considerable evidence-based research and literature on drowning reduction in low-income and middle-income countries.10 Thailand conversely has used effective implementation of policy measures to accomplish sustainable drowning reductions, with significant government and community ownership.11 Vietnam, like Thailand, has national drowning prevention policies; however, these policies are poorly implemented and the programmes and research have not been sustainable or scaled. Many programmes identified were limited to small geographical areas and/or were not sustained beyond their pilot phase, winding down when financial support from external organisations ceased. This study aimed to identify barriers and facilitators for sustainability and scale-up of drowning prevention initiatives in Vietnam that can inform future efforts for effective implementation and widespread reach to reduce drowning deaths.

Methods

Study design

This was a qualitative study using semistructured indepth interviews with key stakeholders working in drowning prevention in Vietnam.

Participants

Participants were key informants selected using purposive and snowball sampling based on their involvement in drowning prevention activities in Vietnam. These include representatives from government departments which have a vested interest in drowning prevention, organisations implementing drowning prevention activities and research institutions. The purpose was to select a mix of respondents at different but related levels and specialties in drowning prevention, and subsequently to obtain robust and indepth responses around facilitators and barriers to implementing drowning prevention interventions in Vietnam. Participants were identified from the capital as well as the provincial level. Participants were initially approached by a local research assistant via telephone. The research assistant provided information on the aims of the study, a brief description of the study and the process to obtain consent to participate. On the initial verbal consent, participants were then followed up via email with a full participant information sheet, a copy of the interview guide and a schedule for a face-to-face indepth interview. A total of 12 key informant interviews were conducted (table 1).

Table 1

List of key informants participating in indepth interviews

Data collection

Face-to-face indepth interviews were conducted with key stakeholders by two researchers (HN and NN) using semistructured interview guides (online supplementary appendix 2). The guides explored experiences implementing drowning prevention programmes and perceived enabling factors and barriers to the sustainability and scalability of drowning prevention efforts and recommendations for ensuring future sustainability. Interviews were conducted in a private room and were either audio-recorded or detailed notes taken, and ranged in length from 50 to 80 min. All interviews were transcribed in Vietnamese and translated to English.

Data analysis

We used the Framework Method, a systematic technique creating a matrix of cells with cases and codes to categorise, organise and analyse qualitative data.12 We applied a deductive approach to thematic analysis. The data were primarily analysed by HN in discussion with JJ. Schell et al’s13 theoretical framework for public health programme sustainability was used to examine enablers and barriers to programme sustainability. Schell et al define sustainability as ‘the ability to maintain programming and its benefits over time’, and identify nine domains as critical components of sustainability: funding stability, political support, partnership, organisational capacity, programme adaptation, programme evaluation, communications, public health impacts and strategic planning (table 2).

Table 2

Summary of Schell et al’s13 domains critical for public health programme sustainability

Results

Sustainability has been defined as the continued use of programme components at a sufficient intensity for desirable programme goals and population outcomes. Several public health programmes are challenged by the multisectorality of the interventions, limited resources, competing priorities and robust evaluations. Guided by the framework analysis, we identified enabling factors that can ensure that positive outcomes are maintained over time and also highlight barriers in sustainability of the drowning prevention initiatives in Vietnam.

Enabling factors for the sustainability and scale-up of drowning prevention initiatives

Enabling factors raised by participants surrounded the domains of political support, partnerships, communications and programme adaptations.

Political support

Government recognition and prioritisation of drowning prevention

Strong political support through government recognition of the importance of drowning was identified by stakeholders as a key enabler of drowning prevention activities in Vietnam. This support was critical for passing important policies and has been the catalyst for the development of drowning prevention programmes by setting priorities and targets to be achieved. Since the issuance of the First National Policy on Injury Prevention (2002–2010), drowning has consistently been a priority in many subsequent national policies, showing long-term commitment of the government to address the burden of drowning. Resolutions in 2013 (Resolution 2158/2013/QĐ-TTg) and 2016 (Resolution 234/2016/QĐ-TTg) on a national programme on injury prevention included very specific targets for drowning reductions, as one stakeholder highlighted:

The recent Resolution 234/2016/QĐ-TTg to approve the National Program on Injury Prevention in children for the period from 2016 to 2020 has 5 out of 10 objectives targeted specifically on drowning reduction. (RO)

Several informants recognised that political support has played an important role in facilitating collaborations between provincial-level governments and non-governmental organisations (NGOs) for implementation of drowning prevention activities in the communities:

During the implementation of the program, we received very active engagement from many Government Ministries and Provincial Departments. They made very positive contributions in policy development as well as policy advocacy. (NGO2)

The strong political support for drowning prevention has resulted from the recognition of the huge drowning mortality burden, by governments at all levels. The high mortality rates due to drowning were first acknowledged following the first National Injury Survey conducted in 2002, reporting the nationally representative statistics on drowning.14 Survey findings were instrumental in providing evidence on the burden of drowning and its distribution for targeted injury prevention interventions, including drowning prevention. Since 2005, data on drowning deaths have been routinely collected nationwide as part of the injury mortality surveillance system. This was the result of collaboration between the Ministry of Health and Unicef since 2003 under Unicef’s Childhood Injury Prevention Program. As part of this programme, Unicef also collaborated closely with the Ministry of Labour, Invalids and Social Affairs (MOLISA) to raise awareness of the burden of drowning among policy makers, advocating for policies on drowning prevention:

A significant component of our Childhood Injury Prevention Program is policy advocacy. We worked closely with the Department of Child Protection, Ministry of Labour, Invalids and Social Affair to develop policy briefs and communication materials to advocate for policy on injury prevention for children. Drowning prevention is a large part of these. (NGO2)

Partnerships

Engagement and partnership with local communities

Another enabler contributing to the successful implementation of drowning interventions in Vietnam has been the partnerships established with and support received from local communities, who actively engaged and accepted the programmes. This support has been evident from the number of schools participating in training of swimming instructors, as well as high participation rates by children in swimming lessons organised at local primary schools. For example, during the implementation of the SwimSafe Danang programme between 2006 and 2008, 120 physical education teachers and 8 beach lifeguards were trained in swimming instruction courses, including teaching survival swimming skills and cardiopulmonary resuscitation. In addition, over 4718 school children participated in swimming lessons across 12 different locations in the city.9 A stakeholder from a research organisation explained the importance of this:

While it is vital to get support and approval from the local government to start our program, we have to acknowledge the support from local communities, school principals and physical education teachers, parents and school children to be actively engaged into our program. Without their participation, we would not be able to achieve our goals. (RO)

Intersectoral engagement and partnerships

In addition to the engagement of communities, another key enabling factor identified was the relationships and support provided by actors across other sectors. As this stakeholder from an NGO describes,

During the implementation, the Department of Education mobilised physical education teachers [from local schools] to participate in [swimming] training program. They provided the venue the training and travel support for participants. We only provided the training for teachers, pre-post training assessment, and support for local schools in organising swimming lessons for their students. (NGO8)

This multisectoral engagement was facilitated by an intersectoral plan developed by the government which stipulated how each sector would be engaged in drowning prevention:

…Until 2013, the Government approved the first program, the Program on Injury prevention in children for the period from 2013 to 2015…Also during that time (2012), the government approved an inter-sectoral plan on childhood drowning prevention among 9 sectors. The plan included specific aims and tasks to be implemented by each sector. (GO3)

These partnerships were often used as a strategy to manage financing that limited the scale-up of programmes, as one stakeholder explained:

This is a major challenge because the government is unable to pay for drowning prevention programs on a large scale. However, we are seeing the start of some multi-sectoral partnerships between private companies, INGO’s and the government. (NGO6)

Public–private partnerships

In several districts where government funding was lacking for swimming programmes, the formation of different partnerships with the private sector has enabled the establishment of venues for swimming lessons:

I am also aware that, in some provinces, where there is no swimming pool. Private company partners with schools to install portable pools, at a cost of 100 million VND per pool. They pay for the pool while the schools provide the location. Then they enrol students and charge fees for swimming lessons. I think this type of partnership should be promoted. (GO2)

Communications

Widespread community awareness raising

Several stakeholders spoke of the effectiveness of awareness raising and communication activities conducted in the past at the community level which continued to create demand for swimming programmes.

