Shaun Cleaver reporting on interviews and notes provided by Maria Judd and Danielle Levac's experiences in Vietnam
A. Introduction to the country and region
Vietnam is a relatively small country in South East Asia that follows the coast of the South China Sea. Vietnam ranks 108th out of 170 on the UN Human Development Index, with a population of 86 million people. 6.4% of the total population – 5.1 million people - live with some kind of disability, and 87% of these people live in rural areas. Life expectancy in Vietnam is 69 years for men and 74 years for women.
My volunteer assignment was in Danang, the third largest city in Vietnam. Danang is a bustling port and business city. It is not yet a tourist destination and so most visitors pass through the city on their way to nearby attractions such as the market town of Hoi An, a UNESCO world heritage site. As a Westerner you are on a person of interest, especially if you choose to move about the city on foot, as most people ride motorbikes or bicycles. It’s a great place to watch locals go about their daily lives; working, going to the beach, walking by the river, eating at the many sidewalk restaurants, and drinking coffee at the many new cafes. On foot, negotiating the incredibly chaotic local traffic – with its lack of stop signs, traffic lights or rules of the road – requires courage, a sense of humour, and determination.
B. Population Health
Infectious diseases and injuries as a result of motor vehicle accidents are leading stressors on the Health Care System in Vietnam (http://www.atlanticphilanthropies.org/health/viet_nam). In addition, unexploded ordnance (UXO) from the war continues to cause major health problems for the people of Vietnam. Indeed, an injury or death from finding an UXO happens once a week in Central Vietnam ( Clear Path International Website: http://www.cpi.org/regions/vietnam.php) Some facts about population health in the country include:
10 million children living in poverty
Maternal deaths from pregnancy/childbirth at 7/day
Road accidents are leading cause of death for children age 15 and over
215,000 people affected by HIV and AIDS
Source: Website of The Atlantic Philanthropies: Vietnam. Accessed February 19th 2007. http://www.atlanticphilanthropies.org/health/viet_nam According to the World Health Organization: “Viet Nam's health indices have improved in recent years. However health inequalities are growing between different groups and geographical areas. Maternal and child mortality are much higher among the poor and among some ethnic groups. Infant mortality in remote areas is nearly eight times greater than in urban areas. Malnutrition is still a serious problem among poor children. Viet Nam is also facing a host of relatively new health problems. More than 10 000 people die from road accidents every year; the HIV/AIDS epidemic is escalating; and tobacco-related diseases are growing. The number of non-communicable or “lifestyle diseases”, such as cancer, diabetes and heart disease, has risen in recent years. They now account for nearly half of all deaths. Meanwhile, some communicable diseases, such as tuberculosis continue to persist.”
Source: World Health Organization: Health Situation in Viet Nam (Website) accessed Feb 19th, 2007 http://www.un.org.vn/who/profile.htm The WHO in Vietnam is working on programs in areas such as injury control, malaria, maternal and child health, HIV/AIDS, immunization, health promotion, and health sector development (http://www.un.org.vn/who/profile.htm)
C. Health Care System
My experience with the health care system in Vietnam was at the Danang Orthopedics and Rehabilitation Center, a government-supported Centre which employs physiotherapists, prosthetists-orthotists, and several orthopaedic surgeons and nurses. It serves a large population of people in 7 provinces in central Vietnam. In-patients stay at the center with their families in small cramped rooms, and the families sleep on the floor beside them or underneath the bed. The families do most if not all of the care for their family members, literally staying there with them 24 hours a day, and providing all of their food and water. Inpatients are generally accident victims (traumatic brain injuries and spinal cord injuries, the majority of which result from motorbike traffic accidents), people who have suffered a stroke, or those recovering from the orthopedic surgery that is performed at the Center. The physiotherapy department also sees many out-patients who come daily to the Center and usually stay all day with their families. There are no set appointment schedules, meaning that the therapy gyms can get quite hectic, and therapists are often treating many people at once. Patients generally receive between 30min and 1 hour of therapy a day, and spend the remaining time going through exercise programs or using the various pieces of equipment with the assistance of their families. The physiotherapy gyms at the Centre are quite spacious and are equipped with a variety of equipment: treatment tables, a few plinths, mats on the floors, bicycles, parallel bars, therapy balls, walkers, standers, and a whole “electrotherapy” room in which patients receive short-wave diathermy, ultrasound, acupuncture, ultraviolet radiation, interferential, and traction. There is also a large prosthetic and orthotics laboratory which is truly a sight to behold. NGOs help to fund the provision of prosthetic limbs for the 7 provinces, and so the lab is very busy and productive. They also make clubfoot bracing and AFOs. The difficulty with the AFOs is that most patients cannot afford them, despite their relatively low cost by Canadian standards (approx 40$). Consequently, the potential to make bracing and adaptive equipment goes underused due to the lack of available funding.
D. Disability
The cultural and religious texture of Vietnam creates an interesting viewpoint of disability. There is a very strong belief in fatalism that leads one to expect a disability for a person who has a congenital abnormality or has had major injury. Because of this expectation, people are less likely to look for ways to change their physical function, be it by remediation to reduce an impairment or adaptation improve participation. Interestingly, this expectation isn’t necessarily equivalent to acceptance, as people didn’t seem to be content with having a disability.
E. Rehabilitation
Many of the rehabilitation professionals that we are familiar with in Canada have no equivalent in Vietnam. Occupational therapy does not exist as a profession and there are no social workers or counselors to help with psychosocial issues. This means that many of these responsibilities are left to be addressed by physiotherapists.