In the early years, we had done a lot to raise awareness on injury and drowning among children for the general public. I have to say that awareness of the general public about these issues has improved. Now in many urban cities, parents are actively taking their children to swimming lessons. (GO3)

Such information, education and communication campaigns may be responsible for the strong engagement of communities in drowning interventions such as the swimming lessons raised earlier. Implemented alongside swimming lessons, parents and school teachers received leaflets and flyers with information about the risks of drowning and the approach for drowning prevention from the school and also at the time their children were attending swimming lessons.

To ensure the high rates of enrolment and retention in our swimming classes, we had started our communication campaign during the school year, well before the summer vacation, the time we planned to start the swimming lessons. We delivered communication materials to children at school. We had banners in front of primary schools and also on major streets in Danang. We also had flyers available at the swimming lesson sites and parents could get them when they drop or wait for their children during the lesson. (RO)

MOLISA also regularly issues official correspondence on drowning prevention to local provinces at the beginning of the summer every year. This includes a review and installation of signage in drowning risk areas, communication on swimming lessons for children, increased adult supervision for children during summer holiday etc. We also encourage communications between school and local youth union to organize summer activities for children during the months they are not at school. (GO3)

Continuous advocacy and communication with stakeholders

The widespread reach of advocacy activities and continuous delivery of information to key stakeholders were also an important factor:

…policy advocacy and community awareness education were nation-wide; target groups were not limited to MOLISA – Child protection workers, but also workers from Women Union, Youth Union, Red Cross Association etc. All activities were expanded largely…In addition, our development of training materials also became professionalized and targeted to specific population groups…We also developed materials on how to advocate for policy, specifically on using life jacket for children, swimming lesson for children, developing Injury prevention program with component on drowning prevention. (GO3)

Programme adaptation

Adaptation of programmes to the local context

Teaching survival swimming skills is one of the most common drowning prevention interventions implemented in Vietnam. However, a major challenge for implementing this intervention has been the lack of swimming pools in the local communities. To mitigate this, some programmes have adapted to the local settings so they can still deliver the programme. For example, in areas where there are open bodies of water such as lakes, rivers or beaches, pools for swimming lessons were created by using these water bodies and establishing boundaries and platforms, creating a safe, enclosed swimming area for students. In other areas, low-cost portable pools were set up in school playgrounds during the summer holidays to organise swimming lessons.9 These adaptations in the varying contexts across Vietnam enabled the scale-up of lessons to a wider area, as this stakeholder explains:

When started the swimming program in Danang, the biggest challenge…was the lack of swimming pool to organise swimming lessons for children. There were a few existing pools [concrete pool] but they were only available in some urban district. Parents would not bring their kids for swimming lessons if the pool was too far from their home…It took a while for us to come across the idea of setting up portable pool imported from China. They were affordable, easy and quick to set up. We could make use of the school ground during the summer vacation. We can remove the pool when the school year resume. By using the portable pools, we managed to extend our swimming lessons to 10 primary schools, in addition to one public swimming pool and another site set-up at the beach. (RO)

Organisational capacity

Strategising human resources to fill organisational capacity needs

Some organisations working on drowning prevention in Vietnam have limited resources but have sustained activities through alternative means, such as engaging with volunteers from overseas. For example, one organisation has done so by keeping minimal number of paid employees and actively recruiting volunteers and fundraising:

Our ongoing overheads are kept to a minimum. We have no paid employees. We conduct fundraising activities in Melbourne, Australia and are fully funded by donations and sponsorship. We have no Government funding…We have no trouble attracting high calibre volunteer swim teachers to teach in Vietnam. (NGO7)

To overcome financial barriers and continue implementing swimming programmes, some provinces have garnered financial support from their own communities. This approach has worked well in urban areas:

While there are difficulties in the availability of swimming facilities in many provinces, some have done really well. For example, in Ho Chi Minh City, they have swimming facilities and they have done well in mobilising contribution from families. Families are willing to contribute financially for their children to attend swimming lessons. (GO2)

Barriers to the sustainability and scale-up of drowning prevention

Barriers surrounded the domains of funding stability, programme evaluation and impact, and strategic planning.

Funding stability

Unavailability of consistent government funding

One of the greatest barriers to drowning prevention activities in Vietnam has been related to funding stability. While drowning prevention is acknowledged as an important issue, there is no guaranteed funding allocation from the central government to implement drowning prevention activities. Organisation of such activities is dependent on provincial governments, including their funding availability and other competing priorities, as this stakeholder describes:

One of the difficulties in organising drowning prevention activities is the funding availability. In province or city, where they have surplus funds such as Danang, Quang Ninh, Hanoi, the Provincial People committee could provide funding for swimming lessons for children. In disadvantaged provinces [where expenses exceed incomes] we are trying to advocate for funding support [from the central government and international agencies] to organise swimming lessons for children. (GO2)

Dependence on donor funding

For international NGOs, the lack of financial stability also affects their ability to sustain, let alone expand their activities. This may be more of a concern for organisations whose funding sources are mainly from donations. This manager from an NGO explains the impact on sustainability and any potential to scale up drowning prevention programmes:

Because of the downturn of global economic in recent years, our major donors could not continue their support for our program. The funding becomes very restricted and limits our capacity to scale-up. (NGO8)

Programme evaluation and public health impacts

Inadequate evidence of effectiveness of programmes for prioritisation

Most drowning prevention interventions implemented in Vietnam to date were centred on the provision of swimming lessons for school children and/or information, education and communication campaigns. Programme evaluations have been mainly output evaluations reporting on specific outputs achieved, such as the number of swimming instructors trained, the number of children participating in swimming lessons, or the number of information, education and communication materials delivered.9 15 While these are important indicators, they are not outcome indicators, which are needed to provide crucial information about intervention effectiveness and public health impacts, including the number of drownings that could be prevented, or the cost-effectiveness. The need for such evidence was highlighted by participants:

We need evidence (of the impact of interventions) to present to policy makers. We’ve been focusing on interventions, but we haven’t prioritised research on the cost-effectiveness of interventions or return of investment. I think other countries have done these pretty well and they would present these to their policy makers that they would gain what from their investment dollar (economic effectiveness). In Vietnam, we have nothing. (NGO2)

Another important issue related to programme evaluation was the lack of consensus on and standardisation of intervention activities, either it is swimming lessons, or information, education and communication campaigns. For example, in regard to training for swimming instructors, some organisations had internationally recognised certification for instructors, while others have no specific certification for their trained instructors. Similarly, for children participating in swimming lessons, the criteria for survival swimming appeared to vary between programmes.

Lack of timely and consistent data collection

Although it was the availability of data on the drowning burden that initiated government recognition and commitment to drowning prevention in Vietnam, stakeholders highlighted the challenges associated with obtaining up-to-date data through the government data collection systems and that the variations in data collected across different sectors made it difficult to obtain comparative data:

…I have to admit that, our data on injury, particularly on drowning, would be incomplete and different data collected by other sectors. This could be because of the different age cut-off. For instance, MOH have the age cut-off for children at less than 19 years old and they also have an age group of less than 14 years old. Our Department have the age cut-off for children at less than 16 years old. (GO3)

Strategic planning

Absence of clear national and regional strategic plans for drowning reduction

Another barrier affecting the sustainability and scalability of drowning interventions in Vietnam is a lack of strategic planning within organisations involved in drowning prevention. This issue exists in many government agencies. While the government policies set out specific goals to achieve within a specific time frame, the direction and strategies to achieve these goals are ambiguous. As a result, the necessary resources required to achieve drowning prevention goals are not adequately allocated. The serious lack of human resources within the government sector to coordinate drowning prevention activities in communities is one example and consequence of this lack of planning. As one government stakeholder explains,

In our sector, there is only one staff at commune level. That person is responsible for all welfare issues, from war veteran, older people to child welfare. Drowning prevention is only part of child welfare. (GO3)