My experience in Vietnam is limited to one facility in the centre of the country, so my perception of the status of physiotherapy is not necessarily generalizable to Vietnam as a whole. The physiotherapists that I worked with were very dedicated and caring, but sometimes had trouble converting findings into intervention plans as well as incorporating functional exercise into treatments. The teamwork at the Danang Rehabilitation Centre was great and both local (staff) and foreign (volunteer) physios were well-respected by other healthcare providers. Those who have been involved with the Physical Therapy Overseas’ program in Danang (described below) have stated that this interaction has improved substantially since the start of the project. The physiotherapy profession is still in development in Vietnam. Currently, physios are trained in 2-year programs that would be roughly similar to PTA training in North America. Unfortunately there are very few continuing education training opportunities for practicing therapists.
F. Personal Experience
My husband and I volunteered with Physical Therapy Overseas’ (PTO) Vietnam Project. PTO has developed a partnership with the Danang Orthopedic and Rehabilitation Center in central Vietnam, with the goal of improving rehabilitative care through interaction with physiotherapists onsite. Through the work volunteer professionals from abroad, PTO is able to offer ongoing support for a good portion of the year.
We were able to stay for one month in 2005. Our timing happened to coincide with some of the biggest holidays of the year, including the Tet festival (lunar New Year). This was a fantastic opportunity to learn about Vietnam’s rich culture, but unfortunately meant that the first week of work was extremely slow as there were no in-patients and many of the staff members were still away on vacation.
My role in this project was as a clinical educator. I held one-hour inservice training sessions with the physical therapy staff, twice per week. The balance of my time was spent as a consultant; floating through the treatment areas and offering support as necessary. This gave me the chance to interact with students and therapists on an impromptu basis to discuss treatment techniques and interesting cases. Considering my experience as a hand therapist at the Toronto Western Hospital I focused on hand rehabilitation; reviewing treatment of arthritis, other pathologies that are common in the hand and splinting.
As suggested by the program directors, I tried to emphasize the NAGI model (impairment, functional limitation, disability) to facilitate clinical reasoning. I found that the PT students and some of the younger PTs understood the concepts and components of the model but had difficulty understanding how to gather the data, especially subjective history, and how to connect to findings to a plan of treatment and goals. Many of the physiotherapy staff members did not appear to be familiar with the NAGI model concept.
I found that it was easiest to teach with the use of case studies. While working with the staff and students, the main take home messages in my teaching were to increase the use of functional treatments, including active exercises and weightbearing activities. It seemed to be commonplace for the local physios to have the patients lie down for many of the treatment activities (including strengthening).
Unfortunately, I found it difficult to determine if my activities met the needs of the staff at the Center. When I invited feedback about my activities or asked for concrete suggestions everyone was always very polite and positive. I tried to be responsive to learning needs identified while interacting with them throughout the work day. All of the staff I interacted with were quite open to my presence at the Center.
I was very satisfied with the preparation offered by PTO, but I wish I would have known more about physical therapy in Vietnam prior to arrival in the country. I was able to piece together some information regarding the history of the profession and the current training program. Having known this information it would have been far easier to prepare my training sessions.
The dedication shown towards the patients by the Center staff truly was impressive. The physiotherapy staff demonstrated great teamwork in their daily tasks. At the moment there are no occupational therapists, social workers or counselors at the Center, so the physiotherapists must fill many of these roles. Because of this it is crucial that the staff integrate the concepts of functional limitations and disability into their approach to assessment and treatment planning. I’d recommend that future teachers focus on these points.
During our time in Danang, my husband was able to offer English tutoring at the end of the day for those members of the staff who were interested in improving their English proficiency. This activity was appreciated by all parties and was a lucky match of skill set and need: we had expected to be able to arrange volunteer activities upon arrival onsite and found this much harder to do than foreseen!
Outside of work we were able to do a bit of traveling elsewhere in Vietnam, primarily in the north. Before coming to Danang we visited Hanoi and from there enjoyed wonderful trips to Halong Bay (boat trip) and to Sapa (hiking and a homestay with a family in a village). During the assignment we explored Hoi An and Hue on the weekends.
My husband and I both truly enjoyed our time at the Danang Orthopedic and Rehabilitation Center. The staff at the center was very friendly and welcoming, warmly including us in the holidays that took place when we were in Vietnam. We enjoyed the city of Danang too - especially since it is less of a "tourist" city than others we visited. Thank you to Health Volunteers Overseas/Physical Therapy Overseas, Danang Orthopedic and Rehabilitation Center and the people of Danang for the opportunity to be part of life in Danang and at the Center while we were there and experience such a rich culture.
G. Recommendations
The therapists at the Centre have benefited from the skills of the many HVO volunteers who have spent time there, and I’m sure that each of us has in turn absorbed a great deal from our experiences. The practice model in Vietnam is such that issues like functional therapy, goal setting, treatment progression and re-evaluations, and the importance of considering the patient’s environment, family situation and goals in treatment are all areas that are slow to change.
Physiotherapists are faced with many additional challenges in Vietnam – more patients, less resources, less education, and little communication with physicians, to name but a few – and work longer hours for a pay of about 100-200 $US/month. This working environment is all that they have known and they are very creative with limited resources. Despite the definite problems inherent to the lack of continuing education, the passive approach to treatment and the hierarchical model of practice, these physiotherapists are all working towards restoring independence and regaining lost motion, as are therapists throughout the world. Related website www.hvousa.org – Health Volunteers Overseas (parent organization of Physical Therapy Overseas)
I. Contact Information
I would welcome the opportunity to share our experience with potential future volunteers and/or answer any questions and can be contacted at <>.