Inadequate direction and lack of clear strategies also affected the mobilisation of resources needed to sustain and expand drowning prevention activities. Maintaining swimming lessons for children requires substantial ongoing costs for the maintenance of swimming pools and support for swimming instructors. In the beginning, these costs are often met by implementing agencies—usually international organisations; however, once this funding ceases, there are limited options to mobilise resources to continue the activities, as this stakeholder from an NGO explains:

There is a limitation within the regulation of mechanism to mobilise resource for non-government organisation. We cannot organise activities to charge fees to sustain our activities as a non-government organisation. To sustain our activities, in addition to mobilise resources from donations [which are not always stable], it is necessary to acquire additional resources, such as fee-for-service. (NGO8)

Inefficiencies in intersectoral collaboration

The absence of ownership, coordinated efforts, and clarity on roles and responsibilities were factors perceived to hinder drowning prevention efforts in Vietnam and were raised by stakeholders from governments and NGOs:

…I recently attended a meeting of the disaster management steering committee, in which, injury and drowning prevention were discussed. There were representatives from MOLISA, Youth Union, Farmer Union, Women Union etc. They talked about their work on injury and drowning prevention. I had a feeling that, they are all doing a lot of the same thing but there was no coordination. I think there should be a central coordination and tasks should be allocated to individual. (GO2)

One big challenge is the lack of clarity on roles and responsibilities among the various government agencies at the national, provincial and district levels in terms of drowning prevention. There also isn’t collaboration among the agencies which creates a lot of inefficiencies. (NGO6)

This absence of adequate strategic planning also has an impact on the roles and responsibilities of various agencies, and the new approach taken in the plan for 2016–2020 has led to a lack of clarity around the responsibilities of various sectors:

Before 2010, you would be aware that there was a national policy on injury prevention. MoH had the coordinator role for the policy. After 2010, there was a change, and a cross-cutting national policy like from 2002 to 2010 no longer existed, and instead, the responsibility was assigned to individual Ministries. For the period from 2011 to 2015, we had the advisory role the national plan and our MoH also had our own community-based injury prevention plan. (GO1)

Programme adaptations

Inadequate adaptations for areas with low participation

Although several adaptations have been made to ensure swimming lessons can continue in many areas, mountainous and remote areas continue to be a challenge. Stakeholders pointed to a need for further adaptations and innovation to facilitate uptake of swimming lessons in these regions as even providing free classes could not ensure participation:

…in mountainous or remote provinces, their condition is extremely difficult and thus there are limitations in what they can do….in our visit to Lang Son (a northern mountainous province), swimming lessons were organised for school children free of charge but it was hard to get children enrolled in the program…Asking for reasons of not enrolling, the responses were that they had to work to support their family, or they had to go to the farm with their parents, no one would take them to the swimming lesson. (GO2)

Political support

Enforcement and compliance with regulations

Although several policies exist on regulations to ensure safe water transport, these are rarely enforced and contributing to drowning incidents:

Safety of water transport is another issue. While enforcement of water transport safety is increased, violations of the regulation still exist, such as passenger not wearing life jacket, overloaded vessel, and vessel operator without a license. If you are on board and not wearing a life jacket, when an incidence happens, you would not have enough time to wear the life jacket. When life jacket is available for vessel passenger, it is difficult to force the passenger to wear the life jacket. In this case, both the passenger and the vessel operator are violating the regulation. The passenger is negligent, and they think that the life jacket is unnecessary because they can swim. Regulation is one important but the compliance to the regulation is also critical. (GO3)

Another factor which has made long-term planning and sustainability challenging has been changes in government and health system reforms, resulting in poor evaluation data for informing furture investment,

Constant reform of the health system leads to continual separation and merging of departments and offices at the central as well as provincial and district levels. We don’t have enough staff to maintain the operation [of the injury mortality surveillance system] as it was originally designed. (GO1)

Discussion

In this qualitative study, we explored enabling factors and barriers to the sustainability and scale-up of drowning prevention initiatives in Vietnam. Since 2001, there have been several key government policies and actions on drowning prevention and a number of drowning prevention interventions implemented in Vietnam (online supplementary appendix 1, tables S1 and S2). A key enabling factor behind these was the initial generation and dissemination of robust data on the drowning burden from the Vietnam mortality surveillance system, which garnered political support for this public health issue. Engagement and partnerships with communities to deliver and facilitate uptake of interventions have also been an important driver creating demand for and sustaining drowning prevention programmes, as have local adaptations of programmes, intersectoral partnerships, and enhancing organisational capacity through mobilisation of volunteers and alternative funding sources. These successes are evident with continued collaboration between Unicef, WHO, Royal Life Saving Society - Australia and MOLISA on a series of Australian Agency for International Development and Royal Life Saving Society - Australia funded workshops to organise the World Conference on Drowning Prevention in Danang 2011, and to support the development of the first National Policy on Drowning Prevention in 2016.

However, funding instability has been a major barrier to the sustainability of programme implementation, and ensuring action is taken on policies will affect the potential for future scale-up of drowning prevention initiatives. Despite key government support and political will, this has not translated into sustained national or local funding of programmes. Vietnam has progressively decentralised fiscal arrangements and given more autonomy to local governments; thus, resource allocation for national-level policies is decided by the provinces, often with other competing health and development priorities.16 17 Most interventions have been implemented by international agencies and are not continued by local agencies once the funding or evaluation is complete. The study participants identified overseas volunteering as an enabler to programme sustainability in the form of capacity building and/or training of local staff. However, it is well known in the public health space that donor-driven and volunteer-reliant programmes often do not sustain.18 In the context of drowning prevention, volunteering over a long period of time discourages community ownership. Thus, volunteering without agreed outcomes and planned scale and sustainability can inhibit programme sustainability.

Limited evaluations have also inhibited ongoing funding, due to inadequate evidence of effectiveness, as have limited availability of timely and comparable data. The lack of strategic planning within the government also impacts long-term funding and coordination of activities across sectors and stakeholders.

Teaching swimming and developing skills among children are an effective approach to reducing the number of drowning incidents. Evidence from studies in other low-income and middle-income country settings, including rural China19 and Bangladesh,20 shows that teaching children to swim can reduce the risk of drowning. A case–control study conducted in the USA showed that participation in formal swimming lessons was associated with an 88% reduction in the risk of drowning in the 1–4 years age group.21 However, to date, penetration of swimming training in the community in Vietnam is low; of 63 provinces and cities, only 11 provide swimming lessons supported by international organisations, and these interventions only partially covered the province/city. Therefore, there is a real opportunity to scale up teaching survival swimming, water safety and rescue skills to children. Future interventions would also benefit21 from the wealth of existing experience gained from implementation of programmes in many parts of Vietnam with various socioeconomic, geographical and climatic characteristics. However, there is a need for all key stakeholders and implementing agencies involved in delivering swimming lesson interventions to work together to develop a standardised implementation package which includes modules to be adapted to ensure feasibility of implementation in different settings, as well as monitoring and evaluation indicators. A strategic plan to ensure sustainability and a well-defined strategy for the scale-up of a programme should be included, together with a built-in component for cost-effectiveness evaluation for all current and future interventions.

The impact of evidence and data in gaining the attention of policy makers in Vietnam in the past showcases how critical this can be and how important it is to continue generating data on the burden of drowning and on future drowning prevention programmes through robust monitoring and evaluation. Such evaluations are important for identifying areas for improvement and the most effective strategies that make the best use of resources, and are essential for future scale-up of interventions.22 This would provide essential evidence to gain support from policy makers and funding agencies as well as communities, and contribute to long-term programme sustainability and potential scalability. Ensuring consistency of data collection across agencies is also important to ensure the utility and comparability of data sources.

This study has shown how provincial governments have engaged in different partnership approaches as a means to sustain, expand and fund swimming lessons in their communities. Such partnerships should be evaluated and assessed for applicability in other areas in Vietnam. Many of these approaches were used in urban areas and have involved charging user fees for swimming lessons; however, this prevents families of low socioeconomic status from accessing such programmes for their children, and so in these areas alternative models or programme adaptations are needed.

The lack of representation of participants from provincial-level government agencies in our study is a limitation, and our findings may not reflect the views at the local level.

A critical opportunity to ensuring the future sustainability and scale-up of drowning reduction programmes in Vietnam is the development of a clear strategic plan that outlines the responsibilities of all actors that can facilitate improved intersectoral coordination to minimise duplication and maximise use of resources. These were some of the recommendations included in a recent implementation guide released by the WHO which detailed steps needed to be taken by countries to reduce drowning.4 Four key strategies highlighted in this guide included strengthening public awareness, promoting multisectoral collaboration, developing a national water safety plan, and advancing drowning prevention through data collection and well-designed studies.4 Given the global commitments to the Sustainable Development Goals (SDGs) to end preventable deaths of children under 5 years (SDG 3) and ‘Ensure availability and sustainable management of water and sanitation for all’ (SDG 6), ensuring steps are taken to integrate these strategies into policy and systems in Vietnam is critical.

Strengths and limitations

This is, to our knowledge, the first study examining the enabling factors and barriers to the sustainability and scale-up of drowning reduction interventions in Vietnam. It identifies existing partnerships and capacity on which to build on. These findings inform drowning prevention practitioner, stakeholders and programme managers on how to plan and implement activities, enabling programme sustainability. The findings also highlight the challenges that must be addressed to bolster future efforts in drowning prevention in Vietnam.

An important strength of this study is the breadth of stakeholders included. We identified key actors from three different government ministries, stakeholders from both provincial and capital levels, from research institutions and NGOs whose work spans the North to the South of Vietnam’s geography. The use of qualitative methods enabled us to elicit deeper understandings of the unique context that drowning reduction programmes operate within Vietnam.

Although we had a good variation of participants for data collection, data saturation may not have been achieved for each theme. Furthermore, our study did not include participation from government representatives at the provincial level; thus, it does not explore challenges at the subnational level, where health priorities and resources could vary with geographical conditions and socioeconomic determinants.

Conclusion

Despite the marginal reduction in drowning mortality in recent years globally, Vietnam still has one of the highest all age mortality rates from drowning in the world. Interventions for drowning prevention need to be sustained and expanded in order to accelerate further declines in drowning mortality and morbidity. Enabling factors that have supported drowning prevention initiatives in Vietnam include the continuity of a legislative framework for drowning prevention, recognition of the burden of drowning by the government at all levels and willingness to support drowning prevention interventions in Vietnam by many international organisations.

While there has been consistent government policy and recognition of the issue, there has been little coordinated and funded local government investment in prevention programmes or flood mitigation. To ensure the sustainability and future scale-up of drowning interventions, it is critical to integrate a mechanism to mobilise resources, ensuring the stability and continuation of funding from multiple sources early in implementation. Sources may include government, global commitment and funding, and contributions from the public and local businesses.

What is already known on the subject

  • Drowning in Vietnam continues to be a leading cause of death especially among children aged 19 years or younger.

  • Although drowning prevention policies exist in Vietnam, implementation and scale-up of drowning prevention interventions have been limited.

What this study adds

  • This study identified strong political support, partnerships with communities and across sectors, local programme adaptation, and communication and advocacy as the key enabling factors for drowning prevention policy implementation in Vietnam.

  • This study also identified several barriers to implementation of drowning prevention policies in Vietnam, including inadequate funding availability, insufficient programme evaluations and long-term strategic planning, and lack of consistent and timely data collection on drowning.

Acknowledgments

We would like to acknowledge and thank Dr Ngan Nguyen from the Centre for Injury Policy and Prevention Research, Hanoi School of Public Health, Vietnam for her support with data collection.

References

View Abstract

Footnotes

  • Contributors JJ and HN designed the study. HN led the data collection and analysis. JJ and AC contributed to the coding of transcripts. All coauthors contributed to the interpretation of data and the manuscript.

  • Funding This study was funded by the Royal National Lifeboat Institution (RNLI), UK.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.